A Comparison of Clinical and Epidemiological Characteristics of Fatal Human Infections with H5N1 and Human Influenza Viruses in Thailand, 2004–2006

Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
PLoS ONE (Impact Factor: 3.23). 04/2011; 6(4):e14809. DOI: 10.1371/journal.pone.0014809
Source: PubMed


The National Avian Influenza Surveillance (NAIS) system detected human H5N1 cases in Thailand from 2004-2006. Using NAIS data, we identified risk factors for death among H5N1 cases and described differences between H5N1 and human (seasonal) influenza cases.
NAIS identified 11,641 suspect H5N1 cases (e.g. persons with fever and respiratory symptoms or pneumonia, and exposure to sick or dead poultry). All suspect H5N1 cases were tested with polymerase chain reaction (PCR) assays for influenza A(H5N1) and human influenza viruses. NAIS detected 25 H5N1 and 2074 human influenza cases; 17 (68%) and 22 (1%) were fatal, respectively. We collected detailed information from medical records on all H5N1 cases, all fatal human influenza cases, and a sampled subset of 230 hospitalized non-fatal human influenza cases drawn from provinces with ≥1 H5N1 case or human influenza fatality. Fatal versus non-fatal H5N1 cases were more likely to present with low white blood cell (p = 0.05), lymphocyte (p<0.02), and platelet counts (p<0.01); have elevated liver enzymes (p = 0.05); and progress to circulatory (p<0.001) and respiratory failure (p<0.001). There were no differences in age, medical conditions, or antiviral treatment between fatal and non-fatal H5N1 cases. Compared to a sample of human influenza cases, all H5N1 cases had direct exposure to sick or dead birds (60% vs. 100%, p<0.05). Fatal H5N1 and fatal human influenza cases were similar clinically except that fatal H5N1 cases more commonly: had fever (p<0.001), vomiting (p<0.01), low white blood cell counts (p<0.01), received oseltamivir (71% vs. 23%, p<.001), but less often had ≥1 chronic medical conditions (p<0.001).
In the absence of diagnostic testing during an influenza A(H5N1) epizootic, a few epidemiologic, clinical, and laboratory findings might provide clues to help target H5N1 control efforts. Severe human influenza and H5N1 cases were clinically similar, and both would benefit from early antiviral treatment.

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    • "During 2003–2013 a total of 628 laboratory-confirmed influenza A H5N1 virus infections occurred, with around 60% human case-fatality. Most cases occurred in children and young adults who were exposed to live infected poultry (Shinde et al., 2011). Several studies have revealed that poultry workers are at high risk of infection with avian influenza viruses (AIVs), due to their frequent exposure to chickens (Wang et al., 2009; Zhou et al., 2009). "
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    ABSTRACT: A cross sectional survey was conducted involving 354 farm poultry workers on 85 randomly selected commercial poultry farms in high density poultry farm areas in Pakistan to estimate the sero-prevalence of H5, H7 and H9 and to identify the potential risk factors for infection with the avian influenza virus. A haemagglutination inhibition test titre at 1:160 dilution was considered positive, based on WHO guidelines. The estimated sero-prevalence was 0% for H5, 21.2% for H7 and 47.8% for H9. Based on a generalized linear mixed model, the significant risk factors for H7 infection were area, type of farm and age of poultry worker. Risk of infection increased with the age of poultry workers. Compared with broiler farms, breeder farms presented a greater risk of infection (odds ratio [OR] = 3.8, 95% confidence interval [CI]: 1.4, 10.1). Compared with the combined Khyber Pakhtunkhwa Province and Federal area, North Punjab had higher observed biosecurity measures and presented a lesser risk of infection (OR = 0.3, 95% CI 0.1, 0.9). Biosecurity should therefore be enhanced (especially in breeder farms) to reduce the occupational risks in poultry farm workers and to decrease the risk of emergent human-adapted strains of AI H7 and H9 viruses.
    Preventive Veterinary Medicine 10/2014; 117(3-4):610-614. DOI:10.1016/j.prevetmed.2014.10.007 · 2.17 Impact Factor
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    • "The median duration between admission and death was shorter than that reported in Indonesia, (one compared to three days), with more patients dying on the day of admission (44% in Cambodia versus 12% in Indonesia) [23]. This contrasts with Thailand where fatal cases were hospitalised for a median of six days before death [24]. The death of the majority of patients within two days of hospitalisation suggests that, like those patients in Indonesia, the Cambodian cases had progressed to a stage when treatment was unlikely to impact on clinical outcome [23]. "
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    ABSTRACT: Background Southeast Asia has been identified as a potential epicentre of emerging diseases with pandemic capacity, including highly pathogenic influenza. Cambodia in particular has the potential for high rates of avoidable deaths from pandemic influenza due to large gaps in health system resources. This study seeks to better understand the course and cost-of-illness for cases of highly pathogenic avian influenza in Cambodia. Methods We studied the 18 laboratory-confirmed cases of avian influenza subtype H5N1 identified in Cambodia between January 2005 and August 2011. Medical records for all patients were reviewed to extract information on patient characteristics, travel to hospital, time to admission, diagnostic testing, treatment and disease outcomes. Further data related to costs was collected through interviews with key informants at district and provincial hospitals, the Ministry of Health and non-governmental organisations. An ingredient-based approach was used to estimate the total economic cost for each study patient. Costing was conducted from a societal perspective and included both financial and opportunity costs to the patient or carer. Sensitivity analysis was undertaken to evaluate potential change or variation in the cost-of-illness. Results Of the 18 patients studied, 11 (61%) were under the age of 18 years. The majority of patients (16, 89%) died, eight (44%) within 24 hours of hospital admission. There was an average delay of seven days between symptom onset and hospitalisation with patients travelling an average of 148 kilometres (8-476 km) to the admitting hospital. Five patients were treated with oseltamivir of whom two received the recommended dose. For the 16 patients who received all their treatment in Cambodia the average per patient cost of H5N1 influenza illness was US$300 of which 85.0% comprised direct medical provider costs, including diagnostic testing (41.2%), pharmaceuticals (28.4%), hospitalisation (10.4%), oxygen (4.4%) and outpatient consultations (0.6%). Patient or family costs were US$45 per patient (15.0%) of total economic cost. Conclusion Cases of avian influenza in Cambodia were characterised by delays in hospitalisation, deficiencies in some aspects of treatment and a high fatality rate. The costs associated with medical care, particularly diagnostic testing and pharmaceutical therapy, were major contributors to the relatively high cost-of-illness.
    BMC Public Health 06/2013; 13(1):549. DOI:10.1186/1471-2458-13-549 · 2.26 Impact Factor
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    ABSTRACT: Recent studies have shown that most of deaths in the 1918 influenza pandemic were caused by secondary bacterial infections, primarily pneumococcal pneumonia. Given the availability of antibiotics and pneumococcal vaccination, how will contemporary populations fare when they are next confronted with pandemic influenza due to a virus with the transmissibility and virulence of that of 1918? To address this question we use a mathematical model and computer simulations. Our model considers the epidemiology of both the influenza virus and pneumonia-causing bacteria and allows for co-infection by these two agents as well as antibiotic treatment, prophylaxis and pneumococcal vaccination. For our simulations we use influenza transmission and virulence parameters estimated from 1918 pandemic data. We explore the anticipated rates of secondary pneumococcal pneumonia and death in populations with different prevalence of pneumococcal carriage and contributions of antibiotic prophylaxis, treatment, and vaccination to these rates. Our analysis predicts that in countries with lower prevalence of pneumococcal carriage and access to antibiotics and pneumococcal conjugate vaccines, there would substantially fewer deaths due to pneumonia in contemporary populations confronted with a 1918-like virus than that observed in the 1918. Our results also predict that if the pneumococcal carriage prevalence is less than 40%, the positive effects of antibiotic prophylaxis and treatment would be manifest primarily at of level of individuals. These antibiotic interventions would have little effect on the incidence of pneumonia in the population at large. We conclude with the recommendation that pandemic preparedness plans should consider co-infection with and the prevalence of carriage of pneumococci and other bacteria responsible for pneumonia. While antibiotics and vaccines will certainly reduce the rate of individual mortality, the factor contributing most to the relatively lower anticipated lethality of a pandemic with a 1918-like influenza virus in contemporary population is the lower prevalence of pneumococcal carriage.
    PLoS ONE 01/2012; 7(1):e29219. DOI:10.1371/journal.pone.0029219 · 3.23 Impact Factor
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