Assessment of the Community Awareness and Exposure to Highly Pathogenic Avian Human influenza in Wet-land Areas of Ethiopia

Background: The avian influenza virus has different subtypes which have the potential to cause disease in animals and humans. Human cases with influenza A (H5N1), A (H5N6) and A(H7N9) viruses, have been reported to WHO and various influenza A(H5) subtypes continue to be detected in birds globally. Little is known about the types of exposure that result in human infections. In Ethiopia, risk assessment studies were not conducted and the awareness of the community and the risk of exposure for potential avian influenza is undetermined. The aim off this survey is to assess the level of the community awareness and the risk for human exposure to avian influenza viruses (HPAI) in the wet land areas of Ethiopia. Method: The survey was conducted from February - April 2018 in the wet land areas of Ethiopia by using a standard questionnaire and purposive random sampling method. Epi info version 7.0 and SPSS (V.20) were applied for data analysis. Result: Of the total 200 respondents 94.7% don’t know about the mode of transmission and 43.5%, 27%, 16.9% of the respondents believed that HAI it transmitted by inhalation of air droplet (breathing), contact with ill person and eating raw poultry meat and egg products.36.2% of respondents believed that Human avian influenza is preventable by keeping hand hygiene, followed by respiratory hygiene (28%) and environmental hygiene (19.3%). However, 68.6% had close contact with animals (poultry) and high exposure to raw animal products. Conclusion: The awareness level of the community in the mode of transmission, risk factors and preventive measures is very low while the exposure for infected birds, food products remaining high. Further risk assessment studies and community awareness creation on the prevention and control of highly pathogenic avian influenza is recommended. Key words:


Abstract
Background: The avian influenza virus has different subtypes which have the potential to cause disease in animals and humans. Human cases with influenza A (H5N1), A (H5N6) and A(H7N9) viruses, have been reported to WHO and various influenza A(H5) subtypes continue to be detected in birds globally. Little is known about the types of exposure that result in human infections. In Ethiopia, risk assessment studies were not conducted and the awareness of the community and the risk of exposure for potential avian influenza is undetermined. The aim off this survey is to assess the level of the community awareness and the risk for human exposure to avian influenza viruses (HPAI) in the wet land areas of Ethiopia. Method: The survey was conducted from February -April 2018 in the wet land areas of Ethiopia by using a standard questionnaire and purposive random sampling method. Epi info version 7.0 and SPSS (V. 20) were applied for data analysis. Result: Of the total 200 respondents 94.7% don't know about the mode of transmission and 43.5%, 27%, 16.9% of the respondents believed that HAI it transmitted by inhalation of air droplet (breathing), contact with ill person and eating raw poultry meat and egg products.36.2% of respondents believed that Human avian influenza is preventable by keeping hand hygiene, followed by respiratory hygiene (28%) and environmental hygiene (19.3%). However, 68.6% had close contact with animals (poultry) and high exposure to raw animal products. Conclusion: The awareness level of the community in the mode of transmission, risk factors and preventive measures is very low while the exposure for infected birds, food products remaining high. Further risk assessment studies and community awareness creation on the prevention and control of highly pathogenic avian influenza is recommended. Key words: Avian Influenza, Exposure, Ethiopia Background Avian influenza (AI) represents one of the greatest concerns for public health that has emerged from the animal reservoir. It affects mammals, including humans, usually after close contact with infected poultry [1,2]. The influenza virus has different subtypes which have the potential to cause disease in animals and humans. The types of exposures associated with the transmission of AIV to humans have been ingestion, inhalation of aerosolized virus, or direct contact through mucous membranes [3,4].
The probability of infection with AIV varies with the activity and depends on the contact type (duration and route) and dose [5]. In Ethiopia, , there has not been an experience of a confirmed outbreak of HPAI [8]. However, there are several contributing factors for the introduction of avian influenza Virus, such as the low level of biosecurity and the relatively high number of migratory water birds wintering in rift valley lakes and wet lands. Awareness is one of the important determinant for the decision making process for poultry producers and for biosecurity action as well [9]. In addition, the living style of the population is also favorable to increase the risk to the pandemic. In most cases, especially in rural areas, people lives with their poultries in the same household in an attachment where there is no strong barrier. Poultry also mixes regularly with the people their droppings in every quarter of the compound often mixing with food items. So that there is high potential for the introduction of the infection of AI by migratory birds and infected poultries and poultry products which leads Ethiopia at the fore front to face the problem of this possible pandemic [10,119]. However, risk assessment studies were not conducted and the awareness of the community and the risk of exposure for potential avian influenza is undetermined in Ethiopia. Therefore the aim of this study was to assess the level of the community awareness and the risk for human exposure to avian influenza viruses (HPAI) in the wet land areas of Ethiopia.

Study area and period
The survey was conducted from February 2018 to April, 2018 in the wet land areas of Ethiopia (in the rift valley lakes and 10 km radius backyard chickens in the surrounded woredas). This includes, the surrounding woredas in Bahir dar (around Lake Tana and others); Asela and Sodo areas.

Study population, Study design, Sample size and Sampling technique
The study constitutes both animal and human population. The animal population involves migratory/wild birds and domestic chicken. All study village chickens were often kept out-door and scavenge all day near the vicinity of the house of the owners. The domestic poultry were not vaccinated with any diseases. A risk based surveillance study design was employed. Purposive sampling method were used to select the study population living in the wet land areas and with close proximity to wild birds and back yard poultry farms included. Sample size was determined using statistical calculation http://epitools.ausvet.com.au/ which calculates the sample size for simple risk based surveillance including a survey in which a high risk population is targeted. . A standard questionnaire were used to assess the awareness level of the communities on potential risks, the modes of transmission of disease, hygienic conditions practiced and possible infection preventive and control measures.

Blood and fecal samples
A 2-3 ml blood sample was also taken from a wing vein of each 819 unvaccinated domestic chicken of various types (pullets, cockerels and layers). Sample was labeled and set tilted on a table at room t 0 .
In addition, a total of 1836 pooled tracheal and cloaca swab samples from 5-6 birds were collected from the same house hold and 4211 fresh wild birds' fecal dropping samples were collected early in the morning from the wild/migratory birds resting sites ( fig.3 B). Then it was inserted into a labeled sterile cryogenic vial containing viral transport media and stored at -20 0 c till RT-PCR test performed and submitted to NAHDIC for molecular confirmatory diagnosis.

Data analysis
Data was entered and cleaned using Epi infoversion 7.0 and exported to SPSS version 20.0 for further analysis. The analysis was verified using descriptive interpretation. The socio-demographic differences among participants' awareness on AI and exposure was identified using the Chi-square.
Binary logistic regression was used to identify the effect of socio-demographic characteristics on participants' awareness and exposure to AI and multivariate analysis used to statistically adjust the estimated effect of each variable to control confounder.

Socio demographic characteristics
A total of 207 respondents,120 (58% female) subjects participated in the study. The age distribution of majority of the respondents 137 (66.2%) were between 19-40 years of age and the mean age of participants was 33.7±14.2 SD years, with a range of 13 -78 years. Ninety six (46.4%) were from Amhara region (surrounding Lake Tana Most participants 180 (87%) haven't ever experienced respiratory infection and the remaining 27 (13%) had experienced Respiratory Tract Infection (RTI). Among those who ever experienced RTI, 9 (33.3%) individuals visited health facility when they first get ill and 9 (33.3%) of them visited traditional healers. The number of people living together in one household for 138 (66.7%) participants, ranged 4-8 individuals and followed by for 49 (23.7%) participants has<4 individuals in a single room.
Regarding participants' contact history for the last 10 days, 6 (2.9%) of study subjects had a close contact with a person who had fever and cough, and described the modes of contact was speaking and caring. The rest 201 (97.1%) participants did not have any contact with a person with those symptoms. About 34 (16.4%) participants responded that they had contact with a person who had a close contact with animals and the remaining 173 (83.6%) haven't had contact history.

Measures of Associations
In the bivariate logistic regression education showed significant association with the awareness level of participants on HPAI and respondents' age and occupation showed significant association with contact with poultry and domestic animals.

Hemagglutination test result of poultry specimens for avian influenza
From the total of 819 serum samples collected and carried out the hem agglutination test, the result were found negative (0 -2 2 ) titration. The result interpreted according to NAHDIC hem agglutination inhibition Test method for avian influenza (AI).

RT-PCR test result of poultry specimens for avian influenza
From the total of 1836 swab samples and 4211 fecal droplet tested by RT-PCR. The result revealed that all faces droplet and swab samples were found negative for avian influenza virus nucleic acid

Discussion
The result of this study showed that the level of awareness towards HPAI is very limited. Out of the total participants only 5.3% respondents had heard of AI. This finding is very low as it is compared to the study conducted in China which showed that 88% of rural population had heard about AI which is a high degree of awareness [12]. Similarly, a higher percentage of awareness was found in Thailand, Nigeria and Cambodia [13, 14, and 15]. It might be due to the presence of repeated outbreak of HPAI to the countries. In our study almost all participants' perception regarding the modes of transmission of AI is inhalation of air droplet. However, transmission by direct contact with ill person and eating raw poultry meat and egg products is responded by few participants as it is compared to other studies. For instance, the result of a cross-sectional study conducted among Cambodian women showed that majorities' response on the modes of transmission of AI is, direct contact with sick or dead birds and followed by airborne transmission which showed a better awareness as compared with our study finding [16]. This difference might be the difference in educational level among the two study groups. Almost half of participants in our study perceived that AI is cured by modern medicine.
This finding is a little bit lower than the finding of similar study done among Cambodian women, which showed that more than half (57.3%) of respondents suggested that modern medicine available for curing HPAI [16].In general the finding of our study shows that the level of participants' awareness on HPAI is low which contradicts with the studies done in Italy and china reporting high level of awareness [17,18]. This gap could be explained by the fact that the level of literacy among our respondents and the media coverage on HPAI is poor.
In our study, we assessed three exposure levels for HPAI, including close contact with sick person having respiratory symptom, close contact with poultries and exposure to raw animal products.
Among the identified exposure levels, the reported contact history with a person who has flu like symptom is very low, which is accounted only 2.9%. However frequent direct contact with poultry or domestic animals like chicken, dog, cats are found to be the most reported contacts which are considered to be risk for AI. However few had exposed to sick/dead poultries for the previous ten days. This finding is inconsistent with the previous studies conducted in China and Indonesia reported that most participants had direct or indirect contact with sick/dead poultry which was found to be the major risk factor for AI [19,20].This study also illustrates that about 33% of respondents slaughter poultry at home and some (13%) had handled and consumed raw meat and vegetable. This finding is as low as the previous report from Bangladesh and Egypt and in which it was found 83% and 93% of respondents practice slaughtering poultry at home respectively [21,22].
According to our study, the status of respondents' awareness of HPAI is highly influenced by educational background which is in line with the study conducted in china confirmed that education was found to be one of influential factor for respondents' awareness of AI. Unlike to this finding, the previous report from Nigeria, kogi state showed that high media coverage on AI found to be the highest contributing factor for respondents' awareness of AI [14]. Additionally our study illustrates that occupation and age were significantly associated with having direct contact with domestic animals and poultries which is thought to be risky for the occurrence of AI.

Conclusions
The awareness level of the community in the mode of transmission, risk factors and preventive measures is very low while the exposure for infected birds, food products remaining high. All the specimens collected from poultry and wild birds were negative for avian influenza but the risk of introduction through migratory birds of affected neighboring countries remains a concern. Further risk assessment studies and community awareness on the prevention and control of highly pathogenic avian influenza is recommended. Awareness level of respondents on avian human influenza by age group Figure 3 Awareness level of respondent on the curative and preventive approach of HPAI Figure 4 Level of participant's exposure to poultry in the wet lands of Ethiopia, 2018for HPAI by age group and occupation in the wet lands of Ethiopia, 2018.