Strengthening Avian Influenza Detection and Response SAIDR:

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• Strengthening Avian Influenza Detection and
  Response (SAIDR)
• One Health Approach
• Dr. Gavin Macgregor-Skinner
• BVSc, MSc, MPH, MRCVS
• Senior Public Health Advisor/Epidemiologist
• U.S. Agency for International Development

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Should we be prepared?
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Prerequisites for a pandemic

• A novel virus subtype must emerge
• The virus must be able to replicate in humans and
  cause serious disease
• X The virus must be efficiently transmitted from
  one human to another

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Egypt Strengthening Avian Influenza Detection
and Response Team, 18 June 2008
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DIP Focus

• Implementation of surveillance and response
  methods
• Strengthening epidemiological analysis
• Further review and adjustment of control
  strategies
• Strengthening operational field activities.
• Nation-wide training
• Improving communication.
• Improving inter-ministerial coordination.
• Participatory approaches

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Partners

• Ministry of Health and Population
• Ministry of Agriculture and Reclamation
• Ministry of Environment
• FAO
• WHO
• CHL
• USAID
• USDA/APHIS
• CDC
• NAMRU3
• World Bank
• EU
• OIE
• UNICEF

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Overview of the Current Situation
As of 28 May 2008? H5N1 detected in birds in
60 countries - affected countries in
Asia, Europe, Near East, Africa? H5N1 detected
in humans in 15 countries - total of
383 cases and 241 deaths reported -
average of 5-9 new cases per month -
fatality rate 63
sources WHO, OIE
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Confirmed Bird outbreaks in 2008
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H5N1 Burden Concentrated in 15 Countries

• Countries
• Afghanistan
• Bangladesh
• Burma
• Cambodia
• China
• Egypt
• Indonesia
• Kuwait
• Nigeria
• Pakistan
• Russia
• South Korea
• Thailand
• Turkey
• Vietnam

• These 15 countries account for
• 94 of poultry outbreaks since Dec 2003
• 89 of poultry outbreaks in 2007
• 75 of poultry died/culled in 2007
• 93 of human cases since Dec 2003
• 96 of human cases in 2007

Source OIE and WHO reports. All countries have
had at least 20 poultry outbreaks since Dec 2003
and at least 1 poultry outbreak or human case in
2007.
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Animals Affected by HPAI H5N1 Since 2003
Mammals cat civet dog human leopard pig stone
marten tiger
Birds buzzard chicken cormorant coot crow duck
eagle falcon flamingo goosander goose grebe guin
ea fowl gull heron Japanese white eye
magpie myna ostrich owl partridge peacock pheasan
t pigeon quail robin smew sparrow stork swan turke
y vulture
Highly-Pathogenic Avian Influenza domestic
and wild.
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Clinical Symptoms - Chicken
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Confirmed human cases since 2003
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Human Clinical H5N1 Cases Whats New?

• Answer NOT MUCH!
• 383 H5N1 human cases, 241 deaths (15 countries)
• Limited H5N1 clinical data available or published
• Limited epidemiological data available since 2006
• Case-finding focused upon severe respiratory
  disease

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Some ideas Human cases

• Expand data collected from human cases beyond
  "contact with sick or dead poultry - define
  species of poultry (chickens, ducks, geese etc.)
  and contact e.g. touching, slaughtering, burying,
  preparing for consumption, playing with dead
  poultry parts, playing with live poultry,
  de-feathering dead birds, visited a poultry farm
  or live bird market, etc.
• Conduct sero-surveys to investigate frequency of
  asymptomatic infection or mild illness in humans.
  e.g Hong Kong 1997 - 10 of poultry workers and
  3 of government poultry cullers had H5N1
  neutralizing antibodies.
• Follow-up studies of survivors - Identify factors
  possibly associated with survival and conduct
  serology, measure lung volume, radiographic
  findings in survivors, other complications

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CXR findings in confirmed H5N1 cases, Vietnam 2004
Hien TT et al., New England J Med
20043501179-1188
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Many Unanswered Questions

• Better understanding of pathogenesis
• How to implement early, rapid diagnosis of H5N1?
• Immunology of H5N1 virus infection?
• Identify risk factors for infection?
• Outbreak investigations, epidemiological data?
• Case-Control studies
• Magnitude of H5N1 infections (hotspots)
• Much more collaborative data collection and
  integrated analysis of data

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Egypt Feb 2006 to Nov 2007
958 outbreaks
Source www.oie.int 3 Dec 07
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Location of Human H5N1 cases
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www.gains.org
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Africa AI www.africaai.net
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Local Resources
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Influenza Type A Antigen Positive
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Licensing Diagnostic Tests and Vaccines

• We need data!

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FAO Manual Participatory Epidemiology
http//www.participatoryepidemiology.info/Training
Materials.html
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Participatory Disease Surveillance - Sudan
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Indonesia - Community Mapping
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Mapping in the rural Indonesian PDS Context
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Mapping in the peri-urban Indonesian PDS Context
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Indonesia HPAI H5N1 Cases
AI confirmed in 30/33 Provinces 216/444 Districts
Source GOI and FAO Indonesia
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Tracheal Samples
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Cloacal Samples
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Personal Protection
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PPE Distribution Nov 07
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PPE kit in use
PPE kit unpacked
Snow not included
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Mapping outbreaks and resources Google Earth
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Effective Response
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Egypt Immunization status in children by
household
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Egypt Caging poultry and separation of species
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Egypt Caging poultry and separation of species
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Egypt Caging poultry and separation of species
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Standardized Protocols - Hospitals
Source Tim Uyeki/Ray Arthur, CDC
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Standardized Protocols - Farms
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Standardized protocols
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Vaccination Team
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Vaccination Records
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Biosecurity Disinfecting People
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Biosecurity Disinfecting Vehicles
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Biosecurity Disinfecting Vehicles
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Biosecurity Disinfecting Vehicles
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Let Others Know of Outbreak
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Let Others Know of Outbreak
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Let Others Know of Outbreak
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Conclusion

• By integrating and coordinating both animal and
  human health sectors, we have the chance to
  simultaneously save lives and secure livelihoods.
• One World, One Health, One Legacy