Avian influenza in Hong Kong 1997-2002

Associations between attributes of live poultry trade and HPAI H5N1 outbreaks: a descriptive and network analysis study in northern Vietnam

Background

The structure of contact between individuals plays an important role in the incursion and spread of contagious diseases in both human and animal populations. In the case of avian influenza, the movement of live birds is a well known risk factor for the geographic dissemination of the virus among poultry flocks. Live bird markets (LBM's) contribute to the epidemiology of avian influenza due to their demographic characteristics and the presence of HPAI H5N1 virus lineages. The relationship between poultry producers and live poultry traders (LPT's) that operate in LBM's has not been adequately documented in HPAI H5N1-affected SE Asian countries. The aims of this study were to document and study the flow of live poultry in a poultry trade network in northern Vietnam, and explore its potential role in the risk for HPAI H5N1 during 2003 to 2006.

Results

Our results indicate that LPT's trading for less than a year and operating at retail markets are more likely to source poultry from flocks located in communes with a past history of HPAI H5N1 outbreaks during 2003 to 2006 than LPT's trading longer than a year and operating at wholesale markets. The results of the network analysis indicate that LPT's tend to link communes of similar infection status.

Conclusions

Our study provides evidence which can be used for informing policies aimed at encouraging more biosecure practices of LPT's operating at authorised LBM's. The results suggest that LPT's play a role in HPAI H5N1 transmission and may contribute to perpetuating HPAI H5N1 virus circulation amongst certain groups of communes. The impact of current disease prevention and control interventions could be enhanced by disseminating information about outbreak risk and the implementation of a formal data recording scheme at LBM's for all incoming and outgoing LPT's.

Association between human cases and poultry outbreaks of highly pathogenic avian influenza in Vietnam from 2003 to 2007: a nationwide study

This study quantifies the spatio-temporal association between outbreaks of highly pathogenic avian influenza H5N1 in domestic poultry (n = 3050) and human cases (n = 99) in Vietnam during 2003-2007, using rare events logistic regression. After adjusting for the effect of known confounders, the odds of a human case being reported to authorities increased by a factor of 6.17 [95% confidence interval (CI) 3.33-11.38] and 2.48 (95% CI 1.20 - 5.13) if poultry outbreaks were reported in the same district 1 week and 4 weeks later respectively. When jointly considering poultry outbreaks in the same and neighbouring districts, occurrence of poultry outbreaks in the same week, 1-week later, and 4 weeks later increased the odds of a human case by a factor of 2.75 (95% CI 1.43-5.30), 2.56 (95% CI 1.31-5.00) and 2.70 (95% CI 1.56-4.66) respectively. Our study found evidence of different levels of association between human cases and poultry outbreaks in the North and the South of the country. When considering the 9-week interval extending from 4 weeks before to 4 weeks after the week of reporting a human case, in the South poultry outbreaks were recorded in 58% of cases in the same district and 83% of cases in either the same or neighbouring districts, whereas in the North the equivalent results were only 23% and 42%. The strength of the association between human and poultry cases declined over the study period. We conclude that owner reporting of clinical disease in poultry needs to be enhanced by targeted agent-specific surveillance integrated with preventive and other measures, if human exposure is to be minimized.

Characterization of avian influenza viruses A (H5N1) from wild birds, Hong Kong, 2004-2008

Repeated detection of subclade 2.3.2 viruses in nonpasserine birds from different regions suggests possible establishment of this lineage in wild bird species.

From January 2004 through June 2008, surveillance of dead wild birds in Hong Kong, People’s Republic of China, periodically detected highly pathogenic avian influenza (HPAI) viruses (H5N1) in individual birds from different species. During this period, no viruses of subtype H5N1 were detected in poultry on farms and in markets in Hong Kong despite intensive surveillance. Thus, these findings in wild birds demonstrate the potential for wild birds to disseminate HPAI viruses (H5N1) to areas otherwise free from the viruses. Genetic and antigenic characterization of 47 HPAI (H5N1) viruses isolated from dead wild birds in Hong Kong showed that these isolates belonged to 2 antigenically distinct virus groups: clades 2.3.4 and 2.3.2. Although research has shown that clade 2.3.4 viruses are established in poultry in Asia, the emergence of clade 2.3.2 viruses in nonpasserine birds from Hong Kong, Japan, and Russia raises the possibility that this virus lineage may have become established in wild birds.

Analysis of H5N1 avian influenza infections from wild bird surveillance in Hong Kong from January 2006 to October 2007

Intensive surveillance of dead wild birds for H5N1 avian influenza infection is conducted in Hong Kong. Between January 2006 and October 2007 pooled cloacal and tracheal swabs from 17692 dead wild birds (from 16 different orders including 82 genera) were tested and 33 H5N1 highly pathogenic avian influenza viruses were isolated. No H5N1 infection has occurred in poultry farms since January 2003, or in live poultry markets in Hong Kong since November 2003 until a recent detection of H5N1 virus by surveillance of live poultry markets in June 2008. The gross and histopathology in the various H5N1-infected avian species is described, along with the performance of the virus isolation and polymerase chain reaction (PCR) tests used. This evaluation also included determination of virus titres and detection limits for the H5 haemagglutinin gene (H5)and matrix gene real-time reverse-transcription PCR tests in cloacal and tracheal swabs from 12 wild birds. The viruses isolated belonged to Clades 2.3.2 and 2.3.4, and within Clade 2.3.4 some clustering was evident based on H5 haemagglutinin gene haemagglutinating sequencing. There were no differences in the pathology findings between these subgroupings and the various diagnostic tests gave similar results for these viruses, except for a loss in sensitivity of the H5 real-time reverse-transcription PCR for several viruses in one cluster from birds submitted in February 2007. The use of multiple test methods was important in maintaining the diagnostic sensitivity for detecting avian influenza viruses with high genetic variability.

Highly pathogenic H5N1 avian influenza virus: cause of the next pandemic?

Since 1997, when human infections with a highly pathogenic (HP) avian influenza A virus (AIV) subtype H5N1 - previously infecting only birds - were identified in a Hong Kong outbreak, global attention has focused on the potential for this virus to cause the next pandemic. From December 2003, an unprecedented H5N1 epizootic in poultry and migrating wild birds has spread across Asia and into Europe, the Middle East, and Africa. Humans in close contact with sick poultry and on rare occasion with other infected humans, have become infected. As of early March 2007, 12 countries have reported 167 deaths among 277 laboratory-confirmed human infections to WHO. WHO has declared the world to be in Phase 3 of a Pandemic Alert Period. This paper reviews the evolution of HP AIV H5N1, molecular changes that enable AIVs to infect and replicate in human cells and spread efficiently from person-to-person, and strategies to prevent the emergence of a pandemic virus.

Linkages between animal and human health sentinel data

INTRODUCTION

In order to identify priorities for building integrated surveillance systems that effectively model and predict human risk of zoonotic diseases, there is a need for improved understanding of the practical options for linking surveillance data of animals and humans. We conducted an analysis of the literature and characterized the linkage between animal and human health data. We discuss the findings in relation to zoonotic surveillance and the linkage of human and animal data.

METHODS

The Canary Database, an online bibliographic database of animal-sentinel studies was searched and articles were classified according to four linkage categories.

RESULTS

465 studies were identified and assigned to linkage categories involving: descriptive, analytic, molecular, or no human outcomes of human and animal health. Descriptive linkage was the most common, whereby both animal and human health outcomes were presented, but without quantitative linkage between the two. Rarely, analytic linkage was utilized in which animal data was used to quantitatively predict human risk. The other two categories included molecular linkage, and no human outcomes, which present health outcomes in animals but not humans.

DISCUSSION

We found limited use of animal data to quantitatively predict human risk and listed the methods from the literature that performed analytic linkage. The lack of analytic linkage in the literature might not be solely related to technological barriers including access to electronic database, statistical software packages, and Geographical Information System (GIS). Rather, the problem might be from a lack of understanding by researchers of the importance of animal data as a 'sentinel' for human health. Researchers performing zoonotic surveillance should be aware of the value of animal-sentinel approaches for predicting human risk and consider analytic methods for linking animal and human data. Qualitative work needs to be done in order to examine researchers' decisions in linkage strategies between animal and human data.

Avian influenza vaccines and vaccination in birds

Although the use of vaccines against avian influenza viruses in birds has been discouraged over the years, the unprecedented occurrence of outbreaks caused by avian influenza (AI) viruses in recent times has required review of this policy. A variety of products are now available on the market, ranging from inactivated conventional to live recombinant products. The general consensus on the use of vaccination is that if complying to GMP standards and properly administered, birds will be more resistant to field challenge and will exhibit reduced shedding levels in case of infection. However, viral circulation may still occur in a clinically healthy vaccinated population. This may result in an endemic situation and in the emergence of antigenic variants. In order to limit these risks, monitoring programmes enabling the detection of field exposure in vaccinated populations are recommended by international organisations and are essential to allow the continuation of international trade. Adequate management of a vaccination campaign, including monitoring, improved biosecurity and restriction is essential for the success of any control program for AI.

Detection of mortality clusters associated with highly pathogenic avian influenza in poultry: a theoretical analysis

Rapid detection of infectious disease outbreaks is often crucial for their effective control. One example is highly pathogenic avian influenza (HPAI) such as H5N1 in commercial poultry flocks. There are no quantitative data, however, on how quickly the effects of HPAI infection in poultry flocks can be detected. Here, we study, using an individual-based mathematical model, time to detection in chicken flocks. Detection is triggered when mortality, food or water intake or egg production in layers pass recommended thresholds suggested from the experience of past HPAI outbreaks. We suggest a new threshold for caged flocks--the cage mortality detection threshold--as a more sensitive threshold than current ones. Time to detection is shown to depend nonlinearly on R0 and is particularly sensitive for R0<10. It also depends logarithmically on flock size and number of birds per cage. We also examine how many false alarms occur in uninfected flocks when we vary detection thresholds owing to background mortality. The false alarm rate is shown to be sensitive to detection thresholds, dependent on flock size and background mortality and independent of the length of the production cycle. We suggest that current detection thresholds appear sufficient to rapidly detect the effects of a high R0 HPAI strain such as H7N7 over a wide range of flock sizes. Time to detection of the effects of a low R0 HPAI strain such as H5N1 can be significantly improved, particularly for large flocks, by lowering detection thresholds, and this can be accomplished without causing excessive false alarms in uninfected flocks. The results are discussed in terms of optimizing the design of disease surveillance programmes in general.

The onset of virus shedding and clinical signs in chickens infected with high-pathogenicity and low-pathogenicity avian influenza viruses

Some avian influenza viruses may be transmissible to mammals by ingestion. Cats and dogs have been infected by H5N1 avian influenza viruses when they ate raw poultry, and two human H5N1 infections were linked to the ingestion of uncooked duck blood. The possibility of zoonotic influenza from exposure to raw poultry products raises concerns about flocks with unrecognized infections. The present review examines the onset of virus shedding and the development of clinical signs for a variety of avian influenza viruses in chickens. In experimentally infected birds, some high-pathogenicity avian influenza (HPAI) and low-pathogenicity avian influenza (LPAI) viruses can occur in faeces and respiratory secretions as early as 1 to 2 days after inoculation. Some HPAI viruses have also been found in meat 1 day after inoculation and in eggs after 3 days. There is no evidence that LPAI viruses can be found in meat, and the risk of their occurrence in eggs is poorly understood. Studies in experimentally infected birds suggest that clinical signs usually develop within a few days of virus shedding; however, some models and outbreak descriptions suggest that clinical signs may not become evident for a week or more in some H5 or H7 HPAI-infected flocks. During this time, avian influenza viruses might be found in poultry products. LPAI viruses can be shed in asymptomatically infected or minimally affected flocks, but these viruses are unlikely to cause significant human disease.

Risk factors and characteristics of H5N1 Highly Pathogenic Avian Influenza (HPAI) post-vaccination outbreaks

Highly pathogenic avian influenza (HPAI) virus H5N1 is now endemic in South-East Asia but HPAI control methods differ between countries. A widespread HPAI vaccination campaign that started at the end of 2005 in Viet Nam resulted in the cessation of poultry and human cases, but in 2006/2007 severe HPAI outbreaks re-emerged. In this study we investigated the pattern of this first post-vaccination epidemic in southern Viet Nam identifying a spatio-temporal cluster of outbreak occurrence and estimating spatially smoothed incidence rates of HPAI. Spatial risk factors associated with HPAI occurrence were identified. Medium-level poultry density resulted in an increased outbreak risk (Odds ratio (OR) = 5.4, 95% confidence interval (CI): 1.6–18.9) but also climate-vegetation factors played an important role: medium-level normalised difference vegetation indices during the rainy season from May to October were associated with higher risk of HPAI outbreaks (OR = 3.7, 95% CI: 1.7–8.1), probably because temporal flooding might have provided suitable conditions for the re-emergence of HPAI by expanding the virus distribution in the environment and by enlarging areas of possible contacts between domestic waterfowl and wild birds. On the other hand, several agricultural production factors, such as sweet potatoes yield, increased buffalo density, as well as increased electricity supply were associated with decreased risk of HPAI outbreaks. This illustrates that preventive control measures for HPAI should include a promotion of low-risk agricultural management practices as well as improvement of the infrastructure in village households. Improved HPAI vaccination efforts and coverage should focus on medium poultry density areas and on the pre-monsoon time period.

Seroprevalence of low pathogenic avian influenza (H9N2) and associated risk factors in the Gyeonggi-do of Korea during 2005-2006

Between November 2005 and March 2006, a total of 253 poultry flocks in the Gyeonggi-do of Korea were examined for seroprevalence against avian influenza (AI) using a hemagglutination inhibition (HI) test and an agar gel precipitation test. No low pathogenic avian influenza (LPAI) virus was isolated from 47 seropositive flocks that lacked clinical signs during sampling. The unadjusted percentage of seroprevalence rates of layer and broiler flocks were not significantly different, i.e., 26% (25/96) and 23% (22/97), respectively. The HI titer of the layers (mean = 89) was higher than the broilers (mean = 36; p < 0.001). A cross-sectional study was conducted for the seroprevalence of LPAI in the layers. Of 7 risk factors, farms employing one or more workers had a higher seropositive prevalence as compared to farms without hired employees (adjusted prevalence OR = 11.5, p = 0.031). Layer flocks older than 400 d had higher seropositivity than flocks younger than 300 d (OR = 4.9, p = 0.017). The farmers recognized at least one of the clinical signs in seropositive flocks, such as decreased egg production, respiratory syndromes, and increased mortality (OR = 2.3, p = 0.082). In a matched case-control study, 20 pairs of case and control flocks matched for type of flock, hired employees, age, and flock size were compared. Frequent cleansing with disinfectants was associated with a decreased risk of seropositivity (OR = 0.2, p = 0.022). Although there was a low statistical association, using a foot disinfectant when entering the building led to a decreased rate of seropositivity (OR = 0.3, p = 0.105).

Genotypic diversity of H5N1 highly pathogenic avian influenza viruses

Besides enormous economic losses to the poultry industry, recent H5N1 highly pathogenic avian influenza viruses (HPAIVs) originating in eastern Asia have posed serious threats to public health. Up to April 17, 2008, 381 human cases had been confirmed with a mortality of more than 60 %. Here, we attempt to identify potential progenitor genes for H5N1 HPAIVs since their first recognition in 1996; most were detected in the Eurasian landmass before 1996. Combinations among these progenitor genes generated at least 21 reassortants (named H5N1 progenitor reassortant, H5N1-PR1-21). H5N1-PR1 includes A/Goose/Guangdong/1/1996(H5N1). Only reassortants H5N1-PR2 and H5N1-PR7 were associated with confirmed human cases: H5N1-PR2 in the Hong Kong H5N1 outbreak in 1997 and H5N1-PR7 in laboratory confirmed human cases since 2003. H5N1-PR7 also contains a majority of the H5N1 viruses causing avian influenza outbreaks in birds, including the first wave of genotype Z, Qinghai-like and Fujian-like virus lineages. Among the 21 reassortants identified, 13 are first reported here. This study illustrates evolutionary patterns of H5N1 HPAIVs, which may be useful toward pandemic preparedness as well as avian influenza prevention and control.

The live bird market system and low-pathogenic avian influenza prevention in southern California

Although live bird markets (LBMs) have been associated with outbreaks of avian influenza (AI), there are some LBM systems where AI outbreaks are extremely rare events. The California LBMs have not had any detected avian influenza viruses (AIVs) since December 2005. Responses to a detailed questionnaire on the practices and characteristics of the participants in the California low-pathogenic (LP) AI control program have been described to characterize possible reasons for the lack of AI outbreaks in LBMs. Compliance with an LPAI control program that contains active surveillance, prevention, and rapid response measures by those involved in the LBM system, rendering services to dispose of carcasses, no wholesalers, and few third-party bird deliveries was associated with the lack of LPAIV circulating in the Southern California LBM system.

Modeling the spread of bird flu and predicting outbreak diversity

Avian influenza, commonly known as bird flu, is an epidemic caused by H5N1 virus that primarily affects birds like chickens, wild water birds, etc. On rare occasions, these can infect other species including pigs and humans. In the span of less than a year, the lethal strain of bird flu is spreading very fast across the globe mainly in South East Asia, parts of Central Asia, Africa and Europe. In order to study the patterns of spread of epidemic, we made an investigation of outbreaks of the epidemic in one week, that is from February 13-18, 2006, when the deadly virus surfaced in India. We have designed a statistical transmission model of bird flu taking into account the factors that affect the epidemic transmission such as source of infection, social and natural factors and various control measures are suggested. For modeling the general intensity coefficient f ( r ) , we have implemented the recent ideas given in the article Fitting the Bill, Nature [R. Howlett, Fitting the bill, Nature 439 (2006) 402], which describes the geographical spread of epidemics due to transportation of poultry products. Our aim is to study the spread of avian influenza, both in time and space, to gain a better understanding of transmission mechanism. Our model yields satisfactory results as evidenced by the simulations and may be used for the prediction of future situations of epidemic for longer periods. We utilize real data at these various scales and our model allows one to generalize our predictions and make better suggestions for the control of this epidemic.

Avian influenza vaccines: a practical review in relation to their application in the field with a focus on the Asian experience

Vaccination can be a useful tool for the control of avian influenza (AI) outbreaks, but its use is prohibited in most of the countries worldwide because of its interference with AI surveillance tests and its negative impact on poultry trade. AI vaccines currently in use in the field increase host resistance to the disease but have a limited impact on the virus transmission. To control or eradicate the disease, a carefully conceived vaccination strategy must be accompanied by strict biosecurity measures. Some countries have authorized vaccination under special circumstances with contradictory results, from control and disease eradication (Italy) to endemicity and antigenic drift of the viral strain (Mexico). Extensive vaccination programmes are ongoing in South East Asia to control the H5N1 epidemic. This review provides practical information on the available AI vaccines and associated diagnostic tests, the vaccination strategies applied in Asia and their impact on the disease epidemiology.

Genetic susceptibility and resistance to influenza infection and disease in humans and mice

Although genetic risk factors for influenza infection have not yet been defined in people, differences in genetic background and related variation in the response to infection, as well as viral virulence, are all likely to influence both the likelihood of infection and disease severity. However, apart from characterization of viral binding sites in avian and mammalian hosts, relatively little investigation has focused on host genetic determinants of susceptibility or resistance to infection, or the severity of the associated disease in humans or other species. Similarly, the role of genetic background in the generation of an efficacious immune response to either infection or vaccination has not been extensively evaluated. However, genetic influences on susceptibility and resistance to numerous infectious agents and on the resultant host inflammatory and immune responses are well established in both humans and other animals. Mouse-adapted strains of human influenza viruses and the use of inbred strains of laboratory mice have supported extensive characterization of the pathogenesis and immunology of influenza virus infections. Like individual humans, inbred strains of mice vary in their reactions to influenza infection, particularly with regard to the inflammatory response and disease severity, supporting the potential use of these mice as a valuable surrogate for human genetic variation. Relying heavily on what we have learned from mice, this overview summarizes existing animal, human and epidemiologic data suggestive of host genetic influences on influenza infection.

Avian influenza viruses in wild birds: a moving target

The long-standing evolutionary and ecological relationships between wild birds and influenza A viruses has created a broad pool of viral genetic diversity and a reservoir of potentially transmissible viruses. An understanding of these relationships can help us identify and modify critical control points to reduce transmission of avian influenza viruses into animal and human populations.

Epidemiology of H5N1 avian influenza

High pathogenic (HP) H5N1 avian influenza (AI) infection has been reported in domestic poultry, wildlife, and human populations since 1996. Risk of infection is associated with direct contact with infected birds. The mode of H5N1 spread from Asia to Europe, Africa and the Far East is unclear; risk factors such as legal and illegal domestic poultry and exotic bird trade, and migratory bird movements have been documented. Measures used to control disease such as culling, stamping out, cleaning and disinfection, and vaccination have not been successful in eradicating H5N1 in Asia, but have been effective in Europe.

Application of the updated CDC isolation guidelines for health care facilities

The Centers for Disease Control and Prevention has published updated guidelines for isolation precautions that outline how health care workers can prevent the transmission of infectious agents to their patients and to themselves. The guidelines re-emphasize standard precautions, which guide clinicians in the use of appropriate personal protective equipment (PPE), depending on the expected type of exposure. Respiratory hygiene/cough etiquette is incorporated into infection control practices as a new component of standard precautions. The article provides information on the new guidelines as well as information on newly emerging pathogens and methods to prevent disease transmission in health care settings.

Effect of interventions on influenza A (H9N2) isolation in Hong Kong's live poultry markets, 1999-2005

Live poultry markets (LPMs) are a recognized source of influenza viruses. Since 2001 and 2003, respectively, a first and second monthly "rest-day" has been implemented in Hong Kong's LPMs, when stalls are cleared of unsold poultry and disinfected. We assessed the incremental effectiveness of each rest-day and the banning of live quail sales in 2002 in reducing (H9N2) subtype isolation rates for chickens and minor poultry, by using a multivariable Poisson generalized linear model. There was a 58% reduction (p = 0.001) in virus isolation after 1 monthly rest-day in minor poultry compared with 27% (p = 0.22) in chickens. Combining 1 rest-day with the removal of quails further reduced virus isolation in chickens but not in minor poultry. However, an additional rest-day each month did not appear to affect isolation rates for either species.

Influenza viruses and the evolution of avian influenza virus H5N1

Although small in size and simple in structure, influenza viruses are sophisticated organisms with highly mutagenic genomes and wide antigenic diversity. They are species-specific organisms. Mutation and reassortment have resulted in newer viruses such as H5N1, with new resistance against anti-viral medications, and this might lead to the emergence of a fully transmissible strain, as occurred in the 1957 and 1968 pandemics. Influenza viruses are no longer just a cause of self-limited upper respiratory tract infections; the H5N1 avian influenza virus can cause severe human infection with a mortality rate exceeding 50%. The case death rate of H5N1 avian influenza infection is 20 times higher than that of the 1918 infection (50% versus 2.5%), which killed 675 000 people in the USA and almost 40 million people worldwide. While the clock is still ticking towards what seems to be inevitable pandemic influenza, on April 17, 2007 the U.S. Food and Drug Administration (FDA) approved the first vaccine against the avian influenza virus H5N1 for humans at high risk. However, more research is needed to develop a more effective and affordable vaccine that can be given at lower doses.

Dynamic patterns of avian and human influenza in east and southeast Asia

The seasonal patterns of human influenza in temperate regions have been well documented; however, much less attention has been paid to patterns of infection in the tropical and subtropical areas of east and southeast Asia. During the period 1997-2006, this region experienced several outbreaks of highly pathogenic avian influenza A (H5N1) in hosts including wild and domestic poultry, human beings, and other mammals. H5N1 is thought to be a likely source of a pandemic strain of human influenza. Incidence of both human influenza and avian influenza in human beings shows evidence of seasonality throughout east and southeast Asia, although the seasonal patterns in tropical and subtropical areas are not as simple or as pronounced as those in temperate regions around the world. The possibility of a human being becoming co-infected with both human and avian strains of influenza is not restricted to a short season, although the risks do appear to be greatest during the winter months.

Risk for infection with highly pathogenic influenza A virus (H5N1) in chickens, Hong Kong, 2002

We used epidemiologic evaluation, molecular epidemiology, and a case-control study to identify possible risk factors for the spread of highly pathogenic avian influenza A virus (subtype H5N1) in chicken farms during the first quarter of 2002 in Hong Kong. Farm profiles, including stock sources, farm management, and biosecurity measures, were collected from 16 case and 46 control chicken farms by using a pretested questionnaire and personal interviews. The risk for influenza A (H5N1) infection was assessed by using adjusted odds ratios based on multivariate logistic regression analysis. Retail marketing of live poultry was implicated as the main source of exposure to infection on chicken farms in Hong Kong during this period. Infection control measures should be reviewed and upgraded as necessary to reduce the spread of influenza A (H5N1) related to live poultry markets, which are commonplace across Asia.

Lessons learned from Asian H5N1 outbreak control

Numerous lessons have been learned so far in controlling H5N1 avian influenza in Asia. Early detection of incursions of virus prevented establishment of the disease in several countries, notably Japan, South Korea, and Malaysia. In countries where detection of early cases was delayed, infection is endemic and has been for three or more years. Control measures implemented in these countries need to reflect this finding. Vaccination will continue to be one of the key measures used in these endemically infected countries. Used alone, vaccination will not result in elimination of H5N1 viruses from a country, but, if used correctly, it will markedly reduce the prevalence of and susceptibility to infection. Vaccination has already played a valuable role in reducing the adverse effects of H5N1 viruses. Mass culling also reduces the level of infection in infected areas. However, the long-term benefits are limited in endemically infected countries owing to the high probability of reinfection on restocking unless other measures are used in parallel. Full epidemiological studies have not been conducted in many infected countries. Nevertheless, it is recognized that the number of clinical cases does not truly reflect the levels of infection. Domestic ducks and large live poultry markets have played a key role in the persistence of infection, because they can be infected silently. In tackling this disease, countries should adopt integrated control programs using the combination of measures best suited to the local environment. All surveillance data should be shared, both positive and negative, and should include information on cases of infection and disease. Socioeconomic and ecological implications of all control measures should be assessed before implementation, especially the impact on the rural poor.

Surveillance for avian influenza in Nepal 2004-2005

Highly pathogenic avian influenza has not been reported in Nepal to date. Surveillance for the presence of avian influenza viruses was conducted in 16 districts of Nepal from February 2004 to December 2005. Four hundred forty-six serum samples were collected from ducks, chickens, and pigeons and tested for antibodies to all influenza A viruses by competitive enzyme-linked immunosorbent assay (C-ELISA). Any sera positive by C-ELISA were tested for antibodies to H5, H7, and H9 influenza viruses by hemagglutination inhibition tests. One hundred and thirty-five cloacal swabs from healthy ducks and chickens were tested by commercial avian influenza antigen detection kits. A further 13 tissue samples from diseased birds were tested for the presence of virus by virus isolation in eggs, cell culture, and immunohistochemistry. No influenza viruses were detected in any of the tissues or swabs. All serum samples collected before October 2005 were negative for antibodies. The first sera positive for antibodies were collected on October 13, 2005, which were determined to be of the H9N2 subtype. This is the first report of serologic evidence of an avian influenza virus infection in Nepal.

Molecular changes in the polymerase genes (PA and PB1) associated with high pathogenicity of H5N1 influenza virus in mallard ducks

The highly pathogenic (HP) influenza viruses H5 and H7 are usually nonpathogenic in mallard ducks. However, the currently circulating HP H5N1 viruses acquired a different phenotype and are able to cause mortality in mallards. To establish the molecular basis of this phenotype, we cloned the human A/Vietnam/1203/04 (H5N1) influenza virus isolate that is highly pathogenic in ferrets, mice, and mallards and found it to be a heterogeneous mixture. Large-plaque isolates were highly pathogenic to ducks, mice, and ferrets, whereas small-plaque isolates were nonpathogenic in these species. Sequence analysis of the entire genome revealed that the small-plaque and the large-plaque isolates differed in the coding of five amino acids. There were two differences in the hemagglutinin (HA) gene (K52T and A544V), one in the PA gene (T515A), and two in the PB1 gene (K207R and Y436H). We inserted the amino acid changes into the wild-type reverse genetic virus construct to assess their effects on pathogenicity in vivo. The HA gene mutations and the PB1 gene K207R mutation did not alter the HP phenotype of the large-plaque virus, whereas constructs with the PA (T515A) and PB1 (Y436H) gene mutations were nonpathogenic in orally inoculated ducks. The PB1 (Y436H) construct was not efficiently transmitted in ducks, whereas the PA (T515A) construct replicated as well as the wild-type virus did and was transmitted efficiently. These results show that the PA and PB1 genes of HP H5N1 influenza viruses are associated with lethality in ducks. The mechanisms of lethality and the perpetuation of this lethal phenotype in ducks in nature remain to be determined.

History and evolution of HPAI viruses in southeast Asia

Highly pathogenic avian influenza (HPAI) has been recognized as a serious viral disease of poultry since 1878. The number of outbreaks of this disease globally has increased in the past 10 years culminating in 2004 with the unprecedented outbreak of H5N1 HPAI involving nine countries in East and South East Asia. Apart from the geographical extent of this outbreak and apparent rapid spread, this epidemic has a number of unique features, among which is the carriage of highly pathogenic AI viruses by asymptomatic domestic waterfowl. When this disease first emerged it was recognized almost simultaneously in a number of countries for the first time. This created considerable concern among both veterinary and public health authorities especially as the virus was also shown to cause fatal disease in humans. This article brings together a range of information on H5N1 HPAI viruses in Asia that were collected by FAO during the past year through field projects and explores possible reasons for the emergence of the disease in late 2003 and early 2004. Key epidemiological features of the disease in different Asian countries are described in an attempt to look for, and where possible, explain similarities and differences. This includes assessment of factors that could have contributed to the spread of the disease. Molecular aspects of the viruses are examined to assess relationships between isolates from different locations and times so as to gain insights into the origins of viruses in various countries. It is apparent that the coincidence and grouping of the reports declaring the outbreaks of HPAI did not truly reflect the time course of disease emergence, which was widespread well before the outbreak. The factors that could have led to a change from infection to emergence of widespread disease in 2003-2004 are discussed. There are still some questions that remain unanswered regarding the origins of the 2004 outbreak. This article does not provide answers to all of these, but brings together what is currently known about these outbreaks and the viruses that have caused them.

Avian influenza virus (H5N1): a threat to human health

Pandemic influenza virus has its origins in avian influenza viruses. The highly pathogenic avian influenza virus subtype H5N1 is already panzootic in poultry, with attendant economic consequences. It continues to cross species barriers to infect humans and other mammals, often with fatal outcomes. Therefore, H5N1 virus has rightly received attention as a potential pandemic threat. However, it is noted that the pandemics of 1957 and 1968 did not arise from highly pathogenic influenza viruses, and the next pandemic may well arise from a low-pathogenicity virus. The rationale for particular concern about an H5N1 pandemic is not its inevitability but its potential severity. An H5N1 pandemic is an event of low probability but one of high human health impact and poses a predicament for public health. Here, we review the ecology and evolution of highly pathogenic avian influenza H5N1 viruses, assess the pandemic risk, and address aspects of human H5N1 disease in relation to its epidemiology, clinical presentation, pathogenesis, diagnosis, and management.

Geographic and Temporal Distribution of Highly Pathogenic Avian Influenza A Virus (H5N1) in Thailand, 2004–2005: An Overview

Outbreaks of H5N1 highly pathogenic avian influenza (HPAI) occurred in various types of domestic poultry in Thailand during 2004-05. H5N1 viruses were also detected in humans and other mammalian species. Infections were mainly detected in backyard chickens and domestic ducks. The geographic distribution of the 2004 outbreaks was widespread throughout Thailand; most outbreaks occurred in the Central Region, the southern part of the Northern Region, and the Eastern Region. In 2005, the H5N1 outbreaks continued and showed a clustered pattern in four provinces in the southern part of the Northern Region and in one province in the Central Region. H5N1 HPAI outbreaks caused serious socioeconomic consequences to the poultry industry, the social community, farmers' livelihood, and human health. After key measures were implemented, the incidence of the outbreaks declined remarkably in 2005.

Inactivation of avian influenza virus by heat and high hydrostatic pressure

Avian influenza viruses threaten the life of domestic terrestrial poultry and contaminate poultry meat and eggs. Recently, these viruses rarely infected humans but had a high mortality rate in Southeast Asia, the Middle East, and Egypt. Thereby, these viruses caused high economic costs for production of poultry and health protection. We inactivated a highly pathogenic avian influenza A virus of subtype H7N7 in cell culture medium and chicken meat by heat and high hydrostatic pressure. Because heat and pressure inactivation curves of the H7N7 virus showed deviations from first-order kinetics, a reaction order of 1.1 had to be selected. A mathematical inactivation model has been developed that is valid between 10 and 60 degrees C and up to 500 MPa, allowing the prediction of the reduction in virus titer in response to pressure, temperature, and treatment time. Incubation at 63 degrees C for 2 min and 500 MPa at 15 degrees C for 15 s inactivated more than 10(5) PFU/ml, respectively. Thus, we suggest high-pressure treatment of poultry and its products to avoid the possible health threat by highly pathogenic avian influenza viruses.

Within-Flock Mortality During the High-Pathogenicity Avian Influenza (H7N7) Epidemic in the Netherlands in 2003: Implications for an Early Detection System

Daily within-flock mortality data, from a few days before until a few days after onset of increased mortality, from H7N7-infected flocks were analyzed with nonlinear regression for layer (organic and free-range or caged), broiler, and turkey flocks. The following notification thresholds were recommended for The Netherlands: 1) organic layer flocks, broiler flocks, and turkey flocks < or = 11 wk of age: > or = 0.5% mortality/day for two consecutive days; 2) layer flocks with birds housed in cages: > or = 0.25% mortality/day for two consecutive days; 3) turkey flocks > or = 16 wk of age: > or = 1% mortality/day for two consecutive days. Notification of increased mortality to the veterinary authorities should take place on the second day of increased mortality. Interpretation of mortality thresholds should be on the level of the poultry barn in which clinical problems arise. Because of nonoptimal specificity of proposed thresholds (mortality possibly caused by other diseases), use of PCR-diagnostics (results within 24 hr) without costs to the individual farmer should be promoted to exclude avian influenza in suspect clinical situations in order to minimize negative economic consequence for farmers and stimulate notification by farmers and veterinary practitioners.

Birds and influenza H5NI virus movement to and within North America

Highly pathogenic avian influenza (HPAI) H5N1 expanded considerably during 2005 and early 2006 in both avian host species and geographic distribution. Domestic waterfowl and migratory birds are reservoirs, but lethality of this subtype appeared to initially limit migrant effectiveness as introductory hosts. This situation may have changed, as HPAI H5N1 has recently expanded across Eurasia and into Europe and Africa. Birds could introduce HPAI H5N1 to the Western Hemisphere through migration, vagrancy, and importation by people. Vagrants and migratory birds are not likely interhemispheric introductory hosts; import of infected domestic or pet birds is more probable. If reassortment or mutation were to produce a virus adapted for rapid transmission among humans, birds would be unlikely introductory hosts because of differences in viral transmission mechanisms among major host groups (i.e., gastrointestinal for birds, respiratory for humans). Another possible result of reassortment would be a less lethal form of avian influenza, more readily spread by birds.

Emerging respiratory viruses: challenges and vaccine strategies

The current threat of avian influenza to the human population, the potential for the reemergence of severe acute respiratory syndrome (SARS)-associated coronavirus, and the identification of multiple novel respiratory viruses underline the necessity for the development of therapeutic and preventive strategies to combat viral infection. Vaccine development is a key component in the prevention of widespread viral infection and in the reduction of morbidity and mortality associated with many viral infections. In this review we describe the different approaches currently being evaluated in the development of vaccines against SARS-associated coronavirus and avian influenza viruses and also highlight the many obstacles encountered in the development of these vaccines. Lessons learned from current vaccine studies, coupled with our increasing knowledge of the host and viral factors involved in viral pathogenesis, will help to increase the speed with which efficacious vaccines targeting newly emerging viral pathogens can be developed.

SARS and Emerging Infectious Diseases: A Challenge to Place Global Solidarity above National Sovereignty

Severe acute respiratory syndrome (SARS) emerged in a world where information about infectious disease outbreaks travels at speeds and in ways not imagined just 30 years ago, and where scientists are increasingly working together on detecting and responding to public health events that threaten international public health and economic security. The SARS outbreak clearly demonstrated that it is no longer the exclusive privilege of countries to report and respond to infectious diseases occurring in their own territories, but that the global community has also assumed this role, aided by the ease and power of electronic communication through the World Wide Web. This phenomenon has been cited by some scholars as a potential infringement on national sovereignty that compromises the concept that states reign supreme over their territories and peoples. At the same time, however, countries are increasingly seeking to collaborate internationally in infectious disease surveillance and response, as shown in the current situation of avian influenza (H5N1), and in the formal agreement leading to the revised International Health Regulations (IHR), suggesting that a new world order prevails over issues that once had been considered the sole domain of a sovereign nation.

H5N1 outbreaks and enzootic influenza

Highly pathogenic H5N1 influenza viruses continue to evolve and increase their geographic and host range.

Ongoing outbreaks of H5N1 avian influenza in migratory waterfowl, domestic poultry, and humans in Asia during the summer of 2005 present a continuing, protean pandemic threat. We review the zoonotic source of highly pathogenic H5N1 viruses and their genesis from their natural reservoirs. The acquisition of novel traits, including lethality to waterfowl, ferrets, felids, and humans, indicates an expanding host range. The natural selection of nonpathogenic viruses from heterogeneous subpopulations cocirculating in ducks contributes to the spread of H5N1 in Asia. Transmission of highly pathogenic H5N1 from domestic poultry back to migratory waterfowl in western China has increased the geographic spread. The spread of H5N1 and its likely reintroduction to domestic poultry increase the need for good agricultural vaccines. In fact, the root cause of the continuing H5N1 pandemic threat may be the way the pathogenicity of H5N1 viruses is masked by cocirculating influenza viruses or bad agricultural vaccines.

Inactivated North American and European H5N2 avian influenza virus vaccines protect chickens from Asian H5N1 high pathogenicity avian influenza virus

High-pathogenicity (HP) avian influenza (AI) virus of the H5N1 subtype has caused an unprecedented epizootic in birds within nine Asian countries/regions since it was first reported in 1996. Vaccination has emerged as a tool for use in managing the infection in view of future eradication. This study was undertaken to determine whether two divergent H5N2 commercial vaccine strains, one based on a European and the other a North American low-pathogenicity AI virus, could protect chickens against a recent Asian H5N1 HPAI virus. The North American and European vaccine viruses had 84 and 91% deduced amino acid sequence similarity to the HA1 segment of haemagglutinin protein of Indonesia H5N1 HPAI challenge virus, respectively. Both vaccine strains provided complete protection from clinical signs and death. The vaccines reduced the number of chickens infected and shedding virus from the respiratory and intestinal tracts at the peak of virus replication. In addition, the quantity of virus shed was reduced by 10(4) to 10(5) median embryo infectious doses. The use of specific neuraminidase inhibition tests allowed identification of infected chickens within the vaccinated groups. These data indicate that the currently available H5 vaccines of European and North American lineages will protect chickens against the Asian H5N1 HPAI virus and reduce environmental contamination by the H5N1 HPAI virus. They will be an adjunct to biosecurity measures to reduce virus transmission.

Comparison of the replication of influenza A viruses in Chinese ring-necked pheasants and chukar partridges

We investigated the replication and transmission of avian influenza A viruses in two species thought to be intermediate hosts in the spread of influenza A viruses in live poultry markets: Chinese ring-necked pheasants and chukar partridges. All 15 hemagglutinin subtypes replicated in pheasants, and most subtypes transmitted to naïve contact pheasants, primarily via the fecal-oral route. Many viruses were shed from the gastrointestinal tract of experimentally inoculated pheasants for 14 days or longer. Virus was isolated from the cloacal swabs of one contact pheasant for an unprecedented 45 days. Chukar partridges were less susceptible to infection with avian influenza viruses. The viruses that replicated in chukar partridges were isolated for 7 days after experimental inoculation, predominantly from the respiratory tract. We detected high neutralizing antibody titers with correspondingly low levels of serum hemagglutination inhibition antibody titers in pheasants and chukar partridges when chicken red blood cells were used in serological analyses. When horse erythrocytes were used, antibody titers were comparable to those obtained by using the neutralization assay. More importantly, the results suggested that pheasants can serve as a reservoir of influenza virus. Because of their continuous asymptomatic infection and longer stay in the markets, pheasants are ideal "carriers" of influenza A viruses. Their continued presence in live markets contributes to the perpetuation and genetic interaction of influenza viruses there. On the basis of our findings, it does not make good sense to ban quail but not pheasants from the live markets.

Pathogenicity of a highly pathogenic avian influenza virus, A/chicken/Yamaguchi/7/04 (H5N1) in different species of birds and mammals

Outbreaks of highly pathogenic avian influenza (HPAI) have been occurring in domestic poultry in Asia since 1996. In the beginning of 2004, HPAI outbreaks were caused by H5N1 virus in two farms and a group of pet chickens in different areas of Japan. In the present study, the pathogenicity of A/chicken/Yamaguchi/7/04 (H5N1), which had been isolated from a dead chicken during the first outbreak in Japan, was assessed in chickens, quails, budgerigars, ducklings, mice, and miniature pigs by experimental infection. The virus was highly pathogenic to all the birds tested. Mice were susceptible to infection with a low mortality rate and miniature pigs were resistant to infection with the virus.

Avian influenza virus infections in humans

Seroepidemiologic and virologic studies since 1889 suggested that human influenza pandemics were caused by H1, H2, and H3 subtypes of influenza A viruses. If not for the 1997 avian A/H5N1 outbreak in Hong Kong of China, subtype H2 is the likely candidate for the next pandemic. However, unlike previous poultry outbreaks of highly pathogenic avian influenza due to H5 that were controlled by depopulation with or without vaccination, the presently circulating A/H5N1 genotype Z virus has since been spreading from Southern China to other parts of the world. Migratory birds and, less likely, bird trafficking are believed to be globalizing the avian influenza A/H5N1 epidemic in poultry. More than 200 human cases of avian influenza virus infection due to A/H5, A/H7, and A/H9 subtypes mainly as a result of poultry-to-human transmission have been reported with a > 50% case fatality rate for A/H5N1 infections. A mutant or reassortant virus capable of efficient human-to-human transmission could trigger another influenza pandemic. The recent isolation of this virus in extrapulmonary sites of human diseases suggests that the high fatality of this infection may be more than just the result of a cytokine storm triggered by the pulmonary disease. The emergence of resistance to adamantanes (amantadine and rimantadine) and recently oseltamivir while H5N1 vaccines are still at the developmental stage of phase I clinical trial are causes for grave concern. Moreover, the to-be pandemic strain may have little cross immunogenicity to the presently tested vaccine strain. The relative importance and usefulness of airborne, droplet, or contact precautions in infection control are still uncertain. Laboratory-acquired avian influenza H7N7 has been reported, and the laboratory strains of human influenza H2N2 could also be the cause of another pandemic. The control of this impending disaster requires more research in addition to national and international preparedness at various levels. The epidemiology, virology, clinical features, laboratory diagnosis, management, and hospital infection control measures are reviewed from a clinical perspective.

Highly pathogenic avian influenza H5N1, Thailand, 2004

Early detection and control curtail outbreaks.

In January 2004, highly pathogenic avian influenza (HPAI) virus of the H5N1 subtype was first confirmed in poultry and humans in Thailand. Control measures, e.g., culling poultry flocks, restricting poultry movement, and improving hygiene, were implemented. Poultry populations in 1,417 villages in 60 of 76 provinces were affected in 2004. A total of 83% of infected flocks confirmed by laboratories were backyard chickens (56%) or ducks (27%). Outbreaks were concentrated in the Central, the southern part of the Northern, and Eastern Regions of Thailand, which are wetlands, water reservoirs, and dense poultry areas. More than 62 million birds were either killed by HPAI viruses or culled. H5N1 virus from poultry caused 17 human cases and 12 deaths in Thailand; a number of domestic cats, captive tigers, and leopards also died of the H5N1 virus. In 2005, the epidemic is ongoing in Thailand.