TURKEY IN THE STRUGGLE
Against avian influenza (21 January 2006)
Dr. Turan BUZGAN

General Directorate of Primary Health Care, Ministry of Health, Ankara
Avian influenza is disease that results in the epidemics and mortality of birds in various place of the world. The viruses of the influenza A group may mutate gradually and result in diseases in human beings. 3 big influenza epidemics occurred in the last century and millions of people were affected by these diseases (Spanish Influenza, Asian Influenza and Hong Kong Influenza). Millions of people died due to these diseases. More than the people lost in the wars between 1918 and 1919 were lost in the Spanish Influenza epidemic. Scientists state that such epidemics will occur 3 times in every century. According the most recent data it may spread from animals to human beings; however it does not spread among human beings. Today it is feared that the virus will gain the ability to transmit among human beings and result in a pandemic.

Avian influenza or the bird flu emerged in the winged animals in Hong Kong in 1997 and 6 of 18 people infected by the virus died. Afterwards the disease was also monitored in Southeast Asia countries in December of 2003 and millions of winged animals died. The World Health Organization (WHO) and other international institutions have begun to truck the disease more closely since this date. Before the emergence of the disease in our country, 143 cases and 76 mortality cases had been notified by the WHO. All of these cases were monitored in Southeast Asia Countries.

The avian Influenza was first seen in our country in the October of 2005 in Kızıksa, Manyas, Balıkesir Province. Later on 27 December 2005 it was notified that there had been avian influenza in the birds in Aralık, Iğdır Province by the Agriculture and Rural Affairs Ministry. On 31 December 2005 4 people from the same family consulted the hospital with the same disease picture and H5N1 virus was detected in these people. This virus is a germ with high mortality rates.

Thus for the first time in our country this disease was detected in human beings.

Step by step struggle against avian influenza

 We have been taking precautions since the emergence of the disease in the Southeast Asian countries as the Ministry. We have carried out relevant studies due to the fact that immigrant birds call by in our country.

Now we have been registered on the International Influenza Surveillance Net and we have been monitoring seasonal influenza diseases for 2 years. At first we identified the types of the viruses coming from the 14 provinces chosen; afterwards we started to examine the samples coming from all across the country. We identified Refik Saydam Hygiene Center Directorate Virology Laboratory and Istanbul University Medical Faculty Virology Department as the National Reference Laboratory.

According to the Curricular Letter Dated 16 March 2004 it was stated that the disease did not exist in the winged animal and we transmitted this information to physicians and other health personnel.

• In December 2004 we constituted the Influenza Scientific Consultation Board and met for the first time.
  
  
• On 19 January, we demanded that the risk groups identified by the Primary Health Care Services General Directorate be vaccinated with seasonal influenza vaccines.
  
  
• Since February 2005, we have published the "Influenza Bulletin" by the Primary Health Care General Directorate and sent it to provinces. The bulletins concerned have also been published on the web page of Ministry.
  
  
• On 11 July 2005 we initiated "The National Pandemic Preparation Plan". Nearly 60 experts from universities and Training and Investigation Hospitals took part in preparing this plan.
  
  On 5 September 2005, we arranged a symposium on the avian influenza in cooperation with the Ministry of Agriculture and Rural Affairs and carried out a practice in relation with the subject.
  
•  On 8 October 2005 we sent a group of experts from the Primary Health Care Services General Directorate to Kızıksa Province upon the first avian influenza case. We carried our training programmes here in order to enlighten people living there. We handed out brochures in order to educate people. We administered protective medicine to those that had contacted with diseased or dead animals. We carried out an active case investigation in the region.
  
  
• In October 2005 we ordered 1 million boxes of Oseltamivir (Tamiflu ®) from Roche, the only producer of the medicine within the scope of the National Pandemic Plan.
  
  
• On 11 October 2005 5 thousand boxes of Oseltamivir (Tamiflu ®) were delivered to the Ministry of Health.
  
  
• On 14 October 2005, we demanded 100 thousand boxes of Tamiflu from the World Bank sources via Health Project General Directorate.
  
  
• We sent brochures to all provinces via a circular letter dated  25 October 2005 under the name "The procedures and Principles to be Followed in case of Avian Influenza".
  
  In October 2005, we vaccinated 60 thousand health personnel getting in contact with patients.
  
  
• In October 2005 we made an attempt in order to vaccinate the personnel working in poultries in coordination with the Ministry of Agriculture and Rural Affairs.
  
  
• We increased the sensitivity of the personnel for the subject communicable diseases via in-service training.
  
  In October 2005 we announced the National Pandemic Preparation Plan to the public and published it on the web page of the ministry of Health (www.grip.saglik.gov.tr.)
  
• On 27 October 2005 we notified the matter of vaccination of poultry workers in integrated facilities to the White Meat Industrialists and Breeders' Association.
  
  
• In October 2005, the studies initiated for the National Pandemic Preparation Plan were completed and sent to the World Health Organization.
  
  
• On 15 December 2005, a Budget Implementation Order was published with regard to the administration of seasonal influenza vaccines to people at the age of 65 and older than this age free of charge.
  
  
• On 16 December 10.000 boxes of Tamiflu more were obtained.
  
  
• On 27 December 2005 it was announced that by the Ministry of Agriculture and Rural Affairs avian influenza was seen in Aralık Province in the winged animals. On the same day we sent a group of experts to the region by the Ministry. Heath personnel and the public were trained for this subject by the experts we sent there and education brochures were sent. We achieved coordination in order to maintain the studies in a fast and scientific way. The same group went to Ağrı Province in order to enlighten the employers of Provincial Health Directorate, District Health Group Directorates and relevant physicians.
  
  
• On 30 December 2005, the experts carried out investigations in Erzurum upon the the notification that there were some suspected winged animal deaths in Erzurum Province Horasan District. The health personnel and the public living there were trained for the subject. The suspected ones were administered protective medicine.
  
  
• On 31 December 2005, 4 people from the same family between the ages of 4 and 15 were referred to Van Yüzüncü Yıl University and hospitalized due to high fever, respiration insufficiency, leucopenia and severe pneumonia picture.

In relation with these patients it was reported that:

• 21 December 2005: this family's chickens died because of some reason, 2 chickens were slaughtered by the children, the chickens were contacted closely and these chickens were eaten by the whole family,
• 23-24 December 2005: The first symptoms of the disease appeared,
• 27 December 2005: One of the family members consulted to hospital with the complaint of upper respiratory system deficiency.
• 28 December 2005: A second family member consulted to hospital with the complaint of upper respiratory system deficiency.
• 29 December 2005: A third family member consulted to hospital with the complaint of upper respiratory system deficiency.
• 31 December 2005: Four of the family members consulted to hospital, there was the notification of avian influenza in the region and there was the history of contact with the diseased animals and these patients were referred to Van Yüzüncü Yıl University.
• 31 December 2005: Smear samples were obtained from the patients and these samples were sent to Refik Saydam Hygiene General Directorate. On the same day, the antiviral medicine for this Oseltamivir (Tamiflu ®) was sent to Van Province by the Ministry.
• 1 January 2006: There were no avian influenza virus in the samples in the smear samples of the patients (Rapid test, ELISA, RT-PCR). On the same day Mehmet Ali KOÇYİĞİT died because of the disease. 2 more people were also hospitalized because of the same reason.
• On 1 and 2 January 2006: The clinical situations of the patients got worse and they did not respond to treatments, and samples from the lower respiratory system of the patients and a sample from the lungs of the dead patient were taken.
• 3 - 4 January 2006:   It was found that there was the avian influenza virus in the second samples sent to Refik Saydam Hygiene General Directorate (H5N1). The results were also sent to Istanbul University Çapa Medical Faculty Virology Department and the results were confirmed. We sent the samples to the reference laboratory of WHO in London for additional confirmation. We notified the case to WHO on the same day and announced the results to the public via press conference.
• 4 January 2006 : We sent another group consisting of experts from the Primary Health Care Services General Directorate, Ankara Training and Investigation Hospital Infectious  Diseases Clinic and Hacettepe University Medical Faculty. The group concerned carried out investigations in Van, Doğubeyazıt, Iğdır, Aralık and Erzurum. The health personnel was trained, some emergent precautions were taken relevant tasks were organized. Additionally, they ensured that some enlightening and educating programmes were carried out.
• 4 January 2006: We formed a Crisis Coordination Center with regard to avian influenza within the Ministry. We accelerated notification activities via press.
• 5 January 2006: We sent case notification forms to relevant place. The patient named Fatma Yiğit also died.
• 5 January 2006: A group of experts from WHO, European Commission and CDC came into our country and we handled the first negotiations.
• 5 January 2006: We reviewed together with the Ministry of Agriculture and Rural Affairs the precautions taken and to be taken.
• 6 January 2006: The analyses carried out in London confirmed the result obtained here. H5N1 virus was also detected in a patient that consulted from Van Province. The third patient named Hülya Koçyiğit died.
• 6 January 2006: We sent teams consisting of doctors and nurses and ambulances to the region.
• 6-7 January 2006:  The Avian Influenza Scientific Board of the ministry of Health negotiated with WHO, European Commission and European CDC experts.
• 7 January 2006: Meetings were carried out at the level of ministers between the Ministry of Health and The Ministry of Agriculture and Rural Affairs.
• 7 January 2006: 100 thousand more boxes of Tamiflu were added to the current stock.
• 8 January 2006: The Minister of Health Prof. Dr. Recep Akdağ went to Van Province together with WHO, European Commission and European CDC experts, the Avian Influenza Scientific Board of the Ministry of Health and Ministry staff. Because of the bad weather conditions in Van Province, the plane landed in Erzurum and they drove to Van. The group visited the hospital and carried out some investigations. Some additional practitioners were reinforced in the region.
• 8 January 2006:  The authorities from WHO stated that Turkey treated the matter early, behaved transparently, notified early and maintained any kind of cooperation.
• 8 January 2006: Governors from the 9 provinces, Provincial Health Directors, Provincial Agriculture Directors and other relevant people met and discussed the situation.
• 8 January 2006: 5 more new cases were detected ( 2 from Ankara, Beypazarı, 1 from Sincan, 2 from Ağrı, Doğubeyazıt). Thus the number of cases with positive results in terms of avian influenza became 9.
• 9 January 2006: There were five more case notifications (1 from Van, 2 from Kastamonu, 1 from Çorum and 1from Samsun) and thus the number of cases became 14.
• 9 January 2006: The Minister of Health Prof. Dr. Recep Akdağ left Van and went to Doğubeyazıt and Ağrı  and carried out some investigations together with the committee. The committee returned Ankara late at night on the same day.
• 9 January 2006: 5 ventilators were delivered to Van Provincial Health Directorate by the Ministry of Health and it was ensured that these devices be installed in the hospital.
• WHO stated that the testing quality of the reference laboratory (RSHCD) in Turkey was high, there was contact histories with the dead or diseased winged animals of the cases and there were no proof of transmission among human beings.
• 10 January 2006: There was one more case in Kangal, Sivas. Thus the number of laboratory confirmed cases became 15 with this case hospitalized in Cumhuriyet University Medical Faculty. 5 more ventilators were sent to Van Yüzüncü Yıl University Medical Faculty.
• 11 January 2006: 2 more cases were detected (one of them hospitalized in Diyarbakır Dicle University Medical Faculty, the other in Şanlıurfa Children Hospital).
• 11 January 2006: The H5N1 virus detected in the laboratory analysis of the patient Hülya Koçyiğit was found positive, thus the number of confirmed cases became 18.
• 11 January 2006: The Minister of Health Recep Akdağ and the European Region Director of WHO Marc Danzon arranged a press conference. M. Danzon stated that Turkey treated the matter just on time and appropriately and there were no danger and there were not any limitations in visiting Turkey.
• 11 January 2006: The Scientific Consultation Committee under the directorship of the Under secretary of the Ministry of Health. On 14 January 2006, a bigger meeting in terms of participation was planned.
• 12 January 2006: A meeting in which Under secretaries from the Ministry of Internal Affairs, Health, Environment and Forest, Agriculture and Rural Affairs participated was carried out on the subject of the avian influenza and the precautions to be taken.
• 12 January 2006: 6 thousand 500 "N-95" type preventive masks taken by the Borders and Coasts Health General Directorate were delivered to 81 provinces.
• 13 January 2006: 109 new samples were investigated in RSHCGD and no positive results were detected.
• 14 January 2006: The studies were evaluated in a meeting under the directorate of esteemed Abdüllatif Şener. It was decided that the studies were going to be carried out within the scope of National Avian Influenza Coordination Center under the co-presidency of Health and Agriculture under secretaries.
• 14 January 2006: The foreign experts from WHO, America and Europe CDC, FAO and OIE,  the Avian Influenza Scientific Consultation  Committee member and representatives from the Ministry of Agriculture met under the directorship of the Under secretary of the Ministry of Health.
• Case definitions, preventive measures, surveillance and treatment protocols   with regard to the avian influenza were reviewed.

14 January 2006: It was decided that an enlighten and education meeting  to be arranged with the participation of governors, health directors, agriculture and internal affairs directors of 81 provinces and 2 physicians from every province on 20