The Highly Pathogenic Avian Influenza A (H7N7) Virus Epidemic in the Netherlands in 2003—Lessons Learned from the First Five Outbreaks

Preventable H5N1 avian influenza epidemics in the British poultry industry network exhibit characteristic scales

Epidemics are frequently simulated on redundantly wired contact networks, which have many more links between sites than are minimally required to connect all. Consequently, the modelled pathogen can travel numerous alternative routes, complicating effective containment strategies. These networks have moreover been found to exhibit 'scale-free' properties and percolation, suggesting resilience to damage. However, realistic H5N1 avian influenza transmission probabilities and containment strategies, here modelled on the British poultry industry network, show that infection dynamics can additionally express characteristic scales. These system-preferred scales constitute small areas within an observed power law distribution that exhibit a lesser slope than the power law itself, indicating a slightly increased relative likelihood. These characteristic scales are here produced by a network-pervading intranet of so-called hotspot sites that propagate large epidemics below the percolation threshold. This intranet is, however, extremely vulnerable; targeted inoculation of a mere 3-6% (depending on incorporated biosecurity measures) of the British poultry industry network prevents large and moderate H5N1 outbreaks completely, offering an order of magnitude improvement over previously advocated strategies affecting the most highly connected 'hub' sites. In other words, hotspots and hubs are separate functional entities that do not necessarily coincide, and hotspots can make more effective inoculation targets. Given the ubiquity and relevance of networks (epidemics, Internet, power grids, protein interaction), recognition of this spreading regime elsewhere would suggest a similar disproportionate sensitivity to such surgical interventions.

A flock-tailored early warning system for low pathogenic avian influenza (LPAI) in commercial egg laying flocks

The aim of this study was to develop and evaluate an early warning system (EWS) for commercial egg laying flocks to detect the subtle mortality and egg production changes that characterize low pathogenic avian influenza virus (LPAIV) infections. An EWS will create an alert when the recommended 'trigger point' is reached or exceeded. Previously used EWSs are based on fixed alert levels, while the proposed EWS customizes the alert level to each flock. While a fixed approach may be valid for highly pathogenic diseases, it results in a lower detection probability for low pathogenic diseases. The EWS was based on daily data collected from flocks affected by the 2000-2004 H6N2 LPAI epidemic in California. Three EWSs were evaluated: (1) EWS1, which is triggered when the observed mortality increase or production decrease exceeds more than "x" times the expected daily value (2.75-3.50 times the expected mortality), (2) EWS2, which is triggered when the observed mortality increase or production decrease exceeds more than "y" times during each of 2 consecutive days the expected daily values (1.75-2.15 times the expected mortality), and (3) a combination of the two. The EWSs were evaluated according to three parameters: detection delay (days) of a LPAI outbreak, false alerts (%) and outbreaks missed (%). Results showed that an egg production-based EWS added no benefit to a mortality-based system, mainly because H6N2 LPAI-related egg production decrease always occurred after increase in mortality. Combining the two EWSs resulted in a reduced detection delay and no missed outbreaks, but at the expense of a slight increase in the number of false alerts triggered. The system presented in this study also outperformed fixed EWSs in all three evaluated parameters. The proposed EWS, if used as part of a poultry cooperative program and combined with a rapid laboratory diagnosis, could be a useful tool in the detection and control of LPAI outbreaks and other poultry diseases. Built in a spreadsheet, the system could be inexpensively, easily and quickly incorporated into a commercial egg production farm decision support system. In addition, the proposed system could be quickly adjusted to changing epidemic situations, and easily customized to individual flocks.

A geographical spread of vaccine-resistance in avian influenza epidemics

Vaccination can be a useful tool for control of avian influenza outbreaks in poultry, but its use is reconsidered in most of the countries worldwide because of its negative effects on the disease control. One of the most important negative effects is the potential for emergence of vaccine-resistant viruses. Actually, in the vaccination program in China and Mexico, several vaccine-resistant strains were confirmed. Vaccine-resistant strains usually cause a loss of the protection effectiveness of vaccination. Therefore, a vaccination program that engenders the emergence of the resistant strain might promote the spread of the resistant strain and undermine the control of the infectious disease, even if the vaccination protects against the transmission of a vaccine-sensitive strain. We designed and analyzed a deterministic patch-structured model in heterogeneous areas (with or without vaccination) illustrating transmission of vaccine-sensitive and vaccine-resistant strains during a vaccination program. We found that the vaccination program can eradicate the vaccine-sensitive strain but lead to a prevalence of vaccine-resistant strain. Further, interestingly, the replacement of viral strain could occur in another area without vaccination through a migration of non-infectious individuals due to an illegal trade of poultry. It is also a novel result that only a complete eradication of both strains in vaccination area can achieve the complete eradication in another areas. Thus we can obtain deeper understanding of an effect of vaccination for better development of vaccination strategies to control avian influenza spread.

Paradox of vaccination: is vaccination really effective against avian flu epidemics?

Background

Although vaccination can be a useful tool for control of avian influenza epidemics, it might engender emergence of a vaccine-resistant strain. Field and experimental studies show that some avian influenza strains acquire resistance ability against vaccination. We investigated, in the context of the emergence of a vaccine-resistant strain, whether a vaccination program can prevent the spread of infectious disease. We also investigated how losses from immunization by vaccination imposed by the resistant strain affect the spread of the disease.

Methods and Findings

We designed and analyzed a deterministic compartment model illustrating transmission of vaccine-sensitive and vaccine-resistant strains during a vaccination program. We investigated how the loss of protection effectiveness impacts the program. Results show that a vaccination to prevent the spread of disease can instead spread the disease when the resistant strain is less virulent than the sensitive strain. If the loss is high, the program does not prevent the spread of the resistant strain despite a large prevalence rate of the program. The epidemic's final size can be larger than that before the vaccination program. We propose how to use poor vaccines, which have a large loss, to maximize program effects and describe various program risks, which can be estimated using available epidemiological data.

Conclusions

We presented clear and simple concepts to elucidate vaccination program guidelines to avoid negative program effects. Using our theory, monitoring the virulence of the resistant strain and investigating the loss caused by the resistant strain better development of vaccination strategies is possible.

An inactivated H5N2 vaccine reduces transmission of highly pathogenic H5N1 avian influenza virus among native chickens

Vaccination against H5N1 highly pathogenic avian influenza in endemically affected areas is a potentially attractive option for local prevention and control. In Indonesia the majority of local outbreaks have occurred in back yard flocks with native chickens, and it is therefore of interest to determine whether these birds can be protected against infection by vaccination. To this end two transmission experiments were carried out with H5N1 virus (A/chicken/Legok/2003) in vaccinated and unvaccinated native chickens. The vaccine contained an inactivated heterologous H5N2 strain (A/turkey/England/N28/73 H5N2). Birds were vaccinated at 4 and 7 weeks of age and challenged at 10 weeks of age. During 10 days post-challenge tracheal and cloacal swabs were taken for virus isolation, and serum blood was collected regularly to measure haemaglutinin inhibiting (HI) antibody responses. The results show that transmission of H5N1 virus was rapid and efficient in unvaccinated birds, that infection and transmission were completely prevented in vaccinated birds, and that vaccinated birds that were exposed to unvaccinated inoculated birds were still protected from infection. These findings indicate that vaccination with a heterologous H5N2 vaccine is able to prevent virus transmission in flocks of native chickens.

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.

A proposed taxonomy for characterization and assessment of avian influenza outbreaks

PURPOSE

The speed and high potential impact of avian influenza's (AI) on local bird populations, poultry economies and human health make timely and coordinated characterization, assessment and response to possible threats essential. To collaborate effectively, stakeholders (public health, medical, veterinary, and agricultural professionals) must be able to communicate and record findings, assessments, and actions in a standard fashion. We seek to discern a taxonomy of concepts and relationships that are important to the stakeholder community when sharing information about the characterization and assessment of an AI outbreak, according to a consistent and common perspective, interpretation, and level of detail.

METHODS

To derive concepts relevant to AI characterization and assessment, we reviewed selected journal articles, reporting and laboratory forms, and public health websites associated with AI case reporting. We mapped concepts to existing medical terminologies within the Unified Medical Language System when possible, using the National Library of Medicine's MetaMap program.

RESULTS

From 54 distinct information sources, we extracted 1113 concepts, of which 533 mapped to 15 medical terminologies; 580 did not map to specific terminologies. Using a combination of semantic type-relationship matching and expert consensus, we constructed the proposed taxonomy, with linkages to existing terminologies where pragmatic.

CONCLUSION

The proposed taxonomy describes core knowledge, data and communication needs for the characterization and assessment of AI outbreaks in the context of existing medical terminologies across different domains. We also describe areas for further work.

Contact structures in the poultry industry in Great Britain: exploring transmission routes for a potential avian influenza virus epidemic

Background

The commercial poultry industry in United Kingdom (UK) is worth an estimated £3.4 billion at retail value, producing over 174 million birds for consumption per year. An epidemic of any poultry disease with high mortality or which is zoonotic, such as avian influenza virus (AIV), would result in the culling of significant numbers of birds, as seen in the Netherlands in 2003 and Italy in 2000. Such an epidemic would cost the UK government millions of pounds in compensation costs, with further economic losses through reduction of international and UK consumption of British poultry. In order to better inform policy advisers and makers on the potential for a large epidemic in GB, we investigate the role that interactions amongst premises within the British commercial poultry industry could play in promoting an AIV epidemic, given an introduction of the virus in a specific part of poultry industry in Great Britain (GB).

Results

Poultry premises using multiple slaughterhouses lead to a large number of premises being potentially connected, with the resultant potential for large and sometimes widespread epidemics. Catching companies can also potentially link a large proportion of the poultry population. Critical to this is the maximum distance traveled by catching companies between premises and whether or not between-species transmission could occur within individual premises. Premises closely linked by proximity may result in connections being formed between different species and or sectors within the industry.

Conclusion

Even quite well-contained epidemics have the potential for geographically widespread dissemination, potentially resulting in severe logistical problems for epidemic control, and with economic impact on a large part of the country. Premises sending birds to multiple slaughterhouses or housing multiple species may act as a bridge between otherwise separate sectors of the industry, resulting in the potential for large epidemics. Investment into further data collection and analyses on the importance of industry structure as a determinant for spread of AIV would enable us to use the results from this study to contribute to policy on disease control.

Avian influenza outbreak management: action at time of confirmation, depopulation and disposal methods; the 'Belgian experience' during the H7N7 highly pathogenic avian influenza epidemic in 2003

Eradication of H5 and H7 influenza in a positive flock will include mass depopulation of birds, containment and inactivation of the virus in the carcasses and litter, and decontamination of the facility. A quick response is desired in the event of a disease outbreak. Ideally, birds should be depopulated within 24 h after detecting the virus. Mass depopulation of birds must be performed in a humane manner while minimizing human health and biosecurity risks. In the framework of the European legislation, a number of methods are authorized for the killing of poultry for processing prior to marketing. However, during emergencies such as a disease outbreak, there are fewer options. The current most commonly used procedures for large-scale emergency depopulation of birds consist of exposing poultry to CO or CO(2) gas. Both gasses have been used in Belgium during the H7N7 crisis in 2003. The gassing procedures include whole house gassing, portable panel enclosures, cage cabinets, containers and polyethylene tent method. Whole house gassing requires sealing the house to prevent gas leakage and, using specialized equipment, introducing large volumes of gas evenly over the birds. All procedures are very labour intensive, create a biosecurity risk and require a large number of personnel. There are considerable region-to-region differences in emergency depopulation techniques and disposal of carcasses and infected material. Because of the differences in bird type and species, management, housing and stocking density, it is difficult to propose a depopulation technique that will be suitable for all circumstances. Safety of the human operators is an increasing concern with all H5 and H7 strains and in particular with the highly pathogenic H5N1 strain. Researchers and commercial poultry companies in the United States recently established that non-toxic water-based foam with a certain bubble size presents a practicable, effective and humane method for mass depopulation. Foam of the right bubble size creates an occlusion in the trachea of birds, causing a rapid onset of hypoxia. The foam that blankets the broiler house induces physical hypoxia - the same cause of death as the approved method using carbon dioxide gas (CO(2)). The article illustrates the different culling and disposal methods with a focus on the methods used during the 2003 H7N7 crisis in Belgium.

Epidemiological consequences of an incursion of highly pathogenic H5N1 avian influenza into the British poultry flock

Highly pathogenic avian influenza and in particular the H5N1 strain has resulted in the culling of millions of birds and continues to pose a threat to poultry industries worldwide. The recent outbreak of H5N1 in the UK highlights the need for detailed assessment of the consequences of an incursion and of the efficacy of control strategies. Here, we present results from a model of H5N1 propagation within the British poultry industry. We find that although the majority of randomly seeded incursions do not spread beyond the initial infected premises, there is significant potential for widespread infection. The efficacy of the European Union strategy for disease control is evaluated and our simulations emphasize the pivotal role of duck farms in spreading H5N1.

The indirect immunofluorescence assay using cardiac tissue from chickens, quails and ducks for identification of influenza A virus during an outbreak of highly pathogenic avian influenza virus (H5N1): A rapid and simple screening tool for limited resource settings

Here we describe the diagnostic utility of the indirect immunofluorescence assay (IFA) during a recent outbreak of highly pathogenic avian influenza (HPAI) subtype H5N1 virus in southern Thailand and demonstrate the usefulness of the cardiac tissue from infected chickens, quail, and ducks for diagnosis. The most reliable sample for IFA diagnosis of influenza A virus was cardiac tissue (83.0%; 44/53) which when divided by species (chicken, quail and duck cardiac tissues) gave respective positivity rates of 88% (22/25), 88.9% (16/18) and 60.0% (6/10). Cardiac tissue also gave the highest IFA intensity for the three species. We believe that the IFA method has wide applicability in developing countries or remote settings where clinically similar avian diseases with high morbidity and mortality such as Newcastle disease and fowl cholera are common and could be rapidly excluded thereby conserving valuable reference laboratory capacity for true HPAI outbreaks.

Transmission parameters of highly pathogenic avian influenza (H7N1) among industrial poultry farms in northern Italy in 1999–2000

We estimated between-farm transmission parameters of the highly pathogenic avian-influenza (HPAI) epidemic that struck the poultry industry of northern Italy (including turkeys, layer hens, broilers, gamebirds, and waterfowl) from December 1999 through April 2000. We estimated the average number of susceptible farms that were infected with HPAI virus by each infectious farm during a day (beta) with a generalised linear model (GLM). The HPAI's reproductive ratios (R(h); the average number of new infected farms (IFs) that were caused by an infectious farm) were calculated separately for the regions of Lombardy and Veneto, where 382 out of 413 (92.5%) of IFs were located. In both regions, R(h) decreased to approximately 1 during the second month of the epidemic (showing that its containment had been initiated). Subsequently, during the last two months of the epidemic, beta and R(h) were reduced to 0.04/day and 0.6, respectively, in Veneto and to 0.07/day and 0.8 in Lombardy. The reduction of the susceptible population through strict control measures, including pre-emptive slaughter of at-risk poultry flocks, was implemented to a greatest extent in Veneto and this might have been associated with a more rapid control of the epidemic in this region than in Lombardy.

Avian influenza H5N1: risks at the human-animal interface

BACKGROUND

Great concern has arisen over the continued infection of humans with highly pathogenic avian influenza (HPAI) of the H5N1 subtype. Ongoing human exposure potentially increases the risk that a pandemic virus strain will emerge that is easily transmissible among humans. Although the pathogenicity of a pandemic strain cannot be predicted, the high mortality seen in documented H5N1 human infections thus far has raised the level of concern.

OBJECTIVES

To define the three types of influenza that can affect humans, discuss potential exposure risks at the human-animal interface, and suggest ways to reduce exposure and help prevent development of a pandemic virus.

METHODS

This review is based on data and guidelines available from the World Health Organization, the scientific literature, and official governmental reports.

RESULTS

Epidemiological data on human exposure risk are generally incomplete. Transmission of HPAI to humans is thought to occur through contact with respiratory secretions, feces, contaminated feathers, organs, and blood from live or dead infected birds and possibly from contaminated surfaces. Consumption of properly cooked poultry and eggs is not thought to pose a risk. Use of antiviral containment and vaccination may protect against development of a pandemic.

CONCLUSIONS

To most effectively decrease the risk of a pandemic, the public health and animal health sectors--those which are responsible for protecting and improving the health of humans and animals, respectively--must collaborate to decrease human exposure to HPAI virus, both by controlling virus circulation among poultry and by assessing the risks of human exposure to avian influenza virus at the human-animal interface from primary production through consumption of poultry and poultry products, and implementing risk-based mitigation measures.

The challenge of avian influenza to the veterinary community

Avian influenza (AI) is a listed disease of the World Organisation for Animal Health (OIE) that has become a disease of great importance both for animal and human health. The increased relevance of AI in the fields of animal and human health has highlighted the lack of scientific information on several aspects of the disease, which has hampered the adequate management of some of the recent crises. Millions of animals have died, and there is growing concern over the loss of human lives and over the management of the pandemic potential. The present paper aims to identify areas of knowledge of veterinary competence that need to be improved in order to generate information to support the global AI crisis, and highlights the major changes in AI legislation, including regulations related to trade. It also reviews the human health implications of AI, including the mechanisms by which a human pandemic virus may be generated, and the food safety issues related to this infection. The application of control policies, ranging from stamping out to emergency and prophylactic vaccination, are discussed on the basis of data generated in recent outbreaks, and in the light of new regulations, also in view of the maintenance of good animal welfare. Poultry veterinarians working for the industry or for the public sector represent the first line of defence against the pandemic threat and for the prevention and control of this infection in poultry and in wild birds. However, given the current situation, it is imperative that close collaboration is sought and achieved by health officials involved in the veterinary, agricultural and medical aspects of the disease. Only through the exchange of data, experiences, views and information will it be possible to combat this zoonosis, which represents a major threat to public health and animal well-being.

Estimating the day of highly pathogenic avian influenza (H7N7) virus introduction into a poultry flock based on mortality data

Despite continuing research efforts, knowledge of the transmission of the highly pathogenic avian influenza (HPAI) virus still has considerable gaps, which complicates epidemic control. The goal of this research was to develop a model to back-calculate the day HPAI virus is introduced into a flock, based on within-flock mortality data. The back-calculation method was based on a stochastic SEIR (susceptible (S) - latently infected (E) - infectious (I) - removed (= dead; R)) epidemic model. The latent and infectious period were assumed to be gamma distributed. Parameter values were based on experimental H7N7 within-flock transmission data. The model was used to estimate the day of virus introduction based on a defined within-flock mortality threshold (detection rule for determining AI). Our results indicate that approximately two weeks can elapse before a noticeable increase in mortality is observed after a single introduction into a flock. For example, it takes twelve (minimum 11 - maximum 15) days before AI is detected if the detection rule is fifty dead chickens on two consecutive days in a 10 000 chicken flock (current Dutch monitoring rule for notification). The results were robust for flock size and detection rule, but sensitive to the length of the latent and infectious periods. Furthermore, assuming multiple introductions on one day will result in a shorter estimated period between infection and detection. The implications of the model outcomes for detecting and tracing outbreaks of H7N7 HPAI virus are discussed.

The transmissibility of highly pathogenic avian influenza in commercial poultry in industrialised countries

Background

With the increased occurrence of outbreaks of H5N1 worldwide there is concern that the virus could enter commercial poultry farms with severe economic consequences.

Methodology/Principal Findings

We analyse data from four recent outbreaks of highly pathogenic avian influenza (HPAI) in commercial poultry to estimate the farm-to-farm reproductive number for HPAI. The reproductive number is a key measure of the transmissibility of HPAI at the farm level because it can be used to evaluate the effectiveness of the control measures. In these outbreaks the mean farm-to-farm reproductive number prior to controls ranged from 1.1 to 2.4, with the maximum farm-based reproductive number in the range 2.2 to 3.2. Enhanced bio-security, movement restrictions and prompt isolation of the infected farms in all four outbreaks substantially reduced the reproductive number, but it remained close to the threshold value 1 necessary to ensure the disease will be eradicated.

Conclusions/Significance

Our results show that depending on the particular situation in which an outbreak of avian influenza occurs, current controls might not be enough to eradicate the disease, and therefore a close monitoring of the outbreak is required. The method we used for estimating the reproductive number is straightforward to implement and can be used in real-time. It therefore can be a useful tool to inform policy decisions.

Risk maps for the spread of highly pathogenic avian influenza in poultry

Devastating epidemics of highly contagious animal diseases such as avian influenza, classical swine fever, and foot-and-mouth disease underline the need for improved understanding of the factors promoting the spread of these pathogens. Here the authors present a spatial analysis of the between-farm transmission of a highly pathogenic H7N7 avian influenza virus that caused a large epidemic in The Netherlands in 2003. The authors developed a method to estimate key parameters determining the spread of highly transmissible animal diseases between farms based on outbreak data. The method allows for the identification of high-risk areas for propagating spread in an epidemiologically underpinned manner. A central concept is the transmission kernel, which determines the probability of pathogen transmission from infected to uninfected farms as a function of interfarm distance. The authors show how an estimate of the transmission kernel naturally provides estimates of the critical farm density and local reproduction numbers, which allows one to evaluate the effectiveness of control strategies. For avian influenza, the analyses show that there are two poultry-dense areas in The Netherlands where epidemic spread is possible, and in which local control measures are unlikely to be able to halt an unfolding epidemic. In these regions an epidemic can only be brought to an end by the depletion of susceptible farms by infection or massive culling. The analyses provide an estimate of the spatial range over which highly pathogenic avian influenza viruses spread between farms, and emphasize that control measures aimed at controlling such outbreaks need to take into account the local density of farms.

Modern approaches in the epidemiology of infectious diseases include the use of mechanistic mathematical models to analyze and predict the dynamics of disease transmission. Modelling work during the massive epidemic of foot-and-mouth-disease in 2001 in Great Britain has provided an important example of how such analyses can be performed whilst an epidemic unfolds, predicting the effectiveness of intervention efforts and thus helping to inform policymaking. In this article, we use the example of highly pathogenic avian influenza in poultry to set out a computational approach yielding risk maps for the spread of highly transmissible livestock diseases. In these risk maps, geographic areas are identified in which a given intervention strategy fails to control the spread of the disease between farms. Using the epidemiological data of a large avian influenza epidemic in The Netherlands in 2003, this approach yields an estimate of the distance-dependent transmission probability. From this transmission probability, the transmission potential is calculated for all farms in The Netherlands, leading to the identification of two high-risk areas, defined as clusters of farms with transmission potential exceeding unity. The risk map concept is an instrument suitable for analyses of epidemic control options both during crisis and in peacetime.

The development of an exposure risk index as a rational guide for biosecurity programs

Population disease risk can be ranked using an exposure risk index that uses quantitative data on exposure risk factors and the proximity of susceptible animals to disease reservoirs. The reservoir represents the available microbial load (a quantity), derived from the mass of the contaminant, the percentage available for dissemination, the initial microbial content of the contaminant, and its age and half-life. The proximity measurement uses distance from the reservoir to calculate an area over which the microbial exposure might be spread. Dividing the reservoir by the proximity measurement, one obtains an exposure risk measurement that is significantly correlated with veterinarians' perceptions of risk. This exposure risk ranking can be used to rank population disease transmission risks associated with events and practices in animal production. The advantages of the exposure risk index are that it derives an exposure risk measurement from available objective information, it provides a way to compare disparate sources of disease exposure risk, it can be modified for specific diseases, and it provides a foundation for developing and evaluating mitigation strategies. From the exposure risk measurement, mitigation strategies and available resources can be focused appropriately to prevent or control disease. Biosecurity programs and disease control measures can be directed at those areas of greatest risk for spreading disease.

Practicalities of the Implementation of a Vaccination Campaign for Avian Influenza

Emergency vaccination for avian influenza (AI) infections caused by viruses of the H5 or H7 subtypes has been used in several instances over the past years. It has been applied primarily in the chicken and turkey industry with the general objective of controlling, and in some instances eradicating, infection. The use of vaccination as a tool to eradicate AI requires the enforcement of a coordinated set of control and monitoring measures. In fact, only certain attempts at eradicating AI with the support of vaccination have been successful, and the outcome of the vaccination campaign has been shown to depend greatly on effective application of the field strategy that complemented the vaccination program. While it is taken for granted that the product and companion diagnostic test are suitable for that given situation, a monitoring system must be in place to promptly identify whether vaccinated birds have been field exposed, and the latter should be dealt with in an appropriate manner, avoiding the spread of infection to other premises. Prophylactic vaccination could also become a tool for AI management in the European Union, provided that its application is based on a systematic assessment of AI risk. The correct use of this tool can be a valuable support for the control of AI in poultry, with the added value of limiting the economic losses to the industry and to the taxpayer. Eventually, this will also reduce human exposure to potentially dangerous 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.

Silent spread of H5N1 in vaccinated poultry

International debate on the merits of vaccinating poultry against the H5N1 influenza A virus has raised concerns about the possibility of an increased risk of between-flock transmission before outbreaks are detected. Here we show that this 'silent spread' can occur because of incomplete protection at the flock level, even if a vaccine is effective in individual birds. The use of unvaccinated sentinels can mitigate, although not completely eliminate, the problem.

Public health risk from avian influenza viruses

Since 1997, avian influenza (AI) virus infections in poultry have taken on new significance, with increasing numbers of cases involving bird-to-human transmission and the resulting production of clinically severe and fatal human infections. Such human infections have been sporadic and are caused by H7N7 and H5N1 high-pathogenicity (HP) and H9N2 low-pathogenicity (LP) AI viruses in Europe and Asia. These infections have raised the level of concern by human health agencies for the potential reassortment of influenza virus genes and generation of the next human pandemic influenza A virus. The presence of endemic infections by H5N1 HPAI viruses in poultry in several Asian countries indicates that these viruses will continue to contaminate the environment and be an exposure risk with human transmission and infection. Furthermore, the reports of mammalian infections with H5N1 AI viruses and, in particular, mammal-to-mammal transmission in humans and tigers are unprecedented. However, the subsequent risk for generating a pandemic human strain is unknown. More international funding from both human and animal health agencies for diagnosis or detection and control of AI in Asia is needed. Additional funding for research is needed to understand why and how these AI viruses infect humans and what pandemic risks they pose.

Preventing influenza: an overview of systematic reviews

BACKGROUND

Many options are available for preventing people from getting infected by influenza virus, with vaccination being the most widely used.

METHODS

We assessed the evidence available in Cochrane systematic reviews. We found nine reviews, five of them addressing influenza vaccination, and four addressing medication.

RESULTS

Vaccination is effective in healthy adults and children, but the effect is modest in adults, and for young children few data are available. In patients with asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis, more evidence is needed to determine effectiveness. Vaccination does not result in exacerbation of asthma. Neuraminidase inhibitors may also have a place in limiting the spread of infection, at least in adults. Amantadine and rimantadine seem effective but have unfavourable adverse-effect profiles. The popularity of homoeopathic Oscillococcinum, especially in France, is not supported by current evidence.

CONCLUSION

In many areas, more clinical trials are needed, as the current evidence is inconclusive. Furthermore, several other measures that may be helpful in preventing influenza that have not been addressed in Cochrane reviews.

Performance of clinical signs in poultry for the detection of outbreaks during the avian influenza A (H7N7) epidemic in The Netherlands in 2003

The aim of this study was to make an inventory of the clinical signs of high-pathogenicity avian influenza (HPAI), to facilitate the development of an operational syndrome-reporting system (SRS) in The Netherlands as an early warning system for HPAI outbreaks. A total of 537 poultry flocks (240 infected and 297 non-infected) with a clinical suspicion of an infection with HPAI virus were investigated with respect to the clinical signs observed. Standardized reports were analysed with respect to observed clinical signs in the flocks. Various poultry types were distinguished. In infected commercial flocks with egg-producing chickens, the presence of increased mortality, apathy, coughing, reduction in normal vocalization, or pale eggs appeared to be overall the most sensitive indicators to detect a HPAI outbreak, matching a sensitivity of 99% with a specificity of 23%. In infected turkey flocks, the presence of apathy, decreased growth performance, reduction of normal vocalization, swollen sinuses, yawning, huddling, mucosal production from the beak, or lying down with an extended neck appeared to be overall the most sensitive indicators to detect a HPAI outbreak, matching a sensitivity of 100% with a specificity of 79%. In infected backyard/hobby flocks, increased mortality or swollen head appeared to be overall the most sensitive indicators of a HPAI outbreak, matching a sensitivity of 100% with a specificity of 26%. These results indicate that there is a solid basis for the choice of using increased mortality in the operational SRS in The Netherlands as an early warning system for HPAI outbreaks. The presence of apathy, specifically for turkeys, should be added to the SRS as an indicator.

A cross-sectional serological survey of the Dutch commercial poultry population for the presence of low pathogenic avian influenza virus infections

After the discovery of poultry infected with highly pathogenic avian influenza (HPAI) virus of subtype H7N7 in the central area of The Netherlands on 28 February 2003, the hypothesis was put forward that an outbreak of the low pathogenic (LP) variant of H7N7 had preceded, unnoticed, the occurrence of the HPAI virus. Consequently, a cross-sectional serological survey of the Dutch poultry population was executed in the second week of March 2003. The basic requirements set were detection of a 5% prevalence of flocks exposed to LPAI virus with 95% confidence within the production type stratification level within each province in The Netherlands. Because of supposed higher risk of avian influenza infections in ducks, turkeys and free-range poultry, all the commercial flocks of these production types present in The Netherlands were sampled. The serological screening of 28018 sera from 1193 randomly selected poultry farms, located outside surveillance zones showed that LPAI H7 virus infections had occurred on three neighbouring farms all located in the southwest of The Netherlands. No antibodies against the neuraminidase N7 subtype were detected in the sera of these farms, indicating that the subtype was different from the HPAI H7N7 subtype that caused the avian influenza epidemic in 2003. In addition, evidence of infections with non-H5 or non-H7 subtypes of influenza A virus were obtained in two other farms located in the northeast and the southeast of The Netherlands. It was concluded that the HPAI subtype H7N7 outbreak was most likely not preceded by a significant circulation of a LPAI subtype H7N7 virus. Based on the Dutch experience, recommendations are made to detect avian influenza infections faster in the future.

Ability of veterinary pathologists to diagnose classical swine fever from clinical signs and gross pathological findings

Clinical signs recorded in a classical swine fever (CSF)-suspect situation and the results of the subsequent post-mortem examination (PME) from swine submitted to post-mortem during the 1997-1998 CSF epidemic in the Netherlands, were presented in an experiment as anonymous cases (without knowledge of the actual infection status of the submission) to five veterinary pathologists for their judgment: CSF-suspect or non-suspect. It was presented to them in two hypothetical situations: country was free of CSF for 5 years and CSF was detected in the country 2 weeks ago. Subsequently, their judgment was compared to the gold standard (infection status of the submission on the basis of an immunofluoresence assay on tissue samples) and the sensitivity (Se) and specificity (Sp) of clinical diagnosis was estimated. Furthermore, intra- and inter-pathologist agreement on pathological diagnosis was measured. Adding information on clinical signs to information on PME resulted in a significant increase in median Se and a significant decrease in median Sp for a clinical judgment by pathologists. Also, median Se was significantly higher-and Sp significantly lower-for a clinical judgment by pathologists in a situation in which CSF was detected 2 weeks ago in the country compared to the situation in which the country had been free of CSF for 5 years. Apparently, the internal threshold of pathologists is severely adjusted depending on the actual disease situation in a country. Intra-rater agreement ranged from fair to almost perfect for a clinical diagnosis on the basis of PME. There was considerable variation between pathologists, especially if clinical diagnosis was based on the combined information on PME and clinical signs observed in the herd. Inter-rater agreement was substantial for the diagnosis based on information on PME. Inter-rater agreement was considerably lower for the diagnosis based on the combined information on PME and clinical signs observed in the herd.

Performance of gross lesions at postmortem for the detection of outbreaks during the avian influenza A virus (H7N7) epidemic in The Netherlands in 2003

A total of 123 submissions (on average, five birds per submission) from poultry flocks with a suspicion of an infection with highly pathogenic avian influenza virus were investigated at postmortem during the 2003 epidemic in The Netherlands. A total of 86 of these submissions were from infected flocks (positive submissions), and 37 submissions were from non-infected flocks (negative submissions). Peritonitis was the most frequently (62%) recorded pathological finding in positive submissions, followed by tracheitis (43%), oedema of the neck and/or wattles (12%) and (petechial) haemorrhages in the proventriculus (4%). A total of 17% of the positive submissions consisted of birds without any macroscopic lesion. The pathological lesions observed in our study do not fully comply with descriptions in literature, especially the lack of haemorrhagic changes in tissues and low prevalence of oedema of the neck, comb and wattles. It is recommended that if peritonitis, or tracheitis, or oedema of the neck and/or wattles or (petechial) haemorrhages in the proventriculus is observed at postmortem examination, especially if accompanied by an anamnesis describing acute and high mortality in a flock, this should consistently result in follow-up action to exclude highly pathogenic avian influenza in the differential diagnosis as cause of the disease problems by testing tissue samples with an avian influenza-specific laboratory test at the avian influenza reference laboratory.