1. 1 بسم الله الرحمن الرحيم Pandemic Influenza School of Health ShahidBeheshti University of Medical Sciences By: Hatami H. MD. MPH 2008

2. 2 1)Incubation period 2)Natural course 3)Geographical distribution 4)Timeline trend 5)Age, Gender, Occupation, Social situation 6)Predisposing factors 7)Susceptibility & Resistance 8)Secondary attack rate 9)Modes of transmission, period of communicability  Definition and public health importance  Etiologic agents Clinical Epidemiology of Avian flu  Prevention : primary, secondary, tertiary OCCURRENCE مقايسه

3. 3 هنگ كنگ 1997 اوّلين موارد آنفلوآنزاي پرندگان در انسان 18 + 387 = 405 6 + 245 = 251

4. 4 دلايل اهميت ويروس H5N1 آسيب زايي و حدّت آسيب زايي و حدّت ميزان مرگ ميزان مرگ وسعت انتشار وسعت انتشار راه ‌ هاي انتقال راه ‌ هاي انتقال احتمال تغييرات ژنتيك احتمال تغييرات ژنتيك احتمال وقوع جهانگيري انساني احتمال وقوع جهانگيري انساني

5. 5 Definitions An epidemic - is an increase in disease above what you what would normally expect A pandemic - is a worldwide epidemic

6. 6 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

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8. 8 How Do Influenza Pandemics Arise? When avian influenza viruses experience sudden changes in genetic structureWhen avian influenza viruses experience sudden changes in genetic structureAnd Are capable of infecting humansAre capable of infecting humansAnd Can reproduce and spread from person to person….a pandemic occursCan reproduce and spread from person to person….a pandemic occurs

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11. 11 وضعيت فعلي پاندمي

12. 12 Declared globally by the World Health Organization Declared nationally by the Department of Health and Human Services Interpandemic Pandemic Alert Pandemic Phase I Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Phases of a Pandemic World Health Organization PreparednessResponse جايگاه فعلي پاندمي دوره ها = Periods مراحل = Phases

13. 13 World Health Organization Phases of a Pandemic Inter-pandemic periodInter-pandemic period Pandemic Alert periodPandemic Alert period Pandemic PeriodPandemic Period Post Pandemic PeriodPost Pandemic Period

14. 14 World Health Organization Phases of a Pandemic Inter-pandemic periodInter-pandemic period Phase 1 – No new virus subtypes in humansPhase 1 – No new virus subtypes in humans Phase 2 – Animal subtype poses a risk of human diseasePhase 2 – Animal subtype poses a risk of human disease Pandemic Alert PhasePandemic Alert Phase Pandemic PeriodPandemic Period Post Pandemic PeriodPost Pandemic Period

15. 15 World Health Organization Phases of a Pandemic Inter-pandemic periodInter-pandemic period Pandemic Alert periodPandemic Alert period Phase 3 – Human infection, no human to human spreadPhase 3 – Human infection, no human to human spread Phase 4 – Small localized clusters of human to human spreadPhase 4 – Small localized clusters of human to human spread Phase 5 – Larger clusters, still localized, virus adapting to humansPhase 5 – Larger clusters, still localized, virus adapting to humans Pandemic PeriodPandemic Period Post Pandemic PeriodPost Pandemic Period

16. 16 World Health Organization Phases of a Pandemic Inter-pandemic periodInter-pandemic period Pandemic Alert PhasePandemic Alert Phase Pandemic PeriodPandemic Period Phase 6 – Increased and sustained transmission in the general population. Waves of 8-12 weeks.Phase 6 – Increased and sustained transmission in the general population. Waves of 8-12 weeks. Post Pandemic PeriodPost Pandemic Period

17. 17 World Health Organization Phases of a Pandemic Inter-pandemic periodInter-pandemic period Pandemic Alert PhasePandemic Alert Phase Pandemic PeriodPandemic Period Post Pandemic PeriodPost Pandemic Period

18. 18 Declared globally by the World Health Organization Declared nationally by the Department of Health and Human Services Interpandemic Pandemic Alert Pandemic Phase I Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Phases of a Pandemic World Health Organization PreparednessResponse جايگاه فعلي پاندمي دوره ها = Periods مراحل = Phases

19. 19 ويروس عامل پاندمي ؟؟ H5N1 ??H1N1 ?? HxNy ??

20. 20 موارد گزارش شده آنفلوآنزاي پرندگان در سطح جهان تا28/3/1386

21. 21 نوپديدي آنفلوآنزاي H5N1 در انسان تا 19/9/1387 تعداد موارد موارد مرگ كل موارد = 389 موارد مرگ = 246 (63%) 138 2 138 3 138 4 138 5 138 6 18 مورد بيماري و 6 مورد مرگ 1376

22. 22 تا 8/4/1386 موارد آنفلوآنزاي H5N1 در انسان تا 20/7/1387

23. 23 اثرات مخرب پاندمي تاثير بر كليه جوانب و شئون زندگي اجتماعي

24. 24 اثرات مخرب پاندمي كاهش پرسنل به ميزان تقريبي 30 % در كل سيستم مديريت چه اموري قائم به فرد مي ‌ باشد؟؟ مديريت چه اموري قائم به فرد مي ‌ باشد؟؟

25. 25 Estimated numbers of Illness, Hospitalization, and Deaths Moderate and Severe Pandemic Scenarios - US and King County تخمين ميزان مرتاليتي و مربيديتي CharacteristicModerate(1957–like)Severe (1918 – like) Total Population يك ميليون و هشتصد هزار نفر Illness540,000540,000 Outpatient Care 270,000270,000 Hospitalizatio n 5,19059,400 Deaths1,25011,500

26. 26 اثرات مخرب پاندمي  كاهش پرسنل به ميزان تقريبي 30 % در كل سيستم  كاهش توان مراكز خدمات بهداشتي ـ درماني  كاهش توان نيروهاي امدادي  كاهش نيروهاي امنيتي  محدوديت منابع و امكانات

27. 27 اثرات مخرب پاندمي محدوديت منابع و امكانات :  اختلال در امر حمل و نقل  اختلال در امر ارتباطات  مشكل برق  مشكل آب  مشكل سوخت ...

28. 28 گشوده شدن زندان ‌ ها  ناامني اجتماعي ... اثرات مخرب پاندمي

29. 29 تاثير بر كليه جوانب و شئونات زندگي اجتماعي اثرات مخرب پاندمي

30. 30 همكاري هماهنگي ارتباط

31. 31 ساماندهي اثرات مخرب پاندمي مسئول تامين، حفظ و ارتقاء سلامتي جسمي، رواني، اجتماعي ؟؟؟؟؟

32. 32 وزارت بهداشت معاونت سلامت محور اصلي وزارت بهداشت معاونت سلامت محور اصلي ارگان ‌ هاي دولتي نيروهاي مردمي NGO ها ستاد بحران وزارت كشور استانداري ‌ ها بسيج جامعه پزشكي

33. 33 برنامه كلي ساماندهي 1 ـ كاهش ميزان بيماري و مرگ و مير 2 ـ به حداقل رساندن ازهم پاشيدگي اجتماعي 3 ـ به حداقل رساندن زيان ‌ هاي اجتماعي 4 ـ حفظ كيان حكومتي

34. 34  كاهش توان مراكز خدمات بهداشتي ـ درماني  كاهش توان نيروهاي امدادي  محدوديت منابع و امكانات پيش ‌ بيني و پيشگيري

35. 35 پيش ‌ بيني و پيشگيري محدوديت منابع و امكانات :  اختلال در امر حمل و نقل  اختلال در امر ارتباطات  مشكل برق  مشكل آب  مشكل سوخت ... نياز به اجراي مانور مشترك

36. 36 محدوديت منابع و امكانات :  اختلال در امر حمل و نقل حمل زودرس برخي از كالاها ( دارو، غلات، مواد سوختي... ) حمل و نقل زودرس مواد اوليه، پيش ‌ بيني و پيشگيري

37. 37 محدوديت منابع و امكانات :  اختلال در امر ارتباطات تهيه راديوهاي كوچك... پيش ‌ بيني و پيشگيري

38. 38 محدوديت منابع و امكانات :  مشكل برق آموزش پرسنل ذخيره، تهيه يخچال ‌ هاي بدون برق در مراكز بهداشتي پيش ‌ بيني و پيشگيري نياز به اجراي مانور مشترك

39. 39 محدوديت منابع و امكانات :  مشكل آب حفر چاه ‌ هاي اضطراري،... پيش ‌ بيني و پيشگيري

40. 40 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 Public Health Preparedness

41. 41 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 continuity of government

42. 42 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

43. 43 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 Social Distancing / Isolation and Quarantine

44. 44 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 Social Distancing / Isolation and Quarantine

45. 45 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 Health Care Coalition

46. 46 Health Care Coalition Participants HospitalsHospitals Large medical groupsLarge medical groups Safety net healthcare organizationsSafety net healthcare organizations Professional associationsProfessional associations Home health and long term care providersHome health and long term care providers Key stakeholders, e.g. EMS, Puget Sound Blood Center, Red CrossKey stakeholders, e.g. EMS, Puget Sound Blood Center, Red Cross

47. 47 Health Care Coalition Responsibilities Develop all-hazard preparedness plansDevelop all-hazard preparedness plans Develop an Executive Advisory Body:Develop an Executive Advisory Body: Review plans and agreementsReview plans and agreements Advise the LHO on health issues during disastersAdvise the LHO on health issues during disasters Develop a Regional Medical Resource CenterDevelop a Regional Medical Resource Center Information ManagementInformation Management Resource ManagementResource Management CommunicationCommunication

48. 48 Regional Responsibilities Emergency Management Public Works First Responders Human Services General Government Private Sector

49. 49 1.Educate and Inform: Department / Business Leaders Department / Business Leaders Supervisors Supervisors Staff Staff Families Families Pandemic Preparedness Responsibilities of All Partners

50. 50 Influenza Prevention Stay home when sickStay home when sick Cover your coughCover your cough Wash hands regularly and use alcohol hand gelWash hands regularly and use alcohol hand gel Avoid touching eyes, nose, mouthAvoid touching eyes, nose, mouth Pandemic Preparedness Responsibilities of All Partners

51. 51 2.Individual Preparedness Store an extended supply of food and water at homeStore an extended supply of food and water at home Store nonprescription drugs and health supplies at homeStore nonprescription drugs and health supplies at home Plan with family members about the following:Plan with family members about the following: Caring for loved ones who get sickCaring for loved ones who get sick Caring for children if the schools are closedCaring for children if the schools are closed Other impacts on your life if you need to stay at home for an extended period of timeOther impacts on your life if you need to stay at home for an extended period of time Pandemic Preparedness Responsibilities of All Partners

52. 52 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 available Pandemic Preparedness Responsibilities of All Partners

53. 53 4.Information Management Develop ways to track absenteeismDevelop ways to track absenteeism Identify thresholds for critical capacitiesIdentify thresholds for critical capacities Develop reporting strategies for tracking region-wide impacts to critical systemsDevelop reporting strategies for tracking region-wide impacts to critical systems Develop templates for region-wide situation reportingDevelop templates for region-wide situation reporting Pandemic Preparedness Responsibilities of All Partners

54. 54 Avian Influenza Caused by Orthomyxoviridae, Caused by Orthomyxoviridae, type A type A Multiple spike glycoproteins— Multiple spike glycoproteins— Hemagglutinin (15) Hemagglutinin (15) Neuraminidase (9) Neuraminidase (9) Viruses classified on combination Viruses classified on combination of H and N types (eg. H5N1 ) of H and N types (eg. H5N1 ) Recombination occurs very commonly by “shift and drift” Recombination occurs very commonly by “shift and drift” احتمال نوتركيبي و تغييرات كلّي آنتي ‌ ژنيك

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57. 57 Migratory pattern

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61. 61 Human Infections H5N1 - severe H5N1 - severe 1997 Hong Kong: 18 cases; 6 deaths 1997 Hong Kong: 18 cases; 6 deaths 2003-2007, 313 Cases and 191 Deaths 2003-2007, 313 Cases and 191 Deaths (15 June 2007, 25 Khordad 1386) (15 June 2007, 25 Khordad 1386) H9N2 - mild H9N2 - mild 1999 Hong Kong: 2 cases (mild) 1999 Hong Kong: 2 cases (mild) 2003 Hong Kong: 1 case (mild) 2003 Hong Kong: 1 case (mild) H7N7 - mild H7N7 - mild 2003 Netherlands: 89 cases; 1 death 2003 Netherlands: 89 cases; 1 death 2004 Canada: 2 cases 2004 Canada: 2 cases

62. 62 Avian influenza (H5N1) In May 1997, influenza A(H5N1) virus was isolated from a child who died with Reye’s Syndrome in Hong Kong. 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, 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: It was first discovered in terns in South Africa in 1961 and can be deadly to chickens:

63. 63 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

64. 64 Subdivisions of virus types on basis of pathogenicity:Subdivisions of virus types on basis of pathogenicity: NonpathogenicNonpathogenic Low pathogenicityLow pathogenicity High pathogenicityHigh pathogenicity Avian Influenza

65. 65 Reservoir primarily waterfowl Reservoir primarily waterfowl Co-mingling with waterfowl considered primary risk factor for introduction of viruses to domestic poultry Co-mingling with waterfowl considered primary risk factor for introduction of viruses to domestic poultry Waterfowl typically subclinical infections Waterfowl typically subclinical infections Live bird markets where co-mingling occurs also major source of virus Live bird markets where co-mingling occurs also major source of virus Avian Influenza

66. 66 Pathogenicity : HPAI = severe diseaseHPAI = severe disease Can have high mortalityCan have high mortality LPAI = mild or no disease, not uncommonLPAI = mild or no disease, not uncommon Can become HPAI in some casesCan become HPAI in some cases Occurs only with H5 and H7 types of influenzaOccurs only with H5 and H7 types of influenza

67. 67 LPAI vs. HPAI LPAI conversion to HPAI has occurred several times in recent pastLPAI conversion to HPAI has occurred several times in recent past Pennsylvania, 1983Pennsylvania, 1983 Mexico, 1995Mexico, 1995 Italy, 2001Italy, 2001 Pakistan, ongoingPakistan, ongoing Multiple others, undocumented / untested in numerous countries in worldMultiple 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 typesBecause of possible conversion of H5 and H7 LPAI to HPAI, special attention is paid to these two Hemagglutinin types

68. 68 Avian Influenza transmission Can persist in affected birds and flocks for monthsCan persist in affected birds and flocks for months Transmitted by most meansTransmitted by most means Easily transmitted on contaminated: clothing,Easily transmitted on contaminated: clothing, shoes, shoes,equipment, cages, cages,etc.

69. 69 The H5N1 Influenza Pandemic Threat Avian infection in many Avian infection in many countries countries 317 human cases and 317 human cases and 191 deaths (61%) 191 deaths (61%) Culled >100 m chickens Culled >100 m chickens 20032004199719981999200020012002 Avian infection in Avian infection in Hong Kong Hong Kong 18 human cases and 18 human cases and 6 deaths (33%) 6 deaths (33%) Culled poultry Culled poultry Ongoing avian H5N1 infections Ongoing avian H5N1 infections 2005 2006 3 36 95124 2007

70. 70 ( 1957: Asian flu – 1968: Hong Kong flu) 1918 Army Photo of Victims of the Spanish Flu Avian Influenza

71. 71 Influenza Type A Viruses: Antigenic Shift 1889-1977 YearSubtypeCommon Name Source 1889H2N2? 1900H3N8? 1918H1N1Spanish flu Avian 1957H2N2Asian flu Avian 1 1968H3N2Hong Kong flu Avian 1 1977H1N1Russian flu ? 1 Reassortant with avian virus

72. 72 When Will the Next Influenza Pandemic Occur? 1976 – H1N1 Swine flu 1986 – H1N1 Swine virus 1988 – H1N1 Swine virus 1993 –Swine/avian recombinant 1995 – H7N7 Duck virus 1997 – H5N1 Avian virus 1999 – H9N2 Quail virus 2003– H5N1 Avian virus 2003 – H7N7 Avian virus 2004 – H5N1 Avian virus Timeline of human infection with novel influenza viruses (since the 1968 pandemic) 2004 – H7N3 Avian virus 2004 – H7N1 Avian virus

73. 73 Human Infection Avian influenza Case definitions :

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77. 77 Any individual presenting with fever ( >38°C) AND one or more of the following symptoms: cough; sore throat; shortness of breath Case definitions for influenza A/H5 Case definitions for influenza A/H5 Patient under investigation

78. 78 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 this case was infectious

79. 79 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.

80. 80 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 this case was infectious

81. 81 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).

82. 82 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.

83. 83 HPAI-clinical signs Initial symptoms include :fever, cough and chills persistent high fever (>39oC)persistent high fever (>39oC) May cause a rapid downhill course in some casesMay cause a rapid downhill course in some cases

84. 84 Ending with viral pneumonia, respiratory distress syndrome and multi-organ failureEnding with viral pneumonia, respiratory distress syndrome and multi-organ failure HPAI-clinical signs

85. 85 DiagnosisDiagnosis 1 - Serology1 - Serology Many good tests available:Many good tests available: ELISA (multiple different kits available)ELISA (multiple different kits available) HI (common in other countries)HI (common in other countries) 2 - Antigen capture ELISA tests2 - Antigen capture ELISA tests 3 – PCR3 – PCR 4 - Virus isolation4 - Virus isolation 5 - Genetic sequencing5 - Genetic sequencing

86. 86 4 - Virus isolation4 - Virus isolation Gold standardGold standard Done in chicken embryosDone in chicken embryos Good samples include trachea, lungGood samples include trachea, lung 5 - Genetic sequencing / relationships may be established after virus isolation5 - Genetic sequencing / relationships may be established after virus isolation DiagnosisDiagnosis

87. 87 Control of HPAI Prevention of exposure to likely carriers of AIV (waterfowl, exotic pets, etc.)Prevention of exposure to likely carriers of AIV (waterfowl, exotic pets, etc.) Quarantine zone implementation / official notification systems in place for positive areasQuarantine zone implementation / official notification systems in place for positive areas DepopulationDepopulation VaccinationVaccination

88. 88 HPAI Control (vaccination) Effective at limiting disease, reducing viral shedEffective at limiting disease, reducing viral shed Used successfully as adjunct to quarantine and depopulationUsed successfully as adjunct to quarantine and depopulation

89. 89 VACCINATION QURANTINE DEPOPULATIO CONTROL

90. 90 Overall Operation Phase I : During the OutbreakPhase I : During the Outbreak Eradication of the diseaseEradication of the disease Phase II : Post OutbreakPhase II : Post Outbreak Proof freedom from diseaseProof freedom from disease Phase III : Surveillance and MonitoringPhase III : Surveillance and Monitoring Long term surveillanceLong term surveillance

91. 91 Phase I : During the outbreak Preemptive cullingPreemptive culling Depopulation and disinfection all flocks within 5 km radius (Restriction zone)Depopulation and disinfection all flocks within 5 km radius (Restriction zone) Surveillance during the outbreakSurveillance during the outbreak all flocks within 50 km radius (Control zone)all flocks within 50 km radius (Control zone) Movement controlMovement control area within 60 km radiusarea within 60 km radius Public awareness campaignPublic awareness campaign

92. 92 Surveillance during the outbreak Cloacal swabs Viral Isolation Laboratory assays

93. 93 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

94. 94 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.

95. 95 Some guideline to prevent Avian influenza 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.

96. 96 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. Some guideline to prevent Avian influenza Some guideline to prevent Avian influenza

97. 97 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. Some guideline to prevent Avian influenza Some guideline to prevent Avian influenza

98. 98 Potential Interventions to Decrease Disease Transmission Healthcare settingCommunity 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

99. 99 References : 1) Raphael Dolin, Influenza, in : Kasper, Braunwald, Fauci, Harrison’s Principles of Internal medicine, McGraw-Hill medical publishing division, New York, 16 th ed. 2005, pp 1066-71. 2) Proper Storage and Handling of Influenza Vaccine, South Dakota Department of Health, 605- 773-3737 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, 6 th 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 4 -....