1 بسم الله الرحمن الرحيم pandemic influenza school of health shahidbeheshti...

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بسم الله الرحمن الرحيمبسم الله الرحمن الرحيمPandemic InfluenzaPandemic Influenza

School of HealthSchool of Health

ShahidBeheshti University of ShahidBeheshti University of Medical SciencesMedical Sciences

By: Hatami H. MD. MPHBy: Hatami H. MD. MPH

20082008

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1)1) Incubation periodIncubation period2)2) Natural course Natural course 3)3) Geographical distributionGeographical distribution4)4) Timeline trendTimeline trend5)5) Age, Gender, Occupation, Social situationAge, Gender, Occupation, Social situation6)6) Predisposing factorsPredisposing factors7)7) Susceptibility & ResistanceSusceptibility & Resistance8)8) Secondary attack rateSecondary attack rate9)9) Modes of transmission, period of communicabilityModes of transmission, period of communicability

Definition and public health importanceDefinition and public health importanceEtiologic agents Etiologic agents

Clinical Epidemiology of Avian fluClinical Epidemiology of Avian flu

Prevention : primary, secondary, tertiaryPrevention : primary, secondary, tertiary

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مقايمقايسهسه

3

گ نگ كنه1997

موارد ناو�ليزاي نفلوآنآ

در ندگانپرنسانا

18 + 387 = 405 6 + 245 = 251

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داليل اهميت ويروس داليل اهميت ويروس H5N1H5N1

آسيب زايي و حد�ت آسيب زايي و حد�ت مرگ مرگنن ميزا ميزا تشارتشارنن وسعت ا وسعت اتقالتقالنن راه هاي ا راه هاي اتيكتيكنن احتمال تغييرات ژ احتمال تغييرات ژ احتمال وقوع احتمال وقوع

ييننساساننگيري اگيري اننجهاجها

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Definitions• An epidemic - is an increase

in disease above what you what would normally expect

• A pandemic - is a worldwide epidemic

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How Do Influenza Pandemics Arise?

• Wild birds are natural reservoirs of flu viruses, including those that infect people

• Flu viruses undergo slight changes each year (“Drift”) , requiring us to update our vaccines Epidemic influenza

• Periodically, avian flu viruses will undergo major genetic changes (“shift”) Pandemic influenza

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How Do Influenza Pandemics How Do Influenza Pandemics Arise?Arise?

• When avian influenza viruses When avian influenza viruses experience experience sudden changessudden changes in in genetic structuregenetic structure

AndAnd

• Are capable of Are capable of infecting humansinfecting humansAndAnd

• Can reproduce and spread from Can reproduce and spread from person to personperson to person….….a pandemic a pandemic occursoccurs

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HumanHumanvirusvirus

ReassortantReassortantvirusvirus

NonNon--humanhumanvirusvirus

15 HAs15 HAs9 NAs9 NAs

DIRECTDIRECT

Mechanism of antigenic shift

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وضعيت وضعيت فعلي فعلي

دميدميننپاپا

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Declared globally by the World Health OrganizationDeclared globally by the World Health OrganizationDeclared nationally by the Department of Health and Human ServicesDeclared nationally by the Department of Health and Human Services

InterpandemicInterpandemic Pandemic AlertPandemic Alert PandemicPandemic

Phase IPhase I Phase 2Phase 2 Phase 3Phase 3 Phase 4Phase 4 Phase 5Phase 5 Phase 6Phase 6

Phases of a PandemicPhases of a PandemicWorld Health OrganizationWorld Health Organization

PreparednessPreparedness ResponseResponse

جايگاه فعلي پاندميجايگاه فعلي پاندمي PeriodsPeriodsدوره ها = دوره ها =

PhasesPhasesمراحل = مراحل =

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World Health Organization World Health Organization Phases of a PandemicPhases of a Pandemic

• Inter-pandemic periodInter-pandemic period• Pandemic Alert periodPandemic Alert period• Pandemic PeriodPandemic Period• Post Pandemic PeriodPost Pandemic Period

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World Health Organization Phases World Health Organization Phases of a Pandemicof a Pandemic

• Inter-pandemic periodInter-pandemic period• Phase 1Phase 1 – No new virus subtypes in – No new virus subtypes in

humanshumans• Phase 2Phase 2 – – Animal subtypeAnimal subtype poses a poses a

risk of human diseaserisk of human disease

• Pandemic Alert PhasePandemic Alert Phase• Pandemic PeriodPandemic Period• Post Pandemic PeriodPost Pandemic Period

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• Inter-pandemic periodInter-pandemic period• Pandemic Alert periodPandemic Alert period

• Phase 3Phase 3 – – Human infectionHuman infection, no human , no human to human spreadto human spread

• Phase 4Phase 4 – – Small localizedSmall localized clusters of clusters of human to human spreadhuman to human spread

• Phase 5Phase 5 – – Larger clustersLarger clusters, still localized, , still localized, virus adapting to humansvirus adapting to humans

• Pandemic PeriodPandemic Period• Post Pandemic PeriodPost Pandemic Period

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• Inter-pandemic periodInter-pandemic period• Pandemic Alert PhasePandemic Alert Phase• Pandemic PeriodPandemic Period

• Phase 6Phase 6 – Increased and sustained – Increased and sustained transmissiontransmission in in the general populationthe general population. . Waves of 8-12 weeks.Waves of 8-12 weeks.

• Post Pandemic PeriodPost Pandemic Period

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• Inter-pandemic periodInter-pandemic period• Pandemic Alert PhasePandemic Alert Phase• Pandemic PeriodPandemic Period• Post Pandemic PeriodPost Pandemic Period

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Declared globally by the World Health OrganizationDeclared globally by the World Health OrganizationDeclared nationally by the Department of Health and Human ServicesDeclared nationally by the Department of Health and Human Services

InterpandemicInterpandemic Pandemic AlertPandemic Alert PandemicPandemic

Phase IPhase I Phase 2Phase 2 Phase 3Phase 3 Phase 4Phase 4 Phase 5Phase 5 Phase 6Phase 6

Phases of a PandemicPhases of a PandemicWorld Health OrganizationWorld Health Organization

Preparedness Preparedness

ResponseResponse

جايگاه فعلي پاندميجايگاه فعلي پاندمي PeriodsPeriodsدوره ها = دوره ها =

PhasesPhasesمراحل = مراحل =

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ويروس ويروس عامل عامل

پاندمي ؟؟پاندمي ؟؟

ويروس ويروس عامل عامل

?? H5N1پاندمي ؟؟پاندمي ؟؟ H1N1 ??

HxNy ??

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نندگادگاننزاي پرزاي پرننفلوآفلوآننموارد گزارش شده آموارد گزارش شده آنندر سطح جهادر سطح جها

28/3/138628/3/1386تاتا

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139

113106

52 50

2230

20 2517

7 7 8 512

4 3 2 2 20

20

40

60

80

100

120

140

اندونزي ويتنام مصر چين تايلند كامبوج آذربايجان تركيه عراق الئوس

در انسان تا در انسان تا H5N1H5N1نوپديدي آنفلوآنزاي نوپديدي آنفلوآنزاي 1919/9/1387/9/1387

تعداد مواردموارد مرگ

389389كل موارد = كل موارد =

246246موارد مرگ = موارد مرگ = ((6363)%)%

13813822

13813833

13813844

13813855

13813866

مورد مورد 66 مورد بيماري و مورد بيماري و 181813761376 مرگمرگ

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8/4/13868/4/1386تا تا

تا تا ننساسانن در ا در اH5N1H5N1زاي زاي ننفلوآفلوآننموارد آموارد آ2020/7/1387/7/1387

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اثرات مخرب اثرات مخرب دميدميننپاپا

تاثير بر ب نكليه جوا نو شئو

دگي نزاجتماعي

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ل به نكاهش پرس تقريبي نميزا% در كل 30

مديريت چه اموري قائم به مديريت چه اموري قائم به سيستمفرد مي باشد؟؟فرد مي باشد؟؟

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Estimated numbers of Illness, Hospitalization, and Deaths Moderate and Severe Pandemic Scenarios - US and King County

تخمين ميزان مرتاليتي و مربيديتي

CharacteristicCharacteristic ModerateModerate)1957–like()1957–like(

Severe Severe )1918 – like()1918 – like(

Total PopulationTotal Population هزار هشتصد و ميليون هزار يك هشتصد و ميليون يكنفرنفر

IllnessIllness 540,000540,000 540,000540,000

Outpatient Outpatient CareCare

270,000270,000 270,000270,000

HospitalizatioHospitalizationn

5,1905,190 59,40059,400

DeathsDeaths 1,2501,250 11,50011,500

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تقريبي نل به ميزان كاهش پرس % در كل سيستم30

مراكز خدمات بهداشتي ن كاهش توا ينـ درما

يروهاي امدادين ن كاهش توا

يتينيروهاي امن كاهش

اتنابع و امكانمحدوديت م

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اثرات مخرب اثرات مخرب دميدميننپاپا ات :نابع و امكان محدوديت م

قلن اختالل در امر حمل و

اختالل در امر ارتباطات

مشكل برق

مشكل آب

مشكل سوخت

. . .

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هاندان زنگشوده شد ي اجتماعيناامن

. . .


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تاثير بر كليه ب و نجوا

ات نشئودگي نز

اجتماعي


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همكاري •گينهماه •ارتباط •

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دهي دهي ننساماسامااثرات مخرب اثرات مخرب

دميدميننپاپا، نمسئول تامي

حفظ و ارتقاء سالمتي جسمي،

ي، نروااجتماعي ؟؟؟؟؟

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وزارت بهداشتوزارت بهداشتت سالمتت سالمتننمعاومعاو

محور اصليمحور اصلي

وزارت بهداشتوزارت بهداشتت سالمتت سالمتننمعاومعاو

محور اصليمحور اصلي

هاي هاي ننارگاارگادولتيدولتي

نيروهاي نيروهاي مردميمردمي

NGONGOهاها

ستاد ستاد بحرانبحران

وزارت كشوروزارت كشور

استانداري هااستانداري ها

بسيج جامعه بسيج جامعه پزشكيپزشكي

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امه كلي امه كلي ننبربردهيدهيننساماساما

بيماري و ن ـ كاهش ميزا1مرگ و مير

ازهم ندن ـ به حداقل رسا2پاشيدگي اجتماعي

ندن ـ به حداقل رسا3 هاي اجتماعينزيا

حكومتين ـ حفظ كيا4

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مراكز خدمات بهداشتي ن كاهش توا ينـ درما

يروهاي امدادين ن كاهش توا

اتنابع و امكانمحدوديت م

ي و ي و ننپيش بيپيش بيپيشگيريپيشگيري

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ي و ي و ننپيش بيپيش بيات :نابع و امكان محدوديت مپيشگيريپيشگيري

قل ن اختالل در امر حمل و

اختالل در امر ارتباطات

مشكل برق

مشكل آب

مشكل سوخت

. . . ور ور ننياز به اجراي ماياز به اجراي ماننمشتركمشترك

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ات :نابع و امكان محدوديت م قلن اختالل در امر حمل و

حمل زودرس برخي از كاالها )دارو، قل نحمل و غالت، مواد سوختي . . . (

زودرس مواد اوليه،


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ات :نابع و امكان محدوديت ماختالل در امر ارتباطات

تهيه راديوهاي كوچك . . .


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ات :نابع و امكان محدوديت ممشكل برق

ل ذخيره، تهيه يخچال هاي نآموزش پرس برق در مراكز بهداشتينبدو


ور ور ننياز به اجراي ماياز به اجراي ماننمشتركمشترك

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ات :نابع و امكان محدوديت ممشكل آب

حفر چاه هاي اضطراري، . . .


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Public Health Objectives

Maintain and expand functions critical to pandemic response

Maintain critical day-to-day operations

• All Department resources may be needed to address the consequences of a pandemic

• Some Department functions may be suspended

• Business continuity planning and “response team” development are underway

Public Health Preparedness

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Direction and Control• PHSKC will direct the countywide health and medical

response with health care system partners

• Local Health Officer will issue countywide directives when needed (i.e. school closings, health and medical response)

• PHSKC response actions will emphasize surveillance, social distancing and communications

• All local jurisdictions will activate emergency operations plans as needed

• Local Elected Officials will issue directives to ensure continuity of government

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Antiviral Medications

• CDC is stockpiling anitivirals in the SNS

• KC developing a local stockpile of antivirals

• Vaccines and antivirals will be prioritized for predefined target groups

• Local Health Officer will direct (via PH Order) how these medications will be used

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• Isolation of patients will occur throughout the event (mainly at home)

• Quarantine of close contacts may occur only in the early phases

• Decisions regarding closings and reopening will be based on current epidemiological data

Social Distancing / Isolation and Quarantine

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• Schools, large child care centers and libraries may be closed early by the LHO

• Stadiums, theaters, churches may be closed by the LHO and KC Executive

Social Distancing / Isolation and Quarantine

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• Comprised of representatives from a broad base of health care organizations

• Coordinating body and information clearinghouse for the medical system during major emergencies

• Health care system response will resemble Unified Command

Health Care Coalition

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Health Care Coalition Health Care Coalition ParticipantsParticipants

• HospitalsHospitals• Large medical groupsLarge medical groups• Safety net healthcare organizationsSafety net healthcare organizations• Professional associationsProfessional associations• Home health and long term care Home health and long term care

providersproviders• Key stakeholders, e.g. EMS, Puget Key stakeholders, e.g. EMS, Puget

Sound Blood Center, Red CrossSound Blood Center, Red Cross

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Health Care Coalition Health Care Coalition ResponsibilitiesResponsibilities

• Develop all-hazard preparedness plans Develop all-hazard preparedness plans • Develop an Executive Advisory Body:Develop an Executive Advisory Body:

• Review plans and agreementsReview plans and agreements• Advise the LHO on health issues during Advise the LHO on health issues during

disastersdisasters

• Develop a Regional Medical Resource Develop a Regional Medical Resource CenterCenter• Information ManagementInformation Management• Resource Management Resource Management • CommunicationCommunication

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Regional Responsibilities• Emergency Management• Public Works• First Responders• Human Services• General Government• Private Sector

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1.1. Educate and Inform: Educate and Inform:

• Department / Business Leaders Department / Business Leaders

• SupervisorsSupervisors

• StaffStaff

• FamiliesFamilies

Pandemic Preparedness Responsibilities of All Partners

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Influenza PreventionInfluenza Prevention

• Stay home when sickStay home when sick

• Cover your coughCover your cough

• Wash hands regularly and use alcohol Wash hands regularly and use alcohol hand gelhand gel

• Avoid touching eyes, nose, mouthAvoid touching eyes, nose, mouth


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2.2. Individual PreparednessIndividual Preparedness

• Store an extended supply of food and water at homeStore an extended supply of food and water at home

• Store nonprescription drugs and health supplies at homeStore nonprescription drugs and health supplies at home

• Plan with family members about the following:Plan with family members about the following:

• Caring for loved ones who get sickCaring for loved ones who get sick

• Caring for children if the schools are closedCaring for children if the schools are closed

• Other impacts on your life if you need to stay at home for an Other impacts on your life if you need to stay at home for an extended period of timeextended period of time


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3. Continuity of Operations Planning

• Identify key functions

• Cross train staff

• Identify telecommuting opportunities

• Review HR policies (sick leave, flex shifts)

• Identify ways to maintain payroll functions

• Make alcohol gel, disinfectant wipes available


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4.4. Information ManagementInformation Management

• Develop ways to track absenteeismDevelop ways to track absenteeism• Identify thresholds for critical capacities Identify thresholds for critical capacities • Develop reporting strategies for tracking Develop reporting strategies for tracking

region-wide impacts to critical systemsregion-wide impacts to critical systems• Develop templates for region-wide Develop templates for region-wide

situation reportingsituation reporting

Pandemic Preparedness Pandemic Preparedness Responsibilities of All PartnersResponsibilities of All Partners

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Avian InfluenzaAvian Influenza

• Caused by Orthomyxoviridae,Caused by Orthomyxoviridae,• type Atype A

• Multiple spike glycoproteinsMultiple spike glycoproteins——

• Hemagglutinin (15)Hemagglutinin (15)• Neuraminidase (9)Neuraminidase (9)• Viruses Viruses classifiedclassified on combination on combination

• of H and N types (eg. of H and N types (eg. H5N1H5N1))

• RecombinationRecombination occurs very commonly by “ occurs very commonly by “shiftshift and and driftdrift””

وتركيبي و تغييرات وتركيبي و تغييرات نناحتمال احتمال يكيكننتي ژتي ژننكل�ي آكل�ي آ

وتركيبي و تغييرات وتركيبي و تغييرات نناحتمال احتمال يكيكننتي ژتي ژننكل�ي آكل�ي آ

57Migratory pattern

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Human InfectionsHuman Infections• H5N1 - severeH5N1 - severe

• 1997 1997 Hong KongHong Kong: 18 cases; 6 deaths : 18 cases; 6 deaths

• 2003-2007 2003-2007 , 313 Cases and 191 Deaths , 313 Cases and 191 Deaths

(15 June 2007, 25 Khordad 1386)(15 June 2007, 25 Khordad 1386)

• H9N2 - mildH9N2 - mild

• 1999 1999 Hong KongHong Kong: 2 cases (mild): 2 cases (mild)

• 2003 2003 Hong KongHong Kong: 1 case (mild) : 1 case (mild)

• H7N7 - mild H7N7 - mild

• 2003 2003 NetherlandsNetherlands: 89 cases; 1 death: 89 cases; 1 death

• 2004 2004 CanadaCanada: 2 cases: 2 cases

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Avian influenza (H5N1)Avian influenza (H5N1)• In May In May 19971997, influenza A(H5N1) , influenza A(H5N1)

virus was isolated from a child who virus was isolated from a child who died with Reye’s Syndrome in died with Reye’s Syndrome in Hong Hong Kong.Kong.

• Prior to this, the H5N1 virus was Prior to this, the H5N1 virus was known to infect only known to infect only various species various species of birdsof birds, ,

• It was first discovered in It was first discovered in ternsterns in in South Africa in 1961South Africa in 1961 and can be and can be deadly to chickens: deadly to chickens:

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Avian influenza (H5N1)Avian influenza (H5N1)

• Vaccine production is complicated by the fact that the original virus isolates from Hong Kong also kill fertilized eggs which are used for vaccine production.

• The preparation of a vaccine would take several months after the selection of a suitable virus strain

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• SubdivisionsSubdivisions of virus types of virus types on basis of pathogenicity:on basis of pathogenicity:• NonpathogenicNonpathogenic

• Low pathogenicityLow pathogenicity

• High pathogenicityHigh pathogenicity


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• ReservoirReservoir primarily primarily waterfowlwaterfowl• Co-mingling with waterfowl Co-mingling with waterfowl

considered primary risk factor for considered primary risk factor for introduction of viruses to domestic introduction of viruses to domestic poultrypoultry

• Waterfowl typically Waterfowl typically subclinicalsubclinical infectionsinfections

• Live bird marketsLive bird markets where co-mingling where co-mingling occurs also major source of virusoccurs also major source of virus


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Pathogenicity :Pathogenicity :• HPAIHPAI = severe disease = severe disease

• Can have high mortality Can have high mortality

• LPAILPAI = mild or no disease, not = mild or no disease, not uncommonuncommon

• Can become Can become HPAIHPAI in some cases in some cases• Occurs only with Occurs only with H5H5 and and H7H7 types of types of

influenzainfluenza

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LPAI vs. HPAILPAI vs. HPAI• LPAI conversion to HPAILPAI conversion to HPAI has occurred has occurred

several times in recent pastseveral times in recent past• Pennsylvania, Pennsylvania, 19831983

• Mexico, 1995Mexico, 1995

• Italy, Italy, 20012001

• Pakistan, ongoingPakistan, ongoing

• Multiple others, undocumented / untested in Multiple others, undocumented / untested in numerous countries in worldnumerous countries in world

• Because of possible conversion of Because of possible conversion of H5 and H7H5 and H7 LPAI to HPAI, special attention is paid to these LPAI to HPAI, special attention is paid to these two Hemagglutinin typestwo Hemagglutinin types

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Avian Influenza Avian Influenza transmissiontransmission

• Can Can persistpersist in affected birds and flocks for in affected birds and flocks for monthsmonths

• TransmittedTransmitted by most means by most means

• Easily transmitted on contaminated: Easily transmitted on contaminated: clothing,clothing, shoes, shoes,

equipment,equipment, cages, cages,

etc.etc.

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The H5N1 Influenza The H5N1 Influenza Pandemic ThreatPandemic Threat

• Avian infection in many Avian infection in many countriescountries• 317 human cases and317 human cases and 191 deaths )61%(191 deaths )61%(• Culled >100 m chickens Culled >100 m chickens

20032003 2004200419971997 19981998 19991999 20002000 20012001 20022002

• Avian infection inAvian infection in Hong KongHong Kong• 18 human cases and18 human cases and 6 deaths )6 deaths )33%33%((• Culled poultryCulled poultry

• Ongoing avian H5N1 infectionsOngoing avian H5N1 infections

20052005 20062006

33 3636 9595 124124

20072007

70) 1957: Asian flu – 1968: Hong Kong flu() 1957: Asian flu – 1968: Hong Kong flu(

1918 Army Photo of Victims of the Spanish Flu1918 Army Photo of Victims of the Spanish Flu

Avian Influenza

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Influenza Type A Viruses:Influenza Type A Viruses:Antigenic Shift 1889-1977Antigenic Shift 1889-1977

YearYear SubtypeSubtype Common NameCommon Name SourceSource

18891889 H2N2H2N2 ??

19001900 H3N8H3N8 ??

19181918 H1N1H1N1 Spanish fluSpanish flu Avian Avian

19571957 H2N2H2N2 Asian fluAsian flu Avian Avian11

19681968 H3N2H3N2 Hong Kong fluHong Kong flu Avian Avian11

19771977 H1N1H1N1 Russian fluRussian flu ??11Reassortant with avian virusReassortant with avian virus

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When Will the Next Influenza Pandemic Occur?

1976 – H1N1 Swine flu1986 – H1N1 Swine virus

1988 – H1N1 Swine virus

1993 –Swine/avian recombinant

1995 – H7N7 Duck virus1997 – H5N1 Avian virus

1999 – H9N2 Quail virus2003– H5N1 Avian virus2003 – H7N7 Avian virus

2004 – H5N1 Avian virus

Timeline of human infection with novel influenza viruses)since the 1968 pandemic(

2004 – H7N3 Avian virus2004 – H7N1 Avian virus

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Human Human InfectionInfection

Avian influenzaAvian influenza

Case definitions :Case definitions :Case definitions :Case definitions :

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• Any individual presenting with fever ( >38°C) AND one or more of the following symptoms:

• cough;

• sore throat;

• shortness of breath

Case definitions for influenza A/H5Case definitions for influenza A/H5

Patient under investigation

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Case definitions for influenza A/H5 Case definitions for influenza A/H5

Possible (suspect) influenza A/H5 casePossible (suspect) influenza A/H5 case

• fever (>38°C) AND one or more of the following symptoms:

cough; sore throat; shortness of breath; AND one or more of the following:

• 1- laboratory evidence for influenza A by a test that does not sub-type the virus;

• 2- having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious

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Possible Possible (suspect) (suspect) influenza A/H5 caseinfluenza A/H5 case

• 3- having been in contact during the 7 days prior to the onset of symptoms with birds, including chickens, that have died of an illness;

• 4- having worked in a laboratory during the 7 days prior to the onset of symptoms where there is processing of samples from persons or animals that are suspected of having HPAI.

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Possible (suspect) influenza A/H5 casePossible (suspect) influenza A/H5 case

• Death from an unexplained acute respiratory illness AND one or

more of the following• 1- residing in area where HPAI is

suspected or confirmed;

• 2- having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious

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Probable influenza A/H5 caseProbable influenza A/H5 case

• Any individual presenting with fever

(>38°C) AND one or more of the following symptoms:

• cough;

• sore throat;

• shortness of breath;

• AND limited laboratory evidence for Influenza A/H5 (H5 specific antibodies detected in a single serum specimen).

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Confirmed influenza A/H5 caseConfirmed influenza A/H5 case

An individual for whom laboratory testing demonstrates one or more of the following :

• 1- positive viral culture for Influenza A/H5;• 2- positive PCR for Influenza A/H5;• 3- immunofluorescence antibody (IFA) test

positive using Influenza A/H5 monoclonal antibodies;

• 4- 4-fold rise in Influenza A/H5 specific antibody titre in paired serum samples.

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HPAI-clinical signsHPAI-clinical signsHPAI-clinical signsHPAI-clinical signsInitial symptoms Initial symptoms

includeinclude ::fever, cough and fever, cough and chillschills

• persistent high fever persistent high fever (>39oC)(>39oC)

• May cause a rapid downhill May cause a rapid downhill course in some casescourse in some cases

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• Ending with viral pneumonia, Ending with viral pneumonia, respiratory distress syndrome respiratory distress syndrome and multi-organ failureand multi-organ failure

HPAI-clinical signsHPAI-clinical signsHPAI-clinical signsHPAI-clinical signs

85

DiagnosisDiagnosisDiagnosisDiagnosis• 1 - Serology1 - Serology

• Many good tests available:Many good tests available:• ELISAELISA (multiple different kits available) (multiple different kits available)• HIHI (common in other countries) (common in other countries)

• 2 - Antigen2 - Antigen capture capture ELISAELISA tests tests • 3 – PCR3 – PCR• 4 - Virus isolation4 - Virus isolation• 5 - Genetic sequencing5 - Genetic sequencing

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• 4 - Virus isolation4 - Virus isolation• Gold standardGold standard• Done in chicken embryosDone in chicken embryos• Good samples include trachea, Good samples include trachea,

lung lung

• 5 - Genetic sequencing5 - Genetic sequencing / / relationships may be established relationships may be established after virus isolationafter virus isolation

DiagnosisDiagnosisDiagnosisDiagnosis

87

Control of HPAIControl of HPAIControl of HPAIControl of HPAI

• Prevention of exposurePrevention of exposure to likely to likely carriers of AIV (waterfowl, exotic carriers of AIV (waterfowl, exotic pets, etc.)pets, etc.)

• QuarantineQuarantine zone implementation / zone implementation / official notification systems in place official notification systems in place for positive areasfor positive areas

• DepopulationDepopulation• VaccinationVaccination

88

HPAI Control (vaccination)HPAI Control (vaccination)HPAI Control (vaccination)HPAI Control (vaccination)

• Effective at limiting disease, Effective at limiting disease, reducing viral shedreducing viral shed

• Used successfully as adjunct Used successfully as adjunct to to quarantinequarantine and and depopulationdepopulation

•

89

VACCINATIONVACCINATION

QURANTINEQURANTINE DEPOPULATIODEPOPULATIO

CONTROLCONTROL

90

Overall OperationOverall OperationOverall OperationOverall Operation

• Phase IPhase I : During the Outbreak : During the Outbreak• Eradication of the diseaseEradication of the disease

• Phase IIPhase II : Post Outbreak : Post Outbreak• Proof freedom from diseaseProof freedom from disease

• Phase IIIPhase III : Surveillance and : Surveillance and MonitoringMonitoring• Long term surveillanceLong term surveillance

91

Phase IPhase I : During the outbreak : During the outbreakPhase IPhase I : During the outbreak : During the outbreak

• Preemptive cullingPreemptive culling• DepopulationDepopulation and and disinfectiondisinfection all all

flocks within 5 km radius (Restriction flocks within 5 km radius (Restriction zone)zone)

• Surveillance during the outbreakSurveillance during the outbreak• all flocks within 50 km radius (Control all flocks within 50 km radius (Control

zone)zone)

• Movement controlMovement control• area within 60 km radiusarea within 60 km radius

• Public awareness campaignPublic awareness campaign

92

Surveillance during the outbreak

Surveillance during the outbreak

• Cloacal swabs

• Viral Isolation

• Laboratory assays

93

Phase II : Post-outbreakPhase II : Post-outbreak• To confirm freedom from disease

• Includes clinical surveillance and laboratory surveillance• Control zone

• Other

• Duration• Initial phase 30 days

• Later phase 5 months

94

Phase III : Surveillance and monitoring

Phase III : Surveillance and monitoring

• For early detection of the disease

• Since 1997

• Nationwide

• Long term

• Active and Passive surveillance

• All avian spp: farm, migratory, import, exotic etc.

95

Some guideline to prevent Some guideline to prevent Avian influenzaAvian influenza


1. Where possible, minimize direct contact with birds.

2. If you must contact birds, wash your hands thoroughly with soap and warm water after handling them.

96

3. When visiting poultry farms wear additional protective clothing (such as overalls or gowns) which should be removed on leaving the farm.

4. Staff handling bird carcasses or collecting samples directly from birds are advised to wear paper face masks and appropriate protective clothing.



97

5. Avoid working for prolonged periods in confined spaces with birds, especially if ventilation is poor.

6. If you develop a fever or respiratory disease contact your doctor immediately for appropriate treatment and investigation. Please inform your doctor of the history of exposure to birds.



98

Potential Interventions to Decrease Disease Transmission

Potential Interventions to Decrease Disease Transmission

Healthcare setting Community

Decrease potential for contact

• Neg pressure rooms

• Cohort patients

• Cohort staff

• Minimize transport

• Minimize visitors

• Environmental measures

• Travel advisories

• Screen travelers

• Cancel school and other public gatherings

• Limit public transport

• Isolation & quarantine (self-imposed or by HCW)

Decrease potential for infection

• Cough etiquette

• Hand hygiene

• Droplet precautions

• Cough etiquette

• Hand hygiene

• Wear masks in public

99

References :1) Raphael Dolin, Influenza, in : Kasper, Braunwald, Fauci, Harrison’s Principles of Internal

medicine, McGraw-Hill medical publishing division, New York, 16th ed. 2005, pp 1066-71.

2) Proper Storage and Handling of Influenza Vaccine , South Dakota Department of Health , 605-773-3737 or 1-800-738-2301, 2005, http://flu.sd.gov .

3) Cumulative number of confirmed human cases of avian influenza A / (H5N1), reported to WHO, 10 September 2008 . (http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_09_10/en/index.html)

4) John J. Treanor, Influenza Virus, In : Mandell, Douglas, Bennett’s Principles and Practice of Infectious Diseases, 6th ed., 2005, pp. 2060-85.

5) Influenza A (H5N1), WHO Interim Infection Control Guidelines for Health Care Facilities, Last updated: 10 March 2005.

6) WHO, Influenza in the World, Weekly Epidemiological Record, NO. 9, 4 March 2005. pp. 77-84.

7) WHO, Avian influenza A(H5N1) in humans and poultry, Viet Nam, Weekly Epidemiological Record, NO. 3, 16 January 2004. pp. 13-24.

8) WHO, Avian influenza A(H5N1) China, Weekly Epidemiological Record, NO. 5, 30 January 2004. pp. 41-52.

9) WHO, Avian influenza A(H5N1) Situation on 4 February 2004, Weekly Epidemiological Record, NO. 6, 6 February 2004. pp. 53-64.

10) WHO, Avian influenza A(H5N1), Weekly Epidemiological Record, NO. 7, 13 February 2004. pp. 65-76.

1 - Andre F. Ziegler, Emergency Diseases / Highly Pathogenic Avian Influenza (HPAI) ACPV, CVM 6880, Spring 2003

2 - BENSON CHONG F.6s (6210), INFORMATION OF H5N1 VIRUS

3 - WHO guidelines for global surveillance of influenza A/H5 6 February 2004

4 - . . . .

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