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A STUDY OF AVIAN INFLUENZA (H5N1) INFECTION IN EGYPTIAN CHILDREN

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By Dr. Nasser Abdou Kolkailah MD pediatrics, Benha University Ministry Of health consultant of Avian Influenza in pediatrics. E-mail: nasserkolkailah_at_yahoo.com – PowerPoint PPT presentation

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Title: A STUDY OF AVIAN INFLUENZA (H5N1) INFECTION IN EGYPTIAN CHILDREN


1
A STUDY OF AVIAN INFLUENZA (H5N1) INFECTION IN
EGYPTIAN CHILDREN
  • By Dr. Nasser Abdou Kolkailah
  • MD pediatrics, Benha University
  • Ministry Of health consultant of Avian Influenza
    in pediatrics.
  • E-mail nasserkolkailah_at_yahoo.com

2
When you want something, all the universe
conspires in helping you to achieve it.
  • Paulo Coelho
  • The Alchemist

3
Avian Influenza
  • Recent cluster of severe infection with Avian
    Influenza virus was first documented in Hong Kong
    in 1997.

4
  • The global number of H5N1 cases is 554 out of
    whom 324 died.
  • Egypt confirmed the 1st case of H5N1 virus in its
    domestic poultry on February 17th , 2006 and the
    1st human case on March 17th , 2006. Since then,
    there have been 144 cases, among whom 48 died.

5
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6
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7
  • This can be explained by the fact that young
    children often treat poultry as pets. Children
    often care for domestic poultry by feeding them,
    cleaning pans and gathering eggs.

8
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9
  • In children, sex predominance has not been noted.
    In adults, females have been more infected (54
    cases) than males (17 cases) with a P value of lt
    0.01, which is statistically highly significant
    and reassures that those backyards still remain
    the main source of infection.

10
Figure3 Annual distribution of human avian
influenza cases by age group in Egypt
11
  • This may be attributed to the efforts exerted by
    the Egyptian Ministry of Health in controlling
    farms as a main source of infection in adults.
    Nevertheless, there are difficulties faced in
    combating backyards which represent the main
    source of infection in children who play with
    apparently healthy poultry during the early
    infectivity period.
  • Another assumption is the possibility of sub
    clinical infection in adults.

12
  • In 2010 2011 the rates were reversed.
  • This may be due to failure of the ministry of
    health and ministry of agriculture in limiting
    the trading of live poultry.

13
Figure 4 Seasonal predilection of H5N1 human
infection in Egypt
14
Figure 5 Worldwide seasonal predilection of H5N1
human infection
15
Descriptive Data for H5N1 infection in Egyptian
Children
16
  • All cases had an obvious history of close contact
    with infected poultry. There have been 2 affected
    sibs and 2 affected cousins. The exposure to a
    common source of infection is rather a stronger
    explanation than human to human transmission.
  • The duration between the exposure to dead birds
    and the appearance of symptoms ranged from 3 to
    10 days.

17
Clinical Data
  • 49 cases presented with symptoms and signs of
    upper respiratory catarrh and they were stable.
  • 10 cases presented with dyspnea grade II and
    clinical examination revealed acute bronchitis.
  • 14 cases were suffering from severe
    bronchopneumonia hepatomegaly was a finding in 5
    of them.

18
Laboratory results
  • RT- PCR confirmed the diagnosis of H5N1 infection
    in all cases.
  • Our results have shown anemia in 20 cases,
    leucopenia in 14, lymphopenia in 7 and
    thrombocytopenia in 10.
  • There have been 8 cases that developed secondary
    bacterial infection proved by leucocytosis,
    rising titre of CRP, while blood culture was ve
    in 3 cases.
  • Mild elevation of liver enzymes has been noted in
    12 cases and mild elevation of serum creatinine
    in 6.

19
Radiological Findings
  • Increased bronchovascular markings in 10 cases
    denoting acute bronchitis.
  • Bronchopneumonia was found in 14 cases (figures
    5-10).
  • CT scan was requested for 2 cases of pneumonia
    (figures 11-12).

20
Figure 6 Plain chest X-Ray of case number 18
21
Figure 7 Plain chest X-Ray of case number 20
22
Figure 8 Plain chest X-Ray of case number 21
23
Figure 9 Plain chest X-Ray of case number 22
24
Figure 10 Plain chest X-Ray of case number 28
25
Figure 11 A Plain chest X-Ray of case number 34
2/4/2009
26
Figure 11B Plain chest X-Ray of case number 34
3/4/2009
27
Figure 11C Plain chest X-Ray of case number 34
11/4/2009
28
Figure 11D Plain chest X-Ray of case number 34
21/4/2009
29
Figure 12 A Chest CT scans of case number 18
  • 22/6/2007
  • Sizable areas of pneumonic consolidation process
    seen at right middle lobe and left basal lower
    segments, with fine air broncogram at site.
  • The left basal segment pneumonic area showed
    small 1 cm cavity for follow up, left basal
    pleuro-pulmonary reaction, patent main
    tracheo-bronchial tree, fine left basal
    atelectatic bands, and no evidence of hilar
    masses or mediastinal lymphadenopathy

30
Figure 12 B Chest CT scans of case number 18
  • 22/7/2007
  • Improvement of the consolidative process
    previously noted at both lower lobes mainly
    affecting the apical and anterior basal segment
    of right lower lobe and the posterior and
    anteromedial basal segments of the left lower
    lobe.

31
Figure 12 C Chest CT scans of case number 18
  • 21/8/2007
  • Regression of the previously noted bilateral
    lower lobe subsegmental air space consolidation
    changes with areas of ground glass opacities are
    still noticed

32
Figure 13 Chest CT scans of case number 28
  • Multiple areas of pneumonic patches of chest
    infection.
  • Segmental collapse area of right middle lobe.
  • Areas of fine basal atelectatic bands.

33
  • Our management plan is to eradicate the virus and
    to prevent and treat body systems dysfunction.
  • Tamiflu has been given to all cases according to
    the standard dose regimen.
  • The start of Tamiflu ranged from the 1st day to
    the 6th day after the onset of symptoms.
  • One case started therapy 2 weeks after the onset
    of symptoms due to a delayed etiological
    diagnosis.
  • Course of therapy ranged from 5 to 33 days.

34
  • In addition to the standard therapy of Tamiflu,
    10 cases received polyclonal IVIG
  • 7 cases received it on the 1st day of admission
    as they suffered from severe bronchopneumonia.
  • The 8th and 9th cases were stable and received
    polyclonal IVIG due to persistent positive
    cultures after Tamiflu therapy.
  • The 10th case developed respiratory failure as a
    complication of pneumonia and received
    polyclonal IVIG two weeks after the onset of
    symptoms due to delayed etiological diagnosis.

35
  • All cases have shown progressive improvement
    except 7 pneumonic cases.
  • The 1st case deteriorated clinically and
    developed circulatory collapse which was treated
    by inotropics (Dopamine) and has fully recovered.
  • The 2nd case deteriorated clinically and
    developed cardio respiratory failure and was
    mechanically ventilated for four days and has
    eventually recovered.

36
  • The 3rd case was mechanically ventilated as he
    developed respiratory failure and ARDS, but
    unfortunately died.
  • 4 cases have developed respiratory failure and
    died before being referred to our center.

37
Figure 14 Human Avian Influenza (H5N1) cases by
age group and outcome in Egypt (May 2011)
38
Why clinical course and outcome among Egyptian
children were better compared to other countries?
  • 1- Early suspicion of Avian Influenza.
  • 2- Meticulous prevention of secondary bacterial
    infection.
  • 3- Administration of polyclonal IVIG in severe
    cases.

39
My considerations of adding polyclonal IVIG to
the standard therapy regimen in the 1st case
  • The possibility of unresponsiveness to Tamiflu
    as it was started 5 days after the onset of
    symptoms.

40
  • Apoptosis may play a major role in the
    pathogenesis of influenza (H5N1) virus in humans
    by destroying alveolar epithelial cells. Whether
    apoptosis is a direct result of the viral
    replication or a consequence of an over
    activation of the immune system (cytokine storm)
    has not been clearly elucidated. Polyclonal IVIG
    has proved to have a dual action. It functions as
    an antiviral therapy neutralizing the virus and
    immunomodulating agent suppressing various
    inflammatory mediators including cytokines,
    chemokines, and metalloproteinases.

41
The evidence of polyclonal IVIG being greatly
effective in recovery
  • The case has been purely viral with no secondary
    bacterial infection, Thus the antibiotics given
    were not the reason for recovery.

42
  • The role of Tamiflu is doubtful due to
  • a. The therapy started 5 days after the
    onset of symptoms, which was rather late.
  • b. The severe systemic hypoperfusion could
    affect the intestinal absorption of the drug.

43
  • The case developed life threatening pneumonia
    denoting her immunodeficient state. Thus her
    innate immunity was not the key for recovery.

44
  • Due to all the facts mentioned before, we started
    polyclonal IVIG for six severe cases with
    bronchopneumonia on the first day of therapy and
    they fully recovered.

45
More evidence supporting the effectiveness of
polyclonal IVIG
  • An eight-year-old boy received Tamiflu for 5 days
    before being referred to the designed hospital in
    an advanced stage of severe bronchopneumonia and
    huge hepatomegaly. He was given IVIG for 5 days
    as an adjuvant therapy, which resulted in full
    recovery after 5 days.

46
  • Four stable cases among the 2009 cluster and
    one case in the 2011 cluster, showed a delayed
    sero-conversion for more than 20 days and
    received Tamiflu only. On the contrary, the use
    of Polyclonal IVIG as an adjuvant therapy in
    three critical cases of severe bronchopneumonia
    and respiratory failure achieved both a good
    clinical response and a complete eradication of
    the virus in less than 10 days.

47
Conclusion
  • Backyards represent the major source of infection
    in Egypt. Thus, H5N1 infection targets mainly
    young children and housewives.

48
  • There is a seasonal predilection of H5N1 in both
    winter and early spring .

49
  • No evidence has supported human to human
    transmission till now.

50
  • The early seeking of medical advice represents an
    important contribution to a better prognosis in
    children.

51
  • The early administration of oseltamivir within 3
    days of onset of the symptoms is associated with
    excellent prognosis.

52
  • Strong infection control policies play a highly
    favorable role in the outcome of most avian
    influenza cases.

53
  • The availability of detailed descriptive clinical
    data will assist in further comparative studies
    between affected countries.

54
  • Polyclonal IVIG proved to be an effective
    therapeutic tool in the management of critical
    H5N1 cases.

55
Thank You
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