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Influenza a Aviária (H5N1): a Gripe Do Frango

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Influenza a Aviária (H5N1): a Gripe Do Frango 436 Ibiapina CC, Costa GA, Faria AC Review Article Avian influenza A (H5N1) - the bird flu* CÁSSIO DA CUNHA IBIAPINA1, GABRIELA ARAÚJO COSTA2, ALESSANDRA COUTINHO FARIA2 ABSTRACT The objective of this study was to review the literature related to avian influenza A (H5N1). The bibliographic research was conducted using the Medline, MD Consult, HighWire, Medscape and Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS, Latin American and Caribbean Health Sciences Literature) databases, as well as through direct research, limiting the scope to articles published within the past 10 years. We selected 31 original articles addressing the recent outbreaks of infection with the H5N1 subtype of avian influenza A in domesticated birds in Asia, which have resulted in significant economic losses and repercussions for public health, as well as some cases of human infection presenting high lethality. In most cases, infection has been associated with direct exposure to infected birds or contact with surfaces infected with bird excrement. However, cases of human-to-human transmission have been confirmed. In those cases, the incubation period varied from 2 to 4 days. The clinical manifestations range from asymptomatic infection to mild upper airway disease, pneumonia and multiple organ failure. Chest X-rays may reveal bilateral interstitial infiltrate, lobar collapse, focal consolidation and air bronchogram without pleural effusion. Lymphopenia is indicative of a poor prognosis. Supportive care appears to be the only acceptable treatment. Risk factors for poor prognosis include advanced age, delayed hospitalization, lower airway involvement, low white blood cell count or lymphopenia upon admission. Controlling outbreaks in domestic fowl and limiting contact between humans and infected birds must be the priorities in the management of this disease at the public health level. In addition, techniques and knowledge regarding the disease should be widely disseminated. Keywords: Influenza A virus, avian /pathogenicity; Influenza; Disease outbreaks; Disease vectors; Clinical trials 1. Professor of Medicine at the Universidade Alfenas (Unifenas, Alfenas University), Belo Horizonte, Minas Gerais, Brazil 2. Medical Academician at the Universidade Federal de Minas Gerais (Federal University of Minas Gerais), Belo Horizonte, Minas Gerais, Brazil Correspondence to: Cássio da Cunha Ibiapina. Rua Rio de Janeiro 1.758/701, Lourdes, Belo Horizonte - MG. CEP 30160-042. Tel.: 55 31 3335-3654, Fax: 55 31 3275-4194. E-mail: [email protected] Submitted: 4 August, 2004. Accepted, after review: 6 May, 2005. J Bras Pneumol. 2005; 31(5):436-44 Avian influenza A (H5N1) - the bird flu 437 INTRODUCTION generation of recombinant viruses or, in other words, a genetic recombination of human and avian Recent outbreaks of infection with subtype viruses. Genetic studies and biochemical analyses H5N1 of the avian influenza A virus on poultry indicate that the Asian flu and Hong Kong flu farms in Asia have resulted in significant economics pandemics were generated by a recombinant virus. losses and have serious public health implications. It is important to note that the H5N1 isolated in In January of 2004, as had previously occurred in humans is not a recombinant virus like those of 1997 and 2003, cases of human infection with 1957 and 1968, and that all of its genes originate this virus, presenting high lethality, were reported from avian viruses.(1-3) in various parts of Asia, leading public health In 1996, the H7N7 subtype was isolated in officials to declare a state of alert regarding the England in the eye of a patient with conjunctivitis. possibility of a new influenza pandemic.(1-2) In Brazil, That patient had been in frequent contact with during the autumn and winter, outbreaks of ducks. This subtype was identical to the virus respiratory syncytial virus, especially in the infecting birds, presenting 98% homology among southwest of the country, led to increased focus the nucleotides.(1-2) on viral respiratory infections by the media, which In view of these aspects, one can perceive that created misconceptions regarding infection with avian viruses play a key role in the emergence of avian influenza A virus, known in Brazil as gripe pandemic strains. Despite the fact that humans and do frango (“chicken flu"), even naming it as the other mammals can be experimentally infected with cause of these outbreaks. avian viruses, these viruses were not, until recently, The present study aims to review the literature transmitted directly to humans. The reservoir of with the objective of presenting the history of influenza A viruses, in populations of aquatic birds, influenza pandemics in the twentieth century, as is the origin of the influenza A viruses that infect well as addressing the epidemiology, pathogenesis, humans, other mammals and domestic fowl.(3) transmissibility, clinical profile, diagnosis and The theory that the avian influenza virus does treatment of avian influenza A, based on articles not replicate efficiently in humans led to the published within the last ten years. formulation of the hypothesis that an intermediary would be needed in order to promote the infection HISTORY in humans. However, the recent H5N1 epidemics in Asia led researchers to re-examine this concept.(3-4) The twentieth century witnessed three influenza The first case of human infection with H5N1 pandemics: the Spanish flu (viral subtype H1N1) occurred in May of 1997. No other cases were in 1918; the Asian flu (H2N2) in 1957; and the reported for six months, although an epidemic Hong Kong flu (H3N2) in 1968. These epidemics occurred in November and December of the same caused serious illness with high mortality rates. year, during which 17 additional cases were reported.(3) The Spanish flu, in particular, killed at least 20 From December of 2003 until February of 2004, million people worldwide in 1918. The gene a total of 23 cases of human infection with this sequence of the H1N1 influenza virus, which was same virus, confirmed through laboratory testing, responsible for this epidemic, suggests that it were reported in Myanmar, China, Indonesia, Japan, originated in an avian reservoir. The viral subtypes Laos, South Korea, Thailand and Vietnam.(4) responsible for the Asian flu and Hong Kong flu pandemics had two important characteristics in EPIDEMIOLOGY common: they both first appeared in southeast Asia, and they were both antigenically distinct from In May of 1997, the H5N1 subtype was isolated the viral subtypes that had previously circulated in the tracheal aspirate of a 3-year-old child who among humans. Southeast China is considered the presented odynophagia, fever and cough. The epicenter of the influenza virus, based on the two patient was medicated with acetylsalicylic acid and previous epidemics that occurred there. The close antibiotics. However, the symptoms persisted and contact among pigs, people and ducks in this the child was hospitalized. Despite the use of region creates an ideal environment for the mechanical ventilation and broad-spectrum J Bras Pneumol. 2005;31(5):436-44. 438 Ibiapina CC, Costa GA, Faria AC antibiotics, the patient died sixteen days after the on average, three days after contact. None of the onset of symptoms, with extensive influenza-related patients presented pre-existing pathologies and pneumonia complicated by Reye's syndrome. This resided in both urban and rural areas. None of was o first documented case of H5N1 infection in the patients had been in contact with each other humans. In December of 1997, the same virus was prior to hospitalization. The estimated interval isolated in 18 patients, 7 of whom had a history of between the exposure to infected birds and the contact with domestic fowl. Of those 7, 6 did not onset of symptoms suggests that the period of survive.(1-2,4) incubation is from two to four days. There have Epidemiological and molecular evidence been no reports of similar illness among the suggests that domestic fowl are the source of the professionals who cared for these patients, despite H5N1 virus. Research has revealed that fatal the lack of measures to control respiratory epidemics of infection with the avian influenza infections from the beginning of the outbreak. occurred on chicken farms in northeast Hong Kong Another 34 cases were confirmed later. Of the 44 in March and April of 1997, just prior to the first cases diagnosed between the beginning of the reported case of human infection.(4) Subsequently, epidemic and December of 2004, 32 patients died. similar epidemics were reported in October, There are approximately 100 suspected cases November and December of the same year, virtually currently under investigation by national health in parallel with the epidemic in humans. authorities in Thailand and Vietnam. The Centers Epidemiological surveillance in Hong Kong for Diseases Control, the World Health identified H5N1 in approximately 20% of the fecal Organization and national health authorities in samples obtained from chicken and in 2% of those Asian countries are working to monitor and from ducks and geese sold in public markets. All control the situation, providing laboratory testing of the strains isolated in these samples were lethal and epidemiological support.(8) to chicken. These findings implicate the As previously mentioned, despite the fact that contaminated birds bought in these markets as the all of the genes are of avian origin, the H5N1 source of the H5N1 infection in Hong Kong.(4)
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