We’ve been following an unprecedented surge in human H5N1 infection in Egypt since late last fall, and while the Egyptian MOH has been less than forthcoming in their public statements regarding the outbreak, between the WHO, the FAO, and the efforts of independent news gatherers like FluTrackers’ Egypt - 2015 WHO/MoH/Provincial Health Depts H5N1 Confirmed Case List we’ve managed to keep reasonable track of its progress.
Two months ago World Health Organization, along with the FAO, OIE, NAMRU-3, CDC & UNICEF were invited to Egypt as a joint mission to investigate and to make recommendations on containing that outbreak. We’ve been expecting a report on what they found for some time.
Today the WHO has posted a similar - but more abbreviated - summary of their findings along with a link to an executive summary. Changes from the May 3rd release include updated case counts to the end of April (165 cases, 48 deaths), and the removal of a section with specific recommendations for addressing the crisis, which are now to be found in the executive summary.
Egypt: upsurge in H5N1 human and poultry cases but no change in transmission pattern of infection
15 May 2015 – The recent increase in the number of people affected by the avian influenza virus H5N1 in Egypt is not related to virus mutations but rather to more people becoming exposed to infected poultry, according to a recent mission of six organizations assessing the H5N1 situation in the country.
Since November 2014 to 30 April 2015, the period analysed by the international mission, a total of 165 cases, including 48 deaths were reported. This is by far the highest number of human cases ever reported by a country over a similar period. There are indications that H5N1 is circulating in all sectors of poultry production and in all parts of Egypt.
The mission stressed that the way the influenza H5N1 virus is transmitted in Egypt appears to have remained stable despite the recent upsurge in numbers of human and poultry infections. While the risk for the current situation to escalate into an H5N1 pandemic does not appear to have been changed appreciably, the situation remains a cause for considerable concern.
“Based on all the evidence we have, we believe the upsurge is not explained by changes in the virus itself,” said Dr Keiji Fukuda, WHO Assistant Director-General for Health Security and head of the H5N1 investigation team in Egypt. “The most likely reason for the increase in cases is that more poultry in Egypt are infected by H5N1 and so more people are exposed to this virus. Coupled with insufficient awareness, behavioural patterns and inadequate precautions taken by humans when interacting with poultry this explains what we are seeing.”
For successful reduction of the negative impact on human health and associated economic and food security consequences, it will be essential to strengthen animal and human disease surveillance, biosecurity and disease control programmes, in a context of a strengthened and close collaboration between human health and animal health departments. This includes appropriate animal vaccination programmes through joint efforts by the public and private sector in charge of animal health.
The report found that:
- although human-to-human transmission cannot be excluded, the key epidemiological and demographic features of the recent human cases did not significantly change compared to those reported before the recent increase;
- there was no evidence for transmission from patients to health care workers during the upsurge;
- the vast majority of recent human cases – approximately 70% – had known exposure to infected backyard poultry;
- analysis of the genetic sequence data did not identify changes suggesting more efficient human-to-human transmission.
Although some of the apparent upsurge in cases might be a result of increased testing for H5N1 in humans, this cannot explain the whole picture. The upsurge of infections in poultry and the cases in people has likely been caused by changes in the economy and the poultry industry.
Many small farmers have turned to raising poultry for food and income in an unmonitored and uncontrolled farming sector. The implementation of a proper veterinary control strategy will require strengthening the response capacity, public–private partnerships, vaccination strategies and biosecurity in most poultry production sectors. Ensuring compliance with intergovernmental standards on animal health and regulatory statutes at national level, both in poultry production enterprises or households will be critical for limiting the spread of the H5N1 virus.
The report also notes that Egypt has already recognized the key features leading to the increase in disease, and has recently proposed important structures, sound policies and strategies. However, for them to be effective will require better implementation and concerted commitments at national, governorate and local level. The report recommended that Egypt should make long-term investments in agriculture, veterinary services, health and rural communities to combat H5N1. Policies should be developed to engage the large number of unlicensed commercial and semi-commercial poultry farms in developing new means of implementing and assuring effective disease prevention and control.
The 7-page executive summary, warns:
` . . . the presence of H5N1 viruses in Egypt with the ability to jump more readily from birds to humans than viruses in other enzootic countries is of concern and requires a high level of vigilance from the Ministries of Health and Agriculture.’
After reviewing their findings, and listing their recommendations, the report concludes:
A successful approach to addressing H5N1 requires long-term, sustainable investments in agriculture, health and communities. In particular, close collaboration between sectors is required in communications, policy development, surveillance and response, and the production and sharing of information. Accurate, regular assessment of the impact of control measures is required to evaluate progress.
The government should undertake one or more pilot projects at the district level to determine which changes in policies and practices are most effective in reducing spread of infection among poultry and to humans and sustainable on a medium- to long-term basis. Addressing H5N1 nationally will require long-term changes in policies, practices, culture, awareness and community engagement.
Within three months, a two-year action plan that encompasses these recommendations and includes clear outcomes and indicators for monitoring will be developed by the ministries of health, agriculture and local development. FAO, WHO and OIE will support development of the plan, which will be presented to the NSC.
Hopefully we’ll soon see another Influenza at the Human-Animal Interface report from the WHO updating us on the progress and the epidemiology of this outbreak.