Monday, October 09, 2023

Preprint: A Timely Survey of Knowledge, Attitudes, and Practices Related to Avian Influenza (H5N1) in Rural, Cambodia


In yesterday's report (see Cambodian MOH Reports A Human H5N1 Casewe learned of another fatal H5N1 infection in a Cambodian village in Svay Rieng province, following the death of `more than 50 chickens' at the victim's house (and neighbor). 

According to the MOH report, the dead chickens were `. . . distributed to relatives to eat'.

For many Cambodian villagers, their wealth - and their food security - lies in what they can raise, forage, or grow.  The sudden loss of 50 chickens would represent a substantial blow, and so them sharing these birds with relatives so they can be quickly consumed makes a lot of sense. 

It is not much different from the stories my father told me of growing up as a boy during the Great Depression. Once a week his uncle would tell him to go to the chicken coop and pick out the `sickliest looking chicken' for the Sunday stew pot. 

When times are tough, you don't squander resources.  And you eat the healthiest chickens last.

Last week I came across a preprint - published in late September - of a cross-section survey conducted last August in Prey Veng province, where an 11 year-old girl died of H5N1 earlier this year.

Participants (n=208) were invited to be interviewed face-to-face on their knowledge, attitudes, and practices related to avian influenza. 

Although this study is limited both in number of participants, and geographic scope, it is probably fairly representative of the practices of tens, or even hundreds, of millions of people living in this part of the world.  

We've seen many of the practices described before, including the consumption or improper disposal of dead poultry, often in connection with H5N1 spillovers. 

This is a timely and informative survey, and well worth perusing in its entirety.  Due to its length, I've only posted some excerpts.  I'll have a bit more after the break.

Knowledge, Attitudes, and Practices Related to Avian Influenza (H5N1) After the Outbreak in Rural, Cambodia
Daraden Vang, Darapheak Chau, Kimim Vutha, V Samnang Um Samnang Um


From 2003 to 25 February 2023, the avian influenza (H5N1) virus was confirmed in 59 human infections, including 39 deaths (~66% case-fatality rate) reported in 13 of 25 provinces in Cambodia. We aimed to assess current knowledge, attitude, and practice toward changes in poultry handling behaviors, poultry consumption, and poultry mortality reporting among rural villagers in areas affected by Avian influenza (H5N1) in Cambodia.

A cross-section survey was conducted in August 2023. There were 208 participants residing in Prey Veng province who were invited to be interviewed face-to-face. Descriptive statistics were performed using STATA V17. The participants' average age was 55 years old (SD=13.3 years), 78.4% were female, 59% had completed primary school, 56.7% were farmers, 68.3% raised chickens in their backyards, and 10.2% raised ducks, 23% of participants cooked sick or dead birds for their families, 32% knowing information about avian influenza virus was a lower proportion from healthcare providers, 10.6% from village health support groups were, and 2% from village animal health workers were only, 49% have been reported poultry illness and deaths to local authorities.

The avian influenza epidemic in Cambodia is a genuine threat to animals and a possible concern to humans. To prevent and control this, we strongly advise everyone who works with poultry or wild game birds always to be prepared to follow appropriate hygiene standards and to cook poultry meat properly.



We conducted a cross-sectional survey of 208 subjects in Prey Veng province from 4 August to 7 2023 to assess current knowledge, attitude, and practice regarding changes in poultry handling behaviors, poultry consumption, and poultry mortality reporting. Since 23 February 2023, Cambodia's Ministry of Health has reported to WHO one confirmed fatal case of human infection with the avian influenza A(H5N1) virus in an 11-year-old girl from Prey Veng province. Then, on 23 February 2023, epidemiological and analytical studies revealed the second case, the father of the index child [13].

Within the affected village, information, education, and communication (IEC) campaigns were implemented, including leaflets distributed and broadcast media coverage on local television and radio to inform the public through messages aimed at reducing exposure to disease, preventing disease spread in poultry, and encouraging reporting. In our survey, the proportion of subjects who work as farmers was 57%, raising chickens in the backyard was 68.3%, and raising ducks was 10.2%.

Cambodia's higher-risk behaviors or vulnerability groups need priority intervention to reduce infectious and zoonotic diseases. Since the first outbreaks of highly pathogenic avian influenza caused by viruses of the H5N1 subtype (H5N1 HPAI) were detected in geese in 1996 in the Chinese province of Guangdong and 1997 in Hong Kong, Until today, 54 countries in Asia, Europe, and Africa have reported H5N1 HPAI outbreaks among poultry; outbreaks in poultry farms have been reported in every country in Southeast Asia (SEA) [2,6,19,20].

Furthermore, we noticed that 23% of participants cooked sick or dead poultries for their families. Previous research in Cambodia found that direct contact with chickens suspected of being infected with the H5N1 virus was harmful [20]. Of the participants who reported knowing information about the avian influenza virus, a lower proportion from healthcare providers was 32%; village health support groups were 10.6%; village animal health workers were only 2%. Implementing information, education, and communication (IEC) campaigns should be conducting refresher training for villagers. This study found that 49% reported poultry illness and deaths to local authorities.

These reported practices did not improve during the study period. Raising backyard poultry in rural Cambodia provides significant income and nutrition with an excellent annual investment. Government recommendations to reduce the risk of avian influenza transmission did not impact the behavior of poultry producers.

Further research should prioritize developing interventions that simultaneously reduce the risk of avian influenza transmission and increase the productivity of backyard poultry [21]. However, closer relationships between local healthcare providers and residents could promote early healthcare behaviors in people living in rural communities. Educational programs conducted by local healthcare providers might be effective. Still, residents' attitudes must be considered when planning health education in communities with H5N1 patients in neighboring areas [22].

          (Continue . . . )

Over the years, the majority of Asian H5N1 human infections have been linked to attending or working in Live Bird Markets (LBMs), or the raising of backyard poultry.  Repeated attempts to shut down LBMs have met with stiff resistance, and have encouraged the illegal trade in live birds (see Beijing Orders Closure Of Live Bird Markets To Control H7N9).

People are often afraid to report unusual poultry deaths in their backyard flock, for fear the authorities will come and cull the rest of their birds. So midnight dumping of dead birds in the local river or lake are common (see Vietnam: Dozens Of Sacks Of H5N6 Infected Chickens Dumped on Nghe An Beach).

Convincing people that something they have been doing for generations - like raising chickens in their backyard - could suddenly be dangerous can be a hard `sell'.  We saw similar (and often bitter) resistance to the notion that beloved camels in Saudi Arabia carried a new, deadly coronavirus (see Saudi Camel Owners Threaten Over MERS `Slander’).

But the fact remains the level of H5N1 (and other zoonotic viruses) continues to increase around the world, and spillovers - and increased food insecurity - are likely to increase as well.

Getting that message out - and offering people practical alternatives - needs to be a high priority.