FAO-OIE-WHO Joint Technical Consultation on Avian Influenza at ...

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<strong>Joint</strong> Writing Committeepoultry and wild birds. Some birds probably have immunityto a variety of AIV strains, and this may influencewhat subtypes are seen in the populations season to season.Public health aspects of poultry vaccinationThe topic of poultry vaccination in was raised severaltimes during the meeting, and the national vaccinationprograms of China, Egypt, Indonesia, and Viet Nam weredescribed by representatives of the respective Ministries ofAgriculture. Countries consider vaccination of poultryimportant for protecting public health as well as animalhealth. The vaccination coverage varies among countries,among locations in a country, and among poultry sectorsand avian species. Constraints to effective implementationmay include inability to achieve adequate coverage oflarge, dispersed poultry populations, insufficient manpower,inadequate post-vaccination monitoring, use ofdifferent vaccines, variable vaccine quality and lack ofquality assurance, as well as weak regulatory support andinsufficient infrastructure of veterinary services in somecases. Strategically targeting vaccination by species or sectormay increase efficiency of national programs. It wasrecognized that comprehensive recommendations for effectivepoultry vaccination are already available from <strong>OIE</strong>and <strong>FAO</strong>. 9The possibility of harmonizing the selection of virusstrains for avian and human vaccines was raised, as theupdating processes are currently different. However, theneeds, processes, and vaccine development systems are alsodifferent. Given the importance of poultry vaccination forthe protection of animal and public health, the need forcontinued vaccine research was stressed, including workingtowards developing a poultry vaccination platform thatelicits neutralizing antibody, works in multiple species, canbe given orally or is otherwise easy to administer, and providesgood duration of protection. Monitoring of AIVstrains in the field, especially in the commercial productionsectors, is also important.Other variables affecting risk of human diseaseDiscussions of human risk variables invariably raises thequestion of why the number of human cases is relativelysmall given the massive potential exposure of humans inareas where H5N1 is circulating. It was suggested that thereare likely other inherent virus-related or individual hostrelatedvariables that influence transmission to and infectionof humans.Virus-specific factors (described in depth in previous sections)do not seem to explain the observed pattern of9 HPAI Manual chapter, HPAI code chapter, output from Vaccinationmeeting 2007 (http://www.oie.int/eng/info_ev/Other%20Files/A_Guidelines%20on%20AI%20vaccination.pdf)human infections. Differences in virus dose and exposureintensity also do not explain the infection pattern, becausethere are very few cases in cullers and others potentiallyexposed to very large virus doses and 25% of negative controlsreport high levels of exposure to poultry, while 25–30% of H5N1 cases do not report any poultry exposure.The mode of transmission also does not explain theobserved epidemiology as case control studies have notidentified unusual exposures (like swimming in rivers andlakes, or eating raw duck blood) as explanations for themajority of cases. It was therefore suggested that increasedrisk must be associated with host factors, including immunityor genetic or phenotypic susceptibility. Evidence forsome clustering of cases among blood relatives supportsthe potential role of genetic susceptibility, although sharedenvironmental exposures must also be considered wheninvestigating human clusters.How to evaluate these factors was discussed. It wasagreed that a more full assessment of the potential individualvariables (e.g., analyses of ILI ⁄ health history, coinfectionwith other influenza viruses, assessment of antibodyand cell mediated immunity (CMI), glycan arraysfor receptors, genetic evaluation, epidemiological studiesof families where some individuals are highly exposedand some are not), as well as more extensive and consistentdata on exposures as described above (e.g., behavioralfactors, seasonality, climate, links with poultryoutbreaks, gender, age, occupation; behaviors ⁄ activitiesincluding level of skill, species of animals present, virusclade, and cultural aspects) would provide not only cluesto the true exposure risks but practical information formore effective surveillance and monitoring and fordevelopment of more effective control and preventionstrategies.National-level successes and challenges:Invited representatives of selected Ministries of Health andMinistries of Agriculture identified their national successesand challenges regarding H5N1 at the human-poultryinterface, including:Successes:• Increased political commitment and coordination withlocal authorities• Increased cooperation between animal health and publichealth sectors• Increased collaboration with international reference laboratories,and with international partners (<strong>FAO</strong> ⁄ <strong>OIE</strong> ⁄<strong>WHO</strong>) and funding agencies• Increased public and professional awareness and availabilityof community-based information, education, andcommunication activities• Vaccination campaigns preventing disease spread amongpoultry and reducing viral load12 ª 2010 <strong>FAO</strong>, <strong>OIE</strong> and <strong>WHO</strong>, Influenza and Other Respiratory Viruses, 4 (Suppl. 1), 1–29
<strong>FAO</strong>-<strong>OIE</strong>-<strong>WHO</strong> <strong>Joint</strong> <strong>Technical</strong> <strong>Consultation</strong> on Avian Influenza at the Human-Animal Interface• Implementation of government compensation promotingrapid disease reporting and transparency• Upgraded national laboratory diagnostic capacity andinfrastructureChallenges:• Inadequate virological and epidemiological surveillancein domestic poultry including waterfowl, and in wildbirds• Understanding the linkage between poultry outbreaksand disease in humans, including understanding occurrenceof human cases where no cases were reported inpoultry• Risks from extensive backyard, household, and rooftoppoultry production• Risks from LBMs• Large populations of poultry to vaccinate and risks posedby unvaccinated poultry in LBMs and household flocks• Cultural practices such as cock fighting• Ineffective (or unfunded) compensation programs forculled poultry during outbreak control• Ongoing tensions between levels of governments andamong sectors5 Broadening the use of tools andsystems (Session 5)During this session speakers briefly discussed emerginginfectious diseases (EIDs) at the human–animal interface,tools and methods used to evaluate emergence of otherzoonotic diseases, and the <strong>OIE</strong> ⁄ <strong>FAO</strong> ⁄ <strong>WHO</strong> Global EarlyWarning System for transboundary animal diseases(GLEWS). There was recognition that some tools and systemswere developed for, or strengthened by, the H5N1 situationover the past 10 years, but that these systems havealso been used effectively to address many other zoonoticor emerging diseases.Presenters emphasized that EIDs are the ‘‘new reality’’ asup to 34 new EIDs are expected worldwide by 2015, andnoted that 61% of EIDs are zoonoses. Speakers reviewed thefactors influencing emergence including genetic, biological,physical, environmental, ecological, social, political, and economicfactors, as well as the role of animal and public healthsystems. Changes in host–pathogen ecology were consideredthe most important single driver for emergence. The convergenceof these human, animal, and environmental health factorsrequires working collaboratively, in a multidisciplinaryway, and at local, national, and global levels to attain optimalhealth of humans, animals, and the environment. In discussion,it became clear that this concept was not new, howeverthe roles and strategies of all the players globally are not fullyunderstood nor effectively integrated.‘‘Wicked problems’’ (those that have no solution throughtraditional processes) were discussed in the context of EIDs,and it was noted that managing these problems requireslinking together separate problem-solving activities into integratedstrategies and systems. For example, all countries havea stake in everyone else’s disease surveillance, however it isnot necessarily in a country’s best interest to share surveillanceinformation with their neighbors or the internationalcommunity. Managing such dilemmas requires workingacross disciplines, professions, and animal and public healthcommunities and factoring in social, economical, and politicalforces, as well as ensuring political will, prioritizingresearch to support evidence-based policies and decisions,adding value gained from avian influenza H5N1 experienceby applying it to other zoonoses, determining the potentialapplication of ‘‘big science’’ (e.g., global technology and bioinformatics)and creating concurrent planning scenarios ofimproving what exists and creating what doesn’t.The animal and public health sectors have vast experiencein addressing EIDs, and recognize the importance of rapidresponse, global collaboration, and multidisciplinary teams.In the past, these activities have consistently been done separately,but now the continuum between animal and humanpathogens, the need for integrated (meaning linked not necessarilysingle) strategies, and the need for improved animaland public health infrastructures is increasingly apparent.Health is now recognized as an outcome shaped by a broadrange of social, economic, natural, ecological and politicalenvironments that form an ever-changing dynamic. Thus,new ways of working together need to be identified thatreflect this reality. Our work on avian influenza H5N1 hasgiven us valuable experience in how to effectively do riskcommunication and messaging, and how to evaluate socialand cultural determinants of disease; however, we must buildon these experiences and become even better as we appreciatethe need to incorporate the social sciences into our strategiesto confront new emerging zoonoses.Today’s technologies can help to better detect, manage,and contain the international spread of EIDs. There havebeen great improvements in global tools and systems, suchas surveillance and forecasting of emerging diseases throughintersectoral (animal, human, and environment) collaborationsuch as GLEWS, formal collaboration with wildlife diseaseexperts, support of EID vectorborne network, and<strong>WHO</strong> global outbreak alert and response network(GOARN), global public health information network(GPHIN), and connection of different laboratory networks.Technology and successful collaborations have allowed riskmapping, forecasting and early detection of EID events[e.g., Rift valley fever (RVF) and Ebola]. Working togetheron each of the steps from forecasting through response atthe country-level builds trust, and therefore facilitates amore efficient and coordinated response and improved preventionand control. It was noted that standardization ofrisk analysis and forecasting needs to be addressed, includ-ª 2010 <strong>FAO</strong>, <strong>OIE</strong> and <strong>WHO</strong>, Influenza and Other Respiratory Viruses, 4 (Suppl. 1), 1–29 13
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