Endemic and emerging acute virus infections in Indonesia: an overview of the past decade and implications for the future

Figures & data

Table 1. Vaccine-preventable diseases as recommendation from the Ministry of Health Republic of Indonesia, Centers for Disease Control and Prevention, Dutch, Swiss, Singapore’s and Australian perspective.

Retrieval:	October 24 2016
Virus/authority	MoH-RI (1)	CDC (2)	LCR (3)	Swiss TPH (4)	MoH-SG (5)	Australian government (6)
Hepatitis A	No	All travellers	All travellers	All travellers	All travellers	All travellers
Hepatitis B	Yes	Tailored	Tailored^a^,^b	Tailored^a^,^c	Tailored	Tailored (not specified)
Japanese encephalitis	No	Tailored^d	Tailored^e	Tailored^e^,f	Tailored^d	Tailored (not specified)
Measles	Yes	All travellers	All travellers	All travellers	All travellers	All travellers
Rabies	Tailored^h	Tailored^g	Tailored^h	Tailored^i	Tailored^g	Tailored^g

1) Ministry of Health, Republic of Indonesia, retrieved from: http://www.depkes.go.id.

2) Center for Diseases Control and Prevention, Department of Health and Human Service, United States of America, retrieved from http://wwwnc.cdc.gov/travel/destinations/traveler/none/indonesia.

3) Landelijk Coördinatiecentrum Reizigersadvisering (National Coordination Centre for Traveladvise), the Netherlands, retrieved from https://www.mijnlcr.nl (professionals), http://www.lcr.nl (layman).

4) Swiss Tropical and Public Health Institute, Switzerland, retrieved from http://www.safetravel.ch (available in French and German only). Supplemented with data from Bundesamt für Gesundheit BAG, retrieved from http://www.bag.admin.ch/ekif/04423/04428/ (available in German only).

5) Ministry of Health, Republic of Singapore, retrieved from https://www.moh.gov.sg/ and https://www.healthhub.sg/. The latter refers to CDC (2) for vaccine advice.

6) Australian Government, Department of Foreign Affairs and Trade, retrieved from http://smartraveller.gov.au/ No comprehensive travel immunization scheme could be found.

^aFor those having close contact with inhabitants, long-term stay or recreational activities with risk of injury (contaminated blood, non-sterile medical material).

^bImplemented in national vaccination programme since 2011 for all babies (ever since 1989 for specific populations, such as newborns with a hepatitis B carrier mother).

^cImplemented in national vaccination programme for all adolescents 11–15 years of age (vaccine status is checked at 25–29 years of age).

^dFor those spending ≥1 month in endemic areas during transmission season (including 1) long-term travellers, recurrent travellers, expatriates likely to visit rural/agriculture areas, 2) extensive outdoor (e.g. camping and farming), 3) staying in accommodation without air conditioning, screens, or bed nets.

^eFor those spending ≥1 month on rural endemic area in close contact with rice fields and pig population.

^fDuring rainy season only.

^gFor those involved in outdoor activities, working with or around animals, taking long trips/moving into Indonesia, children.

^hFor those with frequent and/or possible unnoticed exposure to domestic or wild mammals.

ⁱFor those with risk of high exposure (hikers, cyclists, cave explorers and zoologists) and those spending more than 3 months in country.

Table 2. Overview of the major discussed viruses including epidemiology, symptomatology, protective actions, and diagnostics.

Virus	Incidence^a	Transmission via^a	Incubation^a	Symptomatology^a	Protective actions^a	Diagnostics
DENV	40:100 000 (MoH-RI, 2014)	Mosquito (Aedes spp.)	5–8 d	High fever accompanied with headache, retro-orbital, joint and/or muscle pain, rash, bleeding tendency.	Avoid mosquito bites^b	Acute phase: RT-PCR on plasma, antigen (NS1) based ELISA or rapid test. Convalescent: IgM/IgG antibodies^c.
WNV	No data available	Birds (reservoir), mosquito (Culex spp.)	2–14 d	In 20% of cases a mild course: fever, headache, myalgia, rash, and lymphadenopathy <1% develops neurological symptoms.	Avoid mosquito bites^b	Acute phase: RT-PCR on plasma or liquor, virus culture, immunohistochemistry on tissue. Convalescent: IgM/IgG antibodies on serum or liquor^c.
JEV	7.1:100 000 (children <10 years, Bali) (Kari et al. 2006)	Mosquito (Culex spp.)	6–16 d	In 1% fever, headache, altered mental state, convulsions (suspected meningitis, encephalitis or acute flaccid paralysis).	Vaccination, avoid mosquito bites^b.	Acute phase: IgM antibodies on serum or liquor. Repeat on convalescent samples when high suspicion. Confirm with virus neutralization test. Convalescent: IgM/IgG antibodies^c.
CHIKV	0.002 (MoH-RI, 2014)– 22 (MoH-RI, 2009) per 100 000	Mosquito (Aedes spp.)	2–4 d	Acute febrile illness, maculopapular rash and joint pain as key symptom.	Avoid mosquito bites^b	Acute phase: RT-PCR on plasma, virus culture. Convalescent: IgM/IgG antibodies.
MV	5:100 000 (MoH-RI, 2014)	Human-human (aerosols)	7–14 d	Fever, cough, coryza, conjunctivitis, Koplik’s spots. Characteristic erythematous and maculopapular rash.	Vaccination	Acute phase: RT-PCR on plasma and/or throat swab, urine. Convalescent: IgM/IgG antibodies (note: possible positive due to previous vaccination).
RABV	17:100 000 (MoH-RI, 2014)	Dogs, monkeys, bats bite/scratch or licking damaged skin.	As less as a few days	Flu-like symptoms, progressive to cerebral dysfunction, agitation, and eventual death when untreated.	Vaccination (no need of immunoglobulins after bite/scratch), avoid contact with animals. When indicated: adequate treatment with immunoglobulins (passive antibodies).	Test euthanized animal that possibly transmitted RABV (brain sample); concurrently test saliva (RT-PCR or virus isolation), serum, spinal fluid (antibodies), and skin biopsies in nape of the neck (antigen).
HANV	No data available	Rodents (rats and mouse)	2–4 weeks (7 d was reported)	Flu-like symptoms, high fever, bleeding tendency, kidney injury.	Pest control, avoid contact with faeces/urine of rodents (via food or by breathing in virus-containing particles).	Acute phase: RT-PCR. Convalescent: IgM/IgG and confirm with virus neutralization.
AI	No data available	Poultry	2–5 d	Conjunctivitis, influenza-like illness sometimes accompanied by gastro-intestinal symptoms and respiratory illness.	Avoid contact with possible infected poultry. Preventively administer influenza antivirals.	RT-PCR on swab of upper respiratory tract (nose or throat).
HAV	No data available. Note: high seroprevalence (up to 100% in elderly).	With faeces contaminated food, water, surfaces, etc. (faecal-oral).	15–50 d	Fever, fatigue, loss of appetite, gastro-intestinal symptoms, jaundice, dark urine. Below 6 years of age: 70% asymptomatic.	Vaccination	Acute: IgM on blood. Occasionally RT-PCR on blood or faeces. Convalescent: IgM/IgG on blood.
Influenza	No data available	Human-human via droplets	1–4 d	Abrupt onset of respiratory signs and symptoms, such as fever, myalgia, headache, and malaise).	Yearly flu vaccine	When indicated: RT-PCR on swab of upper respiratory tract (nose or throat).

^a(n) refers to publication. Where MoH-RI is stated, information from Ministry of Health, Republic of Indonesia was used. Assumed population of 250 × 10⁶.

^bTo avoid mosquito bites: use insect repellent (such as DEET), wear proper clothing (long sleeves, pants, etc.) and reduce exposure to mosquitos during peak biting hours (i.e. for Aedes mosquito: early in morning and before dusk).

^cKnown cross-reactivity in flavivirus essays, interpret with care.

Figure 1. Map of Indonesia with location overview of the discussed cohort studies conducted or reported from 2006 until May 2016 - not including case reports and/or export cases.

Figure 2. Trends in ProMED-mail and Ministry of Health Republic of Indonesia for the reporting of chikungunya, rabies and avian influenzain Indonesia Reporting up till 21st October 2016. Source data ProMED-mail available as supplementary data 2. Restricted to human cases (both laboratory confirmed and unconfirmed), not including summarizing outbreak reports. **indicates no data available.

Figure 3. Rabies outbreak heat map to demonstrate the benefit of combining Ministry of Health and ProMED-mail data.

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