title: Human influenza A H5N1 in Indonesia: health care service-associated delays in treatment initiation.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.forename: Wiku
authors.initials: W
authors.lastname: Adisasmito
authors.forename: Dewi Nur
authors.initials: DN
authors.lastname: Aisyah
authors.forename: Tjandra Yoga
authors.initials: TY
authors.lastname: Aditama
authors.forename: Rita
authors.initials: R
authors.lastname: Kusriastuti
authors.lastname: Trihono
authors.forename: Agus
authors.initials: A
authors.lastname: Suwandono
authors.forename: Ondri Dwi
authors.initials: OD
authors.lastname: Sampurno
authors.lastname: Prasenohadi
authors.forename: Nurshanty A
authors.initials: NA
authors.lastname: Sapada
authors.forename: M J N
authors.initials: MJ
authors.lastname: Mamahit
authors.forename: Anna
authors.initials: A
authors.lastname: Swenson
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Dreyer
authors.forename: Richard
authors.initials: R
authors.lastname: Coker
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D053124:Influenza A Virus, H5N1 Subtype; D007251:Influenza, Human / Q000453:epidemiology* / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D014944:World Health Organization