Case Management of Suspect Human Avian Influenza Infection

1. Case Management of Suspect Human Avian Influenza Infection Part 1: Background information on clinical features and management of avian influenza

2. Learning Objectives • Recognize clinical features of H5N1 in humans • Understand how information about the patient before onset of illness can help you suspect infection • Know the types of treatment options available

3. Part 1 Session Overview • Clinical features • Epidemiologic information • Risk for infection • Transmission • Current antiviral medications • Group exercise

4. Illness Scenario • 5-year-old Darin sick for three days • Fever • Watery diarrhea • Headache • Cough • Short of breath • No one else sick • Darin and a friend play with chickens Question: Is this avian influenza? What should Dr. Sarasin do?

5. Clinical Features

6. General Information

7. Signs and Symptoms

8. Unusual Presentations • Knowledge of avian influenza infection in humans changes as we learn more • Unusual symptoms • Absence of respiratory symptoms • Severe watery diarrhea • Loss of consciousness

9. Seasonal Influenza Ear infection, sinusitis Bronchitis, bronchiolitis Pneumonia viral or secondary bacterial Exacerbation of chronic conditions Muscle inflammation Neurologic Disease Seizures Brain inflammation Reye’s syndrome Avian Influenza Almost all develop pneumonia Acute Respiratory Distress Syndrome (ARDS) Multiorgan failure Encephalitis Complications

10. Laboratory Findings Commonly associated with avian influenza: • Drop in white blood cell count (lymphocytes) • Mild to moderate drop in blood platelet count • Increased aminotransferases (Liver enzymes)

11. Alak and Darin Question: Do you think Darin has signs and symptoms of avian influenza? Why or why not?

12. Epidemiologic Information

13. Risk for Infectionfrom Animals Within 10 days before symptoms begin: • Close contact with live, sick, or dead birds • In setting with confined birds • Contact with contaminated surfaces • Ingestion of uncooked infectious poultry

14. Risk for Infection from Humans • Uncertain risk of person-to-person spread • Within 10 days before symptoms begin: • Face-to-face contact • Touching or within 1 meter of suspected or diagnosed H5N1 patient without proper precautions • Touching or being within 1 meter of a person who has severe pneumonia or dies from an acute respiratory illness without proper precautions

15. Alak and Darin Question: Do you think Darin is at risk for avian influenza H5N1 infection? Why or why not?

16. Routes of Transmission

17. Risk Factors • Direct contact with birds Risk Factors: • Playing with birds • Working with birds • Preparing birds for meals • Contaminated water

18. Routes of Transmission • Indirect contact • Infected materials, surfaces • Person-to-person rare at present • Eating undercooked or raw bird products • Meat, eggs, blood

19. Alak and Darin Question: Has Darin had an exposure that could lead to transmission?

20. Using All of The Information

21. A Clinician Should Suspect H5N1 Infection if a Patient Has: • Severe acute respiratory illness • Exposure 10 days before symptoms to: • Suspect / diagnosed avian H5N1 patient • Poultry or Wild Birds • Residence in an area with known H5N1 activity in poultry

22. Darin’s Situation • 5-year-old Darin sick for three days • Fever • Watery diarrhea • Headache • Cough • No one else sick • Darin and a friend play with and hold chickens

23. Alak and Darin Question: Would you suspect avian influenza H5N1 infection? Why or why not?

24. Current Antiviral Treatment

25. Neuraminidase Inhibitor • Neuraminidase enzyme breaks bond between infected cell and newly formed virus • Inhibitor prevents enzyme from breaking bond and releasing virus • Virus particles cannot infect other cells

26. Neuraminidase Inhibitor • Two drugs available • Oseltamivir (Tamiflu®) and Zanamivir (Relenza ®) • Should be given as soon as possible • Effective for treatment and prevention • Used for seasonal or avian influenza

27. Oseltamivir Dosage for seasonal influenza Adults: 75 mg twice a day for 5 days Children: <1 year, not studied adequately < 15 kg - 30 mg twice a day for 5 day >15 kg to <23 kg - 45 mg twice a day for 5 days >23 kg to <40 kg - 60 mg twice a day for 5 days >40 kg - 75 mg twice a day for 5 days

28. Oseltamivir Dosage for avian influenza • Best dosage for H5N1 unknown • Longer treatment (7 to 10 days) OR • Higher doses (150 mg) • Dosage for prevention • Once daily for 7 to 10 days after last exposure • Side Effects • Nausea and vomiting • Skin rash

29. Oseltamivir • Effectiveness in seasonal influenza • Reduces influenza symptoms 1 - 3 days • Reduces lower respiratory tract complications, pneumonia, and hospitalization • Cautions- Consider Risk versus Benefits • People with kidney disease (adjust dose) • Pregnant or nursing females • Resistance • Detected in several avian influenza H5N1 patients

30. Zanamivir • Inhaled by mouth via special device • May be used for > 5 years of age • Treatment dosage • Once in morning and night, 5 days • Side effects • Wheezing, and breathing problems

31. Zanamivir • Effectiveness in seasonal influenza • Reduces influenza symptoms 1 - 3 days • Reduces lower respiratory tract complications • Consider Risk vs. Benefit • People with chronic respiratory disease • Pregnant or nursing females • Resistance • Not identified in human H5N1 infections • Active against Oseltamivir resistant H5N1

32. Other Treatments? • Amantadine and Rimantadine • H5N1 resistant in some isolates • Not as effective as neuraminidase inhibitors • Corticosteroids • Low dose for sepsis • Unclear if high dose useful • Risk of side effects

33. Alak and Darin Question: What would you tell Dr. Sarasin to do?

34. Part 1 Summary • Ask about recent exposure and contact with humans or animals that may have had avian influenza H5N1 infection • Laboratory can confirm H5N1, but you should not wait • Individuals with avian influenza H5N1 infection may not have respiratory symptoms

35. Questions?

36. Case Study Exercise Background information on clinical features and management of avian influenza

37. Case Management of Suspect Human Avian Influenza Infection Part 2: Case Management of Suspected Avian Influenza Cases

38. Learning Objectives • Collect appropriate clinical and exposure information • Recognize laboratory tests used for a suspected case patient • Know how to advise on treatments and interventions for suspected case-patients and their contacts

39. Session Outline • Data to use in managing a suspect case • Clinical data • Information from medical charts • Epidemiologic context (exposures) • Clinical specimens, types of laboratory tests and imaging (x-rays) • Administration of medical care

40. Assess Suspected Avian Influenza Patients

41. Assess Suspected Avian Influenza Patients Does the patient have avian influenza? • Confirm and / or collect clinical history and physical exam data • Evaluate the epidemiologic context • Consider clinical, laboratory, and epidemiologic information together

42. Date of illness onset Symptoms Clinical measurements Complications Date of onset Any clinical specimens collected for laboratory testing Clinical Data to Collect

43. Clinical Data • Common symptoms: • Fever • Cough • Shortness of breath • Other symptoms that may occur: • Sore throat • Sputum (may be bloody) • Diarrhea / abdominal pain • Vomiting • Muscle aches

44. Clinical Complications • Acute Respiratory Distress Syndrome • Respiratory failure • May occur within a few days to 2 weeks after illness onset • Multiple organ failure • Renal dysfunction • Cardiac problems • Bone marrow depression (lymphocytes and platelets) • Hypotension • Arrhythmia Normal lymphocytes 1500 - 4000 / mm3 Normal platelet count 150,000 - 400,000 / mm3

45. Medical Charts Include: • Demographic information • Medical history • Current medical complaint / symptom history • Physical examination findings • Recommended treatment • Laboratory or other test results

46. Sample Patient Chart:Clinical Information Demographic Information Date: _____ Name __________ Age ____ Gender ___ Occupation_______ Address______________________________________________________ History of Illness Chief Complaint_____________________ Date of Illness Onset _________________ Other Symptoms and symptom onset date: _______________________________________________________ _______________________________________________________ Physical Exam Findings _______________________________________________________ _______________________________________________________

47. Sample Patient Chart:Clinical Information Demographic Information Date: _Nov 1, 2006 Name _Sok Phhoung_ Age __21_ Gender:_F_ Occupation______ Address___Patang village, Rattanakiri, Cambodia_____________ History of Illness Chief Complaint___Dyspnea_________ Date of Illness Onset ___Oct 27, 2006______ Other Symptoms and symptom onset date: __Fever – onset Oct 25_________________________________ __Cough – onset Oct 25 ________________________________ Physical Exam Findings _Current fever – 39.4°C, Pulse 123 beats/min________________ _______________________________________________________

48. Epidemiologic Context • Potential exposure to H5N1 • Occupational exposure • Travel or residence in area affected by avian influenza outbreaks in animals • Direct contact with dead or diseased birds or other animals in affected area • Close contact with a person with unexplained moderate or severe acute respiratory illness Warning!Even if NO reports of ill poultry in a province, there could be disease in that area, especially if poultry influenza vaccines are used

49. Sample Patient Chart: Exposure History Contact with ill people? (If yes, date and name, relationship to patient) ___________________________________________ ___________________________________________ Contact with diseased poultry (Live or dead)? (If yes, date and location) ___________________________________________ ___________________________________________ Recent travel? (If yes, date and location) ___________________________________________ ___________________________________________ Other close patient contacts (Household members, close coworkers) ___________________________________________

50. Use All Information • Clinical signs compatible with avian influenza • History compatible with exposure to avian influenza • 3 or more cases could indicate an emergency • Send samples for laboratory confirmation