For the crack medical team specialising in human avian influenza cases at the East Java Provincial Hospital in Surabaya, Indonesia, Pucang market represents their worst fear.
The crowded market, tucked away on a Surabayan side street, is like thousands of others throughout Indonesia, with its handful of stalls that sell raw chicken parts and live birds. Much of the slaughtering is done on the spot, with feathers flying, and blood and bird entrails covering the floor.
In conversations with the chicken sellers and their customers, IRIN could find none who expressed concern about the dangers of avian flu, or the potential of a human pandemic developing.
“I’ve never been frightened of bird flu,” Maryati, a chicken-seller, told IRIN, while cutting up a bird. “I’ve also heard about cases of human avian flu but I’m not worried.”
It is this sentiment regarding the dangers of avian flu that makes doctors at the provincial hospital particularly worried.
Specialist medical team
he medical team that treats human avian flu cases has had notable success. Since April 2006, the unit has treated 12 suspected cases of human avian flu. Four turned out to be the real thing, and they were able to save two - a commendable achievement in a country in which, as of 14 December, there have been 115 cases of human avian influenza, with 92 people (80 percent) dying, according to the World Health Organization (WHO).
The medical team includes a lung specialist, a paediatrician, an anaesthetist, a clinical pathologist, a microbiologist and specially-trained nurses, and has high-tech isolation rooms that can accommodate up to six patients, with negative air pressure and biohazard protection. It is considered among the best in the country.
“But we are downstream,” said Teguh Sylvaranto, vice-director of medical services at the 1,550 bed teaching hospital, stressing that the top priority is to contain avian influenza at its source. “The most important issue is poultry and containment of the influenza in the communities,” he said. “Prevention is the most important factor in dealing with avian flu in humans.”
Avian flu threat real
Photo: Brennon Jones/IRIN
|A specially-trained nurse (wearing full-biohazard protection) who works in the isolation unit at the East Java Provincial Hospital. Indonesia, December 2007.|
Indonesia ranks amongst a handful of countries worldwide in which highly pathogenic avian influenza is deeply entrenched, and the danger of a human pandemic is a major concern. “Hospitals will be completely swamped should a significant outbreak of human avian influenza cases occur,” Jonathan Agranoff, the UN Avian Influenza and Pandemic Preparedness Coordinator for Indonesia, told IRIN. “We have been trying to get this message across about the potential for a human tsunami.”
“Yes, of course, it’s a big problem,” Sylvaranto told IRIN, when asked if the medical community in East Java Province (population 37 million) is prepared for a modest increase in human avian flu cases, or a full-scale pandemic. “We can’t handle it [a full-scale pandemic]. It is impossible.”
He noted with pride that his medical team made its expertise available to 11 other hospitals in the region and had annual avian influenza training sessions in district hospitals. “But these district clinics don’t have specialists or isolation units or biohazard protection,” he said. “They can’t manage, they don’t have the ventilators.”
Shortage of medical equipment
“Even this hospital, the best, does not have enough isolation units, biohazard equipment, respirators and ventilators, he said. “And you know the cost of treatment? It is an average of 100,000,000 rupiah per patient (US$10,600) which the government has paid up until now.”
Sylvaranto stressed the critical shortage of ventilators, saying that in all of Indonesia, with 245 million people, there are only about one million, and in Surabaya only 200 or so. “We have 40,” he said. “There’s a shortage of hardware.”
“We know of the possibility of a pandemic, but we can just do what we can do,” he said, concluding: “The most important way to deal with a possible pandemic is to deal with prevention - early detection in poultry and early detection, isolation and treatment of human cases.”
The Indonesian health authorities and the Ministry of Agriculture are doing their best to get the message across about surveillance, early detection and sanitary safeguards. With the support of the US Agency for International Development (USAID), AusAID (the Australian government’s overseas aid programme) and the Japanese Trust Fund, the Ministry of Agriculture, with technical support from the Food and Agriculture Organisation (FAO), has a Participatory Disease Surveillance programme to identify avian influenza in poultry.
Based on periodic interviews with poultry producers in East Java’s 38 districts, 3.5 per cent of those interviewed since the beginning of 2006 said they had evidence of clinical outbreaks in their poultry consistent with highly pathological avian influenza.
Awareness and detection
Photo: Brennon Jones/IRIN
|Maryati, a chicken-seller at Pucang market in Surabaya told IRIN: “I’ve never been frightened of bird flu… I’ve heard about cases of human avian flu but I’m not worried.” Indonesia, December 2007.|
At Pucang market, chicken sellers readily confirmed that an awareness and detection campaign was ongoing. Ikuwan, the owner of the largest poultry shop in the market, told IRIN: “Government representatives come around from time to time to inform us about avian flu outbreaks and that culling has occurred in the region.” He also said the agricultural department comes around and sprays disinfectant and tells us each time that the chickens should be well cooked, adding: “They always ask us if we have sick chickens.”
“Sometimes we do have sick chickens,” said Ruserente, a chicken seller who goes by motorbike to purchase as many as 70 birds a day from different communities. “When they die we just throw them in the rubbish bin.”
The UN’s Agranoff said: “The core problem is that people’s day-to-day livelihoods are more important than safeguarding and planning for the future.”
Mixing of deadly strains
He raises a particular concern about Pucang market where a variety of different kinds of poultry from disparate locations are intermixing daily. “The virus has been making great progress,” he said. “In every village now a different strain of the virus can be found and there is no common vaccine.” He said crowding all these birds together in one site has the potential for introducing new strains of the deadly avian influenza virus.
Chicken seller Maryati who is about to close shop adds a final coda to the state of avian influenza awareness and compliance. When asked whether she follows the recommended procedures of washing her hands and cleaning carefully after such close contact with chickens, she says: “No, I’m not washing my hands. I’m just going straight home.”