Transcript Emergency Diseases / Highly Pathogenic Avian Influenza (HPAI)

‫بسم هللا الرحمن الرحيم‬
Pandemic Influenza
School of Health
ShahidBeheshti University of
Medical Sciences
By: Hatami H. MD. MPH
2008
1
Clinical Epidemiology of Avian flu
‫مقايسه‬
Definition and public health importance
Etiologic agents
1)
2)
3)
4)
5)
6)
7)
8)
9)
Incubation period
Natural course
Geographical distribution
Timeline trend
Age, Gender, Occupation, Social situation
Predisposing factors
Susceptibility & Resistance
Secondary attack rate
Modes of transmission, period of communicability
Prevention : primary, secondary, tertiary
2
‫ّاولين موارد آنفلوآنزاي‬
‫پرندگان در انسان‬
‫هنگ كنگ ‪1997‬‬
‫‪3‬‬
‫‪6 + 245 = 251‬‬
‫‪18 + 387 = 405‬‬
‫داليل اهميت ويروس ‪H5N1‬‬
‫ّ‬
‫‪ ‬آسيب زايي و حدت‬
‫‪ ‬ميزان مرگ‬
‫‪ ‬وسعت انتشار‬
‫‪ ‬راههاي انتقال‬
‫‪ ‬احتمال تغييرات ژنتيك‬
‫‪ ‬احتمال وقوع جهانگيري انساني‬
‫‪4‬‬
Definitions
• An epidemic - is an increase
in disease above what you what
would normally expect
• A pandemic - is a worldwide
epidemic
5
How Do Influenza Pandemics
Arise?
• Wild birds are natural reservoirs of flu
viruses, including those that infect
people
• Flu viruses undergo slight changes each
year (“Drift”) , requiring us to update
our vaccines
Epidemic influenza
• Periodically, avian flu viruses will
undergo major genetic changes
(“shift”)
Pandemic influenza
6
7
How Do Influenza Pandemics
Arise?
• When avian influenza viruses
experience sudden changes in
genetic structure
And
• Are capable of infecting humans
And
• Can reproduce and spread from
person to person….a pandemic
occurs
8
9
10
‫وضعيت فعلي‬
‫پاندمي‬
‫‪11‬‬
Phases of a Pandemic
World Health Organization
Preparedness
Phase I
Phase 2
Interpandemic
Response
Phase 3
Phase 4
Phase 5
Pandemic Alert
‫جايگاه فعلي پاندمي‬
Phases = ‫مراحل‬
Phase 6
Pandemic
Periods = ‫دوره ها‬
Declared globally by the World Health Organization
Declared nationally by the Department of Health and Human Services
12
World Health Organization
Phases of a Pandemic
• Inter-pandemic period
• Pandemic Alert period
• Pandemic Period
• Post Pandemic Period
13
World Health Organization Phases
of a Pandemic
• Inter-pandemic period
• Phase 1 – No new virus subtypes in
humans
• Phase 2 – Animal subtype poses a
risk of human disease
• Pandemic Alert Phase
• Pandemic Period
• Post Pandemic Period
14
World Health Organization Phases
of a Pandemic
• Inter-pandemic period
• Pandemic Alert period
• Phase 3 – Human infection, no human
to human spread
• Phase 4 – Small localized clusters of
human to human spread
• Phase 5 – Larger clusters, still localized,
virus adapting to humans
• Pandemic Period
• Post Pandemic Period
15
World Health Organization Phases
of a Pandemic
• Inter-pandemic period
• Pandemic Alert Phase
• Pandemic Period
• Phase 6 – Increased and sustained
transmission in the general population.
Waves of 8-12 weeks.
• Post Pandemic Period
16
World Health Organization Phases
of a Pandemic
•Inter-pandemic period
•Pandemic Alert Phase
•Pandemic Period
•Post Pandemic Period
17
Phases of a Pandemic
World Health Organization
Preparedness
Phase I
Phase 2
Interpandemic
Response
Phase 3
Phase 4
Phase 5
Pandemic Alert
‫جايگاه فعلي پاندمي‬
Phases = ‫مراحل‬
Phase 6
Pandemic
Periods = ‫دوره ها‬
Declared globally by the World Health Organization
Declared nationally by the Department of Health and Human Services
18
‫ويروس عامل‬
‫پاندمي ؟؟‬
‫?? ‪H5N1‬‬
‫?? ‪H1N1‬‬
‫?? ‪HxNy‬‬
‫‪19‬‬
‫موارد گزارش شده آنفلوآنزاي پرندگان در سطح جهان‬
‫تا‪28/3/1386‬‬
‫‪20‬‬
‫نوپديدي آنفلوآنزاي ‪ H5N1‬در انسان تا ‪19/9/1387‬‬
‫‪139‬‬
‫‪1382‬‬
‫تعداد موارد‬
‫موارد مرگ‬
‫‪140‬‬
‫‪120‬‬
‫كل موارد = ‪389‬‬
‫‪1383‬‬
‫موارد مرگ = ‪)%63( 246‬‬
‫‪1384‬‬
‫‪100‬‬
‫‪1385‬‬
‫‪80‬‬
‫‪106‬‬
‫‪1386‬‬
‫‪ 18‬مورد بيماري و ‪ 6‬مورد مرگ ‪1376‬‬
‫‪12‬‬
‫‪25‬‬
‫‪17‬‬
‫‪8 5‬‬
‫‪50‬‬
‫‪30‬‬
‫‪20‬‬
‫‪113‬‬
‫‪60‬‬
‫‪52‬‬
‫‪40‬‬
‫‪22‬‬
‫‪20‬‬
‫‪7 7‬‬
‫‪2 2‬‬
‫‪3 2‬‬
‫‪4‬‬
‫الئوس‬
‫‪21‬‬
‫عراق‬
‫تركيه آذرب ايجان كامبوج‬
‫‪0‬‬
‫تايلن د‬
‫چي ن‬
‫مصر‬
‫ويتنام‬
‫اندونزي‬
‫موارد آنفلوآنزاي ‪ H5N1‬در انسان تا ‪20/7/1387‬‬
‫تا ‪8/4/1386‬‬
‫‪22‬‬
‫اثرات مخرب پاندمي‬
‫تاثير بر كليه جوانب‬
‫و شئون زندگي‬
‫اجتماعي‬
‫‪23‬‬
‫اثرات مخرب پاندمي‬
‫كاهش پرسنل به ميزان تقريبي‬
‫‪ %30‬در كل سيستم‬
‫مديريت چه اموري قائم به فرد ميباشد؟؟‬
‫‪24‬‬
‫تخمين ميزان مرتاليتي و مربيديتي‬
Characteristic
Total Population
Moderate
(1957–like)
Severe
(1918 – like)
‫يك ميليون و هشتصد هزار نفر‬
Illness
540,000
540,000
Outpatient
Care
270,000
270,000
5,190
59,400
Hospitalizatio
n
Deaths
1,250
Estimated numbers of Illness,
Hospitalization, and11,500
Deaths Moderate
and Severe Pandemic Scenarios - US and King County
25
‫اثرات مخرب پاندمي‬
‫‪ ‬كاهش پرسنل به ميزان تقريبي ‪ %30‬در كل سيستم‬
‫‪ ‬كاهش توان مراكز خدمات بهداشتي ـ درماني‬
‫‪ ‬كاهش توان نيروهاي امدادي‬
‫‪ ‬كاهش نيروهاي امنيتي‬
‫‪‬محدوديت منابع و امكانات‬
‫‪26‬‬
‫اثرات مخرب پاندمي‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪ ‬اختالل در امر حمل و نقل‬
‫‪ ‬اختالل در امر ارتباطات‬
‫‪‬مشكل برق‬
‫‪ ‬مشكل آب‬
‫‪ ‬مشكل سوخت‬
‫‪...‬‬
‫‪27‬‬
‫اثرات مخرب پاندمي‬
‫گشوده شدن زندانها‬
‫‪ ‬ناامني اجتماعي‬
‫‪...‬‬
‫‪28‬‬
‫اثرات مخرب پاندمي‬
‫تاثير بر كليه جوانب و‬
‫شئونات زندگي‬
‫اجتماعي‬
‫‪29‬‬
‫• همكاري‬
‫• هماهنگي‬
‫• ارتباط‬
‫‪30‬‬
‫ساماندهي اثرات مخرب‬
‫پاندمي‬
‫مسئول تامين‪ ،‬حفظ و ارتقاء‬
‫سالمتي جسمي‪ ،‬رواني‪،‬‬
‫اجتماعي ؟؟؟؟؟‬
‫‪31‬‬
‫ستاد بحران‬
‫نيروهاي مردمي‬
‫ارگانهاي دولتي‬
‫وزارت كشور‬
‫استانداريها‬
‫‪32‬‬
‫بسيج جامعه پزشكي‬
‫وزارت بهداشت‬
‫معاونت سالمت‬
‫محور اصلي‬
‫‪NGO‬ها‬
‫برنامه كلي ساماندهي‬
‫‪ 1‬ـ كاهش ميزان بيماري و مرگ و مير‬
‫‪ 2‬ـ به حداقل رساندن ازهم پاشيدگي اجتماعي‬
‫‪ 3‬ـ به حداقل رساندن زيانهاي اجتماعي‬
‫‪ 4‬ـ حفظ كيان حكومتي‬
‫‪33‬‬
‫پيشبيني و پيشگيري‬
‫‪ ‬كاهش توان مراكز خدمات بهداشتي ـ درماني‬
‫‪ ‬كاهش توان نيروهاي امدادي‬
‫‪‬محدوديت منابع و امكانات‬
‫‪34‬‬
‫پيشبيني و پيشگيري‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪ ‬اختالل در امر حمل و نقل‬
‫‪ ‬اختالل در امر ارتباطات‬
‫‪‬مشكل برق‬
‫‪ ‬مشكل آب‬
‫‪ ‬مشكل سوخت‬
‫‪. . . 35‬‬
‫نياز به اجراي مانور مشترك‬
‫پيشبيني و پيشگيري‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪ ‬اختالل در امر حمل و نقل‬
‫حمل زودرس برخي از كاالها (دارو‪ ،‬غالت‪ ،‬مواد سوختي ‪.‬‬
‫‪ ) . .‬حمل و نقل زودرس مواد اوليه‪،‬‬
‫‪36‬‬
‫پيشبيني و پيشگيري‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪‬اختالل در امر ارتباطات‬
‫تهيه راديوهاي كوچك ‪. . .‬‬
‫‪37‬‬
‫پيشبيني و پيشگيري‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪‬مشكل برق‬
‫آموزش پرسنل ذخيره‪ ،‬تهيه يخچالهاي بدون برق در مراكز‬
‫بهداشتي‬
‫‪38‬‬
‫نياز به اجراي مانور مشترك‬
‫پيشبيني و پيشگيري‬
‫محدوديت منابع و امكانات ‪:‬‬
‫‪‬مشكل آب‬
‫حفر چاههاي اضطراري‪. . . ،‬‬
‫‪39‬‬
Public Health
Preparedness
Public Health Objectives

Maintain and expand functions critical to
pandemic response

Maintain critical day-to-day operations
• All Department resources may be needed to address
the consequences of a pandemic
• Some Department functions may be suspended
• Business continuity planning and “response team”
development are underway
40
Direction and Control
• PHSKC will direct the countywide health and medical
response with health care system partners
• Local Health Officer will issue countywide directives
when needed (i.e. school closings, health and medical response)
• PHSKC response actions will emphasize surveillance,
social distancing and communications
• All local jurisdictions will activate emergency
operations plans as needed
• Local Elected Officials will issue directives to ensure
41
continuity of government
Antiviral Medications
• CDC is stockpiling anitivirals in the SNS
• KC developing a local stockpile of antivirals
• Vaccines and antivirals will be prioritized for
predefined target groups
• Local Health Officer will direct (via PH
Order) how these medications will be used
42
Social Distancing / Isolation and
Quarantine
• Isolation of patients will occur throughout the
event
(mainly at home)
• Quarantine of close contacts may occur only
in the early phases
• Decisions regarding closings and reopening
will be based on current epidemiological data
43
Social Distancing / Isolation and
Quarantine
• Schools, large child care centers and libraries
may be closed early by the LHO
• Stadiums, theaters, churches may be closed by
the LHO and KC Executive
44
Health Care Coalition
• Comprised of representatives from a broad
base of health care organizations
• Coordinating body and information
clearinghouse for the medical system during
major emergencies
• Health care system response will resemble
Unified Command
45
Health Care Coalition
Participants
•
•
•
•
•
Hospitals
Large medical groups
Safety net healthcare organizations
Professional associations
Home health and long term care
providers
• Key stakeholders, e.g. EMS, Puget
Sound Blood Center, Red Cross 46
Health Care Coalition
Responsibilities
• Develop all-hazard preparedness plans
• Develop an Executive Advisory Body:
• Review plans and agreements
• Advise the LHO on health issues during
disasters
• Develop a Regional Medical Resource
Center
• Information Management
• Resource Management
• Communication
47
Regional Responsibilities
•
•
•
•
•
•
Emergency Management
Public Works
First Responders
Human Services
General Government
Private Sector
48
Pandemic Preparedness
Responsibilities of All Partners
1. Educate and Inform:
•
Department / Business Leaders
•
Supervisors
•
Staff
•
Families
49
Pandemic Preparedness
Responsibilities of All Partners
Influenza Prevention
• Stay home when sick
• Cover your cough
• Wash hands regularly and use alcohol
hand gel
• Avoid touching eyes, nose, mouth
50
Pandemic Preparedness
Responsibilities of All Partners
2. Individual Preparedness
•
Store an extended supply of food and water at home
•
Store nonprescription drugs and health supplies at home
•
Plan with family members about the following:
•
Caring for loved ones who get sick
•
Caring for children if the schools are closed
•
Other impacts on your life if you need to stay at home for an
extended period of time
51
Pandemic Preparedness
Responsibilities of All Partners
3. Continuity of Operations Planning
•
Identify key functions
•
Cross train staff
•
Identify telecommuting opportunities
•
Review HR policies (sick leave, flex shifts)
•
Identify ways to maintain payroll functions
•
Make alcohol gel, disinfectant wipes available52
Pandemic Preparedness
Responsibilities of All Partners
4. Information Management
•
•
•
•
Develop ways to track absenteeism
Identify thresholds for critical capacities
Develop reporting strategies for tracking
region-wide impacts to critical systems
Develop templates for region-wide
situation reporting
53
Avian Influenza
• Caused by Orthomyxoviridae,
• type A
• Multiple spike glycoproteins—
•
Hemagglutinin (15)
•
Neuraminidase (9)
• Viruses classified on combination
• of H and N types (eg. H5N1)
• Recombination occurs very commonly by “shift and
drift”
ّ
‫احتمال نوتركيبي و تغييرات كلي آنتيژنيك‬
54
55
56
Migratory pattern
57
58
59
60
Human Infections
• H5N1 - severe
• 1997 Hong Kong: 18 cases; 6 deaths
• 2003-2007 , 313 Cases and 191 Deaths
(15 June 2007, 25 Khordad 1386)
• H9N2 - mild
• 1999 Hong Kong: 2 cases (mild)
• 2003 Hong Kong: 1 case (mild)
• H7N7 - mild
• 2003 Netherlands: 89 cases; 1 death
• 2004 Canada: 2 cases
61
Avian influenza (H5N1)
• In May 1997, influenza A(H5N1)
virus was isolated from a child who
died with Reye’s Syndrome in Hong
Kong.
• Prior to this, the H5N1 virus was
known to infect only various species
of birds,
• It was first discovered in terns in
South Africa in 1961 and can be
deadly to chickens:
62
Avian influenza (H5N1)
• Vaccine production is complicated
•
by the fact that the original virus
isolates from Hong Kong also kill
fertilized eggs which are used for
vaccine production.
The preparation of a vaccine would
take several months after the
selection of a suitable virus strain
63
Avian Influenza
• Subdivisions of virus types
on basis of pathogenicity:
• Nonpathogenic
• Low pathogenicity
• High pathogenicity
64
Avian Influenza
• Reservoir primarily waterfowl
• Co-mingling with waterfowl considered
primary risk factor for introduction of
viruses to domestic poultry
• Waterfowl typically subclinical
infections
• Live bird markets where co-mingling
occurs also major source of virus
65
Pathogenicity :
•
•
•
•
HPAI = severe disease
Can have high mortality
LPAI = mild or no disease, not uncommon
Can become HPAI in some cases
• Occurs only with H5 and H7 types of
influenza
66
LPAI vs. HPAI
• LPAI conversion to HPAI has occurred
several times in recent past
•
•
•
•
•
Pennsylvania, 1983
Mexico, 1995
Italy, 2001
Pakistan, ongoing
Multiple others, undocumented / untested in
numerous countries in world
• Because of possible conversion of H5 and H7
LPAI to HPAI, special attention is paid to these
two Hemagglutinin types
67
Avian Influenza
transmission
• Can persist in affected birds and flocks
for months
• Transmitted by most means
• Easily transmitted on contaminated:
clothing,
shoes,
equipment,
cages,
etc.
68
The H5N1 Influenza
Pandemic Threat
• Avian infection in many
countries
• 317 human cases and
191 deaths (61%)
• Culled >100 m chickens
• Avian infection in
Hong Kong
• 18 human cases and
6 deaths (33%)
• Culled poultry
1997
2007
• Ongoing avian H5N1 infections
3
1998
1999
2000
2001
2002
2003
36
95
2004
2005
124
2006
69
Avian Influenza
1918 Army Photo of Victims of the Spanish Flu
( 1957: Asian flu – 1968: Hong Kong flu)
70
Influenza Type A Viruses:
Antigenic Shift 1889-1977
Year
1889
1900
1918
1957
1968
1977
Subtype
H2N2
H3N8
H1N1
H2N2
H3N2
H1N1
Common Name
Spanish flu
Asian flu
Hong Kong flu
Russian flu
Source
?
?
Avian
1
Avian
1
Avian
?
1
Reassortant with avian virus
71
When Will the Next Influenza
Pandemic Occur?
2004 – H7N1 Avian virus
2004 – H7N3 Avian virus
2004 – H5N1 Avian virus
2003 – H7N7 Avian virus
2003– H5N1 Avian virus
1999 – H9N2 Quail virus
1997 – H5N1 Avian virus
1995 – H7N7 Duck virus
1993 –Swine/avian recombinant
1988 – H1N1 Swine virus
1986 – H1N1 Swine virus
1976 – H1N1 Swine flu
Timeline of human infection with novel influenza viruses
(since the 1968 pandemic)
72
Avian influenza
Human
Infection
Case definitions :
73
74
75
76
Case definitions for influenza A/H5
Patient under investigation
• Any individual presenting with
fever ( >38°C) AND one or
more of the following symptoms:
• cough;
• sore throat;
• shortness of breath
77
Case definitions for influenza A/H5
Possible (suspect) influenza A/H5 case
• fever (>38°C) AND one or more of the
following symptoms:
cough; sore throat; shortness of breath; AND one
or more of the following:
• 1- laboratory evidence for influenza A by
a test that does not sub-type the virus;
• 2- having been in contact during the 7
days prior to the onset of symptoms with
a confirmed case of Influenza A/H5 while
78
this case was infectious
Case definitions for influenza A/H5
Possible (suspect) influenza A/H5 case
• 3- having been in contact during the 7
days prior to the onset of symptoms with
birds, including chickens, that have died
of an illness;
• 4- having worked in a laboratory during
the 7 days prior to the onset of symptoms
where there is processing of samples from
persons or animals that are suspected of
having HPAI.
79
Case definitions for influenza A/H5
Possible (suspect) influenza A/H5 case
• Death from an unexplained acute
respiratory illness AND one or
more of the following
• 1- residing in area where HPAI is
suspected or confirmed;
• 2- having been in contact during the 7
days prior to the onset of symptoms with
a confirmed case of Influenza A/H5 while
80
this case was infectious
Case definitions for influenza A/H5
Probable influenza A/H5 case
• Any individual presenting with fever
(>38°C) AND one or more of the
following symptoms:
• cough;
• sore throat;
• shortness of breath;
• AND limited laboratory evidence for
Influenza A/H5 (H5 specific antibodies
detected in a single serum specimen).
81
Case definitions for influenza A/H5
Confirmed influenza A/H5 case
An individual for whom laboratory
testing demonstrates one or more of
the following :
• 1- positive viral culture for Influenza A/H5;
• 2- positive PCR for Influenza A/H5;
• 3- immunofluorescence antibody (IFA) test
positive using Influenza A/H5 monoclonal
antibodies;
• 4- 4-fold rise in Influenza A/H5 specific
antibody titre in paired serum samples.
82
HPAI-clinical signs
Initial symptoms include
:fever, cough and chills
• persistent high fever
(>39oC)
• May cause a rapid downhill
course in some cases
83
HPAI-clinical signs
• Ending with viral pneumonia,
respiratory distress syndrome
and multi-organ failure
84
Diagnosis
• 1 - Serology
• Many good tests available:
• ELISA (multiple different kits available)
• HI (common in other countries)
•
•
•
•
2 - Antigen capture ELISA tests
3 – PCR
4 - Virus isolation
5 - Genetic sequencing
85
Diagnosis
• 4 - Virus isolation
• Gold standard
• Done in chicken embryos
• Good samples include trachea,
lung
• 5 - Genetic sequencing /
relationships may be established
after virus isolation
86
Control of HPAI
• Prevention of exposure to likely
carriers of AIV (waterfowl, exotic
pets, etc.)
• Quarantine zone implementation /
official notification systems in place
for positive areas
• Depopulation
• Vaccination
87
HPAI Control (vaccination)
• Effective at limiting disease,
reducing viral shed
• Used successfully as adjunct
to quarantine and
depopulation
•
88
VACCINATION
CONTROL
QURANTINE
DEPOPULATIO
89
Overall Operation
• Phase I : During the Outbreak
• Eradication of the disease
• Phase II : Post Outbreak
• Proof freedom from disease
• Phase III : Surveillance and
Monitoring
• Long term surveillance
90
Phase I : During the outbreak
• Preemptive culling
• Depopulation and disinfection all
flocks within 5 km radius (Restriction
zone)
• Surveillance during the outbreak
• all flocks within 50 km radius (Control
zone)
• Movement control
• area within 60 km radius
• Public awareness campaign
91
Surveillance during the
outbreak
• Cloacal swabs
• Viral Isolation
• Laboratory assays
92
Phase II : Post-outbreak
• To confirm freedom from disease
• Includes clinical surveillance and
laboratory surveillance
• Control zone
• Other
• Duration
• Initial phase 30 days
• Later phase 5 months
93
Phase III : Surveillance and
monitoring
•
•
•
•
•
•
For early detection of the disease
Since 1997
Nationwide
Long term
Active and Passive surveillance
All avian spp: farm, migratory,
import, exotic etc.
94
Some guideline to prevent
Avian influenza
1. Where possible,
minimize direct
contact with birds.
2. If you must contact
birds, wash your hands
thoroughly with soap and
warm water after handling
them.
95
Some guideline to prevent
Avian influenza
3. When visiting poultry farms wear
additional protective clothing (such as
overalls or gowns) which should be
removed on leaving the farm.
4. Staff handling bird carcasses or
collecting samples directly from birds are
advised to wear paper face masks and
appropriate protective clothing.
96
Some guideline to prevent
Avian influenza
5. Avoid working for prolonged periods in
confined spaces with birds, especially if
ventilation is poor.
6. If you develop a fever or respiratory disease
contact your doctor immediately for
appropriate treatment and investigation. Please
inform your doctor of the history of exposure to
birds.
97
Potential Interventions to Decrease
Disease Transmission
Healthcare setting
Community
Decrease
potential for
contact
• Neg pressure rooms
• Cohort patients
• Cohort staff
• Minimize transport
• Minimize visitors
• Environmental
measures
• Travel advisories
• Screen travelers
• Cancel school and other
public gatherings
• Limit public transport
• Isolation & quarantine
(self-imposed or by HCW)
Decrease
potential for
infection
• Cough etiquette
• Hand hygiene
• Droplet precautions
• Cough etiquette
• Hand hygiene
• Wear masks in public
98
References :
1) Raphael Dolin, Influenza, in : Kasper, Braunwald, Fauci, Harrison’s Principles of Internal
medicine, McGraw-Hill medical publishing division, New York, 16th ed. 2005, pp 1066-71.
2) Proper Storage and Handling of Influenza Vaccine , South Dakota Department of Health , 605773-3737 or 1-800-738-2301, 2005, http://flu.sd.gov .
3) Cumulative number of confirmed human cases of avian influenza A / (H5N1), reported to WHO,
10 September 2008 .
(http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_09_10/en/index.html)
4) John J. Treanor, Influenza Virus, In : Mandell, Douglas, Bennett’s Principles and Practice of
Infectious Diseases, 6th ed., 2005, pp. 2060-85.
5) Influenza A (H5N1), WHO Interim Infection Control Guidelines for Health Care Facilities, Last
updated: 10 March 2005.
6) WHO, Influenza in the World, Weekly Epidemiological Record, NO. 9, 4 March 2005. pp. 77-84.
7) WHO, Avian influenza A(H5N1) in humans and poultry, Viet Nam, Weekly Epidemiological
Record, NO. 3, 16 January 2004. pp. 13-24.
8) WHO, Avian influenza A(H5N1) China, Weekly Epidemiological Record, NO. 5, 30 January 2004.
pp. 41-52.
9) WHO, Avian influenza A(H5N1) Situation on 4 February 2004, Weekly Epidemiological Record,
NO. 6, 6 February 2004. pp. 53-64.
10) WHO, Avian influenza A(H5N1), Weekly Epidemiological Record, NO. 7, 13 February 2004. pp.
65-76.
1 - Andre F. Ziegler, Emergency Diseases / Highly Pathogenic Avian Influenza (HPAI) ACPV, CVM
6880, Spring 2003
2 - BENSON CHONG F.6s (6210), INFORMATION OF H5N1 VIRUS
3 - WHO guidelines for global surveillance of influenza A/H5 6 February 2004
99
4-....