Key facts

Avian influenza (AI), commonly called bird flu, is an infectious viral disease of
birds.
Most avian influenza viruses do not infect humans; however some, such as H5N1,
have caused serious infections in people.
Outbreaks of AI in poultry may raise global public health concerns due to their
effect on poultry populations, their potential to cause serious disease in people, and their
pandemic potential.
Reports of highly pathogenic AI epidemics in poultry can seriously impact local
and global economies and international trade.
The majority of human cases of H5N1 infection have been associated with direct
or indirect contact with infected live or dead poultry. There is no evidence that the
disease can be spread to people through properly cooked food.
Controlling the disease in animals is the first step in decreasing risks to humans.
Avian influenza (AI) is an infectious viral disease of birds (especially wild water fowl such
as ducks and geese), often causing no apparent signs of illness. AI viruses can
sometimes spread to domestic poultry and cause large-scale outbreaks of serious
disease. Some of these AI viruses have also been reported to cross the species barrier
and cause disease or subclinical infections in humans and other mammals.
AI viruses are divided into two groups based on their ability to cause disease in poultry:
high pathogenicity or low pathogenicity. Highly pathogenic viruses result in high death
rates (up to 100% mortality within 48 hours) in some poultry species. Low pathogenicity
viruses also cause outbreaks in poultry but are not generally associated with severe
clinical disease.
Avian influenza H5N1 background
The H5N1 virus subtype - a highly pathogenic AI virus- first infected humans in 1997
during a poultry outbreak in Hong Kong SAR, China. Since its widespread re-emergence in
2003 and 2004, this avian virus has spread from Asia to Europe and Africa and has
become entrenched in poultry in some countries, resulting in millions of poultry
infections, several hundred human cases, and many human deaths. Outbreaks in poultry
have seriously impacted livelihoods, the economy and international trade in affected
countries. Ongoing circulation of H5N1 viruses in poultry, especially when endemic,
continues to pose threats to public health, as these viruses have both the potential to
cause serious disease in people and may have the potential to change into a form that is
more transmissible among humans. Other influenza virus subtypes also circulate in
poultry and other animals, and may also pose potential threats to public health.
Avian influenza H5N1 infections and clinical features in humans
The case fatality rate for H5N1 virus infections in people is much higher compared to that
of seasonal influenza infections.
Clinical features
In many patients, the disease caused by the H5N1 virus follows an unusually aggressive
clinical course, with rapid deterioration and high fatality. Like most emerging disease,
H5N1 influenza in humans is poorly understood.
The incubation period for H5N1 avian influenza may be longer than that for normal
seasonal influenza, which is around two to three days. Current data for H5N1 infection
indicate an incubation period ranging from two to eight days and possibly as long as 17
days. WHO currently recommends that an incubation period of seven days be used for
field investigations and the monitoring of patient contacts.

Initial symptoms include a high fever, usually with a temperature higher than 38oC, and
other influenza-like symptoms. Diarrhoea, vomiting, abdominal pain, chest pain, and
bleeding from the nose and gums have also been reported as early symptoms in some
patients.
One feature seen in many patients is the development of lower respiratory tract early in
the illness. On present evidence, difficulty in breathing develops around five days
following the first symptoms. Respiratory distress, a hoarse voice, and a crackling sound
when inhaling are commonly seen. Sputum production is variable and sometimes bloody. 1
Antiviral treatment
Evidence suggests that some antiviral drugs, notably oseltamivir, can reduce the
duration of viral replication and improve prospects of survival.
In suspected cases, oseltamivir should be prescribed as soon as possible (ideally, within
48 hours following symptom onset) to maximize its therapeutic benefits. However, given
the significant mortality currently associated with H5N1 infection and evidence of
prolonged viral replication in this disease, administration of the drug should also be
considered in patients presenting later in the course of illness.
In cases of severe infection with the H5N1 virus, clinicians may need to consider
increasing the recommended daily dose or/and the duration of treatment.
In severely ill H5N1 patients or in H5N1 patients with severe gastrointestinal symptoms,
drug absorption may be impaired. This possibility should be considered when managing
these patients.2
Risk factors for human infection
The primary risk factor for human infection appears to be direct or indirect exposure to
infected live or dead poultry or contaminated environments. Controlling circulation of the
H5N1 virus in poultry is essential to reducing the risk of human infection. Given the
persistence of the H5N1 virus in some poultry populations, control will require long-term
commitments from countries and strong coordination between animal and public health
authorities.
There is no evidence to suggest that the H5N1 virus can be transmitted to humans
through properly prepared poultry or eggs. A few human cases have been linked to
consumption of dishes made of raw, contaminated poultry blood. However, slaughter,
defeathering, handling carcasses of infected poultry, and preparing poultry for
consumption, especially in household settings, are likely to be risk factors.
Human pandemic potential
Influenza pandemics (outbreaks that affect a large proportion of the world) are
unpredictable but recurring events that can have health, economic and social
consequences worldwide. An influenza pandemic occurs when key factors converge: an
influenza virus emerges with the ability to cause sustained transmission from human-tohuman, and there is very low, or no, immunity to the virus among most people. In the
interconnected world of today, a localized epidemic can transform into a pandemic
rapidly, with little time to prepare a public health response to halt the spread of illness.
The H5N1 AI virus remains one of the influenza viruses with pandemic potential, because
it continues to circulate widely in some poultry populations, most humans likely have no
immunity to it, and it can cause severe disease and death in humans. In addition to
H5N1, other animal influenza virus subtypes reported to have infected people include
avian H7 and H9, and swine H1 and H3 viruses. H2 viruses may also pose a pandemic
threat. Therefore, pandemic planning should consider risks of emergence of a variety of
influenza subtypes from a variety of sources.
WHO response

Animal health agencies and national veterinary authorities are responsible the control
and prevention of animal diseases, including influenza. WHO, World Organisation for
Animal Health (OIE), and Food and Agriculture Organization (FAO) collaborate through a
variety of mechanisms to track and assess the risk from animal influenza viruses of
public health concern, and to address these risks at the human animal interface
wherever in the world they might occur.

Conventional reverse transcriptase polymerase chain reaction (RT-PCR) and

realtime reverse transcriptase PCR assay. PCR detects viral RNA present in
either
clinical specimens or virus cultures, and can be targeted at genes that are
relatively
conserved across all influenza A viruses (e.g. matrix gene) or to the
haemagglutinin or
neuraminidase genes which are subtype specific. Including the time taken for
viral RNA
extraction and for amplicon detection, the turn-around time of conventional RTPCR
assays is 68 hours. Real time RT-PCR methods can shorten this time interval to
around
34 hours while providing increased sensitivity and possibility of quantitation of
the
viral target gene.
Other molecular detection systems. These systems, mostly still under
development,
tend to be rapid. They include assays based on nucleic acid amplification and
use various
endpoint detection methods.
Virus culture. Results are available in 210 days using either shell-vial or
standard cellculture methods. Positive influenza cultures may or may not exhibit
cytopathic effects,
thus a second step to specifically identify influenza viruses by
immunofluorescence,

haemagglutination inhibition (HI) or RT-PCR is needed. An advantage of culture

is
that viruses are available for further characterization. Virus culture in appropriate
cell
lines can also detect other clinically important respiratory viruses.
Most avian viruses grow readily in embryonated eggs and this is the option of
choice for
amplification of virus from avian hosts. However, highly pathogenic avian H5N1
viruses
that infect humans are still quite virulent in eggs, killing them quickly. This makes
standard egg culture amplification approaches more difficult. For this reason and

15
List of National Influenza Centres
http://www.who.int/csr/disease/influenza/centres/en/index.html
Recommendations for laboratory procedures to detect avian influenza A H5N1
virus in specimens from suspected human cases
WHO Geneva August 2007
-5because of the biosafety concern, isolation of highly pathogenic H5N1 viruses is
usually
performed only in specially qualified and equipped laboratories.

Rapid antigen detection. Viral antigen detection may be carried out by

immunofluorescence or enzyme immunoassay (EIA) methods. The EIA based
methods
are simple and convenient to use. However, such tests are, at present, directed
at
conserved viral antigens (e.g. virus nucleoprotein, matrix protein) and detect all
subtypes
of influenza A viruses, whether of human or avian origin. Therefore these tests
will not
differentiate human virus subtypes H3N2 or H1N1 from avian influenza H5N1.
Additionally, current viral antigen detection rapid tests, while being sensitive for
the

detection of human seasonal influenza viruses, appear to have low sensitivity for
the
diagnosis of avian influenza H5N1 (i.e. a negative result does not exclude H5N1
disease). Thus overall, presently commercially available antigen detection tests
have
limited utility for diagnosis of A(H5N1) disease in humans.
Examples of protocols for some available assays to detect influenza A(H5N1)
viruses are
described in Annex A. The laboratory protocols outlined in this document have
proven to be
valid for known H5N1 viruses when the listed reagents and platforms (and/or
primers) are
used together as presented, and in accordance with good laboratory practices.
Presented
protocols may require updates as new strains of H5N1 evolve.

Triangle
An epidemiologic triangle describes the intersection of Host, Agent, and Environment when analyzing an
outbreak.The Triangle has three vertices (corners): (1) the agent, or microbe that causes the disease
(the "what" of the Triangle), (2) the host, or organism harboring the disease (the "who" of the Triangle),
and (3) the environment, or those external factors that cause or allow disease transmission (the "where"
of the Triangle).
(1) The agent, or microbe that causes Avian Influenza is the Influenza A (H5N1) virus - also called
"H5N1 virus" -which is an influenza A virus subtype that occurs mainly in birds, is highly contagious
among birds, and can be deadly to them. There are many different subtypes of type A influenza viruses.
These subtypes differ because of changes in certain proteins on the surface of the influenza A virus
(hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA subtypes and 9 known
NA subtypes of influenza A viruses. Many different combinations of HA and NA proteins are possible.
Each combination represents a different subtype. All known subtypes of influenza A viruses can be found
in birds.
(2) Certain birds, particularly water birds, act as hosts for influenza viruses by carrying the virus in their
intestines and shedding it. Infected birds shed virus in saliva, nasal secretions, and feces. Susceptible
birds can become infected with avian influenza virus when they have contact with contaminated nasal,
respiratory, or fecal material from infected birds. Fecal-to-oral transmission is the most common mode of
spread between birds. Most often, the wild birds that are host to the virus do not get sick, but they can
spread influenza to other birds. Infection with certain avian influenza A viruses (for example, some H5
and H7 strains) can cause widespread disease and death among some species of domesticated birds.
(3) The environment which can allow Avian Influenza transmission includes prolonged close contact with
sick birds. It is believed that most cases of avian influenza infection in humans have resulted from
contact with infected poultry or contaminated surfaces. However, other means of transmission are also
possible, such as the virus becoming aerosolized and landing on exposed surfaces of the mouth, nose, or
eyes, or being inhaled into the lungs.There have been very few cases of human-to-human spread of
H5N1. In 2003, influenza A (H7N7) infections occurred in the Netherlands among persons who handled
infected poultry and among their families during an outbreak of avian flu among poultry. More than 80
cases of H7N7 illness were confirmed by testing (the symptoms were mostly confined to eye infections,
with some respiratory symptoms), and one patient died (a veterinarian who had visited an H7N7
influenza-affected farm). Although there was evidence of limited person-to-person spread of infection,
sustained human-to-human transmission did not occur in this or other outbreaks of avian influenza. In
Thailand, in 2004, probable human-to-human spread of H5N1 occurred in a family due to prolonged
close contact between a sick child and her mother. In June 2006, human-to-human spread occurred in
Indonesia where 8 people in one family were infected. The first family member became sick through

contact with infected poultry. This person infected six family members, one of whom, a child, then
infected his father.
http://www.cdc.gov/flu/avian/professional/infect-control.htm
Read more: Avian Flu and epidemiological triandle JustAnswer http://www.justanswer.com/health/0eicg-avian-flu-epidemiologicaltriandle.html#ixzz1Ry7qCryF