Avian Influenza and Ban on Overnight Poultry Storage in Live Poultry Markets, Hong Kong

We analyzed ≈12 years of surveillance data on avian influenza in Hong Kong live poultry markets. A ban on keeping live poultry overnight in these markets reduced virus isolation rates by 84% in chickens (p = 0.006) and 100% (p = 0.01) in minor poultry.

We analyzed ≈12 years of surveillance data on avian infl uenza in Hong Kong live poultry markets. A ban on keeping live poultry overnight in these markets reduced virus isolation rates by 84% in chickens (p = 0.006) and 100% (p = 0.01) in minor poultry. P revious infl uenza pandemics originated from infl uenza viruses of birds (1). Live poultry markets play a crucial role in maintenance, amplifi cation, and dissemination of avian infl uenza viruses (2,3) and are high-risk locations for potential zoonotic transmission of highly pathogenic avian infl uenza (HPAI) virus (H5N1) to humans (4,5). From September 1999 through May 2011, fecal dropping samples were collected monthly under the poultry cages in live poultry markets in Hong Kong as part of a systematic longitudinal avian infl uenza surveillance program. During the 12-year period of surveillance, several interventions were implemented by the Hong Kong government in response to outbreaks of infl uenza virus (H5N1) in live poultry markets and on poultry farms. In July 2001, a monthly rest day was fi rst implemented; under this system, all poultry in live poultry markets must be sold or slaughtered at the end of the day, poultry stalls must be cleaned and disinfected, and the stalls must be left free of live poultry for 1 day before restocking any live poultry the next day. In February 2002, a ban on sales of live quail was implemented in because an infl uenza virus (H9N2) lineage commonly isolated from quail possessed the internal genes of the virus that caused the avian infl uenza (H5N1) outbreak in Hong Kong in 1997 (6). In response to further incursions of avian infl uenza (H5N1) into poultry markets and farms in Hong Kong, a second monthly rest day in live poultry markets was introduced in March 2003, and a complete ban on holding live poultry overnight in live poultry markets was implemented in July 2008.
Previously, we analyzed data from September 1999 through December 2005 and demonstrated that 1 rest day per month signifi cantly reduced isolation rates of infl uenza virus in minor poultry (i.e., silkie chickens, pigeons, chukars, guinea fowls, and pheasants) but that an additional rest day each month did not signifi cantly reduce the isolation rate further (7). In this follow-up study, which includes an additional 6 years of data, we investigated the effect of a ban on keeping live poultry overnight at live poultry markets on isolation rates of infl uenza A virus (H9N2) from chickens and minor poultry.

The Study
When the live poultry market surveillance program began in September 1999, eight of a total of 80 live poultry markets were selected to represent the 3 major regions of Hong Kong: Hong Kong island, Kowloon, and the New Territories. Since then, the number of markets has declined, and by May 2011, only 5 of the 8 selected live poultry markets continued in operation (of a total of 39 operating live poultry markets). A total of 53,541 samples were collected during these 141 months of consecutive sampling.
We previously published data on the effect of introducing various interventions in live poultry markets, which included the ban on the sales of live quail and the introduction of rest days (7). In addition to collecting fecal droppings from the cage fl oors for virus isolation, we collected data on the total sales of chickens and minor poultry, the proportion of chickens imported as a ratio of the whole, the temperature and relative humidity, and the type of ventilation used, as described (7). Laboratory processing of the specimens was conducted as described (7). Samples collected in virus transport medium were inoculated into 9-11-day-old embryonated eggs, and allantoic fl uid with positive hemagglutination was confi rmed and subtyped using standard antiserum.
Because HPAI A virus (H5N1) is rarely detected in live poultry markets in Hong Kong, we used isolation rates of infl uenza A virus (H9N2) as an indicator of the effect of these interventions on avian infl uenza virus circulation. The median numbers of samples collected weekly from chickens and minor poultry were 107 (range 3-722) and 23 (range 1-397), respectively (see online Technical Appendix, wwwnc.cdc.gov/EID/pdfs/11-1879-Techapp.pdf, for weekly numbers of samples). The Poisson generalized model (8) with infl uenza virus (H9N2) weekly isolation counts as the outcome variable was fi tted as described (7) and adjusted for proportion of chickens imported; total sales of chickens and minor poultry; ventilation system; weekly average temperature; relative humidity; seasonal variations; sample size; and periods corresponding to the respective interventions: period I (no rest day), II (1 monthly rest day with quail being sold in the live poultry market), III (1 monthly rest day with elimination of live quail from the live poultry market), IV (2 monthly rest days), and V (ban on holding poultry overnight in live poultry market). These variables were considered potentially important confounders related to transmission effi ciency of avian infl uenza virus (9), source, type, and volume of poultry.
Weekly virus isolation counts were analyzed from September 22, 1999, through May 31, 2011. A separate model for poultry and minor poultry was fi tted, and all analyses were implemented by using R version 2.12.1 software (R Development Core Team, Vienna, Austria).
The Figure shows overall isolation rates by week for chicken and minor poultry from 1999 through 2011; the Table gives the parameter estimates for the fi nal fi tted models, which were adjusted for the effect of covariables that could affect the isolation of infl uenza in the study. For  chickens and minor poultry, compared with the reference category of 2 monthly rest days, the ban on keeping live poultry overnight in live poultry markets was associated with dramatic and signifi cant reduction of infl uenza virus (H9N2) isolation. The isolation rate of infl uenza virus (H9N2) among chickens declined 84% (adjusted relative risk 0.16; p = 0.006), and no infl uenza subtype H9N2 viruses were isolated from minor poultry after the ban on holding poultry overnight in live poultry markets was implemented. Higher volume of minor poultry sales was also signifi cantly associated with higher isolation rate of infl uenza virus (H9N2).

Conclusions
A previous study that used a stochastic metapopulation model showed that frequent rest days in live poultry markets were effective for reducing transmission of avian infl uenza (H5N1) (10). Our fi ndings show a large additional decline in the infl uenza virus (H9N2) isolation rate after implementation of a ban on keeping live poultry overnight, which suggests that this intervention has an even greater effect on reducing viral load in live poultry markets than the previous intervention of 1 or 2 rest days per month. While low pathogenic infl uenza virus (H9N2) was the indicator virus in our study, it is likely that these interventions would have comparable effects on highly pathogenic viruses such as avian infl uenza (H5N1); this effect has been demonstrated by mathematical modeling (10). Studies by others on social network analysis have shown that daily cage cleaning and disinfection of live poultry markets in southern China (11), and protective factors including removal of waste in Indonesia (12) contributed to a reduction of HPAI (H5N1) in live poultry markets. Taken together, these studies show that eliminating the carryover of live poultry in markets from one day to the next, in the form of rest days or a total ban, is highly effective for reducing viral amplifi cation and persistence in live poultry markets and consequently minimizes zoonotic risk.