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Regional Office for Europe
Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a Wild birds and the risk of a
pandemicpandemicpandemicpandemicpandemicpandemicpandemicpandemic
FAO/OIE International Scientific Conference FAO/OIE International Scientific Conference FAO/OIE International Scientific Conference FAO/OIE International Scientific Conference
on Avian Influenza and Wild Birdson Avian Influenza and Wild Birdson Avian Influenza and Wild Birdson Avian Influenza and Wild Birds
Rome, 31 May, 2006Rome, 31 May, 2006Rome, 31 May, 2006Rome, 31 May, 2006
Caroline S. BrownTechnical Officer, Communicable Diseases Surveillance and Response
WHO Regional Office for Europe
Regional Office for Europe
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgementsAcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
Ministries of Health of Turkey, Iraq and
Azerbaijan
WHO Country Offices
WHO teams (GOARN):
EC, ECDC, ECDC/EPIET, FAO, INVS, Swedish CFG, Rabin MC Tel Aviv,
CDC, Robert Koch Institute Berlin, SZU
Prague, NAMRU-3 Cairo, WHO (Euro,
Emro, Geneva, Rome), WHO CC Mill
Hill.
Regional Office for Europe
Overview of the presentationOverview of the presentationOverview of the presentationOverview of the presentationOverview of the presentationOverview of the presentationOverview of the presentationOverview of the presentation
•Current situation regarding avian
influenza in the European region
•Outcome of the Turkey, Iraq and
Azerbaijan outbreaks
•epidemiological findings•virological findings
•Risk to humans: wild birds vs poultry
Regional Office for Europe
Current situation regarding avian Current situation regarding avian Current situation regarding avian Current situation regarding avian Current situation regarding avian Current situation regarding avian Current situation regarding avian Current situation regarding avian
influenza in the European regioninfluenza in the European regioninfluenza in the European regioninfluenza in the European regioninfluenza in the European regioninfluenza in the European regioninfluenza in the European regioninfluenza in the European region
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Russian Federation
Kazakhstan
Turkey
UK
Sweden
Ukraine
Spain
France
Finland
Norway
Italy
PolandGermany
Uzbekistan
Belarus
Turkmenistan
Romania
Kyrgyzstan
BiH
Bulgaria
Austria Hungary
Tajikistan
Latvia
Greece
Ireland
Portugal
Lithuania
Georgia
Estonia
Croatia
Azerbaijan
SlovakiaCzech Republic
Serbia and Montenegro
Belgium
Switzerland
Albania
Denmark
Armenia
Netherlands
Israel
SloveniaRepublic of Moldova
FYR of Macedonia
Cyprus
Luxembourg
Andorra
Malta
San MarinoMonaco
WHO/Europe - Avian Influenza Infections A/H5N1
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
0 1,000 2,000500Kilometers
Data source: World Organisation for Animal Health (OIE); WHO Collaborative Centers; National Governments; UN Cartographic Section; ArcWorld, ESRI
Map production: WHO EUROCommunicable Diseases Surveillance and Response (CSR)© WHO 2006. All rights reserved.
¯
Legend
H5N1 Outbreaks
Area with poultry case confirmed
Area with wild bird case confirmed
Confirmed affected country
Number of WHO confirmed human cases
Areas affected since - Status as of 19 May 20061 July 2005
34 out 52 countries affected
Surveillance in wild birds??
Russian Federation
Kazakhstan
Turkey
UK
Sweden
Ukraine
Spain
France
Finland
Norway
Italy
PolandGermany
Uzbekistan
Belarus
Turkmenistan
Romania
Kyrgyzstan
BiH
Bulgaria
Austria
Tajikistan
Latvia
Greece
Ireland
Hungary
Portugal
Lithuania
Georgia
Estonia
Croatia
Azerbaijan
SlovakiaCzech Republic
Serbia and Montenegro
Belgium
Switzerland
Albania
Denmark
Armenia
Netherlands
Israel
Slovenia
Republic of Moldova
FYR of Macedonia
Cyprus
Luxembourg
Andorra
Malta
San MarinoMonaco
WHO/Europe - Avian Influenza Infections A/H5N1
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
0 1,000 2,000500Kilometers
Data source: World Organisation for Animal Health (OIE); WHO Collaborative Centers; National Governments; UN Cartographic Section; ArcWorld, ESRI
Map production: WHO EUROCommunicable Diseases Surveillance and Response (CSR)© WHO 2006. All rights reserved.
¯
Legend
H5N1 Outbreaks
Area with poultry case confirmed
Area with wild bird case confirmed
Confirmed affected country
Number of WHO confirmed human cases
Areas affected since - Status as of 19 May 20061 May 2006
Regional Office for Europe
0
5
10
15
20
25
30
11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
Date of onset
No
. o
f cas
es
Viet Nam (N=93) Thailand (N=22) Cambodia (N=6) Indonesia (N=33)
China (N=18) Turkey (N=12) Iraq (N=2) Azerbaijan (N=8)
Egypt (N=13) Djibouti (N=1)
Human Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian InfluenzaHuman Case of H5N1 Avian Influenza-------- since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 since 2003 and as of 11 May 2006 --------
142 / 208 (68.3%)
cases occurred in the
December – March
period
142 / 208 (68.3%)
cases occurred in the
December – March
period
2006200520042003
Die-off at Qinghai lake
Regional Office for Europe
Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and Outcome of the Turkey, Iraq and
Azerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaksAzerbaijan outbreaks
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Regional Office for Europe
Epidemiological findingsEpidemiological findingsEpidemiological findingsEpidemiological findingsEpidemiological findingsEpidemiological findingsEpidemiological findingsEpidemiological findings
•Age groups, number of cases and
case fatality rates
•Asymptomatic infection (AZ)
•Nature of exposure
•Family clustering
Regional Office for Europe
Age groups, number of cases and Age groups, number of cases and
case fatality rates case fatality rates
2:61:14:5#Male:female
16-9#Median age
16.5279.5#Average age
62%100%33%Case fatality rates
524No. Deaths
8212No. cases
AzerbaijanIraqTurkey
# data from nine casesAs of 23 May 2006:
218 human cases
including 124 deaths
(CFR 57%)
As of 23 May 2006:
218 human cases
including 124 deaths
(CFR 57%)
Regional Office for Europe
Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)Asymptomatic infection (AZ)
•Clinical specimens were taken from 18 household contacts on 21 March
•No detection of H5N1 virus in throat swabs nor antibodies in serum
•Specimen from mother in close contact with two patients also negative for virus
•Three asymptomatic cases picked up by active surveillance
Regional Office for Europe
Nature of exposure: poultryNature of exposure: poultryNature of exposure: poultryNature of exposure: poultryNature of exposure: poultryNature of exposure: poultryNature of exposure: poultryNature of exposure: poultry
Turkey and Iraq
Clear contact with sick backyard poultry
– Slaughtering, preparation for consumption
– Poultry had been brought indoors due to cold weather (Turkey)
– Caring for sick chickens (Turkey)
– Playing with parts of dead chickens (Turkey)
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Regional Office for Europe
Nature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birdsNature of exposure: wild birds
Azerbaijan
Exposure to dead wild swans
– Feathers were plucked for sale
– Indoors or outdoors??
– Exposure to carcasses before/after de-feathering?
– Consumption of carcasses?
Regional Office for Europe
Risk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birdsRisk to humans: wild birds
Involvement of wild birds in AZ complicated and delayed the investigation:
•the situation in poultry in AZ was unclear•affected families had healthy poultry•affected families did not believe their children had avian ‘flu•affected families denied wild bird contact for fear of punishment
Regional Office for Europe
1.649
0
300
600
900
1.200
1.500
1.800
17-1
-200
6
24-1
-200
6
31-1
-200
6
7-2
-200
6
14-2
-200
6
21-2
-200
6
28-2
-200
6
7-3
-200
6
14-3
-200
6
21-3
-200
6
28-3
-200
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AZ AZ AZ AZ AZ AZ AZ AZ -------- Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals Number of Dead Wild Animals
Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Mostly Wild Birds (animal/day)Courtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of EcologyCourtesy of Ministry of Ecology
* *
Peak of swan die-off
Total dead swans counted 17.01.06 - 12.03.06: 1952
Regional Office for Europe
Age groups: Age groups: behaviourbehaviour related?related?
Mainly children treated chickens as pets.Mainly teenagers responsible for slaughtering sick poultry.
Mainly teenagers involved in plucking swans.Azerbaijan Male:female was 2:6
Or possibly higher susceptibility of this Or possibly higher susceptibility of this
group??group??
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Regional Office for Europe
Family clusteringFamily clusteringFamily clusteringFamily clusteringFamily clusteringFamily clusteringFamily clusteringFamily clustering
Family clusters were seen in all 3 countries
•In Turkey, 2 families had 2 and 3 cases
respectively
•In Iraq, one family had 2 cases
•In Azerbaijan, there were:
• 2 cases in one family
• 6 cases from 5 families were cousins
Regional Office for Europe
Family clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in AzerbaijanFamily clustering in Azerbaijan
7 cases
Regional Office for Europe
Family clustering: significance? Family clustering: significance?
Most likely due to sharing of a common
exposure.
Human to human transmission cannot be excluded.
Implications for prophylaxis:
household members of cases should receive antiviral prophylaxis quickly upon identification of a case due to same (high) risk of common exposure
Regional Office for Europe
VirologicalVirological findings: findings: phylogeneticphylogenetic
comparison comparison
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Many H5N1 viruses
Human viruses 100% avianHuman viruses 100% avianHuman viruses 100% avianHuman viruses 100% avianHuman viruses 100% avianHuman viruses 100% avianHuman viruses 100% avianHuman viruses 100% avian
European and Middle Eastern
H5N1 isolates from human and
animals show phylogenetic
relationship.
These isolates segregate from the
earlier Asian isolates (Clade 1) and
exhibit antigenic differences
(Clade 2)
IMPLICATIONS FOR VACCINE
DEVELOPMENT
Courtesy of Alan Hay (WHO Collaborating
Centre, London), YiPu Lin and associates, and VLA, Weybridge.
Regional Office for Europe
Antigenic analyses of avian and human influenza A H5N1viruses (HI test)
Haemagglutination-inhibition titre
A/ck/Scot/59 A/HK/156/97 A/HK/213/03 RG-14 (Viet/1194)Qu/Cirebon/BB/05 A/Ind/5/05 A/ty/Turkey/1/05
NIBSC Sh NIBSC SH382 RGW Goat 358 WIC hyp F CDC F61/05 CDC F89/05 WIC f C6/05
A/ck/Scotland/59 1,280 320 80 160 40 80 80
A/Hong Kong/156/97 320 640 80 320 80 40 20
A/Hong Kong/213/03 640 160 160 640 80 <40 <20
A/Vietnam/1194/04 2,560 160 80 10,240 40 40 <20
A/qu/Cirebon/BBVet/05 640 80 40 160 640 160 <20
A/Indonesia/5/05 160 40 40 160 640 320 <20
A/ty/Turkey/I/05 640 80 160 2,560 80 160 640
A/Azerbaijan/115TS/06 320 80 80 1,280 40 80 320
A/Azerbaijan/161ser/06 640 160 80 2560 80 160 640
A/Azerbaijan/162ser/06 640 160 80 2560 80 160 320
Courtesy of Alan Hay (WHO Collaborating Centre, London), YiPu Lin and associates
Regional Office for Europe
Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds Risk to humans: wild birds vsvsvsvsvsvsvsvs poultrypoultrypoultrypoultrypoultrypoultrypoultrypoultryCurrent assessmentsCurrent assessmentsCurrent assessmentsCurrent assessmentsCurrent assessmentsCurrent assessmentsCurrent assessmentsCurrent assessments
WHO All evidence to date indicates that close contact with dead or sick birds is the principal source of human infection with the H5N1 virus. Especially risky behaviours identified include the slaughtering,defeathering, butchering and preparation for consumption of infected birds.
ECDC Group 1 – Low but Real RiskThe risk of infection is confined to those who have close and intense contact with sick poultry. Group 2 – Theoretical Risk – Precautions requiredIncludes where H5N1 may be present:
HCW, cullers, farm workers and people who may have close contact with infected wild birds eg. some ornithologists and hunters.
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Regional Office for Europe
ConclusionsConclusionsConclusionsConclusionsConclusionsConclusionsConclusionsConclusions
•Virus acquired by exposure to wild birds is not different to virus acquired from poultry
•Close human contacts with infected wild birdsfar less numerous than with infected poultry
•Therefore virus from wild birds will have less opportunity to adapt/reassort in humans
•Therefore wild birds constitute a lower pandemic risk
Regional Office for Europe
PreventionPreventionPreventionPreventionPreventionPreventionPreventionPrevention
Emphasis should be on the education of the population and identification of vulnerable populations, including hunting communities.
Regional Office for Europe
Thank YouThank YouThank YouThank YouThank YouThank YouThank YouThank You
www.euro.who.intwww.euro.who.int/flu//flu/