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Dr.Siva.P.M

Introduction

• Bird flu

• Infectious viral disease of birds

• Can affects – large scale poultry

• First outbreak – H5N1 – 1997 – China

• Re-emergence – 2003 and 2004

• Total 668 cases with 393 death (2003-2014) – globally

• Around 60% case fatality rate

• No human cases yet reported in India from 2003

Epidemiology

• Agent

• Influenza virus A

• Subtypes based on Hemagglutinin (HA) protein and Neuraminidase

(NA) protein

• Two categories– low pathogenic and highly pathogenic

• H5 and H7 subtypes – Highly pathogenic avian influenza (HPAI)

• Antigenic shift – reassortment – novel virus – pandemic potential

• Antigenic drift – gradual adaptation of virus to human cells

• Host

• Usually birds – geese, ducks etc

• Environmental

• Usually winter

• Overcrowding

Mode of transmission

• Direct or indirect contact with infected live or dead poultry

• No evidence – cooked food

• No human to human transmission

• But mutation – human to human transmission

Clinical features

• Incubation period – 2-8 days (7 days – field investigation (WHO))

• High grade fever >38 deg. C

• Cough/sore throat

• Diarrhea, vomiting, abdominal pain, chest pain and bleeding from

nose and gum

• Common feature – LRI – respiratory distress, hoarse voice , crackling

sound while inhaling

Complications

• Hypoxemia

• Multiple organ dysfunction

• Secondary bacterial and fungal infections

Diagnosis

• Nasopharyngeal aspirate/wash

• Nasopharyngeal / oropharyngeal /throat swab

• Paired serum

• Triple packaging system

• Cold chain – 2-8 deg C

• National reference lab – NIV pune

• Regional reference centers

• National institute of communicable diseases (NICD) – Delhi

• Kings institute of preventive medicine (KIPM) – Chennai

• Virology section, dept. of microbiology – AIIMS, New Delhi

• National institute of Cholera and Enteric diseases (virus Unit) –

NICED, Kolkatta

• Immuno fluorescent assay (IFA)

• Viral culture

• RT-PCR

• Raise in antibody titer in paired sera

Management of human avian influenza cases

• General and supportive treatment

• Hospitalize and isolate

• Monitor vital signs

• Maintain ABC

• Maintain hydration, electrolyte and nutrition

• Oxygen

• Fever - Paracetamol

• Specific treatment

• Oseltamivir – 75mg BD for 5 days

• After discharge – infection control precautions – 7 days

• For children less than 12 years – 21 days

Chemoprophylaxis

• Neuraminidase inhibitors

• Oseltamivir

• Close contacts – 75mg OD -7 days

• Community contacts – 75 mg OD – 6 weeks

• Amantadine derivatives

• Amantadine and Rimantadine

• Above 1 year

• 5 mg/kg/ day (max 150 mg) in two divided doses – up to 9 years

• Above that 100 mg bd daily

• 5- 8 weeks

Prevention and control

• Contingency plan for management – 2005

• Objectives

• Surveillance

• Early detection and management

• Containment of transmission

• Decrease social disruption and economic loss

Action plan

• Institutional framework

• Surveillance

• Clinical management

• Public health measures

• Logistics and supplies

• Communications and media management

What to do if a outbreak occurs in birds???

• Chief veterinary Officer (CVO) , District Animal husbandry officer

(DAHO) – each district – alert all veterinary officers – report sick or

mortality

• Ensure that all officers – PPE kits

• Visit the site with in 24 hours- receipt of preliminary information

• Disease investigation officer (DIO) – clinical investigation – suspect

flu – inform director animal husbandry, collector and others

• Identification of alert zone – 10km radius

• Collection of samples – high security animal disease laboratory

(HSADL) – Bhopal – confirmation

• Restriction in alert zone

• Outbreak confirmed – 3km radius – culling

• Poultry shops – closure – 10km radius

• Limited access to infected premises

• Disinfection of surfaces

• Notification to health authorities

• Bio-security

• Vaccination of birds – 3-10 km zone

• After a cooling off period of 3 weeks – trade

• Random clinical and virological and serological – fortnight – two

months

Advice to people residing in the area

• Avoid contact

• Avoid handling

• Check temperature for next four days of

contact

• Consult a doctor – suspected contact

Suspected case

Fever > 38 deg C

Plus any one

• Muscle ache

• Cough

• Abnormal breathing

• Suspected pneumonia

Plus

• History of contact with infected birds in past 7 days

• Unusual death of birds in past 14 days

• Contact with pneumonia patient

Probable case

• Symptoms like muscle pain, cough , abnormal breathing or pneumonia

• Preliminary test – influenza A but not confirmed – human or birds

origin

• Respiratory failure

• Death

Confirmed case

• One of the following positive

• Positive viral culture for influenza A/H5

• Positive RT-PCR for influenza A/H5

• Positive IFA test using A/H5 monoclonal antibodies

• A 4 fold rise in influenza A/H5 specific antibody titers

What if a human case suspected???

• Samples – with in 72 hours of illness – within 24 hours to laboratory

• Triple packaging

• PPE while taking sample

• Chemoprophylaxis

What if human case is confirmed??

• Isolation of case in a designated hospital

• Chemoprophylaxis for contacts and health care workers

• Strict infection control policies in Hospital

What if human to human transmission occurs??

• Social distancing – closure of schools and other institutions – avoid

social gathering – initial phase

• If large geographical area involved – restriction of travel and trading

Kerala scenario

Kerala

• 24-11-2014 - director of animal husbandry – reported mass death of

birds in three districts

• Meeting – health secretary - in the evening

• Outbreak area defined – plan for daily action decided - surveillance

and PPE kits

• Alappuzha DMO – focal point for drug supply – neethi, karunya –

locate stocks of oseltamivir and shift to Alappuzha

• Drug manufacturer (Hetero drugs) – contacted – promised to supply

oseltamivir – short term – long term with in 14 days

• Emergency procuirement – MD KMSCL – Hetero drugs – 50,000

capsules

25-11-2014

• Avian flu confirmed

• Action plan for health department

• Procurement of medicines and PPE kits

• Surveillance

• IEC

• Assignment of jobs

• SNO – drug logistics and supervision

• State mass education and media officer- IEC material

• SMO conference – all DMO’s –

• surveillance measures

• Ensure prophylactic oseltamivir and PPE

• Daily reports to IDSP

• Special sensitization – high risk groups

• Check and verify stocks

• Viral transport medium – issued to Alappuzha and PTA DMO

Response…

• November 25th confirmed – avian flu

• Kottayam, Alappuzha, Pathanamthitta

• Around 2 lakh birds culled

• Till December 5th –

• 256575 houses visited

• 944683 people examined

• 2812 – suspected

• No human cases

Summary

• Viral disease – HPAI - birds – rarely humans

• 60% fatality in humans

• Pandemic potential

• Recent outbreak in Kerala

• No human cases reported

“NO PINK PARTS “

“NO RUNNY YOLKS”

Thank you……..