avian flu transmission
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Avian InfluenzaEpidemiologi & Penularanpada Manusia
Sri Rezeki S Hadinegoro
Divisi Infeksi & P.TropisDep Ilmu Kesehatan Anak FKUI-RSCM
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Virus avian influenza (H5N1) berasal dariburung liar (wild birds) menyerang unggas(burung, ayam), babi, kuda
Menyebar cepat diantara populasi unggasdengan kematian tinggi
Dapat menyebar antar peternakan
Penularan melalui udara, air tercemar,berasal dari tinja unggas sakit
Dapat menyerang manusia (penyakitzoonosis)
Avian influenza
(bird flu, flu burung)
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Avian influenza
(bird flu, flu burung) Secara epidemiologi
Low pathogenic avian influenza (LPAI)
Highly pathogenic avian influenza (HPAI)
Perbedaan pada susunan genetik virus
HPAI sangat virulen menyebabkan kematian ternak
ayam 90-100% LPAI
infeksi ringan atau tidak tampak sakit
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Wabah Avian Influenza
1997, avian influenza A (H5N1), Hongkong,menyerang ayam dan manusia
1999 Hongkong: avian flu A (H9N2), 2 kasus anak, hidup
Cina: H9N2
2003
Hongkong: avian flu A (H5N1), 2 kasus, 1 meninggal,riwayat perjalanan ke Cina
Netherland: avian flu A (H7N7), 83 kasus pekerjapeternakan, 1 meninggal
Hongkong : avian flu A (H9N2), 1 kasus hidup
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Situasi Virus Influenza H5N1 di Asia6 Februari 2004
Penyebab wabah flu di Hongkong,
Vietnam, Thailand, dan Jepang
Dilaporkan 20 kasus pada manusia Vietnam 15
Thailand 5
Kematian 16 kasus
Vietnam 11
Thailand 5
CFR 80%
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Situasi Virus Influenza H5N1 di Asia21 Juli 2005
Kasus avian influenza A (H5N1) pada
manusia 109 orang
Vietnam 87
Thailand 17
Kamboja 4
Indonesia 2 (WHO), 1 belum ada hasil
Kematian 55 orang (50,45%)
http://www.who.int/csr/disease/avian_influenza/en/
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Situasi di Indonesia 2004 Virus menyerang ternak ayam sejak bulan
Okt 2003-Feb 2004
4,7 juta ayam mati Belum ada laporan menyerang manusia
Serosurvai virus influenza A(H5N1)terhadap peternak semua negatif, dari 2
daerah Bali 102 sera, 28 kontrol, 8 swab hidung
Tangerang: 100 sera, 25 kontrol, 6 swab hidung
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Daerah tertular Avian Flu
di Indonesia
September 2003-Desember 2004
17 provinsi, 108 kabupaten/kota P Sumatera: 5 prop, 17 kab/kota
P Jawa: 6 prop, 71 kab/kota
P Kalimantan: 3 prop, 5 kab/kota Nusa Tenggara: 2 prop, 7 kab/kota
Sumber: Dirjen Peternakan, Deptan; Kompas 31 Juli 2005
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Analisis Epidemiologi
Outbreak of highly pathogenic avianinfluenza A (H5N1)
2003-2004 wabah di 8 negara Asia : Kamboja,Cina, Indonesia, Jepang, Laos, Korea Selatan,Thailand, Vietnam
>100 juta burung mati/ dimusnahkan
Des 2003-Maret 2004: 12 confirmed human avianinfluenza A di Thailand, 23 Vietnam, kematian 23orang
Tidak ada laporan penularan manusia ke manusia
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Analisis Epidemiologi Akhir Juni 2004: epizootic outbreakof new lethal
avian influenza(H5N1) pada ayam di Kamboja,Cina, Indonesia, Malaysia, Thailand, & Vietnam
Agustus
Oktober 2004: kasus pada manusiasecara sporadis di Vietnam, Thailand
Sept 2004: probable limited human to humantransmission(Thailand)
Des 2004: ayam & manusia (Vietnam) Feb 2005: infeksi pada manusia (Kamboja)
Juli 2005 : infeksi pada manusia (Indonesia)
www.cdc.gov/flu/avian.htm
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Penularan dari binatang ke manusia
Infeksi virus influenza A spesifik manusia : H3N2, H2N2, H1N1
babi : H7N7
kuda : H3N8
AS, tahun 1998 ditemukan H1N1 pada babi
H3N2 dari manusia terdapat pada babi
Masa inkubasi 1-3 hari
Penularan ke manusia melalui 2 cara langsung dari unggas atau lingkungan yang tertular virus
melalui hostperantara, misalnya babi
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HA subtypes
ManSwine
Horse
Seal
Turkey
Duck
++
+
+H1
+
+H2
++
+
+H3
+
+
+H4
+
+
+H5
+
+H6
+
+
+
+H7
+H8
+
+H9
+
+H10
+H11
+H12
NA subtypes
++
+
+N1
++
+
+N2
+
N3
+
+N4
+
+N5
+N6
+
+
+
+N7
+
+
+N8
+N9
H1N1, H2N2, H3N2 and H5N1, H1N2 subtypes have been isolated in humans Today, H1N1 and H3N2 and H1N2 (less) subtypes of influenza A co-circulate
No subtypes exist for B or C viruses
Host distribution of influenza Asubtypes
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Masalah yang akan timbul
Epizootic outbreakmerupakan ancaman kesehatanmasyarakat
Imunitas alami infeksi H5N1 pada manusia rendah Mengakibatkan pandemi avian influenza (H5N1) pada
manusia
Penularan dari manusia ke manusia terbukti (jaringanautopsi, nasofarings, usapan tenggorok dg RT-PCR)pada 3 kasus dalam 1 keluarga di Thailand
Kasus Vietnam & Thailand resistans terhadap antivirus
amantadine & rimantadine (sensitif thd antivirus lainoseltamivir & zanamivir)
Belum ada vaksin avian influenza (H5N1) untukmanusia
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"Flu spreads across the world and ages"
INFLUENZAa devastating AIRBORNE infectious disease
Murphy B.R., Webster R.G., Virology, IInd edition, New York, 1990, 1091-2Ghendon Y. Introduction to pandemic influenza through history Eur Jour of Epid, 1994;10: 451-453
412 B.C
Middle ages1781 & 1830
1918
1933
1957
1968
1977
"Asian flu A (H2N2)
"Hong Kong" flu A (H3N2)
"Russian" flu
First human influenza virus isolated
"Spanish influenza" killed 20-40 million people
A(H1N1)Epidemics spread across Russia from Asia
Numerous episodes described
Epidemicrecorded
by Hippocrates
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Epizootic outbreak
Recent research: circulating strain H5viruses are becoming more capable ofcausing diseases (pathogenic) for mammals(pig, cat, tiger, leopard) than earlier H5viruses and more widespread in birds(ducks) in the region
Reassortment of avian influenza genomes ismost likely to occur when these virusesdemonstrate a capacity to infect multiplespecies, as is now the case in Asia
www.cdc.gov/flu/avian.htm
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Frequent with Influenza A, less for type B, never for
type C
To escape population immunity
Involves the external antigens : HA and NA
Two types of mutations depending on whether the
RNA segment variation is small or great
Antigenic drift Antigenic shift
Each year, evolution can induce a different virus
Antigenic variation :intelligence of influenza viruses
Betts FR, Douglas RG, Mandell G.L., Douglas R. G., Bennett J.E., Principles andpractice of infectious diseases, 3rd ed., 1990;39:1306-25
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Antigenic drift minor changes inHA or NA
Affects Influenza A and B viruses
Occurs every year or every few years within an influenza
subtype
Mutations affecting RNA amino acids Does not result in new subtype
Can result in significant epidemics
A/H3N2
Viral population
RNA point mutations
Infected
host cell
RNA segment
one or more
amino acids
change
DRIFTA/H3N2
Betts FR, Douglas RG, Mandell G.L., Douglas R. G., Bennett J.E., Principles and
practice of infectious diseases, 3rd ed., 1990;39:1306-25
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Historical antigenic driftsfor H3N2 and H1N1 subtypes
Assaad F, Bektirimov T, Ljungars-Esteves K. influenza- world experience.
In: Stuart-Harris C, Potter CW eds. The molecular virology
andepidemiology of influenza London, New York and Orlando, Academic
Press 1984- 5-15
?
A/Chile/83
A/Mississipi/85
A/Singapore/86
A/England/80
A/India/80
A/USSR/77
H1N1
A/Brazil/78
A/Johannesburg/94
?
A/Wuhan/95
A/Hong Kong/68
A/Philippines/82
A/Port Chalmers/73
A/Scotland/74
A/Victoria/75
A/Texas/77
A/Bangkok/79
A/Beijing/89
A/Shangha/87
A/Shangdong/93
H3N2
A/England/72
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Antigenic shift
emergence of a "new" virus worldwide Affects only Influenza A virus
Major and sudden genetic variations in HA and/or NA
No immunity in population
Results in pandemics every 10 to 40 years
RNA recombination
Infected
host cell"New" virus
Genetic reassortment
hybrid strain RNA
Result in new subtypes: "new" HA and/or "new" NA
human strain
RNA
avian strain
RNA SHIFT
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H3 H3'H3''
H3 H3'antibody (ab)
to former(H2) virus
anti-H3 abanti-H3 abanti-H3' ab
PANDEMICINTRODUCTION
INTERPANDEMICPERIOD
Shift Drifts
Kilbourne ED Inactivated influenza vaccines. In: Vaccines IInd edition Re 59; 1994:565-81
Influenza viruses:two ways of avoiding population immunity
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InfluenzaPandemics
1918 1957 1968 1977 1997
1998/9
2003
H1
H1
B
H2
H7H5H5
H9
Spanish
Influenza
Asian
Influenza
RussianInfluenza
AvianInfluenza
Hong KongInfluenza
H3
Pandemic
vaccines
Regularvaccines
Ellina, 2004
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Seasonal occurrence of influenza
J F M A M J J A S O N DJ F M A M J J A S O N D
Southern hemisphere Tropical Northern hemisphere
Reichelderfer PS, Kendal AP, Shortridge KF, Hampson A. and al. Influenza surveillance in the pacifi
In: Current topics in medical virology 1988:412-38
Summary of influenza activity and occurrence in different climates
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Choice of vaccine strains procedure
Hannoun C.
Role of international networks for the surveillance of influenza.
Eur Journal of Epidemiol 1994;10:459-61
Sentinel Doctors
National influenza Centers
(110 national laboratories in over 80 countries)
World Health Organisation
(WHO - Geneva)
Collaborating Reference Centers for
Research against influenza
(London, Atlanta, Melbourne and
Tokyo)
Vaccine Manufacturers
International surveillance network
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Influenza vaccines in practice
Age group
6-35 mos
3-8 yrs
9-12 yrs
>12 yrs
Dosage
0.25 ml
0.50 ml
0.50 ml
0.50 ml
Product
Split or subunit
Split or subunit
Split or subunit
Split, subunit or whole
1 or 2*
1 or 2*
1
1
No. of doses
ACIP Recommendations
*at least 1 month apart for children receiving vaccine for the first time
MMWR, ACIP 1996
Whole virus vaccine is prohibited for subjects under 13 years
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Rekomendasi WHOVaksinasi Influenza
Vaksinasi influenza untuk kelompok risikotinggi (populasi yang berhubungan denganpeternakan ayam)
Awam perlu dilindungi terhadap virusinfluenza manusia
Tidak melindungi virus influenza A (H5N1)
Mengurangi kesempatan terjadinya viralshift(subtipe baru yang dapat menyebabkan pandemi)
http://www.who.int/csr/disease/avian_influenza/en/
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Travel Warning
Before any international travel
Always educate yourself and others who maybe traveling with you about any disease risksin areas you plan to visit
http://www.cdc.gov/flu/avian/index.htm
Be sure you are up to date with all yourshots, and see your doctor or health-care
provider, ideally 4
6 weeks before travel toget any additional shots, medications, orinformation you may needhttp://www.cdc.gov/travel/seasia.htm
http://www.cdc.gov/flu/avian/index.htmhttp://www.cdc.gov/travel/seasia.htmhttp://www.cdc.gov/travel/seasia.htmhttp://www.cdc.gov/flu/avian/index.htm -
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Travel Warning
Before any international travel Assemble a travel health kit containing basic
first aid and medical supplies. Be sure toinclude a thermometer and alcohol-basedhand rub for hand hygiene.http://www.cdc.gov/travel/other/travelers-health-kit.htm
Identify in-country health-care resources inadvance of your trip
Check your health insurance plan or getadditional insurance that covers medicalevacuation in case you become sick.www.travel.state.gov/medical.html
http://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.travel.state.gov/medical.htmlhttp://www.travel.state.gov/medical.htmlhttp://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.cdc.gov/travel/other/travelers-health-kit.htmhttp://www.cdc.gov/travel/other/travelers-health-kit.htm -
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Travel Warning
During Travel Avoid places such as poultry farms and bird markets
where live poultry are raised or kept , and avoidhandling surfaces contaminated with poultry feces orexcretions.
Frequent handwashing. Influenza viruses are destroyed by heat; all foods from
poultry, including eggs and poultry blood, should bethoroughly cooked.
If you become sick with symptoms such as a fever,difficulty breathing, cough, or any illness that requiresprompt medical attention, and informing your family orfriends.
http://www.cdc.gov/travel/other/illness-abroad.htm.
http://www.cdc.gov/travel/other/illness-abroad.htmhttp://www.cdc.gov/travel/other/illness-abroad.htmhttp://www.cdc.gov/travel/other/illness-abroad.htmhttp://www.cdc.gov/travel/other/illness-abroad.htm -
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Travel Warning
After your return Monitor your health for 10 days
If you become ill with fever, difficulty breathing,
cough, or any illness during this period, consult a
health-care provider
Before you visit a health-care setting,
tell the provider about your symptoms,
if you have had direct poultry contact,and where you traveled.
This way he or she can be aware you have traveled
to an area reporting avian influenza
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Avian influenza- situation in Indonesia29 July 2005
Laboratory evidence now shows that the 8-year-oldgirl from Tangerang, Banten Province, is a probableavian influenza A/H5 case, based on analysis of
serological samples. She was the daughter of theconfirmed case reported previously
Two WHO Reference Laboratories at the Universityof Hong Kong and the Centers for Disease Control
and Prevention USA, detected high positive risingmicroneutralisation titres specific for H5N1 in 2samples taken 3 days apart
www.who.int/disease/avian_influenza/html
http://www.who.int/csr/don/2005_07_29c/en/%20http:/www.who.int/csr/don/2005_07_21a/en/index.htmlhttp://www.who.int/csr/don/2005_07_29c/en/%20http:/www.who.int/csr/don/2005_07_21a/en/index.html -
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Avian influenza- situation in Indonesia
29 July 2005 Laboratory results for the 1-year-old
daughter are still pending.
Genotyping of the PCR-amplified isolate
from the confirmed case (father) shows highhomogeneity with other H5N1 isolates frompoultry in Java, and no evidence ofreassortment.
Extensive epidemiological and environmentalstudies are ongoing around this familycluster.
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Avian influenza- situation in Indonesia29 July 2005
The Minister of Agriculture stated thatlaboratory results detected H5-infected birdfaeces in a bird cage opposite side of the
road of the family's house; cloacal andthroat swabs of the pet bird inside the cagewere negative for H5.
This is the first, and thus far, the onlyindication of a possible source of exposure.Other environmental sampling wasnegative.
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Rekomendasi Depkes
Kerjasama antara Depkes & Deptan
Survailans (seroepidemiologi)
Biosecurity Deteksi dini kasus, spesimen
Perawatan kasus
Imunisasi (terutama terindikasi pada orangyang berhubungan dengan peternakan)
Tim SARS diaktifkan kembali
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Bacaan www.cdc.gov/flu : basic information
www.cdc.gov/flu/han020302.htm : updating
www.who.int/csr/disease/avian_influenza/avian-
faqs/en/html: frequently asked questions www.who.int/csr/disease/influenza/vaccinerecomm
endations1/en/print.html: influenza vaccine
www.cdc.gov/flu/avian/outbreaks/asia.htm:
influenza antiviral drugs Depkes RI 2004. Pedoman penanggulangan Avian
flu
http://www.cdc.gov/fluhttp://www.cdc.gov/flu/han020302.htmhttp://www.who.int/csr/disease/avian_influenza/avian-faqs/en/htmlhttp://www.who.int/csr/disease/avian_influenza/avian-faqs/en/htmlhttp://www.who.int/csr/disease/influenza/vaccinerecommendations1/en/print.htmlhttp://www.who.int/csr/disease/influenza/vaccinerecommendations1/en/print.htmlhttp://www.cdc.gov/flu/avian/outbreaks/asia.htmhttp://www.cdc.gov/flu/avian/outbreaks/asia.htmhttp://www.who.int/csr/disease/influenza/vaccinerecommendations1/en/print.htmlhttp://www.who.int/csr/disease/influenza/vaccinerecommendations1/en/print.htmlhttp://www.who.int/csr/disease/avian_influenza/avian-faqs/en/htmlhttp://www.who.int/csr/disease/avian_influenza/avian-faqs/en/htmlhttp://www.who.int/csr/disease/avian_influenza/avian-faqs/en/htmlhttp://www.cdc.gov/flu/han020302.htmhttp://www.cdc.gov/flu -
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