Afghanistan is a low-income country. It is a post-conflict country that suffered from 23 years of war. The per capita gross national income (GNI) is US$ 700 (2013)1. It has a geographically vast area with a variety of terrains and a large population, 30.55 million (2013)1. The Human Development Index rank is 175 out of 186 countries (2012)2.
According to WHO, Afghanistan is considered a country at high risk for avian influenza as it lies along the migratory pathways of wild birds. The widespread practice of raising poultry in the home to supplement income, low community awareness and a health system that is in the early stages of delivering effective health services equitably make Afghanistan especially prone to an outbreak of a virulent form of avian influenza. Afghanistan reported a surge in cases from pandemic (H1N1) 2009 virus infection; the outbreak first started on 3 July 2009, and up to 7 November 2009 it had spread to 7 out of the 34 provinces in the country (see table below), with 772 laboratory-confirmed cases, mainly in the age group 5–35 years, and 11 deaths.
The Central Public Health Laboratory in Afghanistan has been recognized as a national influenza centre since 2009. The capacity for virus isolation is present but is not currently functioning. Polymerase chain reaction and serology tests are also available but there is no formal regular feedback provided, which may be due to issues related to the functionality of the laboratory. There are gaps in human resources, training and sustaining performance. The laboratory has no sequencing capacity available. The Central Public Health Laboratory in Kabul has two systems for data sharing; an electronic system for surveillance programmes and a paper-based system for diagnostic activities. Jalalabad Regional Hospital laboratory shares in surveillance, acting as a collecting site for specimens for tuberculosis and influenza surveillance.
Strengths
There is a strong recognition by the Government of Afghanistan and senior policymakers of the importance of preventing avian/pandemic influenza. A national preparedness plan for avian and pandemic influenza already exists. Activities to educate and inform the public (case recognition, prevention, risk behaviours, caring for the sick, etc.) exist and materials specific to avian influenza have been developed with the help of technical partner organizations. Strategic goals during the pre-pandemic phase of influenza have been identified by the WHO. These goals have been addressed in the plans for avian influenza developed in the country.
There have been coordinated efforts by the Ministry of Public Health and the Ministry of Agriculture and Food to develop a comprehensive and coordinated plan for the control of avian influenza in the event of an outbreak in poultry or domestic birds. The rapid response implemented during the avian influenza outbreak and the pandemic influenza (2009) should be re-established to cover events that fall within the context of the International Health Regulations (2005).
Gaps and recommendations
The National Influenza Centre should be fully functional, e.g. a virus isolation unit is present but currently is not functioning. Polymerase chain reaction and serology tests are available but there is no available information about their functionality. Both virus isolation and serology should be strengthened. The availability of reagents and supplies is interrupted owing to the lack of a good purchasing and inventory system. The National Influenza Centre has no sequencing capacity available up till now. The virology unit at the Central Veterinary Laboratory should be part of the team dealing with influenza. It must be provided with all required reagents and supplies for differential diagnostic techniques for influenza before the next influenza season so that it will be able to share effectively in influenza surveillance.
The surveillance activities for influenza-like illness in Afghanistan should be strengthened and surveillance and laboratory testing activities coordinated with the National Laboratory facilities in the Ministry of Public Health and the Ministry of Agriculture. The existing passive surveillance system (for acute respiratory infection) should be restructured and a system to detect cases of influenza-like-illness should be established in all provincial hospitals: all cases of influenza-like-illness in district hospitals in the 15 high-risk provinces should be identified through active surveillance. Health-care staff should be trained to implement prevention, isolation, treatment and control measures in the event of an outbreak of pandemic influenza.
It is expected that Afghanistan will benefit from the Partnership Contribution funds available under the Pandemic Influenza Preparedness Framework for the sharing of influenza viruses and access to vaccines and other benefits. These funds will help in expanding the surveillance system to include severe acute respiratory infection as currently it is conducts surveillance for influenza-like illness only. The funds will also strengthen the functions of the National Influenza Centre to detect and identify influenza viruses from different geographic areas.