WHO Statement On Joint H5N1 Mission To Egypt

 

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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.

 

As I mentioned earlier this week, a summary report was briefly posted on the WHO EMRO  website on May 3rd, but was taken down almost immediately without explanation. 

 

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:

 

The way forward

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.

Media: WHO H5N1 Mission To Egypt

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The Egyptian (Arabic & English) press is filled this morning with reports that the World Health Organization will send an expert envoy (led by Dr Keiji Fukuda) to Cairo later this month to assist the MOH in dealing with their H5N1 outbreak.

 

Aside from the news that Egypt has invited the WHO in, these reports provide some interesting insight on how the MOH continues to `manage’  the outbreak news information.

 

First, the English language version of the report, after which I’ll have a bit more:

 

WHO experts to visit Cairo mid March to curb H5N1: Health Minister

Mar. 01, 2015 11:26

By THE CAIRO POST

CAIRO: An international delegation from the World Health Organization (WHO) is due in Cairo mid-March to discuss ways to tackle Egypt’s endemic outbreak of H5N1 avian influenza, Health Minister Adel Adawy announced Sunday.

The international experts, in collaboration with the health ministry, will work on developing a strategy to ensure the eradication of the H5N1 avian influenza virus in Egypt in a short time,” Adawy was quoted by Youm7 Sunday.

<SNIP>

In Feb. 14, a 35 year-old man died of H5N1 avian flu in Cairo, marking the 11^th death in the country from the disease in 2015, according to the Health Ministry. The death toll reached 10 in 2014.

(Continue . . .)

 

Aside from the good news that Egypt has invited an expert mission to consult on their H5N1 outbreak, there are a couple of things that stick out about this report.

First, the overly ambitious statement that they will `will work on developing a strategy to ensure the eradication of the H5N1 avian influenza virus in Egypt in a short time.’

 

Considering how well entrenched the virus is across Egypt - and that it has been for nine years - one marvels that the words `ensure the eradication’ and `in a short time’ could ever find themselves in the same sentence about H5N1.  

Moving on, we continue to see the `watered down’ case counts for the year (see The Silence Of The Egyptian MOH), even though the World Health Organization released a statement earlier this week saying:

 

H5N1 infections in Egypt

The sudden increase in the number of H5N1 human infections in Egypt that began in November 2014 and continued during January and February 2015 awakened concern. From the start of November to 23 February, Egypt reported 108 human cases and 35 deaths. The number of cases over this period is larger than yearly totals reported by any country since human H5N1 virus infections re-emerged in late 2003.

 

The WHO’s statement, and updated case counts, have been noticeably absent from Egyptian media coverage.  The last MOH statement that included YTD cases was more than 5 weeks ago (see Egypt’s MOH Confirms 21st H5N1 Case).

 

Since the WHO’s most recent tally for 2014 showed Egypt with 31 cases and 9 deaths - even allowing for minor adjustments - one can deduce we must be somewhere in the vicinity of 75-80 cases and well over 20 deaths already for 2015 (based on numbers that are more than a week old). 

 

Yet today’s article continues to quote numbers from a Cairo Post report of February 14th (33 cases & 11 deaths) that at the time, was already far behind FluTracker’s 2015 Global WHO & Ministries of Health Confirmed H5N1 Human Cases List, which showed 53 cases, and at least 17 deaths.

 

While the flow information from the MOH to the Egyptian media may be less than desired, the good news is the Egypt continues to update the World Health Organization under the IHR, the MOH has asked WHO to consult on this outbreak, and our NAMRU-3 team in Cairo is – at last report – still assisting the Egyptians in their epidemiological investigations

 

Despite large surge in  cases, so far we’ve seen no evidence of large clusters or human-to-human transmission of the virus.   The risk of infection still appears to be through contact with infected birds.

Saudi Arabia: WHO MERS Mission Summary

Saudi Arabia

 

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A little over a week ago (see MERS: WHO Mission Invited To Saudi Arabia) we learned that the World Health Organization, along with several other agencies, were invited to Saudi Arabia to consult on the ongoing MERS threat and recent surge in cases.

 

Today the WHO has released a brief summary of their findings and recommendations.

 

Although couched in language diplomatic, the overriding message here is that much more research needs to be done in order to understand how the MERS coronavirus is being transmitted – from animals to humans, within the community, and in the healthcare environment. 

 

First the press release, which also highlights the need for greater consistency in infection control protocols at local hospitals.

 

Surveillance, forecasting and response



More progress needed to control the Middle East respiratory syndrome coronavirus (MERS-COV) in Saudi Arabia

 

Riyadh, Saudi Arabia | 23 February 2015 – A team of experts from  the World Health Organization (WHO), the UN’s Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE) and Institut Pasteur, France concluded a mission to Saudi Arabia to assess the current situation of the Middle East respiratory syndrome (MERS-CoV) following a surge of cases in the past few weeks and to make recommendations for improving the surveillance, prevention and control of the virus. Already this month, more than 50 cases have been reported in several locations in the Kingdom, including infections acquired in health facilities (called nosocomial infections) in Riyadh, Qassim Region and Damman City, eastern region.

Members of the joint mission held discussions with high-level representatives from the Ministry of Health, visited the Command and Control Centre that has been leading all activities related to the control of the MERS-CoV, and toured the emergency and isolation facilities of the Prince Mohammed Bin Abdulaziz Hospital. Government officials and the WHO-led mission shared their concern about the rising number of MERS-CoV cases in recent weeks and in particular in health care facilities.

“The Kingdom did a lot to control the MERS-CoV. We want to hear WHO experts’ feedback on the Kingdom’s progress but also where we can improve. The government is fully committed to implementing the right control and prevention measures and also to funding any activities needed to control this disease,” said Ahmed Bin Aqeel Al Khateeb, the Saudi Arabian Health Minister.

The Minister also stressed the need to enable any hospital, whether government–run or private to handle a MERS-CoV case.

Although data collection and surveillance have improved globally in recent months, critical gaps in knowledge remain, and several challenges in the country will require further work. For example, how and why infections occur in the community is yet to be understood, and  this is critical for stopping the outbreak. In addition, cases that occur in health-care settings require further analysis to fully understand what steps are needed to ensure infection prevention and control measures are adequately implemented. The fact that infections are still occurring in some health-care settings but not in others indicates that current infection control measures are effective but not implemented. 

“When health workers are infected at work, this puts other health-care workers at risk, but also can be a risk to all other patients who seek care for other health conditions. Understanding where the breach in these measures is occurring and taking the steps needed to fully implement infection prevention and control measures can put an end to these nosocomial infections,” said Dr Keiji Fukuda, WHO Assistant-Director General who led the mission to Saudi Arabia.

“The OIE is encouraging close collaboration between public health and animal health at national and international levels.  OIE is ready to help achieve this,” said Dr Ghazi, Regional representative, OIE.

Besides implementing good infection control and prevention measures, efforts to educate professionals and the public are urgently needed. There are also significant gaps in community engagement to fully understand routes of infection and the preventive steps that should be taken. Defining groups that are most at risk, such as the elderly and those with underlying medical conditions, and how to target these groups with the right health messages remains a challenge.

“There are so many aspects of the virus that are still unknown. FAO is determined to use its expertise to better understand the human and animal interface of this virus,” said Dr Berhe Tekola, Director of Animal Production and Health Division, FAO.

The mission, along with the Saudi Arabian health authorities, identified main areas that should be urgently addressed:

• Understanding the animal/human interface, that is, modes of infection and transmission;
• Filling critical knowledge gaps in the science and epidemiology of MERS-CoV by conducting further research studies and by sharing the findings widely and rapidly;
• Improving disease prevention, especially in health facilities that continue to experience avoidable infections; 
• Intensifying social mobilization, community engagement activities and communications. The mission also stressed the need for intersectoral cooperation and coordination, especially between health, agriculture, and other sectors.

Additional information from research studies is also required to better understand the risk factors for infection and transmission. Results from case-control studies from affected countries are urgently needed, in particular, from the most affected one, Saudi Arabia. Understanding the evolution of the virus is needed, through studies to address the knowledge gaps at the human/animal interface environment.

 

 

The recurring theme running through this report can be summed up by the phrase `critical gaps in knowledge remain’ , which includes, but is not limited to, the Saudi’s long promised case-control study (see WHO 2013 case-control study protocol) which has yet to see the light of day.

 

As we discussed a few weeks ago, in WHO MERS Update & The Community Transmission Mystery, while some cases are identified as having animal, hospital, or community exposures – for most cases the route of infection remains undetermined. 

 

One of the tools epidemiologist’s use to determine risks for infection is through case-control study, where they compare laboratory-confirmed cases to a large number of uninfected controls, matched for age, sex, and by neighborhood. 

 

By examining their respective exposures against their outcomes, patterns of risk are often revealed.

 

Unknown at this time are what roles mildly – or even asymptomatically – infected cases in the community (who are never diagnosed or identified) play in the transmission of the virus.  Nor do we know why MERS cases are predominantly male, and their ages tend to  skew towards an older cohort.  

 

While we are coming up on three years since the first known outbreak (Jordan, April of 2012), there is still far too much about this virus that we don’t know. 

 

And with another spring wave expected, we risk having to learn those answers the hard way.

H7N9: WHO Team Completes China Visit

 

Joint Mission Briefing – Credit WHO

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Last Friday, in WHO: H7N9 Team Lands In China, we saw the arrival of a  team of International experts from the World Health Organization, who were invited to assess and provide input on the outbreak of H7N9 in Eastern China.

 

While a  CDC response team has arrived and remains in China, today it was announced that WHO’s team of experts have completed their mission.

 

We’ve two statements this morning. 

 

First up, a press release from the WHO WPRO office, that thanks the Chinese government for their cooperation and summarizes the situation in China, and a press statement from Dr Keiji Fukuda (which I’ll feature in my next blog) on their findings.

 

 

 

International H7N9 assessment team completes mission to China

Beijing, 24 April 2013 - A team of international and Chinese experts has completed its mission to visit Shanghai and Beijing and assess the avian influenza A (H7N9) situation, and to make recommendations to the National Health and Family Planning Commission (NHFPC).

 

"China's response has been exemplary," said Dr Keiji Fukuda, WHO's Assistant Director-General for Health Security. "Government agencies such as Chinese Center for Disease Control and Prevention (CDC) and local authorities of affected areas acted quickly, and have shared critical information such as genetic sequence and virus needed to analyze the situation and to be ready to make vaccine if needed in the future."

 

"The risks of such an outbreak situation are shared in a globalized world where we are all interconnected. This underlines the importance of the example set by China in following the International Health Regulations." Dr Fukuda added.

 

The team, which is jointly led by NHFPC and WHO, is comprised of international and Chinese experts in epidemiology, virology, clinical management, public health, and health policy. The purpose of the mission was to assess H7N9 situation and to provide recommendations.

 

During 19-23 April in China, the team met with those involved in the response, in both Beijing and Shanghai. In Beijing, the team met with staff from China CDC and Beijing CDC. In Shanghai, they met members of the city's H7N9 working group. They also met with the Shanghai Public Health Clinical Center, Shanghai Center for Disease Control and Prevention (CDC) and the Shanghai Center for Animal Disease Control and Prevention. The team visited a wholesale poultry market where they learned first hand about the effectiveness of the shut-down of these markets.

 

"China has experienced extraordinary diseases such as SARS and the 2009 influenza H1N1 Pandemic," said Dr Liang Wannian, Director General, Office of Health Emergency, NHFPC. "We are in new territory again with H7N9, but our experience has taught us how to face it."

 

The team noted the strong reporting systems and awareness in clinicians, municipal health and agricultural authorities in Shanghai, and the support offered by China CDC.

 

"The response reflects earlier and strong investments in health and preparedness made by China," said Dr Fukuda.

 

The team estimates that steps taken so far, such as the suspension of live bird markets in Shanghai, were timely and sound. In Shanghai, it appears that so far poultry infections are limited to live markets. However, they cautioned that experts still have only a limited understanding of the full extent of the disease.

 

The elements that warrant particular concern include the fact that the virus does not seem to cause visible illness in poultry, making it harder to track and control.

 

Almost all cases have been sporadic cases, but a few family clusters have been identified. However, we are not sure if the clusters were caused by common exposure to a source of virus or due to limited person to person transmission. Evidence so far is not sufficient to conclude there is person to person transmission. Moreover, no sustained person to person transmission has been found.

 

The disease has now caused sporadic infections in over 100 people, with the majority developing serious disease including over 20 deaths. It is as yet unclear how many people might have carried the disease without showing any signs of illness. What also remains unclear is whether the virus could gain the ability to become transmissible between people.

 

The potential development of human-to-human spread cannot be ruled out, which is why this virus and outbreak is being taken extremely seriously and followed so closely.

 

In light of this, the team highlighted the need for continued cooperation at the national and international level. At the national level, there is a need for the health and agricultural sectors to continue working closely together. Internationally, the continued sharing of information, guidance, findings, and the viruses themselves is critical.