Avian Influenza.

Avian Influenza

Contents Avian influenza/ Occurrence of Avian influenza A virus infections of humans History of influenza Economic Impact H5N1 Epidemiology Clinical manifestations in birds and human / diagnosis / treatment Prevention /control The Philippines Preparedness and Response Plan Tips for spreading the news

Very contagious among birds and can make domesticated birds, including chickens, ducks, and turkeys, very sick and kill them

Introduction Influenza, originated in birds / slowly mutated to
human flu bird flu has always been around a new type of concern H5N1 virus. highly contagious killing 50 to 100% within 48 hrs Poultry outbreaks in neighboring India and China - alerted the government, UN agencies, donors and other organizations.

Occurrence Highly pathogenic avian influenza A (HPAI) viruses of the H5 and H7 / HA subtypes have been isolated occasionally from free-living birds in Europe and elsewhere. Outbreaks due to HPAI were recorded in the Pennsylvania area, USA, in the years Instances of Avian Influenza A Virus Infections of Humans

Avian influenza A virus infections of humans since 1996
H7N7, United Kingdom, 1996: 1 adult developed conjunctivitis / isolated low pathogenic avian influenza A (H7N7) (not hospitalized and recovered) H5N1, Hong Kong, 1997: - In poultry and humans - the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness - 18 people -hospitalized / six -died. - Killed about 1.5 million chickens H9N2, China and Hong Kong, 1999: Low pathogenic

H7N2, Virginia, 2002: Outbreak among poultry, one person developed uncomplicated influenza-like illness H5N1, China and Hong Kong, 2003: Two cases among members of a Hong Kong family that had traveled to China. One of them died. A family member died of a respiratory illness in China, but no testing was done. H7N7, Netherlands, 2003: 89 people confirmed// 78 - conjunctivitis; 5 - conjunctivitis and influenza-like illness; 2 - influenza-like illness; 4 cases classified as “other.” One death - of acute respiratory distress syndrome. Authorities reported 3 possible instances of human-to-human H7N7 virus transmission from poultry workers to family members H9N2, Hong Kong, 2003: Low pathogenic / a child was hospitalized with influenza-like illness and recovered. H7N2, New York, 2003: low pathogenic/ In November with respiratory symptoms- a patient recovered

H7N3, Canada, 2004: 2 poultry workers - conjunctivitis, /coryza
H7N3, Canada, 2004: 2 poultry workers - conjunctivitis, /coryza. Recovered. H5N1, Thailand and Vietnam, 2004: One instance of probable human-to-human spread of H5N1 virus in Thailand. 50 cases with 36 deaths H5N1, Cambodia, China, Indonesia, Thailand and Vietnam, 2005: 98 human cases with 43 deaths H5N1, Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey, 2006: In Azerbaijan, the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans). 115 human cases with 79 deaths H5N1, Cambodia, China, Egypt, Indonesia, Laos, Myanmar, Nigeria, Pakistan, Vietnam, 2007: Nigeria (January), Laos (February), Myanmar (December), and Pakistan (2007) confirmed their first human infections with H5N1. H7N2, United Kingdom, 2007: Wales, influenza-like illness and conjunctivitis - 4 hospitalized cases. H9N2, China, 2007: A 9-month-old girl with mild signs of disease.

The bird flu outbreak… India
Since Jan 15 in West Bengal, Confirmed in 13 of the 19 districts of West Bengal - alert has been sounded in many states – Uttar Pradesh, Uttarakhand, Haryana, Manipur and Bihar WHO has declared the situation in West Bengal as 'very serious and different' than the earlier outbreaks

…in Nepal Poultry outbreaks influenza virus A/H5N1- not reported in
Outbreaks in India and China alerted the government, UN agencies, donors and other organizations Nepal - vulnerable - The large numbers of migrating birds - Traditional practice of mixed animal farming - Cross-border importation of both eggs and chickens - A large poultry population

….Nepal February the Government of Nepal endorsed a joint Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP) The plan created a joint health and agriculture Technical Subcommittee on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee In August Operational Plan for the period was developed and endorsed by the TSCAI USD18.2 million plan has a human health and an animal health component, under the two responsible line ministries: Ministry of Health and Population and Ministry of Agriculture and Cooperatives

History 1878: First identified case in Italy
: First U.S. cases HPAI Low pathogenic avian influenza first identified mid-twentieth century 1970’s: Migratory waterfowl carriers Outbreaks in mink, seals and whales

Economic Impact Economic losses from avian influenza vary
depending on the strain of virus, species of bird infected, number of farms involved, control methods used and the speed of implementation of control or eradication strategies

Economic Impact Direct losses: Disposal costs
High morbidity and mortality loses Quarantine and surveillance costs Compensation paid for elimination of birds. : outbreaks of LPAI in Minnesota cost growers $22 million

Economic Impact 1983: U.S. outbreak (H5N2)
$65 million in losses Destruction of 17 million birds 30% increase in egg prices : Italy outbreak (H7N1) $100 million in compensation to farmers 18 million birds destroyed Total losses of $500 million

Economic Impact 1997: Hong Kong outbreak (H5N1) 2001: Hong Kong
$13 million loses 1.4 million birds 2001: Hong Kong outbreak (H5N1) 1.2 million birds $3.8 million

Economic Impact 2003: European outbreak (H7N7)
Over 33 million birds destroyed (¼ of Netherlands’ poultry stock) Total Cost of outbreak? : SE Asia (H5N1) 8 countries >100 million birds destroyed Cost? : SE Asia and Eurasia The cost of this outbreak, since it is ongoing is yet to be determined

H5N1 Human Case

What is H5N1 virus? The H5N1 strain is a new and extremely severe influenza virus It has a unique capacity to jump the species barrier and cause severe disease in humans The detection of few human cases, suggest that the virus may not be easily transmitted from birds to human at present

The relationship between bird flu and influenza pandemic
H5N1 is a virus with pandemic potential, - Might ultimately adapt into a strain that is contagious among humans - Once this adaptation occurs it will no longer be a bird virus -it will be a human influenza virus

1918 Virus is an Avian Virus Tissue / victim buried in permafrost
An avian virus that was adapted to humans 25 amino acid changes from avian sequence Some of these changes are already in the H5N1 virus

Epidemiology

Geographic Distribution
Worldwide distribution Reservoir Free flying aquatic birds: Ducks, geese, shorebirds, gulls, terns, auks Outbreaks The Netherlands, Australia, Mexico, U.S., SE Asia, Eurasia Similarity to Newcastle Disease makes actual distribution difficult to define

H5N1 AVIAN INFLUENZA THREAT: HUMAN CASES AT A GLANCE

Morbidity/Mortality Approaches 100% in commercial poultry flocks
Deaths within 2 to 12 days after first signs of illness Survivors -in poor condition; do not begin laying eggs

Key Influenza Viral Features
Surface proteins (major antigens) •Hemagglutinin (HA) Site of attachment to host cells Antibody to HA is protective Neuraminadase (NA) Helps to release virions from cells Antibody to NA can help modify disease severity

“H5N1”

The Influenza Virus Types
• Influenza Type A Can infect people, birds, pigs, horses, seals, whales, and other animals, but wild birds are the natural hosts for these viruses • Influenza Type B - normally found only in humans. - can cause human epidemics, they have not caused pandemics • Influenza Type C - cause mild illness in humans - do not cause epidemics or pandemics

The Influenza Virus subtypes
Influenza type A viruses are divided into subtypes based hemagglutinin (HA) and neuraminidase (NA). There are 15 different HA subtypes & 9 different NA subtypes • Only some influenza A subtypes (i.e., H1N1, H1N2, and H3N2) are currently in general circulation among people. Other subtypes are found most commonly in other animal species. For example, H7N7 and H3N8 viruses cause illness in horses

How are Avian Influenza Viruses different from Human Influenza Viruses?
• Humans can be infected with influenza types A, B, and C. The only subtypes of influenza A virus that normally infect people are influenza A subtypes H1N1, H1N2, and H3N2 Between 1957 and 1968, H2N2 viruses also circulated among people, but currently do not • Only influenza A viruses infect birds. Wild birds are the natural host for all subtypes of influenza A virus. Typically wild birds do not get sick when they are infected

How do outbreaks of avian influenza spread?
Within a country, spreads from farm to farm Large amounts of virus are secreted in bird droppings, contaminating dust and soil. Contaminated equipment ,vehicles, feed, cages or clothing/ shoes From country to country through international trade in live poultry Migratory birds can carry the virus for long distances

Initial source of infection
Transmission of virus Initial source of infection Poultry, migratory waterfowl, pet birds Spread by aerosol, shared drinking water, fomities Virus in respiratory secretions and feces Virus present in eggs laid by infected hens; unlikely to survive and hatch

Spread of Avian Influenza Viruses among Birds
• Certain birds, particularly water birds, act as hosts for influenza viruses by carrying the virus in their intestines and shedding it • Infected birds shed virus in saliva, nasal secretions, and feces • Susceptible birds can become infected with avian influenza virus when they have contact with contaminated nasal, respiratory, or fecal material from infected birds • Fecal-to-oral transmission is the most common mode of spread between birds

Transmission of avian influenza virus to people
􀂃 Most human cases from close contact with infected poultry (chickens, turkeys) 􀂃 OR contact with surfaces or materials contaminated with the virus 􀂃 No sustained person-person transmission 􀂃 Concern is if the virus mutates and can be transmitted person-person

…Human Transmission Previously considered non-pathogenic for humans 1997, Hong Kong 2003, the Netherlands , SE Asia

Environmental survival
Can last indefinitely at a temperature dozens of degrees below freezing, as is found in the northern most areas that migratory birds frequent Over 30 days at 0°C (32.0°F) (over one month at freezing temperature) 6 days at 37°C (98.6°F) (one week at human body temperature) decades in permanently frozen lakes on hard non-porous surface such as plastic or stainless steel for hours on clothes, paper and tissues for 8-12 hours

Heat… inactivates the virus
While cooking poultry to 70°C (158°F) kills the H5N1 virus, it is recommended to cook meat to 165°F to kill all foodborne pathogens Inactivation of the virus also occurs under the following conditions: 30 minutes 60°C (140.0°F) (half hour at a temperature that causes first and second degree burns in humans in ten seconds Acidic pH conditions Presence of oxidizing agents such as sodium dodecyl sulfate, lipid solvents, and B-propiolactone Exposure to disinfectants: formalin, iodine compounds Ordinary levels of chlorine in tap water kill H5N1 in public water systems

….inactivates the virus
Sunlight Most detergents or disinfectants (bleach) But is stable in environment when in pond or lake water and feces 􀂃 4 days at 71.6º F, 30 days at 32º F 􀂃 >1 month in feces at cool temperatures

Problem If a new subtype of influenza A virus is introduced
into the human population, most people have little or no protection against the new virus, and if the Virus can spread easily from person to person, a PANDEMIC (worldwide spread) may occur

Birds with avian flu People with the flu + Sick Pig with both Strands of Influenza

Attack of the Cell

…………..attack of the Cell • A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis, • A cellular trypsin-like enzyme cleaves HA into products HA1 and HA2 which promotes fusion of the virus envelope and the endosome membranes • In the nucleus, the viral polymerase complexes transcribe and replicate the v RNAs. • Newly synthesized mRNAs migrate to cytoplasm where they are translated. • The newly formed nucleocapsids migrate into the cytoplasm and eventually interact with a region of the cell membrane • NA destroys the sialic acid moiety of cellular receptors, releasing the progeny virions.

Clinical Signs Incubation period: 3-14 days Birds - dead
prior to observance of any clinical signs Drop in egg production Neurological signs - reduction in normal vocalizations Depression (drop in egg production) anorexia, ruffled feathers Combs swollen, cyanotic Conjunctivitis and respiratory signs (coughing, sneezing and nasal discharge)

Bird flu in Birds

Post Mortem Lesions Lesions may be absent with sudden death
Severe congestion of the musculature Subcutaneous edema of head and neck area Nasal and oral cavity discharge Petechiae on serosal surfaces Kidneys severely congested Severe congestion of the conjunctivae

Diagnosis Clinically indistinguishable from virulent Newcastle Disease
Suspect with: Sudden death Drop in egg production Facial edema, cyanotic combs and wattles Petechial hemorrhages Virology and serology necessary for definitive diagnoses

Differential Diagnosis HPAI
Virulent Newcastle disease Avian pneumovirus Infectious laryngotracheitis Infectious bronchitis Chlamydia Mycoplasma Acute bacterial diseases Fowl cholera, E. coli infection

Laboratory Diagnosis virus isolation AGID (agar gel immunodiffusion) ELISA RT-PCR Antigen Rapid AIV test kit (immunochromatographic test)

Laboratory identification of human influenza A virus
direct antigen detection, isolation in cell culture, or detection of influenza-specific RNA by reverse transcriptase–polymerase chain reaction.

…identification of human influenza A virus
1. Rapid antigen detection. Results can be obtained in 15–30 minutes. • Near-patient tests for influenza. These tests are commercially available (Nicholson, Wood & Zambon, 2003). • Immunofluorescence assay. A widely used, sensitive method for diagnosis of influenza A and B virus infections and five other clinically important respiratory viruses (Lennette & Schmidt,1979). • Enzyme immunoassay. For influenza A nucleoprotein (NP).

identification …. 2. Virus culture. Provides results in 2–10 days
3. Polymerase chain reaction and Real-time PCR assays. Results can be available within a few hours from either clinical swabs or infected cell cultures

Treatment Specific treatment Not practical in commercial poultry
Supportive care and antibiotics for secondary infections Antivirals (amantadine hydrochloride) effective in reducing mortality Results in resistant viruses

Clinical Signs in Humans
1997: Hong Kong (H5N1) Fever, respiratory disease, vomiting, diarrhea, pain Fatal cases: severe bilateral pneumonia, liver dysfunction, renal failure, septic shock, pancytopenia 1979: in Northeastern U.S (H7N7) -respiratory illness and death Reported also conjunctivitis in workers handling the seals

Clinical Signs in Humans
2003: Netherlands (H7N7) Conjunctivitis Mild influenza or respiratory symptoms Fatal case: acute respiratory distress syndrome : (H5N1) Southeast Asia high case-fatality rate (over 50%)

Antiviral Medications to Prevent and Treat Pandemic Influenza
• Influenza antiviral medications (amantadine, rimantadine, oseltamivir, and zanamivir) • All four work against influenza A viruses. sometimes influenza virus strains can become resistant to one or more of these drugs. • For example, the influenza A (H5N1) viruses identified in human patients in Asia in 2004 and 2005 have been resistant to amantadine and rimantadine • Two other antiviral medications, oseltamavir and zanamavir, would probably work to treat flu caused by the H5N1 virus, though studies still need to be done to prove that they work.

Public Health Significance
Generally risk is low Strains vary in ability to infect humans High occupational exposure may increase risk (poultry workers) resulted from non-compliance with personal bio-safety measures – wearing gloves, gowns and masks There was also evidence of transmission from poultry workers to family members This outbreak emphasizes the need for continuing cooperation between the public health and veterinary medical communities in controlling diseases with a zoonotic potential

Recommended Actions Area Veterinarian in Charge
Notification of Authorities Area Veterinarian in Charge Quarantine While waiting for the authorities or a confirmed diagnosis, all suspect animals should be quarantined

………….Recommended Actions
Confirmatory diagnosis Proper destruction of all exposed cadavers, litter and animal products are required. CO2 gas chambers-garbage cans

To control… The premises must be thoroughly cleaned and disinfected
Insects and mice on the premises should be eliminated The flock depopulated and the carcasses destroyed by burying/ composting The manure - buried at least 5 feet deep. The entire premises - sprayed with Cresylic or phenolic disinfectants

Prevention International import restrictions / testing of all imported birds (poultry, pet birds, etc) before entry into the country Surveillance to aid in detecting any suspicion of the disease Appropriate biosecurity Control human traffic Introduction of unknown disease status birds into flock Education of the poultry industry how the virus is introduced, spread and how it can be prevented

Avian Influenza Vaccine
Killed vaccines are effective against the virus that have the same Hemagglutinin (H) type Vaccines will protect only against other avian influenza viruses with the same hemagglutinin (H) type An H5 type Avian influenza virus will protect against all other H5 avian influenza viruses, but will not protect against other H types such as H7.

…Vaccination Drawbacks to vaccination Expensive
No cross protection between 15 H subtypes Possible creation of reassortant virus In the U.S. an inactivated H5 vaccine and recombinant fowl pox virus vaccine containing the gene that codes for the production of the H5 antigen has recently been licensed for emergency use in future HPAI eradication efforts

BMJ 2005;331:1223 (26 November), doi:10. 1136/bmj. 331. 7527
BMJ 2005;331:1223 (26 November), doi: /bmj Jane Parry News Vaccinating poultry against avian flu Hong Kong Officials of the World Health Organization warned : Inappropriate use of vaccination in poultry to try to prevent the spread of bird flu has become part of the problem and has serious human health implications "Vaccination can sometimes cause silent transmission of infection from asymptomatic birds. Mass vaccination programmes entail people tramping around the countryside from farm to farm and they can spread the disease with them. The first response must be culling," said Peter Cordingley, WHO's spokesman in Manila. Birds have been vaccinated against the disease for about four years. The Chinese government has said that it intends to vaccinate all its four billion chickens. The Indonesian government has said that it did not have the resources to control the outbreak by culling because it could not afford to compensate farmers.

Mutate frequently Influenza A Viruses Antigenic drift Antigenic shift
Point mutations (at one location only) occur during the normal virus replication process accumulated during virus replication Antigenic shift Hybrid virus emerges when cell infected with two different influenza viruses Human, avian, swine, equine Transfer of influenza virus to a different species

Influenza A Viruses Current human influenza vaccines have no efficacy against avian influenza

Stages of Pandemic and WHO
• WHO - developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines WHO’s role and makes recommendations for national measures before and during a pandemic 1. Interpandemic period – Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low. – Phase 2: No new influenza virus subtypes - detected in humans A circulating animal influenza virus subtype poses a substantial risk of human disease.

……..Stages of Pandemic and WHO
2. Pandemic alert period – Phase 3: Human infection with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact – Phase 4: Small cluster with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans – Phase 5: Larger cluster but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk) 3. Pandemic period Phase 6: Pandemic: increased and sustained transmission in general population

The Next Pandemic…. if • The severity of the next pandemic cannot be predicted, but modeling studies suggest that its effect in the United States could be severe • In the absence of any control measures (vaccination or drugs), it has been estimated that in the United States a“ medium–level” pandemic could cause – 89,000 to 207,000 deaths, – between 314,000 and 734,000 hospitalizations, – 18 to 42 million outpatient visits, – 20 to 47 million people being sick. – between 15% and 35% of the U.S. population could be affected by an influenza pandemic, – economic impact could range between $71.3 and $166.5 billion.

The Philippines Preparedness and Response Plan
Avian Influenza Protection Program (defines the biosecurity protocols for the Prevention and Eradication of AI). This was organized in four stages namely: Stage 1. Keeping the Philippines Bird Flu Free Stage 2. Controlling and Eradicating Bird Flu in Domestic Fowl Stage 3. Prevention of Transmission from Fowls to Humans Stage 4. Mitigation of Public Health and Socio- economic Impact of Pandemic Influenza

Coverage of Stage 1. Avian-Flu Free Philippines
A. Prevention Programs Ban on Importation of all Live Domestic and Wild Poultry and All Poultry Products from AI-Affected Countries Minimum Biosecurity Measures Surveillance and Prevention Programs in Airports and Seaports Surveillance of Poultry in Critical Areas in the Philippines Enforcement of the Wildlife Act Preventive Measures in Humans

Coverage of Stage 2: Controlling and Eradicating Bird Flu in Domestic Fowl
In case of an outbreak, a 3-kilometer quarantine zone shall be established and all birds within this area shall be stamped out. Moreover, a 7–kilometer control zone shall be secured so that intensive surveillance can be conducted to detect further outbreaks. CONTROL ZONE 7 km SUSPECT PREMISES QUARANTINE ZONE Level 1 3 km INFECTED PREMISES 3 km QUARANTINE ZONE Level 2

3. Good Practices Avian Influenza Protection Program (AIPP)
Preparedness and Response Plan for Avian and Pandemic Influenza, Guidelines Formulated Localization of AIPP to local government units called Project Blue. Trained composite government-private sector teams organized to undertake nationwide training on bird flu prevention and crisis response preparedness. Strong participation of government agencies in the National Avian Influenza Task Force under the network of the Launch of intensified information campaign dubbed Bird Flu Watch websites for Bird Flu Development of IEC Materials for Bird Flu by target audience, Cough manners, proper handwashing

3. Good Practices 5. Planning workshops- Adoption of table top exercises in workshops/ training 6. Reporting of cases through Short Messaging System 7. Strong private sector participation in all levels of the program 8. Business Continuity Planning – involvement and support of the Business Sector 9. Training of field personnel, epidemiologists, hospitals, Speakers’ Bureau

4. Issues and challenges Massive information demanded by public, local government units, business, academe, civil society, etc. 2. Training for more government personnel to undertake surveillance, laboratory testing, quarantine enforcement and crisis response preparedness (i.e. military, local veterinarians, etc.) Full cooperation on eradication policies 4. Funds to support all aspects of the program

4. Issues and challenges 5. Early warning of human-human spread :
need for stronger global coordination 6. Pandemic preparedness and logistics overwhelmed health care system, existing manpower and resources could response only to a certain extent 7. Antiviral agents : efficacy is uncertain, in short supply, decision on who should be given priority 8. Pandemic Influenza Vaccine : equitable distribution and liability, characteristics of the pandemic vaccine, development and production constraints

Antiviral agents 110,000 capsules for 12,000 treatment courses = for treatment of avian influenza cases and their contacts and patients in areas with initial outbreaks of pandemic influenza, to contain the infection/prevent spread

5. Proposals Short-term training exchange program on various competencies of member countries 2. Establishment of a web-based information exchange Research funds of priority avian flu-related issues Funding support for the establishment of HAIS and SILIPPs and enhancement of ILISS with SMS integration

5. Proposals 5.Advocate equity of pandemic vaccine distribution
6.Involvement of more sectors for preparedness 7.National and international financial support for development activities for pandemic vaccine and for stockpiling of antiviral agents

Tips for spreading the news WHO risk communication advisors Peter M
Tips for spreading the news WHO risk communication advisors Peter M. Sandman and Jody Lanard share 1. Start where your audience starts/ talk about how horrific the next flu pandemic may be compared with the annual flu. 2. Don't be afraid to frighten people 3. Acknowledge uncertainty ("the situation is under control, everything is going to be fine") is terrible risk communication. There is so much we don't know about H5N1. Will it ever achieve efficient human-to-human transmission and ignite a pandemic? How quickly will it spread? How long will it last? How much antiviral medication will be available in different parts of the world? How long will it take for an effective vaccine to be available? Which countries and which people in those countries will get the vaccine first? How well will health care systems cope? How well will national and international economies cope? Bird flu experts and risk communicators cannot answer these questions. But we can raise them, acknowledging our uncertainty at every turn.

…..Tips for spreading the news
3. Acknowledge uncertainty ("the situation is under control, everything is going to be fine") is terrible risk communication There is so much we don't know about H5N1. Will it ever achieve efficient human-to-human transmission and ignite a pandemic? How quickly will it spread? How long will it last? How much antiviral medication will be available in different parts of the world? How long will it take for an effective vaccine to be available? Which countries and which people in those countries will get the vaccine first? How well will health care systems cope? How well will national and international economies cope? Bird flu experts and risk communicators cannot answer these questions but we can raise them, acknowledging our uncertainty at every turn

4. Give people things to do One reason sometimes given for not alarming the public is that there's nothing for people to do anyway. The error is failing to realize—and say—how much they can do to prepare Training volunteers to reach out to village to inform people about the risks and signs of bird flu and how to try to protect themselves and their flocks. Even emotional rehearsal—learning about H5N1 and thinking about what a pandemic might be like and how you'd cope—is a kind of preparedness and a kind of involvement.

5. Stress magnitude more than probability The rationale for H5N1 pandemic preparedness isn't that we're sure it's coming, but how bad it could get 6.Guide the adjustment reaction Once people start taking a new risk seriously, the normal response is an "adjustment reaction"—a temporary fearfulness, sometimes accompanied by misplaced or excessive caution. This is the teachable moment. Don't ignore it or ridicule it; guide it. Then we settle into the "new normal." …………………………………………………

Conclusion Become knowledgeable about the flu
Follow advice of public health authorities and your physician Report large death of waterfowl to the local authority

Thank you

References Park K. Park's text book of preventive and social medicine. 18th edition. Jabalpur India: M/s Bhanot Banarasidas; 2005 Dictionary of Epidemiology. John M Last World Organization for Animal Health (OIE) USAHA Foreign Animal Diseases – “The Gray Book” ld Health Organization News. BMJ 2005;331:1223 (26 November), doi: /bmj http// http//

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