Physician's knowledge, attitudes, and practices regarding seasonal influenza, pandemic influenza, and highly pathogenic avian influenza A (H5N1) virus infections of humans in Indonesia

Indonesia has reported highest number of fatal human cases of highly pathogenic avian influenza (HPAI) A (H5N1) virus infection worldwide since 2005. There are limited data available on seasonal and pandemic influenza in Indonesia. During 2012, we conducted a survey of clinicians in two districts in western Java, Indonesia, to assess knowledge, attitudes, and practices (KAP) of clinical diagnosis, testing, and treatment of patients with seasonal influenza, pandemic influenza, or HPAI H5N1 virus infections. Overall, a very low percentage of physician participants reported ever diagnosing hospitalized patients with seasonal, pandemic, or HPAI H5N1 influenza. Use of influenza testing was low in outpatients and hospitalized patients, and use of antiviral treatment was very low for clinically diagnosed influenza patients. Further research is needed to explore health system barriers for influenza diagnostic testing and availability of antivirals for treatment of influenza in Indonesia.


Physician's knowledge, attitudes, and practices regarding seasonal influenza, pandemic influenza, and highly pathogenic avian influenza A (H5N1) virus infections of humans in Indonesia
Most human cases of HPAI H5N1 in Indonesia have occurred in the western part of the main island of Java. The majority of HPAI H5N1 human cases have been associated with poultry exposure such as direct or close contact with sick or dead poultry or visiting a live poultry market, although limited, non-sustained human-to-human HPAI H5N1 virus transmission has likely occurred. 1,[3][4][5][6][7][8] Mortality from HPAI H5N1 virus infection in Indonesia has been associated with late presentation to health care and hospitalization, delayed clinical diagnosis of HPAI H5N1, and late initiation of antiviral treatment. 5,[9][10][11] In addition to sporadic human infections with HPAI H5N1 virus in Indonesia, seasonal influenza A and B viruses circulate among people.
Limited surveillance data suggest that seasonal influenza viruses circulate year-round in Indonesia, with increased activity during November to March, the rainy season months. [12][13][14][15] However, data on seasonal influenza disease burden in Indonesia are limited. In addition, there are no published data on the impact of the 2009 H1N1 pandemic in Indonesia.
To assess clinicians' familiarity with clinical management of influenza patients in Indonesia, we conducted a survey of outpatient and hospital-based physicians in two districts in western Java: East Jakarta and Bogor. The objectives of the survey were to determine the *Joint 1st author with equal contribution. knowledge, attitudes, and practices (KAP) of physicians about clinical diagnosis, testing, and treatment of patients with seasonal influenza, pandemic influenza, or HPAI H5N1 virus infections. In both of these districts, human cases of HPAI H5N1 virus infection had been identified as recently as 2009 prior to implementation of the survey. In this report, we summarize the findings of the KAP survey.

| MATERIALS AND METHODS
We conducted a cross-sectional survey of practicing clinicians in western Java, Indonesia. The study population was comprised of outpatientand inpatient-based physicians providing medical care for adult and/ or pediatric patients at government or private sector health facilities in Bogor (peri-urban and rural communities) and East Jakarta (primarily urban) districts. We utilized a list of all registered physicians from the District Health Offices in the two districts and randomly sampled general primary care clinicians and subspecialists from the list for recruitment. A standardized data collection instrument was developed with 119 questions about influenza KAP. The instrument was piloted with clinicians in Depok, West Java, to confirm the wording, flow, and time spent for each respondent. Study personnel were trained to use the instrument. Following verbal informed consent from clinician participants, face-to-face interviews were conducted in Bahasa Indonesia, the Indonesian language, during March to June 2012. We collected demographic information and data on participants' clinical practice setting, knowledge of influenza signs, symptoms, and complications, outpatient and inpatient influenza diagnosis, testing, treatment, and preventive measures for seasonal influenza, pandemic influenza, and HPAI H5N1, including the H5N1 suspect case definition used in Indonesia. The suspect case definition for HPAI H5N1 in Indonesia includes acute lower respiratory tract illness with fever and recent exposure to poultry or suspected human cases within 7 days of illness onset and is based upon the World Health Organization (WHO) suspect H5N1 case definition. 16,17 Clinicians were asked about a series of clinical signs and symptoms that are commonly associated with influenza to see whether they thought a particular sign or symptom was related to seasonal influenza, pandemic

| Demographic characteristics
Of 1 725 registered physicians, 1 130 (66%) physicians were approached in the two districts and of those 554 (49%) were enrolled in the survey ( Table 1). The 595 physicians who were not approached to participate did not have a valid address for contact or were no longer practicing physicians. Of the 554 physicians enrolled, the median age was 41 years (interquartile range (IQR): 32-50 years), 42% were male, 43% were from East Jakarta; 88% were general practitioners and 12% were specialists including pediatricians (3%), internists (3%), and obstetricians/gynecologists (2%). Overall, 71% of physicians reported providing outpatient care only, 2% provided inpatient care only, and 27% provided both outpatient and inpatient care.

| Reported knowledge about clinical features of influenza
Clinical signs and symptoms associated with seasonal influenza in outpatients reported by physicians were generally similar for the two districts. Fever (96%), cough (85%), runny nose (75%), nasal congestion (64%), and sneezing (58%) were reported by physicians to be associated with seasonal influenza in outpatients (Table 2). Physicians reported that shortness of breath (24%) was a symptom for hospitalized seasonal influenza patients more frequently than in outpatients (7%).
For pandemic influenza [influenza A(H1N1)pdm09], fever, cough, muscle ache, runny nose, and nasal congestion were less frequently reported by physicians as being signs and symptoms in both outpatients and hospitalized patients ( Table 2).

| Knowledge of seasonal influenza highrisk groups
Physicians correctly identified children aged <5 years old (92%), immunosuppressed persons (64%), and elderly (64%) as high-risk groups for seasonal influenza-associated complications. However, 41% correctly identified persons with chronic lung disease and pregnant women, and few participants (17%) identified persons with heart disease as high-risk groups for influenza-associated complications. 76% of physicians incorrectly identified children aged >5 years as a highrisk group for influenza complications. Overall, the findings were similar for participating physicians in the two districts (data not shown).

| Practices related to influenza diagnosis, testing, and treatment
Among outpatient-based physicians, over 90% reported ever making a clinical diagnosis of seasonal influenza (not laboratory-confirmed), but only 2% reported having diagnosed pandemic influenza, and 4% reported having diagnosed a case of suspected HPAI H5N1 (  (Table 3). Among physicians providing care for outpatients, the most common reported reason that testing was not ordered for seasonal influenza in outpatients was because testing was thought to be unnecessary, too expensive, or was unavailable.
Medicines for relief of symptoms and antibiotics were the most frequently reported treatment prescribed for influenza patients (Table 3). Very few physicians reported prescribing antiviral treatment for seasonal influenza in outpatients (3%) or hospitalized patients (4%).

| Knowledge and practice related to Influenza non-pharmaceutical preventive measures
When asked about ways to prevent influenza, more than half of physicians reported that they recommended that outpatients they diagnosed with suspected seasonal influenza should use a face mask (57%), cover their nose and mouth when sneezing and coughing (44%), and wash hands frequently (38%), but only 13% reported that they would tell the patient to avoid close contact with non-ill persons. Forty-eight percent of physicians reported that they recommended that outpatients diagnosed with suspected HPAI H5N1 should cover their nose and mouth when coughing and sneezing, and wear a face mask, and 57% recommended avoiding close contact with other persons.
For hospitalized patients diagnosed with seasonal influenza, physicians reported recommending that the patient should use a face mask (76%), cover the nose or mouth when sneezing or coughing (67%), and wash their hands frequently (46%) to reduce influenza virus transmission to others (Table 4). However, only 26% physicians reported recommending that the patient should limit interactions and avoid close contact with healthy persons to prevent spread of influenza.
Only 6 (1%) physicians reported diagnosing a hospitalized patient with suspected HPAI H5N1, and of those, only 3 (50%) recommended that the patient should wear a face mask and avoid close contact with healthy persons to prevent further transmission (

| Practice related to influenza vaccination
Only 11% of all physicians reported they had received influenza vaccination in the previous 12 months. Of those that reported receiving influenza vaccination, 82% reported receiving seasonal trivalent influenza vaccine, and 15% could not recall what kind of influenza vaccine they received.
Reasons reported by physicians for not receiving influenza vaccine included that they believed being vaccinated was not important (47%), they were not interested in vaccination (24%), vaccine was unavailable (19%), vaccine was too expensive (9%), and vaccine was not effective (3%).

| DISCUSSION
In this descriptive survey of physicians providing care for outpatients and hospitalized patients in two districts located in western Java, Indonesia, most physicians reported that they were generally familiar with the signs and symptoms associated with influenza.

| CONCLUSIONS
Overall, a very low percentage of physician participants reported ever diagnosing seasonal influenza, pandemic influenza, or HPAI H5N1 in hospitalized patients. Use of influenza testing was low in outpatients and hospitalized patients, and use of antiviral treatment was very low for clinically diagnosed influenza patients. Further research is needed to explore health system barriers for influenza diagnostic testing and availability of antivirals for treatment of influenza in Indonesia.