**4. Human health approaches**

Integrating human health as part of Avian Influenza disease management requires coordination between stakeholders at all levels and involves multiple components. Although the clinical aspects of human health management of Avian Influenza are beyond the scope of this chapter, it is important to note that is an imperative part of disease management. We will address the following 6 components related to human health in this section: planning, surveillance, laboratory work, research, capacity building, and communications.

Planning for both preparedness and response to an outbreak in Bangladesh has involved developing and implementing the National Avian Influenza and Pandemic Influenza Preparedness Plans and Pandemic Contingency Plan by a national multi-sectoral planning team. The goal of the plan is a comprehensive and coordinated response to address H5N1 in domestic poultry and minimize transmission to humans. The plan addresses multiple sectors and works to strengthen capacity among many other aspects of H5N1 prevention.

Surveillance efforts on Avian Influenza have focused on high-risk group surveillance, hospital-based surveillance, population-based surveillance, drug trials, and the previously discussed surveillance at live bird markets. For example, the Avian Influenza Contact Follow-Up Monitoring Committee regularly follows up in affected districts with people exposed to poultry. People involved in culling infected poultry or in close contact (less than 1 meter) with infected poultry were given a single dose of anti-viral tablets for 7 days and followed up for 14 days. People with household contacts (more than 1 meter) and health care worker contact (unprotected) or other contact were followed up for 14 days without

Disease Management of

**6. Logistics management** 

project (USAID/Bangladesh 2010).

(USAID/Bangladesh 2010).

**7. Communication** 

and waste disposal).

Avian Influenza H5N1 in Bangladesh - A Focus on Maintaining Healthy Live Birds 267

Another important aspect of disease management is building the capacity for appropriate laboratory and epidemiological work, which includes developing the physical laboratories

In addition to building capacity and infrastructure support for disease management, it is important to take into the account the logistics of implementing the various aspects of disease management. Logistics management considers issues pertinent to implementing disease management strategies such as space and equipment availability, staffing and human resource skills, supplies of relevant commodities, recordkeeping and reporting, and transportation. In the case of Avian Influezna in Bangladesh, USAID's DELIVER Project has aimed to coordinate plans to "meet the challenges presented by existing and emerging pandemic threats by establishing and operating a secure, reliable global mechanism to store, transport, rapidly deliver, and track in-country distribution of current and future USAID Avian Influenza International Stockpile (AIIS) and outbreak response assets." To achieve these objectives, it has been necessary to work in close partnership with stakeholders from the planning process to implementation, develop a sustainable project design, emphasize the ownership of the stakeholders, gradually phase in the project and stakeholder involvement, and prepare stakeholders to take over by building capacity in private sector to sustain the

In conjunction with various stakeholders, DELIVER has been able to create a dedicated storage floor in the Department of Livestock Services (DLS), introduce warehousing best practices as well as a uniform logistics recording and reporting system, and design, develop and introduce a digital livestock management system. Additionally, DELIVER has trained personnel on logistics management, computer inventory management, and online reporting. As a result, they have been able ensure proper warehousing, distribution and in-country stock of Avian Influenza commodities (detergent, sprayers, decontamination kits, flu detection kits). Similarly, they have cooperated with Directorate General of Health Services (DGHS) and WHO to ensure proper storage and supply of H1N1 vaccines. Sufficient inventory is kept at a central warehouse and commodities are positioned in proximity to potential outbreak areas. DLS has the ability to respond quickly within a few hours to a reported outbreak in any upazila (district). Additionally, DLS can see the current report and inventory online at any time and use it to make supply decisions (USAID/Bangladesh 2010). DELIVER was able to establish a regular field logistics monitoring system for problem solving, capacity building, and troubleshooting. Sustaining the inventory management and web-based reporting system within DLS is challenging though because DLS is an environment of frequent staff turnover. Another challenge is using the available data in forecasting, procurement, and supply decisions. The goals for the future are all focused on sustaining and continuing to build the capacity to sustain and strengthen these efforts

Communication is a crucial aspect of disease management. It includes all forms of communication from daily media surveillance to the distribution of printed materials aimed at raising awareness of Avian Influenza control measures (e.g. hygiene, cleaning/washing,

and training personnel, as well as stocking the laboratories with necessary supplies.

any anti-viral tablets. Follow up was done daily by health care workers to detect influenzalike illness, which was defined as fever, cough and respiratory distress. Suspected cases were reported to the Institute of Epidemiology, Disease Control & Research (IEDCR) and necessary follow-up steps were taken (USAID/Bangladesh 2010).

Other human-health related approaches to managing Avian Influenza include laboratorybased research, such as pharmaceutical development and testing. For example, a drug trail based in Kamalapur has been evaluating the effectiveness of treatment with Oseltamavir on interrupting the transmission of influenza (May 2008- December 2010). Oseltamavir is the generic version of Tamiflu, an anti-viral that slows the spread of the influenza virus between cells.

Hospital-based influenza surveillance has been increasing. In 2007, twelve hospitals participated in surveillance efforts. Six of the 12 hospitals were run by the government, and six were privately-run hospitals. The hospitals were distributed among six divisions in Bangladesh. By 2010, fourteen hospitals distributed in all seven divisions of Bangladesh participated in the influenza surveillance program (USAID/Bangladesh 2010).

Population-based surveillance has involved collecting both epidemiological and biological data. Samples were collected from cullers and poultry workers to examine the seroprevalence of antibodies for H5N1. Additionally, there has been a longitudinal assessment of the effect of influenza on the cognitive development of urban poor children in Bangladesh. For this surveillance, a certain amount of laboratory capacity is necessary to analyze the samples and data. IEDCR has been a WHO-accredited lab since 2007, and IEDCR regularly participates in activities involving H5N1.

It is important to note that Avian Influenza is not easily transmitted to humans. If we were able to prevent and/or manage the disease among the live birds, many of the human-health related aspects of disease management would not be needed. As such, efforts should focus on capacity building, logistics management, and communication for behavior change that will help prevent, manage, or even eradicate Avian Influenza in live birds.
