Avian Influenza

dr Shahrul Rahman, Sp.PD

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
 What is influenza?

 An acute respiratory illness resulting

from infection with an influenza virus
 Highly infectious and can spread
rapidly from person to person
 Some strains cause more severe
illness than others
 Penyebab
 Avian Influenza atau Flu Burung
merupakan penyakit pada unggas yang
disebabkan oleh virus, yaitu
Orthomyxoviridae tipe A, yang
menyerang ayam, burung, itik, kalkun,
angsa dan sebagainya.
 What is avian influenza (bird flu)?

 Bird flu is an infection caused by avian (bird)

influenza (flu) A viruses.
 This flu virus can affect domestic and wild bird
species including chickens, turkeys, ducks,
geese, gulls, shorebirds.
 Aquatic birds (ducks, shore birds, and gulls) are
the natural reservoirs for the avian flu viruses.
 The waterfowl do not develop disease when
infected with avian influenza (asymptomatic).

Leslie Beale Springfield College 4

 Types of influenza viruses
 Influenza viruses are divided into three
main types: influenza A, B, and C
 A viruses – infect birds and other
animals, as well as humans
 A viruses – source of seasonal
influenza epidemics and all pandemics
 B and C viruses – infect humans only
and do not cause pandemics
 How are bird flu viruses different
from human flu viruses?

 There are many different subtypes of type flu A viruses. These

subtypes differ because of certain proteins in the flu A virus.
 There are 16 different HA subtypes and 9 different NA subtypes
of flu A viruses. Many different combinations of HA and NA
proteins are possible. Each combination is a different subtype.
 All subtypes of flu A viruses are found in birds. They do not
usually infect humans, even though we know they can do so.
 Human flu viruses are those subtypes that occur widely in
humans. There are only three known subtypes of human flu
viruses (H1N1, H1N2, and H3N2); it is likely that some genetic
parts of current human flu A viruses came from birds originally.
Flu A viruses are constantly changing, and they might adapt
over time to infect and spread among humans.

Leslie Beale Springfield College 8

Where does influenza A virus
come from?
Human influenza A viruses start as avian (bird) influenza viruses

Migratory Domestic birds Humans

water birds and other
animals
 Influenza symptoms

 Sudden onset
 Fever, headache, muscle aches,
severe weakness
 Respiratory symptoms, e.g., cough,
sore throat, difficulty breathing
 How influenza spreads
 Spreads easily from person to person
through coughing and sneezing
 Transmitted by:
 inhaling respiratory aerosols containing the virus,
produced when infected person talks, coughs, or
sneezes
 touching an infected person or an item
contaminated with the virus and then touching
your eyes, nose, or mouth
Courtesy of CDC
History of influenza

 412 BC - first
mentioned by
Hippocrates
 1580 - first pandemic
described
 1580-1900 - 28
pandemics
 Avian Influenza
 Definitions:
 Epidemic—The occurrence of cases of an
illness in a community or region which is in
excess of the number of cases normally
expected for that disease in that area at that
time.
 Pandemic—An epidemic that strikes a very
wide area, usually hemisphere-wide or world-
wide.
Emergency hospital, Camp Funston, Kansas 1918
Courtesy of National Museum of Health and Medicine
 What are the symptoms of
bird flu in humans?
 Symptoms of bird flu in humans have ranged
from typical flu-like symptoms (fever, cough,
sore throat and muscle aches) to eye infections,
pneumonia, severe respiratory diseases (such
as acute respiratory distress), and other severe
and life-threatening complications. The
symptoms of bird flu may depend on which virus
caused the infection.

Leslie Beale Springfield College 18

 Avian Influenza
 Clinical features
 H5N1
 2004-2005
 Majority < 25 years of age
 All presented with:
 Fever
 Lower respiratory symptoms and pneumonia
 Lymphopenia
 Diarrhea developed in 7 of 10
 All developed ARDS
 All died between days 6-29 post-presentation
 Avian Influenza
 Clinical features
 H5N1
 Incubation period 2-4 days (maximum of 8)
 H7
 Conjunctivitis

 H5N2
 Children show mild, limited URI symptoms
 Avian Influenza
 Diagnosis
 Viral culture
 Polymerase Chair Reaction (PCR) assay for
avian influenza A (H5N1) RNA
 Immunofluorescence for antigen with use of
H5 monoclonal antibody
 Four-fold rise in H5-specific antibody
 Avian Influenza
 Who should be tested?
 High-risk patients
 Patients with a history of travel within 10 days of
symptom inset to a country with documented H5N1
avian influenza in poultry and/or humans
 AND
 Patients with pneumonia on CXR, ARDS, or other
severe respiratory illness for which an etiology has
not been established.
 Avian Influenza
 Who should be tested?
 Low-risk patients
 Patients with history of contact with domestic poultry or a
known or suspected human case in an H5N1-infected
country within 10 days of symptom onset
 AND
 Documented fever ≥38° C
 AND
 One or more of the following:
 Cough
 Sore throat
 Shortness of breath
 Avian Influenza
 Vaccination
 No licensed vaccine.
 Area of intense research.
 Biosecure facilities required
because of viral
pathogenicity.
 Viruses are lethal to eggs
which prevents mass
vaccine production.
 Avian vaccines available
although inconsistently
administered.
 Avian Influenza
 Vaccination
 Fast track process underway
 Initial studies (Phase 1) of 450 patients:
 Rochester, NY
 Baltimore, MD
 Los Angeles, CA
 Avian Influenza
 Treatment
 Effective drugs:
 M2 channel blockers
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Neuraminidase inhibitors
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Avian Influenza
 Treatment
 H5N1 in Thailand has developed mutations in the M2
protein which makes it resistant to amantadine and
rimantadine (neuraminidase inhibitors remain
effective).
 Oseltamivir (Tamiflu) effective when given early in the
course of the infection.
 Oseltamivir (Tamiflu) ineffective when given late in
the course of the infection.
 Treat for 5-8 days.
 Avian Influenza
 Drug resistance:
 Mutation of the hemaggultinin or
neuraminidase genes.
 Drug resistance has been documented in
human strains—specifically in children.
 Prophylactic treatment of a Vietnamese girl
caused drug resistance for oseltamivir.
 Avian Influenza
 Prevention
 Poultry outbreak:
 Quarantine
 Depopulation
 Area surveillance
 Workers:
 PPE (gowns, gloves, frequent hand washing)
 N95 mask
 Prophylaxis
 Vaccination with current influenza vaccine
 Avian Influenza
 Prevention
 Avian influenza should
be treated in the same
manner as SARS.
 Avian Influenza
 Post-Exposure Prophylaxis
 Household contacts of H5N1 patients should
receive oseltamivir daily for 7-10 days.
 Monitor temperature.
 Quarantine.
 Sifat Virus

Kelemahan virus tersebut adalah

tidak tahan panas. Pada daging akan
mati pada suhu 80 0 C selama 1
menit. Pada telur akan mati pada
suhu 64 0 C selama 4,5 menit.
(Deptan RI, 2005)
Hewan peka AI di Indonesia: ayam ras,
ayam buras, burung puyuh,itik, entog,
angsa, burung unta, merpati, merak,
perkutut, burung rangkong, kakaktua, dll.

Hewan peka dan terdeteksi positif AI

di Indonesia: ayam layer, broiler, puyuh,
itik, beberapa jenis burung di Kebun
Binatang Ragunan, babi (Tangerang).
 Avian Influenza
 Sporadic transmission from birds to humans of
H5N1 raises concerns:
 H5N1 may mutate.
 H5N1 may combine with genetic material from human
influenza virus creating a new strain capable of
human-to-human transmission and potential
pandemic.
 WHO describes the H5N1 as a “public health
crisis” and declared that the world is as close as
ever to the next pandemic.
 CARA PENULARAN INFEKSI
 CONTACT TRANSMISSION/MAN-TO-
MAN TRANSMISSION
 DROPLET TRANSMISSION : PERCIKAN
MENGANDUNG MIKROORGANISMA
YANG DISEBARKAN DALAM JARAK
DEKAT (1 –2 METER) MELALUI UDARA
 CARA PENULARAN INFEKSI
 AIRBORNE TRANSMISSION: MENYEBAR
MELALUI RESIDUAL PARTICLE < 5 µm dan
tetap berada dalam aliran udara untuk waktu
cukup lama
 COMMON VEHICLE TRANSMISSION : melalui
makanan tercemar, air, alat kesehatan
 VECTORBORNE TRANSMISSION : nyamuk,
lalat, tikus dll.
 Transparency
in operation and
public information

Outbreak control
in poultry, Man
prevention
Infected birds of Infected
new infection
in nature poultry
 Avian Influenza
 Primary cause of
death is respiratory
failure.