In rural Cambodia, dreaded avian influenza finds a weak spot
Saturday, March 05, 2005
By Jaems Hookway, The Wall Street Journal
PHNOM PENH, Cambodia -- On a recent afternoon, Ly Sovann sat perspiring in his stuffy office and wondered if he had an epidemic on his hands. Since word spread that a Cambodian woman in a remote village succumbed to avian influenza in January, Dr. Sovann's cellphone hasn't stopped ringing as health workers call in suspected cases of the disease.
The problem: Few here know what avian flu is or how to recognize it. That makes Dr. Sovann's job as Cambodia's chief flu-hunter at the cash-strapped Ministry of Health difficult. Worse, his emergency budget for educating this country's 13 million people about bird-flu dangers is just $2,500.
"A lot of the time the reports turn out to be diarrhea or measles," Dr. Sovann said as his phone buzzed to life again.
The long-term diagnosis may not be nearly as benign. Julie Gerberding, director of the U.S. Centers for Disease Control and Prevention in Atlanta, said last week that there was a real risk of Asia's bird-flu problem transforming into a global threat, comparing the danger to the 1918 flu that killed between 20 million and 40 million people. At a conference in Vietnam last week, World Health Organization regional director Shigeru Omi went further. He said: "The world is now in the gravest possible danger of a pandemic."
A close look at Cambodia suggests a worrying complication: a critical shortage here of even the most basic tools or diagnostic skills to identify the virus in the first place, much less control or treat it.
The bird-flu strain, known to scientists as H5N1, was first spotted in Hong Kong's poultry markets in 1997. Since then, the virus has become both more lethal to birds and more widespread. When the virus appeared in Vietnam, Laos and Thailand in late 2003 and early 2004, it caused around $10 billion in damage as officials ordered the destruction of millions of chickens, ducks and other domestic poultry.
Now the virus is resurging in rural Southeast Asia. Cambodia, Thailand and Vietnam have each reported outbreaks in poultry this year. Scientists say the virus has probably become entrenched here, spread by poultry traders and wandering duck populations.
Since 2003, bird flu has killed at least 46 people, with a fatality rate of about 72 percent. That compares with six people who died during the 1997 outbreak in Hong Kong. The virus still doesn't easily spread from birds to humans, nor from one human to another. But each time a person catches it, the avian flu has another chance to evolve into a more readily communicable form. That's the spark believed to have set off prior pandemics -- flu epidemics that spread and kill globally.
The risks are concrete enough that the U.S. plans to begin testing a trial vaccine manufactured by Sanofi-Aventis SA of France later this month. This week, the United Kingdom unveiled a plan to stockpile 14.6 million doses of the antiviral drug Tamiflu, which has proved effective in treating avian-flu cases.
Tracking human cases has now become a top priority for public-health officials. Any change in the virus's behavior could provide an early warning of an emerging pandemic. Catching cases early could buy critical days or weeks in which to prepare hospitals, deliver antiviral drugs and begin producing vaccines, says Klaus Stohr, head of the WHO's influenza program. In disease surveillance, he says, "every day matters."
The biggest holes in the surveillance net are in poor countries like Cambodia, where average life expectancy is 54 years. The nation has been afflicted by years of civil war and hesitant economic development. It was turned upside down by the murderous rule of the Khmer Rouge in the 1970s. Basic malnutrition and diarrhea are common, along with illnesses such as HIV/AIDS and tuberculosis.
Cambodia has struggled to join the mainstream of Asia's economy, largely on the strength of garment exports and tourism. Secluded beaches and ancient temple complexes surrounded by thick jungle attract around a million visitors a year. But an overwhelmingly rural economy and widespread corruption have hindered development.
Because of Cambodia's skeletal infrastructure, epidemiologists worry that avian flu may already be gaining unseen footholds here. Unlike outbreaks of bird-flu strains in the Netherlands and Hong Kong, which prompted massive culling of avian populations, the response in Cambodia has been far more tentative. Cambodia reported its first infected birds last month, only after the first human casualty was found.
Currently, it's unclear how widespread the H5N1 virus may be inside the country. "There may be people dying of this disease right now and we simply wouldn't know," says Laurent Ponta, a veteran medical field worker with Health Unlimited, a British charity providing basic health care in one bird-flu-affected corner of Cambodia.
Poor countries aren't the only places where viruses can take hold. Toronto's bout with severe acute respiratory syndrome in 2002 showed that germs sometimes prefer modern cities over rural settings. But limited technical resources and desperate shortage of funds make countries like Cambodia potentially productive hosts for H5N1.
Cambodia's entire federal budget in 2003 was $644 million, about $500 million of it foreign aid. The aid helps address everything from malaria outbreaks to the establishment of a functional legal system. But it is mostly earmarked for specific purposes, making it difficult to free up for unforeseen emergencies like bird flu.
Most international interest in the country remains focused on bringing former leaders of the Khmer Rouge to justice, and the United Nations is planning a tribunal in Phnom Penh. Foreign donors are being asked to pony up the estimated $56 million needed to hold the trial. Last month, Japan contributed $18.5 million to that cause.
By contrast, several Asian countries have so far received a total of $18 million in international assistance since early 2004 for bird flu, about $1 million of it to Cambodia.
Most of that money was quickly exhausted monitoring the health of poultry flocks, culling birds or compensating farmers. Dr. Sovann, 37 years old, says he's had to scrape for funds, barely raising enough to print some pamphlets and put loudspeakers in affected villages to warn people about the dangers of handling dead birds.
A fast-talking technology enthusiast, Dr. Sovann first created a do-it-yourself monitoring system two years ago, when SARS first appeared in Asia. As chief of the Ministry of Health's Disease Surveillance Bureau, he organized a group of health workers scattered across the country in preparation for that disease's arrival in Cambodia. "This is one of the strengths of Cambodians," Dr. Sovann says. "We don't have many fixed lines, so we like to use our mobile phones. We're harnessing this trend to stop these diseases."
In the end, SARS never reached Cambodia. When bird flu appeared in neighboring Vietnam in early 2004, Dr. Sovann put his phone group into action. "He's very charismatic," says Megge Miller of the WHO's Phnom Penh office, where a handful of foreign experts are based. "You can easily imagine how he talked all these people into helping."
But Dr. Sovann's improvised surveillance system is woefully thin in places. It failed to pick up Cambodia's first confirmed human victim of bird flu, a 25-year-old mother of two named Tit Sokhan.
When Ms. Sokhan first fell ill with respiratory problems in the district of Kampong Trach in January, health workers there hadn't even heard of bird flu, despite the village's heavy dependence on poultry. "We had no idea what this disease was," says Deung Sokhom, who runs a nearby health clinic.
Raising chickens is a way of life in the village, just 2.5 miles from Vietnam. Poultry provides an important source of protein in the villagers' diet and a convenient substitute for the local riel currency. Throughout the rural region, people often use bundles of live chickens tied at the feet as barter payment for major purchases.
So when valuable chickens suddenly began dying at the beginning of January, it was natural that somebody would hurry to collect them. That person was Tit Chiang, Ms. Sokhan's 14-year-old brother.
Relatives say the teenager gathered birds that had dropped dead, plucked them and prepared them for the farming family's meal. Cooking would kill any germs, but handling carcasses is risky. Oi Chanda, a cousin, said that a few days later, the youth fell ill, developing a fever and coughing violently. He died 10 days after getting sick. "We were shocked that he died so quickly," Ms. Chanda says. "He was a very healthy boy."
It's not clear whether Tit Chiang contracted bird flu. His body was cremated soon after his death according to Buddhist custom. That means no tests could be conducted to determine whether he was infected by the virus. Cooked meat isn't considered a risk, but handling sick birds is.
Dr. Sovann and WHO investigators have since concluded that Chiang's sister, Ms. Sokhan, was in close contact with his body. Several days after the teen was cremated, Ms. Sokhan also fell ill. "One theory is that she caught the virus while crying over her brother's body and preparing it for cremation," says Dr. Miller at the WHO. "But we don't really know because we couldn't test her brother."
As Ms. Sokhan's sickness worsened, her relatives took her to a nearby medical clinic. But staff there didn't know anything about bird flu and sent her home with instructions to perform a ceremony to appease the angry spirits of her ancestors.
"She performed the ceremony, but it didn't seem to make any difference. She was still sick," says Kheam Phon, Ms. Sokhan's aunt.
She decided to take her niece to a hospital in Vietnam, in the hope of getting better treatment. But it was too late. On Jan. 30, 12 days after her brother died, Ms. Sokhan also died. Tests performed by Vietnamese authorities revealed she had the H5N1 virus.
When Vietnamese doctors tipped off Dr. Sovann and his team, he drove to the village along with WHO officials to see if anybody else was ill. A cluster of several cases could be a warning sign the virus has acquired the ability to move more easily between people.
No more infections in the village were found. But the episode helped underscore for experts abroad the sizable gaps in Cambodia's surveillance network. "We only heard about it because the patient made it into Vietnam," says Dr. Stohr, the WHO influenza expert in Geneva.
If a new flu strain does emerge, theoretical models prepared by the WHO suggest it could be stopped -- but only if it's caught within the first 21 days. "A massive antiviral effort, under optimal circumstances, could extinguish the fire," Dr. Stohr says.
Dr. Sovann now plans to widen his surveillance group to include contacts at all the private health clinics and pharmacies dotting the Cambodian countryside. "These are the people on the front line," he says. "We need to educate them about bird flu so they can detect it and report it back to my office."
Dr. Sovann is also doing his best to alert local populations to the virus's dangers. He has organized the distribution of cartoon pamphlets illustrating the risks of handling dead birds in a form that illiterate farmers can understand. He is also sending volunteers around villages on motorcycles, with battered loudspeakers tied to the pillion seats warning people to keep away from dead birds. "Word of mouth seems to work best," says Dr. Sovann.
An international conference on bird flu in Vietnam's Ho Chi Minh City ended on Feb. 25 with an appeal for the international community to provide vastly increased aid to countries affected by bird flu such as Vietnam, Laos and Cambodia. In their final communique, delegates said $100 million was needed to improve health-care services, and several hundred million more to restock culled poultry flocks.
Back in Kampong Trach, Dr. Sovann's efforts to publicize the dangers of bird flu are beginning to sink in. Ms. Chanda, one of Ms. Sokhan's cousins, say her family now knows not to collect and prepare dead birds for the cooking pot. "We will only eat chickens we kill ourselves," she says.
Some of her neighbors, however, are unwittingly taking other risks. Worried about the threat from dead chickens, some have switched to raising ducks instead, unaware that waterfowl can spread H5N1 in their droppings without showing any signs of illness.
"How can people avoid exposure to the virus when they don't know which ducks are infected and which ones are not?" says Dr. Omi, the WHO's western Pacific director.
http://www.post-gazette.com/pg/05064/466994.stm
Saturday, March 05, 2005
By Jaems Hookway, The Wall Street Journal
PHNOM PENH, Cambodia -- On a recent afternoon, Ly Sovann sat perspiring in his stuffy office and wondered if he had an epidemic on his hands. Since word spread that a Cambodian woman in a remote village succumbed to avian influenza in January, Dr. Sovann's cellphone hasn't stopped ringing as health workers call in suspected cases of the disease.
The problem: Few here know what avian flu is or how to recognize it. That makes Dr. Sovann's job as Cambodia's chief flu-hunter at the cash-strapped Ministry of Health difficult. Worse, his emergency budget for educating this country's 13 million people about bird-flu dangers is just $2,500.
"A lot of the time the reports turn out to be diarrhea or measles," Dr. Sovann said as his phone buzzed to life again.
The long-term diagnosis may not be nearly as benign. Julie Gerberding, director of the U.S. Centers for Disease Control and Prevention in Atlanta, said last week that there was a real risk of Asia's bird-flu problem transforming into a global threat, comparing the danger to the 1918 flu that killed between 20 million and 40 million people. At a conference in Vietnam last week, World Health Organization regional director Shigeru Omi went further. He said: "The world is now in the gravest possible danger of a pandemic."
A close look at Cambodia suggests a worrying complication: a critical shortage here of even the most basic tools or diagnostic skills to identify the virus in the first place, much less control or treat it.
The bird-flu strain, known to scientists as H5N1, was first spotted in Hong Kong's poultry markets in 1997. Since then, the virus has become both more lethal to birds and more widespread. When the virus appeared in Vietnam, Laos and Thailand in late 2003 and early 2004, it caused around $10 billion in damage as officials ordered the destruction of millions of chickens, ducks and other domestic poultry.
Now the virus is resurging in rural Southeast Asia. Cambodia, Thailand and Vietnam have each reported outbreaks in poultry this year. Scientists say the virus has probably become entrenched here, spread by poultry traders and wandering duck populations.
Since 2003, bird flu has killed at least 46 people, with a fatality rate of about 72 percent. That compares with six people who died during the 1997 outbreak in Hong Kong. The virus still doesn't easily spread from birds to humans, nor from one human to another. But each time a person catches it, the avian flu has another chance to evolve into a more readily communicable form. That's the spark believed to have set off prior pandemics -- flu epidemics that spread and kill globally.
The risks are concrete enough that the U.S. plans to begin testing a trial vaccine manufactured by Sanofi-Aventis SA of France later this month. This week, the United Kingdom unveiled a plan to stockpile 14.6 million doses of the antiviral drug Tamiflu, which has proved effective in treating avian-flu cases.
Tracking human cases has now become a top priority for public-health officials. Any change in the virus's behavior could provide an early warning of an emerging pandemic. Catching cases early could buy critical days or weeks in which to prepare hospitals, deliver antiviral drugs and begin producing vaccines, says Klaus Stohr, head of the WHO's influenza program. In disease surveillance, he says, "every day matters."
The biggest holes in the surveillance net are in poor countries like Cambodia, where average life expectancy is 54 years. The nation has been afflicted by years of civil war and hesitant economic development. It was turned upside down by the murderous rule of the Khmer Rouge in the 1970s. Basic malnutrition and diarrhea are common, along with illnesses such as HIV/AIDS and tuberculosis.
Cambodia has struggled to join the mainstream of Asia's economy, largely on the strength of garment exports and tourism. Secluded beaches and ancient temple complexes surrounded by thick jungle attract around a million visitors a year. But an overwhelmingly rural economy and widespread corruption have hindered development.
Because of Cambodia's skeletal infrastructure, epidemiologists worry that avian flu may already be gaining unseen footholds here. Unlike outbreaks of bird-flu strains in the Netherlands and Hong Kong, which prompted massive culling of avian populations, the response in Cambodia has been far more tentative. Cambodia reported its first infected birds last month, only after the first human casualty was found.
Currently, it's unclear how widespread the H5N1 virus may be inside the country. "There may be people dying of this disease right now and we simply wouldn't know," says Laurent Ponta, a veteran medical field worker with Health Unlimited, a British charity providing basic health care in one bird-flu-affected corner of Cambodia.
Poor countries aren't the only places where viruses can take hold. Toronto's bout with severe acute respiratory syndrome in 2002 showed that germs sometimes prefer modern cities over rural settings. But limited technical resources and desperate shortage of funds make countries like Cambodia potentially productive hosts for H5N1.
Cambodia's entire federal budget in 2003 was $644 million, about $500 million of it foreign aid. The aid helps address everything from malaria outbreaks to the establishment of a functional legal system. But it is mostly earmarked for specific purposes, making it difficult to free up for unforeseen emergencies like bird flu.
Most international interest in the country remains focused on bringing former leaders of the Khmer Rouge to justice, and the United Nations is planning a tribunal in Phnom Penh. Foreign donors are being asked to pony up the estimated $56 million needed to hold the trial. Last month, Japan contributed $18.5 million to that cause.
By contrast, several Asian countries have so far received a total of $18 million in international assistance since early 2004 for bird flu, about $1 million of it to Cambodia.
Most of that money was quickly exhausted monitoring the health of poultry flocks, culling birds or compensating farmers. Dr. Sovann, 37 years old, says he's had to scrape for funds, barely raising enough to print some pamphlets and put loudspeakers in affected villages to warn people about the dangers of handling dead birds.
A fast-talking technology enthusiast, Dr. Sovann first created a do-it-yourself monitoring system two years ago, when SARS first appeared in Asia. As chief of the Ministry of Health's Disease Surveillance Bureau, he organized a group of health workers scattered across the country in preparation for that disease's arrival in Cambodia. "This is one of the strengths of Cambodians," Dr. Sovann says. "We don't have many fixed lines, so we like to use our mobile phones. We're harnessing this trend to stop these diseases."
In the end, SARS never reached Cambodia. When bird flu appeared in neighboring Vietnam in early 2004, Dr. Sovann put his phone group into action. "He's very charismatic," says Megge Miller of the WHO's Phnom Penh office, where a handful of foreign experts are based. "You can easily imagine how he talked all these people into helping."
But Dr. Sovann's improvised surveillance system is woefully thin in places. It failed to pick up Cambodia's first confirmed human victim of bird flu, a 25-year-old mother of two named Tit Sokhan.
When Ms. Sokhan first fell ill with respiratory problems in the district of Kampong Trach in January, health workers there hadn't even heard of bird flu, despite the village's heavy dependence on poultry. "We had no idea what this disease was," says Deung Sokhom, who runs a nearby health clinic.
Raising chickens is a way of life in the village, just 2.5 miles from Vietnam. Poultry provides an important source of protein in the villagers' diet and a convenient substitute for the local riel currency. Throughout the rural region, people often use bundles of live chickens tied at the feet as barter payment for major purchases.
So when valuable chickens suddenly began dying at the beginning of January, it was natural that somebody would hurry to collect them. That person was Tit Chiang, Ms. Sokhan's 14-year-old brother.
Relatives say the teenager gathered birds that had dropped dead, plucked them and prepared them for the farming family's meal. Cooking would kill any germs, but handling carcasses is risky. Oi Chanda, a cousin, said that a few days later, the youth fell ill, developing a fever and coughing violently. He died 10 days after getting sick. "We were shocked that he died so quickly," Ms. Chanda says. "He was a very healthy boy."
It's not clear whether Tit Chiang contracted bird flu. His body was cremated soon after his death according to Buddhist custom. That means no tests could be conducted to determine whether he was infected by the virus. Cooked meat isn't considered a risk, but handling sick birds is.
Dr. Sovann and WHO investigators have since concluded that Chiang's sister, Ms. Sokhan, was in close contact with his body. Several days after the teen was cremated, Ms. Sokhan also fell ill. "One theory is that she caught the virus while crying over her brother's body and preparing it for cremation," says Dr. Miller at the WHO. "But we don't really know because we couldn't test her brother."
As Ms. Sokhan's sickness worsened, her relatives took her to a nearby medical clinic. But staff there didn't know anything about bird flu and sent her home with instructions to perform a ceremony to appease the angry spirits of her ancestors.
"She performed the ceremony, but it didn't seem to make any difference. She was still sick," says Kheam Phon, Ms. Sokhan's aunt.
She decided to take her niece to a hospital in Vietnam, in the hope of getting better treatment. But it was too late. On Jan. 30, 12 days after her brother died, Ms. Sokhan also died. Tests performed by Vietnamese authorities revealed she had the H5N1 virus.
When Vietnamese doctors tipped off Dr. Sovann and his team, he drove to the village along with WHO officials to see if anybody else was ill. A cluster of several cases could be a warning sign the virus has acquired the ability to move more easily between people.
No more infections in the village were found. But the episode helped underscore for experts abroad the sizable gaps in Cambodia's surveillance network. "We only heard about it because the patient made it into Vietnam," says Dr. Stohr, the WHO influenza expert in Geneva.
If a new flu strain does emerge, theoretical models prepared by the WHO suggest it could be stopped -- but only if it's caught within the first 21 days. "A massive antiviral effort, under optimal circumstances, could extinguish the fire," Dr. Stohr says.
Dr. Sovann now plans to widen his surveillance group to include contacts at all the private health clinics and pharmacies dotting the Cambodian countryside. "These are the people on the front line," he says. "We need to educate them about bird flu so they can detect it and report it back to my office."
Dr. Sovann is also doing his best to alert local populations to the virus's dangers. He has organized the distribution of cartoon pamphlets illustrating the risks of handling dead birds in a form that illiterate farmers can understand. He is also sending volunteers around villages on motorcycles, with battered loudspeakers tied to the pillion seats warning people to keep away from dead birds. "Word of mouth seems to work best," says Dr. Sovann.
An international conference on bird flu in Vietnam's Ho Chi Minh City ended on Feb. 25 with an appeal for the international community to provide vastly increased aid to countries affected by bird flu such as Vietnam, Laos and Cambodia. In their final communique, delegates said $100 million was needed to improve health-care services, and several hundred million more to restock culled poultry flocks.
Back in Kampong Trach, Dr. Sovann's efforts to publicize the dangers of bird flu are beginning to sink in. Ms. Chanda, one of Ms. Sokhan's cousins, say her family now knows not to collect and prepare dead birds for the cooking pot. "We will only eat chickens we kill ourselves," she says.
Some of her neighbors, however, are unwittingly taking other risks. Worried about the threat from dead chickens, some have switched to raising ducks instead, unaware that waterfowl can spread H5N1 in their droppings without showing any signs of illness.
"How can people avoid exposure to the virus when they don't know which ducks are infected and which ones are not?" says Dr. Omi, the WHO's western Pacific director.
http://www.post-gazette.com/pg/05064/466994.stm