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

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

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

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

  2. Learning Objectives • Define the surveillance objectives, methods of hospital selection, and key data collection priorities for sentinel surveillance for seasonal influenza and severe respiratory diseases • List appropriate surveillance strategies and trigger criteria needed for the early detection of Influenza A(H5N1) in hospitals and communities • List appropriate surveillance strategies and trigger criteria needed for a broader pandemic early warning system 2

  3. Learning Objectives (Continued) • Describe the benefits of integrating population-based Influenza A(H5N1) surveillance in humans within a sentinel site seasonal influenza surveillance system • Identify five ways to enhance surveillance activities in areas where there are known Influenza A(H5N1) outbreaks in poultry

  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 Be sure to have materials needed to take notes and create a line list

  6. Republic of Pegu: Setting Developing country Southeast Asia 21 provinces Population: 50 million 6

  7. Trigger Event #1 • Mass deaths in chicken, geese, and waterfowl flocks • Beginning March 2006 • Southeastern region • Ministry of Agriculture (MOA) reported 3 test results “weakly positive” for avian influenza (H5N1) • Came from three dead chickens sent to national lab in Anawrahta (April, 2006) • No systemic surveillance exists for H5N1 in poultry, wild bird or animal populations

  8. Question 1 To respond to trigger event #1, you need to put together a Rapid Response Team (RRT) - Which of the following skills or persons should be represented in this RRT? • Team Leader • Epidemiologist • Veterinary Liaison • Respiratory Therapist • Medical Officer / Clinician • Data Manager • Marketing Assistant • Laboratorian or Lab tech • Logistician • Communications Specialist

  9. Question 2 Match who should be notified about the investigation on the left with the reason they should be notified on the right. To give you advice and direction To satisfy their interest and offer education To be ready for samples that will be coming To conduct evaluation of diseased poultry So they know you are coming to investigate To serve as a resource for medical resources • Veterinary Health Authority • Government officials (MOH and other gov’t offices or ministries) • Healthcare personnel • The community • Non-governmental organizations • The laboratory

  10. Question 2 Answer: 1. Veterinary health = d. Evaluate diseased poultry 2. Government officials = a. Advice and direction 3. Healthcare personnel = e. Knowledge that you will investigate 4. Community = b. Interest and education 5. NGOs = f. Medical personnel/supplies resource 6. Laboratory = c. Prepare for incoming samples

  11. Question 3a Which of the following are NOT documents that you would need to bring with you to the field? • Proof of employment • Birth certificate • Case information • SOP’s (case management, lab specimen procedures • Laboratory testing procedures • WHO request for assistance: (PPE, antivirals, personnel) • WHO guidelines for investigation

  12. Question 3b Below are 6 categories of supplies needed when you go to the field. Match the list of supplies to the general category. Categories: Epidemiological, Medical, Laboratory, Educational, PPE, Decontamination Case definitions Antiviral medication Goggles Gloves Graph paper Solution for decontaminating homes or hospital room Transportation containers Pens Gown and cap Reporting forms Specimen collection materials Ice Guidelines for contacts, family members, and healthcare workers Notebook/laptop Portable GIS unit Viral transport media Simple messages Respirators

  13. Question 3b Answers Answer: • Epidemiological: a. Case definitions, j. reporting forms, n. notebook/laptop, h. Pens, e. graph paper, o. portable GIS unit • Medical: b. Antiviral medication • Laboratory: k. Specimen collection materials, g. Transportation containers, l. Ice, p. Viral transport media • Educational materials: q. Simple messages, m. Guidelines for contacts, family members, and healthcare workers • Personal Protective Equipment (PPE): r. Respirators, d. gloves, i. gown and cap, c. goggles • Decontamination: f. Solution for decontaminating homes or hospital rooms

  14. Trigger Event #2 JULY 15 July 15th • Dava Ghar hospital has admitted 2 patients with SARI • Reported to District Health Office • They suspect avian influenza due to poultry outbreaks in area • Patients are related • 65 year old grandmother (JAM) • 10 year old grandson (AAJ)

  15. Character Details JULY 15 • 65 year old grandmother = JAM • Chronically ill • Caretaker of grandson • 10 year old grandson = AAJ • Ill July 11 • Uncle = JRO • Grandfather = AWM • Mother = NJC • Caretaker of son (AAJ) Setting: Small, mountain village in Pelu Jaghai province

  16. July 8th Murg Market in Pelu Jaghai: Local market with live animals and location of A(H5N1) confirmed poultry outbreaks July 13th Dava Ghar hospital: 60 km away from village Exposure & Onset Details JULY 15 • AAJ, NJC, & JRO attended live-market (“Murg Market”) • AAJ becomes ill on July 10th • JAM cares for him starting July 11th • July 13th AAJ brought to hospital with: fever (38.7), cough, diarrhea and shortness of breath

  17. AAJ Clinical Presentation and Further Evidence JULY 15 • Arrived in unstable condition on the night of 13th • Admitted early on 14th • Rapidly deteriorated • Respiratory distress led to endotracheal intubation and ventilatory support • Cefriaxone treatment started 10 year old child (AAJ) CXR on Admission

  18. Caretaker Health Status at Hospital JULY 15 • Mother (NJC) and grandfather (AWM) are asymptomatic or deny symptoms • Grandmother (JAM) reports respiratory condition suddenly worsened on July 9th • Symptoms: fever, cough and dyspnea = SARI • Admitted to hospital on July 14th • Denied contact with Murg Market or poultry

  19. Rumor Surveillance JULY 15 • May be additional sick persons with respiratory symptoms in Pelu Jaghai • May continue to be wide-spread chicken deaths

  20. Question 4a How would you classify AAJ into the WHO influenza A(H5N1) case definition? Information on AAJ is given for your reference. • Under investigation • Suspected • Probable • Confirmed Answer: The Chest X-ray and clinical deterioration extend the ‘suspected A(H5N1) status’ to C, a probable case designation. Clinical: Fever, cough, diarrhea and shortness of breath Epidemiological: Exposure to live-market on July 8th where influenza A(H5N1) infections in animals were confirmed in the last month. Laboratory: No lab specimens available.

  21. Question 4b How does patient JAM fit into the WHO influenza A(H5N1) case definition? • Under investigation • Suspected • Probable • Confirmed Answer: The above information is supportive of a designation of a. person under investigation Clinical: Fever, cough, and shortness of breath Epidemiological: Close contact (within 1 meter) with a person who is a suspected, probable, or confirmed H5N1 case. Close contact with probable case occurred 2 days after “onset of symptoms”. Laboratory: No lab specimens collected at time of questioning.

  22. Create a line list: What variables should be included? Question 5 • ID # • Demographics: (age, gender, patient contact) • Possible exposure to infected animals within 7 days of symptoms • Possible contacts with suspect or confirmed human case within 7 days • Occupation • Symptom onset • Date of onset • Hospital test results • H5 Laboratory diagnosis • Antivirial treatment • Status (Case or Contact) • Disposition (Hospitalized, deceased, etc)

  23. Suggested Line List Format

  24. Question 6 JULY 15 Update the line list with the cases as of July 15th mid-day F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

  25. Question 7a When should you begin assessing contacts of this probable case? • As soon as you become aware of the case • Once you have determined the case status as being “suspect” or highter • Once you have determined the case status as being “probable” or higher • Once you have a confirmed diagnosis Answer: a.

  26. Question 7b Note whether the following statements used to define who is a close contact of this probable case are true or false. Answers: False True True False True True • Anyone who came within 1 meter of the case patient • Anyone who had shared space within 1 meter of the case patient • Close contact 1 day before through 14 days after onset of symptoms • Close contact 7 days before through 14 days after the onset of symptoms • Someone who kissed, embraced or shared utensils with the case patient • Someone who spoke with or touched the case patient

  27. Review: Identifying Contacts • Potential contacts • Household members • Friends • Healthcare providers • Pharmacists • Traditional healers • Workplace contacts • Contact tracing activities • Prioritize high probability of influenza A(H5N1) case patients • Prioritize contacts by duration, proximity, and intensity of exposure to the case patient

  28. Question 8a Assuming that neuraminidase inhibitors are available: • Should AAJ be given anti-viral treatment? • Should JAM be given anti-viral treatment? Answer: • Yes • No Hint: If antiviral drugs are available, treatment doses should be provided to suspected, probable and confirmed cases as classified according to the WHO case definition.

  29. Question 8b • Should JAM receive anti-viral prophylaxis? • Should asympomatic close contacts of AAJ be given anti-viral prophylaxis? • Should close contacts of JAM receive antiviral prophylaxis? Answer: • Yes • Yes • No Hint: The WHO Rapid Advice Guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus suggests that prophylaxis doses should be provided to all identified close contacts of confirmed cases, and if resources allow, to close contacts of “strongly suspected” cases as well.

  30. Question 9 If there are not enough antiviral resources for everyone, persons in the community should be prioritized for antiviral prophylaxis. Match the Risk Group on the left with the description on the right. • High Risk • Moderate Risk • Low Risk Personnel culling likely non-infected animals Personnel handling sick animals or decontaminating environments using insufficient PPE Personnel handling sick animals or decontaminating environments using adequate PPE Unprotected close/direct exposure to H5N1 infected animals Healthcare or laboratory personnel in close contact with strongly suspected or confirmed patients or their samples with insufficient PPE Healthcare workers not in close contact Healthcare workers with close contact using adequate PPE Close household contact of strongly suspected or confirmed patients

  31. Question 9 AnswersHigh and Moderate Risk Groups High risk exposure groups h. Household or close family contacts of a strongly suspected or confirmed H5N1 patient Moderate risk exposure b. Personnel involved in handling sick animals or decontaminating affected environments d. Individuals with unprotected and very close direct exposure to sick or dead animals infected with the H5N1 virus e. Health care or laboratory personnel with unprotected close contact with strongly suspected or confirmed H5N1 patients or their clinical samples

  32. Question 9 Answers:Low Risk Groups Low risk exposure groups f. Health care workers not in close contact g. Health care workers using adequate PPE a. Personnel involved in culling non-infected or likely non-infected animal populations c. Personnel involved in handling sick animals or decontaminating affected environments using adequate PPE Explain (tactfully!) to contacts the scarcity of antivirals, and that they will be monitored. NOTE: Drug allocation plans for treatment and prophylaxis should be made in advance

  33. Update: July 16thThe RRT arrives at Dava Ghar JULY 16 AAJ Update JAM Update Admission Temperature 38.5 °C 28 breaths/minute Blood pressure 160/95 O2 saturation 90% Initial laboratory findings High lymphocyte count High leukocyte count • Admission • Fever 39 °C • Heart rate 120 • 34 breaths/minute • Blood pressure 90/60 • O2 saturation 88% • Outcome • Intubated Jul 14 • Hypotensive with renal failure • Died on the 16th • Respiratory and sputum samples of poor quality

  34. Specimens Needed JULY 16 • You will need to quickly determine whether you’re dealing with H5N1 or some other communicable pathogen • You send biological samples from the grandmother to the National laboratory for testing.

  35. Question 10a What specimens need to be collected from the grandmother? • Endotracheal fluid • Broncho-alveolar lavage • Throat swab (oropharyngeal) • Nasal swab (nasopharyngeal) • Blood Acceptable answers: c. Throat swab, and/or e. Blood specimens Remember! It is vital to use proper safety equipment including goggles and PPE for the protection of the individual(s) carrying out the procedure(s). Treat all clinical samples as though they are potentially infected with avian influenza!!!

  36. Question 10b Which of the following statements about specimen collection is NOT true? • It should begin as soon as possible after symptoms begin • It should begin before antiviral medications are administered • Sample should be collected even if symptoms began more than one week ago • Multiple samples should be collected on multiple days if possible • None of the above (all statements are true) Answer: e. Remember – it is better to collect too many specimens than not enough

  37. Specimen Collection Kit JULY 15

  38. Question 11 Put the following steps for collecting an oropharyngeal specimens in the proper order • Have the patient open his/her mouth wide open • Slowly remove the swab while slightly rotating • The patient should try to resist gagging and closing the mouth • The swab touches the back of the throat near the tonsils • Put tip of swab into vial containing VTM, breaking/cutting applicator’s stick Answers 1. 4. 3. 2. 5.

  39. Question 12a Here is an image of a properly packed specimen. Label the packaging using the answer choices given. 1) 3 layers of _________ 2) Absorbent _________ 3) Labeling of the _________ as UN3373 diagnostic specimens • Answer choices: • contents • packing material • identification • outer package • packaging • biohazard 4) Itemized list of ______ 5) Specimen______ 6) _______ label

  40. Question 12a Here is an image of a properly packed specimen. Label the packaging using the answer choices given. 1) 3 layers of e.packaging. 2) Absorbent b. packing material 3) Labeling of the d.outer package as UN3373 diagnostic specimens 4) Itemized list of a. contents 5) Specimen c. identification 6) f. Biohazard label

  41. Question 12b Determine whether the following statements about storing specimens in VTM are true or false. • Store specimens can be stored at 4 °C within 48 hours of collection both before and during transportation. • Store specimens at -70 °C beyond 48 hours (if you will not be able to immediately transport specimen to laboratory) • Never store specimens on dry ice • Specimens may be stored in standard freezer Answers: True True False False Avoid freeze – thaw cycles. It is better to keep a sample on ice even for a week, than to allow the sample to freeze and thaw multiple times.

  42. Question 12c When transporting specimens from potential cases of avian influenza from the field to the laboratory, you should follow which regulations? • WHO guidelines for safe transport of infectious substances and diagnostic specimens • Local regulations on the transportation of infectious material • Neither a nor b • Both a and b Answer: d.

  43. Transportation Considerations JULY 16 • Documents to include • Itemized list of specimens with identification numbers • Instructions for the laboratory • Information to maintain • Identification numbers, linking to epidemiologic data forms • Case demographics • When and where a specimen was collected • Type of specimen Coordinate shipment with the laboratory so they are prepared when the specimens arrive

  44. Contact Identification JULY 16 • You have finished collecting patient specimens and have sent them off to the national laboratory • You want to identify all potentially exposed individuals who have had contact with the probable case (AAJ) • In a team meeting you determine that the contacts are • Mother (NJC) • Uncle (JRO), • Grandparents (JAM & AWM)

  45. Question 13 Below is shown the line list from mid-day, July 15th. Update the line listing with all known contacts as of July 16th a.m.

  46. Question 13 Answer Line list as of July 16th a.m. F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai

  47. Beyond the Given Scenario Also think beyond the nuclear family • Village health workers • Traditional healers • Taxi drivers • Other people a case may have had close contact with while infectious

  48. Question 14a You want to know whether there are more contacts you should be concerned about. Which of the following places would NOT be one that you would visit at this point to determine if there are more cases and/or contacts? • Health care facilities (hospitals, clinics, traditional healers) • Patient (or family proxy) • Patient’s village/neighborhood • Patient’s school/workplace Answer: d. At this point in time, the appropriate information on close contacts can be gathered from the patient/proxy

  49. Question 14b In conducting contact tracing interviews, in which of these places would you need to wear personal protective equipment (PPE)? • Health care facilities (hospitals, clinics, traditional healers) • Patient (or family proxy) • Patient’s village/neighborhood Answer: b.

  50. Question 14c Match the information source on the left with the contract tracing activities that should be conducted there on the right. • Hospital or other medical facility • Patient (or proxy) • Patients home and village • Administer case finding questionnaire to determine if the interviewee knows of anyone else who is sick, to ask about possible exposures, and to ask about possible contacts • Retrace the steps of the patient and try to determine if there were any close contacts without adequate PPE. • Find out more details about suspected exposures, conduct an environmental survey, and determine if there are any outbreaks among animals. Answer: 1. b 2. a 3. c

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