Avian Influenza

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Avian Influenza

• Chuck Wright, RMO
• American Embassy Jakarta
• September 27,2005

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Picture of Chickens
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What is Influenza (also called Flu)?

• The flu is a contagious respiratory illness
  caused by influenza viruses. It can cause mild to
  severe illness, and at times can lead to death.
• Every year in the United States, on average
• 5 to 20 of the population gets the flu
• more than 200,000 people are hospitalized from
  flu complications, and
• about 36,000 people die from flu.

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Flu

• Flu is not the common cold that produces runny
  nose, cough, low grade fever.
• Flu occurs at certain times of the year in the
  Northern and Southern Hemispheres and year round
  in the Tropics

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Symptoms of Flu

• Symptoms of flu include
• fever (usually high)
• headache
• extreme tiredness
• dry cough
• sore throat
• runny or stuffy nose
• muscle aches
• Stomach symptoms, such as nausea, vomiting, and
  diarrhea, also can occur but are more common in
  children than adults

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Bird Flu Cartoon
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Complications of Flu

• Complications of flu can include bacterial
  pneumonia, dehydration, and worsening of chronic
  medical conditions, such as congestive heart
  failure, asthma, or diabetes. Children may get
  sinus problems and ear infections.

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How Flu Spreads

• Flu viruses spread in respiratory droplets caused
  by coughing and sneezing. They usually spread
  from person to person, though sometimes people
  become infected by touching something with flu
  viruses on it and then touching their mouth or
  nose. Most healthy adults may be able to infect
  others beginning 1 day before symptoms develop
  and up to 5 days after becoming sick.
• That means that you can pass on the flu to
  someone else before you know you are sick, as
  well as while you are sick.

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Cartoon
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Preventing the Flu Get Vaccinated

• The "flu shot" -- an inactivated vaccine
  (containing killed virus) that is given with a
  needle. The flu shot is approved for use in
  people older than 6 months, including healthy
  people and people with chronic medical
  conditions.

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Influenza Pandemics During the 20th Century

• 1918-19, "Spanish flu," A (H1N1), caused the
  highest number of known influenza deaths more
  than 500,000 people died in the United States,
  and up to 50 million people may have died
  worldwide. Many people died within the first few
  days after infection, and others died of
  complications later. Nearly half of those who
  died were young, healthy adults. Influenza A
  (H1N1) viruses still circulate today after being
  introduced again into the human population in the
  1970s.
• 1957-58, "Asian flu," A (H2N2), caused about
  70,000 deaths in the United States. First
  identified in China in late February 1957, the
  Asian flu spread to the United States by June
  1957.
• 1968-69, " Hong Kong flu," A (H3N2), caused
  about 34,000 deaths in the United States. This
  virus was first detected in Hong Kong in early
  1968 and spread to the United States later that
  year. Influenza A (H3N2) viruses still circulate
  today.
• Both the 1957-58 and 1968-69 pandemics were
  caused by viruses containing a combination of
  genes from a human influenza virus and an avian
  influenza virus. The origin of the 1918-19
  pandemic virus is not clear.

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Pandemic A Worldwide Outbreak of Influenza

• An influenza pandemic is a global outbreak of
  disease that occurs when a new influenza A virus
  appears or emerges in the human population,
  causes serious illness, and then spreads easily
  from person to person worldwide.
• Pandemics are different from seasonal outbreaks
  or epidemics of influenza. Seasonal outbreaks
  are caused by subtypes of influenza viruses that
  are already in existence among people, whereas
  pandemic outbreaks are caused by new subtypes or
  by subtypes that have never circulated among
  people or that have not circulated among people
  for a long time.
• Past influenza pandemics have led to high levels
  of illness, death, social disruption, and
  economic loss.

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Flu Travel Pic
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What is Avian Flu?

• Avian Flu is the bird version of our Human Flu.
  The current one is designated H5N1.
• These flu viruses occur naturally among birds.
  Wild birds worldwide carry the viruses in their
  intestines, but usually do not get sick from
  them.
• However, bird flu is very contagious among birds
  and can make some domesticated birds, including
  chickens, ducks, and turkeys, very sick and kill
  them.

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How are bird flu viruses different from human flu
viruses?

• When we talk about bird flu viruses, we are
  referring to those flu A subtypes that continue
  to occur mainly in birds. They do not usually
  infect humans, even though we know they can do
  so.
• When we talk about human flu viruses we are
  referring to those subtypes that occur widely in
  humans. There are only three known subtypes of
  human flu viruses (H1N1, H1N2, and H3N2) it is
  likely that some genetic parts of current human
  flu A viruses came from birds originally.
• Flu A viruses are constantly changing, and they
  might adapt over time to infect and spread among
  humans.

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Instances of Avian Influenza Infections in Humans

• H5N1, Hong Kong, 1997 Avian influenza A (H5N1)
  infections occurred in both poultry and humans.
  This was the first time an avian influenza virus
  had ever been found to transmit directly from
  birds to humans. During this outbreak, 18 people
  were hospitalized and six of them died. To
  control the outbreak, authorities killed about
  1.5 million chickens to remove the source of the
  virus.
• H9N2, China and Hong Kong, 1999 Avian influenza
  A H9N2 illness was confirmed in two children.
  Both patients recovered, and no additional cases
  were confirmed.
• H7N2, Virginia, 2002 Following an outbreak of
  H7N2 among poultry in the Shenandoah Valley
  poultry production area, one person was found to
  have serologic evidence of infection with H7N2.
• H5N1, China and Hong Kong, 2003 Two cases of
  avian influenza A (H5N1) infection occurred among
  members of a Hong Kong family that had traveled
  to China. One person recovered, the other died.
• H7N7, Netherlands, 2003 The Netherlands
  reported outbreaks of influenza A (H7N7) in
  poultry on several farms. Later, infections were
  reported among pigs and humans. In total, 89
  people were confirmed to have H7N7 influenza
  virus infection associated with this poultry
  outbreak. These cases occurred mostly among
  poultry workers.
• H9N2, Hong Kong, 2003 H9N2 infection was
  confirmed in a child in Hong Kong. The child was
  hospitalized but recovered.
• H7N2, New York, 2003 In November 2003, a patient
  with serious underlying medical conditions was
  admitted to a hospital in New York with
  respiratory symptoms. One of the initial
  laboratory tests identified an influenza A virus
  that was thought to be H1N1. The patient
  recovered and went home after a few weeks.
  Subsequent confirmatory tests conducted in March
  2004 showed that the patient had been infected
  with an H7N2 avian influenza virus
• H5N1, Thailand and Vietnam, 2004
• H7N3 in Canada , 2004 In February 2004, human
  infections of H7N3 among poultry workers were
  associated with an H7N3 outbreak among poultry.
  The H7N3-associated illnesses consisted of eye
  infections.
• H5N1, Thailand and Vietnam, 2004 and 2005
  Beginning in late June 2004, new lethal outbreaks
  of H5N1 among poultry were reported by several
  countries in Asia. The new outbreaks of H5N1 in
  poultry in Asia were followed by renewed sporadic
  reporting of human cases of H5N1 infection in
  Vietnam and Thailand beginning in August and
  continuing into 2005. Of particular note is one
  isolated instance of probable limited
  human-to-human transmission occurring in Thailand
  in September.

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Symptoms of Avian Influenza in Humans

• The reported symptoms of avian influenza in
  humans have ranged from typical influenza-like
  symptoms (e.g., fever, cough, sore throat, and
  muscle aches) to eye infections (conjunctivitis),
  pneumonia, acute respiratory distress, viral
  pneumonia, and other severe and life-threatening
  complications.

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Transmission of Influenza A Viruses Between
Animals and People

• Influenza A viruses are found in many different
  animals, including ducks, chickens, pigs, whales,
  horses, and seals.
• Avian influenza viruses may be transmitted to
  humans in two main ways
• Directly from birds or from avian
  virus-contaminated environments to people.
• Through an intermediate host, such as a pig.

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Bird Flu Cartoon
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How Influenza Viruses Change Drift and Shift

• Influenza viruses can change in two different
  ways.
• One type is called "antigenic drift," which
  occurs through small changes in the virus that
  happen continually over time. Antigenic drift
  produces new virus strains that may not be
  recognized by antibodies to earlier influenza
  strains.
• The other type of change is called "antigenic
  shift." Antigenic shift is an abrupt, major
  change in the influenza A viruses, resulting in a
  new influenza virus that can infect humans and
  has a hemagglutinin protein or hemagglutinin and
  neuraminidase protein combination that has not
  been seen in humans for many years.
• Influenza viruses are changing by antigenic drift
  all the time, but antigenic shift happens only
  occasionally.

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The Worry?

• That the H5N1 virus will mutate into a person to
  person transmissible version and spread.
• The virus can share genetic material with a human
  flu virus through reassortment and become more
  virulent
• Pigs could be the intermediary host (receptors
  for both avian and human flu).
• No one knows if this will happen.

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What is the risk to humans from the H5N1 virus in
Asia?

• The H5N1 virus does not usually infect humans.
• So far, spread of H5N1 virus from person to
  person has been rare and spread has not continued
  beyond one person.

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How is bird flu in humans treated?

• Studies suggest that the prescription medicines
  approved for human flu viruses would work in
  preventing bird flu infection in humans. However,
  flu viruses can become resistant to these drugs,
  so these medications may not always work.

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Bird Flu Cartoon
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Graph from USAID August 2005
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Avian Influenza in Indonesia

• Confirmed in birds in 2003
• Expanding epidemic in birds during 2004
• Found among many species of birds and mammals
  (pigs) during 2004 and 2005
• Human infections confirmed in July, August and
  September 2005
• No current evidence of efficient and sustained
  transmission among humans

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60 of Indonesians live on Java Bali
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Confirmed H5N1 in Bird Populations
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NAMRU-2 Influenza Surveillance Network
Established Sites
Expanded Sites (to rural clinics)
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Where are we now?
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Flu and Media
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How is infection with H5N1 virus in humans
treated?

• The H5N1 virus currently infecting birds in Asia
  that has caused human illness and death is
  resistant to amantadine and rimantadine, two
  antiviral medications commonly used for
  influenza.
• Two other antiviral medications, oseltamavir
  (Tamiflu) and zanamavir, would probably work to
  treat flu caused by the H5N1 virus, though
  studies still need to be done to prove that they
  work.

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Is there a vaccine to protect humans from H5N1
virus?

• There currently is no vaccine to protect humans
  against the H5N1 virus that is being seen in
  Asia.
• However, vaccine development efforts are under
  way. Research studies to test a vaccine to
  protect humans against H5N1 virus began in April
  2005. (Researchers are also working on a vaccine
  against H9N2, another bird flu virus subtype.)

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Recommendations

• Avoid all contact with poultry (e.g., chickens,
  ducks, geese, pigeons, quail) or any wild birds,
  and avoid settings where H5N1-infected poultry
  may be present, such as commercial or backyard
  poultry farms and live poultry markets. Do not
  eat uncooked or undercooked poultry or poultry
  products, including dishes made with uncooked
  poultry blood.
• As with other infectious illnesses, one of the
  most important preventive practices is careful
  and frequent handwashing. Cleaning your hands
  often, using either soap and water (or waterless,
  alcohol-based hand rubs when soap is not
  available and hands are not visibly soiled),
  removes potentially infectious materials from
  your skin and helps prevent disease transmission.
  
• CDC does not recommend the routine use of masks
  or other personal protective equipment while in
  public areas.

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Get a Flu Shot

• Prevents flu (but not Avian Flu) and thus keeps
  you healthy and avoids a disease that can look
  like Avian Flu
• Less loss of time from work
• Less chance that Avian Flu will mix with Human Flu

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When to get the Flu Shot

• Embassy is giving it to all FSNs, their spouses
  and children around Oct 23rd.
• Embassy Americans can get it in the Health Unit
  once it arrives (watch for an announcement).
• Non Embassy employees consult your doctor (SOS
  has it).

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Food Hygiene

• Separate raw meat from cooked or ready-to-eat
  foods. Do not use the same chopping board or the
  same knife for preparing raw meat and cooked or
  ready-to-eat foods.
• Do not handle either raw or cooked foods without
  washing your hands in between.
• Do not place cooked meat back on the same plate
  or surface it was on before it was cooked.
• All foods from poultry, including eggs and
  poultry blood, should be cooked thoroughly. Egg
  yolks should not be runny or liquid. Because
  influenza viruses are destroyed by heat, the
  cooking temperature for poultry meat should reach
  70C (158 F).
• Wash egg shells in soapy water before handling
  and cooking, and wash your hands afterwards.
• Do not use raw or soft-boiled eggs in foods that
  will not be cooked.
• After handling raw poultry or eggs, wash your
  hands and all surfaces and utensils thoroughly
  with soap and water.

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IF You Have Been Exposed

• Monitor your health for 10 days.
• If you become ill with fever and develop a cough
  or difficulty breathing, or if you develop any
  illness during this 10-day period, consult a
  health-care provider. Before you visit a
  health-care setting, tell the provider the
  following 1) your symptoms 2) if you have had
  direct poultry contact, and 3) where you
  traveled. The U.S. embassy or consulate also can
  provide names and addresses of local physicians.
  
• Do not travel while sick, and limit contact with
  others as much as possible to help prevent the
  spread of any infectious illness.

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Tamiflu

• The Embassy has this medication and can provide
  it to employees who are infected or exposed.
• Non-Embassy employees should contact their doctor
  about how to access a supply if they are infected

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Sources of Information

• http//jakarta.usembassy.gov/
• http//www.cdc.gov/flu/avian/
• http//www.wpro.who.int/avian_flu/

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Questions????