China Following a Best Practice: Market Rest Days

I caught this on another avian flu blog and was glad to see it - China is implementing market rest days

Regular rest days help stop the spread of H5N1 because poultry vendors are required to stop selling and slaughtering and clean and disinfect their area of the market. Also, it gives the government a chance to clean larger areas of the market, ensure that there is proper drainage of waste, etc.

http://www.news.gov.hk/en/category/healthandcommunity/070423/html/070423en05001.htm

Market clean up days are recommend by WHO - you can find the guidelines at the Communications Initiative website

http://www.comminit.com/avianinfluenza/ma2006/materials-2797.html

Pan Flu Disproportionately Targets the Poor

According to a recent Lancet article by Christopher Murray et al. (see citation below), the vast majority of those affected by the next pandemic influenza will be people living in resource poor settings. Murray and his colleagues used information from the previous 1918 pandemic influenza and made appropriate adjustments for the current (2004) situation to construct a mortality model for the next pandemic. The model suggests that 96% of estimated deaths will take place in the developing world. The death toll is predicted to be 31 times higher in some developing settings when compared to developed settings. The model suggests that nearly half of the difference in projected mortality was due to differences in income.

During the next pandemic, morbidity and mortality will most likely be mediated through factors such as medical infrastructure, nutritional status, the presence of other diseases, and other poverty-related factors. While it is uncertain how the next pandemic influenza will play out, it is certain that its effects will disproportionately target poor and vulnerable groups. As Neil Ferguson suggests, more work needs to be done to explore the means by which poverty affected mortality in the 1918 pandemic so we can prevent and mitigate mortality in these populations during the next pandemic influenza.

Murray, CJL et al. (2006). Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-1920 pandemic: a quantitative analysis. The Lancet 368: 2211-2218.

Is there a uniform case definition of avian influenza?

It seems weird to ask for a set case definition of the bird flu, but if different health departments are looking at different things, some cases may go undetected, and therefore untreated.

Here's New Zealand's case definitions of avian influenza in humans. Are they similar to your country's definition? What's different?

Under Investigation

A person who has been referred to the Public Health service for investigation of possible H5N1 infection.

Suspect case of Influenza A (H5N1)

Person with acute lower respiratory tract illness of abrupt onset, characterised by:

• fever (temperature >38 C) and
• cough and/or
• dyspnoea (difficult or laboured breathing).

AND, in the seven days prior to the onset of symptoms, one or more of the following:

1. having been in close contact (less then 1 metre) with a suspect, probable or confirmed case of influenza A (H5N1)
2. exposure to avian species or their remains, or to environments contaminated by their faeces in an area where H5N1 infection in animals or humans have been suspect or confirmed in the last month
3. consumption of raw or undercooked poultry products in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last month
4. close contact with a confirmed H5N1 infected animal of a species other than avian
5. handling samples from persons or animals that are suspected of H5N1 infection
6. working in a laboratory that is handling samples from persons or animals that are suspected of H5N1 infection.

Probable case of Influenza A (H5N1)

1. a person meeting the definition of a suspected case and
2. limited laboratory evidence for Influenza A (H5N1) (such as IFA+ using H5 monoclonal antibodies).

Confirmed case of Influenza A (H5N1)

1. a person meeting the definition of a suspected case; and
2. laboratory testing demonstrates one or more of the following:
   1. positive PCR for Influenza A (H5N1) or
   2. positive viral culture for Influenza A (H5N1) or
   3. immunofluorescence antibody (IFA) test positive using Influenza A/H5 monoclonal antibodies or
   4. a four-fold rise in H-5 specific Ab titer.

Source: New Zealand. Ministry of Health. http://www.moh.govt.nz/moh.nsf/wpg_index/About-Influenza+-+avian+influenza+-+case+definition#top

Oh, have the times change...for Tamiflu

Tamiflu, one of the two main treatments for avian flu, doesn't seem to be as popular anymore. Scattered reports of resistance to Tamiflu and smaller than expected orders for the drug have forced Roche to reduce its production capacity.

http://www.cnbc.com/id/18330713

I guess this begs the question: well, what's next? More countries are working on their own vaccines using strains found within their borders in hopes of creating a cheaper vaccine that's more effective to their own cases. Is this a vaccine race or a struggle between developing countries and developed nation pharmaceutical corporations?

WHO Stockpiles for the Poor

As WHO considers stockpiling 60 million bird flu vaccine doses to be used in developing countries, the world's most affected nations hope to benefit. Many nations hit hardest by the virus, including Indonesia and Thailand, frequently share samples of the H5N1 virus with the international community. These samples are often used to develop vaccines that are too costly for these countries to purchase for themselves. Therefore, this stockpile may be viewed as a long awaited return on an investment. While WHO officials declare the stockpiling feat "feasible," questions remain in regard to the funding of this task.

With this article, and others like it, we remain hopeful that vulnerable populations will remain in the forefront of our minds as we prepare for a possible pandemic influenza.For further details, view the full article:
http://www.alertnet.org/thenews/newsdesk/L2557204.htm

CARE Afghanistan helps communities report and respond to outbreaks quickly

Our AI point person in Afghanistan, Zohra Shamszai just filled me in on CARE's role in helping report an outbreak in poultry in March.

One of CARE's project beneficiaries brought in several dead chickens to a livestock center and CARE took down the case history. The high mortality rate and symptoms pointed to suspected H5N1, so CARE sent the samples to the nearest reference laboratory. It was confirmed H5N1 and within 2 days of the beneficiary bringing in the dead poultry, outbreak response was happening on the ground. CARE followed up with project beneficiaries in the area, reinforcing the AI prevention messages that they have been including in many of their projects.

WHO to support vaccine technology transfer

Since the beginning of our work in avian flu, equitable access to vaccines and anti viral medications has been a major advocacy point for CARE. It's encouraging to see this press release, that WHO will give grants to six developing countries to establish in-country manufacturing capacity for influenza vaccine. The countries are Brazil, India, Indonesia, Mexico, Thailand and Viet Nam.

Another great point about this, it will boost production capabilities of seasonal flu shots as well.

It's a great step forward, but it will take 3-5 years for production to start locally!

http://www.who.int/mediacentre/news/notes/2007/np18/en/index.html

Mostly quiet day, AI still spreading in Bangladesh

It's been a quiet few days around AI, not too much in the news. Unfortunately, though, H5N1 is still spreading around Bangladesh.

"The infection was detected at a farm in western Magura district 200 km (125 miles) west of the capital Dhaka and five farms at Savar in the Dhaka district"

"Since the detection of the H5N1 virus on March 22, some 98,000 chickens have been culled on 38 farms in nine districts."

http://news.yahoo.com/s/nm/20070421/hl_nm/birdflu_bangladesh_dc

New avian flu vaccince is an "interim measure", but who gets the vaccine?

As Harriet mentioned in the last blog, only 45% of people who receive this new vaccine develop antibodies to the the virus...

Why is this important then? If a pandemic occurred, this vaccine isn't going to save the world. However, it may be useful if we can vaccinate at the very start of a human to human pandemic.
The more cases you can prevent or delay at the onset has huge implications for how many people are affected and how long you have to prepare.

But all the press releases and articles I've seen have only said this won't be available commercially and that the U.S. Govt. is stockpiling the vaccine. There's no word on what other countries may be able to access it and it's very unlikely that a human pandemic will start in the United States...

http://www.reuters.com/article/homepageCrisis/idUSN17435229._CH_.2400

Avian influenza vaccine is approved by FDA, but only offers 45% rate of protection.

“The first vaccine against avian flu won government approval yesterday, even as federal officials conceded its usefulness in a flu pandemic might be limited…”

For more: http://www.nytimes.com/2007/04/18/health/18flu.html

Article - "Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through Compensation: Issues and Good Practice"

It's one thing to say that poor farmers who are forced to kill their poultry to preserve public health should be compensated.

It's another thing to figure out how to do it.

The paper called, "Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through Compensation: Issues and Good Practice" from the World Bank, OIE, ARD, FAO, and IFPRI is a thorough document that gives baby steps in the general direction of compensation.

Many people are leaning toward compensating the losses of private citizens to stop the spread of avian influenza, but this can prove difficult for developing countries who do not have the necessary animal health services and funding mechanisms to even start. This document calls for a collaboration among governments, NGOs, the commercial poultry sectors, poultry farmers’ contributions, livestock and livestock market taxes, stakeholders and international donors.

How should these actors work together? In your experience, how DO they work together?

You can download a copy of the paper at: http://www.avianinfluenzaconference4.org/fileadmin/user_upload/PDF_Uploads/HPAI_Compensation_Final_final.pdf

aprile

Cambodian victim of avian influenza

On April 5^th 2007, a 13 year old Cambodian girl, “died in the Kampong Cham province bordering Vietnam where cases of bird flu have surged again in recent months, the news service Xinhua reported Saturday.

The girl died after cooking and eating a sick chicken from her backyard, officials said. More than 100 ducks and chickens from around her farm have since been killed after some birds tested positive for the H5N1 virus.”

Source and more information: http://www.physorg.com/news95839462.html

http://www.iol.co.za/index.php?set_id=14&click_id=117&art_id=nw20070414111248341C791853

Egypt announces US$42 million investment to combat avian influenza.

For more see: http://www.businessinafrica.net/news/north_africa/775967.htm

India announces a World Bank funded avian influenza preparedness plan

With recent outbreaks in Bangladeshi districts neighboring Assam and West Bengal, India’s Cabinet Committee on Economic Affairs has approved a “Preparedness, Control and Containment of Avian Influenza” scheme. Jointly funded by the World Bank and the Indian Government, the three year program will involved “preparedness planning, coordination of the Outbreak Containment Plan, establishing a Bird Flu Cell in the department of Animal Husbandry, Dairy, and Fisheries, generating public awareness and involving the community in surveillance”. The government of India is also stressing the need for effective surveillance along its national borders. In addition to Bangladesh, Myanmar, Pakistan and China have all experienced avian influenza outbreaks, increasing the risk for another outbreak in India, where no more cases have been officially confirmed since August 2006.

Source: Indian Catholic: http://www.theindiancatholic.com/newsread.asp?nid=7065

CARE-Bangladesh convenes international NGOs as more outbreaks of avian flu are reported

Two more avian influenza (AI) outbreaks on farms in Bangladesh’s Jessore district and Savar have been reported by Bangladesh’s Fisheries and Livestock Ministry. Since the detection of the virus in late March 2007, 79,000 chickens have been culled on 32 farms across 8 districts. At the weekend, a team of ten FAO experts arrived in Bangladesh to visit farms, labs and conduct interviews. The Government of Bangladesh has announced a compensation scheme of 70 taka (US$1) for every chicken culled. However reports have stated that communication about this compensation scheme has not yet been effectively replayed to poultry owners.

A CARE Working Group and Core team have been established to develop an AI contingency plan, identify priority activities to be implemented within CARE programs, and maintain communication with the Government of Bangladesh (GoB). On April 9^th CARE Bangladesh hosted a Coordination Meeting on AI, convening representatives from major international NGOs (Oxfam, Plan, MCC-Bangladesh, Concern Worldwide, International Development Enterprises and Helen Keller International) in order to share experiences and identify collective roles to support the Government against AI. The participants agreed:

• To asses their network capacity in terms of partner NGOs the communities they work with
• Build partnerships with other domestic NGOs
• Collect and print accurate information and training materials to be distributed to staff, partner NGOs, farmers, and other beneficiaries.

Source: CARE Bangladesh & Reuters: http://www.alertnet.org/thenews/newsdesk/DHA226251.htm

http://www.alertnet.org/thenews/newsdesk/SP234314.htm

Egyptian teenager dies from H5N1

Egypt has reported it's 14th death from H5N1. The patient was a 15 year old girl and, sadly, she did not enter the hospital or receive treatement for 10 days after she began experiencing symptoms. We need to keep these cases in mind when we think of the importance of our work in community based surveillance.

http://www.alertnet.org/thenews/newsdesk/L11720107.htm

Interesting Article from Against the Grain.

The link below will bring you to a pretty good opinion piece from Against the Grain that asks the reader if AI prevention has focused on the wrong things, namely migratory birds and backyard poultry farmers. Recently, it has come to light that bird flu (or at least the strains that have caused animal-to-human transmission) actually follows trade patterns instead of migration routes, but there has yet to be renewed discussion on expanding AI prevention efforts to tackle this.

Why?

This article is pretty radical as it points the finger at:
- The formal poultry sector profiting from AI prevention measures that squeeze out local, small-scale farmers
- The formal poultry sector having enough clout with governments to avoid inspections
- Even pharmaceutical companies for receiving AI samples to create vaccines for profit

What do you think?

- Is this far-fetched? Reasonable?
- What can we do to ensure all parties involved are accountable for their actions?

http://www.grain.org/articles/?id=22
Against the Grain's "Bird Flu: A Bonanza for 'Big Chicken,'"


April

Outbreaks in Poultry in Pakistan

New H5N1 outbreaks in poultry in Karachi, no human cases reported.

http://www.dawn.com/2007/04/11/local1.htm

H5N1 in poultry in Saudi Arabia

For the first time since 2006, Saudi Arabia has a new oubreak of H5N1 in poultry

http://today.reuters.co.uk/news/CrisesArticle.aspx?storyId=L23511948

New Outbreak on a Farm in Bangladesh

Bangladesh is reporting a new outbreak on a farm in Dhaka. 3,000 poultry have been culled.

Dr. Jahangir Hossain, CARE Bangladesh's Health Sector Coordinator (and AI point person). Is hosting a coordinating meeting for INGOs to discuss the current situation and how to coordinate efforts and possible joint advocacy.

http://today.reuters.co.uk/news/CrisesArticle.aspx?storyId=DHA203497

2 Additional Human H5N1 Cases this Weekend

The cases just seem to keep coming these past few weeks...

Egypt has its 34th case, a 15 year old girl. Egypt has the highest number of cases outside of Asia.

http://today.reuters.co.uk/news/CrisesArticle.aspx?storyId=L08730796

And, Indonesia had its 74 death, a man from West Java.

http://today.reuters.co.uk/news/CrisesArticle.aspx?storyId=L08730796

First Cambodia case in a while

"A 13-year-old Cambodian girl has died of bird flu, becoming the seventh victim of the deadly virus in the country, said Kampong Cham, Secretary of the Cambodian Ministry of Health on Apr. 6"

http://www.vnagency.com.vn/Home/EN/tabid/119/itemid/190952/Default.aspx

Indonesia death toll from H5N1 raised to 73

A fifteen year old girl from Jakarata died of multiple organ failure after being infected with H5N1, raising the death toll to 73.

http://hosted.ap.org/dynamic/stories/A/AS_GEN_INDONESIA_BIRD_FLU_ASOL-?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2007-04-06-00-38-10

Vientiane Capital declared AI free

Following the recent outbreak of H5N1 in Laos, the Government of the Lao PDR has declared the four districts of Sissatanack, Xaisetta, Sikkhotabong and Chanthabouli in Vientiane Capital, AI free.

Following a ban that has been in place since 7th March, residents in these areas of the Laos capital city are now able to eat poultry and eggs again, however the raising of live poultry in the 216 affected villages is still prohibited.

Strict measures will be put in place to ensure the safe import of 'AI free', killed and plucked poultry from other areas of Lao for sale in markets. At this stage, no live poultry is to be allowed in the villages that were affected.

Indonesia Confirms 72nd death from H5N1

Just on the heels of the 71st death reported two days ago, comes the 72nd.

http://www.forbes.com/business/feeds/afx/2007/04/03/afx3580611.html

H5N1 and Drinking Water

Just received and interesting Q&A update from WHO WatSan team on what the risks may be for transmitting H5N1 through drinking water. This question became especially relevant for CARE during the recent floods in Jakarta, where H5N1 in poultry is widespread.

Here's a few of the truncated Q&A's below, if you'd like the whole document, email us at: AvianFluWG@CARE.org. There's also a good background paper on the latest evidence at:

http://www.who.int/water_sanitation_health/emerging/avianflu/en/index.html

From WHO:

Q. Is there a risk from drinking water?
A. Potentially Yes.

Avian influenza viruses can persist for extended periods of time in water depending on temperature, pH and salinity but information on environmental persistence of H5N1 in water is lacking. As influenza A (H5N1) infection is frequently accompanied by gastrointestinal symptoms this could mean that H5N1 might enter the host also through Gastrointestinal tract.
Based on no evidence but considering a potential risk. Knowing that water supplied for multiple use and for drinking water in health-care facilities, minimum standards are required based on national protocols.


Q. How does avian influenza virus get into drinking water sources?

A. Infected waterfowl carry avian influenza viruses in their gastrointestinal tract, where the virus replicates. Birds infected with avian influenza virus shed large quantities of virus in their faeces as well as in their saliva and nasal secretions. Recent studies of ducks inoculated with H5N1 isolates from 2003 and 2004 showed infective virus shedding up to 17 days post-infection. Thus, it is likely that infected droppings or other secretions from both symptomatic and asymptomatic waterfowl will enter water environments where these birds gather. Avian influenza virus has been isolated from unconcentrated lake water where ducks gathered and deposited large amounts of faeces, but virus concentrations were not determined in these studies. Still, avian influenza virus detection in unconcentrated water and in small sample volumes suggests that levels could be relatively high.

While there have been no quantitative studies on the transport of avian influenza virus to groundwater underlying poultry operations, the disposal and composting of infected waste on poultry farms could create a potential pathway for the virus to enter groundwater. Similarly, interconnected surface water and groundwater systems might provide a potential route to groundwater if surface waters are carrying high concentrations of the virus.

Q. Do we know how long avian influenza viruses persist in drinking water sources?

A. Avian influenza viruses are known to persist for extended periods of time in water depending on environmental conditions, including temperature, pH and salinity, but information on the persistence of highly pathogenic avian influenza (HPAI) viruses, including H5N1, in water is lacking. Persistence of avian influenza in water is most sensitive to temperature.

More Avian Flu cases and death

Four workers test positive for Avian Flu in Kuwait

Four Bangladeshi workers, who were part of an official culling team in Kuwait, have tested positive for Avian Flu. These cases have not yet been confirmed by WHO lab test.

For more:

http://www.turkishpress.com/news.asp?id=169716

72^nd Victim of Bird Flu in Indonesia:

The Health Ministry announces the death of a maid who cared for a pet eagle:

For more: http://www.sciam.com/article.cfm?alias=indonesian-woman-dies-of&chanID=sa003&modsrc=reuters

HPAI community awareness in Lao: Challenges and future directions

Studies have shown that while knowledge about AI has increased in many regions around Lao, there has been very little change in behaviours. These findings and others were showcased last week at a workshop on communications initiatives related to HPAI in Lao PDR.

The workshop, attended by representatives from all 17 provinces together with international partners focused on independent research conducted by CARE, UNICEF and AED. This research, together with reports from government lead communication campaigns guided discussions about the direction that behavior change communication activities in Lao should take in the future.

Lao PDR has had 3 AI outbreaks, in 2004, 2006 and the early 2007 outbreak which saw 2 human fatalities from H5N1. However, there are still many obstacles to be overcome in raising awareness of the disease. ‘Of critical importance to communications campaigns is that people still do not understand the risk of the disease. To many of the backyard farmers, who make up 80% of people raising poultry in Lao, HPAI is just another seasonal disease poultry disease that affects their flock. When people do not understand the danger, it is difficult to make campaigns strong. This is something all campaigns need to focus on’, says Khounkham, Project Manager for the CARE Avian Influenza Local Risk Reduction Project.

The difficulty in reaching all areas of the country was also discussed. Findings from national campaigns indicate that only 5% of the 12,000 villages in Lao have received information on AI. The geographic disparity of Lao, combined with the large number of ethnic minority languages makes communications campaigns difficult. CARE AI programs are attempting to fill the niche of involvement at the village level; working with village volunteers and committees to deliver awareness raising activities and pilot behaviour change models.

Following the recent outbreak, discussions also focused on communications needed in an AI response. ‘Messages need to be targeted for before, during and after an AI outbreak. There needs to be a dedicated team that is responsible for informing the community of important decisions in an outbreak’, says Siphone, Training and Capacity building officer for the CARE AI Program. ‘From our experience, we need to create clearer messages to inform the community why culling of their poultry is occurring and why it is important that they report sick or dead poultry. Having trained staff available to do this if and when another outbreak occurs is critical.’

Will a double dose of Tamiflu do the trick?

In the past year, you may have read about the debate over whether or not Tamiflu will be effective during a pandemic or if H5N1 is becoming resistant to it.

A clinical trial is about to be launched that will test whether doubling the dose of
oseltamivir (Tamiflu) will improve H5N1 patients chances of recovery and/or reduce illness in seasonal flu patients. The trial will last for two years

According to Thailand's MoH, animal studies with higher doses have yielded better survival rates.

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/mar2907tamiflu.html

Trade versus migratory birds, again...

Well, we've pointed this out from the beginning - the fact that trade might be a far more important factor in transmission of H5N1 among poultry than migratory birds.

In 2005, we started focusing more of our program strategy on trade and travel after plotting outbreaks and noticing how they often follow major roads or railways! Since then, many researchers have put forth evidence for these points 1) once H5N1 enters a country or region, most of the spread of H5N1 is related to trade 2) wild birds may introduce the virus to a country, but trade has been equally important in establishing the virus in new areas.

Now, an article from Bird Life Interational goes even further and suggests that in many cases migratory birds were actually the victims of a virus that was already present.

It's an interesting theory and well written article, check it out and let us know what you think!

http://www.birdlife.org/news/news/2007/03/avian_flu_report.html

Two more human deaths from H5N1 in Indonesia

Two more human deaths from H5N1 have been confirmed in Indonesia. This brings the toll to 91 cases and 71 deaths in that country.

http://www.channelnewsasia.com/stories/afp_asiapacific/view/267818/1/.html


In the meantime, a national panel is recommending to the MoH that autopsies be done on H5N1 victims to better understand the virus. Indonesia has the highest number of human H5N1 deaths in world

http://www.thejakartapost.com/detailnational.asp?fileid=20070403.H03&irec=2

Several new outbreaks over the last few days - Vietnam, Bangladesh, Kuwait and Myanmar

Over the last few days, there have been several new outbreaks in birds....

H5N1 resurfaced in 2 duck farms in Southern Vietnam (Cau Mau Province). Vietnam continues to be plagued with outbreaks for the last few months after over a year with none.

http://www.thanhniennews.com/healthy/?catid=8&newsid=26630

H5N1 Continued to spread among poultry in Bangladesh. 1,500 birds were culled in Jessore and Dhaka. The infected districts now include Dhaka, Gazipur, Tangail, Jessore, Jamalpur and Narayanganj.

http://www.thedailystar.net/2007/04/01/d70401013120.htm

Poultry and eggs culled in Kuwait outbreak. The outbreak is seriously affecting egg producers around the outbreak.

http://news.yahoo.com/s/afp/20070331/hl_afp/healthflukuwait_070331104244;_ylt=AqO6GizKZtA7W6_zxZqNpRyTvyIi


5th outbreak of H5N1 on the outskirts of Yangoon, Myanmar

http://www.alertnet.org/thenews/newsdesk/B73017.htm

New avian flu resource site

Nature Magagzine really led the way in reporting on pandemic flu issues (perhaps you've read an article by one of their reporters, Declan Butler?) and now they have a new website devoted to pandemic and avian flu!

This is a very reliable resource for information on more technical questions (evolution of the virus, vaccine and drug issues) and also a good resource for timelines for past pandemics and the current H5N1 threat

http://www.nature.com/avianflu/index.html