- Email: [email protected]
Averting avian influenza pandemic: SOS from a developing country
Reflection and Reaction
and universal hygiene promotion (despite difficult surroundings) such as handwashing with soap and water, and cough/respiratory etiquette. Other measures comprise infection-control procedures including the use of surgical masks (or scarves if masks are unavailable) by patients and health-care providers, maximising physical separation between patients, and the establishment of triage systems at health-care facilities that are based on lessons learnt from trauma cases in war situations. Whereas the guidelines are directed at refugee and displaced populations, some of the conclusions are equally applicable to stable, resource-poor settings. Some general issues, equally important for displaced populations, remain unanswered, such as the most appropriate antibiotics for secondary bacterial pneumonia and the duration and effectiveness of antiviral prophylaxis for health-care staff.
WHO is working with ministries of health in countries with refugee and displaced populations to ensure inclusion into national plans. WHO is also providing technical support to humanitarian agencies working towards minimising the health and social impact of pandemic influenza in these populations. *Michelle Gayer, John T Watson, Máire A Connolly Communicable Diseases Cluster, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (MG, JTW, MAC). [email protected] We declare that we have no conflicts of interest. 1 2
Ezard N, Gupta R. Influenza pandemic plans: what about displaced populations? Lancet Infect Dis 2006; 6: 256–57. WHO. Pandemic influenza preparedness and mitigation in refugee and displaced populations: WHO guidelines for humanitarian agencies. Geneva: World Health Organization, 2006. http://www.who.int/csr/ disease/avian_influenza/guidelines/avian2006-04-9a.pdf (accessed Oct 25, 2006).
Averting avian influenza pandemic: SOS from a developing country
Binsar Bakkara/AP/Empics
The number of human avian influenza H5N1 cases in Indonesia continues to increase. Up to Oct 27, 2006, 72 confirmed cases were reported of which 55 were fatal. There are many more probable cases (12, four fatal) and suspect cases (120, 37 fatal).1,2 The biggest cluster is in Garut district, west Java, where 20 suspect cases were recorded, three of them confirmed cases of whom two have died and one recovered.2,3 In Indonesia, not all people have access to health facilities, especially the poor and people living in remote areas. Therefore, the recorded cases might be the tip of the iceberg. According to government policy, human cases should be isolated. However, in practice this is difficult to do—eg, in Garut district a confirmed case was forced to go home. Fortunately this person recovered.4 In Karo, north Sumatra, three people with suspected disease went home without doctor’s permission.5 This situation obviously has a role in the appearance of new cases, when human-to-human transmission can happen as suspected.6 Therefore, every case should be properly handled. Spread of avian influenza in poultry cannot be stopped yet. In north Sumatra, avian influenza has spread recently to three additional villages in Dairi 756
district,2 even though culling was done in a 1 km radius from the point of positive finding.7 In west Java, avian influenza in poultry has been found in 20 out of the 25 districts.2 Poultry in affected areas should be culled and their owners compensated, a practice that is part of government policy. However, in areas where the local population is resistant to the policy, culling might involve the police and army, as happened in Karo, north Sumatra. Though the government gave compensation for the culled poultry, some farmers were reluctant to have their poultry killed.5,8 Moreover, some people did not like their village being declared as affected, and they denied the fact.5 This behaviour might be because of compensation for the culled poultry not being given directly. Corruption still flourishes in Indonesia, and farmers might have doubted that they would get proper compensation for their culled poultry. Considering the many problems in handling avian influenza in poultry and human cases, Indonesia might be the source of a pandemic. Therefore, national governments and international organisations should work shoulder to shoulder with the Indonesian government by providing funding, expertise, and monitoring of activities. http://infection.thelancet.com Vol 6 December 2006
Reflection and Reaction
Jeanne Adiwinata Pawitan Department of Histology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia [email protected]
4 5 6
I declare that I have no conflicts of interest. 1 2 3
Anon. 12 000 ready-to-act villages are ready to be launched at 12th November. Kompas 2006, Oct 27; 13 (in Indonesian). Anon. Dead victims became 18. Kompas 2006 Aug 23; 15 (in Indonesian). Anon. Avian influenza. Suspect cases become 20. Kompas 2006 Aug 24; 15 (in Indonesian).
7 8
Anon. Avian influenza victims appeared in Garut. Kompas 2006 Aug 22; 13 (in Indonesian). Anon. Avian influenza. Patients from Karo left hospital silently. Kompas 2006 Aug 7; 15 (in Indonesian). Santoso Soeroso. Questions and lesson learnt from current situation on avian influenza in Indonesia. International symposium. Challenge and implication of avian flu on human security: sharing problems and solutions. Jakarta, Indonesia; July 13–14, 2006. Anon. Avian influenza virus has spread. Kompas 2006 Aug 14; 24 (in Indonesian). Anon. Culling of around 3000 chickens was guarded by the army. Kompas 2006 Aug 4; 13 (in Indonesian).
Surveillance for avian influenza in human beings in Thailand Timely and thorough surveillance for avian influenza in human beings is essential to monitor the disease situation and prevent possible person-to-person spread. On July 26, 2006, Thailand reported its 23rd confirmed human case of avian influenza, marking the onset of the fourth wave of H5N1 infections in poultry and human beings in Thailand since early 2004.1 During this fourth wave, Thailand’s routine reporting of suspected human avian influenza cases, often more than 100 each day, has led to confusion among both lay and scientific observers.2 In fact, the reporting of “high” numbers of influenza-like illness or pneumonia cases requiring epidemiologic investigation should be considered a model for affected countries with similar poultry and human demographics. Although country reports of laboratory-confirmed cases to WHO remain the official channel for reporting and international notification, it is difficult for the global community to assess the effectiveness of a country’s surveillance system if these reports are the only official surveillance data available. Reporting to WHO indicates that a country is able to confirm avian influenza A (H5N1), but the reports provide no denominator data (ie, the total number of confirmed and suspected cases), which would allow understanding of the data’s relevance or context. Because contact with poultry is widespread in most countries where avian influenza has been reported, and because pneumonia is among the leading infectious causes of mortality worldwide, one would expect a high background rate of cases requiring investigation. Here we estimate the expected number of people with severe pneumonia and poultry contact in Thailand and compare these data with recent surveillance reports. Since 2001, the Thailand Ministry of Public Health and the US Centers for Disease Control and Prevention (CDC) http://infection.thelancet.com Vol 6 December 2006
have collaborated to implement active, populationbased surveillance for severe pneumonia requiring hospital admission in two provinces in rural Thailand. Standard case definitions, routine radiographic confirmation with standard interpretations from a panel of radiologists blinded to clinical information produce reliable data on incidence, which range from a measured incidence of 177 to a maximum estimate of 580 cases per 100 000 people per year.3 Additionally, household surveys conducted in 2004 showed that 74% of people in rural Thailand reported having poultry in their backyards.4 Therefore, the background rate of both pneumonia and poultry exposure could be between 131 and 429 per 100 000 people per year. Applied to the Thailand population of 64 631 595, as many as 84 667–277 270 people might be expected to have both pneumonia and poultry exposure each year. Assuming an equal frequency of pneumonia throughout the year, 7056–23 106 cases might fit the criteria for investigation each month. The Thailand Ministry of Public Health reported a cumulative total of 5354 influenza-like illness or pneumonia cases that were investigated in 72 of 76 provinces between Jan 1 and Oct 26, 2006—an average of 535 cases per month.5 Reporting was lower in provinces deemed unaffected and during months when H5N1 virus among poultry was not observed. Among these suspected human cases, only three had laboratory-confirmed avian influenza A (H5N1). Many more people have had confirmed human influenza infection, especially during July, a peak month for human influenza in Thailand, as recently shown by the enhanced surveillance system.6 These data indicate both a low rate of true cases and an active surveillance system with routine reporting. 757
and universal hygiene promotion (despite difficult surroundings) such as handwashing with soap and water, and cough/respiratory etiquette. Other measures comprise infection-control procedures including the use of surgical masks (or scarves if masks are unavailable) by patients and health-care providers, maximising physical separation between patients, and the establishment of triage systems at health-care facilities that are based on lessons learnt from trauma cases in war situations. Whereas the guidelines are directed at refugee and displaced populations, some of the conclusions are equally applicable to stable, resource-poor settings. Some general issues, equally important for displaced populations, remain unanswered, such as the most appropriate antibiotics for secondary bacterial pneumonia and the duration and effectiveness of antiviral prophylaxis for health-care staff.
WHO is working with ministries of health in countries with refugee and displaced populations to ensure inclusion into national plans. WHO is also providing technical support to humanitarian agencies working towards minimising the health and social impact of pandemic influenza in these populations. *Michelle Gayer, John T Watson, Máire A Connolly Communicable Diseases Cluster, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (MG, JTW, MAC). [email protected] We declare that we have no conflicts of interest. 1 2
Ezard N, Gupta R. Influenza pandemic plans: what about displaced populations? Lancet Infect Dis 2006; 6: 256–57. WHO. Pandemic influenza preparedness and mitigation in refugee and displaced populations: WHO guidelines for humanitarian agencies. Geneva: World Health Organization, 2006. http://www.who.int/csr/ disease/avian_influenza/guidelines/avian2006-04-9a.pdf (accessed Oct 25, 2006).
Averting avian influenza pandemic: SOS from a developing country
Binsar Bakkara/AP/Empics
The number of human avian influenza H5N1 cases in Indonesia continues to increase. Up to Oct 27, 2006, 72 confirmed cases were reported of which 55 were fatal. There are many more probable cases (12, four fatal) and suspect cases (120, 37 fatal).1,2 The biggest cluster is in Garut district, west Java, where 20 suspect cases were recorded, three of them confirmed cases of whom two have died and one recovered.2,3 In Indonesia, not all people have access to health facilities, especially the poor and people living in remote areas. Therefore, the recorded cases might be the tip of the iceberg. According to government policy, human cases should be isolated. However, in practice this is difficult to do—eg, in Garut district a confirmed case was forced to go home. Fortunately this person recovered.4 In Karo, north Sumatra, three people with suspected disease went home without doctor’s permission.5 This situation obviously has a role in the appearance of new cases, when human-to-human transmission can happen as suspected.6 Therefore, every case should be properly handled. Spread of avian influenza in poultry cannot be stopped yet. In north Sumatra, avian influenza has spread recently to three additional villages in Dairi 756
district,2 even though culling was done in a 1 km radius from the point of positive finding.7 In west Java, avian influenza in poultry has been found in 20 out of the 25 districts.2 Poultry in affected areas should be culled and their owners compensated, a practice that is part of government policy. However, in areas where the local population is resistant to the policy, culling might involve the police and army, as happened in Karo, north Sumatra. Though the government gave compensation for the culled poultry, some farmers were reluctant to have their poultry killed.5,8 Moreover, some people did not like their village being declared as affected, and they denied the fact.5 This behaviour might be because of compensation for the culled poultry not being given directly. Corruption still flourishes in Indonesia, and farmers might have doubted that they would get proper compensation for their culled poultry. Considering the many problems in handling avian influenza in poultry and human cases, Indonesia might be the source of a pandemic. Therefore, national governments and international organisations should work shoulder to shoulder with the Indonesian government by providing funding, expertise, and monitoring of activities. http://infection.thelancet.com Vol 6 December 2006
Reflection and Reaction
Jeanne Adiwinata Pawitan Department of Histology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia [email protected]
4 5 6
I declare that I have no conflicts of interest. 1 2 3
Anon. 12 000 ready-to-act villages are ready to be launched at 12th November. Kompas 2006, Oct 27; 13 (in Indonesian). Anon. Dead victims became 18. Kompas 2006 Aug 23; 15 (in Indonesian). Anon. Avian influenza. Suspect cases become 20. Kompas 2006 Aug 24; 15 (in Indonesian).
7 8
Anon. Avian influenza victims appeared in Garut. Kompas 2006 Aug 22; 13 (in Indonesian). Anon. Avian influenza. Patients from Karo left hospital silently. Kompas 2006 Aug 7; 15 (in Indonesian). Santoso Soeroso. Questions and lesson learnt from current situation on avian influenza in Indonesia. International symposium. Challenge and implication of avian flu on human security: sharing problems and solutions. Jakarta, Indonesia; July 13–14, 2006. Anon. Avian influenza virus has spread. Kompas 2006 Aug 14; 24 (in Indonesian). Anon. Culling of around 3000 chickens was guarded by the army. Kompas 2006 Aug 4; 13 (in Indonesian).
Surveillance for avian influenza in human beings in Thailand Timely and thorough surveillance for avian influenza in human beings is essential to monitor the disease situation and prevent possible person-to-person spread. On July 26, 2006, Thailand reported its 23rd confirmed human case of avian influenza, marking the onset of the fourth wave of H5N1 infections in poultry and human beings in Thailand since early 2004.1 During this fourth wave, Thailand’s routine reporting of suspected human avian influenza cases, often more than 100 each day, has led to confusion among both lay and scientific observers.2 In fact, the reporting of “high” numbers of influenza-like illness or pneumonia cases requiring epidemiologic investigation should be considered a model for affected countries with similar poultry and human demographics. Although country reports of laboratory-confirmed cases to WHO remain the official channel for reporting and international notification, it is difficult for the global community to assess the effectiveness of a country’s surveillance system if these reports are the only official surveillance data available. Reporting to WHO indicates that a country is able to confirm avian influenza A (H5N1), but the reports provide no denominator data (ie, the total number of confirmed and suspected cases), which would allow understanding of the data’s relevance or context. Because contact with poultry is widespread in most countries where avian influenza has been reported, and because pneumonia is among the leading infectious causes of mortality worldwide, one would expect a high background rate of cases requiring investigation. Here we estimate the expected number of people with severe pneumonia and poultry contact in Thailand and compare these data with recent surveillance reports. Since 2001, the Thailand Ministry of Public Health and the US Centers for Disease Control and Prevention (CDC) http://infection.thelancet.com Vol 6 December 2006
have collaborated to implement active, populationbased surveillance for severe pneumonia requiring hospital admission in two provinces in rural Thailand. Standard case definitions, routine radiographic confirmation with standard interpretations from a panel of radiologists blinded to clinical information produce reliable data on incidence, which range from a measured incidence of 177 to a maximum estimate of 580 cases per 100 000 people per year.3 Additionally, household surveys conducted in 2004 showed that 74% of people in rural Thailand reported having poultry in their backyards.4 Therefore, the background rate of both pneumonia and poultry exposure could be between 131 and 429 per 100 000 people per year. Applied to the Thailand population of 64 631 595, as many as 84 667–277 270 people might be expected to have both pneumonia and poultry exposure each year. Assuming an equal frequency of pneumonia throughout the year, 7056–23 106 cases might fit the criteria for investigation each month. The Thailand Ministry of Public Health reported a cumulative total of 5354 influenza-like illness or pneumonia cases that were investigated in 72 of 76 provinces between Jan 1 and Oct 26, 2006—an average of 535 cases per month.5 Reporting was lower in provinces deemed unaffected and during months when H5N1 virus among poultry was not observed. Among these suspected human cases, only three had laboratory-confirmed avian influenza A (H5N1). Many more people have had confirmed human influenza infection, especially during July, a peak month for human influenza in Thailand, as recently shown by the enhanced surveillance system.6 These data indicate both a low rate of true cases and an active surveillance system with routine reporting. 757