Bob

Bob
Wahyudin
Wahyudin
Respirology division
BIKA FK-UNHAS
Current Phase of Alert
http://www.who.int/csr/disease/avian_influenza/phase/en/
 A new
A new emerging-potentially-pandemic
emerging-potentially-pandemic disease
disease 


“ Suatu penyakit menular yg

disebabkan oleh virus influenza yg
ditularkan oleh unggas yg dapat
menyerang manusia”

DEPKES RI. Pedoman penanggulangan flu burung pada manusia, 2004

 M2

Struktur Influenza Virus A

 <10 10-19 20-29 30-39 40-49 ≥50

WHO Weekly epidemiological report 2006; 81:249-60

WHO Weekly epidemiological report 2006; 81:249-60
WHO Weekly epidemiological report 2006; 81:249-60
 Keterangan

Kasus confirmed: 1 orang

Lokasi : Makassar
Kasus probable:9orang
Lokasi : Makassar 7 orang
Takalar 1 orang
Maros 1 orang
Kasus Suspek: 9 orang
Lokasi : Maros 1 orang
Makassar 7 orang
Bulukumba 1 orang
Cara penyebaran

-Mengisap percik yg infeksius

- Kontak langsung
- Kontak tdk langsung (muntah dll)

saluran napas, mata

Binatang ke manusia

Kontak dgn binatang yg sakit (dlm waktu 1 minggu)

Makan atau menyiapkan daging yg terinfeksi
 risiko kurang

Manusia ke manusia
Telah dicurigai pd beberapa clusters
Surveillance di Vietnam 
Strain virus sedang beradaptasi agar bisa
menginfeksi manusia dgn lbh efisien !!!
 Lingkungan ke manusia

Memungkinkan secara teoretis

Menelan atau inokulasi langsung ke hidung/mata

dari air yg terkontaminasi

Kontaminasi dr tangan yg menyentuh muntahan

Pupuk kandang (dr kotoran ayam)

Masa inkubasi

Kisarannya lebih lama dari Human Influenza

1 – 8 hari, Kebanyakan dalam 2 – 4 hari

setelah paparan

Case –to-case interval dalam family clusters

8 – 17 hari
Spektrum klinik

Asymptomatic

ILI (penyakit serupa influenza)

Pneumonia

Gastroenteritis

Ensefalitis akut
Spektrum klinik
ARDS

dema Pneumonia
m ILI berat

Mild-Modr ILI
diare
asimtomatik
kejang
 Faktor risiko
• Penanganan terlambat
• Usia muda
• pneumonia
• leukopenia (sel darah putih kurang)
• limfopenia
 Lekopenia, khususnya lymphopenia
thrombocytopenia
Tes fungsi hati dan fungsi ginjal meningkat

Nyata dan progresif, tapi tak spesifik

Infiltrat: difus, multifocal, patchy, interstitial
Konsolidasi: segmental, lobular dgn air bronchogram
Efusi Pleura
Vietnam
Hongkong
Thailand
 Kapan kita curiga flu
burung?
• semua pasien flu ???
• semua pasien pneumonia ???
 Kasus tersangka
• demam >380C
• batuk, pilek, nyeri tenggorok
DAN,
Dalam seminggu terakhir terdapat salah satu :
• Kontak erat (1 meter) dgn pasien suspek, probable atau confirmed
• Kontak dgn unggas/burung liar atau kotorannya di daerah dimana
terdapat kasus suspek/confirmed pada unggas/manusia dalam satu
bulan terakhir
• Konsumsi produk unggas mentah/setengah matang di daerah dimana
terdapat kasus suspek/confirmed pada unggas/manusia dalam satu
bulan terakhir
• Kontak erat dgn binatang selain unggas (mis; kucing, babi) yg
terbukti terinfeksi H5N1
• bekerja di lab yang mengelola spesimen virus flu burung
 Kasus mungkin
• kasus tersangka DAN salah satu:

- foto Ro pneumonia + sesak

- uji lab positif untuk antibodi H5N1 Ab

  krn penyakit pernapasan akut, yg secara epidemiologik (tempat, waktu,

paparan) berhubungan dgn kasus probable/confirm
 Kasus terbukti

seseorang dengan >1 berikut:

• biakan virus influenza A/H5 positif
• PCR influenza A/H5 positif
• peningkatan titer 4-kali lipat untuk
antibodi specifik H5 pd masa
konvalesens dibanding masa akut
 TATA LAKSANA

• Istirahat
• Respiratory care
• Antivirus  Oseltamivir (DOC)
• Antibiotik bila perlu
• Vitamin
• Imunomodulator
• Steroid: prednisolone 2 mg/kgBB/hari 
kontroversial
Antiviral
Neuraminidase inhibitor:
Zanamivir (Relenza)  Inhaler
Oseltamivir (Tamiflu)  oral (DOC)
Peramivir (investigational)

Harus diberikan dalam 48 jam pertama !!

Recent study in children (Japan):

“Tamiflu may be linked to risk for self-injury
and delirium”
http://www.medscape.com/viewarticle/547783
 DOSIS OSELTAMIVIR

Pencegahan:
Pencegahan:
1 x 75 mg selama > 7 hari

Terapi: (durasi paling sedikit 5 hari)

Terapi:

Anak: BB < 15 kg: 2 x 30 mg

15 – 23 kg: 2 x 45 mg
23 – 40 kg: 2 x 75 mg
> 40 : dosis dewasa

Dewasa: 2 x 75 mg
 Kapan dipulangkan ?

• Dewasa: 7 hari setelah demam menghilang

• Anak: 21 hari setelah demam menghilang

Infection control (1)

• use high efficiency mask in addition to droplet and

contact precautions
• a negative pressure room – if available – is
recommended
• isolate the patient to a single room, if not available
bed should be placed >1m apart, preferably
separated by a physical barrier (curtain, partition)
• appropriate Personal Protective Equipment (PPE)
for all those entering patients room, consist of
mask, gown, face shield or goggles, and gloves

WHO Guidelines Feb 2004

Infection control (2)

• limit the number of Health Care Workers (HCWs)

who have direct contact with the patient(s), these
HCWs should not look after other patients, they
all properly trained in infection control
precautions
• the number of hospital employees (cleaners, lab
personnel) should also be limited
• restrict the number of visitors and provide them
with appropriate PPE
• dispose of waste properly
• linen and reusable materials should be handled
separately and disinfected

WHO
Case management (1)

• if not requiring hospitalization, educate patient and

family on personal hygiene and infection control
• if clinically indicated, hospitalize patients
• take respiratory & blood specimens for lab testing
for influenza and other infections
• treat with neuromidase inhibitor, such as oseltamivir
• provide supportive care, monitor oxygen saturation
and treat desaturation with supplemental oxygen as
required

WHO Guidelines Feb 2004

Case management (2)

• take respiratory and blood specimens serially to

check for possible bacterial infection
• consider IV antibiotic therapy to control secondary
bacterial infections as required
• steroids should be used only in the context of
clinical trial
• do not used amantadine or rimantadine because of
the risk of increasing resistance
• do not use ribavirin since no evidence to support its
effectiveness
• avoid salicylates in children<18 years because the
risk of Reye syndrome, instead use paracetamol or
ibuprofen
WHO Guidelines Feb 2004
The next pandemic:
“it’s a matter of time”

Co-ordinator ofWHO's global influenza program.