Preliminary considerations for tuberculosis control programme in Albania ANNEX 6 I. Foreseen tuberculinisation of cattle in September 2014 1. Introduction According to the annual plan for animal health measures, it is foreseen to test on presence of tuberculosis (by single injection of bovine tuberculin) approximately 61.000 animals. Tuberculinization is foreseen to be implemented in September and only in larger herds with more than 10 animals. According to the data from the national farm register there are approximately 2.000 herds (>10 animals) with a total of 57.000 animals. Category 2. National legislation Table 1: Size structure of bovine herds in Albania Number of cattle in holding Number of holdings Mean number of cattle per holding Total number of cattle in the category % of cattle population per category I >50 198 96 18.971 5 II 21 to 50 532 32 17.228 5 III 11 to 20 1.333 15 19.481 5 IV 5 to 10 7.390 6 46.634 12 V 1 to 4 166.035 2 272.903 73 Total number of cattle in registered holdings 375.217 100 Source: Farm register National legislation on tuberculosis is transposed from Council Directive of 13 September 1977 establishing Community criteria for national plans for the accelerated eradication of brucellosis, tuberculosis and enzootic leucosis in cattle (78/52/EEC). Within stated directive several topics are covered: - Compulsory notification; - Treatment and de-sensibilisation are forbidden; - Placing under official investigation of herds where tuberculosis is suspected and/or confirmed; - Prohibition of movement; - Additional control measures in the herds where tuberculosis is confirmed including slaughtering of positive animals and/or additional animals including depopulation; - Retesting; - Movement rules; At this stage it is not clear on the case definition (these issues are not covered with the stated directive but with the Council Directive 64/432/EEC). 1
3. Tuberculin For the implementation of the diagnostic activity in 2014, it is foreseen to use the bovine tuberculin produced at ISUV. ISUV has in stock more than 120.000 doses of bovine tuberculin. This stock was produced in 2012 and has expired date June 2015. Produced tuberculin is certified and allowed for use in accordance with Albanian legislation. No quality assurance testing is performed out of the ISUV. It is not clear on the quality assurance testing done at ISUV. The tuberculin is packed in a 10 ml vials with 1 ml of tuberculin corresponding to 5 doses (0.2 ml/dose) corresponding to 20.000 IU. At ISUV there is also 5-6.000 doses of avian tuberculin. 4. RUDA Data on results of tuberculin testing may be entered in RUDA system. According to the RUDA procedures, updated information on the status including ear tag numbers of cattle present on each holding has to be entered into the database prior to the possibility to prepare a Process Verbal which can be used at the field to record skin measurements. 5. Objectives of the foreseen activity At this stage it is not completely clear on the objective of the foreseen testing for tuberculosis. In case the objective is to estimate the epidemiological situation in Albania with the disease in larger herds, than more adopted statistical approach by testing of proportion of herds and animals may be adopted. This requires certain preparation in advance. In case that the objective is to start the eradication process in larger herds, than comprehensive planning and preparation phase is missing. Such phase is compulsory so to expect certain results achieved with the campaign and shall at least include: Budget In case when positive results are produced, according to the national legislation positive animals needs to be slaughtered. According to the national budget for 2014 the total amount of financial resources for compensation of slaughtered animals (including brucellosis and anthrax) is 42,116,000 ALL ( 301,000 Euro). This amount of financial resources is already transferred to the regional Agriculture Directorates and need to be confirmed that are not reallocated. The stated financial resources may be used to compensate approximately 350-400 cattle if amount of approximately 800 Euros per cattle are paid. It must be taken into account that for both diseases (brucellosis in cattle and BTB, complete depopulation has to be considered). Investments required by private veterinarians Sub-cutaneous injection of a tuberculin requires a standard set of equipment that enables the operator to effectively and correctly inject the animal. 2
Tuberculosis testing was not a regular part of the annual disease control programme activities that were implemented by private veterinarians. This is one of the reasons why private veterinarians in Albania do not have such set of equipment for tuberculin injection. In the past, tuberculin injection was done using an insulin syringes and needles and the skin thickness was measured using a ruler. This approach may lead to several inconsistencies: - Measurements units: insulin syringes are calibrated for units and not ml. If the insulin syringe is calibrated to 100 units than it corresponds to 1 cc 3. - The use of insulin syringes is impractical when needs to be injected a large number of animals in field conditions. The application of tuberculin intra-cutaneous to a cattle have to be fast and accurate which is not assured by use of insulin syringes since the animal (usually) does not stand still and by that disable the practitioner to inject full dose appropriately (0.1 or 0.2 ml). - Skin thickness is measured in millimeters. The difference of skin thickness from negative to a positive case is 4 millimeters only. Use of a simple ruler does not assure accurate measurement of skin thickness and may lead to false results. Taking into account the above, certain investments are essential before the start with a campaign for tuberculin testing of cattle. The minimum investments are estimated to: - tuberculin syringes, - needles, - caliper, and - shaver, which are estimated (depending on the type and quality of supplied equipment) to several hundreds of Euros excluding the costs for transport, PPE, etc. It may be reasonably assumed that at the current stage the private veterinarians, in general, are not prepared to cover those costs. Even in case that they are prepare to meet the costs, the availability of that equipment is not possible to be reached for 2014. Training Since the tuberculinisation was not performed for many years in Albania, many of the private veterinarians are not experienced in practicalities of such exercise. General drawbacks of tuberculin testing: 1. Two visits are required to perform single tuberculin testing. 2. Although single tuberculin testing has been a hallmark of bovine tuberculosis eradication campaigns, it lacks sensitivity, can be confounded by exposure to nontuberculous mycobacteria, and cannot be repeated for 6 weeks due to desensitization. The positive predictive value of single tuberculin test is low (in case of Bllice village was 16%) which precludes that many villages (herds) will have to be revisited to complete the field testing by simultaneous tuberculin injection. 3. In order to achieve correct results, the injection has to be performed intra cutaneous and with the proper dose. This requires proper equipment and training. 3
4. Interpretation of the results is essential and it must be assured that all private operators have correct approach to interpretation of results. 5. In order to have the final status of the animal in regards to tuberculosis, all positive and slaughtered animals must be sampled and isolation and identification of bacteria to be performed. The results of this laboratory testing will have influence on the further measures that needs to be implemented in the positive herd. 6. Conclusions The general conclusion that arose from the above is that the foreseen tuberculinisation process in September 2014 is premature and will probably result in failure to achieve stated objectives nevertheless they are to estimate the epidemiological situation and/or to start with the control programme. At the same time, considerable financial resources will be allocated to such exercise (according to the annual budget a total of 50,000 Euros) excluding the compensation costs. 7. Recommendations Objective In case that foreseen testing on tuberculosis is going to be implemented, an operational plan has to be adopted including clear objective and the expected results. Legislation A set of legislation in line with EU standards and Albanian conditions has to be adopted in advance of the start of the field activities. Tuberculin Initiation of quality assurance procedure in the producing of tuberculin (bovine and avian) at ISUV is highly recommended. Pilot area Pilot area may be selected where large herds may be tested. Preparation activities may be implemented in the pilot area. Training to be considered Given the relatively limited experience of private veterinarians with the tuberculosis testing, control and eradication, a comprehensive training programme including practical exercises (injection, interpretation of results, use of forms, data entry, etc.) shall be prepared. Amendments to RUDA Although RUDA has the capability to accept the data on tuberculosis testing, certain fine tunings are essential in order to achieve full support in the control measures. Until then, empty forms for recording of skin measures shall be adopted. Such form should be combined with the form for brucellosis testing. 4
Budget More detailed budget for compensation (which shall not be allocated in advance to the regions but should remain under responsibility of the CVO who will than allocate it based on needs) shall be prepared. Public awareness A very good experience gained during the previous years on raising of public awareness for brucellosis and rabies shall be used to raise the awareness of tuberculosis as well. Although according to the official report of Albania to the OIE the number of human cases of tuberculosis for 2012 is only three, seven cases were reported in Peshkopia from the public health authorities in 2014. This requires also to achieve clear understanding of the public health problem (and its association with animal TB) in relation to tuberculosis. Comprehensive strategy for TB control A comprehensive stepwise strategy including standard operating procedures for control of tuberculosis shall be prepared and adopted by the end of 2014 and its implementation commence in 2015. Passive surveillance and trace back of positive cases from the slaughterhouses and butchers shall be the initial measure of the strategy. Other essential parts of surveillance system Beside the above mentioned segments essential for proper implementation of tuberculosis control programme, additional prerequisites are essential for effective implementation of any control programme especially those based on test and slaughter: - Identification and registration; - Movement control; - Inspection services; - Laboratory capacity; - Etc. Most of the above are target objectives of PAZA II project and activities for strengthening will be implemented in parallel. II. Case study in Bllice village in Peshkopia region 1. Aim After receiving a report on a case of generalized tuberculosis in a slaughtered calf originating from village Bllice in Dibra region, a team of PAZA DSE and representative from the FVM in Tirana went on a field to implement a case study. They were supported by the PAZA II field coordinator from Dibra region-dr. Hekuran Huna. The aim was to assess the epidemiological situation with tuberculosis in the village and to investigate the positive case of tuberculosis. 5
2. Itinerary 14 July 2014 18:30 Depart Tirana 23:30 Arrive Peshkopia 21 July 2014 13:00 Depart Peshkopia 18:00 Arrive Tirana 3. Activities during field visit 3.1. Meetings conducted: On 15 July a meeting with the Director of Agriculture regional CVO Dr. Bilbil Hoxha and their collaborators was held in the premises of the regional Agriculture Directorate in Peshkopia where the purpose of the field visit was presented. The veterinary authorities explained the situation with tuberculosis in the region. Other relevant issues were also covered such as the epidemiological situation with brucellosis and results of the current SVS activities on the situation as well as situation with other animal diseases. Tuberculosis The regional veterinary authorities have stated that nonsystematic tuberculin testing was performed in the last several years. Even before, only a proportion of animals were tested where target were villages and herds where it was believed that the disease is present. Tuberculin injection was done using bovine tuberculin produced at ISUV that was injected using insulin syringes and needles. Skin thickness was measured using simple ruler. There is no evidence that specific forms were used to record the data from the field (skin thickness). Animals that were injected with tuberculin were not systematically identified. Human cases are regularly reported by the regional Public Health authorities. In 2014, 7 cases were reported. 3.2. Tuberculin testing in village Bllice Village Bllice is situated several kilometers north-west from town of Peshkopia. The village is relatively big with 388 families and 1442 citizens. The village is accessible by asphalt road. According to Farm register the total number of farms with cattle is 140 and the number of animals is presented in the table below: Table 1: Animal population in Bllice Village Sheep Goats Cattle Horse Poultry Bee hives Bllice 707 94 241 56 864 103 Source: Farm register Picture 1: Google map perspective of village Bllice 6
Operators: The tuberculinisation process was done by the following operators: - Hekoran Huni-PAZA II field coordinator - Romir Nezha-private veterinarian from the village Bllice; - Xhelil Koleci-FVMT; - Toni Kirandjiski-DSE PAZA II. The team was also supported by representatives from the regional SVS and additional private veterinarians who were present in different days: - Naim Cela-private veterinarian; - Besnik Marku-private veterinarian; - Fitim Majmari-official veterinarian; - Hajjrulla Nikolli- official veterinarian; - Shpetim Pira- official veterinarian; - Basir Bushi-official veterinarian; - Emrush Bushi-official veterinarian - Dashamir Selmani-official veterinarian. It must be highlighted the role of the private veterinarian Dr. Romir Nezha who highly effectively has planned and lead the team through the village. Without his knowledge of the livestock situation in the village it would take much longer to complete the activity and surely without comparable results. His contribution is highly appreciated. Equipment and consumables: The injection of tuberculin was done using following equipment and consumables: - Bovine and avian tuberculin produced by Bioveta: 7
o Bovitubal-(Active substance Proteinum tuberculin, Mycobacterii bovis-strain AN 5, 28.000 IU, dose 0,1 ml), batch number: 955420A and expire date: April 2015; and o Avitubal-(Active substance Proteinum tuberculin, Mycobacterii avium-strain D4 ER, 28.000 IU, dose 0,1 ml), batch number: 515420A and expire date April 2015. - Two automatic tuberculin syringes; - Caliper; - Tuberculin needles; and - Shaver. Picture 2: Equipment used for the tuberculin injection The form that was used to collect data from the field is given in Attachment 1 to this report. Tuberculin testing The tuberculinisation process was performed in the period from 15 July until 21 July for 7 working days. In general, the working day started in the morning (except for the first day when morning meeting was held in the regional Agriculture Directorate) and lasted throughout the day. Five to six persons were present at each time with the team. Table 2: Summary of workload 8
Date Improving consumer protection against zoonotic diseases Phase II Project No: EuropeAid/133990/C/SER/AL Start hour End hour Number of field working hours/day Number of farms tested Number of animals injected Number of farms with read reaction Number of animals with read reaction 15.07.2014 13:30 17:55 4:25 23 43 0 0 16.07.2014 9:30 17:00 7:30 37 95 0 0 17.07.2014 9:45 19:05 9:20 49 88 0 0 18.07.2014 9:50 17:50 8:00 32 51 23 43 19.07.2014 7:30 12:15 4:45 0 0 37 95 20.07.2014 11:20 15:29 4:09 0 0 49 88 21.07.2014 6:45 11:50 5:05 0 0 32 51 Total 19:14 141 277 141 277 Farmers accepted the intervention. Only one farmer refuses to inject his animals. Several farmers refused to identify their animals but did not refuse the tuberculinisation. A total of 141 farms and 277 animals were tested. Since the private veterinarian responsible for the village was not available during the first day of work, the animals that were not identified were ear tagged during the fourth day when the reading of reaction was performed. The data for the identification was not collected in a prescribed way but on a piece of paper. At the end of the exercise most of the cattle within the village were identified. Table 3: Summary on the status in regards to identification and registration of cattle in village Bllice: Status in regards to identification and registration of cattle Number of fully identified animals (two ear tags) on the spot Number of partially identified animals (one ear tag) on the spot Number of not identified animals Number (%) 102 (36.8%) 30 (10.8%) 121 (43.7%) Testing was done by simultaneous injection of bovine and avian ppd. The tuberculin was injected on the left side of the neck of the animals where avian was injected upper and bovine 10-15 cm lower. The process itself went through following steps: - Filling the form with the data on the farmer name and date and time of injection; - Reading of cattle ear tag (if any) and filling the number in the form; - Shaving of the place where the tuberculins were to be applied; - Measurement of the skin thickness using the caliper and filling the form with the findings; - Intra cutaneous injection of avian and then bovine tuberculin; 9
- Bleeding the animal for brucellosis testing (only animals older than 12 months) and labeling the tube. - Applying ear tags to the animal (if not previously identified). Animals with one ear tag were not retagged. Approximately 72 hours later, reading of reaction was performed. All cattle that were injected with tuberculin were checked for allergic reaction. Generally, if it was obvious that there is any reaction on the injection site, skin thickness was not measured again, however, many of the animals were measured the thickness again. If there was any suspicion on allergic reaction compulsory measuring was performed. Measurements of the skin thickness was entered in the form including the date and time of reading of reaction. Picture 3: Reading of reaction 72 hours latter Reading of reaction in most cases was done in the farm. In this case, cattle was returning back from pasture when the team has read the reaction approximately 72 hours after injection. The private veterinarian is behind the cattle (white coat). Farmers were then asked to sign the form as confirmation that the tuberculinisation was performed. 10
Picture 4: Confirming the tuberculinisation process by signature of the farmer All farmers signed the form except two when actually the team forgot to ask them to sign. On average, one to two animals were present on a farm. There were several farms with more than two animals and one farm with 10 animals. Farms were situated within the house yard. Most of the farms has no or just a small window: inside the stable was dark and poorly aerated. Picture 5: Farm conditions On 24 and 25 July the activities of the team were filmed with aim to produce two video films: one for training purposes and one reportage for training and public awareness purposes. 11
Results Out of 277 tested animals in 141 farms a total of 3 animals (1.1%) in 2 farms (1.4%) gave positive result by simultaneous tuberculinisation. Suspected results were established in 2 farms where 3 animals gave suspected result. Positive Farm 1: Several months ago the farmer sell a calf to a butcher. The calf was not in a good health condition and after slaughtering generalized tuberculosis was suspected by the butcher who reported to the official veterinarian (municipal meat inspector). PAZA team went on the field and confirmed generalized tuberculosis lesions. On the date of testing (15.07.2014) only one cow (AL 05024842) of Simmental breed was present in the farm-the dam of the slaughtered calf. The cow was born on the farm. The farmer didn t report any health problems in the past. All animals that were slaughtered on the farm (the dam of the positive cow and other calves) had any lesions on the carcass. The farmer do not buy animals but only use his owns as replacement. The last time when he bought cattle was 15 years ago. However, the farmer reported that he sell animals to the market. In 2013 the animal was on a summer pasture for two months together with other animals. During other years, animal is sent to a daily pasture nearby village. Skin measurements: Date and time of application: 15.07.2014 / 17:18 Date and time of reading reaction: 18.07.2014 / 15:00 Animal ID Breed Age Sex Measurement of skin thickness at injection sites Diff. after Avian ppd Bovine ppd applic. before after diff. result before After diff. result Other obs. Final result 05024842 Sim 5 y F 6.5 7.8 1.3-7.3 15.0 7.7 + 6.4 Oedema + Positive Farm 2: A total of three animals were present (and tested) on the farm. Two animals (cow and heifer) gave positive result on simultaneous testing. The location of the farm is next to the other positive farm. The conditions in the farm are in line with average conditions on the farms in the village: dark, poorly aerated and bad hygienic conditions. Ten years ago he bought a cow that is a mother of the currently positive cow (AL 05025017). Since then, he do not buy animals but he keep only his animals for replacement. Usually, heifers are naturally inseminated for the first time and then he uses artificial insemination. Animals are mainly kept inside except in Spring when for one month they are sent on a nearby pastures (returning on a daily basis) where they mix with other animals from the village. Currently, animals are in good condition. He reported that he sell animals on a market. Latter was also discovered that he sold an animal to a farmer from a village (the farm was not tested during this exercise since it was not accessible; name of the farmer is known to the team). Ten years ago the farmer was treated against pneumonia and since then is in good health. There are no health problems with animals. The positive cattle 12
produce 18-20 liters of milk. It was claimed that the milk is boiled and consumed in total at home (no selling of milk). Manure is collected in front of the stable (as in all cases in the village) and then spread in the field. In 2013 his animals were on a pasture for 4 months (with the animal of his brother). Date and time of application: 15.07.2014 / 17:50 Date and time of reading reaction: 18.07.2014 / 14:30 Animal ID Breed Age Sex Measurement of skin thickness at injection sites Diff. after Avian ppd Bovine ppd applic. before after diff. Result Before after diff. Result Other obs. Final result 05025018 Mix 15 m F 7.8 15 7.2 + 7 34.5 27.5 + 20.3 Oedema, necrosis + NN Mix 3 m F 6 6 0-5 5 0-0 / - 05025017 TR mix 6 y F 7.2 12.5 5.2 + 6.5 17.0 10.5 + 5.2 Oedema + Suspected farm 1: A total of 4 animals were present and tested on the farm with the following results: Animal ID Breed Age Sex Measurement of skin thickness at injection sites Diff. after Avian ppd Bovine ppd applic. before after diff. Result Before after diff. result Other obs. Final result 05024964 TR Mix 5 y F 5 7,6 2,6 +/- 5,5 10,5 5 + 3 Loc. oedema, +/- 05024920 TR Mix 5 m F 7,8 8,9 1,1-7 7 0-0 / - 05024966 Mix 3 m F 5,8 5,8 0-6,3 6 0-0 / - 05024965 TR Mix 4 y F 6 7 1-6,2 9,3 3,1 +/- 2,1 Loc. oedema +/- Many years ago (not specified) the farm had positive animals on tuberculosis. Suspect farm 2: Animal ID Breed Age Sex Measurement of skin thickness at injection sites Diff. after Avian ppd Bovine ppd applic. before after diff. Result Before After diff. result Other obs. Final result Kucje Mix 12y F 8.5 7 / - 6,8 9,6 2.8 +/- 2.8 Loc. oedema, +/- The farmer refuses to identify his animal. 13
Four farmers with 5 animals were not tested during the exercise. One of those farmers bought an heifer (now cow) from a farm with positive animals (positive farm 2). In addition, approximately 70 animals from the village were not tested since they were on the high mountain pastures. These animals will return to the village by late September when testing may be performed. Details on the farms and animals that were tested is given in excel sheet in Attachment 2. Details on the animals from the Farm register are given in Attachment 3. Conclusion: The two positive farms were epidemiologically linked: the farmers are brothers and in 2013 they took animals to a summer pasturing. One suspected farm had previous cases of tuberculosis. Test results: Table 4: Summary of the test results: Total no. animals tested for TB: 277 Total no. tested farms: 141 Average number of animals/farm: 2 Total no. animals with positive result on simultaneous testing: 3 (1.1%) Total no. of farms with positive animals: 2 (1.4%) Total no. animals with suspect result on simultaneous testing:3 Total no. farms with suspect animals: 2 Age data: Average age of female cattle: 5.82 years Oldest female: 20 years I&R: Total number of animals tested: 277 Animals without ear tags at the time of testing: 121 (43.7%) Animals with one ear tag at the time of testing: 30 (10,8%) Animals with two ear tags at the time of testing: 102 (36.8%) Missing information: 24 (8.7%) Given the conditions in all farms in this village the disease can readily be spread among all animals if the agent is present in the farm. Testing with single bovine tuberculin injection commonly have low positive predictive value (PPV) when comparing to simultaneous injection. In the case of Bllice village, the PPV of single compared to simultaneous tuberculinisation was (15.8%) 14
4. Recommendations: The positive animals has to be slaughtered as soon as possible. In the case of second positive farm all present animals (one animal gave negative result) needs also to be slaughtered. Samples shall be collected when animals are slaughtered and identification of bacteria shall be performed at ISUV. The farms has to be thoroughly cleaned and then disinfected using common (and available) disinfectants. Final disinfection with quick lime (calcium oxide), which is considered as highly effective in farms with poor hygienic conditions is highly advisable. Data in the RUDA system needs to be updated. Toni Kirandjiski Disease Surveillance Expert 15