Open Access Research article

Human influenza A H5N1 in Indonesia: health care service-associated delays in treatment initiation

Wiku Adisasmito1*, Dewi Nur Aisyah1, Tjandra Yoga Aditama2, Rita Kusriastuti2, Trihono3, Agus Suwandono3, Ondri Dwi Sampurno3, Prasenohadi4, Nurshanty A Sapada5, MJN Mamahit6, Anna Swenson7, Nancy A Dreyer7 and Richard Coker8

Author Affiliations

1 Universitas Indonesia, Depok, Indonesia

2 CDC-EH MoH, Jakarta, Indonesia

3 NIHRD MoH, Jakarta 10560, Indonesia

4 Persahabatan Hospital, Persahabatan Raya St. No. 1, East Jakarta, Pisangan Timur, Pulo Gadung 13230, Indonesia

5 Sulianti Saroso Hospital, North Jakarta, Sunter, Indonesia

6 Tangerang Hospital, Tangerang, Indonesia

7 Outcome Quintiles, Cambridge, MA, USA

8 CDPRG, London School of Hygiene and Tropical Medicine, Bangkok, ThailandCDPRG, London School of Hygiene and Tropical Medicine, Bangkok, Thailand

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BMC Public Health 2013, 13:571  doi:10.1186/1471-2458-13-571

Published: 11 June 2013



Indonesia has had more recorded human cases of influenza A H5N1 than any other country, with one of the world’s highest case fatality rates. Understanding barriers to treatment may help ensure life-saving influenza-specific treatment is provided early enough to meaningfully improve clinical outcomes.


Data for this observational study of humans infected with influenza A H5N1 were obtained primarily from Ministry of Health, Provincial and District Health Office clinical records. Data included time from symptom onset to presentation for medical care, source of medical care provided, influenza virology, time to initiation of influenza-specific treatment with antiviral drugs, and survival.


Data on 124 human cases of virologically confirmed avian influenza were collected between September 2005 and December 2010, representing 73% of all reported Indonesia cases. The median time from health service presentation to antiviral drug initiation was 7.0 days. Time to viral testing was highly correlated with starting antiviral treatment (p < 0.0001). We found substantial variability in the time to viral testing (p = 0.04) by type of medical care provider. Antivirals were started promptly after diagnosis (median 0 days).


Delays in the delivery of appropriate care to human cases of avian influenza H5N1 in Indonesia appear related to delays in diagnosis rather than presentation to health care settings. Either cases are not suspected of being H5N1 cases until nearly one week after presenting for medical care, or viral testing and/or antiviral treatment is not available where patients are presenting for care. Health system delays have increased since 2007.

Influenza A virus H5N1; Delivery of health care; Virulence; Indonesia