Avian influenza

Avian influenza
Fact sheet Updated April 2011

Key facts

Avian influenza (AI), commonly called bird flu, is an infectious viral disease of birds. Most avian influenza viruses do not infect humans; however some, such as H5N1, have caused serious infections in people. Outbreaks of AI in poultry may raise global public health concerns due to their effect on poultry populations, their potential to cause serious disease in people, and their pandemic potential. Reports of highly pathogenic AI epidemics in poultry can seriously impact local and global economies and international trade. The majority of human cases of H5N1 infection have been associated with direct or indirect contact with infected live or dead poultry. There is no evidence that the disease can be spread to people through properly cooked food. Controlling the disease in animals is the first step in decreasing risks to humans.

Avian influenza (AI) is an infectious viral disease of birds (especially wild water fowl such as ducks and geese), often causing no apparent signs of illness. AI viruses can sometimes spread to domestic poultry and cause large-scale outbreaks of serious disease. Some of these AI viruses have also been reported to cross the species barrier and cause disease or subclinical infections in humans and other mammals. AI viruses are divided into two groups based on their ability to cause disease in poultry: high pathogenicity or low pathogenicity. Highly pathogenic viruses result in high death rates (up to 100% mortality within 48 hours) in some poultry species. Low pathogenicity viruses also cause outbreaks in poultry but are not generally associated with severe clinical disease. Avian influenza H5N1 background The H5N1 virus subtype - a highly pathogenic AI virus- first infected humans in 1997 during a poultry outbreak in Hong Kong SAR, China. Since its widespread re-emergence in 2003 and 2004, this avian virus has spread from Asia to Europe and Africa and has become entrenched in poultry in some countries, resulting in millions of poultry infections, several hundred human cases, and many human deaths. Outbreaks in poultry have seriously impacted livelihoods, the economy and international trade in affected countries. Ongoing circulation of H5N1 viruses in poultry, especially when endemic, continues to pose threats to public health, as these viruses have both the potential to cause serious disease in people and may have the potential to change into a form that is more transmissible among humans. Other influenza

virus subtypes also circulate in poultry and other animals, and may also pose potential threats to public health. Avian influenza H5N1 infections and clinical features in humans The case fatality rate for H5N1 virus infections in people is much higher compared to that of seasonal influenza infections. Clinical features In many patients, the disease caused by the H5N1 virus follows an unusually aggressive clinical course, with rapid deterioration and high fatality. Like most emerging disease, H5N1 influenza in humans is poorly understood. The incubation period for H5N1 avian influenza may be longer than that for normal seasonal influenza, which is around two to three days. Current data for H5N1 infection indicate an incubation period ranging from two to eight days and possibly as long as 17 days. WHO currently recommends that an incubation period of seven days be used for field investigations and the monitoring of patient contacts. Initial symptoms include a high fever, usually with a temperature higher than 38oC, and other influenza-like symptoms. Diarrhoea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums have also been reported as early symptoms in some patients. One feature seen in many patients is the development of lower respiratory tract early in the illness. On present evidence, difficulty in breathing develops around five days following the first symptoms. Respiratory distress, a hoarse voice, and a crackling sound when inhaling are commonly seen. Sputum production is variable and sometimes bloody.1 Antiviral treatment Evidence suggests that some antiviral drugs, notably oseltamivir, can reduce the duration of viral replication and improve prospects of survival. In suspected cases, oseltamivir should be prescribed as soon as possible (ideally, within 48 hours following symptom onset) to maximize its therapeutic benefits. However, given the significant mortality currently associated with H5N1 infection and evidence of prolonged viral replication in this disease, administration of the drug should also be considered in patients presenting later in the course of illness. In cases of severe infection with the H5N1 virus, clinicians may need to consider increasing the recommended daily dose or/and the duration of treatment. In severely ill H5N1 patients or in H5N1 patients with severe gastrointestinal symptoms, drug absorption may be impaired. This possibility should be considered when managing these patients.2 Risk factors for human infection

The primary risk factor for human infection appears to be direct or indirect exposure to infected live or dead poultry or contaminated environments. Controlling circulation of the H5N1 virus in poultry is essential to reducing the risk of human infection. Given the persistence of the H5N1 virus in some poultry populations, control will require long-term commitments from countries and strong coordination between animal and public health authorities. There is no evidence to suggest that the H5N1 virus can be transmitted to humans through properly prepared poultry or eggs. A few human cases have been linked to consumption of dishes made of raw, contaminated poultry blood. However, slaughter, defeathering, handling carcasses of infected poultry, and preparing poultry for consumption, especially in household settings, are likely to be risk factors. Human pandemic potential Influenza pandemics (outbreaks that affect a large proportion of the world) are unpredictable but recurring events that can have health, economic and social consequences worldwide. An influenza pandemic occurs when key factors converge: an influenza virus emerges with the ability to cause sustained transmission from human-to-human, and there is very low, or no, immunity to the virus among most people. In the interconnected world of today, a localized epidemic can transform into a pandemic rapidly, with little time to prepare a public health response to halt the spread of illness. The H5N1 AI virus remains one of the influenza viruses with pandemic potential, because it continues to circulate widely in some poultry populations, most humans likely have no immunity to it, and it can cause severe disease and death in humans. In addition to H5N1, other animal influenza virus subtypes reported to have infected people include avian H7 and H9, and swine H1 and H3 viruses. H2 viruses may also pose a pandemic threat. Therefore, pandemic planning should consider risks of emergence of a variety of influenza subtypes from a variety of sources. WHO response Animal health agencies and national veterinary authorities are responsible the control and prevention of animal diseases, including influenza. WHO, World Organisation for Animal Health (OIE), and Food and Agriculture Organization (FAO) collaborate through a variety of mechanisms to track and assess the risk from animal influenza viruses of public health concern, and to address these risks at the human animal interface wherever in the world they might occur.

Avian Influenza A (H5N1) Infection in Humans The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5. (New England Journal of Medicine, 2005, 353:1374-1385.) 2 WHO rapid advice guidelines on pharmacological management of humans infected with avian influenza A(H5N1) virus [pdf 1.2Mb] World Health Organization, 2006

Key Facts About Avian Influenza (Bird Flu) and Highly Pathogenic Avian Influenza A (H5N1) Virus
This website is archived and is no longer being maintained or updated. For updated information on avian influenza, see the CDC Avian Influenza website and the World Health Organization (WHO) Avian Influenza Situation Update page.

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What You Should Know About Avian Flu

Key Facts Infections in Humans Questions & Answers Current Situation

This fact sheet provides general information about avian influenza (bird flu) and information about one type of bird flu, called highly pathogenic avian influenza A (H5N1), also called "HPAI H5N1," that has caused infections in birds and in humans. Also see Questions and Answers on the CDC website.

Avian Influenza (Bird Flu)

Avian influenza in birds
Avian influenza is an infection caused by avian (bird) influenza (flu) A viruses. These influenza A viruses occur naturally among birds. Wild birds worldwide get flu A infections in their intestines, but usually do not get sick from flu infections. However, avian influenza is very contagious among birds and some of these viruses can make certain domesticated bird species, including chickens, ducks, and turkeys, very sick and kill them. Infected birds can shed influenza virus in their saliva, nasal secretions, and feces. Susceptible birds become infected when they have contact with contaminated secretions or excretions or with surfaces that are contaminated with secretions or excretions from infected birds. Domesticated birds may become infected with avian influenza virus through direct contact with infected waterfowl or other infected poultry, or through contact with surfaces (such as dirt or cages) or materials (such as water or feed) that have been contaminated with the virus. Infection with avian influenza viruses in domestic poultry causes two main forms of disease that are distinguished by low and high extremes of virulence. The "low pathogenic" form may go undetected and usually causes only mild symptoms (such as ruffled feathers and a drop in egg production). However, the highly pathogenic form spreads more rapidly through

flocks of poultry. This form may cause disease that affects multiple internal organs and has a mortality rate that can reach 90-100% often within 48 hours.

Human infection with avian influenza viruses

There are many different subtypes of type A influenza viruses. These subtypes differ based on differences in two main proteins on the surface of the influenza A virus (hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA subtypes and 9 known NA subtypes of influenza A viruses. Many different combinations of HA and NA proteins are possible. Each combination represents a different subtype. All known subtypes of influenza A viruses can be found in birds. Usually, avian influenza virus refers to influenza A viruses found chiefly in birds, but infections with these viruses can occur in humans. The risk from avian influenza is generally low to most people, because the viruses do not usually infect humans. However, confirmed cases of human infection from several subtypes of avian influenza infection have been reported since 1997. Most cases of avian influenza infection in humans have resulted from contact with infected poultry (e.g., domesticated chicken, ducks, and turkeys) or surfaces contaminated with secretion/excretions from infected birds. The spread of avian influenza viruses from one ill person to another person has been reported very rarely, and has been limited, inefficient and unsustained. "Human influenza A viruses" usually refers to those influenza A subtypes that have spread widely among humans. Currently, H3N2 and H1N1 influenza A subtypes are circulating among humans and H2N2 influenza A circulated from about 1957-1968. Some genetic parts of current human influenza A viruses had their origin in bird flu viruses originally. Influenza A viruses are constantly changing, and they might adapt over time to infect and spread among humans. During an outbreak of avian influenza among poultry, there is a possible risk of infection for people who have contact with infected birds or surfaces that have been contaminated with secretions or excretions from infected birds. Symptoms of avian influenza in humans have ranged from typical human influenza-like symptoms (e.g., fever, cough, sore throat, and muscle aches) to eye infections, pneumonia, severe respiratory diseases (such as acute respiratory distress), and other severe and lifethreatening complications. The symptoms of avian influenza may depend on which virus caused the infection. Studies done in laboratories suggest that some of the antiviral drugs approved in the United States for human influenza viruses should work in treating avian influenza infection in humans. However, influenza viruses can become resistant to these drugs, so these medications may not always work. Additional studies are needed to demonstrate the effectiveness of these medicines. When avian influenza A viruses are identified to cause illness in humans, the viruses should be tested for susceptibility to influenza antiviral medications.

Highly pathogenic Avian Influenza A (H5N1)

Highly pathogenic Influenza A (H5N1) virus also called "HPAI H5N1 virus" is an influenza A virus that occurs mainly in birds, is highly contagious among birds, and can be deadly to them, especially domestic poultry. HPAI H5N1 virus does not usually infect people, but infections with these viruses have occurred in humans. Most of these cases have resulted from people having direct or close contact with H5N1-infected poultry or H5N1contaminated surfaces.

Human health risks from HPAI H5N1

Of the few avian influenza viruses that have crossed the species barrier to infect humans, HPAI H5N1 has caused the largest number of detected cases of severe disease and death in humans. However, it is possible that those cases in the most severely ill people are more likely to be diagnosed and reported, while milder cases are less likely to be detected and reported. For the most current information about avian influenza and cumulative case numbers, see the World Health Organization (WHO) avian influenza website. Of the human cases associated with the ongoing HPAI H5N1 outbreaks in poultry and wild birds in Asia and parts of Europe, the Near East and Africa, about 60% of those people reported infected with the virus have died. Most cases have occurred in previously healthy children and young adults and have resulted from direct or close contact with H5N1-infected poultry or H5N1-contaminated surfaces. In general, HPAI H5N1 remains a very rare disease in people. The HPAI H5N1 virus does not infect humans easily, and if a person is infected, it is very difficult for the virus to spread to another person. While there has been some human-to-human spread of HPAI H5N1, it has been limited, inefficient and unsustained. For example, in 2004 in Thailand, probable human-to-human spread in a family resulting from prolonged and very close contact between an ill child and her mother was reported. In June 2006, WHO reported evidence of human-to-human spread in Indonesia. In this situation, eight people in one family were infected. The first family member is thought to have become ill through contact with infected poultry. This person then infected six family members. One of those six people (a child) then infected another family member (his father). No further spread outside of the exposed family was identified. Nonetheless, because all influenza viruses have the ability to change and because the HPAI H5N1 known ability to cause human infections, scientists remain concerned that HPAI H5N1 viruses have the potential to possibly change into a form of the virus that is able to spread easily from person to person. Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population. If HPAI H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. For more information about influenza pandemics, see PandemicFlu.gov. Experts from around the world continue to monitor for potential changes in the HPAI H5N1 virus and changes in patterns of human infection and work with the many stakeholders to prepare for the possibility that the virus may begin to spread more easily and widely from person to person. For more information about influenza pandemics, see Flu.gov.

Treatment and vaccination for HPAI H5N1 virus in humans

The HPAI H5N1 virus that has caused human illness and death in Asia is resistant to amantadine and rimantadine, two antiviral medications licensed by the US Food and Drug Administration (FDA) for influenza A. However, these drugs are not recommended for influenza treatment at this time because of resistance among both HPAI H5N1 and resistance against circulating human influenza A H1N1 and H3N2 viruses. . Two other antiviral medications, oseltamivir and zanamivir, can be used for the treatment of HPAI H5N1 although WHO guidance includes a preference for oseltamivir. For more information on the treatment of HPAI H5N1, visit: http://www.who.int/csr/disease/avian_influenza/guidelines/ClinicalManagement07.pdf.

Virus H5N1
Virus jenis H5N1 dikenal sebagai virus flu burung yang paling membahayakan yang telah menginfeksi baik manusia ataupun hewan. Virus yang juga dikenal dengan A(H5N1) ini merupakan virus epizootic (penyebab epidemik di mahluk non manusia) dan juga panzootic (yang dapat menginfeksi binatang dari berbagai spesies dari area yang sangat luas. Virus HPAI A (H5N1) pertama kali diketahui membunuh sekawanan ayam di Skotlandia pada tahun 1959, namun virus yang muncul pada saat itu sangat berbeda dengan virus H5N1 pada saat ini. Jenis dominan dari virus H5N1 yang muncul pada tahun 2004 berevolusi dari virus yang muncul pada tahun 2002 yang menciptakan gen tipe Z. Virus H5N1 dibagi menjadi 2 jenis turunan, turunan yang pertama adalah virus yang menginfeksi manusia dan burung yang ada di Vietnam, Thailand, Kamboja dan burung yang ada di Laos dan Malaysia. Jenis turunan pertama ini tidak menyebar ke daerah lain. Sedangkan yang turunan jenis 2 dikenali dari burung yang ada di China, Indonesia, Jepang, dan Korea Utara yang kemudian menyebar ke Timur Tengah, Eropa dan Afrika. Virus jenis turunan ke 2 ini adalah virus yang menjadi penyebab infeksi ke manusia yang terjadi dalam kurun waktu 2005-2006 di berbagai Negara. Analisa genetik yang telah dilakukan membuktikan bahwa ada 6 jenis subklas dari turunan jenis ke 2, yang 3 diantaranya tersebar dan menginfeksi manusia di Negara-negara berikut ini : Subklas 1 : Indonesia Subklas 2 : Eropa, Timur Tengah dan Afrika Subklas 3 : China H5N1 sebenarnya adalah jenis virus yang menyerang reseptor galactose yang ada pada hidung hingga ke paru-paru pada unggas yang tidak ditemukan pada manusia, dan serangan hanya terjadi disekitar alveoli yaitu daerah daerah di paru-paru dimana oksigen disebarkan melalui darah. Oleh karena itu virus ini tidak gampang disebarkan melalui udara saat batuk atau bersin seperti layaknya virus flu biasa.

Sejak pertama kali ditemukan pada tahun 1997, peneliti menemukan bahwa virus H5N1 terus berevolusi dengan melakukan perubahan di zat antigen dan struktur gen internal yang kemudian dapat menginfeksi beberapa spesies yang berbeda. Virus yang pertama kali ditemukan di Hongkong pada tahun 1997 dan 2001 tidak mudah ditularkan dari burung satu ke lainnya dan tidak menimbulkan penyakit yang mematikan pada beberapa binatang. Namun pada tahun 2002, jenis baru virus H5N1 muncul, dikenal dengan virus H5N1 tipe gen Z yang menjadi tipe gen dominan, yang menyebabkan penyakit akut pada populasi burung di Hongkong, termasuk disfungsi neurologi dan kematian pada bebek dan jenis unggas lainnya. Virus dengan tipe gen inilah yang menjadi epidemic di Asia Tenggara yang menyebabkan kematian jutaan ekor ayam dan dari 2 sub klas yang tercipta akibat mutasi virus yang selalu berubah telah menimbulkan korban ratusan manusia yang meninggal dunia. Mutasi yang terjadi dari jenis virus ini meningkatkan patogen virus yang dapat memperparah serangan virus ke berbagai spesies dan ditakutkan nantinya mampu menularkan virus dari manusia ke manusia lainnya. Mutasi tersebut terjadi di dalam tubuh burung yang menyimpan virus dalam jangka waktu lama di dalam tubuhnya sebelum akhirnya meninggal akibat infeksi. Mutasi yang terjadi pada virus H5N1 merupakan karakteristik jenis virus influenza, dimana virus tersebut mampu mengkombinasikan jenis 2 jenis virus influenza yang berbeda yang berada dalam 1 jenis reseptor pada saat yang bersamaan. Kemampuan virus untuk bermutasi menghasilkan jenis yang mampu menginfeksi berbagai jenis spesies adalah karena adanya variasi yang ada di dalam gen hemagglutinin. Mutasi genetik dalam gen hemaglutinin menyebabkan perpindahan asam amino yang pada akhrinya dapat mengubah kemampuan protein dalam hemagglutinin untuk mengikat reseptor dalam permukaan sel. Mutasi inilah yang dapat mengubah virus flu burung H5N1 yang tadinya tidak dapat menginfeksi manusia menjadi dapat dengan mudah menular dari unggas ke manusia. Oleh karena itu peneliti sekarang sedang giat-giatnya mencoba memahami sifat virus ini dan berusaha melakukan rekayasa genetika dengan memasukkan 2 asam amino virus flu spanyol H1N1 ke dalam hemaglutinin H5N1 sehingga nantinya virus H5N1 tidak menjadi pandemik yang membahayakan manusia seperti yang terjadi pada wabah tahun 1918. Penelitian itu membuahkan hasil yang menggembirakan dimana objek penelitian dapat tetap sehat meskipun ditempatkan dalam 1 ruangan bersama objek yang sakit.

Gejala pada Manusia Virus Flu Burung yang pada awalnya diketahui hanya bisa menular antar sesama unggas, menciptakan mutasi baru yang dapat juga menyerang manusia. Mutasi virus ini dapat menginfeksi manusia yang berkontak langsung dengan sekresi unggas yang terinfeksi. Manusia yang memiliki resiko tinggi tertular adalah anak-anak, karena memiliki daya tahan tubuh yang lebih lemah, pekerja peternakan unggas, penjual dan penjamah unggas, serta pemilik unggas peliharaan rumahan.

Masa inkubasi virus adalah 1-7 hari dimana setelah itu muncul gejala-gejala seseorang terkena flu burung adalah dengan menunjukkan ciri-ciri berikut : 1. 2. 3. 4. 5. 6. 7. Menderita ISPA Timbulnya demam tinggi (> 38 derajat Celcius) Sakit tenggorokan yang tiba-tiba Batuk, mengeluarkan ingus, nyeri otot Sakit kepala Lemas mendadak Timbulnya radang paru-paru (pneumonia) yang bila tidak mendapatkan penanganan tepat dapat menyebabkan kematian

Mengingat gejala Flu burung mirip dengan flu biasa, maka tidak ada yang bisa membedakan flu burung dan flu biasa. Jika ada penderita yang batuk, pilek dan demam yang tidak kunjung turun, maka disarankan untuk segera mengunjungi dokter atau rumah sakit terdekat. Penderita yang diduga mengidap virus Flu burung disebut penderita suspect flu burung dimana penderita pernah mengunjungi peternakan yang berada di daerah yang terjangkit flu burung, atau bekerja dalam laboratorium yang sedang meneliti kasus flu burung, atau berkontak dengan unggas dalam waktu beberapa hari terakhir. Kasus probable adalah kasus dimana pasien suspek mendapatkan hasil tes laboratorium yang terbatas hanya mengarah pada hasil penelitian bahwa virus yang diderita adalah virus jenis A, atau pasien meninggal karena pneumonia gagal. Sedangkan kasus kompermasi adalah kasus suspek atau probable dimana telah didukung dengan hasil pemeriksaan laboratorium yang menunjukkan bahwa virus flu yang diderita adalah positif jenis H5N1, PCR influenza H5 positif dan peningkatan antibody H5 membesar 4 kalinya. Namun, gejala yang dimunculkan oleh virus H5N1 ini berbeda-beda dimana ada kasus seorang anak laki-laki yang terinfeksi virus H5N1 yang mengalami diare parah dan diikuti dengan koma panjang tanpa mengalami gejala-gejala seperti influenza, oleh karena itu pemeriksaan secara medis penting dilakukan terutama bila mendapati timbulnya gejala penyakit yang tidak wajar. Pengobatan Penanganan flu burung dapat dilakukan dengan pengobatan atau pemberian obat flu seperti Tamiflu atau jenis lainnya, tapi harus tetap dalam pengawasan dokter atau pihak rumah sakit yang ditunjuk oleh Dinas Kesehatan RI. Jenis obat penanggulangan infeksi flu burung ada 2, pertama adalah obat seperti amantadine dan rimantadine yaitu ion channel (M2) blocker, yang menghalagi aktivitas ion channel dari virus flu jenis A dan bukan jenis B sehingga aliran ion hydrogen dapat diblok dan virus tidak dapat berkembang biak. Sayang sekali bahwa jenis obat yang pertama ini dapat memicu tingkat resistensi virus terhadap zat obat, sehingga di hari ke 5 hingga ke 7 setelah konsumsi obat, 16-35% dari virus akan resisten karena adanya mutasi pada protein M2 pada virus. Oleh karena itu, obat jenis

ini tidak dijual bebas di sembarang apotik, meskipun dengan pemberian resep dokter, karena dikhawatirkan kesalahan pemberian obat dapat menimbulkan munculnya jenis virus baru yang lebih ganas dan kebal terhadap obat ini. Jenis obat yang kedua adalah Neurimidase (NA) inhibitor, jenis seperti Zanamivir dan Oseltamivir, dengan protein NA-nya yang berfungsi melepaskan virus yang bereplikasi di dalam sel, sehingga virus tidak dapat keluar dari dalam sel. Virus ini nantinya akan menempel di permukaan sel saja dan tidak akan pindah ke sel yang lain. Jenis obat yang kedua ini tidak menimbulkan resisten pada tubuh virus seperti jenis pada ion channel blocker. Hingga sekarang peneliti telah berusaha keras untuk menciptakan jenis vaksin yang dapat mengantisipasi pandemik virus H5N1, namun karena virus ini selalu bermutasi maka dirasa penciptaan vaksin yang efektif tidak dapat cukup kuat melawan jenis virus H5N1 yang sekarang walaupun dirasa dapat efektif untuk mengantisipasi jenis baru yang akan muncul. Walaupun penelitian vaksin jenis baru sedang digalakkan, WHO mengatakan bahwa percobaan klinis virus jenis pertama haruslah tetap dilakukan sebagai langkah yang esensial untuk mengatasi pandemik yang mungkin akan terjadi. Walaupun begitu, alangkah lebih baik jika masyarakat melakukan pencegahan dan melakukan beberapa tindakan yang benar untuk mengantisipasi serangan flu burung. Tak perlu panik dan berlebih, hanya perlu untuk memperhatikan beberapa hal berikut : 1. Gunakan pelindung (Masker, kacamata renang, sarung tangan) setiap berhubungan dnegan bahan yang berasal dari saluran cerna unggas 2. Setiap hal yang berasal dari saluran cerna unggas seperti sekresi harus ditanam/dibakar supaya tidak menular kepada lingkungan sekitar 3. Cuci alat yang digunakan dalam peternakan dengan desinfektan 4. Kandang dan Sekresi unggas tidak boleh dikeluarkan dari lokasi peternakan 5. Memasak daging ayam dengan benar pada suhu 80 derajat dalam 1 menit dan membersihkan telur ayam serta dipanaskan pada suhu 64 derajat selama 5 menit. 6. Menjaga kebersihan lingkungan dan diri sendiri. Yang paling penting adalah : 1. Menjauhkan unggas dari pemukiman manusia untuk mengurangi kontak penyebaran virus 2. Segera memusnahkan unggas yang mati mendadak dan unggas yang jatuh sakit utnuk memutus rantai penularan flu burung, dan jangan lupa untuk mencuci tangan setelahnya. 3. Laporkan kejadian flu burung ke Pos Komando Pengendalian Flu Burung di nomor 021-4257125 atau dinas peternakan-perikanan dan dinas kesehatan daerah tempat tinggal anda.