The Monster at Our Door: The Global Threat of Avian Flu

A previously fit and healthy 22-year-old male student has recently returned home from holiday in the Far East with his girlfriend. He complains of flu-like symptoms including fevers, myalgia and coughs which are becoming worse. His girlfriend is well. He is worried that he may have contracted bird flu and seeks your advice.

What you should cover

• Fever in a returning traveller is common and can be due to infections involving any bodily system.
• Find out what vaccinations he has received prior to travel.
• If he has been to an area where malaria is present, ask whether suitable prophylaxis was taken. Malaria is the most frequent tropical cause of fever, accounting for up to 40% of fever in returning travellers.
• Find out the exact dates of departure and arrival as well as the date of onset of symptoms.
• Be aware that a self-limiting viral respiratory tract infection such as the common flu is a frequent cause of fever and cough in many individuals.
• Given his history of travel to the Far East, his ongoing concern and the imminent risk of a bird flu pandemic, it is important to determine whether the returning traveller is in fact at risk of avian influenza A (H5N1) infection or bird flu.
• Find out which countries he has visited. If he has not been to any of the countries listed (see box), reassure him that it is extremely unlikely that he has bird flu.
• If he has stayed in any of these countries, find out if he has been in direct contact with fowls or pigs, if there has been an exposure to objects contaminated with bird faeces or if he has he eaten undercooked poultry or eggs.
• Determine whether he has visited areas where there has been illness or death in poultry or wild birds.
• Has he been in direct contact with a person with known bird flu?
• Has there been an exposure to a person with an unexplained acute respiratory illness which later resulted in pneumonia or death?

What you should do

• Check his temperature. Patients with bird flu tend to present with temperatures greater than 38°C.
• Examine the respiratory system, paying particular attention to the respiratory rate and breath sounds. Clinical signs of pneumonia are a common presentation of bird flu.
• Tailor the rest of your general physical examination to address whether there is an obvious source or cause for the fever.
• Be wary of ominous signs such as respiratory distress, sepsis, shock and haemorrhage.
• Treat any temperature with paracetamol.
• In the event of possible pneumonia, prescribe broad-spectrum antibiotics and organise an urgent chest x-ray. Bird flu pneumonia is primarily viral in origin although secondary bacterial infection can occur.
• If you suspect bird flu, refer him immediately to hospital. Confirmatory diagnosis of bird flu is complicated and requires sophisticated laboratory support.
• Patients with bird flu require isolation in hospital. Treatment consists of antiviral therapy such as oseltamivir and zanamivir, along with supportive care such as supplementary oxygen, fluids and ventilatory support.
• Ask him to arrange a follow up appointment if his symptoms do not resolve after a few weeks should the common flu be your likely diagnosis.

Competing interests:
None declared