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CDC (CENTER OF DISEASE CONTROL AND PREVENTION AVIAN INFLUENZA (FLU) TRANSMISSION OF INFLUENZA A VIRUSES BETWEEN ANIMALS AND

PEOPLE Influenza A viruses have infected many different animals, including ducks, chickens, pigs, whales, horses, and seals. However, certain subtypes of influenza A virus are specific to certain species, except for birds, which are hosts to all known subtypes of influenza A. Subtypes that have caused widespread illness in people either in the past or currently are H3N2, H2N2, H1N1, and H1N2. H1N1 and H3N2 subtypes also have caused outbreaks in pigs, and H7N7 and H3N8 viruses have caused outbreaks in horses. Influenza A viruses normally seen in one species sometimes can cross over and cause illness in another species. For example, until 1998, only H1N1 viruses circulated widely in the U.S. pig population. However, in 1998, H3N2 viruses from humans were introduced into the pig population and caused widespread disease among pigs. Most recently, H3N8 viruses from horses have crossed over and caused outbreaks in dogs. Avian influenza A viruses may be transmitted from animals to humans in two main ways: Directly from birds or from avian virus-contaminated environments to people. Through an intermediate host, such as a pig. Influenza A viruses have eight separate gene segments. The segmented genome allows influenza A viruses from different species to mix and create a new influenza A virus if viruses from two different species infect the same person or animal. For example, if a pig were infected with a human influenza A virus and an avian influenza A virus at the same time, the new replicating viruses could mix existing genetic information (reassortment) and produce a new virus that had most of the genes from the human virus, but a hemagglutinin and/or neuraminidase from the avian virus. The resulting new virus might then be able to infect humans and spread from person to person, but it would have surface proteins (hemagglutinin and/or neuraminidase) not previously seen in influenza viruses that infect humans. This type of major change in the influenza A viruses is known as antigenic shift. Antigenic shift results when a new influenza A subtype to which most people have little or no immune protection infects humans. If this new virus causes illness in people and can be transmitted easily from person to person, an influenza pandemic can occur.

It is possible that the process of genetic reassortment could occur in a human who is co-infected with avian influenza A virus and a human strain of influenza A virus. The genetic information in these viruses could reassort to create a new virus with a hemagglutinin from the avian virus and other genes from the human virus. Theoretically, influenza A viruses with a hemagglutinin against which humans have little or no immunity that have reassorted with a human influenza virus are more likely to result in sustained human-to-human transmission and pandemic influenza. Therefore, careful evaluation of influenza viruses recovered from humans who are infected with avian influenza is very important to identify reassortment if it occurs. Although it is unusual for people to get influenza virus infections directly from animals, sporadic human infections and outbreaks caused by certain avian influenza A viruses and pig influenza viruses have been reported. (For more information see Avian Influenza Infections in Humans .) These sporadic human infections and outbreaks, however, rarely result in sustained transmission among humans.

AVIAN INFLUENZA A VIRUS INFECTIONS OF HUMANS Although avian influenza A viruses usually do not infect humans, rare cases of human infection with avian influenza A viruses have been reported. Most human infections with avian influenza A viruses have occurred following direct contact with infected poultry. Human clinical illness from infection with avian influenza A viruses has ranged from eye infections (conjunctivitis) to severe respiratory disease (pneumonia) to death. Since November 2003, nearly 400 cases of human infection with highly pathogenic avian influenza A (H5N1) viruses have been reported by more than a dozen countries in Asia, Africa, the Pacific, Europe and the Near East. Highly pathogenic avian influenza A (H5N1) viruses have never been detected among wild birds, domestic poultry, or people in the United States. The World Health Organization (WHO) maintains situation updates and cumulative reports of human cases of avian influenza A (H5N1). Most human cases of H5N1 virus infection are thought to have occurred as a result of direct contact with sick or dead infected poultry. Other subtypes of avian influenza A viruses also have infected humans, including low pathogenic and highly pathogenic virus strains. (For more information, see Low Pathogenic versus Highly Pathogenic Avian Influenza Viruses on the CDC Influenza Viruses Web page.) Public health authorities closely monitor outbreaks of human illness associated with avian influenza because of concerns about the potential for more widespread infection in the human population. The spread of avian influenza A viruses from one ill person to another has been reported very rarely, and has been limited, inefficient and unsustained. However, because avian influenza A viruses have the potential to change and gain the ability to spread easily between people, monitoring for human infection and person-to-person transmission is important. (See Information about Influenza Pandemics for more information.) INSTANCES OF AVIAN INFLUENZA A VIRUS INFECTIONS IN POULTRY Avian influenza outbreaks among poultry occur worldwide from time to time. Since 1997, for example, and based on the World Organization for Animal Health (OIE) reporting criteria for Notifiable Avian Influenza in commercial poultry, the United States has experienced 17 incidents of H5 and H7 low pathogenic avian influenza (LPAI), and one incident of highly pathogenic avian influenza (HPAI) that was restricted to one poultry farm. The U.S. Department of Agriculture monitored and responded to these incidents.

In 2004, the United States experienced the first highly pathogenic avian influenza outbreak among poultry in 20 years. This was an outbreak of avian influenza A (H5N2) which occurred in Texas. The outbreak was reported in a flock of 7,000 chickens in south-central Texas. There was no report of transmission to humans. For more information on reportable poultry outbreaks of avian influenza, visit the World Organization for Animal Health (OIE). INSTANCES OF AVIAN INFLUENZA A VIRUS INFECTIONS OF HUMANS Confirmed instances of avian influenza A virus infections of humans since 1996 include: H7N7, United Kingdom, 1996: One adult developed conjunctivitis after a piece of straw contacted her eye while cleaning a duck house. Low pathogenic avian influenza A (H7N7) virus was isolated from a conjunctiva specimen. The person was not hospitalized and recovered. H5N1, Hong Kong, Special Administrative Region, 1997: Highly pathogenic avian influenza A (H5N1) virus infections occurred in both poultry and humans. This was the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness. During this outbreak, 18 people were hospitalized and six of them died. To control the outbreak, authorities culled about 1.5 million chickens to remove the source of the virus. The most significant risk factor for human H5N1 illness was visiting a live poultry market in the week before illness onset. H9N2, China and Hong Kong, Special Administrative Region, 1999: Low pathogenic avian influenza A (H9N2) virus infection was confirmed in two hospitalized children and resulted in uncomplicated influenza-like illness. Both patients recovered, and no additional cases were confirmed. The source is unknown. Several additional human H9N2 virus infections were reported from China in 1998-99. H7N2, Virginia, 2002: Following an outbreak of low pathogenic avian influenza A (H7N2) among poultry in the Shenandoah Valley poultry production area, one person developed uncomplicated influenza-like illness and had serologic evidence of infection with H7N2 virus. H5N1, China and Hong Kong, Special Administrative Region, 2003: Two cases of highly pathogenic avian influenza A (H5N1) virus infection occurred among members of a Hong Kong family that had traveled to China. One person recovered, the other died. How or where these two

family members were infected was not determined. Another family member died of a respiratory illness in China, but no testing was done. H7N7, Netherlands, 2003: The Netherlands reported outbreaks of highly pathogenic avian influenza A (H7N7) virus among poultry on multiple farms. Overall, 89 people were confirmed to have H7N7 virus infections associated with poultry outbreaks. Most human cases occurred among poultry workers. H7N7-associated illness was generally mild and included 78 cases of conjunctivitis (eye infections); five cases of conjunctivitis and influenza-like illness with fever, cough, and muscle aches; two cases of influenza-like illness; and four cases that were classified as other. One death occurred in a veterinarian who visited one of the affected farms and developed complications from H7N7 virus infection, including acute respiratory distress syndrome. The majority of H7N7 cases occurred through direct contact with infected poultry. However, Dutch authorities reported three possible instances of humanto-human H7N7 virus transmission from poultry workers to family members. H9N2, Hong Kong, Special Administrative Region, 2003: Low pathogenic avian influenza A (H9N2) virus infection was confirmed in a child in Hong Kong. The child was hospitalized with influenza-like illness and recovered. H7N2, New York, 2003: In November 2003, a patient with serious preexisting medical conditions was admitted to a hospital in New York with respiratory symptoms. The patient recovered and went home after a few weeks. Testing revealed that the patient had been infected with a low pathogenic avian influenza A (H7N2) virus; the patients underlying medical conditions likely contributed to the severity of the patients illness. H7N3, Canada, 2004: In March 2004, two poultry workers who were assisting in culling operations during a large influenza A (H7N3) poultry outbreak had culture-confirmed H7N3 conjunctivitis, one of whom also had coryza. Both poultry workers recovered. One worker was infected with low pathogenic H7N3 and the other with high pathogenic H7N3. H5N1, China, Thailand and Vietnam, 2003-2004: In late 2003 and early 2004, severe and fatal human infections with highly pathogenic avian influenza A (H5N1) viruses were associated with widespread poultry outbreaks. Most cases had pneumonia and many had respiratory failure. Additional human H5N1 cases were reported during mid-2004, and late 2004. Most cases appeared to be associated with direct contact with sick or dead poultry. One instance of possible, limited, human-to-

human spread of H5N1 virus is believed to have occurred in Thailand. Overall, 50 human H5N1 cases with 36 deaths were reported from three countries. H5N1, Cambodia, China, Indonesia, Thailand, Vietnam, 2005: Severe and fatal human infections with highly pathogenic avian influenza A (H5N1) viruses were associated with the ongoing H5N1 epizootic among poultry in the region. Overall, 98 human H5N1 cases with 43 deaths were reported from five countries. H5N1, Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey, 2006: Severe and fatal human infections with highly pathogenic avian influenza A (H5N1) viruses occurred in association with the ongoing and expanding epizootic. While most of these cases occurred as a result of contact with infected poultry, in Azerbaijan, the most plausible cause of exposure to H5N1 in several instances of human infection is thought to be contact with infected dead wild birds (swans). The largest family cluster of H5N1 cases to date occurred in North Sumatra, Indonesia during May 2006, with seven confirmed H5N1 cases and one probable H5N1 case, including seven deaths. Overall, 115 human H5N1 cases with 79 deaths were reported in nine countries. H5N1, Cambodia, China, Egypt, Indonesia, Laos, Myanmar, Nigeria, Pakistan, Vietnam, 2007: Severe and fatal human infections with highly pathogenic avian influenza A (H5N1) viruses occurred in association with poultry outbreaks. In addition, during 2007, Nigeria (January), Laos (February), Myanmar (December), and Pakistan (2007) confirmed their first human infections with H5N1. Overall nine countries reported a total of 86 human cases with 59 deaths in 2007. H7N2, United Kingdom, 2007: Human infection with low pathogenic avian influenza A (H7N2) virus resulting in influenza-like illness and conjunctivitis were identified in four hospitalized cases. The cases were associated with an H7N2 poultry outbreak in Wales. H9N2, Hong Kong, Special Administrative Region, 2007: In March 2007, low pathogenic avian influenza A (H9N2) virus infection was confirmed in a 9-month-old Hong Kong girl with mild signs of disease. The World Health Organization (WHO) website provides a timeline of major avian influenza A (H5N1) events. SIGNS AND SYMPTOMS OF AVIAN INFLUENZA IN HUMANS The reported signs and symptoms of avian influenza in humans have ranged from eye infections (conjunctivitis) to influenza-like illness symptoms

(e.g., fever, cough, sore throat, muscle aches) to severe respiratory illness (e.g. pneumonia, acute respiratory distress, viral pneumonia) sometimes accompanied by nausea, diarrhea, vomiting and neurologic changes. ANTIVIRAL AGENTS FOR AVIAN INFLUENZA A VIRUS INFECTIONS OF HUMANS CDC and WHO recommend oseltamivir, a prescription antiviral medication, for treatment and prevention of human infection with avian influenza A viruses. Analyses of available H5N1 viruses circulating worldwide suggest that most viruses are susceptible to oseltamivir. However, some evidence of resistance to oseltamivir has been reported in H5N1 viruses isolated from some human H5N1 cases. Monitoring for antiviral resistance among avian influenza A viruses is important and ongoing. PREVENTION OF AVIAN INFLUENZA A VIRUS INFECTIONS OF HUMANS Persons who work with poultry or respond to avian influenza outbreaks among poultry and are therefore potentially exposed to infected or potentially infected poultry are advised to follow recommended biosecurity and infection control practices including careful attention to hand hygiene, and to use appropriate personal protective equipment. In addition, HPAI poultry outbreak responders should adhere to guidance from CDC and WHO and receive seasonal influenza vaccination and take prophylactic antiviral medication during an outbreak control response. Responders to LPAI outbreaks should consider this guidance as part of their response plan. Seasonal influenza vaccination will not prevent infection with avian influenza A viruses. Exposed persons should be carefully monitored for symptoms that develop during and in 7 days after their last exposure to infected poultry or to environments potentially contaminated with avian influenza A virusexcretions/secretions.

OUTBREAK AVIAN INFLUENZA HOW IS AVIAN INFLUENZA DETECTED IN HUMANS? Avian influenza cannot be diagnosed by symptoms alone, so a laboratory test is required. Avian influenza is usually diagnosed by collecting a swab from the nose or throat during the first few days of illness. This swab is then sent to a laboratory, where they will either look for avian influenza virus using a molecular test, or they will try to grow the virus. Growing avian influenza viruses should only be done in laboratories with high levels of protection. If it is late in the illness, it may be difficult to find an avian influenza virus directly using these methods. If this is the case, it may still be possible to diagnose avian influenza by looking for evidence of the body's response to the virus. This is not always an option because it requires two blood specimens (one taken during the first few days of illness and another taken some weeks later), and it can take several weeks to verify the results. WHAT ARE THE IMPLICATIONS OF AVIAN INFLUENZA TO HUMAN HEALTH? Two main risks for human health from avian influenza are 1) the risk of direct infection when the virus passes from the infected bird to humans, sometimes resulting in severe disease; and 2) the risk that the virus if given enough opportunities will change into a form that is highly infectious for humans and spreads easily from person to person. HOW IS AVIAN INFLUENZA IN HUMANS TREATED? Studies done in laboratories suggest that the prescription medicines approved for human influenza viruses should work in treating avian influenza infection in humans. However, influenza viruses can become resistant to these drugs, so these medications may not always work. Additional studies are needed to determine the effectiveness of these medicines. DOES SEASONAL INFLUENZA VACCINE PROTECT AGAINST AVIAN INFLUENZA INFECTION IN PEOPLE? No. Seasonal influenza vaccine does not provide protection against avian influenza.

SHOULD I WEAR A SURGICAL MASK TO PREVENT EXPOSURE TO AVIAN INFLUENZA? Currently, wearing a mask is not recommended for routine use (e.g., in public) for preventing influenza exposure. In the United States, disposable surgical and procedure masks have been widely used in health-care settings to prevent exposure to respiratory infections, but the masks have not been used commonly in community settings, such as schools, businesses, and public gatherings. CAN I GET AVIAN INFLUENZA FROM EATING OR PREPARING POULTRY OR EGGS? You cannot get avian influenza from properly handled and cooked poultry and eggs. There currently is no scientific evidence that people have been infected with bird flu by eating safely handled and properly cooked poultry or eggs. Most cases of avian influenza infection in humans have resulted from direct or close contact with infected poultry or surfaces contaminated with secretions and excretions from infected birds. Even if poultry and eggs were to be contaminated with the virus, proper cooking would kill it. In fact, recent studies have shown that the cooking methods that are already recommended by the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA) for poultry and eggs to prevent other infections will destroy influenza viruses as well. So to stay safe, the advice is the same for protecting against any infection from poultry: Wash your hands with soap and warm water for at least 20 seconds before and after handling raw poultry and eggs. Clean cutting boards and other utensils with soap and hot water to keep raw poultry from contaminating other foods. Use a food thermometer to make sure you cook poultry to a temperature of at least 165 degrees Fahrenheit Consumers may wish to cook poultry to a higher temperature for personal preference. Cook eggs until whites and yolks are firm. The U.S. government carefully controls domestic and imported food products, and in 2004 issued a ban on importation of poultry from countries affected by avian influenza viruses, including the H5N1 strain. This ban still is in place. For more information, see USDA's Animal and Animal Product Import.

PLANNING & PREPAREDNESS Are you prepared for a flu outbreak or pandemic? The guidance, checklists, and resources in this section are intended to help you create a plan. Business Planning Learn how to protect the health and safety of your employees and local community. Through education and planning, you can help protect your employees from the seasonal flu. Pandemic Flu In a flu pandemic, employers play a key role in protecting employees' health and safety. Organizations can help limit any negative impact on the economy and society as well. Companies that provide critical infrastructure services, such as power and telecommunications, must also plan to continue operations in a crisis. As with any emergency situation, having a contingency plan is essential. Community Planning Get strategies for organizations, such as churches and homeless shelters, to reduce the impact of a pandemic. School Planning Learn how to prevent transmission of disease and keep students, staff, and the local community safe. Promoting healthy choicesvaccination and other preventative measuresat school and at home can prevent seasonal flu from spreading. Pandemic Flu In a flu pandemic, schools play a key role in protecting students health and safety. As with any catastrophe, having a contingency plan is essential. Transportation Planning Learn how to respond to a pandemic situation to ensure citizens can quickly and easily travel long distances. Pandemic Flu The travel and transportation industry will play an integral role in maintaining the Nations continuity of operations in a flu pandemic. The following guidance, checklists, and information will aid the travel and transportation industry in planning and responding to a pandemic flu outbreak. Health Professionals Get information on the crucial role hospitals, health care providers, and emergency medical technicians (EMTs) will play in the event of a pandemic.

Seasonal Flu Health care providers play an important role during flu season. The following guidance and information will assist health care providers and service organizations to plan and respond to seasonal flu. Pandemic Flu Health care providers play a crucial role during a flu pandemic. The following guidance, checklists, and information will assist healthcare providers and service organizations in planning and responding to a pandemic flu outbreak. State & Local Government Find information about plans and response activity at the state, local, and tribal level. Federal Government

STOPPING THE SPREAD OF GERMS AT HOME, WORK & SCHOOL GET VACCINATED The single best way to prevent the flu is to get a flu vaccine each season. The 2012-2013 flu vaccine will protect against 2009 H1N1, and two other influenza viruses (an H3N2 virus and an influenza B virus). GOOD HEALTH HABITS AVOID CLOSE CONTACT. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too. STAY HOME WHEN YOU ARE SICK. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. COVER YOUR MOUTH AND NOSE. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Cover Your Cough STOP THE SPREAD OF GERMS THAT MAKES YOU AND OTHERS SICK. CLEAN YOUR HANDS. Washing your hands often will help protect you from germs. Handwashing: Clean Hands Save Lives Tips on hand washing and using alcohol-based hand sanitizers Wash Your Hands Often Brochures and posters from "An Ounce of Prevention" campaign Clean Hands Campaign Facts and survey results, educational materials from American Society for Microbiologys Clean Hands campaign Consumer Advice: Clean: Handwashing It's a SNAP Toolkit: Handwashing Handwashing materials. Part of It's A SNAP program aimed at preventing school absenteeism. From the School Network for Absenteeism Prevention, a collaborative project of the CDC, the U.S. Department of Health and Human Services and the Soap and Detergent Association

AVOID TOUCHING YOUR EYES, NOSE OR MOUTH. Most experts believe that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth, eyes or nose. STOP THE SPREAD OF GERMS Healthy habits can protect everyone from getting germs or spreading germs at home, work, or school. CLEAN AND DISINFECT SURFACES OR OBJECTS. Cleaning and disinfecting surfaces and objects that may be contaminated with germs like the flu can help slow the spread of influenza.

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