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Thitirat Pongprajuc
Article Summary
The article, “Infection Risk for Persons Exposed to Highly Pathogenic Avian Influenza A
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
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
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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
infections.
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
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.
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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
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.
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
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
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
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
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
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
References
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