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  ARTIKEL FLU BURUNG Background During 2004, a highly pathogenic avian influenza A (H5N1) virus caused poultry disease in eight Asian countries and infected at least 44 persons, killing 32; most of these persons had had close contact with poultry. No evidence of efficient person-to-person transmission has yet been reported. We investigated possible person-to-person transmission in a family cluster of the disease in Thailand. Full Text of Background... Methods For each of the three involved patients, we reviewed the circumstances and timing of exposures to poultry and to other ill persons. Field teams isolated and treated the surviving patient, instituted active surveillance for disease and prophylaxis among exposed contacts, and culled the remaining poultry surrounding the affected village. Specimens from family members were tested by viral culture, microneutralization serologic analysis, immunohistochemical assay, reverse-transcriptase  – polymerase-chain-reaction (RT-PCR) analysis, and genetic sequencing. Full Text of Methods... Results  The index patient became ill three to four days after her last exposure to dying household chickens. Her mother came from a distant city to care for her in the hospital, had no recognized exposure to poultry, and died from pneumonia after providing 16 to 18 hours of unprotected nursing care. The aunt also provided unprotected nursing care; she had fever five days after the mother first had fever, followed by pneumonia seven days later. Autopsy tissue from the mother and nasopharyngeal and throat swabs from the aunt were positive for influenza A (H5N1) by RT-PCR. No additional chains of transmission were identified, and sequencing of the viral genes identified no change in the receptor-binding site of hemagglutinin or other key features of the virus. The sequences of all eight viral gene segments clustered closely with other H5N1 sequences from recent avian isolates in Thailand. Full Text of Results... Conclusions Disease in the mother and aunt probably resulted from person-to-person transmission of this lethal avian influenzavirus during unprotected exposure to the critically ill index patient. KASUS FLU BURUNG Probable Person-to-Person Transmission of Avian Influenza A (H5N1)  Kumnuan Ungchusak, M.D., M.P.H., Prasert Auewarakul, M.D., Scott F. Dowell, M.D., M.P.H., Rungrueng Kitphati, M.D., Wattana Auwanit, Ph.D., Pilaipan Puthavathana, Ph.D., Mongkol Uiprasertkul, M.D., Kobporn Boonnak, M.Sc., Chakrarat Pittayawonganon, M.D., Nancy J. Cox, Ph.D., Sherif R. Zaki, M.D., Ph.D., Pranee Thawatsupha, M.S., Malinee Chittaganpitch, B.Sc., Rotjana Khontong, M.D., James M. Simmerman, R.N., M.S., and Supamit Chunsutthiwat, M.D., M.P.H. N Engl J Med 2005; 352:333-340January 27, 2005 AbstractArticleReferencesCiting Articles (281 . During the first months of 2004, outbreaks of highly pathogenic avian influenza caused by influenza A (H5N1) virus were recognized in eight Asian countries.1,2 The poultry outbreaks receded and then reappeared in July in five countries, with human cases recognized in Vietnam and Thailand.3 As of November 11, 2004, there had been 44 documented human infections and 32 deaths (mortality, 73 percent), sparking fears that this lethal pathogen might cause a pandemic. Since the first avian influenza outbreak, in 1997,4 there has been concern that the influenza A (H5N1) virus might either mutate and adapt to allow efficient transmission during the infection of mammals or reassort its gene segments with human influenzaviruses during the coinfection of a single host, resulting in a new virus that would be both highly lethal and transmissible from person to person. Such events are believed to have preceded the influenza pandemics of 1918, 1957, and 1968.5 Several lines of evidence indicate that the currently circulating influenza A (H5N1) viruses have in fact evolved to more virulent forms since 1997, with a higher mortality among human cases,1,4 different antigenic properties,6 a different internal gene constellation,7 and an expanded host range.8,9 In most of the human cases to date, the patients had well-documented exposure to sick or dying poultry,10-12 but there have been several episodes of possible person-to-person spread. Two health care workers who cared for patients in Hong Kong in 1997 were later found to have antibodies to hemagglutinin H5, and one recalled having had a respiratory illness after exposure to one of the patients.13 Two family clusters in Vietnam in 2004 were considered to be compatible with bird-to-human spread, although limited person-to-person spread could not be ruled out.12 We report the results of an investigation into a family cluster of influenza A (H5N1) virus infections. This cluster was unusual in that one of the infected family members lived in a distant city but provided  direct, in-hospital care for the index patient, highlighting the possibility of person-to-person transmission. Methods Patients The index patient was an 11-year-old girl who lived with her aunt and who presented to a clinic with fever, cough, and a sore throat on September 2, 2004. She was admitted to the hospital on September 7 with a temperature of 38.5°C and moderate dyspnea. Initial testing identified lymphopenia and thrombocytopenia (Table 1Table 1Clinical and Epidemiologic Features of the Family Cluster of Avian Influenza (H5N1).) and a left-lower-lobe infiltrate on chest radiography (Figure 1AFigure 1Chest Radiographs from the Three Patients with Avian Influenza A (H5N1).). Because of progressive respiratory distress, hypoxemia, and shock, she was transferred to the provincial hospital the next day with a diagnosis of viral pneumonitis or the dengue shock syndrome. A serum sample was negative for antibodies to dengue virus. Despite mechanical ventilation, administration of broad-spectrum antibiotics, and fluid resuscitation, the patient died three hours after admission to the provincial hospital. The index patient's mother was a 26-year-old woman who lived in another province. She provided bedside care for her daughter in the hospital for 16 to 18 hours on September 7 and 8. She began to have fever and headache three days later and spent a night in her daughter's village before returning to her home. On September 17, she was admitted to a hospital in her own province with fever and severe dyspnea. She had lymphopenia and thrombocytopenia (Table 1) and bilateral interstitial infiltrates on chest radiography (Figure 1B). Pneumonia and progressive respiratory failure were diagnosed, and she died on September 20. The index patient's aunt was a 32-year-old woman who lived with her niece. She provided bedside care for her niece for 12 or 13 hours on September 7 and noted the onset of fever, myalgia, and chills on September 16. An upper respiratory infection was diagnosed at a clinic on September 19, but she had progressive difficulty breathing and was admitted to the district hospital on September 23 with a temperature of 39.7°C, lymphopenia (Table 1), and left-lower-lobe consolidation (Figure 1C). On the
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