AVIAN INFLUENZA AND PROGRAMME GUIDELINES FOR ITS
PREVENTION AND CONTROL IN PAKISTAN
Lt. Gen (R) K.A.Karamat1
Dr. F.H Khattak2
Beenish Mahmood3
INTRODUCTION
AVIAN INFLUENZA (BIRD FLU)
Bird flu, or avian influenza, is a disease caused by viruses. It is a contagious
disease which infects only birds, and sometimes pigs. The avian influenza
viruses attack specific species - they have, on occasions jumped the species
barrier
and
infected
human
beings
though
rare.
There are two main types of avian influenza - one is fairly mild while the other is
deadly (for birds).
Low pathogenic forms of bird flu may cause a bird to have more ruffled feathers
and lay fewer eggs. This form is often undetected among farmed poultry (in many
cases the bird is infected, and then gets better )The highly pathogenic form of
bird flu is much more dangerous. It has a mortality rate of virtually 100% and
spreads very rapidly among flocks of birds. A bird infected with the more virulent
type of bird flu (the highly pathogenic form) experiences deterioration of many
internal organs. The most dangerous strain of the bird flu virus is called H5N1.
Infected birds shed influenza virus in their saliva, nasal secretions, and feces.
Susceptible birds become infected when they have contact with contaminated
excretions or with surfaces that are contaminated with excretions or secretions.
Domesticated birds may become infected with avian influenza virus through
direct contact with infected waterfowl or other infected poultry or through contact
1
Advisor (Health) Planning Commission
Deputy Chief (Health) Planning Commission
3
Intern (Health) Planning commission
2
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with surfaces (such as dirt or cages) or materials (such as water or feed) that
have been contaminated with the virus.
SCIENTIFIC DIMENSION OF AVIAN INFLUENZA
Avian Influenza (AI) is highly contagious viral infection; primarily of the avian
species. The casual virus mainly affects gastrointestinal, respiratory, reproductive
and/or nervous systems of the affected birds. In case of systematic infection, the
virus is capable of causing sudden death resulting in high mortality and egg
production losses in the affected flocks. Of the known 16 subtypes of AI virus, H5
and H7 are high-risk strains and are known to cause severe infection in poultry
and on some occasions in humans too. The world animal Health Organization
(OIE) has declared H5 and H7 infection as notifiable AI, making it mandatory for
all the countries to notify the disease to OIE.
Avian influenza does not usually infect humans, however, once transmitted; the
infection may lead to the influenza-like symptoms, viral pneumonia, and other
severe life threatening complications. Beginning in 2003, incidence of H5N1
infection in humans has increased mostly in the Asian countries. So far, all the
genes identified from the recovered viruses are of avian origin, indicating that the
virus has not yet acquired human genes. The acquisition of Human gene is
known to increase the likelihood that a virus of avian origin can be readily
transmitted from one human to another, resulting into human pandemic.
However, molecular epidemiology data indicates that currently circulating strains
of H5N1 viruses are more capable of causing diseases (pathogenic) in animals
than were the earlier H5N1 viruses. The virus continues to evolve and may adopt
so that other mammals (including human) may be susceptible to infection as well.
There is a hypothesis that explains why wild birds die of avian flu at winter
nesting areas. If the virus has already emerged in the environment, it persists
there for a long time. Its pathogenic qualities become more pronounced during
winter, when wilds birds have a hard time (in Europe and Southern Russia).
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Stress, low temperatures, and lack of food reduce their immunity, and they are
more likely to catch different diseases, including avian flu.[1]
HUMAN INFECTION WITH AVIAN INFLUENZA VIRUSES
There are different subtypes of type A influenza viruses. These subtypes differ
because of changes in certain proteins on the surface of the influenza A virus
(hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA
subtypes and 9 known NA subtypes of influenza A viruses. Many different
combinations of HA and NA proteins are possible. Each combination represents
a different subtype. All known subtypes of influenza A viruses can be found in
birds. [2]
Usually, “avian influenza virus” refers to influenza A viruses found chiefly in birds,
but infections with these viruses can occur in humans. The risk from avian
influenza is generally low to most people, because the viruses do not usually
infect humans. However, confirmed cases of human infection from several
subtypes of avian influenza infection have been reported since 1997. Most cases
of avian influenza infection in humans have resulted from direct or close contact
with infected poultry (e.g., domesticated chicken, ducks, and turkeys) or surfaces
contaminated with secretions and excretions from infected birds. The spread of
avian influenza viruses from an ill person to another person has been reported
very rarely, and transmission has not been observed to continue beyond one
person. During an outbreak of avian influenza among poultry, there is a possible
risk to people who have direct or close contact with infected birds or with
surfaces that have been contaminated with secretions and excretions from
infected birds
Studies done in laboratories suggest that some of the prescription medicines
approved in the United States for human influenza viruses should work in treating
avian influenza infection in humans. However, influenza viruses can become
resistant to these drugs, so these medications may not always work. Additional
studies are needed to demonstrate the effectiveness of these medicines.
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STATUS OF HUMAN CASES AND DEATHS IN THE REGIONAL COUNTRIES
The following table depicts the picture of human cases and deaths in the 14
countries of the globe:
TABLE: 1
Sr
No.
Country
2003
1.
Azerbaijan
C
0
D
0
C
0
D
0
C
0
D
0
C
8
D
5
C
0
D
0
C
0
D
0
C
8
D
5
2.
Cambodia
0
0
0
0
4
4
2
2
1
1
0
0
7
7
3.
China
1
1
0
0
8
5
13
8
5
3
0
0
27
17
4.
Djibouti
0
0
0
0
0
0
1
0
0
0
0
0
1
0
5.
Egypt
0
0
0
0
0
0
18
10
25
9
0
0
43
19
6.
Indonesia
0
0
0
0
20
13
55
45
42
37
10
8
127
103
7.
Iraq
0
0
0
0
0
0
3
2
0
0
0
0
3
2
8.
Lao PDR
0
0
0
0
0
0
0
0
2
2
0
0
2
2
9.
Nigeria
0
0
0
0
0
0
0
0
1
1
0
0
1
0
10.
Thailand
0
0
17
12
5
2
3
3
0
0
0
0
25
17
11
Turkey
0
0
0
0
0
0
12
4
0
0
0
0
12
4
12.
Viet Nam
3
3
29
20
61
19
0
0
8
5
2
2
103
49
13.
Pakistan
0
0
0
0
0
0
0
0
1
1
0
0
1
1
14.
Mayammar
0
0
0
0
0
0
0
0
1
0
0
0
1
0
4
4
46
32
98
43
115
79
86
59
12
10
361
227
TOTAL
2004
2005
2006
2007
2008
Total
C: Case
D: Deaths
SOURCE: World Health Organization
DATA ANALYSIS
The dangerous H5N1 strain has been circulating for five years. This is an
unprecedented long period, but the strain is still as active as before. It was
revealed in domestic geese in China in 1996 for the first time. A year later, it
killed poultry at farms and wholesale markets of Hong Kong. Since 2003, people
started dying from it. All in all, 361 people have been infected with this strain in
14 countries (Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq,
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Laos, Myanmar, Nigeria, Pakistan, Thailand, Turkey and Vietnam), with 227
deaths.
The data analysis shows a very alarming situation of the cases and deaths in the
above 14 countries. A quantum jump from 04 cases and deaths, in 2003 to 86
cases and 59 deaths in 2007 is alarming. The most responsible factors in 2003
may be that the majority of cases were not diagnosed and registered because of
the unawareness and due to lack of advocacy and proper information system.
Out of 46 Cases in 2004; there were 32 deaths (69%), while deaths in 2005 are
44% of the total cases registered/diagnosed. However cases registered during
2005 are 113% higher than 2004.Maximum cases registered were 115 in 2006
with 79 deaths (Deaths were 69% of the cases diagnosed). There is a gradual
decline of the cases and deaths in 2007, but it is still higher than the base year of
2003 and 2004.Total cases in the five years period (2003-07) are 349, and
deaths are 217 (62%).
The data analysis suggests having more preventive and curative measures of
avian influenza. Despite the fact new technology and vaccines have emerged,
still the spread of avian influenza is faster than the cure rate. This trend also
embarks for more research to discover the cost effective and efficient ways and
means for prevention, control and treatment of influenza.
The analysis also shows the highest cases and deaths registered in Indonesia
which is 127 and 103 respectively, followed by Vietnam which is 103 and 49,
respectively. The ecology and environment of such countries needs a special
attention to be studied through research for identification of the factors
responsible for the high cases and deaths in these countries. Such ecological
and environmental factors shall be studied and controlled before it becomes
endemic in the other countries.
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SITUATION ANALYSIS OF AVIAN INFLUENZA IN PAKISATN
The first case of human infection with H5N1 avian influenza was confirmed in
Nov. 2007 in Pakistan. Laboratory tests conducted by the WHO H5 Reference
Laboratory in Cairo, (Egypt) and WHO Collaborating Center for Reference and
Research on Influenza, (London, United Kingdom) have confirmed the presence
of avian influenza virus strain A(H5N1) in samples collected from one case in an
affected family. The H5N1 positive case was a 25 year old male from the
Peshawar area who developed febrile respiratory illness on 21 November, 2007
and was hospitalized on 23 November, but died on 28 November 2007.
Additional laboratory analysis, including gene sequencing, was ongoing till
compiling the data for this article.
On the request of the Government, a WHO team travelled to Pakistan for
participation with national authorities in the ongoing investigations of several
suspected cases of human H5N1 infections. Following are the findings of the
team report:
I. The preliminary risk assessment found no evidence of sustained or
community human to human transmission.
II. All identified close contacts including the other members of the affected
family and involved health care workers remain asymptomatic and have
been removed from close medical observation.
III. The Ministry of Health in Pakistan has taken timely steps to investigate and
contain this event including case isolation, contact tracing and monitoring,
detailed epidemiological investigations, increasing the availability of
personal protective equipment, dedicating hospital facilities for any new
suspected cases, and other infection control measures. In addition,
agricultural authorities, including the Ministry of Food, Agriculture and
Livestock and FAO, have activated technical partners for the effective
control of this limited outbreak.
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IV. Pakistani authorities confirmed another fresh outbreak of the H5N1 strain of
bird flu at a poultry farm on the outskirts of Karachi in 2007.
V. Authorities have found several outbreaks of the virus in poultry and birds in
North West Frontier Province and the capital, Islamabad, since it was first
detected in the country in early 2006. Samples taken from it were tested and
found positive for H5N1."Some 500 to 600 birds died of the virus and the
remaining 5,500 chickens were culled now.” Tests were also being done on
samples taken from poultry farms in Punjab province but no outbreak had
been confirmed.
Following are the major steps to be taken for the control of Avian influenza in
future
A. SURVEILLANCE OF HUMAN CASES:
I. Immediate dispatch of Joint MoH-WHO Rapid Response teams to the
affected districts.
II. Strengthening of Lab capacity at NIH-Islamabad for viral culture, sub-typing,
serology and molecular (PCR) testing
III. Existing Polio Surveillance System activated for case finding, sample
collection and transportation to the virology Laborotary, NIH-Islamabad.
IV. Hospital-based surveillance of severe pneumonia at 20 tertiary hospitals
across Pakistan launched
V. Provinces/AJK/NAs directed to attach public health specialists with rapid
Response Teams for joint response to the outbreaks amongst farmers and
cullers.
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VI. Districts Monitoring and response Committees under DCOs to be
constituted.
VII. Federal Monitoring Cell at NIH is monitoring the situtaion 24 hours.
VIII. Viral transport media has been supplied to the provincial Health
Departments for the collection and transportation of the samples from any
suspected patients.
IX. Antiviral medicine, Oseltamivir (Tamiflu and other) has been purchased from
national manufactureres and 6000 doses has been stockpiled (5000 adults
and 1000 children)
X. Establishment of Joint Steering Committees at Federal Level by the
Government of Pakistan under the chairmanship of Federal Minister for
health with federal Minister for Food, Agriculture and
Livestock as Co-
Chairman.
B. STRATEGIES:
Public health

Surveillance of human infections, with epidemiologic and laboratory
investigations

Stockpiling and logistics

Emergency responses

Strengthened case management

Infection control

Public communication

Integrated command and coordination
Animal health

Active surveillance

Culling infected flocks with compensation

Controlling movement of poultry
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
Improving biosecurity

Biosecurity Zoning and compartmentalization
PREVENTION AND CONTROL OF AVIAN INFLUENZA IN PAKISTAN
Government of Pakistan has taken prompt action to prevent and control the virus
in the country by launching a Programme at the national level. The Programme
addresses all epidemiological phases of expected influenza outbreak i.e. PrePandemic, Pandemic and Post-pandemic for efficient, timely and comprehensive
response to contain outbreak, prevent possible losses of life and social disruption
through mobilizing all national and provincial line departments, NGOs and Civil
society. It includes persistent monitoring of information, assessment of impact,
assessment of resource needs (e.g. morbidity, mortality, workplace absenteeism,
region affected, risk groups affected, health-care workers and other essential
worker’s availability, health care-supplies, bed occupancy/availability, admission
pressures, use of alternative health facilities, mortuary capacity). The specific
objectives of the program are;[3]
I. Reduction of morbidity and mortality due to human cases of Avian
influenza and/or human influenza pandemic by monitoring the spread of
influenza-A/ H5N1 and pandemic strain viruses in humans.
II. To ensure a prompt, coordinated and organized emergency response to
influenza pandemic by all stakeholders
III. To ensure availability of efficient and adequate clinical services and
antiviral medicines by the public and private sectors health care facilities
and providers during an influenza pandemic.
IV. To develop and evolve strategies for selection, usage/distribution and
monitoring of influenza vaccines(s).
V. To develop and evolve strategies based on non-pharmaceutical public
health actions for the containment of the flu pandemic
VI. To create awareness about modes of transmission and preventive
measures.
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Main activities and the Budget of the programme is given in the following table:
TABLE: II
Main Activities and Budget of the Programme
Sr. No.
1
2
3
4
5
6
7
8
9
10
11
12
Activities
Emergency Response
Clinical Health Services
Antiviral Medicines
Containment and Quarantine
Communication
Establishment
Transport
Lab Supplies
Civil Work
Office Equipment etc.
Personal protective Equipment
Center for Disease Control (CDC) Atlanta as
technical assistance under Lab Base
Influenza Like Illness (ILI) Surveillance project.
Proposed Cost
(Rs. Million)
2.400
8.900
161.040
6.120
5.000
34.989
2.700
5.000
37.000
2.902
50.000
5.000
321.051
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Sub-Total
Contingencies @ 3% of sub-total
9.632
330.683
Grand Total
Source: PC-I of Prevention and Control of Avian Influenza, Health Division (N.I.H.)
Islamabad 2006
2. The above program activities are under implementation at the total cost of
project Rs. 330.683 million. An amount of Rs. 100.00 million has been
provided in the PSDP 2007-08.Following activities will be undertaken
under the Programme.[4]
1: Emergency Response
-2: Clinical Health Service
3: Antiviral Medicine
4: Containment and Quarantine Activities
5: Health education and Communication
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6: Pre testing the Emergency Response
CONCLUSION AND RECOMMENDATION:
1. The outbreak in poultry weakens and jeopardizes food security. In the
past H9N3 and H9N2 have caused significant poultry losses. At preset
there is approximately Rs.8.00 billion investments in poultry business
in Pakistan according to Pakistan Poultry Association. With the
implementation of project the losses will be reduced to their minimum
level saving investment of people and increased production of better
quality meat. This virus infects human beings too and can make a
number of people (attached with this business) ill having adverse
impact on their earning and in such case large amount of money will
be spent on medication.
2. High distortion of the poultry decreases the supply, depresses the
prices down and on other hard prices of meat soar up and go beyond
the purchasing power of a middle income family.
3. Community mobilization for awareness shall be the important factor of
the Programme.
4. Reference Laboratories shall be established at the provincial levels.
The required medicines, will be made available and awareness
programme to be launched at the gross root levels.
5. LHWS can be effective medium for awareness, and developing
preventive measure in cooking and using of the poultry and poultry
product.
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REFERENCES
1. http://en.rian.ru/analysis/20080206/98571615.html
2. http://www.cdc.gov/flu/avian/gen-info/facts.html
3. P.C 1 of National Programme of Prevention Control of Avian
Influenza (bird flu) in Pakistan- 2006.
4. Public Sector Development Programme (PSDP 2007-08) Planning
Commission of Pakistan, June 2007.
5. Tool Kit for Early detection and control of Human Cases of avian
Influenza, WHO-MOH, Pakistan 2006.
6. WHO Manual on Animal Influenza Diagnosis and Surveillance
7. WHO/CDS/CSR/NCS/2002.5 Rev. 1
http://www.who.int/csr/resourses/publication/influenza/whocdsrncs2
0025rev.pdf
8. WHO Guidelines for the collection of human specimen for
laboratory diagnosis of avian influenza infection.12 January 2005
http://www.who.int/csr/disease/avianinfluenza/guidelines/humanspecimens/en/print.html
9. http://www.who.int/csr/disease/avianinfluenza/guidelines/transport/en/
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