Editor’s note: This is the first of a two-part Special Report on bird flu in Vietnam. Part two, “When avian flu control meets cultural resistance,” appeared Oct 26.Oct 25, 2006 (CIDRAP News) – HANOI, Vietnam – Among countries affected by avian influenza H5N1, Vietnam stands out twice over.It was one of the first hit by the virus in the current outbreak: It discovered its first human infections in December 2003 and its first widespread poultry outbreaks in January 2004. And it was one of the hardest hit, with 66 million birds culled to prevent spread of the virus, and more human infections than any other country to date.But it has also controlled the virus more successfully than any other country where the disease became endemic, with no new human cases since last November and only a handful of infected birds this year—12 farm chickens and ducks, and a small flock of tame storks in an amusement park.The shift is so striking that international health authorities are asking whether Vietnam’s success can be replicated elsewhere. But reproducing its efforts faces an unusual hurdle: sorting out which of its aggressive interventions actually made a difference.”The absence of human cases is a direct reflection of the lack of cases on the animal side,” said Dr. Richard Brown, a World Health Organization epidemiologist based in Hanoi. “But it is actually difficult to know exactly what that is due to, because there were a number of different interventions applied in the latter half of 2005 on the animal health side.”After responding to its 2004 outbreaks mainly by culling infected flocks, Vietnam in 2005 became the first country to institute mandatory nationwide poultry vaccination.In addition—and almost simultaneously—the national government banned poultry rearing and live-market sales in urban areas; restricted commercial raising of ducks and quail, which can harbor the virus asymptomatically; imposed strict controls on poultry transport within Vietnam and agreed to examine illegal cross-border trade; and launched an aggressive public education campaign that deployed radio and TV advertising, neighborhood loudspeaker announcements, and outreach by powerful internal groups such as the Women’s Union and Farmers’ Union.The country also compensated farmers for birds that had to be killed—initially at 10% of the birds’ market value, and now at 75%.”Who knows what impact any of these interventions had? This is a natural experiment” that lacks controls that could measure impact, said Dr. David Dennis, the Hanoi-based Vietnam influenza coordinator for the US Centers for Disease Control and Prevention. “How much [of the reduction in cases] is due to the natural history of this organism in birds? We don’t know.”Outside the country, experts presume the engine of flu control to be the pervasive influence of Vietnamese-style socialism, which extends from the national government through provinces, districts, and communes to individual “neighborhood committees.”Dr. David Nabarro, the United Nations’ senior coordinator for avian influenza, implicitly endorsed that view in a Sep 19 Financial Times story, when he contrasted Vietnam’s continued control of the virus with Thailand’s recent uptick in human cases during a time of political turmoil.”You don’t maintain control over this disease unless there is regular top-level direction from a senior committed political figure that wants to be sure the necessary activities are being undertaken,” Nabarro told the Financial Times.But within Vietnam, workers in avian-flu control say the country’s success depends as much on the population’s support as it does on political coercion—a factor that may bode well for the national government’s plans to change the country’s entire culture of poultry rearing, distribution, purchase, and sale. (See tomorrow’s follow-up story for more details.)”What makes the system work is not that it is top-down, but that it achieves consensus at every level,” said Don Douglas, chief of party for Mekong Region avian flu efforts at Abt Associates, a US consulting firm that in July was awarded a 3-year contract for avian flu assistance in north Vietnam. “Imagine the stigma associated with being the farm that lets everyone down and causes all its neighbors’ chickens to be culled.”At the village level, flu education efforts are already struggling against selective amnesia.”Some farmers may not understand that they cannot eat duck blood, because they see that the duck looks healthy,” said Nguyen Van Mai, a trainer with the humanitarian organization CARE International, an Abt Associates partner. “Some think that [avian flu] has stopped already, and do not believe that it is coming back.” (Photo at right* shows the village hall in Lien Ap village, Viet Doan commune, north Vietnam, at the start of an avian flu educational event hosted by CARE International.)The farmers’ confidence is not shared by health authorities apprehensive over the approach of winter—Vietnam’s regular flu season, and also the time of year when avian flu cases have spiked.”I think Vietnam . . . has to prepare to deal with the comeback of this epidemic,” said Dr. Le Truong Giang, vice-director of the health department in Ho Chi Minh City, which is Vietnam’s largest municipality and has enacted the strictest local flu controls.Asked whether the city could keep the virus at bay indefinitely, Dr. Giang paused. “We try to do that,” he said. “But we are not sure.”*Photo ©2006 Maryn McKenna. Used with permission.Reporting for this story was supported by the East-West Center, Honolulu (www.eastwestcenter.org).