Pigs, chicks and other flus - ISTM

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!