Re: Indonesian man dies from bird flu - update
Re: Indonesian man dies from bird flu - update
In the bird-flu fight, Indonesia falls behind
By Donald G. McNeil Jr. The New York Times
Published: July 20, 2006
Indonesia is poised to surpass Vietnam as the country hardest hit by avian flu. And while Vietnam has not had a single human case or poultry outbreak this year, public health officials and experts say the situation in Indonesia is likely to get worse.
Indonesia received word from a Hong Kong laboratory that a 44-year- old man who died last week near Jakarta had tested positive for the H5N1 virus, the Indonesian Health Ministry said Thursday. That brought number of confirmed bird flu deaths in Indonesia to 42 since the first human case was confirmed a year ago, equal to the toll in Vietnam.
The flu is ubiquitous in thousands of Indonesian backyard flocks, and appears to be killing more birds every month, increasing the likelihood of human cases.
"It's like trying to fix the roof while there's a storm going on," said Dick Thompson, a spokesman for the World Health Organization. "Until the animal situation gets under control, there's going to be this steady drip, drip, drip of human cases, and that's a problem."
Although the H5N1 flu came relatively late to Indonesia, it soon spiraled out of control, and deaths have mounted quickly.
Unlike Thailand, which quenched outbreaks by killing millions of chickens, or Vietnam, which used mandatory vaccination, Indonesia has tried a mix of limited culling and vaccinating in rings around the cull - so far, with little success.
Mathur Riady, chief of livestock for the Indonesian Health Ministry, said recently that more than a million birds had died of the flu between January and March, about the same number as died all of last year.
The biggest obstacle to beating the disease, international flu experts say, is the decentralized Indonesian government. Health officials in the capital, Jakarta, have been described as having powers extending no further than their office walls, while real power resides in the governors of the 33 provinces and the elected bupatis, or regents, of 480 districts.
"It's a real mish- mash," said Dr. Jeffrey Mariner, a veterinary medicine professor from Tufts University, in Boston, who is helping the UN Food and Agricultural Organization train new veterinary workers. "You have to sit down with each decision-making unit and get them all on board. It's hard to mount a coordinated response."
As a result, the country is not only slow to report human cases, but it no longer even reports poultry outbreaks to the World Organization for Animal Health in Paris.
However, decentralization is not a principle that Indonesians are likely to abandon. Like the former Yugoslavia under Marshal Tito, the 245 million Indonesians, living on about 6,000 populated islands, are a contentious mix of ethnic and religious rivalries, formerly held together by harsh central control from Jakarta.
With the collapse of the Suharto dictatorship in 1998, independence movements sprouted from East Timor to Aceh, and Jakarta responded with different mixes of military power and grants of semi-autonomy.
The regions prefer having more self- government, and "decentralized units get very wary when the center takes on emergency powers," said Dr. David Nabarro, a UN chief pandemic flu coordinator.
Shortages of trained veterinarians and slow compensation of farmers have also been major obstacles to crushing the outbreak, Mariner said.
He and nine colleagues from Tufts and the UN agency are training local people to find and do rapid tests on sick birds, cull flu-infected flocks and vaccinate others in a ring around them. But each trainee needs two to three months of class and field work to become proficient, he said, and then many of them must, in turn, become trainers.
"By February, we should have enough for 157 districts on three islands," he said. Asked how long it would take to train enough disease-trackers to cover all 480 districts, he said "I don't have an answer. Maybe two or three years."
Another problem, he said, is the sheer profusion of backyard chickens. The outbreak is not a big problem in commercial flocks, but "in the country, every household has poultry," he said. "Retired people here keep chickens like other retirees take up woodworking. It's household food, and income, and something to do. Asking Indonesians to give up their chickens is like asking Americans to give up their dogs and cats."
Until recently, he said, many farmers refused to let their birds be killed because they received only vouchers that could take six months to be paid.
"Now we're seeing the districts willing to advance money, so people are paid in a few days," he said. "That's begun real cooperation."
The government pays about $1 per bird - just a bit below market value, which veterinary experts suggest is the best way to get compliance while not creating the temptation to breed just for the culling payments.
Indonesians also raise fighting cocks, songbirds and trained doves worth much more than $1, he said, but they are paid nothing extra, giving the owners little incentive to cooperate.
Making matters more difficult, some outbreaks begin in remote villages which may themselves be estranged from local government. For example, Kubu Sembilang, the village in the Karo District in northern Sumatra where the flu killed seven members of one family, was a Christian and animist village, while northern Sumatra is a center of fundamentalist Islam.
Some wary villagers there blamed the deaths on witchcraft and refused to take the antiviral drug Tamiflu that the authorities offered.
Given the huge Indonesian population - Vietnam has 84 million people - avian flu remains a relatively rare disease there, said Dr. Tim Uyeki, an epidemiologist from the U.S. Centers for Disease Control and Prevention who was part of a World Health Organization investigative team.
But the way Indonesian cases have clustered - often infecting just the blood relatives in one family in a village - has boosted a theory that some people are genetically more likely than others to get infected, he noted.
"We can't prove that; it remains a hypothesis," Uyeki said. "But when a village has a lot of people and a large outbreak and they all have lots of contact - burying or slaughtering or whatever - and only one family gets sick, you have to ask: is there something unique in that family that creates susceptibility?"
Studies to test that theory are needed, he said.
Under the right circumstances, Indonesia can rouse itself to beat a threatened epidemic. Just last year, it defeated an unexpected polio outbreak. After a polio-free decade, it had a lone imported case in May, 2005, that quickly became 303 cases, the third-biggest outbreak in the world after Nigeria and Yemen. (Each detectable case of paralysis means there are 200 people with "silent" cases, who can still spread the virus.)
A huge immunization campaign drove new cases down to a mere two this year so far.
That was possible partly because polio involved only the health bureaucracy, not the battered agriculture sector too, said Dr. David Heymann, the World Health Organization director general's representative for polio eradication.
Also, polio prevention is cheaper because farmers do not need to be compensated, and longtime polio donors like Rotary International buy the vaccine and pay stipends to vaccination teams, even though they are nominally "volunteers."
Also, Heymann said, "We pushed them and we pushed them hard."
Luckily for the effort, the rumors that polio vaccine is a plot to sterilize Muslim girls - rumors that still hinder vaccinations in northern Nigeria helping to spread polio across Africa - never took hold, even though Indonesia is a largely Muslim country.
http://www.iht.com/articles/2006/07/20/news/flu.php
</TD></TR></TBODY></TABLE>JAKARTA, Indonesia (AP) ? A 44-year-old man died of bird flu in Indonesia, a senior health official said Sunday, putting the country on the cusp of being the world's hardest hit by the disease.
