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Interaction between humans and poultry, rural Cambodia.

Because avian influenza avian influenza: see influenza.  H5N1 infection risks are associated with exposure to infected poultry, we conducted a knowledge, attitudes, and practices survey of poultry-handling behavior among villagers in rural Cambodia. Despite widespread knowledge of avian influenza and personal protection measures, most rural Cambodians still have a high level of at-risk poultry handling.


The circulation of the highly pathogenic H5N1 avian influenza (AI) strain throughout Asia since late 2003 (1), and more recently in Europe and Africa, has resulted in considerable concern for the potential of a new pandemic pandemic /pan·dem·ic/ (pan-dem´ik)
1. a widespread epidemic of a disease.

2. widely epidemic.

Epidemic over a wide geographic area.

. In Cambodia, outbreaks of HPAI HPAI Highly Pathogenic Avian Influenza
HPAI Hospital Pharmacists Association, Ireland
HPAI Hewlett Packard Associates International
 A/H A/H Ampere/Hour
A/H Air Handling
5N1 infection were first reported in poultry in early 2004 (2). Since 2005, 6 human cases have occurred (100% fatal); the 2 most recent cases occurred in early 2006 (3,4).

Most Cambodians live in rural areas and raise animals for consumption (2), typically keeping poultry, swine, or cattle close to the home. Because H5N1 infection has been associated with exposure to infected poultry (5-10) and little is understood of the perceptions of rural farmers regarding AI (11), we conducted a knowledge, attitude, and practices survey of poultry handling in rural Cambodia to estimate the extent of interactions between humans and poultry, to understand practices in poultry handling among villagers, and to develop interventions designed to increase reports of poultry deaths and safe poultry handling.

The Study

We conducted a 2-stage household based cluster survey (12) with a goal of 500 participants: 20 persons [greater than or equal to]15 years of age in each of 25 villages from Prey Veng Prey Veng is the capital of Prey Veng Province, Cambodia.


 and Kampong Cham Provinces. The sampling frame of eligible villages within these provinces were those located in H5N1 high-risk communes, as defined by the Food and Agriculture Organization of the United Nations Noun 1. Food and Agriculture Organization of the United Nations - the United Nations agency concerned with the international organization of food and agriculture
FAO, Food and Agriculture Organization
 training program for village animal health workers. The villages were selected with probability proportional to size. For the second stage, we randomly selected the first household within each village. Subsequently, households were selected by proximity until 20 eligible participants were enrolled in each cluster.

Verbal consent was obtained from all participants. All were interviewed by using a structured questionnaire designed to collect information on demographics, basic hygiene practices, quantity of poultry owned, poultry death reporting, practices when deaths occurred, knowledge and attitude of sick and dead poultry, and knowledge of AI.

Twenty-three villages were included in Kampong Cham
  • Kampong Cham Province
  • Kampong Cham (city)
  • Kampong Cham District
  • Kampong Cham Airport
  • Apostolic Prefecture of Kompong Cham
 (11) and Prey Veng (12) Provinces (Figure 1). Four hundred sixty respondents from 269 households completed the questionnaire. Most were women (60%), farmers (88%), and persons who had completed less than primary schooling (57%). The median number of household members was 5 (range 1-16), and 77% of all households included children <15 years of age.


Many households owned chickens (97%) and ducks (39%) (Figure 2), although the size of most poultry flocks was small (Table). Almost all poultry were free ranging (100% of chicken flocks; 96% of duck flocks), and mixing of the poultry with pigs and other domestic animals was common. Respondents reported that they use poultry feces for manure (77%), touch sick/dead poultry with bare hands (75%), eat poultry that died from illness (45%), eat wild birds (33%), let children touch sick/dead poultry with bare hands (20%), and gather dead wild birds for consumption (8%).

During the previous 6 mouths, of the 260 households that owned poultry, 162 (62%) experienced poultry deaths; however, only 18 (7%) reported these deaths to local authorities. Half of the respondents (n = 231) believed that it was important to report any poultry deaths because the death may be due to AI (61%) or because the poultry owners may receive management advice from the village veterinarians Veterinarians and veterinary surgeons (vets) are medical professionals who operate exclusively on animals. Well-known and notable veterinarians include:
  • Wayne Allard, a U.S.
 (39%). Among these 231 respondents, many did not report poultry deaths because they did not know how (41%), were in the habit of not reporting poultry deaths (31%), believed they would have a problem selling poultry if they reported deaths (18%), did not know the risks of AI (7%), or feared poultry culling culling

removal of inferior animals from a group of breeding stock. The removal is premature, i.e. before completion of its life span, disposal of an animal from a herd or other group.
 (5%). Among those respondents who did not believe reporting deaths was important, the reasons provided included the following: "the number of poultry deaths were too few" (62%), "poultry are not as important as cattle" (18%), "no help would be provided from veterinary staff or authorities" (13%), or "because mortality was similar to previous years" (7%). Of respondents that experienced poultry deaths, 62% buried or burned dead poultry, 53% prepared them for food, 22% threw away the dead poultry, 3% used them to feed other animals, and 2% prepared them for sale or gave them to their neighbors.

Participants had learned about AI from television (81%) and radio (78%). Thirty-one percent of respondents were able to describe AI symptoms in humans, and 72% believed that AI is a fatal disease among poultry that can be transmitted to humans. Most respondents believed it is unsafe to touch sick or dead poultry with bare hands (67%), eat wild birds (70%), let children touch sick or dead birds with bare hands (83%), and eat meat or eggs that are not fully cooked (86%). Sixty-one percent of respondents mentioned at least 1 of the recommended behavioral practices that protect against AI infection.


General media reports about AI through radio and television broadcasts appear to have been effective at reaching rural people. However, despite high awareness and widespread knowledge about AI and personal protection measures, most rural Cambodians still often practice atrisk poultry handling. Anecdotally, we also reported that family members of H5N1-infected patients, who knew about AI risks, still prepared dead or sick poultry for household consumption during massive die-offs, because they observed that neighbors with the same behavior did not become sick (Institute Pasteur in Cambodia, unpub. data). These findings provide evidence that high awareness does not necessary lead to behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. . Behavior change involves comprehensive and multidisciplinary intervention, which combines risk perception communication and feasible and practical recommendations, including economic considerations. We speculate that it is hardly feasible to sustain good poultry-handling practices if access to personal protective equipment is cost prohibitive, particularly when disease occurrence poultry die-offs are common. Further studies are needed to determine appropriate behavior change strategies in Cambodia.

We did find that many of the villagers were willing to report poultry deaths but did not know how. However, this finding should be interpreted in light of some limitations. We observed difficulties and frustrations among farmers whose flocks underwent culling after identification of H5N1 viruses in their flocks because compensation has not yet been approved by the government of Cambodia. In contrast, Thailand and Vietnam have introduced compensation along with the introduction of poultry vaccination in Vietnam and the reduction of backyard poultry ownership in Thailand in an effort to protect the commercial poultry industry. Thus, it is difficult to envision effective control strategies in Cambodia based exclusively on culling. Coincidentally, Vietnam has reported far fewer H5N1 outbreaks in poultry and humans since the introduction of the vaccination program, while Cambodia detected 4 outbreak sites in domestic poultry and 2 unrelated human cases in 2006. The real effect of a no-compensation policy on willingness to report poultry deaths needs to be assessed.

Not surprisingly, direct contact with poultry and poultry products was common among household members. Transmission of H5NI from poultry to humans, even in circumstances in which human--poultry interactions are regular and intense has been limited; however, as the virus continue to circulate and evolve among poultry, bird-to-human transmission may increase. In this context, improvement in risky practices can only be achieved through relentless behavior change efforts. Because lack of knowledge does not appear to be a factor, intervention programs must include feasible options for resource-poor settings that have limited materials for personal protection (water, soap, rubber gloves rubber gloves rubber nplgants mpl en caoutchouc , masks) and must offer farmers alternative methods to safely work with poultry on a daily basis.


We thank Neak Sotheary, Chhim Vutha, and Nget Kiry for their help in data collection and Megge Miller for her comments and suggestions on the questionnaire.

This study was supported by the Pasteur Institute The Pasteur Institute (French: Institut Pasteur) is a French non-profit private foundation dedicated to the study of biology, microorganisms, diseases and vaccines.  in Cambodia.


(1) World Health Organization (WHO). Epidemiology of WHO-confinned human cases of avian A(H5N1) infection. Wkly Epidemiol Rec. 2006;81:249-60.

(2.) Desvaux S, Sorn S, Holl D, Chavernac D, Goutard F, Thonnat J, et al. F R. HPA (1) (High Performance Addressing) Refers to a variety of earlier addressing techniques that improved the quality of a passive matrix (LCD) screen.

(2) (High Power A
1 surveillance programme in Cambodia: results and perspectives. Dev Biol (Basel). 2006; 124:211-24.

(3.) World Health Organization. Avian influenza: situation in Cambodia, update. Disease Outbreak News, April 6, 2006.

(4.) World Health Organization. Avian influenza: situation in Cambodia, update. Disease Outbreak News, March 24, 2006.

(5.) Mounts AW, Kwong H, Izurieta H, Ho Y, Au T, Lee M. et al. Case-control study case-control study,
n an investigation employing an epidemiologic approach in which previously existing incidents of a medical condition are used in lieu of gathering new information from a randomized population.
 of risk factors for avian influenza A (H5N1) disease, Hong Kong Hong Kong (hŏng kŏng), Mandarin Xianggang, special administrative region of China, formerly a British crown colony (2005 est. pop. 6,899,000), land area 422 sq mi (1,092 sq km), adjacent to Guangdong prov. , 1997. J Infect Dis. 1999;180:505-8.

(6.) Bridges CB, Lim W, Hu-Primmer J, Sims L, Fukuda K, Mak K, et al. Risk of influenza A influenza A
Influenza caused by infection with a strain of influenza virus type A.

influenza A Infectious disease An avian virus, especially of ducks–which in China live near the pig reservoir and 'vector';
 (H5N1) infection among poultry workers, Hong Kong, 1997-1998. J Infect Dis. 2002;185:1005-10.

(7.) World Health Organization. Avian influenza A(H5) in rural areas in Asia: food safety considerations, 2004.

(8.) Areechokchai D, Jiraphongsa C, Laosiritaworn Y, Hanshaoworakul W, O'Reilly M; Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center.  (CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
). Investigation of avian influenza (H5N1) outbreak in humans Thailand, 2004. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg,  Morb Mortal Wkly Rep. 2006;55(Suppl 1):3-6.

(9.) Thorson A, Petzold M, Nguyen T, Ekdahl K. Is exposure to sick or dead poultry associated with flulike illness? A population-based study from a rural area in Vietnam with outbreaks of highly pathogenic avian influenza. Arch Intern Med. 2006; 166:119-23.

(10.) Webster RG. Wet markets: a continuing source of severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition

Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century.
 and influenza? Lancet. 2004;363:234-6.

(11.) Morris SK. H5N1 avian influenza, Kampot Province

Kampot is a southern province of Cambodia. Its capital is Kampot. Kampot province has a population of 528,405.
, Cambodia. Emerg Infect Dis. 2006;12:170-h

(12.)Bennett S, Woods T, Liyanage W, Smith D. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat Q. 1991;44:98-106.

Sowath Ly, * Maria D. Van Kerkhove, [dagger] Davun Holl, [double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.

Noun 1.
] Yves Froehlich, [section] and Sirenda Vong *

* Pasteur Institute in Cambodia, Phnom Penh Phnom Penh (nŏm pĕn, pənŏm`) or Phnum Penh (pənm`), city (1994 est. pop. , Cambodia; [dagger] London School of Hygiene and Tropical Medicine tropical medicine, study, diagnosis, treatment, and prevention of certain diseases prevalent in the tropics. The warmth and humidity of the tropics and the often unsanitary conditions under which so many people in those areas live contribute to the development and , London, United Kingdom; [double dagger] Ministry of Agriculture, Forestry and Fisheries
  • Ministry of Agriculture, Forestry and Fisheries (Japan)
  • Ministry of Agriculture, Forestry and Fisheries (Cambodia)
, Phnom Penh, Cambodia; and [section] Food and Agriculture Organization of the United Nations, Phnom Penh, Cambodia

Dr Ly works in the Epidemiology and Public Health Unit of the Pasteur Institute in Cambodia. His research interests include infectious diseases infectious diseases: see communicable diseases.  epidemiology, in particular of avian influenza, rabies rabies (rā`bēz, ră`–) or hydrophobia (hī'drəfō`bēə), acute viral infection of the central nervous system in dogs, foxes, raccoons, skunks, bats, and other animals, and in , and dengue dengue
 or breakbone fever or dandy fever

Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash.

Address for correspondence: Sirenda Vong, Head of Epidemiology Unit, Pasteur Institute in Cambodia, POB PoB - Prisoner of Bill  983, 5 Blvd Monivong, Phnom Penh, Cambodia; email:
Table. Poultry raising and flock characteristics, rural Cambodia

                                  Chickens    Ducks
Flock characteristics             (n = 261)   (n = 97)

Median number                     10(1-110)   6(1-800)
per flock
  1-25                            83%         93%
  26-50                           15%         3%
  51-100                          2%          0%
  >100                            0.4%        4%
Animal age when raising           0 (0-15)    0(0-12)
begins (months)
Type of raising
  Free ranging                    100%        96
Raising purpose (noncumulative)
  Household needs                 73%         70%
  Meat for sale                   54%         42%
  Eggs for sale                   1%          16%

Figure 2. Proportions of animals raised in the household (n = 29)
rural Cambodia.

Chicken                 97%
Dog                     80%
Cow/buffalo             73%
Pig                     48%
Duck                    39%
Chicken + duck          36%
Chicken + duck + pig    22%
Singing bird             3%
Fighting cock           12%
Geese                  0.4%

Note: Table made from bar graph.
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Author:Vong, Sirenda
Publication:Emerging Infectious Diseases
Geographic Code:9CAMB
Date:Jan 1, 2007
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