Dr Rahmini Shabariah SpA

family
Orthomyxoviridae
large, single-stranded
RNA virus
2 major surface
glikoprotein serotype
1/. hemagglutinin (H) &
2/. neuromidase (N)
project as spikes
through the envelope
H1-15 and N1-9

type

type

type

human & animal

primary
pathogen
mild severe
AURI & ALRI
epidemic,
potenly
pandemic
Avian
Influenza

human
primary
pathogen
mild - moderate
AURI,
epidemic

human
sporadic
cases
mild
AURI,
no epidemic
th ed,
Nelson 17th
2004

animal host, mainly aves reservoir for

diverse strain
potential for infecting human
any of 15H & 9H in animal may be
introduced into humans
many serotypes, potential changes

antigenic drift: minor changes within a serotype

antigenic shift: major changes within a serotype

migratory avian host spread of disease

th ed,
Nelson 17th
2004

live in the water: 4 days in 220C, and

>30 days in 00C
live in avian feces up to 32 days
very labile, mutate easily: LPAI HPAI

in chicken carcasses, die in 800C for 1

and 600C for 30
in chicken egg, die in 640C for 5
die in: alcohol 70%, formalin 2-5%,
chlorine, iodine, fenol, Na/K hypochloride

Avian influenza H5N1 in poultry

confirmed in Asia
South Korea, Vietnam, Japan, Thailand,
Cambodia, Taiwan, Laos, China,
Indonesia, Pakistan, Malaysia
possible virus sources:

birds migration
transportation of infected poultry

1997: Hong Kong (H5N1) 18 cases, 6 died

1999: China & Hong Kong (H9N2) 2 cases
2002: Virginia (H7N2);1 seropositive case
2003: Fujian, Hong Kong (H5N1) 2 cases, 1
died
2003: Netherlands (H7N7); 89 cases, 1
died
2003: Hong Kong (H9N2); 1 case
2004-2005: Canada (H7N3); Vietnam
(H5N1) 87 cases; Thailand (H5N1) 17
cases; Cambodia (H5N1) 4 cases;
Indonesia
(H5N1) 1 case

Spanish flu
1918
virus H1N1
40-50 million
death
50% victim
young
healthy
people
die in a few
days

Asian flu
1957
virus H2N2
China, Feb
1957
spread to
USA in 4
months
1 million
death

Hong Kong
flu 1968
virus H3N2
Hongkong,
early 1968
spread
quickly to
USA
still circulate
today

Age Onse
Clinical
Lab
Duratio
t
n
8 y 24.06.0 fever,cough, positiv
20
5
diarrhea,RDS
e
days
serolog
y
1y

29.06.0
5

38
y

02.07.0
5

fever,cough,
diarrhea,RDS
fever,cough, positiv
cold,diarrhea
e
, RDS
PCR

10
days
10
days

limited cases, only 109 confirmed cases up

to July 2005
vary clinical features, usually with
respiratory symptoms, but one cases
without respiratory symptoms at all
progressive clinical process leading to death
despite aggressive treatment retrospective
analysis

incubation period for human influenza: 23 days (range 1-7 days )

incubation period for avian influenza: 3
days (2-4)
clinical features: vary, from
asymptomatic, mild ILI (Influenza like
illness) to severe ARDS (Acute respiratory
distress syndrome)

similar with the usual influenza ILI

Acute respiratory febrile illness

fever >380C
cough
coryza / runny nose
sore throat
myalgia
headache
malaise

can progress rapidly, to pneumonia and

ARDS

ARDS

fever

Pneumoniae
Severe ILI

Mild-Modr ILI
asymptomatic

diarrhe
a
seizure

all

patient with ILI ???

all patient with
pneumonia ???

fever >380C
cough, coryza, sore throat
AND, 1 of the following:
in the last week, visiting a farm with an AI
outbreak in the poultry OR
history of contact with a confirmed AI case
OR
working in the lab which processing AI
virus specimen

suspect case AND

progressive clinical features, leading to
pneumonia / respiratory failure / death OR
laboratory test positive for H5N1 Ag OR
no other proven etiology

a person with acute respiratory febrile

illness, with >1 of the following:
positive viral culture for influenza A/H5
positive PCR for influenza A/H5
positive IFA (Immuno-fluorescent antibody)
test to H5 antigen using monoclonal
antibodies
4-fold rise in H5 specific antibody titre in
paired serum sample

the disease will have bad prognosis if:

late hospitalized
older age
pneumonia
leucopenia
lymphopenia

bad general condition, severely ill

fever >380C
tachypnea, dyspnea
ronchi, crackles
respiratory failure

marked leucopenia
marked lymphopenia

marked and progressive abnormalities, but

non specific
extensive bilateral infiltrates
diffuse, multifocal, or patchy infiltrates
lobar collapse
focal consolidation
air bronchogram

early implementation of infection control

precautions to minimize nosocomial
spread of disease
proper case management to prevent
severe illness and death
early identification and follow up of
persons at risk of infection to facilitate
early intervention with antiviral therapy
to reduce morbidity an mortality an limit
further spread of the disease

WHO Guidelines Feb

2004

use high efficiency mask

a negative pressure room if available
is recommended
isolate the patient to a single room, if
not available bed should be placed >1m
apart, preferably separated by a
physical barrier (curtain, partition)
appropriate Personal Protective
Equipment (PPE)

WHO Guidelines Feb

2004

limit the number of Health Care Workers

(HCWs) who have direct contact with
the patient(s),
restrict the number of visitors and
provide them with appropriate PPE
dispose of waste properly
linen and reusable materials should be
handled separately and disinfected

WHO Guidelines Feb

2004

if not requiring hospitalization, educate

patient and family on personal hygiene
and infection control
if clinically indicated, hospitalize patients
take respiratory & blood specimens for lab
testing for influenza and other infections
treat with neuromidase inhibitor, such as
oseltamivir
provide supportive care, monitor oxygen
saturation and treat desaturation with
supplemental oxygen as required

WHO Guidelines Feb

2004

take respiratory and blood specimens serially to

check for possible bacterial infection
consider IV antibiotic therapy to control
secondary bacterial infections as required
steroids should be used only in the context of
clinical trial
avoid salicylates in children<18 years because
the risk of Reye syndrome, instead use
paracetamol or ibuprofen

WHO Guidelines Feb

2004

Isolation room

beware of airborne transmission

infectious period, the first 7 days of symptoms

Moved to ward

PCR or culture of nasopharyngeal swab is

negative for several times
no fever for 7 days

rest
body defense mechanism improvement
antiviral therapy
antibiotic
respiratory care
anti-inflammation : steroid (prednisolone
2mg/kg/hari), if needed
immuno-modulator

should be given in the first 48 hours

two kinds:
M2 protein inhibitor:
amantadine (Symmetrel, Symadine)
rimantadine (Flumadine)

Neuromidase inhibitor:
oseltamivir (Tamiflu)
zanamivir (Relenza)

adult patients remain in hospital for 7 days

after resolution of fever
children patients remain in hospital for 21
days after resolution of fever

human to human transmission is very rare

clinical features of AI are not specific, and
vary from asymptomatic to severe ARDS
the severe form, progress rapidly and
usually fatal
acute respiratory febrile illness with
progressive clinical features should be
suspected as an AI
oseltamivir is an important drug for
treatment and prevention of AI
AI has a potential to become a new
pandemic
increase awareness of this potential threat