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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: Part 1. 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: Part 1 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 Principles are applicable to outbreaks from other known or newly emerging pathogens 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. Epidemiologic Setting • Mass deaths in chicken, geese, and waterfowl flocks • Five months ago (March) • Southeastern region • Ministry of Agriculture (MOA) reported 3 test results “weakly positive” for avian influenza A(H5N1) • Came from three dead chickens sent to national lab in Anawrahta (April) • 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. So they can raise concerns and be aware of possible cases To be ready for samples that will be coming So they can undertake enhanced surveillance for sick or dying poultry So they know you are coming to investigate, can have medical records ready to review, and have appropriate staff available So they can leverage resources such as medical supplies or additional staff • Veterinary Health Authority • Healthcare personnel • The community • Non-governmental organizations • The laboratory

  10. Question 2 Answers Answer: 1. Veterinary health = c. Evaluate diseased poultry 2. Healthcare personnel = d. Knowledge that you will investigate 3. Community = a. Can raise concerns 4. NGOs = e. Medical personnel/supplies and resources 5. Laboratory = b. Prepare for incoming samples

  11. Question 3 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 & Communications, 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

  12. Question 3 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

  13. Trigger Event 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)

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

  15. 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

  16. 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

  17. 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 about July 9th • JAM symptoms: fever, cough and dyspnea = SARI • JAM admitted to hospital on July 14th • JAM denied contact with Murg Market or poultry

  18. Rumor Surveillance Update from Local Health Authorities JULY 15 • May be additional sick persons with respiratory symptoms in Pelu Jaghai • May continue to be wide-spread chicken deaths

  19. Question 4 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, Chest x-ray positive for pneumonia 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.

  20. Question 5 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.

  21. What variables should be included? Create a Line List • 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)

  22. Suggested Line List Format

  23. Update the Line List 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

  24. Question 6 Which of the following would be considered contacts of AAJ? • JAM • A teacher who last spoke to him 2 weeks ago • A tuk-tuk driver who drove him to a friends home on the 6th • A neighbor who walked by AAJ but didn’t say anything to him on the 10th Answer: a.

  25. Question 7 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

  26. 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

  27. Question 8 Assuming that neuraminidase inhibitors are available: • Should AAJ be given anti-viral treatment? • Should JAM be given anti-viral treatment? Answer: • Yes • Maybe 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.

  28. Question 9 • 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.

  29. Question 10 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

  30. Question 10 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

  31. Question 10 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

  32. 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

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

  34. Question 11 What specimen type is the top priority to be collected from JAM for laboratory testing for influenza? • Endotracheal fluid • Broncho-alveolar lavage • Throat swab (oropharyngeal) • Nasal swab (nasopharyngeal) • Blood Answer : c. Throat swab Comment: Nasal swabs should be collected to rule out seasonal influenza. In general, collect multiple samples on multiple days. Remember! It is vital to use proper safety equipment including eye protection 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!!!

  35. Question 12 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 (but treatment should not be delayed for specimen collection) • 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

  36. Specimen Collection Kit JULY 15

  37. Question 13 Put the following steps for collecting an oropharyngeal specimens in the proper order • Done appropriate PPE • Slowly remove the swab while slightly rotating ; the patient should try to resist gagging and closing the mouth • Swab oropharyngeal area behind tonsils • Have the patient open his/her mouth wide open • Put tip of swab into vial containing VTM, breaking/cutting applicator’s stick Answers 1. 3. 4. 2. 5.

  38. Question 14 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

  39. Question 15 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

  40. Question 16 Determine whether the following statements about storing specimens in VTM are true or false. • 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.

  41. Question 17 When transporting specimens from potential human cases of influenza A(H5N1) infection from the field to the laboratory, you should follow which sets of 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.

  42. Epidemiologic and Specimen Tracking for Transportation 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

  43. 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) • You determine that close contacts are • Mother (NJC) • Uncle (JRO), • Grandparents (JAM & AWM)

  44. Update the Line List 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.

  45. 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

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

  47. Question 18 You want to know whether there are more contacts that 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 • None of the above Answer: e. Depending on the places visited by a case, any of these places could be important places to undertake additional contact tracing activities

  48. Question 19 Which of the following scenarios does NOT list the appropriate PPE measure? • You will interview a symptomatic person that could be infected with influenza A(H5N1): • Interview from more than 1-2 meters away and wear no PPE • You will be within 1-2 meters of a symptomatic person that could be infected with influenza A(H5N1) • Wear a fit tested respirator and eye protection • You physically examine a person that could be infected with influenza A(H5N1) • You need to wear droplet and contact precautions • You are entering an environment where poultry products or feces may be contaminated, • Wear droplet and contact precautions including boots and undertake appropriate biosecurity/decontamination measures before leaving the premises Answer: Scenario 2. Respirators are used for aerosol-generating procedures.

  49. Question 20 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 in the facility 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. Look for additional cases Answer: 1. b 2. a 3. c

  50. Question 21 Questions to ask the case patient/case patient’s family regarding potential H5N1 exposures should cover which of the following? • Contact with confirmed , suspect, or probable human H5 cases • Exposure to sick or dying animals, wild birds, other animals, or their environment • Exposure to environments that may be contaminated with influenza A (H5N1) • Exposure to cooked chicken products • Handling/preparation of raw poultry and other animal products

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