What Would You Do About Bird Flu

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What Would You Do About Bird Flu? Andrew
Clements USAID/Asia and Middle East
Bureaus USAID/Bureau for Global Health Mini
University 9-12-08
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• Format
• Presentation of key information on context (e.g.
  disease situation, country vulnerabilities,
  available tools, etc.)
• (25 minutes)
• Discussion on strategic approaches
• (35 minutes)

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Nature of the Public Health Threat

• Based on current incidence, H5N1
  Highly-Pathogenic Avian Influenza (HPAI) not a
  significant public health threat
• lt100 confirmed H5N1 human deaths per year
• ? HIV, TB, and malaria each kill gt1 million per
  year

• However, H5N1 qualifies as a significant public
  health threat if potential impact is taken into
  consideration
• influenza pandemics occur periodically and vary
  in severity
• ? 1918 flu pandemic killed 50 million people
  worldwide
• H5N1 already has some properties associated with
  pandemic flu viruses, but lacks ability to
  efficiently spread among people
• ? inefficient spread among people likely
  occurred in at least 4 countries
• H5N1 continues to spontaneously mutate
• ? 10 clades (i.e. families) of H5N1 HPAI since
  1996 emergence

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Potential Impact (Part 1)
A new threat and a gloomy forecast
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Potential Impact (Part 2)
Planning, financing, and response related to new
potential disasters is influenced by previous
experiences, particularly recent ones
Influenza Pandemic 1918-1919
SARS Pandemic 2003
Hurricane Katrina 2005
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(No Transcript)
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Who is Most Affected?

• H5N1
• Almost all H5N1 infections occur in birds and
  majority of these in domestic poultry
• H5N1 infections in humans (and other mammals)
  can occur, but relatively uncommon
• most associated with close contact with
  sick/dead poultry

• Human Flu Pandemic
• Mortality rates during 1918 pandemic highest
  among poor, especially in developing countries
• Future flu pandemic ? estimated that gt95 of
  excess mortality worldwide will be in developing
  countries

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Where do H5N1 Outbreaks Occur?
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Which Countries are Most Affected?

• All have Gross National Income Purchasing Power
  Parity per capita lt US10,000
• All have poultry populations gt100 million and 3
  have poultry populations gt 1 billion

sources WHO, OIE reports from 2003-2008
Population Reference Bureau. All countries
have reported poultry outbreaks and at least one
human case, except for India (only poultry
outbreaks).
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What Risk Factors are Associated with H5N1
Introduction Maintenance in Poultry?

• Large and dense poultry populations
• ? especially ducks and free-range poultry in
  some countries
• Poor biosecurity on poultry farms and in live
  bird markets
• Proximity to or trade with highly-affected areas
• ? especially where weak regulation of
  poultry movement, including ducks
• and vaccinated chickens that can be H5N1
  infected, but not appear sick
• Presence and movement of migratory and other
  wild birds?
• Most poultry outbreaks occur in December?March
• Weak H5N1 surveillance and slow detection times
• Slow outbreak response times and incomplete
  containment

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What Risk Factors are Associated with Human H5N1
Infections?

• Close association with infected poultry and
  feces
• ? Number/timing of human H5N1 cases correlates
  with number/timing of poultry outbreaks
  indicating direct or indirect bird-to-human
  transmission
• High-risk behaviors thought to include
  slaughtering and defeathering
• Close association with H5N1 infected people
• At least 11 cases of likely limited and
  unsustained human-to-human transmission of H5N1
  in China, Indonesia, Pakistan, Thailand
• Susceptibility to H5N1 infection based on
  genetic
• predisposition???

Source WHO reports of lab-confirmed H5N1 cases
in humans through 6/20/08.
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What Challenges Exist for Poultry Production
Marketing in Developing Countries?

• Commercial and backyard farms commonoften in
  close proximity to human populations
• Massive increases in poultry production in recent
  decades, often outpacing regulatory capacity?high
  poultry densities
• General lack of good biosecurity (to prevent
  disease introduction/spread) on many farms and in
  live bird markets
• ?markets facilitate disease spread by bringing
  together different types of birds from different
  areas/countries
• Legal (and illegal) poultry transport in/outside
  of countries common
• Preference for local slaughter of poultry,
  including at home

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Illustrative Examples of Poultry Production in
Developing Countries
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Illustrative Examples of Bird-Human Interactions
in Developing Countries
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What Other Systemic Challenges Exist?

• Most developing countries have limited ability
  to
• monitor disease patterns
• identify new organisms
• - investigate outbreaks, routes of transmission
• stockpile and mobilize commodities
• rapidly respond with trained staff
• educate public on prevention care seeking
• regulate unsafe animal rearing/transport/selling
• coordinate routine and emergency operations
  among
• health, animal, other sectors

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How Fast Can H5N1 Spread?
Bangladesh (2007-2008)
Sources OIE
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What Tools are Available for Preventing and
Containing H5N1 AI in Poultry?
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What Tools are Available for Preventing and
Containing H5N1 AI in Poultry?
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What International Funding is Available for AI
Prevention and Control Worldwide?
Total funding (FY2005-FY2007) 2.7 billion
All other donors
United States
Japan
World Bank
European Commission
Asian Development Bank
Data from State Department Avian Influenza Action
Group
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H5N1 Summary

• H5N1 outbreaks
• Mostly concentrated in a limited number of
  developing countries in Asia and Middle East
• Mostly occur in December to March timeframe
• Mostly affect poultry
• Caused by a variety of different H5N1 clades
• Can be contained using tools such as active
  surveillance, farm biosecurity, culling, poultry
  vaccination, and IEC/BCC
• Systemic problems make rapid detection
  containment difficult

Pandemic flu impact is likely to be most severe
in developing countries

• Significant amounts of donor funding available
• Mostly for pandemic prevention

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Discussion
What Would You Do About Bird Flu?
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• What is your objective Stop a human pandemic?
  Prevent human cases? Prevent poultry outbreaks?
• Would you fund activities with developing
  country funds or with donor funds?
• How would you divide resources between pandemic
  prevention and pandemic preparedness?
• Where would you focus activities geographically?
• On which animal populations would you focus
  activities?
• Would you focus activities on certain times of
  year?
• What kinds of tools would you use?
• Would you target interventions on the commercial
  poultry producers, live bird markets, or back
  yard farms?
• How would you address systemic weaknesses in
  country capacity?