This study represents the first analysis of health system delays in the clinical management of human H5N1 influenza and shows that, in Indonesia, delays result largely because of health service limitations rather than patients delaying seeking care. We found that delays in treatment are principally a function of health services rather than delays in patients seeking care. Even in rural settings, patients present soon after symptoms develop which suggests that public awareness campaigns regarding H5N1 and the need for early presentation hve been successful. Early treatment with oseltamivir is recommended, and delays beyond 48 hours after symptom onset result in worse outcomes [3, 6, 7]. We found that the median time from health service presentation to antiviral drug initiation was 7.0 days in Indonesia, and case fatality rates remain high despite the use of oseltamivir treatment. The delayed initiation of treatment appears to be an important contributor to the especially high case fatality rates documented from Indonesia .
Delays in the initiation of influenza specific antiviral drugs may be the result of either a lack of drugs at sites of care or a lack of clinical suspicion of H5N1 by the treating health care workers. The latter seems most likely, and concurs with other reports suggesting better clinical outcomes in patients who are part of clusters of cases where clinical suspicion is likely to be high . Furthermore, H5N1 case-finding has not focused on the identification of asymptomatic or mild cases of H5N1 virus infection [4, 9–11]. Moreover, the Indonesian Ministry of Health has distributed stockpiles of drugs to all provincial health offices, referral hospitals, and other hospitals. Seven million capsules of oseltamivir have already been distributed to health center level in accordance with the Indonesia Centre for Disease Control (CDC) guidelines .
A low clinical suspicion of disease by health care workers likely remains an important impediment to early diagnosis, virological confirmation, and appropriate treatment initiation . The signs and symptoms during the first two days of disease in cases reported here were mostly non-specific. This nonspecific clinical presentation of influenza A (H5N1) disease raises challenges. The differential diagnosis of cases may include other influenza-like illnesses, dengue, or typhoid , to the exclusion of influenza A (H5N1). In an earlier report, only 12% of influenza H5N1 cases were initially diagnosed as having influenza H5N1 .
Early treatment is important in achieving clinical success and a high index of clinical suspicion is necessary for patients presenting, sometimes with non-specific symptoms, to clinical settings. For any benefits to accrue from prompt presentation for medical care, clinical suspicion needs to be raised amongst physicians and other care-givers. Whilst patients presented earlier for medical care prior to 2008, perhaps because of the significant investments in community awareness of avian influenza , increasing delays in viral testing and the initiation of appropriate treatment, irrespective of type of health care setting, appear to be increasing. The late health care seeking behaviour in 2005-2007 may have resulted from a low level of awareness in population . By 2009, research suggests, community awareness in Indonesia had increased .
We found that those presenting to rural health services and public health centres had lower fatality rates than those presenting to other sites of care (Table 2). This was a surprising finding. A possible explanation may be that patients with an obviously poor prognosis may have been referred to higher level health facilities without being formally admitted to rural health centres or public health centres.
There are some limitations in our study. Whilst we analysed data from 124 out of 171 cases, we could not collect data for the remaining cases due to administrative challenges. Since the missing cases mostly are from the island of Sumatra, these results may not be generalizable to health care services delays in a a different geographic area.
Although we found that the median time from presentation to antiviral drug initiation was 7.0 days, some questions remain unanswered. For example, we have insufficient data to determine which health care providers are limited in their capacity to provide prompt treatment for patients, and why. Most patients (55%) first seek medical treatment at a physician’s office or clinic and go to the hospital when the disease becomes severe. But we are not able to offer insights into how the movement of patients between health care settings influences care provision in terms of delay in initiation of treatment. Nonetheless, we believe our analyses provide important insights on delays in presentation from symptom onset, to viral testing, and to initiation of treatment in Indonesia.