2006 COURSE TITLE: THE BIRD FLU AND YOU

Transcription

1 COURSE INTRODUCTION Southeast Asia is experiencing the largest and most severe avian influenza outbreak in poultry (domesticated chickens, turkeys, and ducks) in history. Direct infection of humans from poultry has occurred in Southeast Asia. In the present outbreak, more than half of those infected with the virus have died. This occurrence has caught the attention of the media and has resulted in concern about a worldwide human influenza pandemic. This CE module will review avian influenza, human influenza, past influenza pandemics, current pandemic risk, and global and United States pandemic influenza preparedness planning. Ver /2006 1

2 2006 COURSE TITLE: THE BIRD FLU AND YOU Author: Lucia Johnson, MA Ed, CLS(NCA), MT(ASCP)SBB Director of Continuing Education National Center for Competency Testing Number of Clock Hours Credit: 3.0 Course # P.A.C.E. Approved: _ Yes _X_ No Course Objectives Upon completion of this CE module, the professional will be able to: 1. Name the three types of influenza viruses. 2. Identify influenza A viruses by subtype. 3. Define antigenic shift. 4. Define antigenic drift. 5. Describe treatment and prevention of influenza A virus infection. 6. Identify patients who should not receive the influenza vaccine. 7. Name three human influenza pandemics that occurred in the 20 th century. 8. State the influenza A subtype that is currently causing outbreaks in Southeast Asia. 9. List the countries currently affected by avian influenza outbreaks. 10. State the total number of human influenza A H5N1 cases and deaths in the current outbreak. 11. Identify three conditions that must be met for an influenza A pandemic to occur. 12. Describe the three phases of the WHO influenza pandemic preparedness plan. 13. Describe the three pillars of the U.S. National Strategy for Pandemic Influenza. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2

3 INTRODUCTION Avian influenza (bird flu) is an infection caused by avian influenza viruses. These flu viruses occur naturally among birds. Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. However, bird flu is very contagious among birds and can make some domesticated birds, including chickens, ducks, and turkeys, very sick and kill them. In mid-2003, Southeast Asia began experiencing the largest and most severe avian influenza outbreak in poultry (domesticated chickens, turkeys, and ducks) in history. An estimated 150 millions birds have died or been destroyed in an attempt to control the outbreak. Control of the disease in poultry is expected to take several years. Direct infection of humans from poultry has occurred in Southeast Asia. In the present outbreak, more than half of those infected with the virus have died. This occurrence has caught the attention of the media and has resulted in concern about a worldwide human influenza pandemic. HUMAN INFLUENZA General Information Influenza or flu is a respiratory tract infection that affects millions of people every year. Influenza is highly contagious and occurs mainly in the late fall, winter, or early spring. Influenza is spread from person-to-person through respiratory secretions caused by coughing and sneezing. Every year about 20,000 Americans die because of influenza or influenza-related pneumonia. Over 90% of the deaths occur in people 65 years of age or older. Influenza is caused by a ribonucleic acid (RNA) virus. The virus contains a core of RNA covered by a protein membrane. The protein membrane is covered by a lipid (fatty) envelope. Two different types of protein molecules, called the hemagglutinin or H protein and the neuraminidase or N protein, protrude through the lipid membrane like spikes. The presence of the H and N proteins helps the virus attach to and enter the cells it infects. There are three types of influenza: influenza A, influenza B, and influenza C. The influenza A virus is also identified by the subtypes of the H and N spikes. There are 15 subtypes of the H protein and 9 subtypes of the N protein. As an example, influenza A virus could be identified as Influenza A H4N3. Influenza B viruses and subtypes of influenza A virus are further characterized into strains. There are many different strains. Influenza A viruses are named by their type, their starting location, the year it was isolated, the type of H protein, and the type of N protein. An example would be Influenza A/Sydney/5/97 (H3N2). This is influenza A virus, isolated in Sidney, Australia in May of 1997, and has type 3 H and type 2 N proteins. The virus names are often shortened to only the H and N type. The example above would then be H3N2. 3

4 How Influenza Viruses Change Influenza A viruses continually mutate (change). The changes occur in the H and N protein spikes. One series of changes is very gradual and is called antigenic drift. Immunity to one strain of influenza does not necessarily confer immunity to the new strain of influenza that resulted from antigenic drift. This is why a yearly influenza vaccine is necessary to protect persons against newly circulating strains of the virus. The other change is rapid and is called antigenic shift. Many types of animals, including swine, birds, horses, aquatic mammals, and others may become infected with influenza A viruses. Antigenic shifts typically occur in areas where there are high concentrations of humans, pigs, and birds, or other animals living in close proximity, such as parts of Asia where chickens and pigs may share living quarters with humans. This close contact allows for transmission of the animal virus to humans. The genetic change that allows the virus to jump from one species to another is called antigenic shift. Infections across species can result in major changes of the H and N spikes. Thus, a completely new virus arises for which humans have no immunity. Antigenic shifts can occur unpredictably and are the first step towards a potential pandemic or global epidemic. NOTES: Epidemic: Infectious disease that attacks many people at the same time in the same geographical area. In viruses, this is usually a result of an antigenic drift. Pandemic: Infectious disease that affects the majority of the population of a large region or one that is epidemic at the same time in many different parts of the world. With viruses, this is usually the result of an antigenic shift. Antigenic drifts and shifts in viruses occur independently of each other; i.e., drifts do not automatically lead to shifts. Virus Types and Disease VIRUS TYPE INFECTS CAUSES Influenza A humans Significant respiratory illness with increased rates of swine hospitalization and death. birds May cause epidemics and pandemics. horses Human infections are almost always caused by subtypes aquatic mammals H1N1, H1N2, and H3N2. H2N2 viruses circulated in but currently do not. others Subtypes H5 and H7 viruses typically infect birds. Influenza B humans Significant respiratory illness with increased rates of hospitalization and death. May cause epidemics. Influenza C humans Very mild respiratory illness with little or no symptoms. Symptoms Symptoms of influenza will occur 1-2 days after exposure to the virus. Common symptoms include sudden fever, often as high as 104º F, with shaking chills, moderate to severe muscle and joint aches and pains, sweating, a dry cough, nasal congestion, sore throat, moderate to severe malaise and fatigue, and headache. The illness can last up to 1-2 weeks, although fever generally lasts only 3-8 days. 4

5 Complications The most severe complication of influenza is secondary bacterial pneumonia. Influenza damages the lining of the respiratory tract and allows for certain types of bacteria to establish an infection. Streptococcus pneumoniae and Staphylococcus aureus are two types of bacteria that can cause pneumonia resulting from influenza. Pneumonia caused by the influenza virus itself is less common but may occur. The very young, the elderly, and the immunocompromised are most likely to get a secondary bacterial infection and require hospitalization. Most deaths from influenza occur in these risk groups. Treatment of Influenza A Fever and muscle aches may be treated with aspirin, acetaminophen, or ibuprofen. Only those 18 years of age or older should use aspirin due to the possibility of children developing a severe liver and central nervous system condition called Reye s Syndrome. Adequate liquids and nutrition are necessary to prevent dehydration and aid in rapid recovery. Some bed rest is also helpful. If symptoms persist for more than two days, specific antiviral treatment may be necessary. Two neuraminidase inhibitor drugs, oseltamivir (Tamiflu) and zanamivir (Relenza) can reduce the severity and duration of illnesses caused by influenza. Both of these drugs work best if administered within 48 hours of onset of symptoms. Two older antiviral drugs, amantadine and rimantadine, can be used to both prevent and treat influenza A. However, these drugs produce undesirable side effects. For prevention of influenza infection, the drugs must be given before exposure. For effective treatment of existing influenza, the drugs must be given within 48 hours of onset of symptoms. Vaccine The receipt of an annual influenza immunization is the best way to be protected from influenza. The vaccine is an inactivated (killed) virus prepared from the influenza strains that scientists have determined to be the predominant strains during the current influenza season. The influenza vaccine is safe for almost everyone older than six months, including individuals with chronic medical conditions such as asthma. One shot is needed for older children and adults. Previously unvaccinated children less than nine years of age may require two doses of vaccine given one month apart. Individuals with a moderate or severe illness, including those with a fever, should wait to be vaccinated until their symptoms lessen. Influenza vaccine can prevent symptoms of influenza in 70% - 90% of healthy young adults. However, the vaccine s effectiveness in preventing influenza may be as low as 30% - 40% in very frail elderly persons. This is a result of elderly persons being less able to make protective antibodies. Although the vaccine cannot protect all of the elderly from influenza illness, it may protect them from severe illness and death. The following people should avoid the influenza vaccine until they have consulted with their physician: 5

6 Individuals allergic to chicken eggs (welts, tongue swelling, difficultly breathing, loss of blood pressure, etc.). Individuals who have had a previous serious reaction to an influenza vaccine. Individuals who have had Guillain-Barré Syndrome thought to be caused by a previous influenza vaccine. HUMAN INFLUENZA PANDEMICS An influenza pandemic is a worldwide outbreak of influenza that causes much illness and death. Past human influenza pandemics have led to high levels of illness, death, social disruption, and economic loss. In the 20 th century, three influenza pandemics occurred. Years Common Name/ Virus Type Spanish Flu / Influenza A H1N1 Asian Flu / Influenza A H2N2 Hong Kong Flu / Influenza A H3N2 Statistics More than 500,000 deaths in the U.S. Estimated 50 million deaths worldwide. Many died within the first days of infection; others died of secondary complications. H1N1 virus was reintroduced into human population in 1977 and still circulates today. Appears to have originated as an avian virus. About 70,000 deaths in U.S. Appears to have originated as a combination of human and avian virus. About 34,000 deaths in the U.S. Appears to have originated as a combination of human and avian viruses. H3N2 still circulates today. AVIAN INFLUENZA A VIRUSES aka BIRD FLU General Information Only influenza A viruses infect birds. Wild birds are the natural hosts for all subtypes of influenza A virus. Typically, wild birds do not get sick. However, infected birds shed flu virus in their saliva, nasal secretions, and feces and the disease can be transmitted to poultry (domesticated turkeys, chickens, and ducks). Birds become infected when they are exposed to contaminated secretions or surfaces that are contaminated with secretions. Two main forms of influenza disease occur in domestic poultry. A low pathogenic form commonly causes only mild symptoms and can easily go undetected. A high pathogenic form spreads very quickly among poultry flocks and has a high mortality rate. Only influenza A viruses with H5 and N1 subtypes are known to cause the highly pathogenic form of the disease. However, not all H5 and N1 subtypes will cause severe disease in poultry. It is thought that wild waterfowl have carried low pathogenic forms of H5 and N1 for centuries. The low pathogenic form is transmitted to domestic poultry. Once present in domestic poultry, the virus mutates to a highly pathogenic form. 6

7 The role of wild waterfowl in the spread of highly pathogenic avian influenza is not well understood. On very rare occasions in the past, highly pathogenic viruses have been isolated from dead migratory birds in areas experiencing a poultry outbreak. Recent events make it likely that some migratory waterfowl are directly spreading the H5N1 virus in its highly pathogenic form. Therefore, further spread to new areas is expected. When highly pathogenic influenza H5 or N1 viruses cause outbreaks, between 90% - 100% of domesticated poultry can die from infections. Animal health officials worldwide carefully monitor avian influenza during outbreaks in domestic poultry for the following reasons: The potential for low pathogenic H5 and H1 viruses to mutate into highly pathogenic forms. The potential for rapid spread and significant illness and death among poultry during outbreaks of highly pathogenic influenza. The economic impact and trade restrictions from a highly pathogenic outbreak. The possibility that avian influenza could be transmitted to humans. Recent Avian Influenza Outbreaks in the U.S. In 2004, two poultry outbreaks of avian influenza A were reported in the United States. There was no transmission to humans during either outbreak. Feb 2004/Texas o Outbreak of highly pathogenic avian influenza A H5N2 reported in a flock of 7,000 chickens in south-central Texas o First outbreak of highly pathogenic avian influenza in U.S. in 20 years Feb 2004/Delaware, New Jersey, Maryland o Outbreak of low pathogenic avian influenza A H7N2 reported in two chicken farms in Delaware and in four live bird markets in New Jersey supplied by the farms o In March 2004, surveillance samples from a flock of chickens in Maryland tested positive for H7N2 Current Avian Influenza Outbreaks The H5N1 subtype is causing the current outbreak in poultry in Southeast Asia. It is a very contagious and pathogenic virus. The current outbreak began in mid-2003 and is the largest and most severe on record. Despite the death and destruction of an estimated 150 million birds, the virus still persists and is now considered to be endemic in many countries. Control of the disease is expected to take several years. Affected Countries Dates Dec 19, 2003 Jan 8, 2004 Jan 12, 2004 Jan 23, 2004 Jan 24, 2004 Countries in order of reporting Republic of Korea* Vietnam Japan* Thailand Cambodia 7

8 Dates Jan 27, 2004 Feb 2, 2004 Feb 4, 2004 Jun/Jul 2004 Aug 7, 2004 Jul 23, 2005 Aug 2, 2005 Aug 12, 2005 Oct 13, 2005 Oct 15, 2005 Oct 26, 2005 * Now considered free of the disease Countries in order of reporting Lao People s Democratic Republic Indonesia China China, Indonesia, Thailand, and Vietnam Malaysia* Russia (Siberia) Kazakhstan Mongolia Turkey Romania Croatia AVIAN INFLUENZA INFECTIONS IN HUMANS It is unusual for humans to get influenza virus infections directly from animals. However, sporadic human infections and outbreaks by certain avian influenza A viruses have been reported. Most cases of avian infection in humans are thought to have resulted from direct contact with infected poultry or contaminated surfaces. To date, most human cases have occurred in rural or outlying areas where households keep small poultry flocks, which often roam freely, sometimes entering homes or sharing outdoor areas where children play. Moreover, because many households in Asia depend on poultry for income and food, many families slaughter or sell their flocks when signs of illness appear. Exposure to the influenza virus is highly likely during slaughter, defeathering, and butchering. There is no evidence that properly cooked poultry or eggs can be a source of infection. The virus is not easily spread from poultry to humans. Huge numbers of birds have been affected with numerous opportunities for human exposure and slightly more than 100 human cases have occurred in the current outbreak. It is not understood why some people are infected and others are not. The H5N1 virus has infected 122 humans, killing 62. However, human infections with avian influenza A viruses detected since 1997 have not resulted in sustained human-to-human transmission. In no instance has the virus spread beyond a first generation of close contacts or caused illness in the general community. Data suggests that human-to-human transmission required very close contact with an ill person. 8

9 Confirmed instances of avian influenza viruses in humans since 1997 include: Dates Countries Human Infections 1997 Hong Kong H5N1* infections occurred in both poultry and humans First time an avian influenza A virus transmission directly from birds to humans had been found 18 people hospitalized; 6 died Virus spread primarily from infected chickens to humans; rare human-to-human spread noted 1999 China Hong Kong Low pathogenic avian influenza A H9N2 virus infection confirmed in two children with uncomplicated influenza-like illness Evidence suggested poultry was the source of infection but human-to-human spread could not be ruled out 2002 USA (Virginia) Following an outbreak of H7N2 among poultry, one person found to have serologic evidence of infection with H7N2 Early Hong Kong Two cases of highly pathogenic H5N1* confirmed in 2003 two family members; one died o History of recent travel to China o Source of infection unknown Child hospitalized with H9N2 low pathogenic virus; recovered; source of infection unknown 2003 The Netherlands Nov 2003 Feb 2004 U.S. (New York) *strain in current outbreak Outbreaks of H7N7 in poultry; later in pigs and humans 89 people with confirmed cases; one death Majority of cases resulted from direct contact with infected poultry Three possible human-to-human infections One patient with a serious underlying illness was hospitalized with infection determined to be H7N2 avian influenza virus; patient recovered Unknown exposure Canada Outbreak of H7N3 in poultry Two cases of confirmed infection; both recovered Both cases exposed to infected poultry Confirmed H5N1 Cases in Current Outbreak (as of 10/28/05) DATES INDONESIA VIETNAM THAILAND CAMBODIA TOTAL Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths 12/26/ /10/04 07/19/ /08/04 12/16/ CURRENT TOTAL

10 CURRENT PANDEMIC RISK General Information It is impossible to know if the currently circulating H5N1 virus will cause a human pandemic. An influenza pandemic can start when three conditions have been met: 1. a new influenza virus subtype emerges, 2. it infects humans causing a serious illness, and 3. it spreads easily from person to person. The H5N1 influenza virus has met the first two conditions. At present, it does not spread easily from person to person. However, the risk of pandemic influenza caused by H5N1 is serious. The H5N1 virus is firmly entrenched in large parts of Asia and the risk that additional human cases will occur persists. Each additional human infection gives the virus the opportunity to improve on its ability to infect humans. Furthermore, the H5N1 virus has never circulated widely among people. Therefore, no one has immunity to it. The recent spread of the virus to poultry and wild birds in new areas further broadens opportunities for human cases to occur. While neither the timing nor the severity of the next pandemic can be predicted, the probability that a pandemic will occur has increased. Influenza pandemics are remarkable events that can rapidly infect virtually all countries. Once an international influenza A virus spread begins, it is essentially unstoppable as the virus is easily spread by sneezing and coughing. Infected people can shed virus before they show symptoms, which further increases their ability to spread the virus. International spread of the virus could easily occur via asymptomatic air travelers. Pandemics can cause large increases in the numbers of people requiring or seeking medical or hospital treatment, temporarily overwhelming healthcare services. High rates of employee absenteeism can also interrupt other essential services, such as law enforcement, transportation, power, and communications. In today s complex global world, the effects of an influenza pandemic would be amplified. Economic and social disruption would be great. Potential Treatments in the Event of a Pandemic The best way to prevent a pandemic would be to eliminate the virus from birds. It is doubtful that this will occur in the near future. A vaccine against the H5N1 influenza is not yet available. It is under development in several countries and clinical trials are in process. Current global production capacity falls far short of the demand expected during a pandemic. The two neuraminidase inhibitor drugs, oseltamivir (Tamiflu) and zanamivir (Relenza), could improve prospects of survival if administered within 48 hours of symptom onset. Clinical data is currently very limited but it is assumed that the H5N1 virus will be susceptible to the neuraminidase inhibitor drugs. Viruses very easily become resistant to amantadine and rimantadine, the older class of antiviral drugs, thus limiting the effectiveness of these two drugs. 10

11 HUMAN PANDEMIC INFLUENZA PLANNING Global Pandemic Planning The World Health Organization (WHO) does not believe the world is adequately prepared for an influenza pandemic. For two years, WHO has been issuing warnings and has encouraged all countries to develop preparedness plans. Only about 40 countries have done so. WHO is further urging countries with adequate resources to stockpile antiviral drugs nationally for use at the start of a pandemic. Around 30 countries are purchasing large quantities of these drugs, but the manufacturer does not have the capacity to fill these orders immediately. WHO works closely with ministries of health and various public health organizations to support surveillance of circulating influenza strains. The most important warning that a pandemic is beginning comes when clusters of patients with clinical symptoms of influenza, closely related in time and place, occur as this suggests human-to-human spread is taking place. The detection of H5N1 virus in healthcare workers caring for H5N1 patients would also suggest human-tohuman risk. If these warning signs are noted, immediate field investigation of the outbreak should occur. Specialized WHO laboratories conduct viral studies and WHO repeatedly asks affected countries to share viruses with the international research community. WHO will alert the world when the pandemic threat increases. WHO recommends that all countries undertake immediate action to prepare for a pandemic. They have published two guidelines to assist in the efforts to prepare for an influenza pandemic: WHO Global Influenza Preparedness Plan and WHO Checklist for Influenza Pandemic Preparedness Planning. WHO s recommended strategic actions are: PHASE: Pre-Pandemic Reduce opportunities for human infection. Strengthen the early warning system. *current stage PHASE: Emergence of Pandemic Virus* Contain or delay the spread at the source. PHASE: Pandemic Declared and Spreading Internationally Reduce morbidity, mortality, and social disruption. Conduct research to guide response measures. WHO, the Food and Agriculture Organization, the World Organization for Animal Health, and the World Bank cosponsored a meeting on avian influenza and human pandemic influenza in November of The goals of this conference were to: 1. confirm a two-prong strategy: to control avian influenza in animals and to prepare for pandemic influenza; 2. support national plans; 3. discuss shared responsibilities of the international community and technical organizations and agencies in assisting affected countries and countries at risk; 4. assess national, regional, and global needs to identify resources; 11

12 5. discuss and outline coordination mechanisms at national, sub-regional, regional, and global levels to assure effective and rapid mobilization of resources; and 6. identify key next steps with political support and backing from the international community. United States Pandemic Planning President George W. Bush commissioned the Homeland Security Council to develop a national strategy for pandemic influenza in the U.S. The National Strategy for Pandemic Influenza will guide the U.S. government in preparing and responding to an influenza pandemic. The National Strategy is guided by the following principles: The federal government will use all instruments of national power to address the pandemic threat. States and communities should have credible pandemic preparedness plans to respond to an outbreak within their jurisdictions. The private sector should play an integral role in preparedness before a pandemic begins, and should be part of the national response. Individual citizens should be prepared for an influenza pandemic, and be educated about individual responsibility to limit the spread of infection if they or their family members become ill. Global partnerships will be leveraged to address the pandemic threat. The pillars of the National Strategy are: PILLAR ONE: Preparedness & Communication Planning for a pandemic Communicating expectations and responsibilities Producing and stockpiling vaccines, antivirals, and medical material Establishing distribution plans for vaccines and antivirals Advancing scientific knowledge and accelerating development PILLAR TWO: Surveillance and Detection Ensuring rapid reporting of outbreaks Using surveillance to limit spread PILLAR THREE: Response and Containment Containing outbreaks Leveraging national medical and public health surge capacity Sustaining infrastructure, essential services and the economy Ensuring effective risk communication 12

13 The Centers for Disease Control and Prevention (CDC) Activities CDC is taking part in a number of pandemic prevention and preparedness activities, including: 1. Providing Leadership to the National Pandemic Influenza Preparedness and Response Task Force, created in May 2005 by the Secretary of the U.S. Department of Health and Human Services. 2. Working with the Association of Public Health Laboratories on training workshops for state laboratories on the use of techniques to identify H5N1 viruses. 3. Working with the Council of State and Territorial Epidemiologists to help states with their pandemic planning efforts. 4. Working with other agencies such as the Department of Defense on antiviral stockpile issues. 5. Working with WHO and Vietnamese Ministry of Health to investigate H5N1 outbreaks in Vietnam and to provide help in laboratory diagnosis and training to local authorities. 6. Performing laboratory testing on H5N1 viruses. 7. Starting a $5.5 million initiative to improve influenza surveillance in Asia. 8. Holding or taking part in training sessions to improve local capacities to conduct surveillance for possible human cases of H5N1 and to detect H5N1 viruses using laboratory techniques. 9. Developing and distributing reagent kits to detect the currently circulating H5N1 viruses. CONCLUSION Avian influenza A H5N1 is infecting domesticated poultry in Southeast Asia. Human infection with this virus has occurred. It is impossible to know if the circulating influenza A H5N1 will cause a human influenza pandemic. The risk is great. Both the international community and individual nations have begun pandemic planning to minimize the morbidity, mortality, social, and economic impact of an influenza pandemic. REFERENCES Centers for Disease Control and Prevention. Avian Flu. Centers for Disease Control and Prevention. Information About Influenza Pandemics. National Foundation for Infectious Diseases. Influenza-The Virus, the Disease, and How to Protect Yourself. World Health Organization. Avian Influenza Frequently Asked Questions. World Health Organization. Confirmed Cases of Avian Influenza A (H5N1). World Health Organization. Ten Things You Need to Know About Pandemic Influenza. World Health Organization. H5N1 Avian Influenza: Timeline. 13

14 The White House. National Strategy for Pandemic Influenza. TEST QUESTIONS THE BIRD FLU & YOU # Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or a test questions have been revised. If you do not have access to the internet, call Customer Service at Influenza C viruses typically cause severe illness. a. True b. False 2. H1N1 influenza A subtypes typically infect birds. a. True b. False 3. Antigenic drift is the first step toward a potential pandemic or global epidemic. a. True b. False 4. Influenza A infections that last for more than two days can be treated with. a. acetaminophen b. antibiotics c. ibuprofen d. oseltamivir 5. Which of the following individuals would NOT be a candidate for the influenza vaccine? a. healthy 2 year old b. healthy 85 year old c. 35 year old with asthma d. 54 year old with fever 14

15 6. The currently circulating avian influenza virus causing outbreaks in Southeast Asia is subtype. a. H1N1 b. H3N2 c. H5N1 d. H7N2 7. Migratory waterfowl may directly spread the current avian influenza virus to parts of the world outside of Southeast Asia. a. True b. False 8. Human cases of avian influenza occurred in the U.S. in a. True b. False 9. As of 10/28/05, how many total human cases of avian influenza infection have occurred since 12/26/03? a. 78 b. 122 c. 192 d Which one of the following is NOT a condition that must be met before a human influenza pandemic can occur? a. A new virus subtype emerges b. The virus causes serious human illness c. The virus must cause serious illness in birds d. The virus must spread easily from person to person 11. The WHO has guidelines for countries to use to contain or delay the source of a virus as a method to prevent or minimize an influenza pandemic. a. True b. False 12. The U.S. government believes that individual citizens should be prepared for an influenza epidemic, and be educated about individual responsibility to limit the spread of infection if they or their family members get sick. a. True b. False *end of test* 15