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Avian Flu
Preparedness pays


How can we keep up our guard against avian influenza while avoiding panic? Around the globe, National Societies have a unique role to play in preparing for the worst while hoping for the best.


It’s an uncomfortable experience, watching Red Cross volunteers hand out literature on avian influenza amid the flashing blades, gore and giblets of a poultry market in rural Indonesia. The traders give Rahmet Encep and his leaflets a frosty welcome despite the sweltering heat in Parang Kuda market, three hours’ drive south of Jakarta.

“Always wash your hands after touching meat.” “Don’t store different types of meat together.” Rahmet hurries from stall to stall, trying to deflect the angry glares that make it clear he’s as welcome as an environmentalist at an oil baron’s ball.

The inconvenient truth that Rahmet is peddling is that over 80 people have died from bird flu in Indonesia infected from ingesting contaminated meat, handling infected birds or getting germs from bird droppings. And he’s trying to get public hygiene messages across to chicken vendors on tight margins.


Eventually, he seems to have an epiphany, or at least remember his training. He stands up straight and addresses a young butcher in a clear, confident, friendly voice. It seems to do the trick as 23-year-old Lucas Naryani takes a poster, depicting a succulent piece of fried chicken next to practical health advice, and pins it to the wall of his stall.

“I wash my hands three, five, maybe seven times a day,” says Lucas, although there is no running water (or refrigeration) at his stall. “All the chickens that come in the morning are sold today or thrown out. I know how to keep meat safe,” says this graduate of the local tourism school.

“But I don’t know what to do if I get sick from avian flu. We get information on TV and the radio but it’s not enough. Where can I get medicine? How much does it cost? You should be going face to face with the public, not just talking to the chicken sellers.”

Down the road, the Chianjar Red Cross branch is doing just that, and has an easier time of it. Led by Hari Hiddayya, fellow volunteers Cecen Suryana and Dewi Lesnasar help take the campaign into schools and village halls. Their style is interactive, and they have everyone, from kids to pensioners, alternating between sage nods, riotous laughter and mobbing the presenters for the posters, leaflets and health education material disguised as games like snakes and ladders.

“The interaction is so important,” says Dewi Sitompul, the International Federation’s avian influenza programme coordinator, as we drive to an inter-agency meeting that will draft Indonesia’s pandemic preparedness plan. “There’s no point in just handing out leaflets; we have to really engage with the communities. We are targeting housewives who deal with chicken every day. We are reaching out to the sellers, and we target kids who play in the dirt or shoot and kill wild birds for fun.

“When you look at the message of the [Red Cross] campaign it’s basic public hygiene. It’s applicable to all health epidemics because it’s basic hygiene promotion. A lot of people think we are OK because being Muslims we wash our hands five times a day but we have to reinforce the message that you have to wash your hands every time you come in from outside.”

Indonesian mystery

Her colleague P.G. Jenssen, the International Federation’s health coordinator in Indonesia, notes that the country’s high case fatality rate (81 out of 102 cases, compared with a global rate of under 60 per cent) is a mystery that needs investigation.

“Are doctors able to recognize avian influenza early enough? Are patients seeking help promptly? Are people hiding sick animals to avoid having stocks slaughtered? And the whole question of adequate compensation to farmers that have lost their stocks needs to be constantly monitored,” he says.

One of the biggest challenges in Indonesia is geography. The country is huge, and people live on thousands of islands scattered between the Andamans and Australia. This makes the Indonesian Red Cross Society essential to the national prevention and preparedness work, says Lily Sulistyowati, head of public communications at the Indonesian Health Ministry.

Treading a fine line

Sulistyowati is also vice-chair of COMNAS, the national committee of human influenza pandemic preparedness. She hopes that with the new draft plan Indonesia will be ready for a pandemic by 2008.

“The Red Cross has been very supportive,” she says. “We need their volunteers to do the social sensitization, to spread our four messages — wash hands, separate birds from humans, cook poultry well and report any signs of infection to the head of your village.”

The work is crucial, with one expert warning, “If the flu mutated and moved into the human population in Indonesia we would be in big trouble. What we have now is close to chaos.”

The plan includes sensitization of health workers, seen as a particularly important aspect — a newspaper on Sumatra reported that the body of someone with avian influenza was left in an ambulance overnight before being handed over to the family.

The Red Cross Red Crescent has a fine line to tread: keeping bird flu front and centre whilst refraining from panic-mongering or “crying wolf”, as the International Federation’s special envoy for avian influenza, Pierre Duplessis, puts it. He puts the lack of headlines down to the simple fact that the virus has not proved itself very adaptable to the human body. But the situation, while encouraging, is still serious.

“We have a little break just now,” says Duplessis, “which is good, and it allows us to carry on refining our preparedness and prevention work. If we can limit the pandemic in birds, then down the road we might be able to say H5N1 is gone.

“But there is still significant viral activity (widespread, mutating viruses) in the environment; in Indonesia there have been 2,000 separate pandemics in birds since 1998. We have to remember that a human pandemic is overdue; there were three in the last century so we mustn’t let our guard down.”

Duplessis believes that the International Federation and its National Societies have come a long way in their avian influenza programming since 2005, when the World Health Organization’s (WHO) special representative for avian influenza, Robert Nabarro, warned the General Assembly in Seoul that between 5 and 150 million people could be killed in an avian influenza pandemic.

“It would depend on the magnitude of the outbreak, but I believe the International Federation and its National Societies would respond well. It would be a major disruption of course, and if the absenteeism rate of our staff went up to 40 per cent then it might affect all our work,” says Duplessis.

High likelihood

Miro Modrusan, avian influenza programme manager with the International Federation, agrees. “If we are to respond successfully to a large-scale pandemic, everybody involved needs to know who is doing what. We need to look at things holistically, and we have not gone far enough down that road. Everyone agrees that there is a high likelihood that a pandemic will develop sometime over the next ten years, but no one can predict when, where or on what scale. This proposal is all about getting ready and defining National Society roles in national plans.”

Although governments are taking measures to address the threat of avian influenza and human influenza pandemics, the virus that is circulating in Asia, Africa and Europe is of particular concern in poorer countries, where due to insufficient infrastructure to cope with the magnitude of the problem, as well as the tradition of poultry rearing in the backyard, it is difficult to implement prevention and control measures, including comprehensive poultry vaccination and other bio-security measures.

Strengthening public health

“We can isolate key steps that we know will help us manage the challenge of a pandemic,” notes Keiji Fukuda, head of the WHO’s influenza programme. “One of the biggest benefits is that investments in strengthening the overall public health capacity will allow us to invest limited resources effectively and build protection against other public health threats.”

The WHO checklist for influenza pandemic preparedness planning describes key steps member states can take to evaluate their preparedness, including surveillance systems, case investigation and treatment, vaccine and antiviral programmes, and plans to maintain essential services.

Social challenge

“One critical key to pandemic preparedness is the broadening of participation outside government public health authorities,” says Fukuda. “A pandemic represents a societal challenge whose impact will be felt beyond the health sector and therefore by extension, preparedness demands the involvement of multiple sectors. The efforts of the private sector as well as specific organizations such as the Red Cross Red Crescent will play a crucial role in helping manage a pandemic.”

The primary goal for public health is to make sure people and countries are as prepared as possible for a pandemic. One of the critical roles for media is to keep the public informed.

“As with any longer-term public health risk, we should expect media profile and even risk perceptions to vary. It’s normal to see behavioural adaptation over time to an elevated public health risk. Communities tend to adapt and get on with life,” says Fukuda. But the fact is, although media reporting may wax and wane, the risk itself and dangers posed by a pandemic have not changed and in the estimation of WHO, the threat of a pandemic remains elevated.

“A straightforward and open dialogue on what we know, what we don’t know, and what people and partners can do to help manage this risk is the most effective communications strategy — through periods of intense interest, and otherwise,” says Fukuka.

Risks of panic

Up to now, there are no confirmed human-to-human transmissions of H5N1 — only highly suggestive family clusters. Yet, if human transmission occurs, the impact from the pandemic may be immense. WHO estimates that, based on the scenario of a mild pandemic, mortality could range from 2 to 7.4 million deaths worldwide. According to World Bank estimates, the next pandemic might cost the world economy US$ 800 billion per year.

There is no reliable treatment or vaccine and, faced with a human influenza pandemic, health authorities will have to rely mainly on public health measures such as health education, quarantine and case management. It is highly likely that in the event of a pandemic, the greatest impact may arise not from the number of cases and deaths, but from the economic and social consequences of the general public’s panic reactions to avoid infection.

This is why, notes Amgaa Oyungerel, an Asia-based International Federation regional health delegate, the private sector has taken a lead in “business continuity”. She dismisses suggestions that the investment in avian influenza and human influenza pandemics leads to the neglect of diseases like malaria or measles, which are actual, rather than hypothetical, diseases.

“A devastating pandemic would reverse much of the economic development we have seen in recent decades,” she says. “It’s not surprising that governments and businesses want to prevent it happening. And the money that is being pumped into avian influenza and pandemic research is new money.”

Not prepared enough

Oyungerel says that the focus on bird flu has already had notable benefits to health systems in South-East Asia, particularly in Viet Nam and Thailand. From a standing start three years ago, the latter has become one of the regional leaders in the field of blood diagnostics for influenza. But she cautions that vigilance is the best form of preparedness, recalling that 90 per cent of diseases come from the animal world. People are also living in closer contact with animals as when they migrate from the countryside, they bring their animal husbandry practices (such as keeping poultry in their yards) with them. Meanwhile, animals are kept in ever-higher densities.

“World preparedness is not satisfactory, even though considerable progress has been made in containing avian influenza as a potential cause for the human strain in certain countries.”

Campaigns can help strengthen public health systems in general, says Oyungerel. “Too much emphasis still is placed on the medical issues such as vaccines, antivirals and so on. We are advocating for more community-based and public health-oriented preparedness and the establishment of better prevention mechanisms.”

A further risk is the increasing consumption of chicken and ducks, she says. “As the economies of countries like China grow, people have more money to vary their diet, and as a result are consuming more poultry.”

Certain groups might be hard hit. ICRC doctor Eric Burnier says “one of ICRC’s roles would be to remind governments of their obligations to especially vulnerable groups such as prisoners and internally displaced people”.


Were a human-to-human pandemic to occur, traditional international assistance mechanisms would probably not be feasible (because of border closures and travel restrictions), leaving the affected developing countries to cope with negative consequences on their own. It is also highly likely that the world’s attention would be diverted to dealing with the pandemic, so any parallel natural disaster or complex humanitarian emergency would be neglected.

Despite the need to avoid whipping up panic, tough decisions may ultimately have to be taken by governments and other agencies. Words like “containment” and “quarantine” have a sinister ring for civil libertarians, while for those dealing with an epidemic in a crowded city they may seem the most sensible options.

Through the preparedness campaign, the International Federation is finding that there are unexpected opportunities for work which might not otherwise have been undertaken.

Its International Disaster Response Laws, Rules and Principles programme is carrying out pioneering work on legal preparedness that might be used to help governments act in large-scale disasters and widespread outbreaks of communicable diseases. “There’s been a lot of talk about contingency planning and business continuity but not much discussion about the legal issues around control that could arise during a pandemic,” says the International Federation’s International Disaster Response Laws coordinator, Victoria Bannon. Vital international support could be hampered by a lack of legal recognition for foreign aid organizations; customs and tax requirements could delay medication, relief goods and equipment; visa complications could hinder aid workers; and a lack of recognition of foreign professional qualifications could stop them from helping in an emergency. Coordination and information-sharing between response agencies might also be lacking, as well as adherence to human rights, humanitarian principles and standards of quality and accountability.

“We are preparing guidelines for how to work in non-conflict emergencies, looking at legal preparedness at a national level,” says Bannon.

A pilot study is being prepared Cambodia, involving WHO and the International Federation. “Our study in Cambodia has three main categories,” says Bannon. “First is national response, how the government will respond. It may be that our study will show that some things we see as problems may not be.

“Secondly we are looking at legal arrangements, like how to transport medicines across borders, or the whole issue of containment and how humanitarian workers will be able to operate if there are restrictions on movement.

“The third area is the consequences of a government declaring a state of emergency: what would be the ramifications for private hospitals, how would quarantine work and so on. SARS [Severe acute respiratory syndrome] threw out a lot of moral and legal dilemmas,” Bannon notes. “This pilot study will help us answer some of them.”

International Federation special envoy Duplessis is candid when it comes to the awkward question. The millennium bug, SARS and now avian influenza. All this preparedness, is it all just jobs for the boys, quangoism? Is it all just a big waste of money and emotion for something that may never happen?

“In the relief business,” he says, “we don’t know where the next disaster is coming from. It could be an earthquake, a flood, an act of terrorism, we just don’t know. But we do know that there is a major threat out there from avian influenza, so the sensible thing to do is to be prepared. It’s certainly not a waste of resources. We are better prepared to respond to all pandemics now; we are learning a lot through our avian influenza work.”




















A boy stands near a hen house in Abidjan, Côte d’Ivoire, where the World Organisation for Animal Health found 17 birds infected with the deadly H5N1 strain of avian flu.

































An Indonesian Red Cross Society volunteer hands out leaflets at a poultry farm in Semper village, near Jakarta, during a campaign of spraying and information dissemination in areas potentially infected by avian flu.










































A South Korean girl eats a piece of chicken at an event to promote poultry after an avian flu scare.




















An Indonesian Red Cross Society volunteer hands out leaflets on the risks of avian flu.
©Rano Sumarno / Indonesian Red Cross Society



Joe Lowry
Joe Lowry is International Federation information delegate for South-East Asia.



Bird flu facts

What is avian influenza (bird flu)?
Avian influenza is a viral infection primarily affecting domestic and wild birds but it can, rarely, cause severe infections in humans. A strain labelled H5N1 is the deadliest to humans.
How does avian influenza spread?
From infected poultry or wild birds. Close contact with feathers, faecal material, blood, droplets and infected meat itself should be avoided, and hands should be washed after contact with poultry.
Why is avian influenza dangerous?
The avian influenza virus kills 40 to 60 per cent of the people it infects. The H5N1 form of avian influenza has the potential to change and develop into a human strain which could cause large global outbreaks.
What is pandemic influenza?
Pandemic influenza occurs when that the virus emerges from one location and spreads very quickly throughout the world. During the last century this happened in 1918, 1957 and 1968. The Spanish flu of 1918 killed 40 million people and infected 20 per cent of the world’s population.
Is it about to happen again?
Scientists and the World Health Organization predict that the world is now closer to a pandemic than in the past 50 years.
What are the symptoms of avian influenza in humans?
The symptoms of avian influenza are very similar to normal seasonal flu: fever, muscle aches, cough, shortness of breath and fatigue.
Is it safe to eat chicken or eggs?
There is no risk in eating well-cooked poultry meat and products. Meat should be well cooked so there are no pink juices or raw parts in the food. Eggs should be hard boiled or fully cooked and never eaten raw. Handling chickens that have been frozen is not safe as the virus may survive. Washing hands with soap and cleaning the work surface with water and detergent is recommended after handling thawed meat.
What can you do to protect yourself against avian or human influenza infection?
Basic hygiene measures, such as regular hand washing and covering your mouth when you cough, avoiding contact with sick or dead poultry, and ensuring that all poultry meat and eggs are well cooked are the best measures.
Is there an avian influenza vaccine?
Yes, but only for poultry. Vaccines are being developed, but none have proven safe and effective in humans yet. Prototype vaccines are in the pipeline, but it will take several months to produce enough vaccines, and by that time, they may not be effective against avian influenza because it changes its genetic composition frequently.


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