Influenza A(H5N1) in Humans: Outbreak Investigation in an International Setting

1. Influenza A(H5N1) in Humans: Outbreak Investigation in an International Setting Case Study 2: Part 2 1

2. Learning Objectives Describe key outbreak management issues that need to be addressed related to supplies, team composition, WHO policy and epidemiologic data management during an internationally located A(H5N1) outbreak investigation. Identify critical coordinationpriorities involving the interface between animal and human health sectors, key stakeholders such as WHO, CDC and Ministries of Health and communication processes between CDC field staff, CDC Headquarters and relevant subject matter experts. 2

3. Learning Objectives (cont.) • List appropriate practices and procedures for: • Specimen collection and transport • Epidemiologic investigation • Identification of transmission mechanisms • Contact tracing • Isolation/quarantine policy • Treatment/control policy • Risk communication priorities • Recommended laboratory specimen protocols methods • Ethical considerations

4. Outline • Review of the preparation for an outbreak investigation • Description of the situation and available details on the case, surrounding events/history and environment • Engage in outbreak investigation activities: • Case definition • Clinical / laboratory findings, samples, recommendations • Line listing • Contract Tracing • Treatment options/ recommendations 4

5. Introduction

6. Situation Review • Dava Ghar • Severe respiratory illness in boy (AAJ) and grandmother (JAM) • Boy has died, grandmother is hospitalized • Pelu Jaghai • Severe respirtoary illness in boy (TMU) • Mother (ACM) followed as a contact 6

7. July 17 JULY 17 • Suspect or probable cases of Influenza A(H5N1) • Dava Ghar • Pelu Jaghai • Contacts are being monitored • Concern about healthcare worker safety

8. Question 1 Which of the following are standard precautions? • Patient placement into single room/cohorting for influenza A(H5N1) cases • Hand hygiene • Respiratory and cough etiquette • Personal protective equipment (PPE), depending on risk of contact with patient bodily fluids • Safe injection practices • Surgical mask on entry into room • Environmental control Answer: b, c, d, e, and g

9. Question 2 Which of the following are droplet precautions? • Private room/cohorting for patients with the same infection • Surgical mask on entry to patient’s room (and on patient when outside the room) • Patients should be places in negative air pressure airborne isolation rooms • Eye protection • Change of PPE and hand hygiene between patients • Respirator for entry into patient room • Daily cleaning and disinfection of surfaces in patient room Answer: a b, d, e, and g.

10. Question 3 You provide advice about infection control to the hospital. When should each of the following sets of precautions be taken? Match the precaution to its appropriate use. Answer: a) 2 b) 1 c) 3

11. Epidemiologic Connection JULY 17 • TMU • 11 year-old boy in Pelu Jaghai • AAJ • 10 year-old boy in Dava Ghar • Both at Murg market • Chased a “slow and unsteady” chicken

12. Murg Market JULY 17 • You collect respiratory specimens from TMU • You learn AAJ’s uncle, JRO, took him to the market • You return to Dava Ghar, anxious that you are missing other suspected cases of influenza A(H5N1)

13. July 18: Grandparents JULY 18 Patient rounds • Grandmother (JAM) • Not progressing to respiratory failure • Laboratory tests negative for influenza A(H5N1) • Suggestive of tuberculosis • Grandfather • Fever and myalgia • Stayed by JAM’s bedside with respirator • On Oseltamivir chemoprophylaxis, but rapidly worsening • Hospitalized

14. H5 Test Results JULY 18 • TMU (11-year-old) specimen is positive for H5 influenza by real-time PCR • Chicken specimen also positive for H5 Apisarnthanarak A, Kitphati R, Thongphubeth K, et al. Atypical avian influenza (H5N1). Emerg Infect Dis 10(7):1321-1324, 2004.

15. Market Closure JULY 18 • Murg market is closed • Perimeter for culling and surveillance • Active surveillance at source farms • Cases reported to WHO • WHO mobilizing to assist

16. Update the line list given below to be current up until the afternoon of July 18 JULY 16th, PM F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

17. Linelist as of July 18th, Afternoon F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

18. Public Alert JULY 18 • A reporter from a regional newspaper has contacted the Director of Epidemiology about ill patients, and has learned about the potential exposures at the July 8th live-market • The reporter wants to write an article notifying the public • The Director of Epidemiology wants you to prepare talking points to share with the Ministry of Health’s Public Information Officer

19. Question 4 Place yourself in the shoes of the Pegu Ministry of Health. What would be the three concepts that it would be most important to convey with this messages? • Show empathy, openness, and understanding • Indicate that the government is taking steps to address this problem • Assure the public that no more people will get sick • Indicate that the MOH are the scientific experts on this complicated issue and the public has nothing to worry about • Indicate what the public can do for themselves Answer: a, b, and e

20. Question 5 Form a small group with those seated around you. Choose one of the communication types from the previous question, and develop a message for this situation.

21. Question 6 You begin working on a situation report. Which one of the following would NOT be a section in your situation report? Answer: All! Epidemiologic assessment and likelihood of human to human transmission Laboratory tests pending Hospital infection control update Outbreak control measures being implemented Planned next steps Material / personnel assistance needed • Current staff in the field • Update on human cases • Changed case classifications since last report • Close contacts being monitored • Update on active/enhanced human surveillance activities • Update on animal surveillance and animal outbreak control activities

22. Question 7 Match the statements on the right to the appropriate section of the situation report on the left. Answers: 1) b 2) d 3) a 4) c Active surveillance is being undertaken among poultry owners that supplied birds to the Murg Market There is a new suspected case of influenza A(H5N1) Efforts to identify additional cases beyond close contacts The uncle of the 10-yr-old decedent, who attended the live bird market on July 8 • Update on current suspect, probable, and confirmed human cases of influenza A(H5N1) • Close contacts of suspect, probable, or confirmed cases being monitored • Update on active/enhanced human surveillance activities • Planned next steps

23. A New Problem JULY 18 • Family of case AAJ have refused voluntary quarantine • Mother (NJC) • Uncle (JRO) • Symptoms of family include weakness, tiredness, aches

24. Question 8 The goal of quarantine is to protect the public health by… • restricting the movement of an ill individual. • separating persons exposed to a communicable disease from the general population. • limiting the activities of persons exposed to a communicable disease. • limiting the activities of an ill individual. Answer: b

25. Question 9 The ethical justification of quarantine requires that… • person-to-person spread of a disease is possible. • only lower SES individuals should be placed into quarantine. • quarantine only be used if influenza A(H5N1) is suspected, and not another pathogen. • voluntary quarantine is used before more restrictive measures are used. • physical needs are met and psychological affects are minimized. • quarantined individuals are closely monitored for onset of symptoms. Answer: a, d, e, and f

26. Question 10 In this situation whose responsibility is it to determine whether the family members refusing voluntary quarantine should be forced into quarantine? • Yours • The local and national authorities of Pegu • The World Health Organization’s • UN Secreteriat for Respectful Quarantine (UNSRQ) Answer: b.

27. Key Point: Quarantine Ethical justification of quarantine or isolation requires that: • There is a possibility of person-to person spread of disease and the necessity of quarantine • The least restrictive measures be used. Voluntary quarantine should be used before more restrictive measures are enacted. • Society provide necessary support services for those in quarantine • Public health officials justify their actions and allow for a process of appeal • Quarantined individuals be closely monitored to detect onset of symptoms

28. Visit to NJC and RJO JULY 18 • Persuasion • Local religious leaders help NJC and JRO accept voluntary quarantine • Interview • 19-year-old brother, DKS, was exposed during family vigil July 12-13 • DKS returned to university July 14

29. July 19: Late Evening Updates JULY 19 • TMU (11 yr-old boy) intubated • JRO (uncle of AAJ) admitted • NJC (mother of AAJ) admitted • JAM (grandmother of AAJ) cared for AAJ • AWM (grandfather of AAJ) cared for AAJ

30. July 20: MOH Updates JULY 20 • DKS (19 yr-old student) symptom onset today • Returned to home province • Denied live-market or poultry exposure • Affirmed exposure to his ill brother • AWM (grandfather) died • Multiple complications – renal failure, encephalitis, ventricular arrhythmias • PCR+ for influenza A(H5N1)

31. Update the line list given below to be current up until the afternoon of July 20 JULY 18th, PM F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

32. Line List: July 20th F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

33. Question 11 Do any of these recent events give you any further evidence about the possible reason for AAJ’s death? a. Yes b. No Answer: a. Yes. AWM was been confirmed with influenza A (H5N1) infection and his only reported exposure so far was to AAJ

34. New Concerns from Healthcare Workers JULY 20 • Respiratory technician on duty when AAJ admitted felt droplets, has a fever • Nurse #1 gave end-of-life and post-mortem care to grandfather, is unsure of PPE use • Nurse #2 scared but adhered to precautions All of these individuals request antiviral therapy.

35. Question 12 Assuming Oseltamivir is available…. Should the respiratory therapist receive therapy? If so, what dose should he receive? • Yes: 150 mg per day, given as 75 mg twice a day for at least five days • Yes: 75 mg once per day for 7-10 days • No, don’t give him any oseltamivir Answer: a. Yes; 150 mg per day, given as 75 mg twice per day for at least 5 days

36. Question 13 Assuming Oseltamivir is available…. Should Nurse #1 receive therapy? If so, what dose should she receive? • Yes: 150 mg per day, given as 75 mg twice a day for at least five days • Yes: 75 mg once per day for 7-10 days • No, don’t give him any oseltamivir Answer: b. Yes. 75 mg/day, once a day for 7-10 days

37. Question 14 Assuming Oseltamivir is available…. Should Nurse #2 receive therapy?If so, what dose should she receive? • Yes: 150 mg per day, given as 75 mg twice a day for at least five days • Yes: 75 mg once per day for 7-10 days • No, don’t give him any oseltamivir Answer: No KEY POINT: Consistent and appropriate use of PPE is the first line of defense against infection.

38. Evening of July 20 JULY 20 • Colleagues return from Pelu Jaghai • DKS has radiologically confirmed pneumonia • Teams gather to update line lists and review epidemiologic data

39. Reminder of the Linelist JULY 20th, PM F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

40. Epidemic Curve in Pegu

41. Question 15 Considering the estimated incubation period for influenza A(H5N1), look at the epi curve and infer the exposure that most likely occurred for each of the following cases. Arrows on the epi curve indicate timing of potential exposure sources (live market and family vigil). • Answer: • 1) a 2) a 3) b 4) b 5) d 6) c

42. Update! JULY 21-23 • Confirmed positive for Influenza A(H5N1) • Mother (NJC) • Uncle (JRO) • Sibling (DKS) • Remaining ‘contacts’ tested negative • Respiratory therapist positive for Influenza A(H3N2)

43. Diagram of the Outbreak

44. Blank Diagram of the Outbreak

45. Components Exposure Case Possible zoonotic transmission Possible human-to-human transmission

46. Possible Exposure Sources Murg Market July 8 Family Vigil for AAJ July 11-13

47. Probable and Confirmed Cases AAJ Jul 10 NJC Jul 19 Murg Market July 8 AWM Jul 18 TMU Jul 12 JRO Jul 19 DKS Jul 20 Family Vigil for AAJ July 11-13

48. Links to Possible Exposures 2 days AAJ 9 days 11 days NJC 6-8 days Murg Live Bird Market July 8 12 days AWM 10 hours 4 days TMU 5-7 days JRO 7-9 days DKS Family Vigil for AAJ July 11-13

49. Diagram Summary

50. Human-to-Human Transmission Criteria Well documented exposure to a confirmed, probable, or suspect human case AND The time interval between contact with a human case and illness onset is 7 days or less AND Absence of an alternative source of exposure such as exposures to birds, animals, feathers, droppings, fertilizers made of fresh bird droppings, contaminated environments, or laboratory specimens OR Several generations of transmission linked to a primary case