29 October 2002 11:30 GMT

by Julie Clayton

[caption and credit]

The flu outbreak in August that killed more than 800 people in Madagascar is a grim reflection of gaping holes in flu surveillance in developing countries, according to a World Health Organization (WHO) report released this week. A new Working Group last week met in Malta to begin plugging precisely those gaps.

"In developing countries the vaccines are underused because the impact of influenza is not known," Klaus Stohr, project leader for the WHO Influenza Programme told BioMedNet News. "So how does influenza compete against other health priorities, such as malaria or tuberculosis?"

The WHO asked national influenza centers to survey flu activity in their countries between October 2001 and September 2002, reports the WHO's Weekly Epidemiological Bulletin this week.

Countries in Africa, the Middle East, and Asia were particularly underrepresented due to inadequate infrastructure for viral and disease surveillance, however.

Taking advantage of the presence of many leading authorities on influenza surveillance and control at the First European Influenza Conference in Malta, Stohr convened a closed meeting of the new Working Group.

The Group aims to assess the burden of disease in developing countries - the number of people suffering from flu and the number killed - and to use the information to help national authorities decide whether to proceed with vaccination.

The Working Group's task is to establish the necessary surveillance facilities, including a laboratory to identify local strains, links with local health authorities, and funding agencies. This move would expand the current network of 112 WHO national laboratories in 82 countries.

But a national laboratory alone is not enough defense against an outbreak. For example, Madagascar already had a national laboratory - established by the Pasteur Institute in 1978 - which quickly alerted the WHO and had an international team on the ground in five days.

But Madagascar is also one of the 10 most underdeveloped nations, and does not have a national vaccine program. With no access to the main towns, most of the victims, who lived in the highlands, had little access to primary health care. Most of the afflicted were children under the age of five, many of whom were too malnourished and weak to fight the disease.

The main cause of death in most cases was secondary bacterial infection, such as pneumonia. When the WHO team arrived, they organized the administration of antibiotics, limiting the overall tragedy.

To examine the likely impact of vaccination in such nations, the Group is scheduled to meet invited members from developing countries in January. Together, the members plan to create research protocols for a series of pilot studies. The strongest candidate thus far is Thailand; the list includes Vietnam, South Africa, China, India, and Senegal.

Such a pilot project in one country could serve as a starting point for expanding surveillance to include others in the same region, with similar socio-economic status and climate, said Keiji Fukuda, epidemiology chief for influenza at the US Centers for Disease Control and Prevention and a member of the Group. "Europe is an outstanding example where the European Influenza Surveillance System is drawing together different countries."

The whole world would benefit from the extra surveillance in developing countries because a newly identified strain could become incorporated into WHO's yearly global vaccine recommendations, says Stohr. The H3N2 strain that caused the outbreak in Madagascar helped predict the formulation of vaccines recommended for the coming flu season.

"This is all time-dependent - if we pick up the virus when it emerges then it gives us more time to produce the vaccine," Stohr said. "In Madagascar," he added, "it could have been the pandemic strain."

Picture caption:
Magnifying glass and photomicrograph of Hemophilus influenzae, CDC.

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See also:
Infectious disease surveillance update
P. Das
Lancet Infect Dis, 2002 Sep 2:516

Ecology and evolution of the flu
[Review]
David J.D. Earn, Jonathan Dushoff and Simon A. Levin
Trends in Ecology & Evolution, 2002, 17:7:334-340

Global Agenda on Influenza
[In brief]
Cathel Kerr
Trends in Microbiology, 2001, 9:10:470

Influenza vaccines: new developments
[Review]
Guus F. Rimmelzwaan and Albert D.M.E. Osterhaus
Current Opinion in Pharmacology, 2001, 1:5:491-496

Therapeutic options for the management of influenza
[Review]
Michael G. Ison and Frederick G. Hayden
Current Opinion in Pharmacology, 2001, 1:5:482-490

Population biology of emerging and re-emerging pathogens
[Review]
Mark E.J. Woolhouse
Trends in Microbiology, 2002, 10:10:s3-s7
 

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