Indonesia has been in the spotlight as having the highest number of bird flu infections and fatalities in the world since the deadly virus first appeared here in 2005. And even though Indonesia is said to pose a "moderate risk" in terms of HIV/AIDS infections, the failure of preventive measures suggests a future boom in HIV infections.
But these two high-profile diseases are not the only major concerns of the archipelago. Indonesia still has to deal with tuberculosis -- the same old problem the WHO named (in 2002) as the second-highest cause of death in the country after stroke and cardiovascular diseases -- and dengue fever, which is an annual threat, especially during rainy season.
This report looks at the state of these four microorganism-caused diseases in 2008, along with the progress the government has made in tackling them.
BIRD FLU
Since the deadly H5N1 virus was first found in humans in Indonesia in 2005, the country has recorded the greatest number of bird flu infections and fatalities globally.
As of Dec. 12 this year, Indonesia had recorded 139 cases of infection and 113 fatalities, with a case fatality ratio of 81.3 percent -- accounting for nearly half the global figures of 389 infections and 246 deaths.
In the past two years, however, there has been a declining trend in both infection and fatality rates, which were at 20 and 13 in 2005, respectively; 55 and 45 in 2006; 42 and 37 in 2007; and 21 and 19 in 2008.
So far, H5N1 infections in humans have been found in 12 of the country's 33 provinces, although seven of these provinces did not report any cases in the past year. The provinces with the highest number of infections were, in order, Jakarta, West Java, Banten, Central Java and North Sumatra.
Despite the declining trend, the specter of a rise in infections and fatalities still looms, with live poultry widely found in residential backyards and traditional markets.
The National Committee for the Bird Flu and Pandemic Preparedness Program recently said that 50 percent of poultry sold in live bird markets in Jakarta, Banten and West Java were infected by the bird flu virus and the government would turn its attention to these markets as part of its prevention campaign.
The frequency of infections is also feared to lead to a pandemic, which could sweep through the population as soon as the H5N1 bird flu virus -- now only transmittable from bird to human -- mutates into a human-to-human transmittable virus.
Fearing the huge numbers of deaths and devastating economic effects such a pandemic may cause, the government, with its foreign partners, has begun a number of preventive programs, including pandemic simulations in a number of regions this year, the latest taking place in Makassar, South Sulawesi.
Recently, in Geneva, Health Minister Siti Fadilah Supari again proposed that WHO replace its current Global Influenza Surveillance Network (GISN) with a "more equal and transparent" system that includes a standard Mutual Transfer Agreement.
The minister believes that under GISN, virus samples collected by WHO have been used by large vaccine companies in developed countries to produce vaccines that are too expensive for developing countries.
HIV/AIDS
Reflecting global trends, the number of people living with HIV/AIDS in Indonesia has continued to increase each year. The number of reported cases may not be growing significantly, but it is believed to be just the tip of the iceberg.
According to the Health Ministry, there were 21,151 reported cases of people with HIV/AIDS in Indonesia as of September this year. Of these, 72 percent had AIDS and 21 percent died. The figure represents a 19 percent increase from 17,207 in 2007.
But the ministry estimates the real figure now stands at 270,000, about 15 percent of who have developed AIDS. This is a significant rise compared with the estimate of 193,000 in 2006 and 110,000 in 2002.
Provinces with the highest numbers of reported cases are Papua, Jakarta, West Java, East Java and Bali. While Jakarta has the largest number of AIDS patients, Papua has the recorded the highest number of people living with HIV.
In Indonesia, HIV/AIDS infections are still concentrated among "high-risk" groups, comprising injecting drug users, members of the transgender and transvestite community, female sex workers, homosexuals and men who frequently visit sex workers. About 48.5 percent of the reported infections were transmitted via sexual intercourse and 42.8 percent via injecting drug use.
However, campaigns to prevent the spread of the disease, including promoting the use of condoms and sterile needles, are said to have failed. There is fear that a greater proportion of the population will become infected, especially with most of those already infected appearing to be either married to or having sexual relations with low-risk people.
Indonesia is also struggling to provide proper medical treatment for people with HIV/AIDS because of a shortage of anti-retroviral (ARV) drugs in hospitals over the past three years. The causes are the same as always: lack of funding and poor drug distribution management.
Discrete, incomplete treatment may potentially lead to HIV resistance to first-line drugs and force patients to take the more expensive second-line drugs.
Head of the contagious diseases division at the Indonesian Doctors Association (IDI), Pandu Riono, has suggested the government stop subsidizing ARV drugs for wealthy patients to prevent the funding shortfall.
To curb the spread of the disease, Pandu said it was necessary to apply all preventive measures recommended by the 17th international meeting on AIDS in Mexico last August, including improving access to laboratory tests and proper healthcare, vaccinations, circumcision and the use of ARV drugs to prevent infection.
TUBERCULOSIS
Tuberculosis (TB), a deadly infectious disease caused by mycrobacteria, is no longer as common as it was in the 1990s, when TB prevalence reached its peak of 438 cases per 100,000 people, and 90 out of every 100,000 people died from the disease each year.
The rate of infection has been steadily declining and, according to the 2008 WHO report, now stands at 253 cases per 100,000 people with a mortality rate of 38 per 100,000 people each year. This means there are now 580,000 people infected with TB and 87,000 TB-related deaths annually.
Despite the decline, Indonesia still has the third-highest number of TB cases in the world after China and India, according to the report, based on 2006 data, which shows the incidence rate in 2006 declined by 2.4 percent from the year before.
The WHO report indicates Indonesia managed to exceed its case detection target of 70 percent for the first time in 2006 and its treatment success target of 85 percent under the WHO-recommended Directly Observed Therapy Shortcourse (DOTS), with the national case detection and treatment success rates at 73 percent and 91 percent, respectively.
But the detection rate also means there are tens of thousands of people who do not know they are infected with TB and that they can easily infect others.
DOTS is the core part of WHO's Stop TB Strategy (launched in 2006), recommended to countries tackling a TB problem. Patients undergoing DOTS are observed by a medical professional while taking medication to ensure the correct dosage of the drug is taken at the right time, as discrete and incomplete medication is often the reason for the failure of TB treatment.
In Indonesia, 40 percent of TB patients fail to complete their medication mostly because of low awareness of the need to finish the cycle. The Health Ministry said only 30 percent of hospitals here have been using DOTS.
This problem has sparked concerns over the expanding rate of anti-TB drug resistance, with MDR-TB accounting for 2 percent of new TB cases in 2004. MDR-TB is a form of TB that does not respond to the standard six-month treatment using first-line drugs, i.e., isoniazid and rifampicin.
An MDR-TB patient needs second-line drugs, which are typically more expensive, have more adverse side effects and require a longer medication period. XDR-TB, which is resistant to some second-line drugs, has not yet been detected in Indonesia.
DENGUE FEVER
As of November, Indonesia had recorded 101,646 cases of dengue fever this year, a surprise 32 percent decrease from 149,321 cases in the same period last year, according to the Health Ministry.
The incidence rate of the disease, which is typical for tropical urban areas, has thus also declined to about 44 cases per 100,000 people this year from 72 cases per 100,000 people in 2007, while the case fatality ratio has dropped slightly to 0.73 percent from 1 percent last year.
This decline, if it is correct and continues until the end of the year, will be the first drop after five consecutive years of rises in the number of cases. Overall, Indonesia has been experiencing an almost consistently rising trend in dengue fever infections since they were first recorded in 1968, when the case fatality ratio was still as high as 40 percent.
With the number of cases usually reaching its peak between January and March, it is likely the 2008 figure for dengue fever cases will indeed end up being lower than last year's.
The government claims that the drop in dengue fever cases this year is a consequence of its anticipative measures, which include improving epidemiological surveillance, improving the quality of dengue services management, intensifying vector control and providing quick responses to "extraordinary occurrence" cases.
But Pandu Riono of the IDI said the drop was very probably due to the cycle in the population growth of Aedes aegypti, the mosquito that is the species vector to dengue fever.
During the past 40 years, in about every decade showing a rising trend in cases, there has always been one year with a significant drop.
If this drop is indeed part of this cycle, then next year Indonesia will likely see another rise in infections.
As well as the disease's cyclic pattern, the threat of global warming could also boost the number of dengue fever cases in the future, as vector mosquitoes will be able to expand their territory to the highlands, which were once too cool for them to survive, but are now growing warmer.
There are no data yet to confirm this theory, but the spread of malaria into the Papuan highlands (where malaria had never previously been recorded) provides a good example of the possibility.
Former director general for disease control at the Health Ministry, I Nyoman Kandun, said early this year that the temperature increases could shorten the incubation period of the dengue virus in the bodies of both mosquitoes and humans. This could subsequently lead to more vector mosquitoes and, hence, more dengue fever cases.
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