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Home Eurosurveillance Weekly Release  2006: Volume 11/ Issue 5 Article 2 Printer friendly version
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Eurosurveillance, Volume 11, Issue 5, 02 February 2006
Articles

Citation style for this article: Influenza team (ECDC), the international outbreak response team in Turkey. No new human infections with A/H5N1 in Turkey but national measures and international support continue. Euro Surveill. 2006;11(5):pii=2890. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2890

No new human infections with A/H5N1 in Turkey but national measures and international support continue

Influenza team (influenza@ecdc.europa.eu), European Centre of Disease Prevention and Control, Stockholm, Sweden, on behalf of the international outbreak response team in Turkey

There have been no new human cases of A/H5N1 diagnosed in Turkey since mid-January, and only three patients were still receiving care in hospital at 27 January,[1] but probable outbreaks of H5N1 infections in poultry are still being detected and so the potential for further human cases remains. The Turkish Ministry of Health is therefore continuing to recommend and enforce the measures already taken to prevent more human infections. These measures are essentially:

• Control of infection in birds
• Case finding, surveillance, laboratory confirmation, patient isolation and infection control
• Community mobilisation and education to reduce risk of human exposure to infected birds

Community mobilisation is the use of local healthcare providers, local government, other social structures and the media to disseminate messages effectively: these messages are to the effect that people should report sick poultry and not have unnecessary close contact with domestic birds. The message is particularly targeted at parents and children, as young children have been disproportionately represented in the cases.

There has been considerable progress in culling domestic flocks, especially in the areas where most of the human cases appeared in eastern Turkey, and so the overall risk to humans in those areas has declined. People are continuing to seek medical assessment to exclude infection with H5N1. Therefore, the absence of new cases for some time indicates initial success of current control measures.

The Turkish Ministry of Health has announced that H5N1 has been confirmed in clinical samples from 12 patients by the national influenza reference laboratory in Ankara (the National Influenza Centre, NIC) and the World Health Organization (WHO) influenza reference laboratory in London (a WHO collaborating centre). The 12 confirmed cases include the four patients who died. There are an additional nine patients whose samples have tested positive for A/H5 by the NIC, but which have not yet been confirmed by further testing at the WHO influenza laboratory in London.[2] The prime objective of the NIC’s initial testing was to support case finding and control of the outbreak, using clinical data as well as the preliminary test results. It was successful in supporting the control of the outbreak The NIC and the WHO laboratories are now performing further tests on samples from patients, including serology.

International support in outbreak control continues
When the first two human cases of influenza type A/H5N1 (bird ‘flu) were reported by the Turkish Ministry of Health in the first week of January 2006 [3], the Turkish authorities made a request for assistance to the World Health Organization (WHO). An international team of technical experts in of the fields of outbreak investigation, laboratory diagnostics, veterinarian epidemiology and infection control from WHO, the European Centre for Disease Prevention and Control (ECDC) and the European Commission set out for Ankara within 24 hours [4]. These experts formed the core of a WHO-led international team which has been working with Turkish colleagues both in Ankara and in Van province in eastern Turkey, where the greatest concentration of infected patients received medical treatment.

With the agreement of the authorities in Turkey, specific work concerning human health has been undertaken by the team, including:

  • Laboratory strengthening: through training to improve handling of large amounts of samples, equipment and reagents, with the intention of further improving the NIC’s capacity. Laboratory scientists from Turkey will visit the WHO influenza centre in London for further training.
  • Clinical care and infection control: additional training and support has been supplied in Van and Ankara, and Turkish clinicians have joined the WHO clinical teleconference group which provides a discussion forum for those who have provided care to H5N1 infected people in several parts of the world.
  • Epidemiology and surveillance: Technical discussions and advice based on experience from other parts of the world have led to the further modification of case definitions, sampling procedures, field investigation and data management.
  • Community mobilisation and health education: The international activity in this area has been led by a UNICEF team who are working with Turkish authorities and WHO to increase the public awareness and collaboration to report animal outbreaks and warn of the risks of H5N1 infection through close contact with infected birds.
  • Media communication: the team leaders and communications specialists in Ankara have worked together with international media, allowing the Ministry to respond to the many demands of the local media.

The veterinary component of the team has been working intensively with the Turkish Ministry of Agriculture. Much more work on animal health is needed before what seems to be a complex pattern of infection in the bird population can be adequately described. The extent of infection in birds in Turkey has yet to be fully delineated by the Turkish authorities, but may be extensive. Therefore, the risk to humans may continue for some time, and a prolonged collaboration with the Turkish Government is foreseen. This will require substantial investment, a point which is now being addressed by the Turkish authorities with support from the European Union and international agencies such as the World Bank.

A number of international organisations responded to the request for assistance by the Turkish authorities and the WHO, and formed the International Team: ECDC, European Commission, UNICEF, the Food and Agriculture Organization of the United Nations (FAO), World Organisation for Animal Health (OIE). There was close cooperation incountry with the World Bank, the United Nations Development Programme (UNDP), the Delegation of the Europe Commission to Turkey, and the EU Presidency (currently Austria) and WHO itself.

Experts from national institutions were brought together through the Global Outbreak Alert and Response Network (GOARN, http://www.who.int/csr/outbreaknetwork/en/) and the veterinary bodies represented by the European Commission, FAO and OIE. These included the Institute de Veille Sanitaire (France,) the Centers for Disease Control and Prevention (USA), the Swedish Central Field Epidemiology Group (Sweden), Tel Aviv University (Israel), the State Veterinary Service (UK) and the Veterinary Laboratory Agency (UK).

References:
  1. Ministry of Health (Ankara). Press Release. 27 January 2006
  2. World Health Organization Epidemic and Pandemic Alert and Response. Avian influenza - situation in Turkey .Update 7. 30 January 2006. (http://www.who.int/csr/don/2006_01_30/en/index.html)
  3. Ministry of Health (Ankara). GRIP (INFLUENZA) ve PANDEMI. (http://www.grip.saglik.gov.tr/) [accessed 1 February 2006]
  4. World Health Organization Epidemic and Pandemic Alert and Response. Avian influenza - situation in Turkey. 5 January 2006. (http://www.who.int/csr/don/2006_01_05/en/index.html)

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