Avian Influenza (AI)

Common Influenza, commonly called ‘the flu’, is a contagious respiratory disease in humans which causes fever, headaches, sore throat, body aches and congestion of the nose; it occurs every year, usually in winter. It causes illness in 5 out of 100 adults and 20 out of 100 children each year; it kills between 250,000 and 500,000 people around the world every year, mostly among the elderly and the very young.

Avian influenza, commonly called ‘bird flu’, is the general name for a form of viral disease that affects birds, particularly poultry, and can take two forms: highly pathogenic avian influenza (HPAI) and low pathogenic avian influenza (LPAI).

All Avian Influenza (AI) viruses are type A influenza viruses in the virus family of Orthomyxoviridae and are subdivided into subtypes based on hemagglutinin (H) and neuraminidase (N) protein spikes from the central virus core. There are 16 H types, each with up to 9 N subtypes, yielding a potential for 144 different H and N combinations. In addition, all AI viruses fall into one of 2 pathotypes: low (LPAI) and high (HPAI) pathogenicity, based on how dangerous to poultry.

Unlike seasonal influenza, in which infection usually causes only mild respiratory symptoms in most people, H5N1 infection may follow an unusually aggressive clinical course, with rapid deterioration and high fatality. Primary viral pneumonia and multi-organ failure have been common among people who have become ill with H5N1 influenza.

Viral Mutations

Of the 16 H types known, only subtypes H5, H7 and H9 are known to be capable of crossing the species barrier from birds to humans. It is feared that if the avian influenza virus undergoes antigenic shift with a human influenza virus, the new subtype created could be both highly contagious and highly lethal in humans. Such a subtype could cause a global influenza pandemic, similar to the Spanish Flu that killed over 20 million people in 1918 (though a variety of sources quote average figures even higher, up to 100 million in some cases).

transmission

Many health experts are concerned that a virus that mutates to the point where it can cross the species barrier (i.e. from birds to humans) will inevitably mutate to the point where it can be transmitted from human to human. It is at that point that a pandemic becomes likely.

Contaigon Detection

Avian influenza in humans can be detected with standard influenza tests. However, these tests have not always proved reliable. In March 2005, the World Health Organization announced that seven Vietnamese who initially tested negative for bird flu were later found to have carried the virus. All seven have since recovered from the disease. Currently (6/05) the most reliable test (microneutralization) requires use of the live virus to interact with antibodies from the patient’s blood; because live virus is required, for safety reasons the test can only be done in a level 3 laborator

Limiting Transmission

The transmission of avian influenza refers to the passing of the disease from one animal to another (and in very limited cases from an animal to a human). The spread of avian influenza refers to the wide diffusion (geographically or throughout production and market systems) of the disease among a large number of animals.

Transmission
From what we know today, the avian influenza virus can be transmitted through contact among and with poultry and their droppings, feathers, intestines and blood. The greatest risk of infection for humans appears to be through the handling and slaughtering of live infected poultry.

Spread
Unlike some diseases, avian influenza is not an air-borne disease. Most current evidence suggests that the virus spreads mainly through the movements of poultry, poultry products, people and the vehicles they use for transport.

Most patients with pandemic influenza will be able to remain at home during the course of their illness and can be cared for by other family members or others who live in the household. Anyone residing in a household with an influenza patient during the incubation period and illness is at risk for developing influenza.

A key objective in this setting is to limit transmission of pandemic influenza within and outside the home. When care is provided by a household member, basic infection control precautions should be emphasized (e.g., segregating the ill patient, hand hygiene). Infection within the household may be minimized if a primary caregiver is designated, ideally someone who does not have an underlying condition that places them at increased risk of severe influenza disease. Although no studies have assessed the use of masks at home to decrease the spread of infection, use of surgical or procedure masks by the patient and/or caregiver during interactions may be of benefit.

Elimination of the source of contamination is fundamental to the prevention and control of biological hazards. In businesses operating under a pandemic engineering controls such as improvement of ventilation, partial isolation of the contamination sources, installation of negative pressure and separate ventilation and airconditioning system (e.g. in medical wards for infectious diseases) and the use of ultraviolet lamps can help contain the spread of contaminants.

If the contact with biological hazards cannot be prevented, the employees must use personal protective equipment and adhere strictly to the practice of personal hygiene. The personal protective equipment includes masks, gloves, protective clothing, eye shields, face shields and shoe covers.

Infection Symptoms

The symptoms of H5N1 infection may include fever (often high fever, > 38°C) and malaise, cough, sore throat, and muscle aches. Other early symptoms may include abdominal pain, chest pain and diarrhoea. The infection may progress quickly to severe respiratory illness (for example, difficulty breathing or shortness of breath, pneumonia, Acute Respiratory Distress Syndrome) and neurologic changes (altered mental status or seizures).

Definitive Diagnosis

Since several other respiratory pathogens (including adenovirus, respiratory syncytial virus, parainfluenza virus, rhinovirus, coronavirus, human metapneumovirus, Mycoplasma pneumoniae and Legionella) can also cause a similar clinical picture, definitive diagnosis of influenza requires laboratory confirmation. However, laboratory testing is not necessary for all patients. In the presence of a community outbreak of respiratory illness, a presumptive diagnosis can be made based on knowledge of the predominant agent causing the outbreak.

Influenza Complications

Uncomplicated influenza gets better with or without treatment, but may cause substantial discomfort and limitation of activity before getting better.

Complications of influenza can include bacterial infections, viral pneumonia, and cardiac and other organ system abnormalities. People with chronic medical conditions may have increased risk of complications when they get influenza. Many other diseases, including serious infections such as rapidly progressive bacteremias, may start with symptoms that resemble influenza and may need to be considered in treatment decisions. Many people with uncomplicated influenza use over-the-counter medicines to help lessen their symptoms.

Everyone can prevent spread

§  Cover your nose and mouth with a tissue when sneezing, coughing or blowing your nose.

§ Throw out used tissues in the trash as soon as you can.

§ Always wash your hands after sneezing, blowing your nose, or coughing, or after touching used tissues or handkerchiefs. Wash hands often if you are sick.

§ Use warm water and soap or alcohol-based hand sanitizers to wash your hands.

Take care of yourself

§ Try to stay home if you have a cough and fever.

§ See your doctor as soon as you can if you have a cough and fever, and follow their instructions, including taking medicine as prescribed and getting lots of rest.

§ If asked to, use face masks provided in your doctor’s office or clinic’s waiting room; follow their instructions to help stop the spread of germs.

Take consideration for others

Washing hands with liquid soap is the simplest and most basic method to avoid infection. However, it is often neglected. Wash hands before and after work. Also washing hands immediately before and after wearing protective clothing, uniforms or gloves to reduce the possibility of infection.

§ Wash your hands before eating, or touching your eyes, nose or mouth.

§ Wash your hands after touching anyone else who is sneezing, coughing, blowing their nose, or whose nose is running.

§ Don’t share things like cigarettes, towels, lipstick, toys, or anything else that might be contaminated with respiratory germs.

§ Don’t share food, utensils or beverage containers with others.

Protective Shoe Covers

• Shoe covers prevent pathogens from being carried outside the workplace; • Shoe covers are usually disposable after use;

• Boot covers offer further protection. Cover the boots with the trousers of protective clothing to prevent contaminants from getting into the boots;

• Shoe covers should be water resistant and skid proof;

• The size should fit so as not to hamper movement. To ensure their protectiveness, all personal protective equipment requires correct selection and use, as well as proper maintenance and storage. Re-useable protective equipment should be cleaned and sterilized thoroughly before they are used again.

Damaged items should be replaced immediately. When using the complete set of protective equipment, medical personnel should follow strictly hospital guidelines on infection control.

Hope for the best, prepare for the worst!

People should plan ahead and think about what they need to have in their house in case someone in their household were to become infected with influenza and need to receive care at home. If you live alone, are a single parent of young children, or are sole caregiver for a frail or disabled adult, it would be a good idea to have some items stored in your home in case of illness.

Respiratory Protection

Using the appropriate respiratory protective equipment is important for the securing an adequate protection from biological hazards. Common protective equipment includes:

• Surgical masks

– Surgical mask generally consists of three layers of non-woven fabrics. It provides a barrier protection against large respiratory droplets;

• N95 or higher level respirators

– This type of respirator filters out particulates and liquid droplets in small particle size, therefore providing protection from inhaling aerosols and microorganisms that are airborne such as avian influenza.

In general, where there are no oil mists or fumes as in a hospital setting, respirators of the N-series with filter efficiency of 95% (Type N-95), 99% (Type N-99) or 99.97% (Type N-100) are suitable.

How to use disposable masks Surgical mask offers a barrier protection from respiratory droplets. In the use of the masks, it is important to wear them correctly. When the mask is damp, damaged or soiled, replace it. A surgical mask in general can be used for several hours. If the surface of the mask is touched or the wearer has coughs, the mask needs to be changed more often. After use, the mask should be put in a bag or wrapped with paper before disposal. Wash the hands thoroughly afterwards.

Points to note about wearing a surgical mask:

• The mask fits snugly over the face;

• The coloured side of the mask faces outwards, with the metallic strip uppermost ;

• The strings or elastic bands are positioned properly to keep the mask firmly in place;

• The mask covers the nose, mouth and chin;

• Press the metallic strip on both sides of the bridge of the nose to keep the mask snugly over the face;

• Try not to touch the mask once it is worn over the face. If it is necessary to handle the mask, hands must be washed before and after touching the mask.

• Under normal circumstances, a surgical mask should be changed daily. Replace the mask immediately if it is damaged or soiled.

N.B: Improper use of the mask may cause discomfort or reduce its level of protection.

N95 masks should not be used by persons:

• suffering from respiratory diseases, such as asthma and emphysema

• having difficulty in breathing or feeling dizzy after wearing it

Protective clothing

• Protective clothing includes protective coverall (with attached hood), gown, apron, head and shoe covers;

• Protective clothing should be waterproof or impervious to liquids to protect the body from contamination by blood, droplets or other body fluids and prevent these contaminants from getting into the body through open wounds or contaminating the worker’s own clothing, thus reducing the chance of spreading of pathogen and cross-infection;

• Protective clothing is disposable in most cases though some can be reused after sterilization;

• Standard protective clothing should be chosen (for example, EU EN 340);

• Protective clothing should fit the wearer and should not hamper movement;

• Protective clothing should be checked before use and replaced if damaged;

• Biologically contaminated protective clothing should be disposed of in specially designed rubbish bag marked with “biological hazard” warning and label. Seal the bag and place it in designated location for special disposal;

Protective Goggles/Face shields

• Safety goggles/glasses and face shields can protect the eyes from contacting pathogen-carrying blood, droplets or other body fluids which may then enter the body through the mucosa;

• Standard goggles should be chosen (for example, EU EN 166; U.S. ANSI Z87.1-1989);

• Glasses without side shields can only protect the front from liquid splash ;

• Goggles fit the face snugly and therefore are better than glasses in eye protection;

• If necessary, face shield should be used to protect the whole face;

• Both face shields and goggles/glasses should be cleaned with liquid soap regularly. If contaminated by blood, they should be soaked in 1:49 diluted liquid bleach and then rinsed with clean water. Place them in plastic bags after wiping dry and store them in a cabinet;

• Check them regularly. Replace them if out of shape, cracked, scratched or fogged;

Protective Gloves

• Gloves protect the hands from contacting blood, droplets, body fluids and other body tissue of the infected, or pathogen-contaminated objects and can avoid infection when touching the eyes, mouth or nose afterwards. Gloves can also protect open wounds from contamination by pathogen;

• Most gloves are disposable after use;

• Standard gloves should be chosen (for examples, EU EN 374; U.S. ASTM F1670, ASTM F1671);

• Check whether the material used for the gloves is resistant to chemicals. Ask for details from the gloves suppliers;

• Gloves should fit the hands snugly but they should not hamper movement or affect sensibility;

• Keep the nails short to avoid piercing the gloves;

• Two pairs of gloves might be worn in handling highly hazardous substances;

• Wash hands thoroughly before and after use;

• Contaminated gloves should be disposed of in special rubbish bag marked with “Biological hazard” warning and label. Fasten the bag and place it in a designated location for special disposal;

• How to put on gloves: put them on before handling any blood or objects with potential biological hazards. Wear a pair that fits the hands and appropriate for the job;

• How to take off gloves: change or take off the gloves every time after contacting a patient or handling laboratory specimens. Disposable gloves should never be reused. To take off the gloves, grab the rim of the left glove with the right hand and then pull it off away from the body to turn it inside out. Then use the inside of the left glove to cover the right glove and peel it 15

Sterilization Equipment

Sterilization is the process using ultra heat or high pressure to eliminate bacteria, or using biocide to eliminate microorganisms, including spores in bacteria.

A complete sterilization process should include disinfecting the contaminated premises and thorough cleaning of any residual toxic substances, to ensure that employees would not be harmed through exposure in the risk area.

Effective sterilization depends on the strain and amount of microorganisms, the level of organic material present, the properties of the organisms to be eliminated, and the duration, temperature and concentration of the sterilizing agent.

Sterilization must be carried out by following strictly safety guidelines and taking personal protection to safeguard the health and safety of family members and employees. There are many kinds of sterilizing and antiseptic agents, the most common ones being liquid bleach and rubbing alcohol. Hands must be washed thoroughly after taking off any personal protective equipment.

Getting outside help

· Think of someone you could call upon for help if you became very ill with the flu and discuss this possibility with him or her.

· Think of someone you could call upon to care for your children if you were required to work and their school or day care was closed because of the influenza pandemic; discuss the possibility with them.

Infection Control Measures

· All persons in the household should carefully follow recommendations for hand hygiene (i.e., handwashing with soap and water or use of an alcohol-based hand rub) after contact with an influenza patient or the environment in which care is provided.

· Although no studies have assessed the use of masks at home to decrease the spread of infection, use of surgical or procedure masks by the patient and/or caregiver during interactions may be of benefit. The wearing of gloves and gowns is not recommended for household members providing care in the home.

· Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary.

· Laundry can be washed in a standard washing machine with warm or cold water and detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other household laundry. Care should be used when handling soiled laundry (i.e., avoid “hugging” the laundry) to avoid contamination. Hand hygiene should be performed after handling soiled laundry.

· Tissues used by the ill patient should be placed in a bag and disposed with other household waste. Consider placing a bag for this purpose at the bedside.

· Normal cleaning of environmental surfaces in the home should be followed.

Management of healthy persons in the home

· Persons who have not been exposed to pandemic influenza and who are not essential for patient care or support should not enter the home while persons are actively ill with pandemic influenza.

· If unexposed persons must enter the home, they should avoid close contact with the patient.

· Persons living in the home with the pandemic influenza patient should limit contact with the patient to the extent possible; consider designating one person as the primary care provider.

· Household members should monitor closely for the development of influenza symptoms and contact a telephone hotline or medical care provider if symptoms occur.

Management of influenza patients

Persons who have a sudden onset of influenza-like symptoms (e.g. headache, fever, chills, cough, chest pain, sore throat, muscle aches, weakness, exhaustion) should do the following:

· Remain at home at least until all symptoms have resolved (approximately 4-5 days)

· Take medication as needed to relieve the symptoms of the flu.

Administering medications

§ Decongestants, such as phenylephrine, and pseudoephedrine, produce a narrowing of blood vessels. This leads to clearing of nasal congestion, but it may also cause an increase in blood pressure in patients who have high blood pressure. OTC drugs to relieve stuffy noses often contain more than one ingredient. Some of these products are marketed for allergy relief and others for colds. They usually contain both an antihistamine and a nasal decongestant. The decongestant ingredient unstuffs nasal passages; antihistamines dry up a runny nose. But some of these products may also contain aspirin or acetaminophen, and some contain a decongestant alone. Closely related products with similar names may have different ingredients. There are other medications in the form of nasal drops and sprays sold OTC for this purpose. As with pills, some of these are long acting (up to 12 hours) and some are shorter acting.

§ Dextromethorphan, an antitussive, is used to relieve a nonproductive cough caused by a cold, the flu, or other conditions. Dextromethorphan comes as a liquid or as a lozenge to take by mouth. It is usually taken every 4-8 hours as needed. Do not take more than 120 mg of dextromethorphan in a 24-hour period. Refer to the package or prescription label to determine the amount contained in each dose. The lozenge should dissolve slowly in your mouth. Drink plenty of water after taking a dose. Follow the directions on the package or prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand.

§ Antipyretics are fever-reducing medications; the term comes from the Greek word pyresis, which means fire. Ibuprofen (Motrin) and acetaminophen (Tylenol) are generally recognized as safe and effective single analgesic-antipyretic active ingredients. These two antipyretics can be taken together or on an alternating 4 hour schedule. Ibuprofen provides greater temperature decrement and longer duration of antipyresis than acetaminophen when the two drugs are administered in approximately equal doses.

Adminstering supplements

Most of the research into the H5N1 virus suggests that this virus actually overstimulates the immune system, and that the body kills itself while trying to eliminate the avian flu infection. Avian influenza related pneumonia, is caused by a massive inflammatory cytokine storm (or inflammatory cascade) which the H5N1 virus induces.

The end stage, or final result, of cytokine storm (SIRS) or sepsis is multiple organ dysfunction syndrome (MODS). Symptoms of the bird flu, precipitating the cytokine storm may include: hypotension, tachycardia, dyspnea, fever, Ischemia, or insufficient tissue perfusion, uncontrollable hemorrhage, and multisystem organ failure (caused primarily by hypoxia, tissue acidosis, and severe metabolism dysregulation. Simply ‘stimulating the immune system’ could increase the risk of death from the H5N1 virus.

A number of compounds as seen bellow, have shown to be good treatments known to interfere with the viral life cycle, or substances that block the immune over-reaction that damages the body’s own tissues.

Among these are: Antioxidants, anti-inflammatories, neuraminidase- inhibitors, hemagglutinin inhibitors, TNF inhibitors, and inhibitors of the MAPK p38 system.

storm

 

Green Tea “Green tea is rich in a group of chemicals known collectively as catechins. These catechins have demonstrated anti-viral activity, inhibit the enzyme Neuraminidase, act as Hemagglutinin Inhibitors and reduce the production of TNF and other inflammatory compounds”

Selenium “Several studies have have shown that selenium can inhibit the MAPK p38 pathways. This results in lower levels of TNF and inflammatory cytokines, and prevention of tumor growth”

St. Johns Wort “Preliminary field and laboratory tests have shown that hypercin, a compound extracted from the medicinal herb St John’s Wort can be used to treat poultry infected with bird flu. ”

Ginger “Ginger is related to the turmeric plant (source of Curcumin), and like curcumin, ginger can block TNF by interfering with the MAPK p38 pathway. Compounds in ginger also increase levels of antioxidant.

Astragalus “A number of studies have shown that astragalus decreases TNF levels. It is widely used in China for diseases including congestive heart failure, diabetic neuropathy, and ischemia, all of which are associated with and elevation in TNF, IL-1, IL-6 and other inflammatory cytokines”

Kava “lthough kava is best known as an herb for anxiety, the root of the kava plant has also been shown to block TNF. In a a study where mice were exposed to okadaic acid, kava compounds inhibited TNF release with a potency equivalent to the Green Tea compound”

Coconut Oil “According to the study on Bovine enterovirus, in the presence of lauric acid: “Fatty acid-bound virions attach to susceptible cells but fail to undergo cell-mediated uncoating. This and other research suggests that lauric acid and other medium chain fatty acids can inhibit most enveloped viruses.

Skullcap “Both the Baikal and common varieties of skullcap contain neuraminidase inhibitors. Common scullcap (S. lateriflora) contains baicalin (40 mg/g) and baicalein (33 mg/g)” Baicalin and baicalein inhibit the neuraminidase/sialidase enzymes.”

Vitamin E “Vitamin E, or tocopherol, has been shown to exert a number of beneficial effects on influenza infection in animal studies. The low toxicity and low cost of vitamin E make a moderate supplement an attractive option for preparing for avian flu and other possible influenza infections.”

Garlic “Garlic has long been regarded for its anti-infective properties, many of which have been demonstrated by modern methods. While there is little direct research on how garlic might inhibit influenza, there is evidence that garlic can play a beneficial role in reducing the cytokine storm”

Zinc “Zinc has been shown to have direct activity against a range of viruses. Zinc is a mild to moderate inhibitor of neuraminidase. Zinc can also turn down TNF, ICAM and other cytokines involved in over reaction to H5N1 and other viruses.”

Resveratrol “Resveratrol is a compound found in large amounts in red wine, grape seeds, and Japanese knotweed. In addition to inhibiting neuraminidase resveratrol also sends a message to cells to stop manufacturing Influenza A and Cytomegalo viruses.”

Nac “NAC prevents the induction of MAPK p38 in cells. Stimulating MAPK p38 is a good way to increase the production of TNF, and seems to be particularly true in H5N1 avian flu”

Curcumin “Curcumin is the compound that gives turmeric spice its bright yellow appearance. It has been used in herbal medicine for a variety of inflammatory conditions, including fever, arthritis, and psoriasis. Curcumin not only blocks TNF, but it is an inhibitor of the MAPK p38 system”

Fever, diarrhea and fluid levels

§ A person’s fluid needs are greater when that person has fever. Drink lots of fluids (water and other non-alcoholic, non-caffeinated beverages) to avoid becoming dehydrated. Start with sips of any fluid other than caffeinated beverages. Drinking too much fluid at once can bring on more vomiting.

Electrolyte solutions available in drugstores are usually best. Sport drinks contain a lot of sugar and can cause or worsen diarrhea.

§ If you have diarrhea, it’s a good idea to rest, eat only small amounts of food at a time, and drink plenty of fluids to prevent dehydration. Avoid over-the-counter diarrheal medications unless specifically instructed to use one by your doctor. Certain infections can be made worse by these drugs.

When you have diarrhea, your body is trying to get rid of whatever food, virus, or other bug is causing it. OTC products marketed to stop diarrhea may contain loperamide (Imodium A-D), or attapulgite (Diasorb, Kaopectate and others), or bismuth subsalicylate (Pepto-Bismol and others).

DISCLAIMER

The products and information mentioned on this site are not intended to diagnose, treat, cure, or prevent any disease. Information and statements made are for education purposes and are not intended to replace the advice of your treating doctor.

BirdFlu.Link does not dispense medical advice, prescribe, or diagnose illness.

We relate information concerning possible individual health care procedures  & pandemic preparedness plans that allows you to stand a better chance in preventing an infection, dealing with an infection and recovering from and infection of avian influenza.

The views and nutritional advice expressed by herein are not intended to be a substitute for conventional medical service. If you have a severe medical condition we strongly advice you to see your physician of choice.

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Identifying the sick

· Physically separate the patient with influenza from non-ill persons living in the home as much as possible.

In a pandemic influenza event, some individuals who are cared for at home may develop complications. Should complications develop, these individuals should seek medical care immediately, either by calling the doctor or going to an emergency room. Upon arrival, the receptionist or nurse should be told about the symptoms so that precautions can be taken (providing a mask and or separate area for triage and evaluation).

Protective equipment

· In general, wearing goggles or a face shield for routine contact with patients with pandemic influenza is not necessary. If sprays or splatter of infectious material is likely, goggles or a face shield should be worn as recommended for standard precautions.

· In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience.

Protecting everybody

To protect the patients infected with influenza, individuals having contact with the patient, and the community in general, certain infection control measures should be practiced:

· Wash hands often with warm soap and water, scrubbing for 15-20 seconds
· Family members should wash hands or use waterless hand sanitizer after contact with the patient
· Do not share eating utensils or drinks
· Do not rub eyes, touch nose or mouth
· Patients should cover their mouths and noses with tissue when coughing or sneezing, dispose of used tissues immediately after use and wash hands after using tissues

Urgent care for adults

Adults with seasonal flu don’t usually vomit or have diarrhea, but children might. Some symptoms can mean your illness is severe. Get immediate medical help if you have any of the following:

Trouble breathing or shortness of breath
Pain or pressure in your chest or belly
Sudden dizziness
Confusion
Severe vomiting

Urgent care for children

Warning Signs to seek urgent medical care for children:

1. High or prolonged fever for more than 4-5 days
2. Fast breathing or trouble breathing
3. Bluish skin color
4. Not drinking enough fluids
5. Changes in mental status, somnolence, irritability
6. Seizures, confusion or seizures
7. Influenza-like symptoms improve but then return with fever and worse cough
8. Worsening of underlying chronic medical conditions (for example, heart or lung disease, diabetes)
9. Cough becomes productive of yellow sputum