Why is there such concern now?

• Health professionals are

concerned that the continued and
AVIAN Influenza expanded spread of a highly
pathogenic AVIAN H5N1 virus
across eastern Asia and other
countries represents a significant
threat .

Avian Influenza (AI) 1. Seasonal flu / Influenza musiman  Virus influenza strain B, cepat
menyebar antar manusia namun tidak fatal.

• Disebabkan oleh virus Influenza A 2. Avian Influenza (Flu Burung)  Penyakit zoonosis akibat virus H5N1,
penyebaran sporadis, tidak mudah menular dari unggas ke manusia
 endemis, fatal
• Menyerang Unggas dan Mamalia (termasuk 3. Influenza Pandemi  cepat menyebar antar manusia secara
manusia) efisien, berkelanjutan, fatal, penyebaran global

• Pada unggas dikenal dengan Highly Pathogenic AI

(HPAI) and Low Pathogenic AI (LPAI)
• Pada manusia disebut sebagai penyakit Flu Burung
yang berpotensi pandemi
• Wabah HPAI subtype H5N1

PERIODE PANDEMI Challenge

• INTERPANDEMI
– Fase 1: Hanya hewan dengan resiko pada manusia rendah • The current outbreaks of highly pathogenic
Situasi •
– Fase 2: Hanya Hewan dengan resiko pada manusia tinggi
WASPADA PANDEMI
avian influenza, which began in South-
saat
ini
– Fase 3: Ada kasus manusia namun belum ada penularan East Asia in mid-2003, are the largest and
antar manusia
– Fase 4: Penularan terbatas antar manusia (kelompok most severe on record.
kecil)
– Fase 5: Penularan dalam kelompok lebih besar • Never before in the history of this disease
• PANDEMI
– Fase 6: Penularan efektif antar manusia have so many countries been
simultaneously affected, resulting in the
loss of so many birds.

1
 Influenza A viruses have 16 H subtypes Influenza A HA and NA
N1
and 9 N subtypes. Subtypes
H1
H2
H3 N2
• In poultry, the viruses can mutate, usually within
H4
a few months, from then low pathogenic avian N3
H5
influenza (LPAI) form into the highly pathogenic H6
form (HPAI). H7 N4
• Only viruses of the H5 and H7 subtypes are H8
H9 N5
known to cause the highly pathogenic (HPAI)
H10
form of the disease.
N6
H11
N7
H12
N8
H13
N9
H14
H1
5,
H16

• Spektrum Inang Virus Influenza A

• Influenza Anjing Laut
• H7N7 , H4N5, H3N2
• Equine
• Influenza Ayam Influenza
• H4,5,7,9,10 •( H7N7, H3N8 ) • PETELUR
• N1,2,4,7 • Bovine Influenza • BROILER
• H5N1 (2002,2004)
• AYAM KAMPUNG
• Ferret influenza
• Duck • AYAM ARAB
• ( H10N4 )
• AYAM BANGKOK
• ITIK
•babi
• ANGSA
• Unggas air
•H1N1,
H3N2
• unggas • ENTOK
• aya • H1 – H15 • PUYUH
m • N1 – N9 • MERPATI
•• H5N1 • BURUNG PERKUTUT
puyuh •
Swine Influenza •manusia
• Influenza Manusia • PUTER
• H9N2
• H1N1(1933,1979) H5N1 (1997,2003) • H1N1, H3N2
• KAKATUA
• H2N2(1957) H9N2(1999) • H1N2 , H4N6 (2000)
• H5N1 (2004)
• H3N2(1968) H1N2(2002) • Influenza ikan paus
• H7N7(2003)
• H3N2 , H13N9 • SANTHIA-2005

Highly Pathogenic Avian Influenza

HPAI
• In 2004, over 120 million birds died or
were destroyed as a result of a
current avian influenza type, the
H5N1 strain. This number is higher
than the combined total bird deaths of
all prior highly pathogenic outbreaks
recorded throughout the world over
the last four decades.

2
 Changing viral behavior in natural
reservoir, wild waterfowl,
Acceleration of HPAI
• The spring 2005 die-off of upwards of 6,000 • Furthermore, the 2004 deaths
migratory birds at a nature reserve in central
China, caused by highly pathogenic H5N1, was
occurred in just three months.
highly unusual and probably unprecedented. • In the subsequent months, H5N1 has
• In the past, only two large die-offs in migratory expanded to include other wild birds
birds, caused by highly pathogenic viruses, are
known to have occurred: in South Africa in 1961
as well as domesticated ducks, and
(H5N3) and in Hong Kong in the winter of 2002– • its host range now also includes
2003 (H5N1). mammals.

The AVIAN H5N1 virus has raised

More lethal in more animals concerns about a potential
human pandemic because:
• When compared with H5N1 viruses
from 1997 and early 2004, H5N1 • It is especially virulent.
viruses now circulating are more • It is being spread by transported
lethal to experimentally infected mice domestic poultry.
and to ferrets (a mammalian model) • It can be transmitted from birds to
and survive longer in the mammals and in some limited
environment. circumstances to humans.

• HPAI di Indonesia Penyebaran Virus = Pergerakan Virus

Endemik di unggas ( 32 dari 33 propinsi)
191 kasus confirmed dengan 159 orang meninggal (13 dari 33 propinsi) •Manajemen Pasar Unggas
data WHO per Agustus 2012 dan pengepul unggas •Virus yg menyerang manusia dan unggas lokal kemungkinan bukan
akibat infeksi virus lokal,
• tetapi ada kemungkinan diintroduksi dari sumber dari luar .

Ac eh
• April 2011

Sum atera U tara

•Pengendalian
Kalim antan Tim ur

Maluku U tara
G orontalo Sulawesi U tara

Riau

Sum atera Barat

Kepulauan Riau Kalim antan Barat
dan pengawasan
Jam bi Kalim antan Tengah
Sulawesi Tengah

Sulawesi Selatan
Irian Jaya Barat
Unggas dari
daerah
Bangka-Belitung
Sulawesi Barat
Kalim antan Selatan

Sum atera Selatan

Maluku Papua • Managemen
Bengkulu
Sulawesi Tenggara

• Distribusi dan
unggas Aspek pengendalian
•
Lam pung

• Kontrol
Jakarta Raya
Produksi : •Manajemen rantai suplai ter-
•Wabah di
Banten Jawa

Barat

Jawa Tengah
• -- Vaksinasi Integrasi unggas : untuk semua
Yogyakarta Jawa Tim ur

Unggas Bali N usa Tenggara Barat

N usa Tenggara Tim ur • -- Biosekuritas sistem produksi (sector 1-4) dan
• -- Aktivitas Monev
breeds (layers, broilers, ayam
HPAI free Area
kampung, itik)
2003 •-- Rumah
2004 Potong/TPA
2005
2006

3
 DATA KASUS FLU BURUNG
BERDASARKAN KONTAK, TAHUN 2005-FEB 2008
(sumber: Depkes 2008)
2%
1 2%
37 %
4 9%
Low Pathogenic Avian Influenza LPAI
• H5 and H7 viruses are introduced to
poultry flocks in their low pathogenic form
(LPAI).
• The so-called “low pathogenic” form
commonly causes only mild symptoms
(ruffled feathers, a drop in egg production)
and may easily go undetected.
A growing number of human H5N1
cases have been reported
• in Azerbaijan, Cambodia, China, Egypt,
Indonesia, Iraq, Thailand, Turkey and Vietnam.
Kontak langsung
• More than half of the people infected with the
Kontak dg lingkungan H5N1 virus have died.
Pupuk • Most of these cases are believed to have been
caused by exposure to infected poultry.
Inconclusive
• The concern is that H5N1 will evolve into a virus
capable of human-to-human transmission.
Time to prepare
• While no one can state with
complete certainty that a
pandemic will occur, the signs
point to it being a prudent time to
begin careful and thorough
preparation.
HPAI
• First identified in Italy in 1878
• HPAI causes severe disease, rapid
contagion and lethal for > 6 of 8 chickens
inoculated with the virus.
• It spreads very rapidly through poultry
flocks, causes disease affecting multiple
internal organs, and
• Has a mortality that can approach
100%,
often within 48 hours.
4

HPAI Environmental Survival
• Highly pathogenic viruses can survive for
long periods in the environment, especially
when temperatures are low.
• For example, the highly pathogenic H5N1
virus can survive in bird feces for at least
35 days at low temperature (4°C).
• At a much higher temperature (37°C),
H5N1 viruses have been shown to survive,
in fecal samples, for six days.
In the past, HPAI was rare in
Migratory Birds
• In the past, only a few migratory birds
were found dead within the flight
range of a poultry outbreak.
• Current concept is that wild waterfowl
are not agents for the onward
transmission of HPAI.
HPAI Transmission
• Migratory birds can introduce LPAI H5 and H7
viruses to poultry flocks, which then mutate to
HPAI.
• Avian influenza viruses are readily transmitted
from farm to farm by the movement of live birds,
• People (especially when shoes and other
clothing are contaminated), and
• Contaminated vehicles, equipment, feed, and
cages.
The role of migratory birds in the
spread of HPAI
• The role of migratory birds is not fully
understood.
• Wild waterfowl are considered the natural
reservoir of all influenza A viruses.
• They have probably carried H5 and H7
subtypes of LPAI, with no apparent harm,
for centuries.
The role of Ducks in the spread
of HPAI
• Domestic ducks excrete large quantities
of highly pathogenic virus without
showing signs of illness.
• Mallards act as a “silent” reservoir of the
virus, perpetuating transmission to
other birds.
• Adding another layer of complexity to
control efforts and removes the warning
signal for humans to avoid risky
behaviors.
Transmission in Wild Birds
• Influenza virus shed in feces, saliva, nasal
secretions
• Fecal-oral
– Predominant mode of transmission
• Other possible modes
– Fecal-cloacal
– Respiratory
5
 Influenza Virus Survival Transmission in Poultry
• Virus persistence in aquatic environments • In an infected flock, virus can spread in
– Weeks to months multiple ways
– Preferred conditions – Fecal-oral
• Low temperatures, brackish water – Aerosol
– May survive indefinitely when frozen – Fomites
• Virus persistence in feces – Mechanical vectors
– Weeks to months • Virus introduction
– Migratory birds
– Infected poultry, pet birds

Transmission in Mammals Human Transmission

• Close contact with dead or sick birds • Previously considered non-pathogenic for
• Indirect exposure humans
• 1997, Hong Kong
– Contact with feces
– 18 humans infected, 6 died
– Swimming in contaminated water – H5N1 virus linked to outbreak in live bird market and
• Ingestion area farms

• Other routes (experimental) • 2003, the Netherlands

– 83 confirmed cases in humans, 1 death
– Respiratory, oral, intraocular – H7N7 strain
– Transplacental • Swine are proposed “mixing vessel”

Human controlled intensive rice-

domestic duck agriculture
• Virus persistence after extensive culling is
increasingly confined to areas in eastern
and southeastern Asia where humans
cultivate rice and duck meat.
• ~90% of the world’s 1.044 billion domestic
ducks are in Asia.
• China and Viet Nam=775 million or 75%.
• Thailand=11 million ducks.
• http://www.fao.org/newsroom/en/news/2008/1000817/index.html
Dead birds don't fly
• Governments should stop blaming wild
birds for outbreaks of the disease.
• Migratory birds do not move during the
summer, (Ornithologist Martin Williams)
• Waterfowl carry a lot of bird flu viruses, but
they don't carry the Highly Pathogenic
Avian H5N1 flu, because it kills them.
• June 2008 South China Morning Post Publishers Limited, Hong Kong.

6
 Backyard flocks=a heightened risk Endemic Zoonotic H5N1 virus --
of human exposure and infection. especially tenacious.
• Backyard flocks usually roam freely. • Despite the death or destruction of an
• Backyard flocks scavenge for food estimated 150 million birds, the virus is
now considered endemic in many parts of
• Backyard flocks mingle with wild birds or
Indonesia and Viet Nam and in some parts
share water sources with them. of Cambodia, China, Thailand, and
• Abundant opportunities for human possibly also the Lao People’s Democratic
exposure to the virus with birds in Republic.
households, especially during adverse • Control of the disease in poultry is
weather, or when they share areas where
children play or sleep. expected to take several years.

90 % of the world’s 1.044 billion

Ducks, rice and people domestic ducks are in Asia
• A strong link between duck grazing patterns and • China and Viet Nam account for the bulk
rice cropping intensity in H5N1 highly
pathogenic avian influenza in Thailand and Viet of this – 775 million or 75 percent.
Nam. Thailand has about 11 million ducks.
• Ducks feed mainly on leftover rice grains in
harvested paddy fields, so free-ranging ducks in
both countries are moved to many different sites
in line with rice harvest patterns.
• Virus persistence is now increasingly confined to
areas with intensive rice-duck agriculture in
eastern and southeastern Asia.
• "Mapping H5N1 highly pathogenic avian influenza risk in Southeast Asia: ducks, rice and people", Proceedings of
the National Academy of Sciences of the United States (PNAS),
http://www.fao.org/newsroom/en/news/2008/1000817/index.html

Control of HPAI in Thailand Control of HPAI in Vietnam

• The local movements of ducks decreased • Viet Nam started nationwide vaccination of
all poultry at the end of 2005, including
when the Thai government started to the Mekong delta which is home to 50
support in-door keeping of ducks, offering million ducks.
feed subsidies and construction of • This large-scale vaccination was repeated
enclosures. in 2006/07.
• Together, these measures stopped the • Initially, human infections disappeared and
H5N1 transmission cycle and since late levels of disease in poultry fell noticeably.
2005 Thailand has suffered only sporadic • Only gradually did H5N1 viruses re-
outbreaks. appear, mostly in unvaccinated ducks and
particularly in the Mekong delta.

7
How avian influenza A/H5N1 might By 2004, expanded to other
enter the U.S. bird population mammalians. Now found
• Poultry imported into South America (where in:
poultry trade is less restricted) from countries
where H5N1 has affected domestic or wild
• Tigers,
birds poses the greatest risk of introducing • Leopards,
H5N1 into the U.S.
• H5N1 could be transmitted from poultry in • Pigs,
South America to birds that migrate to North
America*
• Domestic cats,
• Palm civets,
*Kilpatrick et al. Proc Natl Acad Sci. 2006 Dec 19;103(51):19368-73
• Humans

Protective and Mitigating

responses
Diagnosis in Humans
• Governmental preparedness • RT-PCR
• Cross Sector planning and – Primary test to identify H5N1
collaboration • Antigen detection
• Cross Boundary planning and • Virus isolation
collaboration – WHO Reference Laboratories
• Expansion of Surveillance, Case tracking • Serology
and Epidemiology – Microneutralization
• Laboratory Diagnostic Enhancement
• Improved information systems

Control Measures Control Measures

• Rapid culling of all infected or exposed • Restrictions on the movement of live
birds, poultry, both within and between countries,
• proper disposal of carcasses, • The logistics of recommended control
• the quarantining and rigorous disinfection measures are most straightforward when
of farms, and applied to large commercial farms,
• the implementation of strict sanitary, or where birds are housed indoors, usually
under strictly controlled sanitary
“bio-security”, measures
conditions, in large numbers.
http://www.who.int/mediacentre/factsheets/avian_influenza/en/index.html

8

Control Measures
• Control is far more difficult under
poultry production systems in which
most birds are raised in small
backyard flocks scattered throughout
rural or peri-urban areas.
• http://www.who.int/mediacentre/factsheets/avian_influenza/en/index.
html
Potential sources of exposure
• Swimming in water bodies with discarded
infected carcasses or contaminated by infected
ducks feces.
• No known plausible exposure source,
suggesting an unknown environmental factor,
involving contamination with the virus.
• A possible role of peri-domestic birds, such as
pigeons
• The use of untreated bird feces as fertilizer.
Smoldering Rural Outbreaks
• Owners may not interpret deaths or signs
of illness in a flock as a signal of avian
influenza and a reason to alert the
authorities.
• The absence of compensation to farmers
for destroyed birds works against the
spontaneous reporting of outbreaks
• Encourages owners to hide their birds
during culling operations.
Vaccination for public health
purposes.
• At least some pandemic viruses are
known to have emerged following a re-
assortment event.
• Vaccination against seasonal influenza will
not protect people against infection with
the H5N1 virus; no vaccine against H5N1
is presently available.
Poverty exacerbates the problem
• In situations where a prime source of food
and income cannot be wasted, households
frequently consume poultry when deaths
or signs of illness appear in flocks.
• This practice carries a high risk of
exposure to the virus during slaughtering,
de-feathering, butchering, and preparation
of poultry meat for cooking, but has proved
difficult to change.
Protection of persons at risk
of occupational exposure
• Personal protective equipment. Those at risk
of occupational exposure on affected or at-risk
farms should wear personal protective
equipment:
• 1. Protective clothing, preferably coveralls plus
an impermeable apron or surgical gowns with
long cuffed sleeves plus an impermeable apron;
2. Heavy-duty rubber work gloves that may be
disinfected;
9

Personal protective equipment
• 3. Standard well-fitted surgical masks should be
used if high-efficiency N95 respiratory masks
(NIOSH-certified N-95 or equivalent) are not
available. Masks should be fit-tested and
training in their use should be provided;
4. Goggles;
5. Rubber or polyurethane boots that can be
disinfected or protective foot covers that can be
discarded.
WHO Recommendations
• WHO continues to recommend that travelers to
affected areas should avoid contact with live
animal markets and poultry farms, and any free-
ranging or caged poultry.
• Large amounts of the virus are known to be
excreted in the droppings from infected birds.
• Populations in affected countries are advised to
avoid contact with dead migratory birds or wild
birds showing signs of disease.
http://www.who.int/csr/disease/avian_influenza/en
Poultry Consumption or Traveling
to an Affected Country
• Not a risk factor, provided poultry is thoroughly
cooked and the person is not involved in food
preparation.
• Traveling to a country with outbreaks in poultry
or sporadic human cases does not place a
traveler at enhanced risk of infection.
• Currently, no efficient human-to-human
transmission of the virus.
• Avoid visiting live or “wet” poultry markets,
farms, or other environments where exposure to
diseased birds may occur.
Pharmaceutical prophylaxis and
treatment.
• Those at risk of occupational
exposure on affected or at-risk farms
can be protected via antiviral
prophylaxis (oseltamivir) or post-
exposure prophylaxis.
• Antivirals should be readily available
for the treatment of suspected and
confirmed cases.
http://www.who.int/csr/disease/avian_influenza/en/
Exposure Risk
• Direct contact with infected poultry, or surfaces
and objects contaminated by their droppings, is
considered the main route of human infection.
• Exposure risk is considered highest during
slaughter, de-feathering, butchering, and
preparation of poultry for cooking.
• There is no evidence that properly cooked
poultry or poultry products can be a source of
infection.
Health monitoring.
Those at risk of occupational
exposure should:
• 1. Be aware of the early clinical signs of H5N1
infection, but also understand that many other
common diseases – of far less health concern –
will show similar early symptoms.
• 2. Check for these signs (especially fever) each
day during potential exposure and for 14 days
after last exposure.
• 3. Communicate any symptoms to a designated
local physician and provide background
information on exposure history.
10
 Symptoms Challenges
• Most patients infected with the H5N1 virus show • Disposal
initial symptoms of fever (38 C or higher)
followed by influenza-like respiratory symptoms,
• Occupational health
including cough, rhinorrhea, sore throat, and • Developing new wild
(less frequently) shortness of breath.
bird surveillance
• Watery diarrhea is often present in the early
stages of illness, and may precede respiratory program
symptoms by up to one week. • Hunting?
• Gastrointestinal symptoms (abdominal pain,
vomiting) may occur and headache has also
• Public perception –
been reported. panic?

Disinfection Disinfection, cont’d

• Sodium hypochlorite • Heat
• 70% ethanol – 56°C (133°F) for a minimum
of 60 minutes
• Oxidizing agents
• Ionizing radiation
• Quaternary ammonium compounds
• Low pH (pH 2)
• Aldehydes
• Phenols
• Acids
• Povidone-iodine

11