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Avian Influenza
Contents
bull Avian influenza Occurrence of Avian influenza A virus infections of humans
bull History of influenzabull Economic Impactbull H5N1bull Epidemiologybull Clinical manifestations in birds and human diagnosis treatmentbull Prevention controlbull The Philippines Preparedness and Response Planbull Tips for spreading the news
Very contagious among birds and can make domesticated birds including chickens ducks and turkeys very sick and kill them
Introduction
bull Influenza originated in birds slowly mutated to human flu bull bird flu has always been around bull a new type of concern H5N1 virus bull highly contagious killing 50 to 100 within 48 hrs bull Poultry outbreaks in neighboring India and China - alerted the government UN agencies donors and other organizations
Occurrence
bull Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere
bull Outbreaks due to HPAI were recorded in the Pennsylvania area USA in the years 1983-84
bull Instances of Avian Influenza A Virus Infections of Humans
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Contents
bull Avian influenza Occurrence of Avian influenza A virus infections of humans
bull History of influenzabull Economic Impactbull H5N1bull Epidemiologybull Clinical manifestations in birds and human diagnosis treatmentbull Prevention controlbull The Philippines Preparedness and Response Planbull Tips for spreading the news
Very contagious among birds and can make domesticated birds including chickens ducks and turkeys very sick and kill them
Introduction
bull Influenza originated in birds slowly mutated to human flu bull bird flu has always been around bull a new type of concern H5N1 virus bull highly contagious killing 50 to 100 within 48 hrs bull Poultry outbreaks in neighboring India and China - alerted the government UN agencies donors and other organizations
Occurrence
bull Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere
bull Outbreaks due to HPAI were recorded in the Pennsylvania area USA in the years 1983-84
bull Instances of Avian Influenza A Virus Infections of Humans
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Very contagious among birds and can make domesticated birds including chickens ducks and turkeys very sick and kill them
Introduction
bull Influenza originated in birds slowly mutated to human flu bull bird flu has always been around bull a new type of concern H5N1 virus bull highly contagious killing 50 to 100 within 48 hrs bull Poultry outbreaks in neighboring India and China - alerted the government UN agencies donors and other organizations
Occurrence
bull Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere
bull Outbreaks due to HPAI were recorded in the Pennsylvania area USA in the years 1983-84
bull Instances of Avian Influenza A Virus Infections of Humans
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Introduction
bull Influenza originated in birds slowly mutated to human flu bull bird flu has always been around bull a new type of concern H5N1 virus bull highly contagious killing 50 to 100 within 48 hrs bull Poultry outbreaks in neighboring India and China - alerted the government UN agencies donors and other organizations
Occurrence
bull Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere
bull Outbreaks due to HPAI were recorded in the Pennsylvania area USA in the years 1983-84
bull Instances of Avian Influenza A Virus Infections of Humans
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Occurrence
bull Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere
bull Outbreaks due to HPAI were recorded in the Pennsylvania area USA in the years 1983-84
bull Instances of Avian Influenza A Virus Infections of Humans
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Avian influenza A virus infections of humans
since 1996 bull H7N7 United Kingdom 1996 1 adult developed conjunctivitis isolated low
pathogenic avian influenza A (H7N7) (not hospitalized and recovered)
bull H5N1 Hong Kong 1997 - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized six -died - Killed about 15 million chickens
bull H9N2 China and Hong Kong 1999 Low pathogenic
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
bull H7N2 Virginia 2002 Outbreak among poultry one person developed uncomplicated influenza-like illness
bull H5N1 China and Hong Kong 2003 Two cases among members of a Hong Kong family that had traveled to China One of them died A family member died of a respiratory illness in China but no testing was done
bull H7N7 Netherlands 2003 89 people confirmed 78 - conjunctivitis 5 - conjunctivitis and influenza-like illness 2 - influenza-like illness
4 cases classified as ldquootherrdquo One death - of acute respiratory distress syndrome
Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members
bull H9N2 Hong Kong 2003 Low pathogenic a child was
hospitalized with influenza-like illness and recovered bull H7N2 New York 2003 low pathogenic In November with
respiratory symptoms- a patient recovered
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
bull H7N3 Canada 2004 2 poultry workers - conjunctivitis coryza Recovered
bull H5N1 Thailand and Vietnam 2004 One instance of probable human-to-human spread of H5N1 virus in Thailand 50 cases with 36 deaths
bull H5N1 Cambodia China Indonesia Thailand and Vietnam 2005 98 human cases with 43 deaths
bull H5N1 Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Thailand Turkey 2006 In Azerbaijan the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans) 115 human cases with 79 deaths
bull H5N1 Cambodia China Egypt Indonesia Laos Myanmar Nigeria Pakistan Vietnam 2007 Nigeria (January) Laos (February) Myanmar (December) and Pakistan (2007) confirmed their first human infections with H5N1
bull H7N2 United Kingdom 2007 Wales influenza-like illness and conjunctivitis - 4 hospitalized cases
bull H9N2 China 2007 A 9-month-old girl with mild signs of disease
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The bird flu outbreakhellip India
bull Since Jan 15 in West Bengal bull Confirmed in 13 of the 19 districts of West
Bengal - alert has been sounded in many states ndash Uttar Pradesh Uttarakhand Haryana Manipur and
Bihar
WHO has declared the situation in West Bengal as very serious and different than the earlier outbreaks
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipin Nepal
bull Poultry outbreaks influenza virus AH5N1- not reported in Nepal
bull Outbreaks in India and China alerted the government UN agencies donors and other organizations
bull Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipNepalbull February 2006 - the Government of Nepal endorsed a joint
Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP)
bull The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee
In August 2006 - Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI
USD182 million plan has a human health and an animal health component under the two responsible line ministries
Ministry of Health and Population and Ministry of Agriculture and Cooperatives
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
History
bull 1878 First identified case in Italy
bull 1924-25 First US cases HPAI
bull Low pathogenic avian influenza first identified mid-twentieth century
bull 1970rsquos Migratory waterfowl carriers
bull Outbreaks in mink seals and whales
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Economic Impact
Economic losses from avian influenza vary
depending on the strain of virus species of bird
infected number of farms involved control
methods used and the speed of implementation of
control or eradication strategies
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Economic Impactbull Direct losses
ndash Disposal costsndash High morbidity and mortality losesndash Quarantine and surveillance costsndash Compensation paid for
elimination of birds
bull 1978-2003
outbreaks of LPAI inMinnesota cost growers $22 million
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Economic Impact
bull 1983 US outbreak (H5N2) ndash $65 million in lossesndash Destruction of 17 million birdsndash 30 increase in egg prices
bull 1999-2000 Italy outbreak (H7N1)ndash $100 million in compensation to farmersndash 18 million birds destroyedndash Total losses of $500 million
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Economic Impact
bull 1997 Hong Kong outbreak (H5N1)ndash $13 million loses ndash 14 million birds
bull 2001 Hong Kong
outbreak (H5N1)ndash 12 million birdsndash $38 million
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Economic Impact
bull 2003 European outbreak (H7N7)ndash Over 33 million birds destroyedndash (frac14 of Netherlandsrsquo poultry stock)ndash Total Cost of outbreak
bull 2003-2004 SE Asia (H5N1)ndash 8 countriesndash gt100 million birds destroyedndash Cost
bull 2004-2005 SE Asia and Eurasia The cost of this outbreak since it is ongoing is yet to be
determined
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
H5N1 Human Case
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
What is H5N1 virus
bull The H5N1 strain is a new and extremely severe influenza virus
bull It has a unique capacity to jump the species barrier and cause severe disease in humans
bull The detection of few human cases suggest that the virus may not be easily transmitted from birds to human at present
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The relationship between bird flu and influenza pandemic
bull H5N1 is a virus with pandemic potential
- Might ultimately adapt into a strain
that is contagious among humans
- Once this adaptation occurs it will no
longer be a bird virus -it will be a
human influenza virus
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
1918 Virus is an Avian Virus
bull Tissue victim buried in permafrost
bull An avian virus that was adapted to humans
bull 25 amino acid changes from avian sequence
bull Some of these changes are already in the H5N1 virus
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Epidemiology
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Geographic Distributionbull Worldwide distributionbull Reservoir
ndash Free flying aquatic birds Ducks geese shorebirds gulls terns auks
bull Outbreaksndash The Netherlands Australia Mexico
US SE Asia Eurasia
bull Similarity to Newcastle Disease makes actual distribution difficult to define
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
H5N1 AVIAN INFLUENZA THREAT HUMAN CASES AT A GLANCE
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
MorbidityMortality
bull Approaches 100in commercialpoultry flocks
bull Deaths within 2 to 12 days after first signs of illness
bull Survivors -inpoor condition
do not begin laying eggs
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Key Influenza Viral Features
Surface proteins (major antigens)
bullHemagglutinin (HA)
Site of attachment to host cellsAntibody to HA is protective
bullNeuraminadase (NA)
Helps to release virions from cells
Antibody to NA can help modify disease severity
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
ldquoH5N1rdquo
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The Influenza Virus
Types
bull Influenza Type A Can infect people birds pigs horses seals whales and other animals but wild birds are the natural hosts for these virusesbull Influenza Type B - normally found only in humans - can cause human epidemics they have not caused pandemicsbull Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The Influenza Virus subtypes
bull Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA) There are
15 different HA subtypes amp 9 different NA subtypes
bull Only some influenza A subtypes (ie H1N1 H1N2 and H3N2) are currently in general circulation among people Other subtypes are found most commonly in other animal species For example H7N7 and H3N8 viruses cause illness in horses
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
How are Avian Influenza Viruses different from Human Influenza Viruses
bull Humans can be infected with influenza types A B and C The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1 H1N2 and H3N2
Between 1957 and 1968 H2N2 viruses also circulated among people but currently do not
bull Only influenza A viruses infect birds
Wild birds are the natural host for all subtypes of influenza A virus
Typically wild birds do not get sick when they are infected
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
How do outbreaks of avian influenza spread
bull Within a country spreads from farm to farm
Large amounts of virus are secreted in bird droppings contaminating dust and soil Contaminated equipment vehicles feed cages or clothing shoes
bull From country to country through international trade in live poultry
bull Migratory birds can carry the virus for long distances
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Transmission of virus
bull Initial source of infectionndash Poultry migratory waterfowl pet
birdsbull Spread by aerosol shared drinking
water fomitiesbull Virus in respiratory secretions and
fecesbull Virus present in eggs laid by infected
hens unlikely to survive and hatch
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Spread of Avian Influenza Viruses among Birds
bull Certain birds particularly water birds act as hosts for influenza viruses by carrying the virus in their intestines and shedding it
bull Infected birds shed virus in saliva nasal secretions and feces
bull Susceptible birds can become infected with avian
influenza virus when they have contact with contaminated
nasal respiratory or fecal material from infected birds
bull Fecal-to-oral transmission is the most common mode of spread between birds
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Transmission of avian influenza virus to people
1048707 Most human cases from close contact with infected poultry (chickens turkeys)
1048707 OR contact with surfaces or materials contaminated with the virus
1048707 No sustained person-person transmission
1048707 Concern is if the virus mutates and can be
transmitted person-person
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipHuman Transmission
bull Previously considered non-pathogenic for humans
bull 1997 Hong Kong
bull 2003 the Netherlands
bull 2004-2005 SE Asia
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Environmental survival
bull Can last indefinitely at a temperature dozens of degrees below freezing as is found in the northern most areas that migratory birds frequent
bull Over 30 days at 0degC (320degF) (over one month at freezing temperature)
bull 6 days at 37degC (986degF) (one week at human body temperature)
bull decades in permanently frozen lakes bull on hard non-porous surface such as plastic or
stainless steel for 24-48 hours bull on clothes paper and tissues for 8-12 hours
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Heathellip inactivates the virus
bull While cooking poultry to 70degC (158degF) kills the H5N1 virus it is recommended to cook meat to 165degF to kill all foodborne pathogens
bull Inactivation of the virus also occurs under the following conditions
bull 30 minutes 60degC (1400degF) (half hour at a temperature that causes first and second degree burns in humans in ten seconds
bull Acidic pH conditions bull Presence of oxidizing agents such as sodium dodecyl
sulfate lipid solvents and B-propiolactone bull Exposure to disinfectants formalin iodine compounds bull Ordinary levels of chlorine in tap water kill H5N1 in public
water systems
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipinactivates the virus
bull Sunlightbull Most detergents or disinfectants (bleach)
bull But is stable in environment when in pond or lake water and feces
1048707 4 days at 716ordm F 30 days at 32ordm F
1048707 gt1 month in feces at cool temperatures
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Problem
If a new subtype of influenza A virus is introduced
into the human population most people have little
or no protection against the new virus
and if the Virus can spread easily from person to
person a PANDEMIC (worldwide spread) may
occur
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Peoplewiththe flu
Birdswithavianflu
+
Sick Pig with both Strands of Influenza
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Attack of the Cell
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
helliphelliphelliphellipattack of the Cell
bull A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis
bull A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes
bull In the nucleus the viral polymerase complexes transcribe and replicate the v RNAs
bull Newly synthesized mRNAs migrate to cytoplasm where they are translated
bull The newly formed nucleocapsids migrate into the cytoplasm
and eventually interact with a region of the cell membrane bull NA destroys the sialic acid moiety of cellular receptors
releasing the progeny virions
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Clinical Signsbull Incubation period 3-14 days bull Birds - dead
prior to observance of any clinical signsbull Drop in egg productionbull Neurological signs
- reduction in normal vocalizationsbull Depression (drop in egg production)
anorexia ruffled feathersbull Combs swollen cyanoticbull Conjunctivitis and respiratory signs
(coughing sneezing and nasal discharge)
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Bird flu in Birds
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Bird flu in Birds
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Post Mortem Lesions
bull Lesions may be absent with sudden death
bull Severe congestion of the musculature
bull Subcutaneous edema
of head and neck areabull Nasal and oral cavity dischargebull Petechiae on serosal surfacesbull Kidneys severely congestedbull Severe congestion of
the conjunctivae
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Diagnosis
bull Clinically indistinguishable from virulent Newcastle Disease
bull Suspect withndash Sudden deathndash Drop in egg productionndash Facial edema cyanotic combs
and wattlesndash Petechial hemorrhages
bull Virology and serology necessary for definitive diagnoses
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Differential Diagnosis HPAI
bull Virulent Newcastle diseasebull Avian pneumovirusbull Infectious laryngotracheitisbull Infectious bronchitisbull Chlamydiabull Mycoplasmabull Acute bacterial diseases
ndash Fowl cholera E coli infection
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Laboratory Diagnosis
ndash virus isolationndash AGID (agar gel immunodiffusion) ndash ELISAndash RT-PCRndash Antigen Rapid AIV test kit
(immunochromatographic test)
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Laboratory identification of human influenza A virus
bull direct antigen detection isolation in cell
bull culture or detection of influenza-specific RNA by reverse transcriptasendashpolymerase chain reaction
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipidentification of human influenza A virus
1 Rapid antigen detection Results can be obtained in 15ndash30 minutes
bull Near-patient tests for influenza These tests are commercially available (Nicholson Wood amp Zambon
2003)bull Immunofluorescence assay A widely used sensitive
method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette amp Schmidt1979)
bull Enzyme immunoassay For influenza A nucleoprotein (NP)
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
identification hellip
2 Virus culture Provides results in 2ndash10 days
3 Polymerase chain reaction and Real-time PCR assays Results can be available within a few hours from either clinical swabs or infected cell cultures
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Treatment
bull Specific treatment Not practical in commercial poultrybull Supportive care and antibiotics for secondary infectionsbull Antivirals
(amantadine hydrochloride) effective in reducing mortality
ndash Results in resistant viruses
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Clinical Signs in Humans
bull 1997 Hong Kong (H5N1)ndash Fever respiratory disease vomiting diarrhea pain ndash Fatal cases severe bilateral pneumonia liver
dysfunction renal failure septic shock pancytopenia
bull 1979 in Northeastern US (H7N7) -respiratory illness
and death ndash Reported also conjunctivitis in workers handling
the seals
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Clinical Signs in Humans
bull 2003 Netherlands (H7N7)ndash Conjunctivitisndash Mild influenza or respiratory symptoms ndash Fatal case acute respiratory distress
syndrome
bull 2004-2005 (H5N1) Southeast Asia
high case-fatality rate (over
50)
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Antiviral Medications to Prevent and Treat Pandemic Influenza
bull Influenza antiviral medications (amantadine rimantadine oseltamivir and zanamivir)
bull All four work against influenza A viruses sometimes influenza virus strains can become resistant to
one or more of these drugsbull For example the influenza A (H5N1) viruses identified in
human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine
bull Two other antiviral medications oseltamavir 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
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Public Health Significance
bull Generally risk is lowbull Strains vary in ability to infect humansbull High occupational exposure may increase risk (poultry
workers)
bull resulted from non-compliance with personal bio-safety measures ndash
wearing gloves gowns and masks There was also evidence of transmission from poultry workers to family members
This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Recommended Actions
Notification of Authorities
bull Area Veterinarian in Charge
Quarantine
While waiting for the authorities or a confirmed
diagnosis all suspect animals should be
quarantined
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
helliphelliphelliphellipRecommended Actions
bull Confirmatory diagnosisbull Proper destruction of all
exposed cadavers litter and animal products are required
CO2 gas chambers-garbage cans
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
To controlhellip
The premises must be thoroughly cleaned and disinfected
bull Insects and mice on the premises should be eliminatedbull The flock depopulated and the carcasses destroyed by
burying compostingbull The manure - buried at least 5 feet deepbull The entire premises - sprayed with
Cresylic or phenolic disinfectants
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Prevention
bull International import restrictions testing of all imported birds (poultry pet birds etc) before entry into the country
bull Surveillance to aid in detecting any suspicion of the disease
bull Appropriate biosecurityndash Control human trafficndash Introduction of unknown disease status birds into flock
bull Education of the poultry industry how the virus is introduced spread and how it can be prevented
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Avian Influenza Vaccine
bull Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type
bull Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type
bull An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses but will not protect against other H types such as H7
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipVaccination
bull Drawbacks to vaccinationndash Expensivendash No cross protection between 15 H subtypesndash Possible creation of reassortant virus
bull In the US an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
BMJ 20053311223 (26 November) doi101136bmj33175271223 Jane Parry
News
Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned Inappropriate use of
vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications
bull Vaccination can sometimes cause silent transmission of infection from asymptomatic birds Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them The first response must be culling said Peter Cordingley WHOs spokesman in Manila
bull Birds have been vaccinated against the disease for about four years The Chinese government has said that it intends to vaccinate all its four
billion chickens The Indonesian government has said that it did not have the resources
to control the outbreak by culling because it could not afford to compensate farmers
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Influenza A Viruses
bull Mutate frequentlyndash Antigenic drift
bull Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication
ndash Antigenic shiftbull Hybrid virus emerges when cell infected
with two different influenza virusesndash Human avian swine equine
bull Transfer of influenza virus to adifferent species
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Influenza A Viruses
Current human influenza vaccines have no efficacyagainst avian influenza
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Stages of Pandemic and WHO
bull WHO - developed a global influenza preparedness plan which defines the stages of a pandemic outlines WHOrsquos role and makes recommendations for national measures before and during a pandemic
1 Interpandemic periodndash Phase 1 No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals the risk of human infection or disease is considered to be lowndash Phase 2 No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
helliphellipStages of Pandemic and WHO
2 Pandemic alert periodndash Phase 3 Human infection with a new subtype but no
human-to-human spread or at most rare instances of spread to a close contact
ndash Phase 4 Small cluster with limited human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans
ndash Phase 5 Larger cluster but human-to-human spread still localized suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk)
3 Pandemic period Phase 6 Pandemic increased and sustained
transmission in general population
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The Next Pandemichellip if
bull The severity of the next pandemic cannot be predicted but modeling studies suggest that its effect in the United States could be severe
bull In the absence of any control measures (vaccination or drugs) it has been estimated that in the United States aldquo mediumndashlevelrdquo pandemic could cause
ndash 89000 to 207000 deathsndash between 314000 and 734000 hospitalizationsndash 18 to 42 million outpatient visitsndash 20 to 47 million people being sickndash between 15 and 35 of the US population could be
affected by an influenza pandemicndash economic impact could range between $713 and $1665
billion
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
The Philippines Preparedness and Response Plan
Avian Influenza Protection Program(defines the biosecurity protocols for the Prevention
and Eradication of AI) This was organized in four stages namely
Stage 1 Keeping the Philippines Bird Flu Free
Stage 2 Controlling and Eradicating Bird Flu in Domestic Fowl
Stage 3 Prevention of Transmission from Fowls to Humans
Stage 4 Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Coverage of Stage 1 Avian-Flu Free Philippines
A Prevention Programs
1 Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries
2 Minimum Biosecurity Measures
3 Surveillance and Prevention Programs in Airports and Seaports
4 Surveillance of Poultry in Critical Areas in the Philippines
5 Enforcement of the Wildlife Act
6 Preventive Measures in Humans
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Coverage of Stage 2
Controlling and Eradicating Bird Flu in Domestic Fowl
CONTROL
ZONE 7 km
SUSPECT
PREMISES
QUARANTINE ZONE Level 1
3 kmINFECTE
D PREMIS
ES
3 km
QUARANTINE
ZONE Level 2
In case of an outbreak a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out Moreover a 7ndashkilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
3 Good Practices1 Avian Influenza Protection Program (AIPP) Preparedness and Response Plan for Avian and
Pandemic Influenza Guidelines Formulated
2 Localization of AIPP to local government units called Project Blue Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness
3 Strong participation of government agencies in the National Avian Influenza Task Force under the network of the
4 Launch of intensified information campaign dubbed Bird Flu Watch
bull websites for Bird Flubull Development of IEC Materials for Bird Flu by target audience
Cough manners proper handwashing
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
3 Good Practices 5 Planning workshops- Adoption of table top
exercises in workshops training
6 Reporting of cases through Short Messaging System
7 Strong private sector participation in all levels of the program
8 Business Continuity Planning ndash involvement and support of the Business Sector
9 Training of field personnel epidemiologists hospitals Speakersrsquo Bureau
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
4 Issues and challenges
1 Massive information demanded by public local government units business academe civil society etc
2 Training for more government personnel to undertake surveillance laboratory testing quarantine enforcement and crisis response preparedness (ie military local veterinarians etc)
3 Full cooperation on eradication policies
4 Funds to support all aspects of the program
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
4 Issues and challenges
5 Early warning of human-human spread
need for stronger global coordination
6 Pandemic preparedness and logistics
overwhelmed health care system existing manpower and resources could response only to a certain extent
7 Antiviral agents efficacy is uncertain in short
supply decision on who should be given priority
8 Pandemic Influenza Vaccine equitable distribution and liability characteristics of the pandemic vaccine development and production constraints
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
5 Proposals
1 Short-term training exchange program on various competencies of member countries
2 Establishment of a web-based information exchange
3 Research funds of priority avian flu-related issues
4 Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
5 Proposals
5Advocate equity of pandemic vaccine distribution
6Involvement of more sectors for preparedness
7National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Tips for spreading the news WHO risk communication advisors Peter M Sandman and Jody
Lanard share
1 Start where your audience starts talk about how horrific the next flu pandemic may be compared with the annual flu
2 Dont be afraid to frighten people
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk communication There is so much we dont know about H5N1 Will it ever achieve efficient human-to-human transmission and ignite a pandemic How quickly will it spread How long will it last How much antiviral medication will be available in different parts of the world How long will it take for an effective vaccine to be available Which countries and which people in those countries will get the vaccine first How well will health care systems cope How well will national and international economies cope Bird flu experts and risk communicators cannot answer these questions But we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipTips for spreading the news
3 Acknowledge uncertainty (the situation is under control everything is going to be fine) is terrible risk
communicationbull There is so much we dont know about H5N1 bull Will it ever achieve efficient human-to-human transmission and ignite a pandemic bull How quickly will it spread How long will it lastbull How much antiviral medication will be available in different parts of the world bull How long will it take for an effective vaccine to be available bull Which countries and which people in those countries will get the vaccine firstbull How well will health care systems cope How well will national and international economies cope
Bird flu experts and risk communicators cannot answer these questions but we can raise them acknowledging our uncertainty at every turn
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipTips for spreading the news
4 Give people things to doOne reason sometimes given for not alarming the public is that theres nothing for people to do anyway The error is failing to realizemdashand saymdashhow much they can do to prepare
bull Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks
bull Even emotional rehearsalmdashlearning about H5N1 and thinking about what a pandemic might be like and how youd copemdashis a kind of preparedness and a kind of
involvement
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
hellipTips for spreading the news
5 Stress magnitude more than probabilityThe rationale for H5N1 pandemic preparedness isnt that were sure its coming but how bad it could get
6Guide the adjustment reactionOnce people start taking a new risk seriously the normal response is an adjustment reactionmdasha temporary fearfulness sometimes accompanied by misplaced or excessive caution This is the teachable moment Dont ignore it or ridicule it guide it Then we settle into the new normal
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Conclusion
bull Become knowledgeable about the flubull Follow advice of public health authorities and your
physicianbull Report large death of waterfowl to the local authority
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
Thank you
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
References
bull Park K Parks text book of preventive and social medicine 18th edition Jabalpur India Ms Bhanot Banarasidas 2005
bull Dictionary of Epidemiology John M Lastbull World Organization for Animal
Health (OIE) http wwwoieintbull USAHA Foreign Animal Diseases ndash ldquoThe Gray Bookrdquo http
wwwvetugaeduvppgray_bookindex ld Health Organization
bull httpwwwwhointcsrdiseaseavian_influenzaguidelineshumanspecimensenindexhtml)
bull httpwwwindiaenewscompolitics2008020595688htmbull httpwwwindiaprwirecomprinttype=newsampid=27315bull wwwaphisusdagovvsarea_officeshtm bull News BMJ 20053311223 (26 November)
doi101136bmj33175271223
bull http wwwfluwikiecombull http wwwcvmuceduavian
ndash http wwwwhoint
