TROPIC AND INFECTION DISEASE II

AVIAN INFLUENZA

LECTURER:

VETTY PRISCILLA, SKp, Mkep, SpMat, MPH

MEMBERS OF GROUP II
Cici Novelia Manurung (1511314005)
Dzikra Fitria Amita (1511314025)
Faradila Lorenza (1511314004)
Suci Raesman (1511314021)

NURSING FACULTY
ANDALAS UNIVERSITY
PADANG
2015/2016
 PREAMBLE

Praise be to God Almighty for His grace and mercy , so that we can complete a
paper on Avian Influenza.
We thanks all those who have helped in completing this paper , particularly our
lecturers who has guided us to this paper resolved .
We realize this paper is far from perfect becouse of that ,criticisms and suggestions
from readers so we need to repair this paper . And hopefully this paper can be useful for us
and readers

Padang.Agust,25. 2016
 CHAPTER I

INTRODUCTION

1.1. Background

The A(H5N1) virus subtype, a highly pathogenic AI virus, first infected

humans in 1997 during a poultry outbreak in Hong Kong SAR, China. Since its
widespread re-emergence in 2003 and 2004, this avian virus has spread from Asia to
Europe and Africa and has become entrenched in poultry in some countries, resulting in
millions of poultry infections, several hundred human cases, and many human deaths.
Outbreaks in poultry have seriously impacted livelihoods, the economy and
international trade in affected countries.

The A(H7N9) virus subtype, a low pathogenic AI virus, first infected 3

humans – 2 residents of the city of Shanghai and 1 resident of Anhui province - in
March 2013. No cases of A(H7N9) outside of China have been reported. Containment
measures, including the closure of live bird markets for several months, have impacted
the agriculture sectors of affected countries and international trade. Continued
surveillance for A(H7N9) will be necessary to detect and control the spread of the
virus.

Ongoing circulation of A(H5N1) and A(H7N9) viruses in poultry, especially

where endemic, continues to pose threats to public health, as these viruses have both
the potential to cause serious disease in people and may have the potential to change
into a form that is more transmissible among humans. Other influenza virus subtypes
also circulate in poultry and other animals, and may also pose potential threats to public
health.

1.2. Formulation of Problem

1. What is definition of Avian Influenza (AI)?
2. How etiology of Avian Influenza (AI)?
3. How epiemiology of Avian Influenza (AI)?
4. What is clinical symptoms of Avian Influenza (AI)?
5. How long incubation period of Avian Influenza (AI)?
6. How diagnosis of Avian Influenza (AI)?
7. What the treatment of Avian Influenza (AI)?
8. What prevention of Avian Influenza (AI)?
9. How the Nursing Care for Avian Influenza (AI)?
 CHAPTER II

AVIAN FLU

2.1 Definition

Avian Inluenza (AI) is disease caused by virus influenza can affect several species
of food producing birds (chickens, turkeys, quails, guinea fowl, etc.), as well as pet birds
and wild birds with some strains resulting in high mortality rates. The virus has also been
isolated from mammalian species including humans, rats and mice, weasels and ferrets,
pigs, cats, tigers and dogs.
2.2 Etiology
Avin Influenza caused by virus influenza type A , genus influenzavirus A and
family Orthomyxoviridae. These viruses are also called type A influenza viruses.
Influenza A viruses are classified into subtypes based on two surface proteins, the
hemagglutinin (HA) and neuraminidase (NA). A virus that has a type 1 HA and type 2
NA, for example, would have the subtype H1N2. At least 16 hemagglutinins (H1 to
H16), and 9 neuraminidases (N1 to N9) have been found in viruses from birds, while two
additional HA and NA types have been identified, to date, only in bats.2,6,12,58-60
Some hemagglutinins, such as H14 and H15, seem to be uncommon, or perhaps are
maintained in wild bird species or locations that are not usually sampled.
Avian Influenza classified two types based on ability to produce the disease are
Lower pathogenic (also called low pathogenicity) avian influenza (LPAI) and highly
pathogenic (high pathogenicity) avian influenza viruses (HPAI). HPAI viruses usually
cause severe disease in chicken and turkey flocks, while LPAI infections are generally
much milder in all avian species (Fowl Plague, Grippe Aviaire).

2.3 Epiemiology

Avian influenza viruses are shed in the feces and respiratory secretions of birds,
although the relative amount of virus can vary with the specific virus, host species and
other factors. The feces contain large amounts of virus in aquatic birds such as
waterfowl, and the fecal-oral route is thought to predominate in wild bird reservoirs.
Fecal-cloacal transmission might also be possible, but respiratory transmission is
 ordinarily thought to play little or no role. However, there are some exceptions. Some
viruses that have adapted to gallinaceous poultry, such as recent isolates of Asian lineage
H5N1 HPAI viruses, can be found in higher quantities in respiratory secretions than the
feces, even in wild waterfowl. There are also reports of a few LPAI viruses found mainly
in respiratory swabs from wild waterfowl, and respiratory spread might be important in
some wild terrestrial birds.
Once an avian influenza virus has entered a poultry flock, it can spread on the farm
by both the fecal–oral route and aerosols, due to the close proximity of the birds. Fomites
can be important in transmission, and flies may act as mechanical vectors. The
possibility of wind-borne transmission of HPAI viruses between farms was suggested by
one study, but has not been conclusively demonstrated. Avian influenza viruses have also
been found in the yolk and albumen of eggs from chickens, turkeys and quail infected
with HPAI viruses. Although infected eggs are unlikely to hatch, broken eggs could
transmit the virus to other chicks in the incubator. It might be possible for LPAI viruses
to be shed in eggs, but the current evidence suggests this is very rare, if it occurs at all.
How long birds remain contagious differs between avian species, and with the
severity of the infection (chickens and turkeys infected with HPAI viruses die very soon
after infection). Most chickens usually excrete LPAI viruses for a week, and a minority
of the flock for up to two weeks, but individual birds of some species, including
waterfowl, can shed some LPAI or HPAI viruses for a few weeks in the laboratory.

2.4 Clinical Symptoms

A. Symptoms in Humans
Reported symptoms of avian influenza A, subtype H5N1, in humans range
from the typical flu-like discomforts

- cough

- Fever

- sore throat

- body aches

another infection to eyes infections, acute respiratory distress, viral

pneumonia, and other life-threatening complications. Diarrhea, vomiting, abdominal
 pain, chest pain, and bleeding from the nose and gums have also been reported as
early symptoms in some patients.

Most patients have symptoms in the lower respiratory tract when they first
seek treatment. Clinical reports show that difficulty in breathing develops around
five days following the first symptoms. Respiratory distress, a hoarse voice, and a
crackling sound when inhaling are commonly seen. Sputum production is variable
and sometimes bloody. Most recently, blood-tinted respiratory secretions have been
observed in Turkey. Almost all patients develop viral pneumonia. Home caregivers,
healthcare personnel, and funeral service professionals have been urged to use full
infectious disease protections and exercise extreme caution around infected patients
or when disposing of those who do not survive.

B. Symtoms in animal

2.5 Incubation Period

Most zoonotic infections caused by Asian lineage H5N1 HPAI viruses seem to
become apparent within approximately 5 days, although the incubation period for some
cases may be as long as 8 and possibly 17 days. Estimates of the mean incubation period
for the zoonotic H7N9 viruses have varied from 3 days (in two analyses, which
considered large numbers of cases) to 5-6 days, with a range of 1-13 days.

2.6 Diagnosis
Infected birds are detected by virus isolation from cloacal swabs in embryonated
chicken eggs, and by serological testing of blood for antibody. The last test indicates that
a bird was exposed to these viruses rather than if it is infected or carries the disease.
Reference antisera to all of the subtype antigen combinations are used to determine the
identity of the virus; however, the virulence of a virus cannot be determined by the
antigenic subtype. Virulent and avirulent strains of the same subtype can circulate in
nature. Laboratory and animal inoculation tests are required to establish the virulence of
strains based on an index established for domestic birds.

2.7 Treatment
There is no specific treatment for influenza virus infections in animals. Poultry
flocks infected with HPAI viruses are depopulated (this is generally mandatory in HPAI-
 free countries), while the disposition of infected LPAI flocks may differ, depending on
the specific virus and the country.

2.8 Prevention
The risk of introducing a virus to poultry or other birds can be reduced by good
biosecurity and hygiene, which includes preventing any contact with other domesticated
or wild birds, mechanical vectors and fomites including water sources.4,5,46,79,462 All-
in/ all-out flock management is helpful in poultry flocks, and birds should not be
returned to the farm from live bird markets or other slaughter channels.4 To help prevent
reassortment between human and avian influenza viruses, people are encouraged to avoid
contact with birds while suffering flu symptoms.
Avian influenza vaccines may include both inactivated whole virus vaccines and
newer recombinant vectored vaccines. Most vaccines are produced for chickens,
although they may be validated for use in turkeys, and their effectiveness can differ in
other species. In addition to suppressing clinical signs, some vaccines are capable of
increasing resistance to infection, and decreasing virus excretion and transmission.
However, clinical protection is not necessarily correlated with reduced virus shedding,
and some birds can become infected even in the best case scenario. Thus, vaccination can
mask infections if good surveillance programs are not used simultaneously. Vaccination
can also place selection pressures on influenza viruses, which may encourage the
emergence of vaccine-resistant isolates. In different countries, vaccines may be used
routinely to protect poultry flocks, as an adjunct control measure during an outbreak, or
to protect valuable species such as zoo birds from highly virulent viruses such as H5N1.
Vaccination in the U.S. is restricted and requires the approval of the state veterinarian,
and in the case of H5 and H7 vaccines, USDA approval.

2.9 Nursing Care for Avian Influenza (AI)

1. Ineffective Airway Clearance
Desired outcomes
 Patient will achieve the return of and ability to maintain patent airways
and respiratory status baselines.
 Patient will achieve and maintain patent airway.
 Patient will have clear breath sounds to auscultation, and will have
respiratory status parameters with optimal air exchange.
 Patient will be compliant and be able to accurately administer
medications on a daily basis, preventing exacerbations of disease
process.
  Patient will be able to cough up secretions and perform coughing and
deep-breathing exercises.

Nursing Interventions Rationale

Changes may vary from minimal to extreme caused by

bronchial swelling, increased mucus secretions caused
Assess respiratory status for rate,
by oversecretion of goblet cells and tracheobronchial
depth, ease, use of accessory
infection, narrowing of air passageways, and presence
muscles, and work of breathing
of other disease states that complicates the current
condition.
Wheezing is caused by squeezing of air past the
narrowed airways during expiration which is caused
by bronchospasms, edema and secretions obstructing
the airways.
Crackles or rales, result from consolidation of
Auscultate the lung fields for the
leukocytes and fibrin in the lung causing an infection or
presence of wheezes, crackles
by fluid accumulation in the lungs.
(rales), rhonchi, or decreased
breath sounds.
Decreased breath sounds may indicate alveolar
collapse with little to no air exchange in the lung area
being auscultated, and usually results in poor
ventilation.

Providing supplemental oxygen benefits the patient.

High level oxygen can cause severe damage to
Administer oxygen as ordered. tissues, oxygen toxicity, increases in A-a gradients,
Monitor oxygen saturation by microatelectasis, and ARDS.
pulse oximetry, and notify
physician of readings <90% or as Oximetry readings of 90 correlate with PaO2 of 60
prescribed by physician. mmHg and levels below 60 mmHg do not allow for
adequate perfusion to tissues and vital organs.

Although not a reliable indicator of the loss of airway

Assess patient for pallor or patency, this may indicate hypoxemia. Cyanosis does
cyanosis, especially to nail beds not occur until a level of 5 grams of reduced
and around mouth. hemoglobin/100 ml of blood in the superficial capillaries
is reached.
Monitor patient for cough and Mucus color from yellow to green may indicate
production of sputum, noting presence of infection. Tenacious, thick secretions
amount, color, character, and require more effort and energy to expectorate through
patient’s ability to expectorate coughing, and may actually create an obstruction stasis
secretions, and ability to cough. that leads to infection and respiratory changes.
Position patient in high Fowler’s
or semi-Fowler’s position, if To promote maximal lung expansion.
possible.
Repositioning promotes drainage of pulmonary
Turn patient every 2 hours and
secretions and enhances ventilation to decrease
prn.
potential for atelectasis.
Promotes relaxation of bronchial smooth muscles to
Administer bronchodilators as
decrease spasms, dilates airways to improve
ordered
ventilation, and maximizes air exchange.
Postural drainage utilizes gravity to help raise
secretions and clear sputum. Percussion and/or
vibration may assist with movement of secretions away
from bronchial walls and enable patient to cough them
Perform postural drainage and
up and increase the force of expiration. Some positions
percussion, as ordered.
utilized during chest physiotherapy may be
contraindicated in elderly patients as they may not
tolerate intense percussion because of fragility of
bones and skin.
Encourage fluids, up to 3-4 L/day Provides hydration and helps to thin secretions for
unless contraindicated. easier mobilization and removal.
Encourage deep breathing
Assists in lung expansion, as well as dislodgement of
exercises and coughing
secretions for easier expectoration.
exercises every 2 hours.
Patient may be too weak or fatigued to remove own
Suction patient if warranted.
secretions.
Teach patient or SO regarding
Promotes increased expiratory pressure and helps to
splinting abdomen with pillow
decrease discomfort.
during cough efforts.
Instruct patient and/or SO on
alternative types of coughing Minimizes fatigue by assisting patient to increase
exercises, such as quad thrusts, expiratory pressure and facilitates cough.
if patient has difficulty during
 coughing.
Instruct patient on deep-breathing
exercises and use of incentive Promotes full lung expansion and decreases anxiety.
spirometry.
Instruct patient and/or SO to Milk and milk products thicken mucus, caffeine reduces
avoid using milk, milk products, the effects of some bronchodilators and alcohol
caffeinated drinks, and alcohol. increases cell dehydration and bronchial constriction.
Instruct patient to avoid
excessively hot or cold fluids or May predispose patient to coughing spells, creating
environmental temperature dyspnea, and bronchospasms.
extremes.
Smoking causes increased mucus production,
Instruct patient to seek help and
vasoconstriction, increased blood pressure,
stop smoking if patient is a
inflammation of the lung lining, and decreased numbers
smoker.
of macrophages in the airways and mucociliary blanket.
Instruct patient/family to avoid
crowds and persons with upper Prevents possible transmission of an infection to the
respiratory infections when patient who already is immunocompromised.
possible.
Instruct patient/family in the use
To provide supporting knowledge, and promotes the
of inhalers, nebulizers, and
correct administration of medication for optimal effect.
medications.

2. Ineffective Breathing Pattern

Desired Outcomes
 Patient will achieve and maintain normal respiratory pattern and rate, with no
adventitious breath sounds to auscultation.
 Patient will be able to expectorate secretions effectively.
 Patient will maintain and adhere to isolation precautions.
 Patient will be able to utilize relaxation techniques to improve pain and
facilitate breathing.

Nursing Interventions Rationale

Assess vital signs, carefully

monitoring respiratory status for Changes may reflect early signs of respiratory
baseline rate, rhythm, and character, compromise and insufficiency.
and notify physician or significant
changes.

Oximetry approximates arterial blood gas oxygen

Monitor pulse oximetry readings and
saturation, and helps to identify oxygenation
notify physician if <90%
dysfunction and respiratory status changes.

Assists with identification of changes in respiratory

Auscultate breath sounds q 2-4 status, presence of adventitious breath sounds or
hours and prn. Notify physician of decreased breath sounds. The elderly patient may
changes. have infiltrates in the interstitium, bilateral lobes,
and anterior and lower lung fields.

Provides supplemental oxygen and helps alleviate

Administer oxygen as ordered.
respiratory distress caused by hypoxemia.

Pain decreases respiratory effort and chest

Assess patient for complains of pain excursion, which decreases ventilation and
and medicate as needed. perfusion. Analgesia, relieves pain and promotes
improved respiratory effort.

Encourage patient to maintain semi-

Promotes chest expansion and enhances
Fowler’s or high Fowler’s position as
respiratory effort.
tolerated.

Encourage patient and assist with

Assists to prevent atelectasis or lung collapse and
use of incentive spirometry,
ensures proper use of equipment.
nebulizers, etc., as ordered

Perform chest physiotherapy, chest

Helps improve airway clearance and respiratory
percussion and postural drainage as
effort. Helps clear secretions.
ordered.

Encourage patient to change

Facilitate comfort and mobilizes pulmonary
position every 2 hours and prn, and
secretions.
assist as needed.

Provide and encourage fluid intake

Maintain hydration and helps to liquefy secretions to
of at least 2 L/day unless
enable patients to expectorate sputum.
contraindicated.

Maintain ordered isolation Prevents cross contamination and exposure to

 techniques. pathogens.

Instruct patient and/or SO regarding

isolation requirements and ensure Provides knowledge, decreases fear, and helps
that they adhere to the proper prevent further spread of infection.
techniques.

Teach patient how to use pillow to

Assists to reduce pain associated with cough.
split chest with cough efforts.

Instruct patient in relaxation

Assist in pain reduction and alleviates anxiety which
techniques, guided imagery, muscle
may improve respiratory effort and oxygenation.
relaxation, and breathing exercises.

3. Hyperthermia
Desired Outcomes

 Patient will achieve and maintain normal temperature.

 Patient will achieve and maintain balanced intake and output with adequate
hydration.
 Patient will be afebrile with stable vital signs.

Nursing Interventions Rationale

Helps to evaluate efficacy of treatment and monitors for

Monitor VS especially
complications that may occur as a result of increased
temperature, every 2-4 hours
temperature. Consistency in methods allows for
and prn. Utilize the same
accurate data collection and correlation. Increased
methods of temperature reading
temperature is a response to the inflammatory process
with each measurement.
associated with the disease.
Administer antipyretics as This type of drug affects the hypothalamic control center
ordered. to reduce elevated temperature.
Increases heat loss by evaporation. Tepid baths help
Provide tepid sponge baths prn. prevent chilling that may aggravate and increase
temperature.
Utilize cooling blanket if Hypothermia blankets remove heat by conduction via
temperature will not decrease the cool solution that is circulated in the mattress placed
with use of other methods and if above and/or below the patient. The cooling blanket
temperature is above 102.5ºF must be covered to prevent skin tissue injury and burns.
(39.1º C) They may also lower the temperature quickly and
should be monitored to ensure that a hypothermic
condition does not occur. Shivering actually increases
the patient’s metabolic rate and temperature.
Decreases environmental
temperature and remove extra Helps reduce temperature
blankets as warranted.
Encourage increase in fluid Increase in body temperature multiply insensible fluid
intake to 3-4 L/day, unless losses by 10% for every 1 degree C of increase in body
contraindicated. temperature, which may result in dehydration.
Monitor intake and output every Helps to identify fluid status changes and imbalances,
2-4 hours and prn. and allows for prompt treatment.
Notify physician of temperature
May indicate other source of temperature aberration and
increases that do not respond to
may cause permanent organ damage.
any measure used.
Seizure may occur with high temperatures because of
Monitor patient for seizures. hyperactivity within the brain, which can cause further
impair tissue perfusion.
Instruct patient/family in use of
hypothermia blanket, reasons for Provides knowledge and helps to involve the patient
use, signs and symptoms of and the family in care.
complications, etc.
Instruct patient/family on
Involves patient and family in care and provide
medications, side effects, and
knowledge that facilitates compliance.
symptoms to report to nurse.

4. Acute Pain
Desired Outcomes

 Patient will achieve relief from aches and pain

 Patient will report pain is controlled or eliminated

Nursing Interventions Rationale

Assess patient for complaints of

headaches, sore throat, general
Caused by inflammation or elevated temperature.
malaise or body weakness, muscle
aches and pain.
Assess VS for changes from VS are usually increased as result of autonomic
baselines response to pain.
Pharmacologic therapy to control pain and aches by
Administer analgesics as ordered.
inhibiting brain prostaglandin synthesis.
Provide restful, quiet environment. Reduces stimuli that may increase pain.
Provide warm baths or heating pad Warmth causes vasodilation and decreases
to aching muscles. discomfort.
Provide cool compress to head prn. Promotes comfort and treats headache.
Provide backrubs prn. Promotes relaxation and relieves aches.
Encourage gargling with warm
water; provide throat lozenges as Reduces throat discomfort.
necessary.
Instruct patient or SO in deep
breathing, relaxation techniques, Helps patient to focus less on pain, and may improve
guided imagery, massage and efficacy of analgesics by decreasing muscle tension.
other nonpharmacologic aids.
Acetaminophen may relieve pain and headache, but
Instruct patient or SO regarding should be used cautiously in patients with liver
use of acetaminophen and to avoid dysfunction because of acetaminophen metabolism in
use of aspirin. the liver. Aspirin can potentially cause hemorrhage
and ulceration, therefore, must be avoided.

5. Deficient Knowledge

Desired Outcomes

 Patient will be able to understand and verbalize appropriate treatment and

care for influenza.
 Patient and/or SO will be able to accurately verbalize understanding of the
influenza disease and methods to use to avoid contracting illness.
 Patient and/or SO will be able to notify physician immediately during flu
season if patient begins to have symptoms of influenza in order to be treated
with antivirals.
 Patient will suffer no complications, such as pneumonia, requiring
hospitalization.
 Patient will be compliant with obtaining annual influenza vaccination.
 Nursing Interventions Rationale

Patient may have misconceptions about the disease that

Assess patient’s
should be corrected. Identifying baseline knowledge helps
understanding of disease
to facilitate and establish plan of care for patient and family
process.
education.

Patient may be in too much pain or too ill to understand

Ensure that patient is willing and comprehend information. If patient is unwilling to listen
and able to listen to to information, accept decision, which will help to facilitate
information about the disease. acceptance of right as a patient to choose level of self-
participation in care.

Use limited amounts of time Helps the elderly patient to remember information being
for teaching, with provision of discussed without distracting stimuli. Limiting sessions of
a quiet environment. instruction helps to avoid overstimulation and overload.

For high-risk patients and healthcare personnel, suggest

annual inoculations at the start of the flu season. Note that
Educate about influenza some vaccines are made from chicken embryo and should
immunizations. not be given to people who are hypersensitive to eggs.
Vaccine administered is based on the previous year’s virus
and is usually about 75% effective.

Adverse effects include: discomfort at the vaccination site,

Inform people receiving the
fever, malaise, and rarely, Guillain-Barre syndrome.
vaccine of the possible
Recommend the inactivated variant of the vaccine to
adverse effects and report
women who are pregnant and who will be in the second or
them immediately.
third trimester during influenza season.

Teach the proper disposal of

tissues and proper hand- To prevent the virus from spreading.
washing technique.

Teaching aids such as written in large font for impaired

patient, and so forth helps to provide information in a
Use appropriate teaching aids manner that will be more easily understood by patient and
for patient’s abilities. remembered. Normal aging changes may cause memory
loss, sensory deficits, and the need for slower, more
repetitive teaching.
 Influenza occurs every year, normally from November
through April, and virus is spread via direct contact or
Instruct patient and/or SO
aerosol droplets.
about influenza types, when
typical outbreaks occur, and Elder people usually have other disease process, are
methods to avoid infection. especially prone to infection and should avoid others who
have upper respiratory symptoms when possible.

Instruct patient and/or SO that Vaccination should be given around October prior to the
those who are at risk for start of the outbreak of influenza season, but can be given
influenza should always be throughout this time until late winter. Prevention of
immunized with the flu influenza is considered optimal in order to prevent
vaccine. complications, such as pneumonia.

Caution should be used if patients have other respiratory

diseases or renal insufficiency.

Instruct patient and/or SO Tamiflu (oseltamivir phosphate) and Relenza(zanamivir)

about newer antiviral drugs, are effective for influenza types A and B. Rimantadine
their effects, when to seek and amantadine are effective for influenza A. These drugs
immediate medical attention, are given within 48 hours of onset of symptoms for
and side effects of maximum efficacy.
medications.
Patients should be also be advised these drugs are not
replacement for their annual vaccination.
 CHAPTER III
CONCLUTION

3.1 conclution
Avian Inluenza (AI) is disease caused by virus influenza can affect several
species of food producing birds (chickens, turkeys, quails, guinea fowl, etc.), as well as
pet birds and wild birds with some strains resulting in high mortality rates. Avin
Influenza caused by virus influenza type A , genus influenzavirus A and family
Orthomyxoviridae. Avian influenza viruses are shed in the feces and respiratory
secretions of birds, although the relative amount of virus can vary with the specific virus,
host species and other factors. Reported symptoms of avian influenza A, subtype H5N1,
in humans range from the typical flu-like discomforts: cough, Fever, sore throat and
body aches. Most zoonotic infections caused by Asian lineage H5N1 HPAI viruses seem
to become apparent within approximately 5 days, although the incubation period for
some cases may be as long as 8 and possibly 17 days.
 REFERENCESS

Brian Fairchild.Avian Influenza Ounce of prevention better than a pound of cure.2015,page 7

Fowl Plague, Grippe Aviaire. Avian Influenza.2015,available in
highly_pathogenic_avian_influenza.pdf
Wallace Hansen. Avian Influenza.2015,page1-4