The war on disease in Asia: Avian virus

Hawaii's defense against the deadly flu requires vigilance by other countries

First of three parts

» ‘Wet market’ slaughters fresh poultry on the spot
» Hawaii health officials preparing for the worst

HONG KONG » With heavy trans-Pacific travel, Hawaii's protection against a bird flu pandemic depends largely on Southeast Asia's success in containing the H5N1 avian virus in millions of chickens and ducks.

Officials in Hong Kong, Vietnam and Indonesia described intensive avian influenza education, prevention, surveillance and biosafety programs in recent meetings with a group of U.S.-Asian health journalists.

They also described almost insurmountable problems: culture and economics related to chickens, lack of resources and more immediate public health crises.

Avian flu is just one of many emerging infectious diseases in these countries. They are also battling dengue fever, HIV/AIDS, tuberculosis, malaria and food-borne diseases, among others.

Risks of infectious diseases sneaking into Hawaii increase with expanding business ties and tourism between the state and countries of Southeast Asia.

"The key is to get programs on the ground in Asia that would allow them to monitor this," said Dr. Duane Gubler, former director of the Asia-Pacific Institute of Tropical Medicine and Infectious Diseases at the University of Hawaii John A. Burns School of Medicine. "It's best to get it before it gets on an airplane and travels around the world."

Suzanna Dayne, UNICEF media relations officer in Jakarta, Indonesia, described a six-step avian flu control policy but said it has been difficult due to countless backyard chickens.

Some parts of the city have banned backyard farming, but it is not effective, she said. "If people don't want to help us, it's impossible."

From 2004-2007 Indonesia had an earthquake, a tsunami and a dengue fever outbreak, she pointed out. "And 30,000 kids die every year from measles. We just contained a polio outbreak. Just to get people concerned about avian flu is difficult."

Bayu Krisnamurthi, secretary of the Indonesia National Committee for Avian Influenza Control and Pandemic Influenza, agreed: "A pandemic is very abstract. ... It's difficult to get them to understand it could kill 1.5 million more people than the 2004 tsunami (which killed about 280,000 in 11 countries, particularly Indonesia), plus the economic impact."

Hawaii health officials are well aware of the potential spread of avian flu if even one infected tourist arrives undetected. The state was the first to establish airport surveillance in 2005 for bird flu or other infectious diseases that could arrive with visitors.

Hawaii has a comprehensive preparedness plan and has taken numerous steps to prevent and deal with a health emergency.

The dangers of a potential bird flu pandemic were seen with previous outbreaks in a farming area in Vietnam's Nam Dinh province, about 60 miles from Hanoi.

"If there is a human epidemic, this would be ground zero," observed Thomas Abraham, University of Hong Kong Public Health Media Program director.

Still others feel Indonesia likely would be "ground zero" for a bird flu pandemic because of its vast size, population and millions of farm and backyard chickens.

Chickens are highly valued by Southeast Asians, not only as a cash crop, but for protein for the family and to honor guests. Many national dishes in Indonesia feature chicken.

Hong Kong implemented a comprehensive preventive and surveillance program after the first avian flu outbreak in 1997.

SARS (severe acute respiratory syndrome) was first diagnosed there in 2003, and the epidemic led to establishment of a Center for Health Protection with highly sophisticated risk communication and emergency response systems.

Princess Margaret Hospital in Kowloon, which cared for one-third of SARS patients, also opened a state-of-the-art infectious disease facility in June.

It has the most advanced technology available to care for infected patients in isolation while protecting medical workers, but it shares a problem with U.S. hospitals: a shortage of nurses, said Dr. Chow Chun-bong, medical director for infectious diseases.

Dr. C.M. Chu, respiratory disease specialist at United Christian Hospital, which bore the brunt of Hong Kong's SARS cases, said avian flu probably will not spread with good security on farms, but there is a chance it will get to humans if a bird is infected in a fresh poultry market, he said.

Live birds are displayed in the markets so customers who want fresh chicken can choose one and have it slaughtered on the spot. Public pressure has kept the "wet markets" open, but the avian flu threat and more stringent operating regulations have reduced the number.

Chu also pointed out there is no avian flu vaccine for humans, just for poultry, and only antiviral drugs for treatment. There are also many strains of avian viruses, he said, adding, "Probably a pandemic will arrive ... or something else."

Vietnam began a nationwide campaign to vaccinate chickens and ducks -- natural carriers of avian virus -- in July 2005 after three epidemics. The virus was contained until a recurrence last May. New outbreaks in unvaccinated ducklings were reported recently.

Smuggling of unvaccinated poultry into Vietnam, especially Hanoi, is difficult to control, and some farmers do not want their poultry vaccinated, either because of egg production or government payments for chickens that are culled, animal health officials said.

CARE has avian influenza awareness and prevention activities in eight provinces.

"We're encouraging people to be open and not throw (diseased) chickens in the river," said Geraldine Zwack, country director, CARE International Vietnam.

In the Lien Minh Village in Nam Dinh, which had a virus outbreak in May, a 52-year-old farmer with more than 200 chickens said through an interpreter, "Avian flu is very dangerous. We all follow vaccination for safety, so no problem."

Tuan, father of three, received government land to farm as a retired soldier of the Vietnam War (called the "American War" in Vietnam). He grows soybeans and rice and cages his chickens so they have no contact with pigs or waterfowl.

But not all farmers heed advice to separate poultry from ducks and keep them away from the family.

The U.S. Agency for International Development is working with the Indonesian Red Cross to train volunteers to teach farmers avian control measures in the scenic mountainous region of Purwakarta in West Java, Indonesia.

Their message is simple: Wash hands after contact with poultry. Don't touch dead chickens. Keep ducks from chickens.

On a trip past green tea plantations to meet with volunteers in Purwakarta, USAID Senior Technical Officer Jonathan Bell said there is not enough vaccine for all poultry, so the policy is to vaccinate around an outbreak and cull the birds.

"It's difficult to enforce because people don't want to kill birds without compensation," he said. "It's a very different system than Vietnam. Control depends on cooperation."

Cases and deaths

The number of confirmed human cases and deaths of Avian Influenza by country in Asia since 2003:

Country	Cases	Deaths
Cambodia	7	7
China	27	17
Indonesia	120	98
Myanmar	1	0
Thailand	25	17
Vietnam	102	48

Source: World Health Organization About this report: Star-Bulletin reporter Helen Altonn looked into emerging and re-emerging infectious diseases in the Asia Pacific region on an East-West Center 2007 Health Journalism Fellowship for U.S. and Asian health writers. They visited Hong Kong, Hanoi and Ho Chi Minh City in Vietnam and Jakarta, Indonesia.