title: Factors associated with case fatality of human H5N1 virus infections in Indonesia: a case series.
abstract: BACKGROUND
  Indonesia has had the most human cases of highly pathogenic avian influenza A (H5N1) and one of the highest case-fatality rates worldwide. We described the factors associated with H5N1 case-fatality in Indonesia.
  
  
  METHODS
  Between June, 2005, and February, 2008, there were 127 confirmed H5N1 infections. Investigation teams were deployed to investigate and manage each confirmed case; they obtained epidemiological and clinical data from case-investigation reports when possible and through interviews with patients, family members, and key individuals.
  
  
  RESULTS
  Of the 127 patients with confirmed H5N1 infections, 103 (81%) died. Median time to hospitalisation was 6 days (range 1-16). Of the 122 hospitalised patients for whom data were available, 121 (99%) had fever, 107 (88%) cough, and 103 (84%) dyspnoea on reaching hospital. However, for the first 2 days after onset, most had non-specific symptoms; only 31 had both fever and cough, and nine had fever and dyspnoea. Median time from onset to oseltamivir treatment was 7 days (range 0-21 days); treatment started within 2 days for one patient who survived, four (36.4%) of 11 receiving treatment within 2-4 days survived, six (37.5%) of 16 receiving treatment within 5-6 days survived, and ten (18.5%) of 44 receiving treatment at 7 days or later survived (p=0.03). Initiation of treatment within 2 days was associated with significantly lower mortality than was initiation at 5-6 days or later than 7 days (p<0.0001). Mortality was lower in clustered than unclustered cases (odds ratio 33.3, 95% CI 3.13-273). Treatment started at a median of 5 days (range 0-13 days) from onset in secondary cases in clusters compared with 8 days (range 4-16) for primary cases (p=0.04).
  
  
  CONCLUSIONS
  Development of better diagnostic methods and improved case management might improve identification of patients with H5N1 influenza, which could decrease mortality by allowing for earlier treatment with oseltamivir.
authors.affiliation: Directorate General of Disease Control and Environmental Health, Ministry of Health, Jakarta, Indonesia.
authors.forename: I Nyoman
authors.initials: IN
authors.lastname: Kandun
authors.forename: Erna
authors.initials: E
authors.lastname: Tresnaningsih
authors.forename: Wilfried H
authors.initials: WH
authors.lastname: Purba
authors.forename: Vernon
authors.initials: V
authors.lastname: Lee
authors.forename: Gina
authors.initials: G
authors.lastname: Samaan
authors.forename: Syahrial
authors.initials: S
authors.lastname: Harun
authors.forename: Eka
authors.initials: E
authors.lastname: Soni
authors.forename: Chita
authors.initials: C
authors.lastname: Septiawati
authors.forename: Tetty
authors.initials: T
authors.lastname: Setiawati
authors.forename: Elvieda
authors.initials: E
authors.lastname: Sariwati
authors.forename: Toni
authors.initials: T
authors.lastname: Wandra
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000818:Animals; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D005260:Female; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D053124:Influenza A Virus, H5N1 Subtype / Q000302:isolation & purification / Q000472:pathogenicity*; D007251:Influenza, Human / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011200:Poultry