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Pigs, chicks and other flus
Paul Ananth Tambyah
Financial disclosure
• Research Support:
– Baxter, Interimmune, Adamas, Inviragen, Lily, MSD,
Wyeth, GSK, Sanofi-Pasteur
• Honoraria/Speaker gifts:
– Pfizer, Novartis, Bristol-Meyers-Squibb, Wyeth,
Johnson& Johnson, Astra-Zeneca
Case presentation
• 24 year old pig chaser
• Admitted February 1999
• 4 day history of fever and confusion
• Lymphocytic meningitis
• Treated with ceftriaxone, Acyclovir, RHEZ
• Responded approx. day 10
• Repeat CSF normal
Discharge
• Discharged on 14th hospital day
• Well
• Diagnosis:
– ”Viral encephalitis of unknown etiology”
Malaysia had identified a
new virus
Patient was called back...
Eaton et al Nat Rev Micro 2006;4:23-35
Natural Host: Bat
Epidemic ended with slaughter and a ban
What is an Emerging Infectious Disease?
• "new, re-emerging or drug-resistant infections whose incidence in humans has increased within the past two decades or whose incidence threatens to increase in the near future."
– Lederberg et al Institute of Medicine 1992
McKenzie et al EID June 2001
MMWR 2003;52:18
Spread rapidly…
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm
The trauma persists
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HCW Inpatient Visitor Family/friend School China Hong Kong (blank)
Count of Name
dOnset
Contact hx
Effectiveness of Barrier Precautions in Healthcare Workers
Barriers No new cases with onset
after 20 Mar
Data courtesy of Dr Lim Suet Wun, Dr Leo YS, TTSH, Singapore
Eventually, it was over
Webby, R. J., Webster, R. G. (2003). Science 302: 1519-1522
Influenza subtypes
Swine origin Flu was the latest
Fear…
Oseltamivir vs Influenza
Nicholson et al. Lancet 2000;355:1845-50
Regular Flu
Neuropsychiatric Adverse events 1 in 10,000
Ring Prophylaxis worked for smallpox
Original Article Oseltamivir Ring Prophylaxis for Containment of
2009 H1N1 Influenza Outbreaks
Vernon J. Lee, M.B., B.S., M.P.H., Jonathan Yap, M.B., B.S., Alex R. Cook, Ph.D., Mark I. Chen, M.B., B.S., Ph.D., Joshua K. Tay, M.B., B.S., Boon Huan Tan, Ph.D., Jin Phang Loh, M.Sc., Seok Wei Chew, B.Sc., Wee Hong Koh, B.Sc., Raymond Lin, M.B., B.S., Lin Cui, Ph.D., Charlie W.H. Lee, M.Sc., Wing-Kin Sung, Ph.D., Christopher W. Wong, Ph.D., Martin L. Hibberd, Ph.D., Wee Lee Kang, M.B., B.S., M.Med., Benjamin
Seet, M.B., B.S., M.P.H., and Paul A. Tambyah, M.D.
N Engl J Med Volume 362(23):2166-2174
June 10, 2010
Summary of the Four Outbreaks of 2009 H1N1 Influenza and Efficacy of Oseltamivir Prophylaxis and Other Interventions
Lee VJ et al. N Engl J Med 2010;362:2166-2174
Timing of Events and Cases during Outbreak 1, According to Date of Onset of Influenza
Lee VJ et al. N Engl J Med 2010;362:2166-2174
Epidemiologic Data and Model Projections for Outbreak 4, According to Date of Onset of Influenza
Lee VJ et al. N Engl J Med 2010;362:2166-2174
Phylogenetic Relationships among the Viruses Identified during the Four Outbreaks with the Use of Whole-Genome Sequencing
Lee VJ et al. N Engl J Med 2010;362:2166-2174
Side Effects of Oseltamivir Prophylaxis
Lee VJ et al. N Engl J Med 2010;362:2166-2174
Conclusion
• Oseltamivir ring chemoprophylaxis, together with prompt identification and isolation of infected personnel, was effective in reducing the impact of outbreaks of 2009 H1N1 influenza in semiclosed settings
The Airline Outbreak An instructive story….
Ooi PL, Lai FY, Low CL, Lin R,
Wong C, Hibberd M, Tambyah
PA. Arch Intern Med. 2010
24;170:913-5
Arch Intern Med. 2010;170:913-5.
NEJM 2003;348:1256-1266
A
A
A
So…is Influenza Airborne? Results of observational studies
Brankston et al Lancet Infectious Disease 2007;7:257-65
1.1 m ER
Transmission of SARS Ooi, Tambyah Am J Med 2004
The last case of smallpox in the world
Staff used N95s vs SARS
PAPRs are available
N95 masks: Problems
Seasonal flu causes 500+ deaths/yr in Singapore
Chow A, Ma S, Ling AE, Chew SK. Emerg Infect Dis 2006;12:114-121
Park & Glass
Lancet Infect Dis 2007;7:543-8
Influenza Seasonality
in Asia
www.talkingcock.com
We were actually looking out for Bird Flu
Taisuke Horimoto and Yoshihiro Kawaoka
Clinical Microbiology Reviews, January 2001, p. 129-149, Vol. 14, No. 1
Avian Flu
Regular Flu
Subbarao et al Science. 1998;279:393-6.
Avian Flu
Sims et al. Avian Dis 2003;47:1083-6
Avian Flu
The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5, N Engl J Med 2005;353:1374-1385
Presentation and Outcomes among Patients with Confirmed Avian Influenza A (H5N1)
Avian Flu
The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5, N Engl J Med 2005;353:1374-1385
Serologic and Clinical Characteristics of Avian Influenza A (H5N1) Infection among Contacts of Patients or Infected Animals
Avian Flu
H5N1 – appeared 1997, then 2003…
First travel associated H5N1 case -appeared in Canada
Avian influenza in Indonesia
Sulianti Saroso
Infectious Disease
Hospital, Jan 06
Avian Flu
H5N2 in birds in Canada
http://www.inspection.gc.ca/animals/terrestrial-animals/diseases/reportable/ai/
2015-investigation-ontario/timeline-of-events/eng/1428460637170/1428460637873
H7N9
Date of Onset of Illness in First 82 Patients with Confirmed
H7N9 Virus Infection, According to Province in China.
Li Q et al. N Engl J Med 2013. DOI: 10.1056/NEJMoa1304617
http://www.wpro.who.int/wpsar/volumes/04/2/2013_PE_EMT_Arima/en/index.html
Unusual epidemiology/demographics
Family clusters - ?Human to human
http://www.scmp.com/news/china/article/1506142/ sichuan-poultry-farmer-confirmed-dead-new-bird-flu-strain-h5n6
Why all this Bird Flu now?
H7N9 cases to 16 April 2013 (red circles), and population densities of humans (A; density in 2010), pigs (B), chickens (C) and ducks (D) in China and Asia in general. (Livestock densities are modelled numbers of animals per square kilometre standardized to 2006 national totals. Note different scale for pigs.) H7N9 case locations courtesy of EMPRES, FAO, Rome. Human population from ASIAPOP. Source: Map supplied by T. P. Robinson, G. R. W. Wint, G. Conchedda, T. P. Van Boeckel, V. Ercoli, E. Palamara, G. Cinardi, L. D’Aietti and M. Gilbert (2013). Unpublished data. (T.P.R., Fonds National de la Recherche Scientifique, Brussels; G.R.W., University of Oxford, UK; G.Co., V.E., E.P., G.Ci. and L.D'A., FAO, Rome; T.P.V.B. and M.G., Université Libre de Bruxelles, Brussels.)
Humans, Pigs, Chickens and Ducks in China
Air travel from China
http://www.nature.com/news/mapping-the-h7n9-avian-flu-outbreaks-1.12863
Emerg Infect Dis. 2015; 21: 142–145
Sepkowitz & Eisenberg EID 2005;1003-8
Are HCW at high-risk of novel
influenza/other occupational diseases???
Regular Flu
Frank & Burnett, Am J Prev Med 2000; 19:155-9 Regular
Flu
See you in Singapore!
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