Factors associated with case = fatality=20 of human H5N1 virus infections in Indonesia: a case=20 series

I=20 Nyoman Kandun MD a, Erna Tresnaningsih=20 MD a, Wilfried=20 H Purba DVM a, Vernon Lee=20 MBBS c, Gina Samaan=20 MAppEpid c, Syahrial Harun=20 MSc b, Eka Soni=20 BSc a, Chita Septiawati=20 MD a, Tetty Setiawati=20 MD a, Elvieda Sariwati=20 MD a and Toni Wandra=20 MD a

Summary

Background

Indonesia=20 has had the most human cases of highly pathogenic = avian=20 influenza A (H5N1) and one of the highest = case-fatality rates=20 worldwide. We described the factors associated with = H5N1=20 case-fatality in Indonesia.

Methods

Between=20 June, 2005, and February, 2008, there were 127 = confirmed H5N1=20 infections. Investigation teams were deployed to = investigate=20 and manage each confirmed case; they obtained = epidemiological=20 and clinical data from case-investigation reports when = possible and through interviews with patients, family = members,=20 and key individuals.

Findings

Of=20 the 127 patients with confirmed H5N1 infections, 103 = (81%)=20 died. Median time to hospitalisation was 6 days (range = 1=E2=80=9316).=20 Of the 122 hospitalised patients for whom data were = available,=20 121 (99%) had fever, 107 (88%) cough, and 103 (84%) = dyspnoea=20 on reaching hospital. However, for the first 2 days = after=20 onset, most had non-specific symptoms; only 31 had = both fever=20 and cough, and nine had fever and dyspnoea. Median = time from=20 onset to oseltamivir treatment was 7 days (range = 0=E2=80=9321 days);=20 treatment started within 2 days for one patient who = survived,=20 four (36=C2=B74%) of 11 receiving treatment within = 2=E2=80=934 days=20 survived, six (37=C2=B75%) of 16 receiving treatment = within 5=E2=80=936=20 days survived, and ten (18=C2=B75%) of 44 receiving = treatment at 7=20 days or later survived (p=3D0=C2=B703). Initiation of = treatment=20 within 2 days was associated with significantly lower=20 mortality than was initiation at 5=E2=80=936 days or = later than 7 days=20 (p<0=C2=B70001). Mortality was lower in clustered = than=20 unclustered cases (odds ratio 33=C2=B73, 95% CI = 3=C2=B713=E2=80=93273).=20 Treatment started at a median of 5 days (range = 0=E2=80=9313 days) from=20 onset in secondary cases in clusters compared with 8 = days=20 (range 4=E2=80=9316) for primary cases = (p=3D0=C2=B704).

Interpretation

Development= =20 of better diagnostic methods and improved case = management=20 might improve identification of patients with H5N1 = influenza,=20 which could decrease mortality by allowing for earlier = treatment with oseltamivir.

Funding

None.

Affiliations

a. Directorate = General of=20 Disease Control and Environmental Health, Ministry of = Health,=20 Jakarta, Indonesia
b. National = Institute of=20 Health Research and Development, Ministry of Health, = Jakarta,=20 Indonesia
c. WHO,=20 Indonesia Country Office, Jakarta,=20 Indonesia

Correspondence to: Toni Wandra, = Directorate=20 General of Disease Control and Environmental Health, = Ministry=20 of Health, Jl Percetakan Negara 29, Katak Pos 223, = Jakarta=20 10560, Indonesia

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