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Article Summary

Thitirat Pongprajuc

Salt Lake Community College


Article Summary

The article, “Infection Risk for Persons Exposed to Highly Pathogenic Avian Influenza A

H5 Virus—Infected Birds, United States, December 2014-March 2015,” was published in

Emerging Infectious Diseases Journal which is available on the CDC website. This study was

conducted by a group of scientists that gathered and analyzed information about the highly

pathogenic avian influenza (HPAI) that emerged in the United States. The purpose of the

research was to see if the influenza virus could be transmitted from animals to humans.

The infections of HPAI have not been commonly reported in the United States. However,

there were outbreaks of HPAI in 13 states from December 2014 to March 2015. The

transmission of the influenza virus occurred from wild birds to domestic birds, but the animal-to-

human transmission is limited because the receptor of avian influenza viruses in birds is different

from human due to the evolution of the viruses.

Most human infections are caused by H5N1 and H7N9. H5N1 is a type of HPAI virus,

but H7N9 belongs to low pathogenic avian influenza (LPAI) category. The infections in humans

result in severe disease. About sixty percent of the outbreaks of H5N1 that have occurred in

Africa, Asia and Europe resulted in a fatality. In China, the spread of H7N9 had a lower fatality

rate at about thirty-six percent. In both cases, humans were exposed to infected poultry.

In the United States, there are three subtypes—H5N1, H5N2, and H5N8—of HPAI H5

viruses that have been found. Only one subtype H5N8 have been found in Europe, so the

researchers assumed that the spread of H5H8 in the United States was caused by the migration of

birds from Russia via the Pacific route. A hypothesis related to the migration and the evolution

of HPAI H5 viruses are that when H5N8 arrived here, it mixed with the LPAI and generated two

new HPAI viruses, which are H5N2 and H5N1. There are two pieces of evidence that support

this hypothesis. Firstly, both H5N2 and H5N1 have the hemagglutinin component which is the

same component originally found in H5N8. Secondly, the two new viruses have the

neuraminidase component which is also found in the LPAI circulation. Moreover, the new H5

viruses that have been found in North America have different genes from those found in Asia. As

of 2015, the H5 viruses found in birds in North America were not associated with human


To prevent the animal-to-human transmission of HPAI H5 viruses, the researchers did

two steps of gathering and analyzing the information. The first step was that the researchers

gathered information of virus detections from “the Animal and Plant Health Inspection Service,

United States Department of Agriculture (USDA); the US Geological Survey, United States

Department of Interior (DOI); the US Fish and Wildlife Service, DOI; and the National Flyway

Council” (Arriola et al., 2015). From these reports, the researchers could identify locations where

the HPAI H5 viruses were detected, influenza virus subtype, species, the number of infected

birds, and what kinds of setting the viruses were found in. After analyzing these data, the

researchers grouped the detections into outbreaks.

After that, the researchers started the second step by contacting state and local public

health departments in order to obtain information regarding human exposures. In this procedure,

the researchers gained information about the number of people who were exposed to the infected

birds and the number of people who had an acute respiratory infection (ARI) or had other signs

or symptoms compatible with avian influenza during a ten-day monitoring period. Signs of

infection include fever, cough, runny nose, nasal congestion, sore throat, difficulty breathing,

fatigue, muscle and body aches, nausea, vomiting, diarrhea, stomach pain, and joint pain.

For a person who had ARI during the monitoring period, the researchers asked the local

health departments to collect specimens (a nasopharyngeal swab, nasal aspirate or wash, the

combination of a nasal or nasopharyngeal swab with and oropharyngeal swap) for reverse

transcription PCR (rRT-PCR) testing at the state public laboratories. If the specimens were not

available, the researchers performed serologic testing at the CDC, Atlanta, GA, USA. For the

rRT-PCR testing, the specimens were screened to see whether they are type A or type B

influenza viruses. Influenza A viruses would go on further testing to see whether they belong to

H1, H3, or H5 subtype by microneutralization and hemagglutination analysis.

The results from the first procedure, the animal infections, were that the outbreaks were

caused by H5N2 (61%), H5N8 (36%), and H5N1 (3%). About 63% of the outbreaks occurred in

wild birds, 15% in backyard flocks, 13% in commercial flocks, and 8% in captive wild birds.

These HPAI infection outbreaks occurred in a total of 41 counties in 13 states.

The results from the second procedure, human exposures, showed that there were 164

incidents of human exposures, which 63% were associated with H5N2 virus, 34% with H5N8

virus, 2% with H5N1 virus, and 1% with H5 virus. Of all human exposures, 39% were exposed

to wild birds, 38% to poultry in commercial flocks, 15% to poultry in backyard farms, and 8% to

captive wild birds.

During the ARI ten-day monitoring period, “ARI develop in 5 people of all 164 exposed

people, 4 of 5 were tested negative for influenza virus by rRT-PCR” (Arriola et al., 2015). The

person whose tested positive for Influenza virus had to do further testing, and the result indicated

that “this person had serologic evidence of seasonal influenza A (H3N2) virus infection” (Arriola

et al., 2015) which it had no relationship with an HPAI H5 virus.


The researcher discussed that within four months the HPAI H5 outbreaks, more than a

hundred people were exposed to infected birds. Their findings suggested that the transmission of

the HPAI H5 viruses from birds to human might be uncommon. It conformed to other studies in

Europe that the bird-to-human transmissions were rarely found, but it might occur in particular

circumstances such as lack of appropriate disposal of slaughtered poultry waste, which could

increase the likelihood of humans getting infected.

The limitations of this research are the following:

1) The number of people who identified to be exposed to the HPAI viruses is

underestimated due to incomplete information of all outbreaks.

2) There is no systematic testing for the people whom ARI did not develop in the ten-day

monitoring period.

3) Lack of ability to collect detailed exposure information for all exposure cases.

4) Lack of ability to provide the quantitative estimate of zoonotic risk caused by these

HPAL H5 viruses due to few HPAI H5 virus exposure events in the United States.

5) There might be some delayed reports that the events might occur during the study

period, but those events might be reported after this investigation.

Even though the bird-to-human transmission of the HPAI H5 viruses may be low in the

United States, the CDC recommends people to keep careful watch for possible danger when

humans are exposed to infected birds in the future. These viruses should be treated as if they

have the potential to cause severe disease in humans. The best ways to prevent the infections are

avoiding unprotected contact with infected poultry, testing for influenza A as soon as a person is

exposed to the infected birds, and receiving influenza antiviral chemoprophylaxis. Other

guidelines can be found on the CDC website.


The researchers predicted that HPAI H5 virus outbreaks will continue to happen, and

there may be some additional assortments with native North American viruses. The researchers

emphasized on an immediate report of virus exposures in order to prevent further infection cases

which may cause the spread of viruses among humans.



Arriola, C. S., Nelson, D. I., DeLiberto, T. J., Blanton, L., Kniss, K., Levine, M. Z....Jhung, M.

(2015). Infection Risk for Persons Exposed to Highly Pathogenic Avian Influenza A H5

Virus–Infected Birds, United States, December 2014–March 2015. Emerging Infectious

Diseases, 21(12), 2135-2140.