title: Highly pathogenic avian influenza (H5N1): pathways of exposure at the animal-human interface, a systematic review.
abstract: BACKGROUND
  The threat posed by highly pathogenic avian influenza A H5N1 viruses to humans remains significant, given the continued occurrence of sporadic human cases (499 human cases in 15 countries) with a high case fatality rate (approximately 60%), the endemicity in poultry populations in several countries, and the potential for reassortment with the newly emerging 2009 H1N1 pandemic strain. Therefore, we review risk factors for H5N1 infection in humans.
  
  
  RESULTS
  Several epidemiologic studies have evaluated the risk factors associated with increased risk of H5N1 infection among humans who were exposed to H5N1 viruses. Our review shows that most H5N1 cases are attributed to exposure to sick poultry. Most cases are sporadic, while occasional limited human-to-human transmission occurs. The most commonly identified factors associated with H5N1 virus infection included exposure through contact with infected blood or bodily fluids of infected poultry via food preparation practices; touching and caring for infected poultry; [corrected] exposure to H5N1 via swimming or bathing in potentially virus laden ponds; and exposure to H5N1 at live bird markets.
  
  
  CONCLUSIONS
  Research has demonstrated that despite frequent and widespread contact with poultry, transmission of the H5N1 virus from poultry to humans is rare. Available research has identified several risk factors that may be associated with infection including close direct contact with poultry and transmission via the environment. However, several important data gaps remain that limit our understanding of the epidemiology of H5N1 in humans. Although infection in humans with H5N1 remains rare, human cases continue to be reported and H5N1 is now considered endemic among poultry in parts of Asia and in Egypt, providing opportunities for additional human infections and for the acquisition of virus mutations that may lead to more efficient spread among humans and other mammalian species. Collaboration between human and animal health sectors for surveillance, case investigation, virus sharing, and risk assessment is essential to monitor for potential changes in circulating H5N1 viruses and in the epidemiology of H5N1 in order to provide the best possible chance for effective mitigation of the impact of H5N1 in both poultry and humans.
  
  
  CONCLUSIONS
  The opinions expressed in this article are those of the authors and do not necessarily reflect those of the institutions or organizations with which they are affiliated.
authors.affiliation: MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, United Kingdom. m.vankerkhove@imperial.ac.uk
authors.forename: Maria D
authors.initials: MD
authors.lastname: Van Kerkhove
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Mumford
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Mounts
authors.forename: Joseph
authors.initials: J
authors.lastname: Bresee
authors.forename: Sowath
authors.initials: S
authors.lastname: Ly
authors.forename: Carolyn B
authors.initials: CB
authors.lastname: Bridges
authors.forename: Joachim
authors.initials: J
authors.lastname: Otte
mesh_terms: D000818:Animals; D001717:Birds; D004199:Disease Vectors; D006801:Humans; D053124:Influenza A Virus, H5N1 Subtype / Q000472:pathogenicity*; D005585:Influenza in Birds / Q000635:transmission*; D007251:Influenza, Human / Q000821:virology; D011200:Poultry