EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL
Update on Avian Influenza A/H5N1 in Turkey(Tuesday 31 January 2006)
There have been no new human cases of A/H5N1 diagnosed in Turkey for the last fortnight. There remain numbers of infected poultry in the country and therefore there also remains a potential for further human cases to occur. Hence the Ministry of Health in Turkey has asked there be no relaxation of measures to protect human health.
People requiring assessment to exclude infection with H5N1 are continuing to come forward in Turkey, and so the fact that there have been no new cases for some time points to the initial success of the control measures in Turkey. The national strategy has three components: 1. controlling the infection in birds (specifically domestic poultry), 2. Social mobilisation and health education of the population to reduce risk of exposure and 3. Case finding, investigation and care. Considerable more work is needed in the veterinary field before it is possible to adequately describe what seems to be a complex pattern of infection in the bird population. Long term control is going to require substantial investment and this is being addressed by the Turkish Authorities with support from international agencies. However culling of domestic flocks in the areas where the human cases mostly appeared in Eastern Turkey have made considerable progress. Therefore the overall risk to humans in those areas has declined.
Looking back on the human cases to date the Ministry of Health has announced that the National Influenza Centre (NIC) in Turkey and the WHO Influenza Collaborating Centre in the UK have confirmed H5N1 in clinical samples from 12 patients. These include all the four patients that died. In addition there are another nine patients that were found to bepositive for A/H5 by the NIC but which cannot yet be confirmed by further testing in London. These are being further investigated jointly by the two laboratories, this will include using convalescent serology to determine whether they were truly infected. The difference between the initial result in the NIC and the final result Collaborating Centre is not unexpected, especially with a new infection. The initial testing had to undertaken rapidly with the prime objective of supporting case-finding and controlling the outbreak, using clinical data as well as the preliminary test results. In controlling the outbreak it can be seen to have been successful. What is happening now is that the two laboratories are going back to all the initial patients using additional specimens and testing to determine scientifically which were truly infected. Not all types of clinical samples are equally useful for diagnosis of infection and samples must be taken at the correct stage of the illness to give the most accurate picture. For this purpose and at this stage in the outbreak it is possible to look at convalescent serum samples to demonstrate or refute the diagnosis and information from this process will be available later.
Previous reports on Avian Influenza outbreaks
Avian influenza in Turkey: situation update (Thursday 19 January 2006)
As of yesterday (Wednesday 18 January), no further human case of influenza A/H5 in Turkey has been confirmed, nor has any new confirmed poultry outbreak been reported
Map of human cases in Turkey
Map of poultry outbreaks in Turkey
Avian influenza in Turkey: situation update (Wednesday 18 January 2006)
As of yesterday (Tuesday 17 January), there are 21 locally confirmed human cases of influenza A/H5 in Turkey, as compared to 20 the day before. The Ministry of Health has reported that the newly confirmed case is from Erzurum in eastern Turkey. The 21 confirmed cases are originating from 9 provinces: Agri (8), Van (2), Ankara (3), Kastamanou (2), Samsun (1), Corum (1), Sivas (1) Sanliurfa (1) Erzurum (1) and Siirt (1). All cases were hospitalized within the first 10 days of January 2006. There is no indication of human-to-human transmission.
There are still confirmed H5 outbreaks in poultry in 13 different provinces, and suspected outbreaks are investigated in additional 19 of the 81 provinces of Turkey. It should be realised that even one single bird with confirmed H5N1 is counted as an outbreak.
Avian influenza in Turkey: situation update(Tuesday 17 January 2006)
As of yesterday (Monday 16 January), there are 20 cases of locally confirmed H5 infection reported from Turkey, of which 4 have died. A European WHO Collaborating Centre has confirmed 4 of the cases to be due to H5N1. The 2 new cases are both from the Dogubeyazit District of Agri Province; a girl who died Sunday 15 January and her brother. Both were exposed on 1 January to sick birds, and subsequently developed symptoms on 4 January. There is no indication of human-to-human transmission. Seasonal influenza is present in Turkey, but reported to be low as in the rest of Europe.
There are now confirmed H5 outbreaks in poultry in 13 different provinces, and suspected outbreaks are investigated in additional 19 of the 81 provinces of Turkey.
Avian influenza in Turkey: situation update (Sunday 15 January 2006)
As of today (Sunday 15 January), there are still 18 confirmed human cases and no indication of human-to-human transmission. There are now 19 confirmed outbreaks in poultry in 13 of the 81 provinces of Turkey.
Media have reported on single cases of flu-like disease in persons travelling from eastern Turkey and falling ill in various European countries. These persons have all proved to be negative for influenza A/H5N1, and other diagnoses have been established. Given that the seasonal (human) influenza is on the increase, it is likely that additional such cases will be investigated in the future.
The conclusions from the 12 January Extraordinary joint meeting of the Health Security Committee (including ECDC), the influenza coordinators of the EU Member States and the representatives of the Member States on the Early Warning and Response System are now available.
Avian influenza in Turkey: situation update (Friday 13 January 2006)
Since the last update yesterday, no further confirmed human case of influenza A/H5N1 infection has been reported from Turkey.
Avian influenza in Turkey: situation update (Thursday 12 January 2006)
3 new confirmed human cases have been reported since yesterday, making the total 18. These include the deceased child from the first family cluster mentioned as negative yesterday, but who was confirmed positive today. The situation still appears to consist of a series of independent outbreaks, almost always involving children (often siblings), who have been in close contact with infected chickens. There is no indication of human-to-human transmission. There are confirmed outbreaks in poultry in 11 different provinces (Turkey has 81 provinces). — It should be realised that even one single bird with confirmed H5N1 is counted as an outbreak.
The European Commission today hosted an extraordinary joint meeting of the Health Security Committee (including the ECDC), the influenza coordinators of the EU Member States and the representatives of the Member States on the Early Warning and Response System in Luxembourg to discuss avian influenza and national pandemic preparedness. The conclusions of the meeting are summarized in a press release from the European Commission.
Avian influenza in Turkey: situation update(Wednesday 11 January 2006)
Since the last update on 10 January, no more cases of human infection have been confirmed, and no more deaths have been reported. Thus, the total number of confirmed cases remains 15. All samples from 1 of the 3 fatal cases from the first family cluster have been negative in the laboratory tests. Nevertheless, this case is still considered to be due to influenza A/H5N1, based on clinical presentation and epidemiological links to laboratory-confirmed cases. There are reports of confirmed HPAI among birds in 1 additional province, bringing the total number of affected provinces to 11. The international team is working in close collaboration with the Turkish Ministries of Health and Agriculture, as well as with local Government officials in Eastern Turkey.
Avian influenza in Turkey: situation update (Tuesday 10 January 2006)
As of 16:00 on Monday 9 January, 42 suspected human cases of avian influenza have been admitted to hospital in Van; 3 have died and one was discharged (38 remaining in hospital). An additional 5 suspected cases are being investigated in Ankara hospital and 21 in Istanbul hospital.
Fifteen cases have been confirmed by the Influenza Reference Laboratory in Ankara, 4 of which have been further confirmed in a WHO Reference Laboratory. The 15 confirmed cases are from the provinces of Agri, Ankara province, Corum, Kastamonu and Samsun. Three of the cases have died, including 2 confirmed cases and one considered as probable.
There are 15 confirmed outbreaks in poultry in 10 different provinces. There is thus indication that the veterinary situation is considerably more serious than hitherto realised.
The Turkish Government has deployed technical staff to the area. The joint WHO-led WHO/ECDC/EC Team has been established in Van since Sunday 8 January.
The objectives of the team are to perform an initial assessment of the situation, gather epidemiological information about exposure, advise health authorities on measures, and plan for further assistance.
The international team has been strengthened in the past few days. It now comprises 9 members, including 2 epidemiologists from the ECDC. The EU has responded to the WHO call for expertise through the Global Outbreak Alert and Response Network by offering 5 EPIET trainees and an epidemiologist with expertise in information systems, who could be dispatched to the field to further assist in the investigation.
Avian influenza in Turkey: situation update (Monday 09 January 2006)
The international team with experts from WHO, ECDC and the European Commission is now in place in Van. The WHO-led mission will support the Turkish authorities by enhancing outbreak investigations and control measures - including laboratory support. The expected outcome will be public health recommendations based on the results of the investigations, an increased global knowledge of H5N1 avian influenza in human and improved global pandemic preparedness.
In all, 9 cases have now been laboratory confirmed (3 with cross-confirmation in a WHO-designate reference laboratory in the UK). The most recent data confirm that mainly children have been affected, and that the cases have had close contact with sick or dead poultry. Available data do not indicate any person-to-person transmission. The situation thus closely resembles the one in Asia, but further epidemiological investigations are needed.
Additional human deaths in avian influenza in Eastern Turkey as reference laboratories confirm influenza A/H5N1 in samples from both humans and poultry (Saturday 07 January 2006)
Influenza A/H5N1 virus has been detected in samples from the two patients in Eastern Turkey that recently died. This was today (7 January) confirmed by a WHO collaborating laboratory in the United Kingdom. Yesterday, a 12-year-old girl died with what is highly suspected to be avian influenza. She was sister to the first two dead children with confirmed infection. A fourth sibling in the family, a six-year-old boy is hospitalised.
Two additional cases have been confirmed to have H5 infection by the Turkish Ministry of Health, bringing the total number of laboratory confirmed cases to four. The two new cases are children, five and eight years of age, and both are hospitalised. Some additional 30 patients have been admitted to a hospital in the Van Province, and are being investigated for possible avian influenza. The majority of these patients are children and from the rural district of Dogubeyazit. Test results from these patients are still pending. The international team with experts from the WHO, ECDC and European Commission has not been able to reach the Van Province due to extreme weather conditions, but the Turkish Government is assisting the team to find transportation as soon as the weather permits travel.
According to available information, the patients have all had close contact with poultry. In the present cold weather poultry is often kept in the houses in very close proximity to humans, a habit that has increased the risk of avian-to-human transmission considerably. The present development in Turkey has therefore not changed the conclusions from the ECDC risk assessment , stating that the risk to humans is almost entirely confined to certain groups of people (those who have close contact with infected domestic poultry). For those people who have no contacts with domestic or wild birds the risk must be almost non existent. Also the ECDC Travel advice and avian influenza from October is still valid.
According to the European Commission, the test results from the EU veterinary reference laboratory in Weybridge, UK, this morning also confirmed that the avian influenza virus isolated from poultry in Eastern Turkey, is of the high pathogenic type A/H5N1. Outbreaks of highly pathogenic avian influenza have now been confirmed in six provinces in the Eastern and South-Eastern part of the country, and outbreaks at additional sites in the area are under investigation. The ECDC guidelines to minimise the risk of humans acquiring highly pathogenic avian influenza from exposure to infected birds or animals have been recently finalised and updated and should be implemented.
Suspected human cases of avian influenza in Turkey (Friday 06 January 2006)
The Turkish Government has announced that influenza A/H5 has been isolated from at least two persons in a family where one adult and three children have fallen ill with suspected avian influenza. Two of the teenage children (a boy and a girl) have died. There are media reports of a third child having died from bird flu but these have yet to be confirmed or refuted by the authorities in Turkey. The human outbreak is close to an area in eastern Turkey where an avian influenza has recently been confirmed. Samples from these patients are being sent to a WHO reference laboratory in the UK for confirmation. Several additional people in eastern Turkey who were hosptialised with acute respiratory infections are being investigated to establish whether they too have been infected with avian influenza.
Experts from the European Centre for Disease Prevention and Control (ECDC), the WHO and a European Commission veterinary expert, who is also a member of the OIE/FAO network of expertise for Avian Influenza (OFFLU) yesterday (January 5th) flew to Turkey to assist the Turkish authorities.
The present information from Turkey does not change the ECDC risk assessment produced in mid-October. The ECDC guidelines to minimise the risk of humans acquiring highly pathogenic avian influenza from exposure to infected birds or animals have been recently finalised and updated and should be implemented. Also the ECDC Travel advice and avian influenza from October is still valid. Additional public health measures may emerge as a consequence of new information from the field investigation mission.
Link to the Commission press statement
Link to the WHO Europe Statement
Further information will be posted later today and more detail on influenza is available in the Regular Friday Influenza Surveillance and Risk Monitoring Output Dated January 6th.
Bird Flu Type A/H5N1 Confirmed in Romania and Turkey (Sunday 16 October 2005)
On 15th October 2005 the European Commission announced that the European Union (EU) World Animal Health Organization (OIE) laboratory in the UK had confirmed that the bird flu samples from Romania and Turkey were of the type A/H5N1. Further genetic analysis indicated that the A/H5N1 strain was of the same type as the one that was recently found to be affecting some birds in Central Asia and Western China. The occurrence in both Romania and Turkey in birds in open air sites close to areas favoured by migratory birds suggests that bird migration has been the method of spread from the East. It also indicates the potential for further spread to other parts of Europe.
The risk to animal health is considerable and is being addressed by the EU by measures announced at 13th October 2005 [read press release]
The risk to the health of people in Europe from A/H5N1 is very low, but not zero. The risk is almost entirely confined to certain groups of people (e.g. those who have close contact with infected domestic poultry). For those people who have no contacts with domestic or wild birds the risk must be almost non existent.
Avian influenza: Romanian import restrictions confirmed and EU preventive measures debated IP/05/1280, (Brussels, 13 October 2005)
The Commission today formally adopted measures restricting imports of live birds, poultry meat and other poultry products from Romania. The virus found in Romania has been confirmed as the H5 type and further tests will be necessary to confirm (expected by late Friday) whether it is the H5N1 strain found in South-East Asia. Reinforced preventive measures proposed by the Commission to reduce risk of introduction of avian influenza into the EU poultry farm are being discussed in an on-going session of the Standing Committee on the Food Chain and Animal Health (SCFCAH) and will be voted on tomorrow.
The Commission proposal on preventive measures includes a requirement for Member States to reduce the possible risk of contact between wild birds from poultry in high risk areas such as wetlands or other areas known to be frequented by migratory birds. Each Member State will define which areas are at risk and apply the necessary measures to separate wild birds from poultry. Where necessary, this could include keeping poultry indoors in high risk areas. The Commission will need to be informed on the way that Member States apply the preventive measures. The criteria and risk factors to be considered are still being discussed with the Member States in the SCFCAH and will be further developed tomorrow when experts on migratory routes, wild birds and hunting will be attending the SCFCAH. The discussion will continue tomorrow and it can be expected that the measures will be submitted to a vote tomorrow to the SCFCAH. Formal adoption of the decision by the Commission will then take some days but Member States may apply the measures immediately.
Following the confirmation of avian influenza in Romania, import restrictions were immediately proposed by the Commission at an emergency session of the Standing Committee on the Food Chain and Animal Health. The measures have been immediately endorsed by the Member States, formally adopted by the Commission and will be published in the Official Journal of the EU tomorrow.
Imports of live birds and feathers from Turkey have already been banned by the Commission since Monday following the finding of avian influenza virus there.