Modelling NPIs

A new study out of Australia gives us some insite into why non-pharmaceutical interventions (NPIs) might be so important during a pandemic. The study doesn't have a summary for laymen so I've pulled out one paragraph and bolded some of the findings.


"For epidemics with an unmitigated R0 of 1.5, case isolation, school closure or community contact reduction made significant reductions in the final attack rate, reducing it from 33% to 6%, 13% and 16% respectively. School closure combined with any of the other interventions reduced the cumulative attack rate to below 10%, which may be deemed to be the threshold below which an epidemic does not occur. School closure combined with case isolation reduced the final attack rate to 8%. For epidemics with an R0 of 2.5, only the combination of all the modelled intervention measures appeared capable of controlling the epidemic, reducing the final attack rate from 65% to 3%. School closure combined with case isolation more than halved the final attack rate (to 30%). To achieve the large reductions in attack rates for R0 values of 2.0 and 2.5, combinations of interventions needed to operate for unfeasibly long periods of time (greater than 5 months)."

Basically, under various scenarios, there's a strong possibility that combining more than one NPI could drastically reduce the number of people that fall ill. One of the challenges would be how long we need to maintain the interventions. As the section above points out, 5 months or longer might be necessary but not feasible.

To read the full article, visit:

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0004005

Bird flu turns 11 years old...

The fantastic public health blog, Effect Meausure called attention to the fact that December 28th, 1997 was the onset of our serious concern over H5N1 (though the virus was identified well before).

"As far as the world is concerned, if any day can be said to be bird flu's birthday, it's today. The disease of birds doctors call influenza A subtype H5N1 may have had a long gestation period, but we're not sure how long. A form of the virus deadly to poultry was isolated from a goose in southern China (Guangdong province) in 1996, marking the first time the highly pathogenic form of the H5 bird virus poked its head above water for us to see. How long it had "been around" before that we don't know. Then in May, 1997, a three year old tot in Hong Kong came down with a flu-like illness that got worse and worse. He died a hard and painful death 12 days after onset. Tests showed it was an influenza A virus, but not the kind that usually infected humans (H1, H2 or H3). It was an unidentified subtype for human infection. Specimens were sent to the Netherlands and the US and in August the Dutch team identified it as the H5N1 subtype. It was designated A/Hong Kong/156/97 (H5N1) and shown to be closely related to isolate A/Chicken/Hong Kong/258/97 (H5N1) (see here for more on the naming system for flu viruses). The latter virus had been isolated from a chicken in Hong Kong in March, just months before the child fell ill. A poultry flu virus had jumped to humans.

But it was only a single case. Everyone hoped it was an isolated one and over the summer there were no others. But with the onset of flu season in November, additional cases did start to appear and by the end of December there were 17 more, of which 6 died. Including the index case, there were 18 cases with a 33% case fatality ratio. By then an emergency team from the US CDC had been in Hong Kong for three weeks and there was grave worry this might be the start of a pandemic with an especially lethal flu virus. On Sunday, December 28, 1997 the world was alerted:

'Alarmed by the continuing spread of a deadly flu virus transmitted from birds to humans, Hong Kong health officials prepared today to slaughter the territory's entire population of farm-raised chickens and other poultry in markets and farms.
The extreme move, which follows a ban on chicken imports from China, was announced Sunday by Hong Kong Director of Health Margaret Chan after doctors confirmed at least 12 cases of the H5N1 virus, four of which were fatal. Nine other people, ranging widely in age, are suspected of having the virus, a particularly virulent type previously believed to infect only birds.
Health and agriculture officials said that more than 1,000 workers wearing masks and protective clothing will fan across the territory beginning this morning to gather an estimated 1.3 million chickens from 1,000 markets and 160 farms. The birds will be captured in sealed containers, asphyxiated, placed in plastic bags and buried in landfills.
"From tomorrow morning, we will start destroying all the chickens in Hong Kong Island, Kowloon and the New Territories," Secretary for Economic Services Stephen Ip told a news conference Sunday. Ip said the workers will also gather and kill ducks, geese, pigeons and quail housed near the chickens, in an operation that he said will be completed in 24 hours. (Rone Tempest, Los Angeles Times, print edition, page A1, Dec. 29, 1997)"

Read the full post here: http://scienceblogs.com/effectmeasure/2008/12/today_is_bird_flus_birthday.php

We've been featured!

The U.S. PharmD website featured us in their blog, "100 Health Blogs that will Open Your Eyes."
This blog highlights other blogs on all different kinds of health topics, from Development and Policy to Global Health and Infectious Diseases. There are even country and continent-specific health blogs!

Stop by the U.S. PharmD website and check out this informative list- definitely worth a read!

-->Click here and follow the link to the website:
http://www.uspharmd.com/blog/2008/100-global-health-blogs-that-will-open-your-eyes/

Social distancing on public transportation

A small experiment was recently run in Japan to test how social distancing might be applied to public transportation during a pandemic.

Currently, expert guidance recommends 1-2 meters distance between each person (though there is little in the way of research to confirm these distances would be effective). In Japan they had a group of study participants use the train and remain 1 meter away from all other riders. Based on the test, officials concluded trains would only be able to have 20% of their normal capacity to maintain 1 meter distance.

This could have an additional effect on asking workplaces to stagger their hours so as to reduce congestion and crowding not only at the job but also on the way to work

http://www.yomiuri.co.jp/dy/national/20081223TDY02306.htm

Can a mobile phone change the world?

There's been a very vibrant online discussion on various blogs about mobile phones being used to detect disease, based on a recent article from Wired Magazine article about mobile phones as laboratory.

Nathaniel Whittemore wrote on www.change.org,

"Wired wrote yesterday about a cell-phone modification that could bring on-the-spot disease detection and monitoring to even the most remote corners of the world. The phone has its lens removed and modified with an LED light source that reveals particular properties of the blood when lit. The camera sensor can then image the blood, creating a diagnostic lab all in a cell phone...

So imagine this.

It's 2011, and a lot has changed in our approach to global health promotion. First, we've established a Department of Development that recognizes that prevention goes a lot further than treatment, and has begun to make strategic investments in technology and training around the world. Michael Kleinman is the director, with Paul Farmer as his Senior Adviser, of course. One of the early initiatives was the promotion of a global health corps which was focused on training community health workers, the backbone of most health systems. To enable even more effective home care, these community health workers have cell-phones outfitted with the LUCAS mobile test system above, and use Ushahidi and FrontlineSMS technology to immediately send results to a global epidemiological database from which regional and international teams can analyze trends in disease prevalence. Nonprofits and national agencies consult with the doctors monitoring the global database to design interventions that strategically head-off possible epidemics. Meanwhile, pharmaceutical companies who have negotiated lower rates with national governments, mediated by partners like the Clinton Foundation, employ a partnership with Coca-Cola to use their delivery trucks to get life saving drugs to even the most inaccessible regions. And of course, patients being treated can use their own cheap mobile phones to send messages to health workers about updates in their condition.

Sounds like fantasy? It's not. Everything above is happening or being discussed. The actors are corporate, nonprofit, and government. All it will take is the right collaboration, predicated on a common sense of moral outrage and an understanding of our immense opportunity to create a healthier world."

There are also some good posts that balance the optimism of what we can do with mobile phones with the realities of business models, scale and the need for human capacity and infrastructure as well. I'll post those view points as well.

http://socialentrepreneurship.change.org/blog/view/the_cellphone_that_could_change_the_world

Updates on outbreaks around the world

1. Cambodia begins poultry cull

Monday we blogged about the confirmed human case in Cambodia. Now culling has begun for poultry

"Cambodian officials began the culling of poultry near the capital of Phnom Penh on December 17, five days after a young man from the area was confirmed to have contracted H5N1 bird flu by the World Health Organization (WHO) and the Cambodian government. The country’s Agriculture Minister Chan Sarun was quoted by news reports as saying that he had ordered a three-month ban on poultry transportation from the province of Kandal, 50km south of Phnom Penh, after tests proved it had been hit by the deadly virus. Cambodian’s Health Ministry said in a statement last week that the 19-year-old man, the eighth person in Cambodia to have contracted bird flu since 2005, was in a stable condition in the capital's Calmette hospital. "

http://www.vnanet.vn/Home/EN/tabid/119/itemid/279353/Default.aspx

2. Egyptian teen dies of H5N1 infection

"The Ministry of Health and Population of Egypt has announced a new human case of avian influenza A(H5N1) virus infection. The case is a 16-year-old female from Assuit Governorate, Upper Egypt whose symptoms began on 8 December 2008. She was initially hospitalized at the district hospital on 11 December and then transferred to the Assuit University Hospital on 13 December where she died on 15 December. Infection with the H5N1 avian influenza virus was diagnosed by PCR at the Egyptian Central Public Health Laboratory and subsequently confirmed by the US Naval Medical Research Unit No. 3 (NAMRU-3) laboratories on 15 December 2008. Investigations into the source of her infection indicate a recent history of contact with sick and dead poultry."

http://www.who.int/csr/don/2008_12_16/en/index.html

3. Unorganized culling efforts meet resistance in West Bengal

Households refused to give up their poultry to cullers when compensation failed to arrive at the same time. Culling teams waited around and had to return home with very little accomplished. The local government promises that tomorrow will be more organized.

" Efforts by state authorities in east India to cull poultry to contain the latest outbreak of the H5N1 bird flu virus are being thwarted by poor villagers hiding their birds, officials said on Wednesday. Hundreds of veterinary workers in protective suits were only able to kill about 250 birds after they began culling operations in the Malda district of West Bengal on Tuesday.
They have set a target of 16,500 chickens and ducks to be killed by Thursday, with owners to be compensated by the state.

"The villagers tried to hide their poultry that survived the virus," said Bishon Chowdhury, a senior local government official. "Also, many resisted because the workers arrived without spot payments for the culled birds," he said"

http://in.reuters.com/article/topNews/idINIndia-37070820081217?rpc=401&=undefined&sp=true

4. China has confirmed H5N1 outbreak in poultry

"NEARLY 380,000 birds were slaughtered after the deadly strain of H5N1 avian flu was found in east China's Jiangsu Province, the Ministry of Agriculture said yesterday. The virus was discovered in Dongtai City and neighboring Hai'an County, the ministry said in a statement posted on its Website. There were no reports of human cases.

The ministry said it received information about H5N1 infection among hens in Dongtai and Hai'an on Monday. It was discovered during routine checks; no birds were reported sick."

http://www.shanghaidaily.com/article/?id=384822&type=National

A Picture is Worth a Thousand Words...

...or in this case, a map!


The Avian Influenza Daily Digest has posted two maps of avian influenza on Google Earth that are worth looking up:

1. An HPAI H5N1 Outbreak Map that allows you to see the global count and spread of all suspected and confirmed cases of HPAI H5N1 in the last 60 days.

---> Click here to go directly to the map: http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=102482117988980681054.00045a2ebacb3c3646bab&ll=-8.015716,112.664795&spn=5.372291,7.514648&t=h&z=7


2. An H5N1 in Humans Map that lets you see all cases of human infection with H5N1 confirmed by the World Health Organization for 2008.

--->Click here to go directly to the map: http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=102482117988980681054.000458ed12a9ceb195b6e&t=h&z=3



These two maps are great tools to help visualize the recent spread of avian influenza in the world. We hope you will find it helpful!

An avian flu success story!

I saw this story on Crofsblog and had to make sure all of you saw it! It's a report about the farmer who had the unlucky distinction of being the first outbreak of H5N1 on the China mainland in 2004. Because of the experience he transitioned from being a backyard farmer that made very little off of poultry to establishing a large poultry farm which follows biosecurity measures and makes a great profit!

Excerpt below:

"Nearly five years ago he was hiding from reporters and even fearing for his life. Today he is a very successful local chicken farmer with a lot to crow about.

His Dingdang chicken brand is now sold in the markets of Nanning, capital of the Guangxi Zhuang autonomous region in Southwest China. It is also sold in Hong Kong and Macao too.
I remember talking to Huang on his duck farm in Dingdang Town during the 2004 crisis. We both wore white coats and masks for fear of contracting bird flu, which killed 200 of Huang's ducks.

It was confirmed to be the first case of H5N1 subtype of avian influenza on the mainland.
A gravel path zigzags through patches of sugar cane and orange trees to Huang's home. Back in 2004, it was coated with white lime for decontamination purposes. Today, grass and bushes grow lavishly near the ponds, which were once swarming with ducks.

Now the grounds are a playground for his chickens, which are fenced inside the 0.4-hec farm.
Huang, a stout man in his mid-30s, walks with brisk steps, and arouses his 10,000 chickens into a cackling chorus. He asks me to dip my shoes into a shallow basin of liquid disinfectant before entering his farm.

"Were it not for bird flu, I would never have dreamed of making business out of it," Huang says, beaming with a broad smile. Huang is a changed man. In 2004, he locked himself in a deserted primary school refusing to meet busloads of journalists who flocked to interview him following the bird flu outbreak.

"I dreaded so much of contracting bird flu, and I was equally afraid of facing the media," he says.
Today, Huang is a spokesperson of Dingdang town, and even speaks on behalf of Longan, a county with 380,000 residents.

Back in 2004, Hui Liangyu, then China's vice-premier, came to Huang's town in the wake of the infection and encouraged local authorities to "help farmers to their feet from where they fell".
The Longan county authorities acted swiftly. Gan Qiangzhong, the then deputy magistrate, decided to modernize and develop a poultry industry out of the ruins.

"It had been a long tradition for farmers to raise fowls in their courtyard, without regular quarantine and disinfection," Gan says. "This meant they could not make decent money out of it, and it also increased the possibility of spreading disease."

The Fengxiang Poultry Co became a pioneer in Guangxi's poultry industry by investing 20 million yuan ($2.2 million) to build a breeding farm capable of supplying 18 million chicks a year to farmers. A skeptical Huang went to see the farm and attended the company's promotion sessions many times until he was convinced.

The company had no record of bird flu since it was founded in 1985 and provided veterinary services, such as drugs, monitoring technology and chicken feed. It also promised to purchase chickens at a preset prices, even when the market prices fluctuated. Huang's farm was the first in the Dingdang town to meet the parameters set by the company: it was far from the residential community, it had good ventilation, an adequate supply of clean water and also had fruit trees.
In July 2004, Huang became the first local partner of the Fengxiang company to raise chickens.
With a loan of 8,000 yuan and a subsidy of 2,000 yuan from local government, Huang built chicken pens for 5,000 baby chicks. To the envy of his peers, the farmer pocketed 4,000 yuan in the first deal. The local annual per capita income is 2,500 yuan.

"A chick grows up in 120 days, so you may raise about three rounds a year," he says. "On average, I can earn 20,000 yuan in profit a year."

Twice a day, Huang and his wife feed chicks and chickens, which also scratch around for insects beneath fruit trees. The couple also administers medicine to the chicks to warn off disease.
The Huangs' orange orchard has also become more profitable. They no longer need to buy tons of manure to fertilize the trees thanks to the steady source of chicken manure. Huang even sells manure to banana growers.

Occasionally, a few chickens die of bowel disease or from sudden temperature changes, and Huang reports the deaths to the Fengxiang company, which sends workers for checkups.
But bird flu has never again haunted his farm, he says."


http://www.chinadaily.com.cn/china/2008-12/15/content_7304190.htm

Update on current outbreaks and human cases

It's begining to look a lot like avian flu season out there...

1. Cambodia has confirmed a new human case

"Cambodia's Health Ministry has confirmed the country's eighth human case of virulent bird flu since 2005.The ministry was quoted by news reports as saying in a statement issued with the UN's World Health Organisation on December 12 that a 19-year-old man from Kandal province, southeast of the capital Phnom Penh, was confirmed to have the deadly H5N1 strain of the virus. The man is being treated at Calmette Hospital in the capital. Cambodian health and agriculture ministry officials have been dispatched to the victim's village to ensure that there is no further spread of the disease. The case, the first this year in Cambodia, comes a day after a senior World Health Organization official warned that Asian nations must remain vigilant against the disease.-Enditem"

http://www.vnanet.vn/Home/EN/tabid/119/itemid/278964/Default.aspx

2. Culling operations in Assam, India are in their 17th day

"Culling operations continued for the 17th day today in Assam, with nearly 3.80 lakh birds culled in six bird-flu affected districts. Director of animal husbandry and veterinary department Dr A Kakati said 17,942 birds were culled, and 33,937 eggs were destroyed today. Culling is expected to be completed by tomorrow, he said. More than 900 members of the rapid response team are active in the affected districts for culling, mopping or combing, surveillance and for disinfection, he said. However, there was no report of avian flu being transmitted to humans, and a strict surveillance was being maintained and measures were being taken, to ensure that the disease does not spread to fresh areas."

http://www.sakaaltimes.com/2008/12/15214011/Culling-operations-on-for-17th.html

3. New H5N1 outbreaks confirmed in birds in West Bengal, India

" Laboratory tests on dead birds have proven a new outbreak of the H5N1 bird flu virus in the eastern Indian state of West Bengal, a state government official said on Monday...West Bengal officials said several hundred birds could have been found dead but disputed local media reports that as many as 5,000 birds were dead."

http://in.reuters.com/article/domesticNews/idINSP42137920081215?sp=true

Looking for human cases in the Assam outbreak in India

Some good news and some bad news this morning. The bad news first:

"India is sending bird flu experts to the northeastern state of Assam and setting up isolation units to treat up to 90 people showing signs of the virus, health authorities said on Friday.
Health workers have yet to confirm any human cases of H5N1, but they said some patients were suffering from fever and respiratory infections, which are symptoms of the virus in humans...

"So far none of the patients has a history of contact with infected poultry, but we are taking no chances. If the disease is transmitted to humans it will be a big disaster," Sarma said.
The medical teams brought supplies of equipment as a preventative measure in case the virus spreads to humans, including 10,000 Tamiflu capsules, 6,000 surgical masks and two ventilators."

Anytime we have large numbers of people with flu like illness there is a possibility that this could be a human to human cluster. The good news is seeing governments take this seriously and "taking no chances"

http://www.reuters.com/article/healthNews/idUSTRE4BB36M20081212

H5N1-confirmed death in Indonesia: Ending three-month stretch of no human deaths

The WHO released an update today announcing the Indonesian Ministry of Health confirmed two new cases of human infection with H5N1.

One patient, a 9-year-old who developed symptoms on November 7 and was hospitalized on November 12 recovered nearly two weeks later. Lab tests recently confirmed the illness was in fact H5N1. The infection was linked to poultry deaths near her home.

"The second case, a 2-year-old female from East Jakarta, developed symptoms on 18 November, was hospitalized on 26 November and died on 29 November. Laboratory tests have confirmed infection with the H5N1 avian influenza virus. Initial investigations into the source of her infection suggest exposure at a live bird market.

The case-fatality rate remains exceedingly high in Indonesia, more than 80% of the 139 confirmed cases in Indonesia have been fatal.

The full report can be found at: http://www.who.int/csr/don/2008_12_09/en/

More on the "One World, One Health" Movement

The Herald Tribue (Sarasota Florida) had a good article today about the "One World, One Health" concept. The concept for "One World, One Health" has been around for a while, but with the recent focus on it at the Sharm El Sheikh conference we may be seeing a renewed interest and commitment to concept by major institutional players and donors.

Guest columnist Bruce Kaplan describes the movement:

"The "One Health Initiative" is a movement to forge co-equal, all inclusive communications and collaborations between physicians, veterinarians and other scientific-health related disciplines. This has been limited or absent for much of the 20th century.

When properly implemented, the sharing of scientific information will help protect and save millions of lives in present and future generations. The One Health concept is a worldwide strategy for expanding interdisciplinary interactions in all aspects of health care for humans and animals. The synergism achieved will accelerate biomedical research, enhance public health efficacy, expand the scientific knowledge base, and improve medical education and clinical care."

Though we often hear about the lack of collaboration, Kaplan gives three examples of success:

"1. A physician and veterinarian research team in 1893, Drs. Theobald Smith and F.L. Kilbourne, discovered the cause of cattle fever, Babesia bigemina, and that it was being transmitted by ticks. This work helped set the stage for the discovery by Walter Reed and his colleagues of the transmission of yellow fever in humans.

2. The Ebola virus was identified as the cause of Ebola hemorrhagic fever in the 1970s through the collaboration of veterinarian Fred Murphy and physician Karl Johnson. These two made history by working closely together at the CDC on this and other topics. Hemorrhagic fever viruses are now designated by CDC as bioterrorism agents.

3. Rolf Zinkernagel (physician) and Peter Doherty (veterinarian) working together as immunologists, discovered how the immune system tells normal cells from virus-infected cells. For this, they received the 1996 Nobel Prize for physiology or medicine."

While all of these examples are biomedical, CARE is working to focus efforts collaboration between human and animal health sectors in the community. It would be great to look at the work of outbreak response and prevention for successful collaboration.

http://www.heraldtribune.com/article/20081202/COLUMNIST/812020315/-1/NEWSSITEMAP

Suspsected human H5N1 cases in Turkey & Indonesia

There are two spots we're watching for potential human cases of H5N1, including hospitalized patients in Turkey and Indonesia

From Avian Influenza Daily Digest

"Turkey: 5 Hospitalized due to Suspected AI in Ortaklar Village
12/1/08 ARGUS--A regional source reports that 5 people in Ortaklar Village, Vezirkopru District who were visiting each other were hospitalized at Vezirkopru Government Hospital due to suspected avian influenza (AI) after consuming an unspecified number of sick chickens and complaining of fever and nausea. According to the source, laboratory tests are underway. Reportedly, 1 child and 1 adult remain hospitalized. 3 were discharged."

The second location is in Rejoso Village, Ampel, Boyolali Indonesia where a family is being tested and observed. However, there is very little information at this time

http://curevents.org/showthread.php?t=262&page=7

http://curevents.org/showthread.php?t=262&page=7

Mapping CARE's programs and capacity in avian and pandemic influenza

Through collaboration with the CDC and our Avian and Pandemic Influenza Program, CARE’s Capacity Map of Avian & Pandemic Influenza programs has been completed and is now available on our AI & pan flu website. This compendium of programs, activities and staff capacity is a wonderful summary of the global efforts being administered by CARE to help prevent and respond to avian influenza and prepare for a pandemic.

The same information is also available in an innovative format - CARE’s work in avian influenza has been imported and mapped into Google Maps & Google Earth. It is now possible for anyone to view CARE’s AI work around the globe when a simple search through the Google Maps program is performed.

The following link will take you to the proper site on Google Maps: http://maps.google.com/maps/ms?msa=0&msid=108637105166402366018.000444f333cd335921d21. Alternatively, you can go to Google.com, select “Maps” and do a search for “CARE's Work in Avian & Pandemic Influ­enza.”

We have also embedded the map on the CARE AI website: http://icarenews.care.org/avianflu.html