Avian Influenza update for health care professionals

1. Clinician Update on Avian Influenza Scott F. Dowell, MD, MPH

3. Recognizing Avian Influenza

4. Pandemic Influenza

5. US Infectious Disease Mortality: The Impact of Influenza and AIDS Armstrong. JAMA 1999;281:61

6. 1918 Hemagglutinin Causes Severe Lung Damage M88 M88/H sp Kobasa et al. Nature 2004;431:703

7. Neuraminidase Sets Up Bacterial Pneumonia Peltola et al. JID 2005;192:249

9. Avian Influenza in Asia (22 August, 2005)

10. Human H5N1 Most Common in Children Chotpitayasunondh. MMWR 2004;53:100 Died Died Recovered Recovered Died Recovered Died Died Recovered Died Died Died Died Outcome Sick/dead fighting cock in backyard Dead fighting cock at neighbors Sick/dead fighting cocks, chicken in backyard Sick/dead fighting cocks in backyard Sick poultry in backyard Sick poultry in backyard Dead poultry in backyard Sick/dead fighting cocks, poultry in backyard Purchased, cooked chicken from affected area Sick poultry in backyard Sick poultry at neighbors Dead poultry at neighbors Dead poultry at neighbors Exposure 31 Aug M 18 1 Mar F 39 13 Feb M 29 3 Feb F 47 26 Jan M 13 25 Jan M 2 24 Jan M 6 21 Jan M 4 20 Jan F 27 19 Jan F 58 M M M Sex 7 Jan 6 Jan 3 Jan Onset 6 6 7 Age

11. Thai Children at Risk for H5N1 Infection * Before and after a public education campaign Olsen et al. EID 2005;11: 0.4 7 (4) 12 (6) Children in your household touched sick or dead poultry with bare hands 0.3 17 (9) 24 (12) Took dead chicken or poultry from your yard and prepared it to eat 9 (5) 27 (14) After <0.01 <0.01 p-value 45 (23) Thought it was safe for children to touch sick or dead poultry with bare hands 78 (40) Thought it was safe to touch sick or dead poultry with bare hands Before Knowledge, attitudes, and practices*

12. Chotpitayasunondh. MMWR 2004;53:100

13. Influenza A (H5N1) Pneumonia Hien. NEJM 2004;350:1179

14. Lymphopenia Predicts Mortality Chotpitayasunondh et al. EID 2005;11:201 WBC/ALC Count Platelet Count 12,000 1,500 3,000 4,500 6,000 7,500 9,000 10,500 13,500 15,000 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000 ALC WBC Platelet Survived Died Survived Died Survived Died . . . . . . . . . . . . Legend: No ARDS ARDS Median value . . . . . . . . . . . . . . . .

15. Early Oseltamivir Associated with Survival Chotpitayasunondh et al. EID 2005;11:201 1 2 3 1 2 3 4 5 6 7 8 9 10 11 12 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Patient No. Days after onset of illness Legend: - Oseltamivir - Day Discharged - Day of Death Died Survived

18. Investigating Person-to-Person Spread

19. Timeline of Exposures and Illness Ungchusak. NEJM 2005:352;333

22. No. of Cases Day of illness No. of Cases Baseline 8-week 80% TAP +2 +15 Outbreak Recognized ~Day 68 Typical “Large” Outbreaks (Hong Kong Calibration) +10