CAIRO, 10 March 2008 (IRIN) - An eight-year-old boy from Fayyum province was diagnosed with avian influenza on 8 March, bringing to four the number of human cases in the past two weeks and raising fresh fears of a pandemic.

Since the first human infection was confirmed in February 2006, there have been 47 others, said John Jabbor, a medical officer for emerging diseases with the World Health Organization (WHO).

A 25-year-old woman from Fayyum, the 45th case, died on 4 March, bringing the total number of avian flu deaths to 20. For a country the size of Egypt (population 80 million), this number of deaths is relatively small in general zoonotic diseases (affecting humans and animals) and in human health terms.

After the first outbreak of (HPA1) H5N1, the government adopted several measures to limit its spread and control the disease, as well as the risk of human infections: An estimated 30 million birds were culled and, more recently, there has been widespread free vaccination of private sector commercial flocks and backyard poultry.

Supply chains to blame?

The rapid spread of the disease in Egypt has been related to the development of poultry product supply chains that move millions of birds per day with low levels of biosecurity, according to the UN Food and Agriculture Organization (FAO) report Socio-economic Impacts of Transboundary Animal Diseases in the Near East with Particular Emphasis on Avian Influenza - which was discussed at a FAO regional conference in Cairo 1-5 March.

"More recent outbreaks would appear to be related to the mixture of ducks and chickens in rooftop and backyard systems and their close proximity to industrial poultry units," said the FAO report, which said ducks played a critical role in the maintenance of HPA1 H5N1.

The report also said that although the medical profession is particularly worried that human infections from the H5N1 virus have a 60 percent mortality rate, "the greater concern is that from the current HPA H5N1 in Egypt a virus might emerge that can easily infect humans, spread rapidly from human to human and create a human flu pandemic."

Mainly rural areas affected so far

So far bird flu has hit mostly rural areas in Egypt. A human case from Choubra in 2007 was the only case that was found in Cairo or in any urban area.

Egyptian law forbids raising birds in urban areas, said Abdel-Nasser Abdel-Ghafar, a Ministry of Health and Population representative in the Supreme National Committee for Combating Avian Influenza. However, not everyone abides by the law, he said. Birds are sometimes raised in large cities, and this could be dangerous should infections begin to appear in city poultry, and especially should the virus begin to transfer to humans.

Experts say no human case has occurred in urban areas because in those areas poultry and people do not inhabit the same space - the birds are mostly isolated on rooftops. Generally only one person tends the poultry and children do not play near them, Abdel-Ghafar said.

"In the villages, you will find people and chickens living together," he said. "Changing the culture of people is not easy… [some] people don't believe [the dangers of avian influenza], and they of course will not believe it until something happens to them."

Highest fatality rates outside Asia

Egypt has the highest infection and fatality rates outside of Asia. In addition to Egypt's backyard farm tradition, the density of rural settlements encourages the spread of infected poultry, and could lead to a rapid pandemic, Abdel-Ghafar said.

Yet for many rural dwellers, the threat of bird flu is not enough to convince them to give up this source of income, WHO's Jabbor said. Most human cases of bird flu are among women and children, since women generally tend to the chickens while children play with and around them, he said.

The government, with the help of the WHO, FAO and other UN agencies, is drafting contingency plans in the event of a pandemic. Response teams have been put in place all over the country and each ministry has taken steps to provide services to the people in the event of a pandemic. Shortages of food, electricity, water and access to communications have all been taken into account.

Raising awareness

As many as 14,000 community health workers have been drafted to educate the population about how to deal with sick and dead poultry and how to protect their families from infection, Abdel-Ghafar said. The health workers are all women living in the areas they work in and are known in the community - a tactic used by the government to raise awareness without intimidating villagers by using outsiders.

Poultry vaccinations are provided free of charge to backyard poultry, but not all villagers with a few chickens on their roofs are aware of this, Jabbor said. Farm-raised poultry are raised in controlled environments and are vaccinated. Out of the 47 human cases to date, only two had been working on commercial farms, he said, and neither patient died.

Some villagers hide the fact that they raise poultry in their homes, Abdel-Ghafar said - even when taken to hospital with symptoms of avian influenza. The villagers prefer to protect their birds and livelihoods, he said.

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