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- Lessons from HPAI D A R T F Source: FAO ECTAD Cambodia T F A R D A Participatory Disease Surveillance and Response officer in Indonesia logs the GPS coordinates of a farm during a field investigation - Lessons from HPAI D A R T F T F All rights reserved. Reproduction and dissemination of material in the Publication for educational purposes or other non-commercial purposes are authorized without any prior permission from the copyright holders, provided the source is fully acknowledged. Reproduction of material in this publication for any other purpose is prohibited without written permission of the copyright holder. Applications for such permissions should be addressed to: The Chief, Electronic Publishing Policy and Support Branch, Communication Division, FAO, Viale delle Terme di Caracalla, 00153 Rome, Italy, or by email to- A R Emergency Centre for Transboundary Animal Diseases • FAO Regional Office for Asia and the Pacific Maliwan Mansion, 39 Phra Athit Road, Bangkok 10200, Thailand. Phone: - Fax: - • www.fao.org D 1 Foreword T F The Food and Agriculture Organization of the United Nations (FAO) has been in the forefront of the global effort to fight highly pathogenic avian influenza (HPAI) over the last 7-8 years since its emergence in Southeast Asia. At its peak, the disease affected 63 countries in Asia, Europe and Africa, but the comprehensive strategies and systems for surveillance, detection, diagnosis and response that were put in place at the international, regional and national levels by FAO, in collaboration with international agencies such as the World Health Organization (WHO) and the World Organization for Animal Health (OIE), and working with governments, regional organizations, and NGOs, have begun to prevail. The disease has now been eliminated from most of the countries in the world, though in Asia it remains endemic in China, Vietnam, Indonesia, Bangladesh and large parts of eastern India. A number of countries in Asia, including Cambodia, Laos, Myanmar and Nepal, also experience regular sporadic outbreaks. A R D Global efforts to address the problem of HPAI have clearly yielded significant results. The understanding that a pathogen that predominantly causes losses in livestock can jump to humans and result in epidemics and pandemics has spurred politicians and decision makers to invest in the problem of emerging infectious diseases (EIDs). The complexity of the drivers of infectious diseases that have such widespread impact has stimulated a One Health movement that promotes multidisciplinary and multisectoral approaches to addressing the problem. The central role played by FAO in the global efforts to control H5N1 HPAI has been explicitly acknowledged by major international agencies and the donor community, particularly given FAO’s broad mandate in the area of developing sustainable agriculture for food security, food safety and poverty reduction. The Emergency Centre for Transboundary Animal Diseases (ECTAD), the implementation platform created by FAO in 2004, which combines the technical and operational expertise of, respectively, the Animal Production and Health Division (AGA) and the Emergency Operations and Rehabilitation Division (TCE), has had a strong focus on the control of HPAI. ECTAD’s Regional office for Asia and the Pacific (ECTADRAP), established in Bangkok in 2005, responded to increasing poultry mortality and human infections due to HPAI in the region with a dynamic and a large HPAI control programme in Asia with a south Asia Sub-regional ECTAD Unit based in Kathmandu, and country ECTAD Units covering over 11 countries in south, southeast and east Asia. The success stories, challenges and lessons learned from these seven years of concerted -: Lessons from HPAI programming in the region are helping inform and shape future programme development against HPAI and other EIDs. The information generated from isolation and genetic and antigenic characterization of a large number of viruses in Asia and other parts of the world, coupled with the information on disease outbreaks, has improved our understanding of the virus’s evolution and the implications for its spread, infectivity and suitability for use in development of vaccines. In recent years, regrettably, the world has seen a progressive decline in funding for HPAI. Political commitment has been on the wane, especially in affected and at-risk countries. This is worrying as H5N1 HPAI continues to circulate in several countries, continually evolving in environments that present opportunities for the emergence of new variants. The disease is increasingly being under-reported and efforts at surveillance are declining in most countries that are chronically short of financial and manpower resources. It is also clear that it would take several years for the endemic countries to achieve freedom from the H5N1 virus. In addition, a number of other new pathogens and diseases are emerging in the region in an environment where the interaction between livestock, wild animals and humans is increasing. It is important to put greater efforts into raising awareness of the potential risks involved due to declining funds in the control of HPAI and other high impact EIDs. A R T F Over the last 3-4 years FAO’s role and priority has evolved from a predominantly emergency response to long term capacity building to improve surveillance, early detection and response in HPAI-infected and at-risk countries. FAO has also broadened its HPAI programme to include other EIDs and adopted a One Health approach to promote greater multisectoral and multidisciplinary participation. This transition provides an opportunity to reflect on the work done so far in HPAI control in the Asia region, and identify achievements, success stories, challenges, lessons learned and impact. This document represents the outcome of this exercise and provides in one place the knowledge, insights and recommendations of experts with first-hand knowledge and over eight years of experience in dealing with H5N1 HPAI in Asia. D May 30, 2012 F Dr Juan Lubroth Dr Subhash Morzaria Chief Veterinary Officer, FAO Regional Manager, ECTAD-RAP (FAO) Contents INTRODUCTION A global response to a virus 1 COORDINATION & PARTNERSHIPS Working as a regional team 7 DISEASE SURVEILLANCE Watching out for H5N1 17 LABORATORY CAPACITY The power to detect and diagnose 33 DISEASE PREVENTION: VACCINATION Staying a step ahead of H5N1 43 DISEASE PREVENTION: BIOSECURITY Keeping the farm secure 53 SOCIO-ECONOMICS Secrets of the market 61 WILDLIFE AND ECOSYSTEM HEALTH Walking on the wild side 73 COMMUNICATION AND ADVOCACY Messages to the farm 79 Lessons learned 91 Acknowledgements 96 References 98 Students of FAO’s Field Epidemiology Training Programme for Veterinarians inspect shells of apple snails, the standard diet of the Open Bill Storks that had been dying in unusual numbers in Thailand’s Ayutthaya province. Abbreviations AAHL..................... Australian Animal Health Laboratory ADB....................... Asian Development Bank AED........................ Academy for Educational Development AEGCD.................. ASEAN Expert Group on Communicable Diseases AGA....................... Animal Production and Health Division AHI......................... Animal and Human Influenza AI............................ Avian influenza AMS....................... ASEAN Member States APEC...................... Asia Pacific Economic Cooperation APRC..................... Asia Pacific Regional Conference AREM.................... Annual Regional ECTAD Meeting ASEAN................... Association of Southeast Asian Nations ASWGL.................. ASEAN Sectoral Working Group on Livestock AusAID.................. Australian Government Overseas Aid Program AVET...................... Applied Veterinary Epidemiology Training BSL......................... Biosafety Level CAHW................... Community animal health worker CBO....................... Community-based organization CDC....................... Centers for Disease Control and Prevention CIRAD.................... Agricultural Research Centre for International Development CMC-AH................ Crisis Management Centre – Animal Health CSIRO.................... Commonwealth Scientific and Industrial Research Organization CVO....................... Chief Veterinary Officer DAH....................... Department of Animal Health DIC......................... Disease Investigation Centre DLD....................... Department of Livestock Development (Thailand) DPRK..................... Democratic People’s Republic of Korea DVE........................ Duck virus enteritis ECTAD................... Emergency Centre for Transboundary Animal Diseases (FAO) EIDs....................... Emerging infectious diseases EMPRES................ Emergency Prevention Systems EPT......................... Emerging Pandemic Threats program -: Lessons from HPAI EU ......................... European Union FAVA...................... Federation of Asian Veterinary Associations FMD....................... Foot and mouth disease FAO........................ Food and Agricultural Organization of the United Nations FETPV.................... Field Epidemiology Training Programme for Veterinarians GETS...................... Gathering Evidence for a Transitional Strategy project GF-TADs................ Global Framework for the Progressive Control of Transboundary Animal Diseases GIS......................... Geographic Information Systems GPS........................ Geographic Position Systems GLEWS.................. Global Early Warning System H1N1..................... Sub-type of influenza A virus H5N1..................... Sub-type of influenza A virus T F HPAI....................... Highly pathogenic avian influenza HPED..................... Highly pathogenic emerging diseases IEC.......................... Information-Education-Communication IGP......................... Indo-Gangetic Plain A R ILRI......................... Indonesian Livestock Research Institute IMCAPI.................. International Ministerial Conference on Avian and Pandemic Influenza INGO...................... International Non-Governmental Organization IPC......................... Institut Pasteur of Cambodia ISO......................... International Standards Organization D IVM........................ Influenza Virus Monitoring KAP........................ Knowledge-Attitude-Practice LBM....................... Live bird market LL........................... Leading Laboratory MoA....................... Ministry of Agriculture MOH...................... Ministry of Health NAHICO................ National Avian and Human Influenza Coordination Office NaVRI.................... National Veterinary Research Institute ND.......................... Newcastle disease NEIDCO................. National Emerging Infectious Disease Coordination Office NGO....................... Non-Governmental Organization NSCAI.................... National Steering Committee for Avian Influenza OFFLU................... OIE/FAO Network of Expertise on Animal Influenza OH.......................... One Health OIE......................... World Organization for Animal Health OSU....................... Oklahoma State University PAHI....................... Partnership on Avian and Human Influenza PCR........................ Polymerase chain reaction PDSR..................... Participatory Disease Surveillance and Response J Abbreviations PPP........................ Public-Private Partnership PRRS...................... Porcine respiratory and reproductive syndrome PT........................... Proficiency Testing QA.......................... Quality Assurance RAP........................ Regional office for Asia and the Pacific (FAO) RCM....................... Regional Coordination Mechanism RDMA.................... Regional Development Mission for Asia (USAID) ROK........................ Republic of Korea RSU........................ Regional Support Unit SAARC................... South Asian Association for Regional Cooperation SARS...................... Severe acute respiratory syndrome SEARO................... South East Asia Regional Office (WHO) T F SEPRL.................... Southeast Poultry Research Laboratory SMS....................... Short Message Service SOP........................ Standard Operating Procedure TADs...................... Transboundary animal diseases A R TCE......................... Emergency Operations and Rehabilitation Division TCP........................ Technical Cooperation Project TOT........................ Training of trainers UNJP...................... United Nations Joint Programme UNICEF.................. United Nations Children’s Fund D UNDP.................... United Nations Development Programme UNSIC.................... United Nations System Influenza Coordination UNTGH.................. United Nations Theme Group on Health USAID.................... United States Agency for International Development USDA..................... United States Department of Agriculture USGS..................... United States Geological Survey VAHW.................... Village animal health worker VBEC...................... Village Biosecurity, Education and Communication VVW...................... Village veterinary worker WAHIS................... OIE World Animal Health Information System WB......................... World Bank WCS....................... Wildlife Conservation Society WEE....................... Wildlife, Ecology and Environment WHO...................... World Health Organization WILD..................... Wildlife Investigation in Livestock Disease and Public Health WPRO.................... Western Pacific Regional Office (WHO) K A R T F D Sample collection in the field in Cambodia INTRODUCTION 1 A global response to a virus T F The emergence and rapid spread of a zoonotic H5N1 highly pathogenic avian influenza (HPAI) in southeast Asia in 2003 and 2004 triggered worldwide interest and response, particularly due to the ability of the H5N1 virus to kill large numbers of infected animals, threatening food security and safety, and the livelihoods of millions poor livestock farmers. By the time the disease appeared in southeast Asia, the zoonotic potential of the virus was well recognized. Soon after, a number of human cases and deaths were reported in Viet Nam and Thailand, coinciding with cases in domestic poultry. In 2005, with the spread of HPAI outside southeast Asia into Russia, Europe and Africa, the potential for the huge impact of this disease on the global community was clear, resulting in an unprecedented response from international organizations and donors to mobilize resources for containing and eliminating the disease. A R D While aquatic birds are the natural reservoirs of influenza viruses, it is well recognized that from time to time the viruses jump and adapt to domestic poultry and then to humans. During this process, influenza viruses change their severity and occasionally cause influenza pandemics. A number of animal influenza viruses (subtypes H2, H5, H6, H7 and H9) have sporadically infected humans and are considered to have pandemic potential. Since the emergence of H5N1 in 2003, the virus has infected over 600 people worldwide, and over half of the infected population have died of the disease. This number is still relatively low. At present the virus is mainly confined to domestic poultry and has not demonstrated that it can be transmitted effectively between humans. But though human infections remain rare and sporadic, the potential for the emergence of pandemic human influenza from H5N1 still remains. Over the last 7-8 years since the emergence of H5N1 HPAI, the disease situation has evolved considerably. At the peak of avian influenza (AI) outbreaks in 2006, 63 countries in Asia, Europe and Africa were affected by the disease, though it has now been eliminated from most of them. Currently, H5N1 is entrenched in a number of countries in Asia and the disease is endemic in China, Viet Nam, Indonesia, Bangladesh and large parts of eastern India. A number of countries in Asia, including Laos, Cambodia, Myanmar and Nepal, also experience regular outbreaks. While disease outbreaks in poultry steadily declined between 2004 and 2008, since 2009 there has been an apparent increase in outbreak numbers, although in the last 2011/2012 HPAI season there was a significant decline in poultry outbreaks. The last newly infected country was Bhutan in February 2010. However the disease is also known 1 -: Lessons from HPAI to be under-reported and there is increasing evidence that some of the smaller countries in Asia with relatively undeveloped poultry industries, including Cambodia and Nepal, have become endemic for H5N1 HPAI. It is estimated that the disease has resulted in the loss of over 400 million domestic poultry and caused economic losses of over US$ 20 billion. The H5N1 virus too has progressively evolved in Asia. Between 2003 and 2007, the H5N1 clades 1 and 2 were the most common. The latter clade progressively replaced clade 1 and by 2005 had become the dominant strain globally. Clade 2 has rapidly evolved and generated a number of subclades in different epidemiological situations in Asia. Of the H5N1 clade 2 viruses, clade 2.2, found in the Indo-Gangetic Plain (IGP) area including Bangladesh, Nepal and India, has been the most common. In Indonesia only the subclade 2.1 has been found. In southeast Asia, the viral clade situation has been more complex and heterogeneous, while in northern Viet Nam the subclade 2.3.4 has been predominant, replacing the previously dominant clade 1 and the newly introduced clade 7. In southern Viet Nam only clade 1 has been seen and continues to be the most important strain of virus present. Cambodia shares the same epidemiological environment and clade as southern Viet Nam. Laos and Myanmar have had multiple incursions of H5N1 viruses with outbreaks caused by clades 1, 2.3.4 and 2.3.2 in the former, and 7, 2.2 and 2.3.4 in the latter. Thailand, which is now free of H5N1 HPAI, has had two incursions, one with clade 1 and the other with 2.3.4. T F Since late 2010 and 2011, there has been evidence that clade 2.3.2.1 is emerging as the most dominant strain in Asia. By early 2011, several countries in Asia had experienced outbreaks of HPAI due to this clade, which appears to have evolved in domestic poultry in China and have altered characteristics with high pathogenicity to wild birds. This virus has been known to spread widely in Asia through infected wild birds, and has affected Bangladesh, India, Japan, Myanmar, Nepal and the Republic of Korea (ROK). Clade 2.3.2 in its various forms exists in China together with clade 2.3.4. A R The information generated from isolation and genetic and antigenic characterization of a large number of viruses in Asia and other parts of the world, coupled with the information on disease outbreaks has improved our understanding of the virus’s evolution and the implications for its spread, infectivity and suitability for use in development of vaccines. The current trends in evolution present a number of concerns, which include the emergence of 2nd, 3rd and 4th order clades, demonstrating rapid evolution and rapid replacement of virus strains in some endemic regions, and the emergence of antigenic diversity including changes in receptor binding capacity and the ability to break through existing vaccine strains. The global response D In the global effort to control avian influenza and reduce the risk of a human pandemic, a series of high level International Ministerial Conferences on Avian and Pandemic Influenza (IMCAPI) were organized by the international technical organizations and donor community. These consultations, held in Beijing (2005), Bamako (2006), New Delhi (2007), Sharm al Sheikh (2008) and Hanoi (2010) have consistently acknowledged that the risk of pandemic influenza can only be reduced by controlling the disease at source in poultry. In this regard, major international agencies and the donor community have recognized the important role of the Food and Agriculture Organization of the United Nations (FAO) in controlling this disease, particularly given FAO’s broad mandate related to the development of sustainable agriculture for food security, food safety and poverty reduction. The IMCAPI meetings have also been influential in generating political and financial support for addressing the HPAI problem. FAO’s response FAO has played a central and leading role in global efforts to control H5N1 HPAI. In 2004, FAO created the Emergency Centre for Transboundary Animal Diseases (ECTAD), an implementation platform for addressing the global issues of HPAI. ECTAD was born of a partnership between FAO’s technical expertise, embodied in the Animal 2 1 A global response to a virus Production and Health division (AGA), and its and emergency operations expertise, represented by its Emergency Operations and Rehabilitation Division (TCE). ECTAD’s Regional office for Asia and the Pacific (RAP) was established in Bangkok in 2005 in response to increasing poultry mortality and human infections due to HPAI in south, southeast and east Asia. By 2007, FAO had a large HPAI control programme in Asia, with a south Asia Sub-regional ECTAD Unit based in Kathmandu, and country ECTAD units covering over 11 countries in south, southeast and east Asia. Driven by a clear decentralized chain of command from the Chief Veterinary Officer (CVO) of FAO as the Head of ECTAD through to the Regional Manager and the country Team Leaders, and supported by clear and synergistic global, regional and national strategies for HPAI control, the ECTAD platform provided an effective model for emergency implementation of a high impact emerging disease control programme. Using the ECTAD platform, FAO’s main role could be broadly grouped under two headings — coordination and technical support. The coordination role has been significant in forging productive partnerships with national governments, regional organizations, national and international non-governmental organizations (NGOs and INGOs), national and international research institutes, other international developmental and technical agencies and the international donor community. FAO’s formal relationship with ministries of agriculture in respective member countries has enabled the rapid development, establishment and implementation of national HPAI programmes. The technical expertise has fostered programmes to improve the capacity to quickly detect, diagnose, report and respond to a disease emergency. Through its technical advice and support, FAO has enhanced regional cooperation and promoted greater transparency in sharing disease information through the establishment of regional diagnosis and surveillance networks in collaboration with regional organizations. FAO was also able to form and mobilise multidisciplinary teams including communicators, socio-economists, wildlife experts, epidemiologists, virologists, molecular biologists and public-private partnership experts, to address a hugely complex disease problem of global significance. T F A R D Global efforts to address the HPAI have yielded significant results. The understanding that a pathogen that predominantly causes losses in livestock can jump to humans and cause epidemics and pandemics has spurred politicians and decision makers to invest in the problem of emerging infectious diseases (EIDs). The complexity of the drivers of infectious diseases has stimulated the development of a One Health approach that promotes multidisciplinary and multisectoral collaboration in addressing the problem. When pandemic H1N1 influenza emerged in 2009, one factor behind the well coordinated global response by various countries and international and regional organizations was increased awareness of such high impact global problems and enhanced capacity to address them. Why this document? FAO continues to play a key role in the global response to HPAI. At its peak, the programme comprised 168 donor-supported projects, of which 64 remain active, more than half of them in Asia. From 2010, there has been a progressive decline in funding for HPAI and clear evidence of declining political commitment among affected and at-risk countries. This is a worrying trend as H5N1 continues to circulate and continually evolve in six endemic countries, with the risk that new variants with unexpected outcomes could emerge unexpectedly. The disease is under-reported and efforts at surveillance are declining in most countries that are chronically short of financial and manpower resources. The FAO publication 3 -: Lessons from HPAI Approaches to Controlling, Preventing and Eliminating H5N1 HPAI in Endemic Countries (FAO 2011) has noted that factors such as the nature of the poultry sector, the quality of veterinary services and the level of commitment from the public and private sectors will play an important role in determining the rate of progressive control of HPAI. It is also clear from the current situation that it would take several years for endemic countries to achieve freedom from the H5N1 virus. In addition, a number of new pathogens and diseases are emerging in the region in an environment where the interaction between livestock, wild animals and humans is increasing. It is important to put greater efforts into raising awareness of the potential risks involved in reducing funds in the control of HPAI and other high impact EIDs. Given this scenario, it was considered important that an attempt be made to reflect on the progress made so far in the control of HPAI in the Asia region. An initiative was launched in late 2011 and early 2012 by ECTAD-RAP to gather information from the ECTAD Regional Programme for Asia, with the broad objective of taking stock of the HPAI programme between 2005 and 2011. T F A structured process coordinated by ECTAD-RAP was adopted to collect this information, with a set of key questions to create a common framework for reporting. What was the situation in the beginning in 2005? How had this changed by 2011? What were some quantifiable outputs and outcomes? What practices were successful, what were the lessons learned? How many of the outputs are sustainable, how many require a little support, and for how long? A R Staff in the regional office, country units and the HQ were requested to provide information on the ongoing HPAI programme using a template of questions, under the following thematic areas — D 1. Coordination and Partnership 2. Surveillance, Epidemiology and Information Management 3. Laboratory Capacity 4. Disease Prevention (Vaccination) 5. Disease Prevention (Biosecurity) 6. Socio-economic Capacity and Disease Control 7. Strategic Communication and Advocacy 8. Wildlife Health and Ecosytems The information gathered was shared among participants at the 6th Annual Regional ECTAD Meeting (AREM) in end February 2012, and validated through further discussions. The resulting output was put together as a document entitled Lessons from HPAI. It is envisaged that this document will principally be used internally by FAO AGAH and ECTAD staff for designing and developing future programmes on HPAI, transboundary animal diseases (TADs) and EIDs by drawing on the last seven years of experience of tackling HPAI in Asia. The document may also be used to generate communication and advocacy materials for garnering continuing support for the HPAI programme and investment from the international donor community. It is also expected that this document may serve as a resource for other key donor partners for extracting information on the impacts of their 4 1 A global response to a virus investment in FAO to control HPAI in Asia. It is important to note that the document neither purports to be a comprehensive account of the activities of FAO in the HPAI arena, nor does it provide detailed lists of outputs, outcomes, impact and gaps. However, the stocktaking process effectively captures the key experiences and challenges of addressing a complex disease problem such as HPAI. T F D A R 5 A R T F D Three faces of tripartite collaboration. FAO has coordinated deepening engagement and collaboration with WHO and OIE in the spirit of One Health 6 COORDINATION AND PARTNERSHIPS 2 Working as a regional team T F FAO has played a central role in forging and coordinating partnerships between players and stakeholders involved in the control of HPAI and other high impact emerging and re-emerging infectious diseases. These have included partnerships with national governments, non-governmental organizations (NGOs), donors, national and international research institutes, regional organizations and other international developmental and technical agencies. Except for Singapore and Brunei, FAO is represented officially in all countries in south, southeast and east Asia, and enjoys formal relationships with their ministries of agriculture or their equivalents. This enables FAO to take up projects at the national level without the need to develop additional memorandums of agreement. FAO also hosts the biannual Asia Pacific Regional Conference (APRC) for ministers of agriculture and regional organizations, where regional priorities and policy issues are discussed and important decisions made. In addition, FAO has formal collaborative agreements with the Association of Southeast Asian Nations (ASEAN), the South Asian Association for Regional Cooperation (SAARC) and other UN and international agencies such as the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the World Organisation for Animal Health (OIE), as well as multilateral donors such as the World Bank (WB) and the Asian Development Bank (ADB). A R D Under FAO, all activities on HPAI and other high impact infectious diseases globally were conducted under ECTAD, the internal mechanism established in 2004 by the Director General of FAO in response to the crisis caused by the emergence and spread of HPAI in southeast Asia. ECTAD is a unique partnership between FAO’s technical and operational arms, set up to manage and deliver an emergency programme across the Asia-Pacific region. FAO has managed major projects funded by a large number of donors, including ADB, the Australian Government Overseas Aid Program (AusAID), the German Government, the Japan Trust Fund, the United States Agency for International Development (USAID), the Avian Influenza Facility of WB, and the European Union (EU). Funding has also come through the multi-donor funded UN Joint Programme (UNJP) in Viet Nam. Many governments have established mechanisms to coordinate the public health and animal health aspects of their overall response to HPAI, and FAO has stayed closely and continuously involved with the functioning of these mechanisms either through the ECTAD team or the FAO Representative. FAO has worked as a neutral broker within the government systems of its member countries, ensuring that the government’s interests receive due priority from a large num- 7 -: Lessons from HPAI ber of national, regional and international partners. Though this may have been a challenge in the beginning, over time FAO has become a trusted partner supporting efficient technical approaches and advocating policy issues that support HPAI control in the interests of international, regional and public good. By adhering to its core principles, FAO has been increasingly effective as a coordinator and partner, and also played a consistent role in the functioning of the UN’s country level coordination mechanism. In 2004, just as HPAI was beginning to sweep across the region, FAO and OIE, representing animal health interests, worked with WHO to develop the FAO/OIE Global Framework for the Progressive Control of Transboundary Animal Diseases (FAO/OIE 2004), a document that articulated the principles for collaboration on priority infectious diseases of livestock. An important initiative in this framework was the establishment of a global early warning system (GLEWS) for animal diseases, located within the FAO Emergency Prevention Systems (EMPRES) programme. T F In 2006, ECTAD-RAP helped develop the first joint strategy against HPAI in Asia and the Pacific, the Strategic Framework for HPAI Prevention and Control in Southeast Asia (FAO 2006). Springboarding off this, FAO, which already had strong links with the ASEAN Sectoral Working Group on Livestock (ASWGL), helped develop The Regional Framework for the Control and Eradication of HPAI in ASEAN (FAO 2006), an initial set of guidelines for HPAI control in ASEAN. Early FAO workshops on epidemiology and laboratory standards also included ASEAN representation. A R FAO and OIE developed FAO Guiding Principles for HPAI Surveillance and Laboratory Diagnosis in Asia (FAO 2004) and made significant contributions to the evolving global response through collaboration within the UN System for Influenza Coordination (UNSIC). In addition FAO has been a central advisor, coordinator and participant in the six IMCAPIs that have been held since late 2005. D Situation in 2005 Though the ECTAD mechanism, established to deliver FAO’s global HPAI emergency programme, already existed it was not until late 2005, when the global fund for avian and human influenza became available, that ECTAD-RAP was set up in Bangkok. Till then, FAO had been using its core funds through Technical Cooperation Projects (TCPs) at both national and regional levels in Asia to coordinate with and support countries in their HPAI control efforts. For example, a regional TCP in 2005 helped establish diagnostic laboratory and surveillance networks for HPAI in many countries of southeast Asia. It was these early emergency missions and TCPs that gave FAO the basis for working with donors in 2005 to prepare national and regional project proposals. By early 2006, funding was in place and activities started in Cambodia, Indonesia, Lao PDR and Viet Nam. Situation in 2011 International partnerships Under the leadership of the ECTAD-RAP, several country ECTAD units were quickly set up in the Asia-Pacific region to manage multi-donor funded country programmes. ECTAD-RAP played a key role in the overall UN system response and had a collaborative alliance with OIE, WHO and UNICEF, the latter being specifically funded to develop a communication programme to prevent and control HPAI in humans. 8 2 Working as a regional team Close coordination on animal health technical matters with UNSIC, and WHO and UNICEF helped widen understanding of the issues at the source of the disease and to synchronize messages across the UN System. Regional partnerships At the regional level, ECTAD-RAP engaged strategically with ASEAN by establishing the ASEAN HPAI Task Force and developing the ASEAN HPAI Roadmap 2020. With significant technical inputs from FAO, this roadmap for an HPAI-free ASEAN community by 2020 was endorsed at the Thirty Second Meeting of the ASEAN Ministers on Agriculture and Forestry, October 2010. ECTAD-RAP’s engagement has developed into a full-fledged collaboration with a broadening of activities from TADs to high-impact emerging and re-emerging infectious diseases of significant socioeconomic impact in the ASEAN and ASEAN+3 member countries. ECTAD-RAP’s expertise came into play in finalizing the ASEAN priority animal diseases and priority zoonotic diseases, which allowed FAO to engage actively with the ASEAN Expert Group on Communicable Diseases (AEGCD), the organization’s human health arm, at a practical level. The establishment of the ASEAN Regional Support Unit (RSU) in 2011 in Bangkok marked a significant step in ECTAD-RAP’s regional coordination role. The process for establishing a regional coordination mechanism with the proposed name ASEAN Coordination Centre for Animal Health and Zoonoses has already been endorsed by the Preparatory Senior Officials Meeting of the Thirty Third Meeting of the ASEAN Ministers on Agriculture and Forestry, October 2011, demonstrating FAO’s alignment with the direction of ASEAN’s policy. T F A R ECTAD-RAP’s Sub-regional Coordination Unit for SAARC, established in Kathmandu, has stimulated effective regional coordination with particularly good outcomes from the South Asia Cross-border project. Project management and coordination mechanisms included technical and policy level committees, meetings and workshops and information bulletins, with SAARC engagement in regional and global meetings. Fifteen issues of a bimonthly Information bulletin were disseminated from May 2009 to October 2011 to ECTAD members, donors, countries, and other stakeholders. Four meetings of technical and policy-level committees were held to review project progress between April 2009 and May 2010 in Kolkata (India), Dhaka (Bangladesh), Pokhara (Nepal) and New Delhi (India). The meetings have contributed towards filling significant gaps in technical capacity within the SAARC Secretariat. D FAO also helps coordinate the Tripartite mechanism, established in early 2010 as an intersectoral platform for dialogue around One Health and collaboration between FAO, WHO Southeast Asia Regional Office (SEARO) and the Western Pacific Regional Office (WPRO), and OIE. The mechanism carries forward the recommendations from the 2010 IMCAPI in Hanoi, where the One Health approach was strongly endorsed, highlighting the importance of strengthening partnerships and intersectoral cooperation. The need to move beyond disciplinary insularity for the One Health approach to be successful was noted, including broadening the scope to include also Ministries of Environment or Natural Resources in addition to the Ministries of Agriculture and Health. Guided by the One Health Action Plan of FAO’s Animal Health Service (FAO 2011), which recognizes advocacy as a key activity, in August 2011 countries of the region developed their first drafts of advocacy action plans to promote One Health in their country settings. FAO is coordinating the creation of comprehensive intersectorally developed One Health strategies at country levels. Bangladesh’s 9 -: Lessons from HPAI One Health country strategy and action plan document is now nearing finalization, and includes a number of ongoing One Health related activities. Country partnerships To provide effective coordination to countries of the region in technical areas, the unit developed a strong synergistic multidisciplinary team of experts in epidemiology, laboratory methods, legislation, socioeconomics and communication. By the end of 2011, FAO had helped manage donor inputs in Bangladesh, Cambodia, China, India, Indonesia, Lao PDR, Malaysia, Myanmar, Nepal, Philippines, Timor Leste and Viet Nam, covering key countries that were at major risk of H5N1 HPAI infection in south, southeast and east Asia. Indonesia: FAO was embedded in the government implementation mechanism and structure of Indonesia, the country with FAO’s largest project investment. This put FAO in a pivotal position for gathering and disseminating information about the national programme, interacting with industry stakeholders on behalf of the government, and engaging with international agencies such as WHO, OIE and UNICEF. FAO’s regular coordination meetings with the government, key stakeholders and donors — including the International Livestock Research Institute (ILRI), USAID, AusAID and the Indonesia Dutch Partnership Project — helped harmonise the programme. FAO served as a bridge between Indonesia’s government and its large international NGOs that were not embedded in the government system and also was heavily involved in helping WB establish a project to support the Indonesian government. In support to the Directorate General of Livestock and Animal Health Services FAO established quarterly HPAI Technical Briefing Meetings with donors and technical partners. This was extended to providing technical donor coordination support to the Director of Animal Health on issues of animal health in 2011/12 by mapping the animal health activities of donors, technical agencies and international NGOs (INGOs) and defining a donor coordination strategy. T F A R D Viet Nam: FAO’s second largest investment was in Viet Nam, where too it worked closely with government structures and instruments to deliver assistance to the Ministry of Agriculture. The Vietnamese Government established a National Steering Committee for Avian Influenza (NSCAI) chaired by the Ministry of Agriculture (MoA). FAO offered advise and advocacy to this committee through the Department of Animal Health (DAH). FAO also had inputs into Viet Nam’s all-important so-called ‘Green Book‘ — Viet Nam Integrated National Operational Programme for Avian and Human Influenza- (Viet Nam 2006)—and used it a guiding tool for implementing donor assistance. Viet Nam’s Partnership on Avian and Human Influenza (PAHI), established in November 2006, was signed by 26 partners including the Government of Vietnam and other national organizations, the UN System, the World Bank, international donors, NGOs, research organizations and other stakeholders. FAO was closely engaged with PAHI’s Annual Plenary meetings, which provided a forum for updating the disease situation, joint monitoring of overall financial commitments and delivery, policy discussions and sharing of experiences. FAO also played an important role in UNJP, which managed funds provided to the trust by a number of donors. In addition to coordination with WHO, FAO had considerable interaction with UNICEF and others related to the UNJP-funded communications strategy. As in Indonesia, FAO played a bridging role between the national animal health services and several INGOs working with USAID support to implement activities at the grassroots. Relationships 10 2 Working as a regional team between partners, including the United States Centers for Disease Control and Prevention (CDC), OIE and the United States Department of Agriculture (USDA), were strengthened at annual retreats organized by FAO to discuss programme progress and plans. China: FAO ECTAD’s coordination role in China has been recognized by both national and provincial partners in Hunan, Yunnan, Guangxi and Chongqing centrally administered municipality (Province level), as well as beneficiary countries in the region. Over the past five years, this has helped build cohesion in the national programmes, strengthened links between FAO and the national government, and enhanced partnerships among stakeholders such as the Ministry of Agriculture and the State Forestry Administration. FAO also established partnerships with the city administration in Guangzhou municipality to facilitate work in markets. As the focal point and knowledge hub on TADs within FAO and the UN family in China, FAO ECTAD China plays a leading role in coordinating the national and local government with other stakeholders and the outside world through science-based technical advisory inputs and continuous communication within its mandate areas, and proposes solutions to address issues and challenges ahead. Under the umbrella of the UN Theme Group on Health (UNTGH), FAO ECTAD China organized meetings of the sub-working group on diseases at the human-animal interface in-, which have helped promote the use of an ecosystem health approach to address EIDs. FAO ECTAD China also extends its technical assistance and expertise through the facilitation, design and implementation of TCPs in Mongolia and the Democratic People’s Republic of Korea (DPRK), with a special focus on foot and mouth disease (FMD). T F A R Myanmar: Here, FAO was able to integrate diverse components into one programme with notable results. From 2005, when there were no coordination structures, FAO established an Integrated Programme on Avian Influenza which coordinated inputs from three funding sources — AusAID, USAID and WB – while reporting to each donor separately and holding consultations with the National HPAI Steering Committee. There were also cooperative interactions with stakeholders such as the different livestock associations and the Myanmar Livestock Federation. Another project was coordinated with WHO. D Lao PDR: FAO in Lao established the National Avian and Human Influenza Coordination Office (NAHICO), later renamed as the National Emerging Infectious Disease Coordination Office (NEIDCO) in line with its broadened responsibility beyond influenza. NEIDCO coordinates the implementation of the National Work Plan for EIDs and Public Health Emergency for Lao PDR -), which includes FAO’s AI Project. Through this mechanism FAO has shared active and passive surveillance information on priority zoonotic diseases and emerging disease events. It also allows joint investigations and risk assessments which can lead to coordinated responses to zoonotic disease threats and joint risk reduction activities. Structures have been set up for intersectoral coordination and the development of a national integrated work plan. The process has fostered communication between appointed officials at policy, implementation and supervisory levels and reduced inconsistencies in response among different agencies. In other countries ECTAD-RAP linked with national efforts through National HPAI committees that included representation from the health and agriculture sectors at both national and international levels, as well as other stakeholders such a UNICEF and poultry industry representative bodies. 11 -: Lessons from HPAI Donor partnerships ECTAD-RAP engaged closely with donors in establishing both regional and national projects. FAO had a strong partnership at international, regional and national levels with USAID in particular as the single largest donor to the global programme. Wherever the World Bank has funded HPAI control programmes, FAO has been involved at varying levels, although contractual difficulties caused by differences in institutional arrangements has been a challenge. Nevertheless this has not hampered the partnership nor impeded coordinated inputs from WB and FAO to the country programmes. The partnership with ADB was particularly important as it supported the regional coordination role of ECTAD-RAP as well as some key technical positions and regional communications activities. Significant support also came from the Japan Trust Fund, used to bolster FAO field support in the ASEAN countries. AusAID provided valuable support to the programme in Indonesia and Myanmar, a partnership that has proven effective. Smaller amounts of support were provided by a number of donors including Germany, Sweden, the Netherlands, China, New Zealand, Ireland and France. T F Other partnerships FAO’s strong partnership with the technical arm of USAID, particularly the one in the Bangkok mission, has led to deep discussions of project design and some interaction with USbased technical officials. The latter was especially true with the programmes in Indonesia and Viet Nam. In addition, ECTAD-RAP played a key role in organising many workshops and review meetings together with USAID’s Regional Development Mission for Asia (RDMA) office. Apart from USAID, FAO has collaborated with technical experts from the Commonwealth Scientific and Industrial Research Organization (CSIRO), the Australian Animal Health Laboratory (AAHL), the US CDC in Atlanta, CDC experts stationed in several Asia countries, and the United States Department of Agriculture (USDA), both the Southeast Poultry Research Laboratory (SEPRL) in Atlanta and their regional office in Bangkok. Another technical partner collaborating with FAO on HPAI was the French Agricultural Research Centre for International Development (CIRAD). D A R Outputs 1. D onor inputs coordinated through involvement as partner in several key meetings of national steering committees or similar bodies. 2. T echnical aspects of the HPAI control programme coordinated through over 200 workshops and meetings at regional or national levels. 3. A ctive and productive regional networks established for HPAI diagnostic laboratories and veterinary epidemiology. 4. A SEAN RSU established at RAP and process for developing the ASEAN Coordination Centre for Animal Health and Zoonoses initiated. 5. E CTAD Sub-Regional Coordination Unit for South Asia and subsequently the RSU for SAARC established. 6. G lobal, regional and national plans and guidelines for HPAI control prepared in collaboration with other agencies and donors. 7. T wo real-time evaluations coordinated by independent reviewers of the FAOexecuted HPAI programme in Asia. 12 2 Working as a regional team 8. M obilization of resources facilitated through the coordination of five IMCAPIs, held respectively in Beijing, Bamako, New Delhi, Sharm el Sheikh and Hanoi. 9. M eeting of high burden HPAI countries for sharing experiences and best practices for controlling HPAI in humans and animals coordinated. 10. Two global and regional HPAI strategy documents and a One Health strategy document developed. Outcomes 1. S ignificant progress with HPAI control across public health and animal health sectors in the region, primarily because of FAO’s effective coordination and collaboration with governments, regional organizations, donors and partners, as well as a strong contribution at global, regional and national fora on HPAI control. T F 2. D evelopment of One Health initiatives at the national level, facilitated by FAO’s efforts to link the public health and animal health sectors. 3. I ncreased cooperation between neighbouring countries and improved understanding of transboundary issues as a result of regional activities coordinated by FAO, such as building and strengthening laboratory and epidemiology networks. This has led to better information sharing between countries, and in the region and internationally. A R 4. I mproved capacity among ASEAN and SAARC to control HPAI and highly pathogenic emerging diseases (HPEDs), because of FAO’s capacity building initiatives supported by the European Union’s (EU) Highly Pathogenic Emerging Diseases (EU-HPED) project. Successful Practices D 1. E xploring and promoting opportunities for intersectoral collaboration between the human health and the animal health sectors, and wildlife in different stages of project design and developing action plans. 2. B ringing together experts from diverse technical, sociological, economic and other fields in planning and review meetings, as well as in research and field activities, to promote richer insights through greater multidisciplinary collaboration. 3. C loser coordination on animal health technical matters with UN agencies such as UNSIC, WHO and UNICEF to widen understanding of issues around HPAI and to synchronise messages across the UN System. 4. M aintaining a development perspective while working in emergency modality, in order to transform the scope and perspective of disease control, and widening the focus to include livelihoods and socioeconomic factors, nutrition and other development aspects. This has in turn helped foster a spirit of professional partnership and collaboration between FAO, donors and governments, based on an acknowledgment of comparative advantages. 13 -: Lessons from HPAI Sustainability Networks: Active technical support for networks does require external assistance although over time they could be subsumed under ASEAN’s regional activities provided the political commitment to continue this is maintained at the regional level. RSUs: he ASEAN and SAARC RSUs will progressively be transferred to the respective regional organizations. The ASEAN RSU transfer will be in line with the comprehensive proposal for the establishment of a Regional Coordination Mechanism (RCM) on Animal Health and Zoonoses, which will empower ASEAN to better coordinate activities related to animal health and zoonoses at the regional level among ASEAN Member States (AMS), and between AMS and development partners. The SAARC RSU will demonstrate a strong model for the organization for addressing many of the other regional technical issues of South Asia. Coordination mechanism: Sustainability in the medium and long term is also close linked to the development of stronger working relationships between the government and the commercial poultry sector in the spirit of public-private partnerships, and based on trust and respect for each other’s capabilities. In the short-term this will continue to require resources, support and advocacy. Future A R T F Regional organisations are demonstrating greater capacity to provide technical leadership for HPAI and other priority diseases and so will assume a greater coordination and support role in the future. FAO will still take the position of the neutral agency and support strategic efforts to institutionalise the One Health approach to infectious diseases. Long term plans will need to be drawn up to strengthen animal health services in the region and to devise strategies for addressing gaps in technical capability and capacity that constrain the implementation of One Health approaches in the livestock sector. Bringing a development perspective to the overall coordination of international inputs would greatly help here. D 14 D A R T F T F A R D A Ruddy Shelduck with a radio transmitter strapped to its back. Monitoring wild birds, which are believed to harbour influenza viruses, is an important aspect of surveillance DISEASE SURVEILLANCE 3 Watching out for H5N1 T F Timely and accurate information about disease occurrences has remained a priority of global, regional and national communities for implementing effective HPAI control programmes in domestic poultry. Achieving this requires the capacity to detect disease outbreaks and to manage, report and analyze outbreak information. In the context of HPAI the objectives are twofold – to reduce the economic impact of the disease in the poultry sector by facilitating timely detection and control; and to inform public health authorities of the risk to human populations. Defining the scope and boundaries of disease surveillance in the context of rapidly evolving disease dynamics under different epidemiological environments is difficult. Asia’s constant question was: how much surveillance activity does a disease control programme need when one weighs the cost of each step in the process against the effectiveness of the approach? International experts differ among themselves as to the structure and desired outputs of an effective surveillance system, but one important principle that must remain in the forefront is ‘fit for purpose’. Important considerations for ECTAD were that the surveillance system must inform and enable a successful disease control programme at the national level, and that there should be a timely flow of information to international reporting systems for the broader analysis of disease information to assess regional and global risks to the livestock as well as the public health sectors. A R D Disease in poultry has been detected in a number of ways since the HPAI epizootic began in southeast and south Asia. Most common and prominent among these was reporting by poultry owners to local authorities, sometimes augmented by reports from concerned community members, or when H5N1 influenza broke out in humans, generally causing mortalities, and triggered searches for sources in poultry. Later, there were specific active surveillance programmes to detect infection or disease, but it has remained generally true that financial stakeholders in a poultry value chain concerned about loss of income or personal safety will alert authorities about outbreaks. Their motivation would generally be personal benefit rather than any concern for the common good. Rumours from the ground level or reported in the media also sometimes constitute indirect triggers to surveillance. Notably, no country has established a formal mechanism for joint public health-animal health surveillance, although in some places community level programmes have been started using community health workers (i.e. public health) to report on poultry health status. Joint outbreak investigations, a form of surveillance, have sometimes been conducted. Some disincentives that make stakeholders reluctant to help the surveillance effort involved 17 -: Lessons from HPAI administrative authorities. For example, the negative impact of disease control measures such as stamping out, coupled with insufficient compensation, created a disinclination to report outbreaks even among those who might have complied with disease control authorities in the beginning. This led to less reporting from those with an economic interest in the poultry production system under pressure. More mundane factors that dampened reporting at the national level and to the international community were fatigue with HPAI by government animal health services, and habituation at the community level. Reluctance to report also arose from district authorities who feared that their superiors might see a disease outbreak as a black mark against them or were reluctant to implement unpopular and difficult control measures. Equally it could stem from concern about the impact of a disease outbreak on province’s trading rights for poultry and poultry products. Reluctance to report or under-reporting also occurred at the national level for political reasons. Early in the regional effort, the emphasis was on active surveillance but it became clear that this was often expensive and not cost effective. As the incidence of disease decreased, it became more viable to gather information using passive or targeted approaches. Since most surveillance information must emerge from the engagement of stakeholders in the routine activity, their lack of involvement is a significant constraint. To overcome this, attention has been paid to strategic communication, better incentives and the economics of value chains, and an effort made to incorporate these elements into surveillance structures. An effective surveillance system would also yield information about risk factors that influence disease occurrence and the effectiveness of disease control measures. The application of epidemiological analyses can also challenge some prevailing practices. Resistance to changing paradigms or policies because of political interests should not be underestimated. T F A R D Another form of surveillance that has grown with support from the international community is the isolation and characterization of H5N1 viruses from disease outbreaks to monitor genetic changes and enable adjustments to vaccines that are compatible with circulating viruses. Post-vaccination monitoring of antibody responses to vaccines as a measure of vaccination effectiveness, and the targeted searching for viruses that might be present in vaccinated populations have also been important activities. It is not realistic to expect a surveillance structure to detect every single instance of H5N1 infection. However it is expected that when a disease outbreak occurs it will be reported to the authorities and disease control measures implemented. Where the disease is endemic the combination of surveillance and control measures are expected to keep incidence to an acceptably low level, which in the case of H5N1 is related to the concurrent incidence of human cases and the production impact on the poultry sector. Where the disease is sporadic, the surveillance system is expected to detect an incident or incursion quickly enough to pre-empt a large focus of secondary cases and help eliminate the disease locally. The role of FAO in surveillance programmes has varied considerably across the region covered by ECTAD-RAP, with deeper involvement in the national surveillance structure in some countries. Except in a few countries, FAO officers do not get directly involved in outbreak investigations and surveillance. Situation in 2005 Three FAO documents provided the conceptual basis and principles for the early detection, rapid response, prevention and control of HPAI. In 2004, FAO and OIE signed an agreement 18 3 Watching out for H5N1 setting up the FAO/OIE Global Framework for the Progressive Control of Transboundary Animal Diseases (FAO/OIE 2004). Two other documents were FAO’s Guiding Principles for Highly Pathogenic Avian Influenza Surveillance and Diagnostic Networks in Asia (FAO 2004) and the Strategic Framework For HPAI Prevention And Control In Southeast Asia (FAO 2006). Efforts to initiate more structured surveillance were under way in the region but the existing infrastructure and capacity limited early detection and response. In the early days, before national contingency plans were developed, surveillance was set up through short term missions mainly by consultants with backstopping by regional staff. Initial fears related to the pandemic potential of HPAI H5N1 promoted early reporting from communities, within the constraints for recognizing differential conditions such as Newcastle disease (ND) and duck virus enteritis (DVE). Cases were mostly reported passively through voluntary submissions. Field and laboratory components required for surveillance were nascent and disconnected. Few countries had epidemiology units within their animal health services and national epidemiology capacity was low or non-existent. In addition, laboratory capability and the capacity to support control activities in the field was severely lacking. Initial efforts to establish laboratory capability and capacity were gradually augmented by field training programs to teach disease recognition, reporting and sample collection methods to staff. Post-outbreak surveillance predominated and serological surveys were conducted in many countries to determine the prevalence of infection in both chickens and ducks. T F A R In its role as FAO’s main implementing platform in the region under GF-TADs, ECTAD-RAP was perfectly placed to identify and take advantage of an extraordinary network of partners and expertise at the global, regional and national levels. ECTAD-RAP helped link individual countries to global tools and platforms for surveillance, diagnosis and data sharing, including GLEWS for major animal diseases including zoonoses; EMPRES for transboundary plants, pests and animal diseases; the Crisis Management Centre – Animal Health (CMCAH); and the OIE/FAO Network of Expertise on Animal Influenza (OFFLU). Despite these, none of the affected countries reported H5N1 HPAI outbreaks or any other disease related events. The only data on disease events came from official reports provided to OIE. D Mass vaccination started in Indonesia early in 2004 and in Viet Nam in late 2005 in response to pressure from the human health sector or industry, but planning for field virus surveillance and post-vaccination monitoring lagged behind. Vaccination had started in China before 2004, when it was officially sanctioned, and post vaccination monitoring and virus surveillance was routine. Situation in 2011 Global Perspective Today, there is significant integration of the surveillance outputs from country programmes into global reporting systems. The reporting outputs from GLEWS and EMPRES have been greatly enhanced by the improved quality of information coming in from the country surveillance programmes. At FAO HQ there is improved disease intelligence analysis capability with the establishment of a core GLEWS team responsible for disease tracking, data integration, analyses and monitoring for early warning purposes. The countries reporting HPAI H5N1 outbreak data and the quality of disease information directly feeding into GLEWS and EMPRES had increased by 2011 to include all the affected countries in south and southeast Asia, including endemic countries such as Viet Nam, Egypt, Indonesia and Bangladesh. 19 -: Lessons from HPAI In keeping with recent public health practice, rumour-tracking and event based surveillance has been established by GLEWS at FAO HQ in Rome, at ECTAD-RAP, Bangkok, and at the Regional Support Unit in Kathmandu, to share early signals of potential outbreaks through formal and informal information generated by communities and reported by media. The EMPRES-i and EMPRES-i Asia platforms have been made operational to upload and disseminate information to participating authorities. Current inputs to the system come from more than 70 authorized users including national veterinary services, FAO field officers and reference laboratories. Apart from inserting disease events, authorized users can utilize spatial analysis tools, discussion forums and access more documents in the repository. Since the system went online in April 2010, over 1,500 disease outbreak events have been reported through this system, of which 300 were additional to those reported through OIE’s World Animal Health Information System (WAHIS) in Asia. The general public can access disease event information, disease mapping tools, the document library and directory of animal health personnel. A link has been made between genetic and epidemiology data in EMPRES-i and spatial analyses of disease occurrences undertaken within EMPRES-i Asia. Countries were assisted to strengthen their disease information management through the provision of TADinfo®, FAO’s open-source database/mapping software for national disease information. T F A R Regional perspective In the six years since its establishment in late 2005, ECTAD-RAP has coordinated country activities in field and laboratory preparedness and response, including technical backstopping and building regional networks. ECTAD-RAP has always viewed building the capacity of the regional laboratory system as key to building national and regional surveillance capability. Its epidemiologists have conducted training at the national level, sometimes in conjunction with other players such as OIE, AAHL, CDC and the United States Department of Agriculture (USDA) and supported regional workshops to standardize and harmonize surveillance methods. The establishment of the regional Field Epidemiology Training Programme for Veterinarians (FETPV) in collaboration with Thailand’s Department of Livestock Development (DLD) has been a major step, along with development and support to epidemiology training programmes in China, Myanmar and Viet Nam. Regional workshops have emphasised the standardisation of outbreak investigations including the importance of defining the geographic location of disease outbreaks, epidemiological units, case definitions, the number of events and their time course, and tracing back and forward, reporting, collection and dispatch of biological samples. D The development of cross-border collaboration, including sharing surveillance information, has sometimes involved coordinated activities with public health partners. Coupling crossborder risk assessments with socioeconomic market chain studies has improved current understanding of trade, its drivers and related disease risks. Interdisciplinary collaboration characterizes interventions, and surveillance in the region is increasingly conducted using a One Health approach to address human, animal and wildlife health. Country level perspectives Surveillance efforts in countries were dictated to some extent by the level of H5N1’s endemicity and the capacity of the animal health services. Cambodia and Laos do not have veterinary schools and so suffer a general shortage of qualified personnel and little or no prospect for continuing education. In others, the curricula have not evolved to provide ap- 20 3 Watching out for H5N1 How FETPV is helping China The regional disparities that exist in China along with increasing population mobility present challenges for any disease control program. The limitations in veterinary epidemiology capacity created by the absence of field epidemiology for animal health practitioners might have caused early disease detection failures, making it more difficult to deal with existing and emerging infectious diseases. China has more than 50 percent of the global biomass of some farmed livestock species. Clearly the gaps in standardizing the knowledge and methodology of veterinary epidemiology needed to be addressed urgently. China’s Field Epidemiology Training Program for Veterinarians (FETPV) was developed in response to the domestic needs for qualified practitioners in veterinary epidemiology. The program introduced successful approaches and practices from the regional FETPV programme and China Centre for Disease Control’s Field Epidemiology Training Programme (FETP) and was tailored to meet China’s training needs. The training program, still in its early stages, already provides government agencies with veterinary field epidemiologists who can meet critical needs including mounting an effective and timely response to disease outbreaks, and surveillance for existing and emerging infectious diseases. China’s FETPV and Training through Services activities have already helped strengthen the capacity of the Veterinary Bureau and the China Animal Health & Epidemiology Centre (CAHEC) to respond to disease outbreaks and set up scientifically sound surveillance programmes. Close collaboration has developed between CDC and the China FETP programme in the public health sector with sharing of trainer resources, materials and case studies between the two programmes. Trainees from the China FETPV and CFETP have been encouraged to work together at the local level. T F A R Fifteen key staff from five national veterinary institutions and five provincial Centres of Animal Disease Control (ACDC) trained as the China’s first FETPV cohort. The key provinces are those with large gross domestic product from the livestock sector (total animal production value of $53.73 billion). The Training through Services approach has resulted in 13 surveillance/survey studies and trainees have reviewed surveillance structures in their provinces. A national epidemiology network is being progressively shaped with five national institutions, 14 provincial ACDCs, the public health sector (China CDC, CFETP), the wildlife sector and universities. Two rabies control awareness campaigns have been organized in Guangxi and Chongqing in collaboration with CFETP, the first such collaboration between the public and the animal health sector at the local level. FETPV is being slowly institutionalized and integrated into the China government national program and there is growing in-kind support from Chinese government. The Ministry of Agriculture gave $127,000 to FETPV in 2011. D The following example illustrates how responsive the animal health system has been to the FETPV programme. Huang Cheng, a trainee from Chongqing (ACDC), conducted rabies surveillance in a county of Chongqing municipality. He helped the local ACDC improve its rabies surveillance plan and guided the implementing work. After the One Health Workshop in the second module, he also helped foster closer collaboration between the local CDC (public health) on rabies control and the Chongqing ACDC. Thanks to his efforts, the local ACDC and the CDC planned to conduct a joint rabies control awareness campaign, the first time that the two sectors collaborated thus in the county. propriate epidemiology training. Building capacity within such a diverse range of settings has required surveillance structures that can be tailored to “fit-for-purpose”. In Indonesia, where the disease was well entrenched, the Participatory Disease Surveillance and Response (PDSR) system was introduced (Alders et al 2009; Azhar et al 2010; and Brum et al 2008). In countries with small numbers of trained veterinarians and no veterinary education, the emphasis was on strengthening existing grassroots animal health extension services that were supported by community-based animal health workers (CAHWs), village veterinary workers (VVWs) or village animal health workers (VAHWs) to increase surveillance networks. In Viet Nam considerable resources were expended to monitor the mass vaccination programme. While post-vaccination monitoring is more closely aligned to disease control there 21 -: Lessons from HPAI was also an element of that programme that focused on virus monitoring of target markets in an area after vaccination. Countries like Bangladesh have exploited mobile telephone technology and Short Message Service (SMS) gateways for sharing disease information in a surveillance network. Cambodia, Indonesia and Laos have introduced hotlines to give the public ready access to the animal health reporting channel. Countries of the region have grown in their capacity, ownership and leadership in surveillance as a result of developing locally relevant models and approaches based on needs. Decision makers in the region are beginning to appreciate the usefulness of a strong surveillance structure not only for avian influenza but also for other animal diseases. Which model of surveillance is best suited to a particular setting and situation? A number of intersecting factors help determine this, such as the prevalence of disease, the structure of government services, the availability of trained personnel, the cost effectiveness of any particular approach in the local poultry production environment, and public health considerations. Grassroots surveillance models T F A R Grassroots surveillance models require the cost effective training of a large number of individuals in a relatively short period. Rather than producing a poultry diseases specialist, training aims to increase the disease recognition and reporting capacity of persons who have been active in or previously trained as extension workers or para-vets such as VAHWs, VVWs or CAHWs. However, these very individuals, who are key in the formal animal health structure, are not part of the official veterinary service. This creates significant reliance on the quality of the upstream officials and the quality of their engagement with village level workers. D Another grassroots issue is the quality of the cascade training system used and the ability of the trainers. Training that tends to emphasise disease recognition results in village level practitioners making diagnostic decisions about disease incidents, leading to information flows being filtered at the very first step in the process. Further filtering can occur at the next level (usually district) if the outbreak is judged to be a common endemic problem rather than a disease incident requiring investigation. For example, it was recognised that while ND was endemic and therefore caused losses, outbreaks were rarely investigated with HPAI as a possible diagnosis. The broader capture of HPAI compatible incidents poses a financial burden, some of which has been borne by the volunteers themselves, so that with time their enthusiasm for the process begins to wane. In balance, however, these grassroots systems may be the only viable option in several countries with relatively sparse human and poultry populations and undermanned and under-resourced animal health services. The challenge is to maintain the networks although in some places a number of village level volunteers are able to derive some income from providing simple services to livestock producers, and there are initiatives to formally register these para-veterinarians within national regulations. Passive surveillance and conventional veterinary services Most countries in the region where FAO has managed donor-funded HPAI control programmes have a conventional veterinary service structure with a strong vertical line of 22 3 Watching out for H5N1 command down to operational interactions with producers. Two such countries, Thailand and Malaysia, have been successful in eliminating incursions of the disease. However, in countries where animal health services are decentralized, management and reporting lines are constrained and not easy to overcome. Strong advocacy campaigns are needed to make local authorities aware of the need to use the linkages inherent in an animal health structure and to support greater interaction between central departments and local animal health services. Most veterinary services structures in the region rely on community level contacts to get early information about disease incidents, and in the more conventional structure these individuals are paid a small stipend and are part of regular training and monitoring procedures. A producer will generally report to authorities if he or she believes some benefit will result from it, either by way of inclusion into a compensation process, or some useful input and advice from the animal health service. Concerned community members may also report outbreaks, either because they recognise the threat to their enterprise or because of their concerns about the public health risk. It is not possible to fully estimate the efficiency of the various passive surveillance approaches for HPAI. T F Active surveillance models Some early attempts at active surveillance were not cost effective as considerable inputs were required for relatively meagre outputs in comparison to an adequately supported and well managed passive surveillance structure. The PDSR model in Indonesia found that it was less cost effective to conduct widespread disease searching than to support the same network to react to voluntary reports of disease from owners. The success of this passive surveillance system in Indonesia was most likely the result of the strong links that the participatory model forges between poultry holders and the local animal health service, as well as the limited culling that is carried out when participatory surveillance confirms a focus of disease. Viet Nam and Laos had similar experiences with active surveillance that targeted provinces with historically higher risk for outbreaks and the presence of risk factors such as market hubs and significant duck populations. A R D Active surveillance using the SMS gateway in Bangladesh detected about 80 percent of outbreaks in 2011, and brought down the time from detection to response from an earlier average of 4.5 days to 1.8 days, though a supporting factor may have been the increase in the compensation paid. Nepal has carried out active surveillance in designated high risk areas with greater efficacy than other active programmes elsewhere, probably because of the network of about 1,250 contact persons who were visited weekly for information. An example that did not involve FAO inputs was the so-called X-ray surveillance in Thailand that was used to detect disease in chickens and then followed by local culling. This active programme contributed to the eradication of HPAI especially from pockets in non-commercial poultry. Viet Nam recently started a pilot study using active surveillance to monitor the presence of virus in live bird markets (LBMs) and especially in ducks, to determine whether this methodology could be used to set a baseline for virus load. An increase in the virus load could point to a virus build up in the general poultry population, and serve as a proxy for risk of human cases. Early findings suggest that this is a useful adjunct to other surveillance systems, particularly now that the government supported vaccination programme has been significantly reduced. Since 2009 LBM surveillance for tracking H5N1 has been carried out in the greater Jakarta 23 -: Lessons from HPAI metropolitan area of Indonesia through environmental swabs collected using a consistent protocol, and has demonstrated seasonal fluctuations in levels of virus and also suggested decline in the amount of virus present. This longitudinal study has established a useful system for determining baseline levels of virus appearing at a point in a value chain and shown that it may be used as a proxy for overall viral circulation in the sector involved in the chain, and as a measure of effectiveness of a control measure applied to the value chain. LBM surveillance was also used in Bangladesh recently and was responsible for demonstrating high levels of environmental contamination with H5N1 virus in all the LBMs in and around Dhaka. In January 2011, FAO, the National Veterinary Research Institute (NaVRI) and the Institut Pasteur of Cambodia (IPC) conducted a joint environmental surveillance for H5N1 in four main LBMs (FAO/IPC 2011). Of the total of 502 specimens (145 water, 120 feather, 117 faeces and 120 mud/soil), 90 (18 percent) tested positive for H5N1 virus, and of them, 10 specimens (2 percent) tested positive after inoculation into embryonated chicken eggs. The virus was successfully isolated from 8 water specimens (5.5 percent) and 2 soil/mud specimens (2 percent). The overall positivity rate of H5N1 virus RNA detection by RT-PCR is approximately 20 percent in all types of specimens except for the faeces samples where the RNA was less often detected (6 percent). T F A R FAO’s engagement with surveillance in China has been building slowly in part due to the size of the country and the autonomy of the animal health services at the provincial level. LBM sampling has been modified as a result of inputs from FAO. The outcomes of surveillance and social network analysis are described in the socioeconomics chapter. D Participatory surveillance Participatory interactions with the community (Brum et al, 2008) are understood to be integral to all good epidemiological work, and there has been emphasis on training veterinary services in using participatory methodologies to engage with stakeholders in the HPAI control programmes, especially in Indonesia, where considerable investments were made to embed participatory community engagement principles in the routine activities of the animal health services. Initially relationships with Sector 4 poultry holders in village communities were built within active surveillance activities, but it soon became clear that where active participatory methodologies were being used, 95 percent of disease outbreaks detected were coming from voluntary reporting to the district animal health service. An important feature of the PDSR approach is the use of an HPAI case definition and a rapid diagnostic test (Robyn et al, 2012; Loth et all 2008) to detect HPAI based on which local control measures can be decided. Analysis of the results of PDSR surveillance has identified a number of determinants of H5N1 HPAI outbreaks in Indonesia (Farnsworth et al, 2011). The success of the PDSR approach depends on having a critical mass of staff with veterinary or paraveterinary qualifications at the field level. PDSR is now being embedded in the local veterinary services, thus building capacity and long term viability for this methodology, not only for HPAI but also for other priority animal diseases (Siregar et al, 2008). Targeted surveillance studies Targeted field surveys have been carried out in Bangladesh, Cambodia, Indonesia, Lao PDR, Myanmar and Nepal to increase knowledge about the prevalence of infections in ducks and to determine if there are links to outbreaks of disease in chickens. These surveys have pro- 24 3 Watching out for H5N1 A web-based gateway The system of using an SMS gateway to gather and disseminate information was introduced to the HPAI surveillance programme in Bangladesh in 2008 with financial support from ADB and USAID. The reporting system was introduced in a step-wise fashion in order to solve problems as they arose and to embed it in the epidemiology unit in the Department of Livestock Services (DLS). The system is now fully functional with 1006 CAHWs being supervised by 103 Additional Veterinary Surgeons (AVS) in 306 of Bangladesh’s 494 upazilas or sub-districts. The operational costs are modest thanks to relatively cheap labour and cheap mobile telephone services ($100 per month per CAHW, about $600 per month per AVS and about 2 cents per SMS). There is a one-time installation cost for the computer and the software although there is a monthly cost for the web-based server system. The apparatus required is relatively simple and easy for operators to use both in the field and the central unit. Field training of the CAHWs emphasizes a standard case definition for a suspect outbreak of HPAI. When the alert message is received the AVS investigates and collects samples to confirm. If H5N1 HPAI seems highly likely, then control measures start before the outbreak is confirmed in the nearest laboratory. Thanks to the SMS Gateway the time between detection and response has been reduced on average from 4.5 days to 1.48 days in 2011 and 1 day in 2012. The system has reduced the labour required for data entry at the Upazila and Central levels and has the potential to eliminate paper reporting completely. At the Central level, the disease management group has a daily picture of the disease situation in each upazila covered every day. Another advantage is that the compliance of the workers in the system can be easily monitored; so far the average monthly compliance has varied between 85 and 90 percent. T F A R A version of the SMS gateway system has been introduced in Cambodia and Indonesia to support the existing national surveillance networks. vided policy influencing information about the potential role of ducks in introduction and maintenance of H5N1. The information also provides a link between the problems facing production systems in each country. Recently ducks have been targeted in surveys carried out in a number of selected markets in Viet Nam and this approach might be used to monitor virus levels in poultry in the future. In addition markets surveys of wild captured birds have been carried out in Cambodia and Viet Nam but generally have not detected H5N1 in such birds. Risk based surveillance D Risk-based active surveillance has had variable success. Viet Nam’s efforts to base village level surveillance on various risk factors did not yield the returns expected. Lao PDR had a similar experience where populations believed to be at risk were sampled regularly. A more intense system put in place to detect sporadic events in Nepal seems to have been more effective, though the reasons for this are not clear. Cross-border studies have helped animal health services in Myanmar identify where increased efforts are required to detect early incursions of H5N1 along trading chains. Agro-ecological studies in China, Thailand, Bangladesh and Indonesia (Loth et al, 2011) have added to a better understanding of risk-based surveillance through risk mapping at the interface of farming and natural environments. China, which is now considering a transition from mass vaccination to targeted vaccination as now implemented in Viet Nam, requires a risk-based surveillance strategy to inform modifications to the mass vaccination regime. 25 -: Lessons from HPAI Field diagnosis of disease The use of field diagnostic kits by surveillance teams has been a somewhat vexing question for animal health services. While the practice, in combination with a HPAI case definition, has proven successful in Indonesia’s PDSR programme, in other jurisdictions central administrations have preferred to leave diagnostic decisions to the central laboratory, a reasonable position where disease occurs sporadically and accurate diagnosis is important. Integration of value chains, strategic communication and surveillance It is clear that value chains have much to do with the circulation of viruses within countries and into farms in the region (Martin et al; 2011). Investments in this area have started to reap good returns in terms of understanding disease epidemiology and how to invest resources for best effect. Some of the attendant risks of virus incursion and spread are dealt with through the application of measures such as biosecurity and disinfection but more needs to be done to monitor the actual presence and movement of viruses along value chains. T F Epidemiology capability and capacity FETPV and the Applied Veterinary Epidemiology Training (AVET) are making significant contributions towards developing epidemiology capacity, with an emphasis on operationalizing surveillance through training for local staff and the frontline workers. For example, the success of the FETPV programme established in China is showing in the improved quality of field reports coming from well-executed disease outbreak investigations that increase understanding of disease dynamics and help identify risk factors for outbreaks. Joint, interdisciplinary training with public health and wildlife professionals is improving the breadth and depth of surveillance capacity in the region. A R D In 2011, every country in the region has staffed an epidemiology unit. In Myanmar, the epidemiology unit’s staff has grown from 3 to 11 since 2006. Surveillance has evolved from a reactive general sero-surveillance approach in chickens and ducks to a risk-based approach that includes targeting high risk sub-populations such as domestic ducks. In some places more advanced technologies for epidemiological analysis such as Geographic Information Systems (GIS) have been introduced, and the use of a Geographic Positioning System (GPS) has become standard in surveys and investigations. Outputs 1. S everal thousand grassroots animal health workers trained in H5N1 detection, reporting and communication to raise public awareness. 2. I n Indonesia, a large network of persons active and reporting on the outcomes of participatory methodology for obtaining information about HPAI in smallholder poultry systems. Over 2,500 local government livestock and animal health services staff trained in the PDSR approach. 3. S ignificant body of data submitted for analysis. In several countries, data on virus loads submitted from market surveillance. 4. I n Viet Nam, 1,678 trained in epidemiology and surveillance, and 2,535 CAHWs in five pilot provinces trained. 26 3 Watching out for H5N1 5. F ETPV course curricula prepared and delivered, along with epidemiology training material for courses in veterinary school, in 10 countries of south and southeast Asia including Cambodia, China, Indonesia, Laos, Malaysia, Mongolia, Myanmar, the Philippines, Thailand and Vietnam. Ten students have now completed the course, and 8 more are currently doing it. 6. T wo weekly disease-scanning reports generated from RSU epidemiology staff in Bangkok and Kathmandu and disseminated to country teams and partners. 7. L ocal staff from countries in the region trained to conduct surveillance for H1N1 in pigs and to undertake cross-sectional and longitudinal surveys of duck populations. 8. R egional molecular epidemiology patterns reported regularly to country teams and partners. T F 9. M eetings held with tripartite (FAO/OIE/WHO) and national partners to promote joint and coordinated surveillance pilot studies for rabies, Ebola Reston, H1N1 and H5N1 HPAI. 10. Two EMPRES-I Asia training workshops conducted for the region. A R 11. Training, hardware and software provided to improve animal health data management. 12. Training in the use of TAD Info, a web-based national disease information system, provided to national veterinary institutes in several countries in south and southeast Asia. Outcomes D 1. T he response to disease trends, new events and disease emergence is better coordinated and more timely across the region. Molecular analysis informs countries and regional strategies for future prevention and control of HPAI and other EIDs. 2. N ational animal health staff, with new and transferable skills in surveillance, are responding to the increasing challenge of other emerging and re-emerging diseases such as porcine respiratory and reproductive syndrome (PRRS), foot and mouth disease (FMD), anthrax and Brucellosis. 3. F ETPV has been accepted in the region as a good model for building epidemiology capacity at the field level for veterinarians. The programme has been modified for local application as in the case of AVET in Viet Nam. FETPV and AVET graduates are contributing to better quality epidemiological investigations in the field. 4. M ore countries of the region now share data with each other, supported by EMPRES-I Asia training. Information flows regularly into the central database, fed in part by the large network coverage obtained with PDSR in Indonesia. 5. I n Indonesia, LBM market surveillance has contributed to better understanding of HPAI risk along the market chain and has highlighted the need for cleaning and disinfection interventions to reduce the risk of HPAI transmission both back to the 27 -: Lessons from HPAI farm and to consumers. 6. I nformation for reporting and analyzing trends and risk factors for disease is retrieved more quickly, thanks to improved data management. Spatial and network analysis of surveillance data has delivered valuable insights into linkages between outbreaks, the likely role of value chains in distributing viruses and other risk factors for disease outbreaks. Successful Practices 1. I ntegrating the training of field and laboratory personnel in the design and analysis of surveillance data was integrated. This led to improved coordination at country and regional levels, including FETPV and the laboratory and epidemiology networks. T F 2. A dopting the In-Service Training approach in FETPV, coupled with surveillance/ survey studies. This has demonstrated the value of the programme to local authorities and fostered collaboration between the public health and animal health sectors. 3. A dopting participatory approaches that acknowledge the concerns and understanding of communities regarding HPAI. These have resulted in closer links between animal health services and community members, making passive surveillance more effective. A R 4. I nvesting in the participatory programme in Indonesia. This has resulted in a surveillance network in that country that provides a robust watch on the HPAI situation in small-holder poultry populations across most of the country. D 5. T argeted surveillance of particular populations or species like ducks. This has provided policy-makers with key information about HPAI. 6. E nvironmental surveillance and market surveillance. These have helped monitor the presence of viruses in poultry value chains and may provide a useful baseline for monitoring the overall effectiveness of control measures. 7. R isk-based surveillance of value chains and specially cross-border chains. This has helped animal health services focus scarce resources on high risk areas. 8. D eveloping linkages with national animal health services and grassroots animal health worker systems. This has helped build large surveillance networks over relatively short periods. 9. A nalysis of Chinese surveillance data by FAO ECTAD China and epidemiology capacity development through the support of regional FETPV. These have promoted greater data sharing and transparency between China and FAO. Lessons learned 1. T argeted surveillance can be useful to detect the virus in healthy birds, but systems of tracing to source are not yet reliable. More effort is required to understand how to monitor the levels of virus in the population to measure either the impact of control measures or to get early warning of an upsurge in virus activity. 28 3 Watching out for H5N1 2. P assive surveillance can be unreliable especially when commercial operators conceal outbreaks because the compensation offered does not fully cover their economic losses. Proxy indicators of disease outbreaks such as market prices also need to be monitored to detect hidden problems. 3. A wareness campaigns do not necessarily result in behaviour change or improve passive surveillance reporting by poultry producers. 4. A nimal health epidemiology needs to be linked to functions with strategies that are more politically sensitive and relevant than the status of endemic animal diseases. Epidemiological units established in the past have been allowed to deteriorate because of lack of routine funding from government budgets. 5. A ctive surveillance can stimulate greater passive surveillance when relationships are established with communities. Participatory approaches such as PDSR in Indonesia have demonstrated this. T F 6. F ield veterinarians need training in basic epidemiology and the proper collection, storage and submission of samples. 7. M ore epidemiology expertise needs to be created at the provincial or state levels. Many countries do not have enough epidemiologists in central departments to cater to the country’s requirements. A R 8. V iruses from field outbreaks must be regularly isolated and characterized. This has been well recognized in Indonesia, where the early problem with poor vaccine efficacy was recently rectified by incorporating the appropriate virus strain compatible with the viruses circulating in the field. D 9. M onitoring and characterising field virus isolates for changes in behaviour may assist in signalling vaccine failure, and possible spread and new outbreaks of disease. The H5N1 sub-clade 2.3.2.1, a genetic variant of the clade 2.3.2.1, was able to break through the vaccine used in Viet Nam. The increased susceptibility of wild birds to the sub-clade 2.3.2.1 has resulted in the spread of the virus in Bangladesh, India, Japan, the Republic of Korea and Nepal. Sustainability Providing personal and professional rewards to those who have built up skills and some experience under the HPAI programme is an important component for sustainability. People trained to provide professional inputs may start feeling disillusioned when they realize that the overall service management is poor or that resources to act on findings are not available. Since some surveillance activities are expensive and require extra effort from staff at all levels, maintaining the momentum calls for external inputs. The animal health services of some countries have bridged a 50-year performance gap in four to six years, and since it will be some time before such a leap is matched by funds from national budgets, there is a definite danger of regression or stagnation. 29 -: Lessons from HPAI Future The effort to build epidemiological expertise in the region must continue, with emphasis on practical aspects such as the design of surveillance activities, data management, simple analysis, the maintenance of regional and international networks, and conducting high quality outbreak investigations with intersectoral collaboration where possible. Each country has questions about disease epidemiology that can be answered by studies, and these should be supported with resources. Building research capability can help sustain existing epidemiological capacity, and training should be institutionalised especially in countries with large domestic production of livestock for national food supplies. Some production systems are extremely wasteful and effective epidemiological services can make a difference to this. The experiences of coordination between animal health and human health authorities in dealing with HPAI has laid the foundation for expansion into other zoonotic diseases and for collaboration on possible EIDs. Growing understanding and acceptance of the One Health approach in the region’s animal health services has also improved the prospects for developing it further. T F The FAO-OIE-WHO four-way linking project, which connects at least four information streams — epidemiological and virological, each from animal health and human health — is critical when assessing the public health risk of influenza at the human-animal interface. The project supports countries in better understanding national risks from H5N1 influenza viruses by building a framework for strengthening systems to collect and link national data and facilitating national-level risk assessments and risk communication. The project is being piloted in H5N1-endemic countries such as Viet Nam, Bangladesh and Indonesia. A complementary linkage which also needs to be strengthened is between field and laboratory data across both the animal health and public health sectors. A R D Institutionalising the role of epidemiology in animal health services without creating inflexibility among epidemiology units at the field level is an area requiring further advocacy. One way to do this might be by making epidemiology training a necessary qualification for being appointed as the head of Provincial Veterinary Services, along with a demonstrated capability to apply the training to field work. A veterinary epidemiology network is required at national and regional levels to keep such individuals informed of developments and to enable the sharing of experience and problems. There is an emerging view that the number of viruses that are sequenced, as well as their geographic representation, needs to be greatly increased, and that the time between virus isolation and sequence information being made available needs to be greatly reduced. The unsatisfactory state of surveillance could be rapidly turned around by, for example, creating a network of sentinel sites, focusing on the countries and regions most at risk, that would collect isolates and sequence them in real time. Such a network, it is argued, would probably even cost less than the fragmented and uncoordinated surveillance efforts in place today. Recent experience with H1N1 influenza has highlighted the need for increased monitoring of influenza viruses circulating in the large concentrations of pigs in several countries. This seems especially important in Asia where H5N1 circulates in poultry populations, and large duck populations mingle with wild birds, presenting pathways for new viruses to enter pigs 30 3 Watching out for H5N1 via poultry. Longitudinal virological surveillance not only in poultry but other livestock is now considered a must for assessing the evolution of the virus and the risk for pandemic influenza. FAO is starting to do this through the Emerging Pandemic Threats Plus programme. T F D A R 31 A R T F D Scientists preparing samples for serological assay in Maros Disease Investigation Center, Sulawesi, Indonesia LABORATORY CAPACITY 4 The power to detect and diagnose T F DIAGNOSING infection quickly and accurately is a key element of any disease control programme. In the case of H5N1 HPAI there is also the imperative for a safe and secure working environment. At the beginning of the major international effort to control HPAI, laboratory capacity for accurately diagnosing the infection across the region was quite varied. Safety standards were rudimentary and there was no programme for checking the proficiency of laboratory testing. In some countries, laboratory capacity existed in a separate or autonomous research division or institute rather than being vested within the animal health services. A R International donors have traditionally been supportive of animal health laboratories. The common model is of the laboratory that provides comprehensive services but this soon leads to run-down facilities and staff disillusioned by the lack of mentoring, inadequate budgets and poorly maintained equipment. The effort to upgrade laboratory capacity to fight H5N1 HPAI was the first such regional initiative supported by both local political and international donor support to address the constant demand for diagnostic services. The focus was on providing equipment, training and reagents. Another outcome, namely increasing engagement with international reference laboratories, has led to mentoring in both laboratory techniques and laboratory safety, the provision of reference technical services and the establishment of laboratory proficiency testing programmes. D This alignment of interests created an opportunity for laboratory services, and despite some residual problems, animal health laboratories now ably support the field programme with capable and reliable diagnostic services. Increasing numbers of laboratory staff have received post-graduate training and are expected to be the laboratory system leaders of the future. The key issue ahead is maintaining the skill base and to apply generic technologies to new diseases. The One Health approach calls for increasing attention to strengthening laboratories without increasing their dependency on external resources. It is becoming important that laboratories develop business plans that enable them to generate income to maintain their reagent supplies and equipment. A telling statistic of the regional laboratory capacity building effort is that not a single scientist has fallen ill from H5N1 infection. Had it happened, it would have resulted in heavy imposts on laboratory operations and exerted serious constraints on the field programme by restricting diagnostic throughput. 33 -: Lessons from HPAI The significant technological leap of the last six years has been the establishment of the complex diagnostic procedures that are now routinely carried out in national laboratories. Impressive though this advance is, it is still somewhat precarious as staff do not always have the in-depth technical understanding needed to solve problems or troubleshoot the systems they are working with. Situation in 2005 A few countries in the region had the capacity to diagnose HPAI at a national facility but some of these did not directly report to the animal health services. With the exception of Thailand, national laboratory systems did not have a strong link to the poultry sector, and the majority of laboratories had low capacity for HPAI diagnosis. As diagnostic systems evolved with support from many different sources, each laboratory began using its own testing protocol. No mechanism existed for standardizing and verifying testing procedures. Little attention was paid to laboratory quality assurance (QA) and biosafety as a result of limited knowledge and lack of laboratory equipment. Proficiency testing was never carried out regionally or nationally, so evaluating test outcomes and laboratory performance was never easy. Lacking biosafety, biosecurity training programmes and Standard Operating Procedures (SOPs), laboratory environments were less than ideal for handling zoonotic pathogens. There was usually no prophylaxis programme for staff, and waste disposal systems left much to be desired. Communication between laboratories in the region was poor and disease diagnosis information and reagents were seldom shared between key laboratories. While a few laboratories enjoyed collaboration with some reference laboratories, most were not internationally connected. Situation in 2011 T F D A R By 2011, laboratory capacity in every south and southeast Asian country involved in the programme had been strengthened using a progressive approach involving equipment and reagent supply, basic biosafety and technology training, the writing of SOPs for local use, standardisation of test procedures, the introduction of QA systems, and review and assessment of performance. Inappropriate procedures for molecular diagnostic testing set up earlier by international experts with research backgrounds and little diagnostic experience had led to lax laboratory habits. As a result, while initial virus detection and confirmation was possible, the procedures were not robust enough to be adopted by technically less adept national staff, and problems arose with contamination in these systems. Much work was required to establish proper work flows and to undo some of the inappropriate and poor habits that had developed. Diagnostic capability All countries in the region have at least one central laboratory that can detect and identify H5N1 HPAI and conduct appropriate serological tests. In most instances the test of choice for virus detection is the polymerase chain reaction (PCR), and while some laboratories use the real-time technology routinely, others prefer to run the conventional PCR in order to save on reagents. However in the long term real time PCR is the recommended and preferred technology for a wide range of virus detection tests. A set of guidelines for HPAI diagnosis have been agreed to by animal health laboratory services from the eight FAO member countries in ASEAN that are members of the regional laboratory network. The guidelines are living documents that should be regularly reviewed 34 4 The power to detect and diagnose and updated to ensure maximum diagnostic sensitivity and specificity based on current circulating viruses. Many laboratories are able to do virus isolation using embyronated chicken eggs to confirm PCR positive results. One of the issues for virus isolation has been the difficulty in testing and certifying biosafety cabinets. Early in the programme cabinets were already in use for which no recent appraisal of safe performance existed. Serological procedures have also been established for detecting prior exposure to wild type virus, especially in ducks, and also most importantly for monitoring vaccination responses. The serological testing of ducks, though more complex, can now be done with consistent performance. From the point of view of the animal health field services and the poultry owner, a result of HPAI negative is not helpful if some other serious disease problem remains undetected. To this end there is now expanded differential diagnosis for other avian disease agents such as the ND and DVE viruses. Expanding the range is now seen as important as it improves the service and so strengthens the links to the producer. Laboratory quality management and proficiency testing T F A R Significant progress has been made in improving the quality and reliability of laboratory diagnostic test results, and many laboratories are now able to apply elements of a laboratory quality management (QM) system to HPAI diagnostics. National laboratories in Thailand and Viet Nam have been accredited to the International Standards Organisation (ISO) laboratory standard ISO 17025 for HPAI diagnostic assays and others have established practices needed for accreditation such as the documentation of internal quality controls required for tests. National laboratories in the Philippines have undergone major renovation in 2011, and a new laboratory building has recently been completed in Lao PDR. The ASEAN-designated leading laboratory (LL) for HPAI in Malaysia has recently constructed a BSL3 facility, which is expected to be operational and accredited in 2012. D Regional Proficiency Testing (PT), implemented since 2007, provides external validation of the accuracy of testing and also helps regional organisations understand how reliable the diagnostics are in indicating the presence or absence of disease. Laboratory biosafety and biosecurity In the beginning of the programme, there were worrying gaps in workplace safety in the handling and generation of infectious materials. As a result of workshops conducted to help national laboratory services develop SOPs for laboratory biosafety and biosecurity, all national laboratories now operate at Biosafety Level 2 (BSL2) for HPAI diagnostic procedures. Class II biosafety cabinets have been calibrated and re-certified to improve laboratory safety standards. Laboratories have been encouraged to implement procedures for improving the safety of biological waste disposal. Regional laboratory networks The FAO/OIE regional laboratory networks have facilitated capacity building, communication and harmonization among ASEAN and SAARC member states. The progressive establishment of regional laboratory networks has improved the level of laboratory engagement in the improvement programme and on information sharing in regional and international 35 -: Lessons from HPAI networks. The strengthening of regional leading laboratories has improved services such as reagent supply, test harmonisation, training and reference activities, and also reinforced linkages to the OFFLU network and the collaborating and reference centres of FAO, OIE and WHO. This has improved overall technical practices and the understanding of HPAI viruses. Outputs 1. L aboratory capacity strengthened in every south and southeast Asian country involved in the programme using a progressive approach involving equipment and reagent supply, basic biosafety and technology training, the writing of SOPs for local use, standardization of test procedures, the introduction of QA systems, and review and assessment of performance. 2. A ll countries in the region have at least one central laboratory that can detect and identify H5N1 HPAI and conduct appropriate serological tests. T F 3. G uidelines established for HPAI diagnosis by animal health laboratory services of the eight FAO member countries in ASEAN that are members of the regional laboratory network. 4. S erological procedures established for detecting prior exposure to wild type virus, especially in ducks, and also most importantly for monitoring vaccination responses. A R 5. E xpanded differential diagnosis set up for other avian disease agents such as the ND and DVE viruses. 6. N ational laboratories in Thailand and Viet Nam accredited to ISO 17025 for HPAI diagnostic assays. D 7. N ational laboratories in the Philippines renovated, new laboratory building completed in Lao PDR, and BSL3 facility constructed by ASEAN-designated leading laboratory for HPAI in Malaysia. 8. R egional Proficiency Testing implemented since 2007. This has provided external validation of the accuracy of testing and also helps regional organizations understand how reliable the diagnostics are in indicating the presence or absence of disease. 9. S OPs developed for laboratory biosafety and biosecurity in national laboratory services. All national laboratories now operate at Biosafety Level 2 (BSL2) for HPAI diagnostic procedures. Class II biosafety cabinets have been calibrated and recertified to improve laboratory safety standards. Outcomes 1. I mproved the submission of viruses to international reference laboratories, leading to deeper understanding of viral strains in circulation. 2. I mproved quality and reliability of laboratory diagnostic test results. Many laboratories are now able to apply elements of a laboratory quality management system to HPAI diagnostics. 3. Many laboratories able to isolate viruses using embyronated chicken eggs to 36 4 The power to detect and diagnose Developing Viet Nam’s laboratory network In 2005, Viet Nam’s diagnostic capability for HPAI was housed in the National Institute for Veterinary Research (NIVR) in Ha Noi, and a fledgling capability existed also at the Regional Veterinary Centre in Ho Chi Minh City. Administrative difficulties arose because NIVR was not part of the general Department of Animal Health but an autonomous institute within the Ministry. Each of the seven Regional Veterinary Centres had a laboratory section and the capacity for serological testing. However, there was no harmonised system to ensure the calibrated performance of tests across the country. The challenge was to develop diagnostic capacity across the system so that regional centres could provide rapid diagnosis for the field services in their zone, and the National Centre for Veterinary Diagnosis (NCVD) could act as the national reference laboratory. The functions envisaged for the NCVD were to lead the process of test harmonisation, provide standardised reagents for testing, act as a repository for viruses for the country, create links to international laboratories to submit viruses for genetic characterisation and to monitor the efficacy of vaccines against the predominant field virus strains. Two main strategies were employed for developing diagnostic capacity – extensive training in the technology and modification of work practices and workflows to ensure good practices and improved biosafety and biosecurity. All nine government laboratories have built up the capacity to use real-time PCR for HPAI H5N1 and its differential diagnosis to give results within 24 hours. The technique was also extended for the diagnosis of other economically important diseases of livestock, increasing the relevance of the laboratories to stakeholders. Laboratory biosafety and biosecurity has improved through the modification of laboratory layout, the installation of necessary equipment, on-site training courses and workshops. The NCVD has been accredited for ISO17025, and all the other laboratories are expected to follow. T F A R National and international networking is an effective element in strengthening overall laboratory performance. To facilitate standardization and modification of test procedures and interchange between laboratories, and between laboratory and field a national lab-epi network was established. Proficiency testing organized through the network has contributed to the quality of diagnostic testing. The network is also a forum where laboratory and epidemiology units can discuss diagnostic issues which facilitate a better outbreak response and more efficient surveillance. Sharing of virus isolates and information with the international community has resulted in better understanding of the virus as well as the epidemiology of H5N1 in Viet Nam and the region. More than 300 H5N1 positive samples have been sent to OFFLU/WHO reference laboratories. Genetic sequences of more than 250 poultry viruses from Viet Nam are available in the public database. D A high biosecurity animal isolation unit was built at the NCVD. Routine monitoring of vaccine efficacy by challenge experiments for emerging strains of H5N1 viruses have been producing the information essential for the choice of vaccines to be used in Viet Nam. For example, it detected the emergence of an antigenic variant in 2011 against which the vaccine currently in use was not effective. confirm PCR positive results. 4. I ncreased harmonization and communication among ASEAN member states. The progressive establishment of regional laboratory networks has improved the level of laboratory engagement in the improvement programme and on information sharing in regional and international networks. 5. I mproved services such as reagent supply, test harmonisation, training and reference activities, and also reinforced linkages to the OFFLU network and the collaborating and reference centres of FAO, OIE and WHO. Successful practices 1. C lose mentoring and establishment of technical working relationships with national laboratory staff. 2. Developing closer linkages with laboratories through visits, on-site technical 37 -: Lessons from HPAI support, conducting capacity building workshops and liaison with regional organisations. The global OFFLU programme’s strong technical engagement in the region has also helped spread technical advances and strengthen linkages between national laboratories and the global network. 3. H aving experts ‘in-residence’ to help speedily introduce new technology into laboratory systems, help national staff set up equipment, establish tests and prepare SOPs. Experts in-residence also facilitate on-site training. 4. A national-level network linking laboratory scientists to epidemiologists in the field. This helped improve the outcome of the diagnostic efforts. Lessons learned 1. T raining on-site is important because training is an iterative process. It is also important to review the outcomes in follow-up sessions, and to mentor closely to avoid staff becoming overwhelmed. T F 2. T he establishment of ‘lab-epi’ networks helps reduce the gap between the two arms of the animal health service and improved overall disease control. The lack of effective linkages between the laboratory and field services at the national level often results in failure to provide a full diagnostic service. Laboratories also act as testing centres and do not extend services beyond the HPAI project requirements, which only reflects gaps in laboratory management capacity and the absence of a case manager approach towards diagnostic submissions. Failure to have a more service-oriented approach can result in difficulties in maintaining support for laboratories within the animal health system. Insufficient training in proper sample submission leads to loss of quality and effectiveness in laboratory submissions. A R D How Indonesia got its animal health laboratory network In response to unique difficulties Indonesia was facing with HPAI and vaccine efficacy, the Animal Health Influenza Virus Monitoring (IVM) Network was established to quickly identify emerging variant viruses, identify candidate viruses to add to vaccine challenge panels, and monitor the efficacy of vaccines in use. The IVM network has been built on the existing government system of eight regional Disease Investigation Centres (DIC) laboratories and the Bbalitvet veterinary research laboratory, and the programme built into the routine activities for these laboratories. This is the first network established around the world to monitor animal viruses at a national level. Activities so far have included strengthening technical capacity and supplying reagents and some equipment. The network has promoted harmonisation of diagnostic procedures and test protocols and the sharing of specimens. It is also possible now to share data or contribute to its analysis over a specially developed data sharing platform. Regular meetings are held to exchange information, discuss and resolve constraints, conduct refresher training and to distribute standardised reagents. A key aspect of the IVM network is its linkage with OFFLU, which has led to the introduction of antigenic cartography to map the relationships between field and vaccine strains of H5N1. This procedure has been used to study some 244 field viruses mostly isolated by the DIC laboratories from village poultry, and the results used to inform vaccine policy in Indonesia. In addition the network has shared viruses with international reference laboratories resulting in over 300 virus sequences being deposited in the public domain, and so greatly increasing global knowledge of H5N1 virus evolution. 38 4 The power to detect and diagnose 3. R eference laboratories should properly understand the expectations of the submitting agency in respect of turnaround times and also publications arising. At times there have been also long delays in obtaining permission to upload sequence data from such submissions, resulting in frustration on the part of the international agency and the reference laboratory. 4. S eparating the national key laboratory from the animal health services can lead to blockages in establishing or upgrading diagnostic facilities and also impede the flow of key information. Something similar arose when international research institutes brokered arrangements with national laboratories to obtain virus isolates for research purposes. 5. W orking with inappropriate technology or insufficient training can erode a national laboratory’s performance and senior officials’ attitudes. For example, gene sequencing equipment was provided to some national laboratories without enough training, maintenance and reagent supplies. T F 6. G ood laboratory practices, including laboratory safety, can be difficult to institute in laboratories that already have a different long established work culture. This also applies to following SOPs, keeping proper laboratory records and habits such as eating within the laboratory. There is no immediate solution in sight as it is often associated with the laboratory managements’ reluctance to take action. A R 7. A nimal health services can on occasion overreach and undertake more than they can manage effectively when it comes to laboratory facilities. Some countries have tried to set up BSL3 laboratory facilities in settings where the power supply was erratic and manpower insufficient in numbers and in skills. This has led to challenges in both maintenance and sustainability, even though on paper they were identified as having BSL3 facilities. Sustainability D Sustaining and expanding the laboratory capacity built up during the HPAI programme is of great importance for the entire region as the emphasis expands to include emerging and re-emerging infectious diseases. Linking laboratories to either routine disease control efforts or new initiatives under One Health projects will be essential to sustaining the momentum, technical expertise and user confidence in the services. The prospects for sustainability vary significantly between countries, depending on their level of reliance on external funding to conduct surveillance. At one end are countries wholly dependent on external support such as Bangladesh, Cambodia and Lao PDR, while on the other are countries like India, Thailand and Viet Nam, nearly self-sufficient through government funding. Regional networks are much more sustainable platforms though they depend on political will since they are tied to the economic community’s efforts. Towards this end, working closely to expand the understanding, capacity and strategies of regional organizations such as ASEAN and SAARC is vital to the regional sustainability of these initiatives. Within the laboratory system there is limited capacity, lack of experience and knowledge about strategic planning and the process of strategic plan development. As a result many countries within the region do not have strategic plans specific to the national animal 39 -: Lessons from HPAI Monitoring progress with the laboratory mapping tool A laboratory mapping tool developed under the IDENTIFY project facilitates the monitoring and evaluation of laboratories by determining their strengths and gaps in a semi-quantitative, systematic and harmonised manner. The tool comprises five modules —general laboratory profile; infrastructure, equipment and supplies; laboratory performance; quality assurance and biosafety/biosecurity; and laboratory collaboration and networking. A total of 372 descriptions define clear and specific indicators for the modules and a friendly questionnaire is used by external assessors or by laboratory staff for self-assessment. Based on the response from each laboratory, a summary score is automatically generated which is used to assign each laboratory into one of three categories: basic, moderate and advanced functionality/capability. During 2010-11, the initial assessment made by external assessors provided the baseline information and categorized the laboratories in the project. In 2011, the tool was applied again in southeast Asia to measure progress made. T F The main constraints of the laboratories in the region emerge as low operating budgets from the national governments; prohibitive costs for equipment, maintenance and reagents; difficulties in ensuring biosafety and biosecurity; lack of human resources both in skills and numbers; insufficient sample flow to the laboratory to justify maintenance and operating costs; and restricted access to updated information including scientific publications. The tool makes it possible to demonstrate progress over years and also identify deeply rooted constraints of one or several laboratories, so that solutions can be devised under the Regional Framework for Laboratory Capacity Building in Asia. A R health laboratory or the national system of laboratories, nor any initiative to develop such plans. This is a concern for the sustainability of the considerable gains made. Future D Post-graduate degrees are one way to cultivate in-depth understanding of the fundamental science that underpins diagnostic tests and their interpretation, though one also needs to build hands-on experience with quality control systems and foster stronger collaboration with field staff in implementing disease control activities arising from diagnostic results. Laboratories in the region need resilience to cope with surges in samples submitted during multiple concurrent outbreaks. Young laboratory staff should be trained and given the technical authority to take over mid-level management functions to maintain interrupted diagnostic services in the absence of senior staff. They should also be able to move to other sites on a temporary basis and seamlessly fit into operations there. Introducing a culture of documented management systems as used under ISO standards would help, especially where hierarchical structures pose challenges, There is a need to foster research projects to build technical and scientific expertise. These would require international collaboration to attract funding in the medium term and to improve success rates. Spurring laboratory staff to engage in research could create an additional avenue for recognising and rewarding effort, though there is also a need for similar mechanisms in the diagnostic services. Laboratories may need longer term mentoring and guidance to bring their services to the private sector and pick up on the needs of commercial livestock production. Investment in laboratory management, business planning and strategy development would spur this. 40 T F A R D An influenza haemagglutination assay test being performed in one of FAO’s network of reference laboratories 41 T F A R D Vaccination of poultry against avian influenza is one method of mitigating the impact of the disease. In some countries, farmers have improved their livelihoods by following the proper schedules for vaccination. VACCINATION 5 Staying a step ahead of H5N1 T F The objective of all HPAI activities conducted by national governments has been better control over the disease or the risk of disease, the protection of public health and the economic interests of commercial poultry producers from H5N1. While the elements of the control programmes have combined to limit the impact of disease, there are specific elements that deal with prevention of, response to or recovery from disease outbreaks. In the realm of disease prevention and control, in particular, there are two distinct technical aspects, namely vaccination and biosecurity. The number of reported disease outbreaks does not always correctly reflect the amount of virus in circulation but is at present the best proxy measure of disease control available to national programmes. One country in the region estimated that as few as 1 in every 2000 flock disease infection events was reported over an 18-month period. Most countries have shown a steady decline in the number of cases and this is arguably due in most part to the HPAI control measures. Much of the discussion in this chapter is a description of the vaccination programmes implemented and owned by the national animal health services, with FAO principally supporting technical issues rather than providing vaccines. Situation in 2005 D A R By December 2005 HPAI had been officially reported in 10 countries in southeast Asia including China, Cambodia, Lao PDR, Indonesia, Japan, Malaysia, Mongolia, South Korea, Viet Nam and Thailand. Vaccination against H5N1 was adopted to meet acute economic and public health demands and pressures. Given the scale and structure of their poultry production and markets, China, Viet Nam and Indonesia undertook vaccination programs while other endemic countries such as Bangladesh and India did not. At this time no country had any experience in deploying vaccination in the face of an outbreak, and procedures applied early against HPAI were derived from best practices in other diseases. The first international guidance documents on vaccination were not developed until 2006, after vaccination had been initiated (FAO/OIE 2006). The scale and scope for undertaking vaccination was unprecedented, particularly in relation to widespread endemicity. There was little documented experience with the use of avian influenza vaccines for disease control, with the exception of Hong Kong. While HPAI is not a new disease, large-scale vaccination programs are a recent phenomenon, beginning in Italy in the late 1990s related to notifiable H7 and later H5. Pakistan has also used vaccination to a limited extent against H5 and H7 subtypes since 2004. Vaccination against H9N2 43 -: Lessons from HPAI has been reported in Afghanistan, Bangladesh, China , Egypt, Jordan, Korea, Hong Kong, Germany, India, Iran, Iraqi Kurdistan, Israel, Nepal, Pakistan, Saudi Arabia, Pakistan, Tunisia, the United Arab Emirates and Viet Nam (EMPRES-i; Nagarajan, 2012; Saif, 2008). By 2003 it was a requirement that all poultry imported from China be vaccinated with an approved vaccine. In 2004 government-sponsored mass vaccination started in China, but unsanctioned vaccination was already taking place by this time, neither coordinated nor monitored officially. Vaccine production was limited to a select group of manufacturers, all subject to quality control procedures. In the first year after the disease was detected in Indonesia the government agreed to vaccinate to control the outbreak, associated with public health and economic impact of the epidemic. The commercial poultry industry in Indonesia commenced vaccination of chicken breeder and egg layer flocks and the central government procured limited vaccine stocks for distribution to selected local governments for district level application. A number of different vaccines had been imported through private channels from international sources including China and QA data was not always available. In addition local vaccine production commenced but initially there were not standardised approaches used for the QA on locally produced vaccines. Despite the challenges and constraints associated with immunization in developing countries, the government supported vaccination of “backyard’ poultry but not meat broilers or ducks. The commercial sector attempted to manage its problems through vaccination with little interaction or exchange of information with the government veterinary services. T F A R Vaccination against HPAI commenced in Viet Nam late in 2005 as the control measures being applied to poultry (stamping out, movement controls and in some cases closure of LBMs were not effective in controlling the epidemic and there was a steady and alarming increase in the number of human cases. Vaccination was combined with market closures in Hanoi to mitigate risk related to virus transmission in market systems. In this case quality assured vaccine from China was deployed in a mass vaccination effort. The decision was made to concentrate on the higher risk areas of the Red River and the Mekong Deltas and to use a twice-yearly calendar related mass campaign one aimed to provide a relatively immune poultry population about the time of the Lunar New Year (Tet) holiday period. Similar calendar based campaigns were not used in Indonesia, but twice yearly campaigns were applied to village poultry in China. D Situation in 2011 In 2009, an international meeting of animal health officials and researchers developed the Verona Recommendations (FAO/OIE 2007) as a guidance document for countries either involved in or considering vaccination programs against H5N1. Although technically sound, the recommendations were difficult to apply successfully by countries that vaccinate. Reasons included technical issues of vaccine efficacy and effectiveness related to species, logistics and cold chain delivery, limited veterinary capacity to conduct surveillance and virus monitoring, and general lack of a structured vaccination strategy. At the global level FAO has been a strong champion of properly implemented vaccination programmes with a clearly defined exit strategy as an adjunct to other control measures when the disease has become endemic, and as a temporary measure to enable animal health services to contain severe outbreaks or protect valuable commercial, genetic or conservation resources. The Verona Recommendations for vaccination programmes prepared by an international conference on vaccination in Verona (FAO/OIE 2007) have served 44 5 Staying a step ahead of H5N1 as guidelines to FAO although they have undergone further modifications over the years based on field experience. At the regional level, FAO has provided advice and technical input to governments, and participated in national level meetings to review information and practices related to vaccination. In particular, by utilizing operational research, FAO is helping governments develop sound plans to transit from mass vaccination to more targeted and risk based strategies that will pave the way for a phased reduction from this financially draining control measure. The notion of an exit strategy is seen as a step-wise process for each country situation and not an all-or-nothing option. China: An ECTAD office was established in China in 2006 and has provided limited technical inputs to the vaccination programme, as this country has been at the forefront of vaccine development for HPAI. FAO provides epidemiological training to China and advice on assessing vaccination, including risk-based vaccination, and the general performance of the mass vaccination programme and exit strategy instituted in 2004 through which more than 10 billion doses of vaccine have been delivered annually. Large numbers of serum samples – over 3 million in 2008 – have been tested to monitor vaccine efficacy. However the surveys are not probability-based and do not represent overall flock immunity, but rather responses from purposefully selected groups. In addition, large numbers of swab samples collected in markets have been tested for virus (over 100,000 per year between 2007 and 2009, and over 500,000 in 2008). The discordance of monitoring results show 90 percent protection at farm level and 30-40 percent protection at market level. Consistent monitoring, and isolation and characterization of field virus strains have enabled the national authorities and researchers to modify vaccines that are compatible with the circulating viruses. T F A R The national authorities have also genetically engineered vaccines through reverse engineering from field isolates, and deployed them in the mass vaccination campaigns. While the campaign has the full commitment and financial resources of the government, there are still constraints to achieving sufficient coverage of poultry raised in rural smallholder communities and areas where ducks abound. In addition there has been an historical overdependence on vaccines for animal disease control and this probably has affected the development of other traditional disease control measures and epidemiological assessments of the outcome. Two issues of concern include the application of selection pressure for virus mutation through either large-scale programs or related to partially immunized poultry. The commercial sector probably has many proficient operators with sufficient biosecurity to avoid infection but who continue to vaccinate to avoid the economic losses that an outbreak could entail. China is now looking to develop more tactical, risk-based vaccination to reduce costs and increase the efficiency in the overall programme. FAO will continue to support these new strategies to the extent its funding allows. D Indonesia: FAO’s strong and persistent advocacy with the government has been responsible for catalysing some important changes to the vaccination programme, along with steadfast technical support for government initiatives. By 2006 the widespread government sponsored vaccination programme had to be restricted to 12 high-risk provinces because of resource constraints. However it had become evident that the use of sponsored vaccines in the so-called Sector 4 — extensively-raised scavenging poultry that are used for household consumption — was not delivering results as expected and so a specific operational research project was conducted in collaboration with the International Livestock Research Institute (ILRI) to investigate the effectiveness of vaccination in this sector. Anecdotal evidence early in the outbreak indicated that the vaccination teams might have been respon- 45 -: Lessons from HPAI sible for spreading the disease. The research yielded evidence (Bett et al, 2012; McLaws et al, 2012) that led to the near cessation of vaccination Sector 4. Another operational research project, investigating the efficacy of the cold chain in vaccine delivery, revealed serious defects in the management of delivery through to the grassroots level. The work carried out under the OFFLU project in Indonesia has also been essential in assisting the government with technical decisions about vaccine strains and has built capacity and ownership for monitoring vaccine-field strain fits through the new technique of antigenic cartography. The OFFLU project has been successful in encouraging collaborative characterization of H5N1 viruses and in placing sequences in the public domain. The FAO ECTAD team has begun engaging with the commercial sector in vaccine testing trials and also applied participatory approaches to gain insights into problems with the application of vaccines in the commercial sector. FAO has also worked with other collaborators such as the USDA and the Government of the Netherlands to help develop QA procedures, convening several technical meetings to bring various players including industry to the table. In recent times FAO has advocated for administrative procedures to enable more rapid approval of vaccine strains and for the registration of genetically engineered vaccines, which is prohibited in Indonesia. The commercial sector had not been included in the Indonesian government’s vaccination efforts, and vaccination in the commercial sector is also not coordinated formally by government, so it becomes doubly important to include industry as a stakeholder in the official programme. Though the government has invested in the vaccination programme, it has equivocated on its commitment to a fully coordinated national approach. Some progress has been made in sharing virus isolates through the work of FAO and OFFLU. T F A R D Viet Nam: Extensive consultations involving FAO and OIE preceded the Vietnamese Government’s adoption of vaccination. The initial biannual government-sponsored vaccination was carried out in most areas except remote parts where it was considered there was low risk of disease occurring, but then was further limited to 32 designated high risk provinces. The criteria adopted to assess high risk included previous occurrence of outbreaks, poultry density, human population density, poultry movement, poultry species especially ducks, nature and location of markets, production practices, and proximity to borders were cross border trade in poultry was common. Some provinces not so designated opted to continue vaccinating using their own resources. FAO has supported the government in conducting an annual review of prevention and control measures, to which national and international participants are invited. A number of studies were conducted to inform the development of new vaccination policies, including cost benefit studies, strategic vaccination and modelling of vaccination options. Considerable funding was provided for post vaccination monitoring using both serological and virus sampling. This work was valuable but did suffer from the selection bias mentioned above for China. To help the Government of Viet Nam with the logistics for implementing vaccination a number of cold stores were established at the provincial level. However, there has not been a systematic investigation of the management of the vaccine delivery system and breaks in the cold chain might explain some of the variations seen in titres detected by post vaccination monitoring. Results from the Gathering Evidence for Transitional Strategy (GETS) project indicate an association between low vaccine coverage and H5N1 infection at the district level, suggesting that vaccination has been quite crucial in controlling H5N1 in some districts. An important contribution, well appreciated by the government, has been the potency 46 5 Staying a step ahead of H5N1 testing of vaccines against local field strains, and studies of the various vaccination schedule options, especially for young ducks. Technical support on vaccination culminated with the GETS project findings in early 2011, which provided additional evidence for the broader application of a targeted vaccination program focused on age-based and risk-based vaccination of ducks in Viet Nam. Other findings of the GETS project included — 1. A ll districts and provinces in the study demonstrated a wide variability epidemiologically between and within north, central and southern study sites. 2. U nder-reporting of H5N1 outbreaks is widely prevalent. As few as 1 in 2000 disease events are being reported. 3. V accination has been effective at the district level in the Mekong and Red River Deltas. T F 4. M obile ducks may be associated with increased risk of H5N1 outbreaks at the commune level. 5. Current vaccination coverage in five GETS provinces is estimated at 65 percent. 6. T he Red River Delta is subject to virus incursions through trade; the risk is higher in districts with lower vaccination coverage. A R 7. GETS led to improved immunity of adult ducks in the Mekong River Delta. 8. H I titers are related to H5N1 and spurious sero-conversion related to other exposures. D 9. M arket surveys were 10 times more sensitive for detecting H5N1 than sentinel surveys. 10. Vaccination withdrawal should be gradual, particularly in the Red and Mekong River Valleys. By late 2011, the Vietnamese Government had suspended all vaccination related to the appearance of one particular subtype of Clade 2.3.2.1. At the time of the annual ECTAD meeting in February 2012 there was some discussion about the possibility of re-introducing riskbased vaccination for ducks in the Mekong delta. Since 2.3.2.1 virus is very restricted within Viet Nam, the Government is considering re-introducing public sector funding for routine vaccination in North and Central Viet Nam. In addition, the private sector can continue to use the licensed vaccine. Regional considerations In China, Indonesia and Viet Nam, FAO has solidly put into practice the Verona Recommendations (FAO/OIE 2007) related to review and reiteration of strategies. An issue that has arisen across the three countries concerns the role of so called vaccinated older ‘spent’ layer hens in the maintenance and spread of viruses. It is clear that inadequate flock immunity enables and allow the development of sub-clinical and/or mild infections, and thus the propagation of the virus in such birds, referred to by some national partners as ‘duck equivalents’. Cross border or local trade in these birds, which may either enter market chains infected or contract infection along the way due to sub-optimal immunity, has been implicated as a source of outbreaks, making compliance and proper adherence to vaccination protocols and schedules is important for long-lived layer birds. The issue of vaccine-asso- 47 -: Lessons from HPAI ciated production drops negatively affects producer compliance. Again the matter of low impact vaccination is important for the production cycle. There is a need to alter triggers for the investigation of disease syndromes in vaccinated flocks as clinical signs are modified by partial immunity. Such enhancement of passive surveillance has been supported by the use of active measures in all countries to quantify virus circulation in LBMs. This is a productive approach, albeit expensive. Studies have attempted to investigate the economics of vaccination in the control programmes but concluded that the benefits of vaccination could not be distilled out from among the other measures being applied. The most useful economic analysis of disease control is likely to be one that does not distinguish measures used, but is comprehensive of the programme. However this does not preclude the use of financial analysis of different vaccination options. T F The vaccination of village poultry remains an important aspect of disease control, household livelihoods and even food security, but for the present is considered too difficult to promote and manage and is not regarded an efficient use of money and manpower due to its low potential for eliminating disease. A R Across the region there continue to be serious constraints with the use of vaccines in ducks, especially meat ducks. Most vaccines are formulated to optimise protection in ducks and there are still gaps in scientific evidence about the protective post-vaccinal antibody titre. There is need to explore the development a vectored vaccine based on the duck enteritis herpes virus, to give dual protection to provide additional incentives for producers to vaccinate. D Outputs 1. A summary of findings and best practices from the Viet Nam GETS Project presented, providing the rational basis for the broader application of a targeted vaccination program focused on age-based and risk-based vaccination of ducks in Viet Nam. Outcomes 1. R eduction in the number of human cases in the region (with the proviso that in China no human cases had been recorded prior to vaccination either). 2. D ecline in the number of poultry outbreaks in China, Indonesia and Viet Nam, (with the proviso that better control due to vaccination in the commercial sector has resulted in fewer outbreaks in Viet Nam, and the outbreak numbers in unvaccinated village poultry are not increasing). 3. E vidence based recommendations from the GETS project in Viet Nam for intensive vaccination of ducks and gradual withdrawal of vaccination from chickens; targeted age-based vaccination in ducks (high risk silent carriers); vaccination coverage of mobile duck flocks via enforceable legislation; replacing the current biannual vaccination schedule with age-based vaccination; matching of vaccine to circulating virus found in market surveys and outbreaks; and adoption of a staged removal of vaccination from poultry that do not act as silent carriers. 4. Reduction in the environmental load of virus for poultry and humans, primarily 48 5 Staying a step ahead of H5N1 due to the vaccination programme. 5. A ssurance of high quality vaccines, because of antigenic, molecular, postvaccination sero-monitoring and challenge studies. 6. G reater collaboration and information exchange among countries vaccinating against HPAI. 7. Improved detection of new virus strains and quicker response. 8. Improved sharing of new virus strains circulating in the field. Lessons learned 1. M ass vaccination campaigns for small-holder poultry are difficult to apply effectively as owner cooperation is not assured, the capture of free range poultry is difficult, vaccinators quickly tire of the task and there is rapid turnover in the population so flock immunity levels wane quickly. T F 2. V accination programmes that interfere with production cycles such as broiler and meat duck production have a smaller chance of being implemented and so vulnerable populations build up in low biosecurity systems. Risk reduction has to arise either from strengthened exclusion measures or improved vaccines. A R 3. D uck farmers are less interested in HPAI prevention and do not see the need to vaccinate ducks as generally there is limited discernible clinical disease and mortality arising from infections. D 4. C ommercial operators are not forthcoming about problems occurring in their systems with vaccination programmes. In spite of the information available concerning proper application of vaccine regimens, some commercial operators do not adhere to instructions. Company technical support is limited, leading to vaccine failures. 5. T he view of some critics that vaccination results in endemicity and increases the likelihood of virus mutation must be dealt with using advocacy and communications. In Asia vaccination was implemented reactively once the virus was well established in the poultry population and there was sufficient scientific evidence that vaccination places selection mutation pressure on field viruses. There is an urgent need to review and revise vaccination guidelines and recommendations from international animal health organizations, and to develop a vaccination planning tool to support decision makers for countries that are considering vaccination as an additional tool to manage their HPAI problem. 6. F ield strains are evolving as predicted, making it necessary to check vaccine suitability regularly. National authorities want the capability to check vaccine efficacy, especially imported ones. It has been necessary to support this process and build capacity in this area. 7. T he introduction of technology to monitor vaccines has proved effective for informing national partners and has increased the credibility of the support effort with the partners. This sort of technical support is a consideration for any animal health programme where vaccines are considered. 49 -: Lessons from HPAI 8. S urveys do not accurately indicate vaccination coverage at the population level as post-vaccination monitoring is biased and generally conducted by the jurisdiction responsible, there is no incentive to change to more population representative sampling. Greater advocacy is needed to promote epidemiologically sound practices. 9. A s there is considerable cross-border trade particularly of spent hens in the shared border between China and Viet Nam, the lack of coordination between the two countries’ respective vaccination programmes creates some issues for regional disease control strategy. 10. The notion of an exit strategy is confusing for some authorities who cannot understand why they should expose their countries to the large risk implied by exiting a vaccination strategy against a virus that has become endemic on some populations. FAO recognizes that it will be some years before the virus circulation is reduced to the point where elimination can be considered. Any moves to change vaccine programmes are best undertaken in a step-wise, iterative manner at country level. T F 11. Currently available vaccines can be difficult to use under current field conditions even if they can be shown to be effective under experimental conditions. New vaccines are needed to overcome technical, economic and logistical challenges and to provide incentives for producers to use them. A R 12. The ideal vaccination protocols use two vaccinations for meat birds and three to four vaccinations for breeder and layer birds. The use of a single vaccination for meat ducks did not provide consistent immunity and protection, especially in the presence of maternal antibodies. D 13. There is still no systematic guidance document based on sound theory and proven practices available to countries concerning vaccination policies. FAO has developed a draft vaccination planning tool to support countries considering vaccination as an intervention. Sustainability The vaccination programme in China is already fully funded by the government, with no indication that this support will be reduced. There also is good collaboration between the commercial sector and the government as the vaccination programme is regulated and government leads the development of new vaccines. In Indonesia the commercial poultry industry uses locally produced vaccine through self-funded programs and this should be encouraged considering the endemic status of the virus. FAO’s initiatives undertaken in partnership with governments and other collaborators are not fully sustainable by the government, and until there are stronger linkages between the public and private sectors driven by mutual benefit from collaboration, these are vulnerable to stagnation and eventual dissolution. The signs are encouraging but the linkages and trust are still relatively fragile. In Viet Nam the government has financial priority resourcing issues with continuing vaccination, although if there were an upsurge in human cases the programme would assume higher priority. It is not likely that the virus and vaccine testing would continue without international technical support. 50 5 Staying a step ahead of H5N1 Future For endemic countries vaccination and virus monitoring remain valuable tools to keep virus levels in poultry in check even while other control strategies are developed and applied. The H5N1 virus will remain a part of the global infectious agent landscape for some years to come. The low-grade circulation of H5N1 with other co-circulating subtypes in poultry decidedly increases the chance of human infections, which in turn increases the risk of the emergence of a virulent strain of H5N1 capable of efficient transmission from human to human. However there are limits to how much financial and other resources can be made available to eliminate a pathogen with limited virulence for man at present. There is a parallel risk that a pandemic can arise from another source as happened with H1N1. There is a strong need to support monitoring programs for influenza and other viruses at the human-animal-ecosystem interface. T F Developing a vaccine that is effective, affordable and easy to apply in both ducks and chickens is a challenge. The option of a vectored vaccine using Duck Virus enteritis (DVE) virus as a delivery vehicle has potential and the benefit that many duck farmers already vaccinate against DVE using a modified live virus vaccine. A similar opportunity might be available with the Marek’s disease herpes virus of turkeys being used as the vector for H5N1 genes. Again it provides for ease of vaccination of day old chicks. A new generation of vaccines against influenza and other important, related poultry pathogens need to be developed, and this will need support from the international community and the private sector. A R The application of surveillance based on sound principles and rigorous epidemiological analysis to vaccination programmes will continue to inform disease control strategists and policy makers of the most effective ways to target vaccine resources. D Operational research related to vaccination and other disease control strategies at country level needs to be supported. Also needed is a review and revision of vaccination guidelines and recommendations by the international animal health organizations. The challenges that face small-holder producers in controlling HPAI are likely to continue, although if vaccines are more easily administered and induce longer lived immunity then it might be possible to have them administered by local animal health workers in a more age-based schedule as part of regular flock health programs, and so reduce losses and virus loads. Until there is a significant change in the structure of the poultry sector in these countries it will not be feasible to rely on the principles of biosecurity to eliminate virus. This is especially true for free-range ducks. However the gradual improvement in the education and understanding of poultry raisers and advances in practices related to live bird markets will also see pressure on the virus and a reduction in the environmental load of the virus. 51 T F A R D A poultry crate being cleaned and disinfected in Indonesia 52 BIOSECURITY 6 Keeping the farm secure T F The unprecedented spread of H5N1 HPAI virus in the region was the result of the alignment of a number of key factors, including rapid, largely unregulated growth of the commercial poultry industry throughout much of the region, the preponderance of live bird markets with relatively poor management and low hygiene standards, low standards of husbandry within the small scale entrepreneur segment, large numbers of ducks being traded through markets in close contact with chickens, complex and unregulated market chains and at the end of the process probably the large numbers of poultry kept for household use in rural communities. The overall production system was very “open” due to a reliance on vaccines by many operators to control endemic poultry diseases. It would appear that in some places once the amount of virus reached some level of threshold it spread across the production landscape. A R D Much effort has been put into many levels to improve the management of poultry production from the free-range operators to the commercial sector. It became evident that in some places proactively providing information and training about biosecurity and better practices was a good entry point to make contacts with the commercial sector and to improve the linkages to the government services in the context of public-private partnerships. One of the small points that can be confusing is the use of the term biosecurity. Animal biosecurity has been defined as the product of all the actions taken to prevent introduction of disease agents into a specific area and safeguard the health of living organisms from hazards. Two basic goals of biosecurity are (1) exclusion and (2) containment. Methods used include: (1) isolation; (2) traffic control; (3) cleaning and disinfection; and (4) disposal of mortality and waste. As such it is a comprehensive approach encompassing different means of prevention and control. In the industrial poultry world biosecurity is a state indicating barriers more or less absolute to the ingress of infectious agents into a production facility. In many instances where the term is used, barriers are not possible, but rather measures that are designed to interfere in some way with the flow or build-up of virus in the environment. Generally the measures used relate to hygiene, although physical interference can be also part of the biosecurity approach. Situation in 2005 Basic management practices in much of the commercial sector were not in keeping with the concept of biosecurity, especially for small commercial operators. Most production units 53 -: Lessons from HPAI were open to the environment and few had even simple barriers to movement of pathogens into facilities. In retrospect many have described the HPAI episodes and spread as a “disaster waiting to happen”. Management was generally built around vaccination against the important industrial diseases such as Newcastle Disease for which effective vaccine regimes exist and with broilers the production cycle was short enough to reduce the impact of other diseases. When H5N1 gained a foothold in the market chains it quickly spread to supplying units. After the initial onslaught of the virus many small operators were put out of business and were waiting to see if it was possible to re-enter. For many household producers HPAI was a more severe manifestation of what had been experienced before with Newcastle disease and to the traditional coping mechanisms were used – i.e. to either quickly slaughter and eat sick chickens before they died or if the disease was near and threatening to sell birds to the market. In many instances this salvage by sale was also a common practice in the commercial sector. While the prevalent official position is that people don’t eat freshly dead birds, in protein scarce communities the opportunity for such a chicken meal is often taken advantage of. Another important issue was that there was a great range of production standards both across the sectors but also within sectors. Producers with significant investments were severely caught out and after the disease arrived attempted to deal with the problem as for any infectious agent seen before i.e. by relying on vaccination and marketing tactics to deal with the disease. Many farms raised broilers in multiple age groups without the barrier of all-in, all-out production and cleaning and disinfection between batches. It was common practice for broiler buyers to enter a number of premises on a given day to select birds for market, and egg trays were not routinely disinfected before entering egg layer facilities. T F D A R The standards of hygiene in many markets were unsatisfactory - practices for disposal of dead birds, offal, feathers and manure in markets were substandard. Opportunities for cross infection between species abounded and there was not an all in all out practices on a given day so birds might remain in the market for a number of days before sale, enabling virus circulation to be sustained in a market environment. Situation in 2011 It is difficult to assess improvements in biosecurity across the poultry sector because of the diversity of the production environments involved. Much work has gone into developing biosecurity guidelines for the commercial sector, and in some countries there have been suggestions about linking compensation to the proper application of the guidelines in this sector. Within ECTAD RAP national biosecurity guidelines have been drawn up for the commercial sector in Bangladesh, Nepal and Lao PDR. Guidelines were developed in the spirit of publicprivate partnerships (PPP), in a consultative process with the participation of the public sector (central and provincial veterinary officer), private sector (poultry companies, poultry associations, veterinary associations, feed and pharmaceutical suppliers) and academia and NGOs. The guidelines are used as the starting point and a driver for the implementation of biosecurity programs. The guidelines are linked to activities, such as development of biosecurity SOPs, development and delivery of biosecurity training and communication materials and development of auditing and certification programs. A guideline implementation structure (oversight committee and working groups) was also developed in line with the 54 6 Keeping the farm secure national administrative requirements. Training programmes were delivered to cover the following areas: the principles of guideline development; policy application of guideline development; operational application of guideline development; roles & responsibilities – who should do what; elements of biosecurity; farm isolation with respect to location, farm characteristics, traffic on and off the farm and pest management and other animals; good farm hygiene including house cleaning and disinfection and personal hygiene and apparel; flock health care and monitoring; good farm management practice, and; the importance of compliance with government regulations and international standards. On the ground the programme has progressed furthest in Bangladesh. Constructive dialogues were established between public and private sectors through neutral facilitation by FAO. Here senior veterinary officers were trained in biosecurity auditing of commercial poultry farms and acted as trainers for field level veterinarians. Biosecurity training was then provided throughout the country for poultry industry suppliers as well as farm managers. Continued dialogue between public and private sectors has evolved into collaborative efforts aiming at accessing international markets through compartmentalization. However a portion of commercial farms remains unregistered and so do not comply with standards, it was seen that and incentive would be needed to encourage registration and hence compliance. A session on biosecurity practices for veterinarians in the field was included into a surveillance training workshop on disease surveillance held in India. T F A R For the small-holder sector a set of biosecurity guidelines was prepared for the chicken and duck producers in Viet Nam. In addition a biosecurity training program targeting small poultry (chicken & ducks) producers was developed and delivered in seven HPAI infected countries in the Asian region (Bangladesh, Indonesia, Lao PDR, Myanmar, Nepal, and Viet Nam). This emphasises that biosecurity is the most effective tool for the prevention and control of HPAI and other important poultry diseases. The training program included modules on introduction to biosecurity, cleaning and disinfection, calculation of rates and application of disinfectants and safe disposal of dead poultry and manure by composting. The training programs, training-of-trainers (TOT) and direct trainings targeted poultry producers (chickens & ducks), allied services providers, private veterinarians, and government officers (veterinarians and animal production officers). D In addition to the work with the producers there was a substantial amount of work done in several countries to improve standards in live bird markets (LBMs). In Lao PDR a pilot project was initiated in a main provincial market to increase awareness of the poultry traders to improve their hygienic conditions in the market, to assist with the construction of a prototype stall model for live poultry marketing. A set of biosecurity guidelines was prepared to assist officials with understanding of the principles of the measures to be applied and then two training courses conducted for market operatives. It was noted that 90 percent of the trainees here were women. After the project had operated for 5 months the impact was evaluated. While the infrastructure and caging was in place with the bird market away from other food areas, different species were caged separately and even though there was good knowledge about hygiene practices, the actual daily cleanup was not diligently practiced (intensive follow-up is needed and live birds not sold at the end of the day were returned to the stall holders house till the next day. LBM projects were also carried out in China and Bangladesh. In China a project was im- 55 -: Lessons from HPAI plemented in one LBM based on 7 critical control points that were ranked by the market stakeholders and included the principle of PPP. The outcome of the activity was that the cooperation between market operators and the local authorities was enhanced and the provincial administration agreed to the PPP principle to expand the improvements to LBM management to the remaining main markets in the province. In Bangladesh 24 markets were upgraded and hygiene practices introduced to improve the overall biosecurity of the markets. In Indonesia, progress has been made in improving the relationship between the public and private sectors, however there is more improvement still possible, particularly in the area of biosecurity on small-scale sector 3 farms. Through the establishment of the National Poultry Health Council, an official partnership was established between the commercial poultry industry and the Directorate-General of Livestock and Animal Health Services. In the area of biosecurity, the gaps in operational biosecurity practices on farms and marketing points along the post-production market chain have been better characterized and are being directly addressed by the disease control programme. Biosecurity training materials have been developed, training has been provided at every level of the production train, and research is currently underway to identify the most cost-effective biosecurity practices for layer farmers. Along the post-production market chain, cleaning and disinfection SOPs have been prepared, 210 private sector stakeholders and public sector livestock service staff trained in effective cleaning and disinfection practices, 17 public and private sector Cleaning & Disinfection (C&D) trainers developed, 47 poultry collector yards equipped with cleaning and disinfection equipment and five poultry truck cleaning and disinfection stations built in the greater Jakarta area. Capacity to implement market cleaning and disinfection days was also established at 22 live bird markets and infrastructure rehabilitation provided to five live bird markets in the Jakarta area. Via the Commercial Poultry Health Programme, 40 local government veterinary service officers have been trained in poultry farm and over 2,000 farmers have been directly engaged and supported by these local government veterinary officers thus far. In South and West Sulawesi, the Village Biosecurity, Education and Communication (VBEC) pilot project was implemented in six village communities to improve awareness of how HPAI spreads and to develop locally suitable methods of control and prevention of poultry disease. A series of videos and a manual were also produced and distributed which demonstrated both the village-based process and findings of the VBEC project. T F A R D As well as formal training programmes for technical staff in animal health services there has been a lot of community based training that has been carried out by non-technical persons in communications initiatives conducted by NGOs. In some instances there has been interest and some uptake within markets for example of some of the simple technical measures it has been possible for such communications to deliver. These programmes often have the slight disadvantage that without technical expertise there is not the capability to observe and record or respond to what is actually being practised and to provide sound advice that is outside the script. There have also been concerns that some of the mass messaging about biosecurity was not nuanced when it was delivered in some situations where it was not practical. For example the message to confine scavenging poultry is not always a practical one and so the overall message is weakened when the audience is actively discarding what are seen as key messages. However mass communications programmes were an effective mechanism to get messages about risk behaviours and practices to large numbers of stake- 56 6 Keeping the farm secure holders on different parts of the poultry sector. Outputs 1. N ational biosecurity guidelines drawn up for the commercial sector in Bangladesh, Nepal and Lao PDR. Guidelines were developed in the spirit of PPP, in consultation with the public sector (central and provincial veterinary officer), the private sector (poultry companies, poultry associations, veterinary associations, feed and pharmaceutical suppliers), academia and NGOs. 2. T raining programmes delivered to cover principles of guideline development, policy and operational application of guideline development, roles and responsibilities; elements of biosecurity; and others. 3. B iosecurity training was provided throughout Lao PDR for poultry industry suppliers as well as farm managers. T F 4. A session on biosecurity practices for veterinarians in the field was included into a surveillance training workshop on disease surveillance held in India. 5. B iosecurity guidelines developed for chicken and duck producers in Viet Nam. Biosecurity training program conducted for small poultry (chicken and ducks) producers in seven HPAI infected countries in the Asian region (Bangladesh, Indonesia, Lao PDR, Myanmar, Nepal, and Viet Nam). A R 6. P rototype stall for live poultry marketing constructed in provincial market in Lao PDR. Biosecurity guidelines prepared to help officials understand the measures to be applied and two training courses conducted for market operatives. D 7. L BM projects carried out in China and Bangladesh. In China, LBM project based on 7 critical control points was implemented on principles of PPP. In Bangladesh 24 markets were upgraded and hygiene practices introduced to improve the overall biosecurity of the markets. 8. N ational Poultry Health Council established in Indonesia, as a partnership between the commercial poultry industry and the Directorate-General of Livestock and Animal Health Services. 9. B iosecurity training materials developed in Indonesia, and training in effective cleaning and disinfection practices provided to 210 private sector stakeholders and public sector livestock service staff. 17 public and private sector C&D trainers developed, 47 poultry collector yards equipped with cleaning and disinfection equipment and five poultry truck cleaning and disinfection stations built in the greater Jakarta area. 10. Capacity to implement market cleaning and disinfection days established at 22 live bird markets and infrastructure rehabilitation provided to five live bird markets in the Jakarta area. 11. 40 local government veterinary service officers trained in poultry farm in Indonesia, and over 2,000 farmers directly engaged and supported by these local government veterinary officers. In South and West Sulawesi, the Village Biosecurity, Education and Communication (VBEC) pilot project implemented 57 -: Lessons from HPAI in six village communities to improve awareness of HPAI, and the control and prevention of poultry disease. Outcomes 1. I ncreased knowledge and awareness of biosecurity concepts among poultry producers, markets, allied services and government officers. 2. Improved implementation of biosecurity measures on small poultry farms. 3. R educed risk of HPAI outbreaks, better health, better performance and better profit for farmers and other stakeholders. 4. Reduced risk of human infection. 5. I ncreased cooperation between market operators and local authorities. Provincial administration agreed to expand improvements to LBM management to the remaining main markets in the province. T F Lessons learned 1. T here was a lot of resistance to the public and private sector coming together, for different reasons in different places. However in many cases once the common ground was found, and the advantages of combining forces was realised cooperation and early collaboration began to emerge. However there is still a long way to go as in some environments public officials are not well respected. A R 2. W hile individuals might understand some of the underlying principles of hygiene and biosecurity it is still not an easy path to have people change perceptions, behaviour and practices that have been ingrained and require effort to change. D 3. I t was encouraging to see that some individuals who introduced better hygiene practices in markets began to enjoy better business as customers recognised the benefits for them from the changes. 4. M any individuals involved in the poultry sector, including veterinary staff, do not appreciate the need for proper cleaning before disinfection. And in many cases manual equipment purchased for disinfection is not likely to deliver disinfectants at the rates required to affect a proper result. In many instances the activity is cosmetic rather than functional. 5. Study of risks from marketing links between sectors is critical to evaluate. 6. I n general, considering the complexity of, and variation within, the commercial poultry industry throughout the region, solutions developed locally through direct engagement with stakeholders have been more effective than transferring solutions from other regions. 7. B uilding commercial poultry health competency within local government veterinary services is necessary for continued improved communication and trust between local government and commercial poultry farmers. 8. T raining and capacity building exercises in cleaning and disinfection practices were most effectively delivered when skilled trainers with experience in both 58 6 Keeping the farm secure adult learning and practical experience in cleaning and disinfection were used rather than relying on trainers provided by an equipment vendor or other unverified sources. Sustainability In some environments there has been uptake of the principles when individuals and groups perceive a benefit from improving standards. However all these aspects require ongoing effort and some investment and there is still a lag in the implementation, especially at the grass roots level. In urban areas as health authorities impose stricter hygiene standards for food then so it will be necessary for markets and traders to adapt or leave the scene. Until the volume of poultry produced in the small-holder sector is reduced from current level (greater than 70 percent of poultry are raised in systems where it is difficult to implement even simple biosecurity measures) and especially with free range ducks, the overall population will remain relatively exposed to risk of disease incursion. T F A variety of public-private partnership mechanisms are needed to improve buy-in and commitment from both government and stakeholders in the commercial poultry industry. This approach has resulted in farmers adopting best practices recommended by government and FAO, as well as in private sector market chain operators assuming the responsibility of covering ongoing costs of cleaning and disinfection in their facilities. Finally, by focusing on building the technical and training capacity of both government and private sector stakeholders in biosecurity practices, a sustainable resource for ongoing training and mentorship has been developed. Future D A R Continuation of biosecurity training programs in HPAI infected countries is required for better awareness and understanding of producers and other partners, to ensure broader implementation of biosecurity programs as a tool for prevention and control of HPAI and other important poultry diseases, particularly zoonotic diseases, such as HPAI and salmonellosis. The sustainability of the training program is largely in the hands of the private sector itself, although the support of government veterinary services will be required, particularly in relation to smaller producers. FAO should continue to support the poultry industry and the veterinary services in the development and delivery of training programs for stakeholder groups with specific needs in the poultry sector. FAO and counterpart government veterinary services should continue focusing on the identification of the most cost-effective approaches for reducing risk of disease spread at market chain critical control points and on farms. With a stronger evidence-base, specific highimpact practices can be targeted for future capacity building and advocacy programmes. In particular, FAO is keen to identify farm biosecurity practices, which will reduce risk from HPAI while also improving farm profitability. 59 A poultry farmer at the Rangpur Live Bird Market in Bangladesh 60 SOCIOECONOMICS 7 The secrets of the market T F Since H5N1 HPAI emerged in Southeast Asia in late 2003 there has been significant strengthening in the application of socioeconomic analysis to disease control programmes, from the perspectives both of FAO and national animal health authorities. The initial control approaches to HPAI focused on implementing technical activities without taking into account socioeconomic aspects, specifically compliance incentives. Since then there has been a steady evolution in the focus of socioeconomic enquiry. The early concentration on structure and function of compensation measures has given way to costs and benefits of technical activities and the integration of value chains with risk assessment and disease control strategy (FAO 2011; FAO 2012). There have also been inputs made to gender and understanding attitudes to disease and its control. Socioeconomics has now been mainstreamed into FAO’s approach to HPAI control. D A R Government systems and structures vary considerably and yet there was only one technical approach to the control of HPAI that often proved difficult to immediately adapt to the country in question. Socioeconomic analysis has been a very valuable mechanism to adapt technical guidelines to cultural and political landscapes. Situation in 2005 In the emergency mode of response to HPAI, there was some expectation that poultry producers would feel a responsibility or a need to cooperate with governments in controlling HPAI. However the global concern about H5N1 was also not locally grounded, and with the exception of Thailand, there was not a strong link between the poultry sector and the regions governments represented by the official animal health services. Many producers in the region did not belong to or have a producer organisation to represent their interests to government. This led to government services not having a reliable conduit into the poultry sector, and in some cases not being interested enough, to deal with them on key issues arising from the H5N1 control programme. The commercial sector did not receive technical inputs from the official animal health services, and in their turn often considered them as lacking the expertise to solve the private sector’s problems. Government services were usually treated with suspicion as they were mainly involved in regulatory activities. Good linkages between producers and official animal health services are thought to be axiomatic for the success of any disease control programme, and official services need to have a sound understanding of the structure and operations of the industry sector in addition to 61 -: Lessons from HPAI the professional competence to provide quality services. Because these conditions did not exist in 2005, FAO did not have a reliable conduit for engaging with the complex poultry sector. At that time, the international community was adhering to disease control models founded on OIE guidelines with a focus on international trade. This model was of little use in most countries as there was little understanding of incentives that would bring about poultry producers’ compliance with disease control measures, especially where there were no industry-based compensation packages for producers after stamping-out operations. Poultry producers adjusted to the effects of HPAI in different ways. Some sharpened their management and biosecurity practices while others simply went out of production. Where vaccines were available commercial producers used them to varying extents, with the commercial layer sector dominating (Hinrichs et al, 2010). When disease was suspected some producers responded by marketing birds to salvage some investment, a practice common early in the outbreak and still prevalent in some places (Otte et al, 2008). Throughout the region, the commonest business model was the low-investment family-run operation that represented a way to turn a labour asset into a financial asset. As long as the capital requirements were low and no outlay required on wages, small commercial producers could continue with low margins to sustain an essentially subsistence livelihood. Many operators choose not to invest in technical knowledge and so represented a huge challenge when it came to engaging them in a disease control programme. To them, HPAI simply represented another constraint to be dealt with in time-honoured ways other than scientific disease prevention and control. In some countries where production practices were diverse, a weakness in one part of the sector could easily threaten the more commercial side. For example, Indonesia’s commercial sector was not transparent about its difficulties in controlling endemic HPAI with vaccination. T F A R D At this time there was limited knowledge of the poultry sector across the region though there was much anecdotal evidence and conjecture about the possible role of cross-border trade activities in spreading HPAI. While FAO had some knowledge of the role of poultry in the small-holder livelihoods context, there was inadequate understanding of the impact of diseases and the strategies adopted by producers to deal with them. Initially the poultry production systems were differentiated by biosecurity levels (sectors 1 to 4), but there was limited knowledge about the different species used, the seasonality of production, market cycles and other parameters such as input supplies and costs. Where the vaccine had been introduced as a control measure, there was no information in 2005 about the costs and benefits of the programmes, or even if the vaccination strategies were cost effective. Mass vaccination programmes were in place in Viet Nam and Indonesia but there were major constraints to the implementation of this measure in small-holder poultry units, and the incentives for compliance were not completely appreciated. While it was recognized that women were heavily involved in small-holder poultry production especially with chickens, most programmes were not designed to reach them, resulting in a significant gap in outreach. Women, who were well represented in markets and marketing of poultry and poultry products, had not been taken into account and their needs integrated within disease control strategies. 62 7 The secrets of the market Situation in 2011 By the end of 2011 socioeconomic analyses of a range of issues related to disease control was well advanced in the region and the usefulness of the outputs was now well appreciated by animal health services. Poultry production systems and the main actors in value chains had been identified and characterized for the purpose of better understanding their disease control compliance incentives and efficiently targeting interventions (FAO 2011). In many countries poultry sector reviews have been made available to disease control planners and sector development policy makers (FAO 2004; FAO 2008b). HPAI control costs for vaccination, surveillance and culling have been assessed and can be used to budget the required financial resources for technically efficient disease control measures (McLeod et al, 2007; Hinrichs et al, 2006). Vaccination costs and willingness-to-pay assessments in Viet Nam showed that there is limited scope for public sector savings with more targeted or voluntary HPAI vaccination while maintaining an acceptable HPAI risk level. FAO and governments now have a clearer picture of the complexity of the poultry production sector and its concerns. In China value chain and network analyses identified LBMs as a high risk for the onward spread of HPAI to other markets (Martin et al, 2011). This enabled the prioritization of the limited funds available to increase biosecurity conditions in markets to these critical points in the chain. T F A R Regional Perspective The insights from socioeconomic activities and analyses have helped make some of the approaches to disease more compatible with national and regional circumstances. The tools used have been impact assessments, compensation frameworks, value chain studies, mapping trade flows, understanding incentives, cost benefit studies and control costs assessments (FAO 2011; FAO 2012). For example, it has been shown that rather than treating the borders themselves as risk points the issue to address is the nature of the value chain that crosses the border. Because many borders are porous, interventions into cross-border trade are not easy, and a risk-based approach based on the value chain has emerged as the most effective way to manage the disease risks. Investments into quarantine-type tactics at borders, still favoured by some administrations, are not really cost effective. Also awareness and behaviour change campaigns targeted to reduce the cross-border trade risk were ineffective in the face of the high economic driver of the price differential of the traded poultry products. Engaging directly with players in the chain so that they are aware of the role that they play and to provide them with tactics to manage risk has proven valuable. Overall there is increased knowledge about the sophisticated, complex and heterogeneous food systems in which disease occurs and surveillance strategies have been adjusted taking into account the trade flow of poultry products. The biosecurity-based classification of poultry production systems has evolved to one that takes into account the purpose for which poultry is produced and the value chain the product it is linked to. With respect to compensation programmes, there were still gaps in the application although models for improving compensation had been developed for Nepal and Viet Nam. D The considerable negative economic and social impacts of culling and movement control were determined and used to advocate for a more tailored use or disease control measure based on epidemiological assessments rather than a fixed 3 km ring (Otte et al, 2008). The estimated vast negative market impact from demand shocks was used also to advocate for enhanced risk communication. Examination of willingness to pay, vaccination costs and coverage of HPAI vaccination scenarios delivered the evidence that cost-effective vaccina- 63 -: Lessons from HPAI tion and substantial costs savings for the public veterinary service were not possible dual outcomes in Viet Nam. An important anthropological study in Cambodia described the attitudes of rural people to HPAI and HPAI control directives, noting that until behaviour change communication took note of and respected cultural beliefs about disease there would exist a gap between awareness and practice (Hickler, 2007). This study has greatly informed communications thinking and also disease control thinking. There were also important studies on gender issues related to poultry production and disease control in Cambodia and Myanmar as well. Country perspectives Cambodia: In 2005 little was known about poultry production systems and their value chains. Socioeconomic studies, which have been a major thrust of the activities, have supported the drafting of veterinary legislation, and also covered the following areas: T F • Socioeconomic impact and small-holder livelihoods assessments • Surveys of consumer preferences for poultry products, especially live birds • P oultry value chains assessments within the country and also at border areas A R • C haracterization of native chicken and duck production systems and the supply of ducklings • B iosecurity assessments of poultry markets and livelihood impacts of involved traders D These studies have greatly increased the understanding of the sector and of the tactics required for the efficient utilisation of resources for disease risk reduction. FAO began helping the Royal Government of Cambodia on drafting the animal health and production legislation on 2007 and after a lengthy consultative process with all the stakeholders, produced the final draft on November 2011. This is now with the inter-ministerial committee, and is expected to be approved and presented to Parliament by early 2013. China: Limited work has been done in China on social and economic aspects of H5N1. These studies have mainly mapped trade flows and the established social networks. In the current China epidemiological context where the clinical expression of the disease is becoming an exception, the Chinese National Veterinary Authorities face new challenges with the silent circulation and likely persistence of HPAI H5N1, in traditional LBMs or specific ecosystems where free-ranging duck-rearing systems are dominant. To address these challenges and design targeted risk-based surveillance and control interventions, better knowledge of HPAI H5N1 risk factors is required as well as innovative ideas for better integrating poultry production and marketing systems into risk assessments. Among these techniques, value chain analyses and social network analyses are playing an increasing role in describing infectious disease transmission patterns and guiding control policies elaborated by health authorities. Value chain analyses have provided an analytical framework to allow characterization of a part of the poultry industry as well as interlinkages among various actors in the industry. The work provides insights into the circulation of and dissemination of H5N1 virus in China, and assists in the design of market surveillance activities and prioritization of market biosecurity upgrading investments. 64 7 The secrets of the market Indonesia: In 2005 little information was available about the structure and complexity of the poultry market chain, or of the value of products at each point along the chain. In particular, the ongoing economic impact of H5N1 on commercial poultry production was not acknowledged by the industry itself; instead, industry representatives at the time claimed the disease was well-controlled via a combination of vaccination and biosecurity. The most successful practice in Indonesia has been direct engagement using participatory techniques with private sector stakeholders to better understand the structure of the poultry market chain, as well as to better understand how farmers manage their farms from an economic perspective. There has been progress on several fronts. The poultry market chains for layer chickens, broiler chickens, native chickens, and ducks have been described for Bali, North Sumatra and the greater Jakarta area (FAO 2007; FAO 2008; FAO 2008) and are now well understood. In addition value chain studies of commercial poultry production systems have elucidated where the value of product changes from input supply until output to the consumer. The on-going impacts of H5N1 on backyard poultry producers and small-scale market chain stakeholders have also been better understood through improved surveillance, targeted research and improved engagement between local government and poultry-rearing communities. Finally, the HPAI control programme has better clarified how specific management and vaccination changes impact on layer farm productivity and profitability, enabling layer farms to make better evidence-based decisions which reduce the risk of HPAI while also improving farm productivity. T F A R An important specific outcome was that the Jakarta market restructuring process was revised to include private stakeholder engagement and the option for private-sector-proposed relocation sites for poultry slaughter. A specific critical control point for the spread of HPAI to humans in Jakarta was identified via the native chicken market chain from Central and East Java. Also, the risk of continued interprovincial movement of H5N1 virus was better understood in the context of production and value disparities amongst provinces, for example between East Java and Bali. D Myanmar: FAO conducted a livestock sector review in Myanmar in 2004 but this did not have the level of detail on the poultry production systems that was necessary to understand the risk factors for the spread of HPAI. Today, though, the country’s animal health services have a good understanding of the principles of supply chains and their linkages to epidemiology and disease risk. There is now information on HPAI’s socioeconomic impact and its control on farmers and households. A large body of socioeconomic assessments were carried out based on individual family case studies on the impact of livestock diseases including HPAI on livelihoods, and is now an accepted approach that could lead to important policy adjustments. Gender studies carried out have already resulted in changes to the departmental training policy. There has also been an emphasis on supply chain studies linked to managing and understanding risks. Early work here focused on risk issues related to cross border trade but later risk assessments included high consumer centres as well as supply chains associated with areas of wild bird migration. A national data base of commercial farms has been created with all farms geo-referenced to provide information to assist disease control activities. A major national study was also done to describe the input and output chains for the poul- 65 -: Lessons from HPAI try sector. Training programmes have been conducted to fully integrate the supply chain methodology into disease surveillance approaches. Nepal: Various studies have been conducted before 2005 in Nepal on livelihood issues for rural families and poultry raising and marketing would have featured in them. Marketing channels and value chain approaches have been topics of studies conducted by various bodies including government, NGOs and academics. However, none of these would have had a focus on disease control. A national study on poultry production has led to an updated understanding of present day poultry raising in Nepal and confirmed the role of poultry in providing rural households with a readily realizable asset and valuable nutritional support. Another study has produced detailed information on market flows, volumes and the factors influencing them. This has informed the formulation and re-formulation of control and surveillance guidelines for the designation of high risk districts and active surveillance sites. World Bank funds have been used for providing compensation based on an updated compensation mechanism. The very existence of a compensation mechanism has had a positive effect on overcoming reticence to report poultry disease events to the authorities and is a critical element in passive surveillance efficiency. However, despite re-calibration, the amounts paid are still below the market values for adult birds. T F A R Lessons learned from the border trade and the effectiveness of regulatory approaches were particularly useful. Movement across Nepal’s open land borders are not controllable and internal animal health check points, properly manned and free from coercion, were identified as more reliable HPAI control measures. D Viet Nam: A government structure that has significant devolution of authority posed special challenges in Viet Nam. As part of a large effort to link disease control activities to the interests and focus of local authorities, value chains were mapped in pilot provinces including hatcheries for ducks and chickens. An atlas of commercial enterprises in pilot areas was also produced as a training tool as well as to guide efforts to understand poultry production. The visual perspective the atlas brought was useful in discussions with local planning authorities and informed poultry sector restructuring policies and development plans. The cost effectiveness of surveillance for HPAI, both active and passive, was compared between several projects for the years 2007 to 2010 at different time intervals. Important among the indicators for effectiveness of surveillance were the number of suspicious cases investigated, the number of confirmed cases, the time taken from reporting to investigation and the number of viruses isolated from positive cases. The study concluded that due to better management of the disease including the adoption of better control measures, the number of outbreaks in a given geographical region has reduced from year to year. With decreasing outbreaks, the cost of surveillance shows an increasing trend over the years. The study also concludes that the quality of surveillance has improved over the years thanks to better trained manpower, improved methodologies, increased awareness about the disease and deeper understanding of the disease at the field level. The GETS project between 2009-11 evaluated the cost-effectiveness of a targeted vaccination strategy in five project provinces. The strategy of vaccination focused on ducks, the high-risk source for HPAI, has shown positive results. By applying the strategy, the Government saved 21 percent in the cost of vaccination in 5 project provinces. However, because 66 7 The secrets of the market of implementing more monitoring activities, the cost of surveillance strategy increased fivefold compared to the pre-GETS period. The total public cost of HPAI control decreased by 4.7 percent compared to a reduction in public vaccine costs of 18 percent in the GETS period. Cross-border market chain studies have been very useful in illustrating that border controls are not effective in the face of a significant economic driver of trade and that a more strategic approach to managing the inevitable inflow of product is more effective in mitigating risk. FAO has facilitated bilateral discussions with China to look at the cross-border trade in spent hens and the potential risks this poses to the poultry sector in north Viet Nam. Establishing a ‘dirty corridor’ or slaughter before entry was identified as one option for reducing the high HPAI disease incursion risk from the informal import of spent hens. An integrated assessment was conducted of the animal health, socioeconomic and environmental impact of government-led poultry sector restructuring. Considerable profitability and disease spread risks were identified. The original policy of having high density mixed species animal production areas was subsequently modified and not implemented nationwide. Studies on the duck production systems have yielded a deeper understanding of production dynamics and the roles of the various stakeholder groups involved, including gender roles. T F A R Outputs 1. P oultry value chain mapping workshops conducted at borders of Laos, Cambodia, China and Myanmar, and border visits in Thailand and Viet Nam. 2. C ross-border HPAI risk assessment tool with twelve epidemiological and socioeconomic risk indicators developed and applied in risk assessments at six border regions. D 3. E xtensive poultry production and market chain study report prepared in Cambodia. 4. T wo flagship guideline documents produced: Taking a value chain approach to disease control and Designing and implementing livestock value chain studies (FAO 2011; FAO 2012). 5. C apacity building to conduct value chain studies and incorporate the methodology into surveillance systems. 6. S ocioeconomics training module developed and applied at regional FETPV programme. 7. R eport prepared on anthropological aspects of HPAI control in Cambodia, Bridging the gap between awareness and practice in Cambodia (Hickler, 2007). Outcomes 1. G reater understanding by animal health authorities of the need go beyond technical issues when undertaking disease control programmes. 2. V alue chain insights have now been mainstreamed into animal health surveillance and risk management strategies (FAO 2011; FAO 2012). 67 -: Lessons from HPAI 3. E asier identification of stakeholders and greater engagement of stakeholders in determining strategies for disease control along value chains facilitates the end implementation of disease risk reduction measures. 4. I dentification of different value chains in the region has increased understanding of the conduits of risk and their relative importance in disease spread (Hickler, 2007). This in turn has increased understanding of the institutional arrangements required to develop better control programmes, especially where cross-border issues are important. 5. V alue chain studies have provided assessments of trading volume, seasonality and socioeconomic drivers of trade, and identified public health risk and disease spread risks associated with trading practices. High risk points in value chains have been identified, which has potential to increase the efficiency of surveillance and control measures. In addition value chain studies have uncovered types of trade that require novel control interventions. T F Best practices 1. T he value chain approach is fundamental to achieving an understanding of the patterns and critical points in the poultry production and marketing chain, and facilitating risk management. Participatory interaction with stakeholders in value chains leads to solutions relevant to their interests and increases their engagement in the disease control programme and ownership of the outcomes (FAO, 2011; FAO, 2012; Martin et al, 2011). A R 2. A ttention is being increasingly paid to incentives of stakeholders in the poultry sector while designing disease control measures that depend on their compliance (Hinrichs et al, 2010). D 3. C ase studies and better understanding at the household level are very useful to inform government about the impacts of disease and control programmes on the livelihoods of the less privileged (Otte et al, 2008). 4. P roviding visual and two-dimensional imaging of production systems, market chains and trade flows using Geographic Information Systems and maps has helped communication with decision makers. 5. L ivelihood frameworks are useful for analyzing the contributions poultry production makes at stakeholder level and to design and assess the likely impact and acceptance of policy changes on stakeholders. 6. T he Inclusion of anthropological analysis can provide vital information on incentives and is a useful dimension to the multidisciplinary approach needed for addressing complex issues such as HPAI control (Hickler, 2007). Lessons learned 1. S ocioeconomics must be integrated into any disease control project for it to be effective, and should take into account stakeholders’ reasons for non-compliance. Required economic data must be collected in real time and in an integrated way as part of any disease control intervention. Interventions should be linked to or integrated with the needs of the disease control authorities to make the outputs 68 7 The secrets of the market useful to decision-makers and policy makers. 2. D isease control interventions should be assessed for likely animal and public health benefits against potential negative socioeconomic impacts and a response adopted which is proportionate to the assessed risks. Overreaching or what can be perceived as over-reaction creates barriers with stakeholders that can take a long time to break down. For example, global level concerns about H5N1 pandemic potential were not shared by producers whose livelihoods depended on the output from small flocks. 3. U nenforceable legislation which goes against the grain of age-old but economically unsound trading practices is counter-productive as communities and stakeholders will continue with the status quo and resist health inspection and other assurances of disease-free status. An assessment of regulatory capacity should be part of developing policies that require regulatory enforcement. T F 4. W here culling is used for control, compensation for slaughter must reflect the market value of the relevant class of poultry. However financial resources for compensation schemes are difficult to obtain, and without control practices and the cooperation of stakeholders, compensation alone might not improve control. Incentives for compliance are not always as expected. A R 5. G overnment disease controllers and the international community also did not recognize the on-going difficulties of the commercial poultry sectors in preventing and controlling H5N1. This partly reflected their lack of expertise in working with the commercial sector, but also lack of transparency within the industry, who distrusted government and had concerns about market shocks. Eventually more effort was made to create bridges to engage with the commercial sector. D 6. M ovement across open land borders is not controllable and in most cases internal animal health check points, properly manned and free from coercion, are likely to be a more reliable way to reduce the spread of HPAI. The internal poultry trade is very efficient at spreading HPAI. 7. F or trade generally and cross border trade especially, awareness campaigns generally produced no evidence of behaviour change in communities or traders who were unconvinced of the risks and were principally guided by economic factors inherent in commercial activity. Besides, while evidence and strategies for different policy approaches might have seemed compelling to international stakeholders, local authorities could sometimes be slow to respond because of the complexities of the policy environment and constraints to change. 8. A ssessment of the governance of poultry production systems and supports to strengthen the efficiency and operation of poultry production chains can have significant animal health and socioeconomic benefits. 9. K ey drivers for change are financial incentives coupled with financial risk minimization. Interventions that bring such financial benefits should communicate them effectively and credibly to those expected to comply with the changes proposed. 69 -: Lessons from HPAI Sustainability Outputs from socioeconomic interventions are appreciated by the animal health services and other stakeholders. The knowledge base will not be lost, but it will be hard for animal health services to find resources to conduct more investigations, especially as circumstances change. The expertise to do such work does not have a natural home in an animal health service and so it must be housed is another part of the Ministry – for example, a department of animal production – or sourced from outside the Government. Because of this, it is necessary to ensure that a certain capacity is maintained in animal health services to analyse and collect the required data, and to ensure more effective and efficient animal disease control. This will also allow for clearer engagement between veterinary services and policy makers, and thereby clearer access to funding resources. Within FAO, the value of the approach is now well recognised and it will be a component of any programmes in animal health. Future T F The control of HPAI and other high impact emerging and re-emerging infectious diseases can only be effective if incentives to stakeholders and the context within which they operate are taken into account. This would require detailed value chain, impact and control cost understanding and assessments for other livestock sub-sectors as part of any disease control intervention, project or program. This applies especially to any projects or programmes that are launched using a One Health approach. The programme should assess the potential impact of market chain-based interventions to reduce the risk of other emerging infectious pathogens concentrating along urban market chains and subsequently spreading to dense urban populations. Guidelines are needed for conducting HPAI impact assessments for use by governments. A R D The poultry industry in Asian countries contributes considerably to their gross domestic products and thus is a valuable national resource that must be protected. Poultry associations need to be kept on board with government policies towards HPAI control and prevention. Backyard, village level producers need more support and guidance on the spectrum of poultry-raising issues including husbandry and health so that poultry production may reach its potential to provide income and nutritional benefits to these community members. The HPAI programme needs to become more aligned to the issues facing poultry farmers from productivity and profitability perspectives as well as simple livelihood resilience. Poultry or general livestock sector development policies to achieve sustainable production with healthy animals must become integral to animal health promotion programmes. 70 7 The secrets of the market T F A R D Dressed to the hilt in ‘IEC material’, these Cambodian children watch the exploits of Super Kai, the super chicken shown on their caps, with rapt attention, at a community event. 71 A R T F D The satellite transmitter fitted on this gadwall in India will reveal its migratory movements. Preventing and mitigating the emergence of new pathogens requires new levels of monitoring, surveillance and research. 72 WILDLIFE HEALTH AND ECOSYSTEMS 8 Walking on the wild side T F Early in the HPAI emergency it was proposed that wild birds might have played an important role in the dissemination of H5N1 to new environments, especially the rather spectacular spread of the virus to Europe and Africa late in 2005. The H5N1 virus had been isolated from captive wild birds in the Hong Kong Special Administrative Region as early as 2003. There were opportunities for contact between poultry and migratory water birds, specially in rice cropping wetlands where both migratory waterfowl, long recognised as the natural reservoir of influenza viruses, and openly-grazed domestic ducks forage together. FAO was seen by both the public and the animal health sectors as a key player for developing a scientific base and technical capacity to address the role of wild animals in the epidemiology of avian influenza. One issue is how manage the risks that wild birds might pose and to avoid unnecessary impact on wild bird populations from overzealous disease management strategies. Situation in 2005 D A R FAO did not have an EMPRES Animal Health-Wildlife Health and Ecology Unit, and most wildlife-related activities were conducted through FAO wildlife officers in the Forestry Department with little emphasis on disease ecology issues related to the interface between livestock, wildlife and humans, or eco-health matters. There was a little work taking place in the disease domain within the animal health service, but no dedicated in-house wildlife expertise to support this. At the country level, general matters related to wildlife fell under the jurisdiction of the Ministry of Forestry’s equivalent of an environment department concerned with natural resource management including wildlife. Animal health services generally did not have established links to facilitate wildlife surveillance or investigations of outbreaks of disease involving wildlife species, and the responsible department generally had no wildlife health expertise. At the global level several large INGOs had strong interests in the issue of wildlife and the potential impact of H5N1 on wild bird populations. There were also a number of international conventions on wetlands and migratory species whose secretariats and field representatives were potential stakeholders in the outcomes of investigations and measures proposed. 73 -: Lessons from HPAI Situation in 2011 In response to the H5N1 HPAI emergency, FAO’s Animal Production and Health Division (AGA) hired a wildlife veterinarian to help determine the role of wild birds in the emergence and spread of HPAI. The EMPRES Animal Health, Wildlife Health and Ecology Unit came into existence in March 2006, and supported the FAO-OIE International Conference on the Role of Wild Birds and Avian Influenza. Initially, the Coordinator served at FAO as a seconded officer from the Wildlife Conservation Society (WCS) but as a result of the international conference and the priority that FAO placed on understanding the role of wild birds in the H5N1 HPAI situation, FAO directly hired the Wildlife Health and Ecology Unit Coordinator in July 2007. From 2006 to 2011 the Unit staff has grown to three within AGA at FAO HQ and one within ECTAD-RAP. The positions in the HQ Wildlife Health and Ecology (W&E) Unit and the Assistant Wild Bird Coordinator position to be stationed at FAO Regional Office for Asia and the Pacific -) were funded by several donors including the UK, Sweden, Canada, and Australia. As H5N1 viruses that cause HPAI have a strong interface with animals, wildlife and humans, in the context of capacity development, surveillance and outbreak response, biosecurity, or disease ecology studies, the Wildlife Health and Ecology Unit directly contributed to many USAID-funded activities. FAO respected USAID’s request to specifically focus their funding on HPAI issues in livestock rather than use it to support wildlife contributions to these activities. FAO also liaised closely with USAID’s GAINS programme to ensure that wildlife surveillance conducted by both organisations was complementary. T F A R The principal focus of the W&E Unit’s activities was the coordination of activities at the interface of wildlife and livestock systems, with some interaction with public health scientists also concerned about the movement of zoonotic agents either through domestic animals to humans or directly to humans. The Unit became a global leader in collaborative research projects aimed at elucidating the potential role of migratory birds in long distance movements of H5N1 viruses. The Unit was also heavily involved in developing capacity to respond to outbreaks and conduct surveillance at the wild-domestic bird interface; providing training within FETPV programmes; developing two influenza and wild bird training manuals; conducting international workshops and meetings; conducting field investigations; providing direct training in the safe handling of wild animals; and providing wildlife health expertise to international working groups and networks including working with UNEP-CMS to co-convene the Scientific Task Force on Avian Influenza and Wild Birds. D The Unit has developed a Wildlife Investigation in Livestock Disease and Public Health (WILD) module for FETPV and has delivered this training three times for African countries, once for southeast Asian countries, and once in China. Further courses are planned for Thailand and Bangladesh. Participants learn about the interface between livestock, wildlife, humans, and environment and their role as field epidemiologists in dealing with disease ecology, transboundary and EIDs. Specific attention is paid to: evidence-based decision making and cooperation among agriculture, natural resource and public health agencies, important diseases in their region, the role that wildlife may or may not play as disease reservoirs or in transmission, designing wildlife and domestic animal surveillance programmes, and identifying the role and importance of wildlife biologists in outbreak investigations. In south and southeast Asia, HPAI H5N1 surveillance and outbreak response strategies that incorporate wildlife have been developed for Bangladesh, Cambodia, China, Hong Kong, India, Laos, Mongolia, Myanmar, Thailand and Viet Nam. These were supplemented by wild- 74 8 Walking on the wild side life capture, handling and sampling field techniques training for Bangladesh, China, Hong Kong, India, Myanmar, Mongolia, Thailand, the Philippines and Viet Nam. Surveillance has involved farmed wild bird species in China; free ranging wild birds in Cambodia, China, Hong Kong, Mongolia and Thailand; and openly grazed domestic ducks in Bangladesh, China and Indonesia. The Unit has participated in CMC-AH missions to India, Nepal, South Korea, Turkey and an outbreak in Thailand. Training manuals produced to support the W&E Unit field activities include: 1. W ild Bird HPAI Surveillance: sample collection from healthy, sick and dead birds. FETPV WILD manual – translations 2. W ild Birds and Avian Influenza: An introduction to applied field research and disease sampling techniques T F 3. I nvestigating the Role of bats in Emerging Zoonoses; Balancing ecology, conservation and public health interest 4. FETV- Wildlife Investigation in Livestock Disease and Public Health Training Manual These have been supplemented by other publications including the Avian Influenza Task Force brochure; the Wildlife Health and Ecology Task Force brochures; the Philippines Bat Conservation brochure; the HPAI and Wild Bird Fact Sheet, a chapter on wildlife health and diseases as part of an FAO Forestry paper 167 Wildlife in a Changing Climate; a One Health chapter in Unasylva, an international journal on forestry and forest industries; and One Health – Integrating Aquatic Biosecurity into the Way Forward - A Natural Progression in the FAO Aquaculture Newsletter. A R D In RAP, the W&E Unit has led and collaborated in migration and disease ecology projects in Bangladesh, China, Hong Kong, India and Mongolia, providing information that contributed to more than 20 peer-reviewed publications. It also plays a technical leadership role in international networks such as the Scientific Task Force on Wildlife and Ecosystem Health (Co-Chair) partner in the East Asia Australasia Flyway Partnership, and as co-chair of the Wild Bird and AI Working Group within the partnership. The Unit helped organize large AI and Wild Bird Workshops with partners such as USDA, WCS, Mahidol University, and the Federation of Asian Veterinary Associations (FAVA). The W&E Unit has also co-led three annual Community based Risk-Modelling Workshops in Asia with many partners, a mechanism for advancing science related to global AI risk modelling (available at http://www.eomf.ou.edu/workshop/). Important global initiatives that the W&E Unit has also contributed to include OFFLU, EMPRESi surveillance and outbreak reporting modules, GLEWS, Movebank, the Earth Observation and Modelling Programme at the Oklahama State University (OSU), the United States Geological Survey (USGS), the Wildlife Health Event Reporter, and most recently, USAID’s EPT program. Beyond HPAI, the W&E Unit has engaged in activities including collaborations on bushmeat, disease transmission, food security and conservation issues, and livestock-wildlife disease transmission among cattle and African buffalo in transborder conservation areas. Other areas of collaboration have included landscape ecology, conservation, disease, ecosystem services, and public health issues related to interface issues among bats, pigs and people in South and Southeast Asia including Ebola Reston and Henipavirus projects; and FMD prevention and control among pastoralist cattle herds and Mongolian gazelles. 75 -: Lessons from HPAI The W&E Unit also made inputs to the FAO-AGA One Health Strategy (Sustainable Animal Health and Contained Animal Related Human Health Risks In Support of the Emerging One Health Agenda), the joint FAO-OIE-WHO-UNICEF-World Bank Strategic Framework Contributing to One World One Health, the FAO inter-departmental One Health Workshop, and the GLEWS collaboration between FAO-OIE-WHO for moving into the One Health domain by supporting broader activities on wildlife health, food safety and fisheries. Outputs The programme’s chief outputs have been in capacity development, studies of migration and disease ecology, and training materials. 1. Over 500 professionals trained in surveillance and outbreak response. 2. A bout 10,000 surveillance samples collected and analysed for H5N1, and reports prepared from five outbreak responses to determine the role of wild birds in HPAI events. T F 3. 5 56 satellite transmitters deployed on 23 species of waterfowl in 12 countries, and the information published on AI disease ecology and the role of wild birds. A R 4. Two manuals produced on wild bird field techniques and sampling. Outcomes 1. I ncreased participation of wildlife health professionals in investigations of the role of wild birds in HPAI ecology, and poultry mortality event investigations at national and regional levels. D 2. Inclusion of wild bird surveillance in national influenza surveillance strategies. 3. T he understanding that wildlife species are not reservoirs of H5N1 HPAI. Additional information from outbreaks in wildlife along the central Asian flyway and East-Asian-Australasian flyways demonstrated that wild bird populations continue to suffer from mortalities due to different clades of H5N1 HPAI. 4. G reater standardizzation of approaches to field investigations and interventions, thanks to the translated training materials that have provided accessible resources for field workers. 5. I ncreased awareness that FAO’s expanded in-house agriculture expertise goes beyond food security and livestock health to also encompasses ecology, conservation, environmental and human health. The engagement with international networks has provided valuable technical leadership and helped guide global efforts in synchrony with principles established by FAO and OIE. 6. R outine integration of the wildlife component into standard HPAI programming and activities by FAO ECTAD teams and RAP. Raised awareness among the veterinary, biology and public health communities about the actual role of wild birds in H5N1 HPAI. 7. I ncreased global visibility for FAO’s leadership, demonstrating how the integration of wildlife expertise and collaboration among between human, animal and ecosystem health is crucial to addressing the global HPAI crisis – a true One 76 8 Walking on the wild side Health approach which now goes beyond avian influenza and includes activities with international partners, multilateral environmental agreements, and other UN partners. There is greater acknowledgement of FAO’s activities and capacity on the wildlife-livestock interface among international organizations and country partners. Successful practices 1. I nclusion of Ministries of Agriculture, Forestry/Environment and Public Health in training programmes. This has developed trust among partners and crosspollinated areas of expertise. 2. I nclusion of Ministries of Agriculture, Forestry/Environment and Public Health in joint planning for surveillance and outbreak response. For large projects such as those on disease and migration ecology, planning, coordination and implementation must involve at least the Ministries of Agriculture and Forestry/ Environment. T F Sustainability Reduced funding has resulted in loss of staff and decreased ability to build capacity, conduct surveillance, and carry out disease/migration ecology projects. Because of its engagement in several large collaborative partnerships, FAO can continue to provide expert opinion and feedback to help address important issues. In countries where local expertise has been developed, FAO can work with these trained personnel, utilizing a One Health approach to support human-animal-ecosystem health initiatives. Future D A R The W&E Unit can continue to contribute significantly and lead One Health initiatives and global animal health concerns. Much work remains to be done on the bats-pigs-peopleOne Health surveillance approach in south-east and south Asia with some emphasis on the Philippines, Thailand and Viet Nam, especially the follow-up on the Ebola-Reston results from the FAO TCP in the Philippines. The FETPV WILD courses need to be expanded to more countries, and a Wildlife, Ecology and Environment (WEE) training course and manual developed for natural resource managers and biologists from the Ministry of Forests/Environment and other partner Ministries. To this end the W&E Unit can also contribute to the finalization of the National One Health strategic framework for Bangladesh and for other interested countries in the region. The role of wildlife in livestock diseases such as FMD will also require further investigation as regional efforts at FMD control gather momentum. The ultimate One Health challenge is working towards biodiversity preservation, sustainable natural resource consumption, and maintaining resilient ecosystem services while improving food security globally, in light of global demographics. 77 T F A R D Backyard farmers in Bangladesh help develop a participatory curriculum that will help them understand the science behind biosecurity — but in their own terms 78 COMMUNICATION AND ADVOCACY 9 Messages to the farm T F Communication was originally promoted as the best remedy for a raft of disease control problems. FAO has never had direct involvement in mass communication for behavioural or social change, which was mandated by the UN to UNICEF instead. However, UNICEF’s experience and approach were stronger in matters of human health, in which it had institutional technical support and experience; this was not the case in communications concerning animal health and poultry production related issues, where it had no in-house experience or support. Also, UNICEF’s working model was to seek initial technical input and then independently develop simple messages to be applied regionally, which created difficulties sometimes when the variable local contexts of animal health and poultry production were not fully taken into account. Developing communication for farmers with production and profit issues was not the same as straightforward symptom-and-action based human health messages. There were periods when FAO’s energy and efforts were being expended in re-aligning mass communications campaigns with the reality of farming systems and poultry production in particular. In general, there was often a cultural void between the agencies that had singular communications roles, and FAO, with its more overview position on the disease control programme and closer alignment to government priorities. A R D While direct donor investment into communications activities declined over six years, FAO’s understanding of the role and nuances of communication, and its proper role in HPAI and later One Health programmes, has grown. In addition, it has garnered deep experience in the proper and systematic use of advocacy to meet regional policy and structural goals such as FETPV and One Health. Going forward, it is important that the previous model of communications and advocacy, in which FAO was mined for technical information and then not engaged in the implementation process, is not repeated. ECTAD set up its communication unit at the FAO HQ in Rome in June 2007, in response to demands for strategic policy guidance, technical assistance, advocacy, capacity development in animal health communication from member countries, as well the need to mobilize new resources through advocacy and communication. The goals of communication and advocacy at this time were predominantly institutional and not directly related to disease control. At this time there were communications officers in seven of the national ECTAD teams, who were fully engaged in a range of communication and advocacy approaches to suit the national environments they worked in. The first version of an institutional communication strategy document , which required more 79 -: Lessons from HPAI intense interaction at the field level to drive and mentor, would not emerge until 2009, a year after a communications unit was established at ECTAD-RAP. FAO’s accumulated insights and analyses into the role of communication in social and behavioural change, informed by technical and ground-level realities in animal and human health sectors, led in 2011 to a regional communication strategy framework, Seeing around corners. This document also marked FAO’s maturity from a variable player in disease control communication to one with significant offerings and influence. Situation in 2005 UNICEF was the designated recipient of major international financial support for communications activities; the coordination between FAO and UNICEF was not smooth or fully effective. Early in the regional effort communications staff were placed in countries to get some traction with key communications programmes required to support the official animal health services in undertaking HPAI control actions, including vaccination if used. There was virtually no expertise within animal health departments to undertake these critical activities and the communications area was rapidly filled with INGOs supported directly by donors but often with no interaction or dialogue with the official animal health service or international technical agencies. While ECTAD-RAP’s work across the region has inevitably entailed continuous advocacy at institutional and governmental levels, FAO initially had little presence in the area of strategic communication for social or behavioural change in response to HPAI. T F A R Situation in 2011 ECTAD-RAP has made significant and influential contributions to strengthening the understanding and practice of advocacy and communication across countries of the region, and is recognized today among agency partners, donors and NGOs as an important and influential partner both in communication and advocacy. As the HPAI programme progressively focuses on EIDs, with emphasis on multisectoral collaboration between human and animal health, FAO role, expertise and contributions to communication and advocacy become uniquely relevant, and it is important that this position remains buttressed. D Regional perspective ECTAD-RAP’s communications activities were mainly in supporting ECTAD country teams in their communication activities on animal health, including field missions, and the production of associated country-specific communication and advocacy materials; and supporting the ECTAD country teams through participation in field-missions. There was also engagement with regional initiatives such as those directed by UNICEF or involving UNSIC. FAO’s communications efforts provided accurate, consistent and timely information to policy makers, regional and international partners, media, livestock producers and traders and consumers to help them inform the public about the disease situation, raise awareness, promote prevention and control measures, and mitigate market shocks when disease outbreaks occurred. Through its understanding of community and individual beliefs and practices, FAO promoted a more effective and focused, community-based approach to communication and public awareness. In collaboration with partners FAO has conducted knowledge, attitude and practice (KAP) studies and anthropological research (in Cambodia, Indonesia, Lao PDR, Timor-Leste and Viet Nam) to better understand the dynamics of community and individual beliefs and 80 9 Messages to the farm behaviour, and incorporate this knowledge into communication plans. Studies have also resulted in the development of audio-visual materials, behaviour guidance, and advocacy and information documents to ensure better understanding of strategic issues and promote FAO’s role in the prevention and control of HPAI. Technical assistance and capacity development for communication planning have been provided, with emphasis on strengthening capacities and competencies of Ministries of Agriculture and Livestock Departments. Since the establishment of the Regional ECTAD Communication Unit, communication strategies have been developed or revised in Cambodia, Indonesia, Lao PDR and Timor-Leste. Trainings to develop capacity have been conducted in Bangladesh, Cambodia, Indonesia, Lao PDR, Timor-Leste and Viet Nam, including the training of CAHWs as grass-roots level communicators; continuing education for animal health officers for community mobilisation and awareness raising; community forums that enable community members to increase their knowledge and capacity for decision-making on HPAI prevention; market forums to provide knowledge and influence the behaviour of stakeholders in poultry production and market chains; and community biosecurity initiatives to encourage communities to identify and develop biosecurity measures. Training materials have been developed, such as flip charts, printed materials and animated training DVDs. Initial analysis of programmes show an increase in awareness among audiences and an increase in trust towards animal health workers as the primary sources of information on animal health, husbandry and disease. T F A R ECTAD-RAP made significant contributions to both communication and advocacy in the southeast Asian region. The most influential of these is One Health: Seeing around corners, the first ever regional strategic communication framework that is driven by One Health considerations and proposes specific new directions and shifts in communication for social and behavioural change. The document is the result of a collaborative effort that has included UNICEF, UNSIC and WHO SEARO, among others. D As a result of specific international support a Media Fellowship Project entitled The Human Face of Avian Influenza was launched by ECTAD-RAP in Viet Nam and Indonesia in order to bring journalists working in various media in contact with FAO and to improve the technical quality of the media products routinely produced. Country level perspective Countries of the region had no capacity to undertake communications activities or interact with NGOs and INGOs who were carrying out communications. The situation varied from country to country, and FAO, because of its strong links to the government system, focussed on strengthening the capacity of government services to deliver communications programmes, while at the same time delivering communications where there was a perceived gap. Where donors preferred to work through INGOs, FAO established working relationships with these parallel systems, setting up working groups to coordinate and harmonize the programme if a number of other parties were involved. Community awareness activities conducted through these processes have reached tens of thousands of farmers, with information about risk reduction, HPAI prevention and control measures. Where necessary, FAO has helped by producing in-country materials, including video films, printed materials, television and radio broadcasts. Some examples of the modalities are outlined below. 81 -: Lessons from HPAI Collaboration and coordination In Cambodia and Lao PDR, where in-country communications operatives were actively involved in field activities, FAO collaborated and coordinated with WHO, UNICEF, and the NGO designated by USAID to carry out the communication programme, the erstwhile Academy for Educational Development (AED). In both countries, FAO participated in building capacity within the government system to deliver communications and also to training key community persons at the next level; and engaged with trusted figures in the community such as village chiefs, local veterinary workers — CAHWs in Cambodia, VVWs in Lao PDR — and the Lao Women’s Union. In both countries FAO was an active participant in national level working groups that coordinated the communications effort, such as the National Coordinating Committee on IEC for AHI in Cambodia. Since Lao and Cambodia hardly have any commercial sector and the disease occurred only sporadically, the effort was to reach as many communities as possible in higher risk areas to stimulate dialogue among villagers about HPAI. In Cambodia, there were specific activities with community forums, and a large effort was put into building the communications capacity of provincial and district officials, as well as village chiefs and CAHWs, both influential with the public. FAO’s anthropological study in Cambodia, Bridging the gap between HPAI awareness and practice in Cambodia, revealed that high levels of awareness about HPAI did not lead to much change in community attitudes and behaviors towards managing the disease. In Lao PDR there was more participatory training involving provincial officials interacting with village chiefs, VVWs and representatives of the Lao Women’s Union. T F A R Participatory approaches D While community participatory approaches were strongly deployed in Indonesia, there was a particular emphasis on training the official veterinary services in these approaches. Also, since government capacity to develop technical communication support materials was low, FAO helped produce these. Participatory approaches have been shown to be effective for developing IEC materials and delivering messages to a range of target audiences, and the use of these processes ensured the development of appropriate materials by stakeholder group and by gender. FAO trained a network of 2500 local animal health workers trained in basic participatory communications and supplied them with standardised training materials. Technical support Initially, FAO supported Viet Nam’s animal health service with mass communications related to the vaccination campaign and disease control such as early reporting and safer practices for poultry production. However when resources available to FAO for general communication were withdrawn, FAO became a key member of the working group for behaviour change communication. Communications was implemented by UNICEF and carried out by NGOs engaged by UNCEF or USAID, and FAO provided technical advice to UNICEF as the agency had no in-house experience or technical expertise in issues regarding farmers, poultry production or animal diseases. FAO’s technical input was a key to the technical direction and the ultimate efficacy of the programme at the small-holder level. There was a locally intense communications programme within the GETS programme that was designed to specifically deal with technical issues at the project level. There were also considerable advocacy inputs from FAO to ensure policy level support for the project at the 82 9 Messages to the farm level of local administrations. Both inputs were key to the success of the GETS project. Training materials In 2006 a significant effort was made to standardise training curricula and to ensure that training materials produced nationally were being properly validated. Across the region many different training materials were developed quickly to initiate the large training programmes required to lift technical understanding of the animal health system as well as for key community persons. However, FAO did not have people experienced with extension methods, and the training principles being used had not been standardised.. An important issue for consideration in the future is the role of government extension services, which in many countries are very well developed although traditionally have only been concerned with agronomy. Animal health services have not always been enthusiastic about using extension services to assist with training and perhaps this resulted in some inefficiency. T F Advocacy FAO had significant involvement in various international and regional forums to advocate for the need to control HPAI at source. In the early days of this, there was a bias towards the human health side of the issue where the focus was chiefly on pandemic preparedness. It was clearly necessary to advocate for an increased focus on the problems confronting poultry producers at all levels. FAO was active in UNSIC, provided technical inputs to the Asia Pacific Economic Cooperation (APEC) forums, had a strong technical interaction with ASEAN in promoting better disease control practices through the ASEAN strategy, and has been a key player in raising critical issues at the level of IMCAPI. FAO has been able to convene Ministers of Agriculture at the Asia regional level and at the ASEAN level (meeting of Ministers of Agriculture and Forestry) to advocate for HPAI policy proposals. A R D FAO has worked closely with international partners such as OIE, WHO, UNICEF, UNSIC and World Bank to develop global and regional plans. A good example of this has been the consensus on the approach to dealing with EIDs, described in the interagency document Contributing to One World One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Human-Animal-Ecosystems Interface (FAO et al, 2008). Guided by this approach, the global conversation has begun to move away from emergency response against individual diseases towards including more measured and integrated action for the long-term prevention of EIDs. Annual strategy review meetings provided FAO with an influential forum for advocating for technical changes to national strategies. Within the HPAI control programme in Indonesia, FAO has invested considerable effort towards developing strategic plans and presenting these to government and donors, as well as strengthening links between the government veterinary services and the commercial poultry sector. FAO has successfully engaged with the laboratory system in the global programme OFFLU to have viruses submitted to reference laboratories for analysis. ECTAD-RAP coordinated an assessment of existing national legislation relevant to disease control and prevention, examining the regulatory frameworks of ten south and southeast Asian countries and evaluating the adequacy of practical measures necessary for the prevention, detection, containment and eradication of epidemic diseases of livestock, particularly HPAI. Among the important recommendations, presented in the Regional Workshop on Strategic and Legislative Aspects of Controlling Highly Pathogenic Avian Influenza and 83 -: Lessons from HPAI Emerging Infectious Diseases held in September 2008 at Bangkok, was that FAO should coordinate the development of a regional agreement on information sharing about regional and country level animal health legislation reviews. As part of planning processes to support advocacy the following were developed and used to guide the HPAI programme in the region: A Strategic Framework for HPAI Prevention and Control in Southeast Asia (May 2006) The Global Strategy for Prevention and Control of H5N1 Highly Pathogenic Avian Influenza (October 2008) The FAO Regional Strategy for Highly Pathogenic Avian Influenza and other Emerging Infectious Diseases of Animals in Asia and the Pacific,- (July 2009) FAO Regional Strategic Framework for Communication on Highly Pathogenic Avian Influenza and other Emerging Infectious Diseases in Asia and the Pacific,- (August 2009) T F Outputs 1. C ontributed to One World One Health: A Strategic Framework for Reducing Risks of Infectious Diseases at the Human-Animal-Ecosystems Interface, an inter-agency document that has guided the move towards greater intersectoral collaboration between FAO, WHO and OIE. A R 2. P roduced Farmers in dialogue and Messages from the farm, two video films documenting successful practices related to communication, biosecurity and outbreak response. D 3. D eveloped regional One Health communication strategy framework, Seeing around corners. 4. H elped countries of the region to develop first drafts of advocacy action plans to promote One Health at the country levels. 5. D eveloped and field-tested a 13-session biosecurity training module that use dialogue-based approaches to build a scientific understanding of the science underlying biosecurity to non-technical, low literacy audiences. 6. D eveloped training materials for animal health workers to strengthen their understanding of HPAI and their capacity for communication with poultry producers at grassroots level. 7. D eveloped training-of-trainers materials (flip charts, disease recognition booklets, and information brochures for farmers) for veterinary officers. 8. I nstituted Media Fellowship Programmes in Viet Nam and Indonesia that resulted in training of 9 media practitioners in responsible reporting on HPAI matters and development of communications resources in both countries 9. C ontributed technical oversight to the UNJP programme on behaviour change communication in Viet Nam. 10. Produced newsletters and bulletins at national level to provide regular information to stakeholders 84 9 Messages to the farm 11. In Indonesia, video films produced on biosecurity for small scale broiler and layer farms, backyard chicken production and hobby birds, and an animation film on how viruses spread for communication with particular target groups. 12. In Viet Nam a film produced in 2008 titled Viet Nam Experience was also reproduced for IMCAPI and was well appreciated by the Government of Viet Nam 13. Developed a FAO website exclusively on HPAI in Viet Nam. Outcomes 1. E ffective and sound training of large networks in the animal health systems across the region. 2. F AO is now in a strong position to advocate and influence the direction of One Health projects in respect of the animal health sector. T F 3. Linkages to partners such as WHO and ASEAN strengthened. 4. B etter understanding of the challenges and requirements of communications for raising awareness and behaviour change. A R 5. I ncreased understanding of the need for country-level strategies to promote One Health across the region, leveraging the growing tripartite collaboration between human health, animal health and wildlife sectors. Successful Practices 1. D ocumentation of country-level successful practices in video and print has been useful for advocacy at the national level, and can also be adapted regionally. D 2. T he use of dialogue-driven participatory processes and tools created understanding and ownership of technical knowledge about infection, transmission, biosecurity and prevention among non-technical audiences such as farmers. 3. R egular review of plans and strategies in partnership with stakeholders helped create greater ownership of policy changes and commitment and uptake by national partners. 4. J oint training of animal and human health staff built synergy and ensured that messages were synchronized and reinforced. 5. T he engagement of a poultry disease specialist with experience in training and communications at the grassroots level and also with evaluation of materials was instrumental in developing a large body of communication materials especially in Indonesia. 6. I n Indonesia, talkback radio was effective as it addressed local concerns in the local language. Questions and comments were analysed to better understand community concerns. 85 -: Lessons from HPAI Lessons learned 1. T here were sometimes multiple players in communication developing messages independently from a narrow technical base and without consultations to harmonize all communication strategically. Sometimes messages were reprogrammed or recycled from other sources and not adequately field tested which led to a glut of sometimes unachievable or inappropriate messages, creating confusion for stakeholders and government partners. In Viet Nam for example a review in 2008 found there was a large number of different messages being promulgated by different players and these has to be aligned, simplified and reduced to prevent the problems that were arising. 2. T here is a clear need for FAO to provide leadership developing guidelines, tools and processes for interpreting and communicating technical information to non-technical audiences such as the government and some farmers. Without such leadership, the poor understanding of technical issues among the ‘nontechnical’ agencies involved in communication becomes the weakest link in communication. T F 3. C ommunication professionals need to weigh the potential of a campaign to promote safe poultry and animal production practices and appropriate consumer behaviour with consistent, scientifically sound messages, against its potential to create local market and trade disruption when communications programmes are implemented. A R 4. T he complexities of poultry production and marketing chains are only just being addressed in national communication strategies; and motivational factors among communities and producers to adopt safe production practices are still not fully understood due to limited analysis of socio-economic/cultural realities. It is essential that communication specialists integrate their response with and incorporate the knowledge from predictive modelling, socio-economic research, supply/market chain analysis, cross border studies, KAP studies and participatory research in order to strategically target high-risk audiences with appropriate, feasible communication recommendations and messages. D 5. T he lack of communication capacity within Ministries of Agriculture and Departments of Livestock Services to respond effectively to HPAI and other EIDs at the beginning of the crisis created significant imbalance in the effort to control the disease and engage communities. Communication capacity needs to be enhanced at these levels. 6. E nhanced capacity of national authorities in surveillance and prevention of disease, together with response to outbreaks of disease, necessitated regular review and revision of National Communication Strategies and the communication component of national emergency preparedness plans. This was achieved by a collaborative and coordinated approach, involving national and sub-national, multi-sectoral authorities, UN agencies and international organisations, donors and other stakeholders, through establishment of formal structures, including National Communication Committees/Working Groups. 7. Coherent messages across sectors reinforce those messages with the community. 86 9 Messages to the farm It is important to establish the cross-sectoral approach at the beginning of the project as it is more difficult to do once the different sectors have become set in their thinking and operational modalities. 8. F AO is probably better placed by maintaining a low profile in communications and leading ‘from behind’ through processes of collaboration and cooperation. This was a major problem early in working with UNICEF. FAO’s image is as a technical lead agency, and communication is not seen as either its mandate or area of strength, especially by USAID. However, the same agency recognizes and funds FAO’s activities in advocacy, recognizing that FAO is uniquely placed to lead in this area. FAO’s technical dominance and its intense activity at humananimal-ecosystem interface places it uniquely for making valuable inputs in communication. T F Sustainability Mass communications that require community engagement require a level of financial support that is unlikely to continue. However strategic communications and advocacy will be a significant component of One Health approaches to problems and it is important that FAO leverages lessons learned and develops guidelines and approaches for maximizing the efficacy of communications within a multisectoral and multidisciplinary programme. A R ECTAD-RAP’s current approach towards both communication and advocacy is tending towards regional level strategies and guidance followed up by national level initiatives. At present considerable animal health communications capacity is in the hands of individuals and is not institutionalised because like socio-economics, communications expertise does not have a natural fit within animal health services. Reducing external resources support for animal health services and communications threatens progress made to date. To sustain the communication capacity built within AHSs, it is necessary to empower the AHS to deal with communications professionals and pursue the course that they see as technically appropriate to the problem at hand. This may be done partly through One Health initiatives, but it may also be necessary to have a communications network that includes animal health professionals across the region. Future D ECTAD-RAP will continue working closely with the animal health services of national governments to ensure close alignment between technical directions of disease control programmes and the advocacy needed to bring about policy and regulatory changes to facilitate disease control efforts. FAO will probably not directly undertake mass communication programmes directly but it will need to take a strong and equal role in helping develop guidelines, strategic frameworks for communication and advocacy, tools, process, and overall guidance, both for HPAI and for One Health projects. To ensure that communications plays a supporting rather than independent role in the field, FAO’s technical leaders will need to be well versed in communications theory and practice. Building and strengthening this capacity will be a key role for a communications practitioner in RAP. There is potential for FAO to engage with existing extension services to deliver communication about biosecurity, improved production management practices and general animal 87 -: Lessons from HPAI health, especially poultry health. Some quality control of the extension process is advisable here as there is generally not resident animal health expertise within national agricultural extension services. A R T F D 88 Risk map of a Bangladesh farm showing virus hot spots, prepared by backyard farmers after they underwent a two-day biosecurity course. T F A R D ECTAD-RAP staff help prepare a gallery walk past posters displaying successful practices and lessons learned from the fight against HPAI in the region since 2005. 90 10 Lessons learned T F Policy Legislation that cannot be enforced is usually counter-productive. Unenforceable legislation which goes against the grain of age-old but economically sound trading practices is counter-productive, as communities and stakeholders will continue with the status quo and resist health inspection and other assurances of disease-free status. An assessment of regulatory capacity should be part of developing policies that require enforcement. A R An example is the Nepal law that bans the direct import of poultry, eggs and other poultry products across the highly porous 800 kms border with India. The legislation, which runs counter to economic good sense as these products are significantly cheaper on the Indian side, has effectively turned cross-border trade into a clandestine activity. This has also reduced opportunities for authorities to inspect poultry and poultry products imported thus. Coordination D Understanding developmental issues is critical —even in an emergency response. By maintaining a development perspective while working in emergency modality, FAO has helped transform the scope and perspective of disease control, widening the focus to include livelihoods and socioeconomic factors, nutrition and other development aspects. This has in turn helped foster a spirit of professional partnership and collaboration between FAO, donors and governments, based on an acknowledgment of comparative advantages. Surveillance Targeted surveillance needs more work; passive surveillance is unreliable. Targeted surveillance CAN be useful for detecting the virus in healthy birds, but systems of tracing to source are not yet reliable. More effort is required to understand how to monitor virus levels in the population to measure either the impact of control measures or to get early warning of a possible upsurge in the level of virus activity. Passive surveillance can be unreliable especially when commercial operators conceal out- 91 -: Lessons from HPAI breaks because the compensation offered is not adequate to fully cover their economic losses. Proxy indicators of disease outbreaks such as market prices also need to be monitored to detect hidden problems. Epidemiology It is important to regularly isolate and characterize viruses. The importance of regularly isolating and characterizing viruses from field outbreaks has been well recognized in Indonesia. The early problem with poor vaccine efficacy in Indonesia was recently rectified by incorporating the appropriate virus strain compatible with the circulating viruses in the field. Monitoring and characterising field virus isolates for changes in behaviour may assist in signalling vaccine failure, and possible spread and new outbreaks of disease. For example, the genetic subgroup of H5N1 Clade 2.3.2.1 was able to break through the vaccine used in Viet Nam. The increased susceptibility of wild birds to this genetic sub-group is associated with the spread of the virus to Bangladesh, Bhutan, China, India, Japan, the Republic of Korea, Lao, Myanmar and Nepal. T F A R Laboratory capacity The secret recipe for developing capacity is backstopping. Establishing technical working relationships with national laboratory staff and offering backstopping support has been an important feature of the FAO strategy for strengthening laboratory performance and developing viable and active laboratory networks. This has involved visiting laboratories, helping with on-site solutions to problems, liaising with regional organisations, developing standardised approaches for diagnosis and conducting workshops. D The global OIE/FAO Network of Expertise on Animal Influenza (OFFLU) has had a strong technical engagement in the region, which has helped spread technical advances and strengthened linkages between national laboratories and the global network. The close linkages have also improved the submission of viruses to international reference laboratories, leading to deeper understanding of viral strains in circulation. Laboratory experts must be made available when needed to help national staff set up equipment, establish diagnostic tests and prepare Standard Operating procedures (SOPs). On-site training was greatly facilitated by experts ‘in-residence’ who helped speedily introduce new technology into laboratory systems. In several countries, a national level network that linked laboratory scientists to field epidemiologists helped improve the outcomes of diagnostic efforts. Biosecurity Local solutions work better than imported ones. Considering the complexity and variation within the commercial poultry industry throughout the region, solutions developed locally through direct engagement with stakeholders have been more effective than those ‘imported’ from other regions. 92 10 Lessons learned Training and capacity building exercises in cleaning and disinfection practices were most effectively delivered by trainers with practical experience in adult learning methodologies as well as cleaning and disinfection rather than trainers provided by an equipment vendor or other sources. Socioeconomics Socioeconomics must be integrated into any disease control project for it to be effective. Disease control fails and leads to non-compliance when it does not take socioeconomic factors into account. Stakeholders’ reasons for non-compliance should be understood and economic data collected in real time in an integrated way as part of any disease control measures. Interventions should be linked to or integrated with the needs of disease control authorities to make outputs useful to those who make decisions and policies. T F The response should be proportionate to the risk. Disease control interventions should be assessed for likely animal and public health benefits against potential negative socioeconomic impact and the response adopted should be proportionate to the assessed risks. Over-reaching or over-reaction can distance stakeholders and set up barriers that can take a long time to break down. For example, global concerns about H5N1’s pandemic potential were not shared by producers whose livelihoods depended on the output from small flocks. A R Compensation should reflect the economic value of poultry. Where culling is used for control, compensation for slaughter must reflect the market value of the relevant class of poultry. However financial resources for compensation schemes are difficult to obtain, and without control practices and the cooperation of stakeholders, compensation alone might not improve control. Incentives for compliance are not always as expected. D Financial incentives coupled with financial risk minimization are key drivers for change. Interventions that bring such benefits should communicate them effectively and credibly to those who are expected to comply with the changes proposed. Communication Awareness alone does not change behaviour or practices. Awareness campaigns have generally produced no evidence of behaviour change in communities or traders, who remained unconvinced of the risks and were principally guided by economic factors. For instance, in Nepal, a country where HPAI communication largely failed to bring about behavior change, messages lost their credibility through overemphasizing the threat of human fatalities. In addition, the initial emphasis on the negative aspects of HPAI rather than the benefits of adopting hygiene-based measures like cooking at high temperatures alienated commercial producers, who saw their livelihoods threatened by the messages. The motivations of communities and producers to adopt safe production practices are still not well understood due to limited analysis of socioeconomic and cultural realities. Communication specialists should compile their knowledge of target audiences through 93 -: Lessons from HPAI diverse tools including predictive modelling, socioeconomic research, supply chain and market chain analyses, cross-border studies, Knowledge-Attitude-Practice (KAP) studies and participatory research. Communication campaigns developed on such a rich understanding are less likely to alienate audiences who are at risk from highly pathogenic and emerging diseases. Participatory approaches work better. Participatory approaches such as those used in the Field Epidemiology Training Programme for Veterinarians (FETPV) and the Participatory Disease Surveillance and Response (PDSR) programme in Indonesia have demonstrated that outcomes improve when relationships are established with communities. Field veterinarians have participated well in surveillance and outbreak control activities, but need to be trained in basic epidemiology and the proper collection, storage and submission of samples. In the case of PDSR, there was an increase in passive surveillance and self-reporting when communities were brought in participatively. T F Establish cross-sectoral collaboration early. Coherent messages across sectors reinforce those messages within the community. It is important to establish the cross-sectoral approach at the beginning of the project as it is more difficult to do once the different sectors have become set in their thinking and operational modalities. A R Building government capacity is key. The lack of communication capacity within Ministries of Agriculture and Departments of Livestock Services to respond effectively to HPAI at the beginning of the crisis created significant imbalance in the effort to control the disease and engage communities. Communication capacity needs to be enhanced at these levels. D From a disease control and prevention perspective, different government sectors should be equally competent in communication, and doors to inter-sectoral communication need to stay open at all times. Also, building commercial poultry health competency within local government veterinary services is necessary for improved communication and trust between local government and commercial poultry farmers. 94 T F A R D Viet Nam’s Farmers Clubs are demonstrating that the participation of stakeholders increases ownership, commitment and biosecurity practices. 11 Acknowledgements T F This document is the product of a ‘stocktaking’ exercise initiated by ECTAD-RAP in Bangkok in January 2012 and consolidated at the 6th Annual Regional ECTAD Meeting (AREM). ECTAD-RAP also coordinated the different stages of data gathering, compilation, feedback and collation of the results, as well as design and develop display materials and this document. A R The gathering of country-level and thematic data was managed by ECTAD-RAP’s Team Leaders as well as their professional staff: Dr Mat Yamage (Bangladesh); Dr Allal Lotfi (Cambodia); Dr Vincent Martin, Dr Fusheng Guo (China); Dr Mandavi Subba Rao (India); Dr James McGrane, Dr Eric Brun, Dr Luuk Schoonman (Indonesia); Dr Tri Naipospos (Laos); Dr Murray Maclean (Myanmar); Dr Mohinder Oberoi (Nepal); and Dr Santanu Bandyopadhyay (Viet Nam), working with Dr Pawin Padungtod (Thailand), Dr Mia Kim (AGAH, Rome), Dr Wantanee Kalpravidh and Dr David Castellan (Thailand). Additional inputs came from Dr Scott Newman, Dr Yoni Segal, Dr Nicoline de Haan, Dr Julio Pinto and Ms Ariella Ginni (Rome). D All data received in this manner was handed over to Dr Laurie J Gleeson, Consultant, who took notes through the discussions and professional question-answer joust sessions that were held through the three-day AREM meeting. He then collated, edited, revised and rearranged the data received into draft chapters. Significant technical inputs and guidance towards the document’s content and final shape came from Dr Subhash Morzaria, Regional Manager, ECTAD-RAP. Inputs in coordination of data, editing, re-writing, design and production of the final document came from C Y Gopinath, Regional Communication Coordinator. Day-to-day logistical support in the management and successful conduct of the 6th Annual Regional ECTAD Meeting, as well as production of all materials, gathering and systematic logging of data, and final printing of output materials came from the Operations team, including Mr BryceTyler Fieldhouse, Operations Manager; Ms Linda Muangsombut; Ms Chananut Auisui; Ms Ornusa Petchkul; and Ms Thapanee Tayanuwattana. 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