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Influenza A(H5N1) in Humans: Outbreak Investigation in an International Setting Case Study 2 11.

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Presentation on theme: "Influenza A(H5N1) in Humans: Outbreak Investigation in an International Setting Case Study 2 11."— Presentation transcript:

1 Influenza A(H5N1) in Humans: Outbreak Investigation in an International Setting Case Study 2 11

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 22

3 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 44

5 Introduction Be sure to have materials needed to take notes and create a line list 5

6 Republic of Pegu: Setting Developing country Southeast Asia 21 provinces Population: 50 million 66

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 7

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 8

9 Question 2 Match who should be notified about the investigation on the left with the reason they should be notified on the right. 1.Veterinary Health Authority 2.Government officials (MOH and other govt offices or ministries) 3.Healthcare personnel 4.The community 5.Non-governmental organizations 6.The laboratory a.To give you advice and direction b.To satisfy their interest and offer education c.To be ready for samples that will be coming d.To conduct evaluation of diseased poultry e.So they know you are coming to investigate f.To serve as a resource for medical resources 9

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 10

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

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 a.Case definitions b.Antiviral medication c.Goggles d.Gloves e.Graph paper f.Solution for decontaminating homes or hospital room g.Transportation containers h.Pens i.Gown and cap j.Reporting forms k.Specimen collection materials l.Ice m.Guidelines for contacts, family members, and healthcare workers n.Notebook/laptop o.Portable GIS unit p.Viral transport media q.Simple messages r.Respirators 12

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 13

14 Trigger Event #2 July 15 th 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) JULY 15 14

15 Character Details 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 JULY 15 15

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

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

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

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

20 Question 4a How would you classify AAJ into the WHO influenza A(H5N1) case definition? Information on AAJ is given for your reference. a.Under investigation b.Suspected c.Probable d.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. 20

21 Question 4b How does patient JAM fit into the WHO influenza A(H5N1) case definition? a.Under investigation b.Suspected c.Probable d.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

22 Question 5 IDAgeGender Create a line list: What variables should be included? 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

23 Suggested Line List Format 23 ID # InitialsLocAgeSexEPI relation OccSyxOnset - July Poss. Exp. Lab Status Case vs. Contact Outcome

24 Question 6 Update the line list with the cases as of July 15 th mid-day ID # InitialsLocAgeSexEPI relationOccSyxOnset - July Poss. Exp. 1AAJDG10MChild (exp at live market) ChildF,C,S10Live Mkt: July 8 th Grandmother: July9th 2JAMDG65FGrandmother of #1 (AAJ) RetiredF,C,S9Caretaker of #1 Timing - ? IDInitial s Lab Status Case status definition (Case v. Contact) Outcome 1AAJNo lab specimenProbable CaseHospitalized on ventilator, pneumonia, respiratory failure 2JAMPendingPerson under invest.Hospitalized F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai JULY 15 24

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

26 Question 7b Note whether the following statements used to define who is a close contact of this probable case are true or false. 1.Anyone who came within 1 meter of the case patient 2.Anyone who had shared space within 1 meter of the case patient 3.Close contact 1 day before through 14 days after onset of symptoms 4.Close contact 7 days before through 14 days after the onset of symptoms 5.Someone who kissed, embraced or shared utensils with the case patient 6.Someone who spoke with or touched the case patient 26 Answers: False True False True

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 27

28 Question 8a Assuming that neuraminidase inhibitors are available: 1.Should AAJ be given anti-viral treatment? 2.Should JAM be given anti-viral treatment? Answer: 1.Yes 2.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. 28

29 Question 8b 1.Should JAM receive anti-viral prophylaxis? 2.Should asympomatic close contacts of AAJ be given anti-viral prophylaxis? 3.Should close contacts of JAM receive antiviral prophylaxis? Answer: 1.Yes 2.Yes 3. 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

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. 1. High Risk 2. Moderate Risk 3. Low Risk a.Personnel culling likely non-infected animals b.Personnel handling sick animals or decontaminating environments using insufficient PPE c.Personnel handling sick animals or decontaminating environments using adequate PPE d.Unprotected close/direct exposure to H5N1 infected animals e.Healthcare or laboratory personnel in close contact with strongly suspected or confirmed patients or their samples with insufficient PPE f.Healthcare workers not in close contact g.Healthcare workers with close contact using adequate PPE h.Close household contact of strongly suspected or confirmed patients 30

31 Question 9 Answers High 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

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 32

33 Update: July 16 th The RRT arrives at Dava Ghar AAJ Update Admission Fever 39 °C Heart rate breaths/minute Blood pressure 90/60 O 2 saturation 88% Outcome Intubated Jul 14 Hypotensive with renal failure Died on the 16 th Respiratory and sputum samples of poor quality JAM Update Admission Temperature 38.5 °C 28 breaths/minute Blood pressure 160/95 O 2 saturation 90% Initial laboratory findings High lymphocyte count High leukocyte count JULY 16 33

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

35 Question 10a What specimens need to be collected from the grandmother? a.Endotracheal fluid b.Broncho-alveolar lavage c.Throat swab (oropharyngeal) d.Nasal swab (nasopharyngeal) e. 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!!! 35

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

37 Specimen Collection Kit Collection vials with VTM Polyester fiber- tipped applicators Sterile saline which is 0,85% NaCI A sputum or mucus trap Tongue depressors Specimen collection cups or Petri dishes Transfer pipettes A secondary container Ice pack Items for collection of blood Personal Protective Equipment (PPE) Field collection forms A pen or marker for labeling samples JULY 15 37

38 Question 11 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 applicators stick Put the following steps for collecting an oropharyngeal specimens in the proper order Answers

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 _________ 5) Specimen______ 6) _______ label 4) Itemized list of ______ 3) Labeling of the _________ as UN3373 diagnostic specimens Answer choices: a.contents b.packing material c.identification d.outer package e.packaging f.biohazard 39

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 5) Specimen c. identification 6) f. Biohazard label 4) Itemized list of a. contents 3) Labeling of the d. outer package as UN3373 diagnostic specimens 40

41 Question 12b Determine whether the following statements about storing specimens in VTM are true or false. 1.Store specimens can be stored at 4 °C within 48 hours of collection both before and during transportation. 2.Store specimens at -70 °C beyond 48 hours (if you will not be able to immediately transport specimen to laboratory) 3.Never store specimens on dry ice 4.Specimens may be stored in standard freezer 41 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. Answers: True False

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

43 Transportation Considerations 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 JULY 16

44 Contact Identification 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) JULY 16 44

45 Question ID # InitialsLocAgeSexEPI relation OccSyxOnset - July Poss. Exp. Lab Status Case vs. Contact Outcome 1AAJDG10MIndex case ChildF,C, S 10Live Mkt: July 8 th Grandmot her: July9th No lab specimen Probable Case Hospitalize d on ventilator, pneumonia, respiratory failure 2JAMDG65FGrandm other of #1 (AAJ) RetiredF,C, S 9Caretaker of #1 Timing - ? PendingPerson under invest. Hospitalize d Below is shown the line list from mid-day, July 15 th. Update the line listing with all known contacts as of July 16 th a.m.

46 Question 13 Answer Line list as of July 16 th a.m. F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai ID # InitialsLocAgeSexEPI relation OccSyxOnset - July Poss. Exp. Lab Status Case vs. Contact Outcome 1AAJDG10Mindex case ChildF, C, D, S 10Live-Mkt: July 8 No lab specimen Probable CASE Died (7/16) 2JAMDG65FGrandm other (# 1) RetiredF, C, S 9Caretaker of # 1 Pending PUI/ Contact Hospitalize d 3AWMDG70MGrandfa ther (# 1) RetiredCaretaker of # 1 Contact 4NJCDG36FMother (# 1) Home- maker Caretaker of # 1; Live-Mkt: July 8 Contact 5JRODG27MUncle (# 1) FarmerLive-Mkt: July 8 Contact 46

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 47

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? a.Health care facilities (hospitals, clinics, traditional healers) b.Patient (or family proxy) c.Patients village/neighborhood d.Patients school/workplace Answer: d. At this point in time, the appropriate information on close contacts can be gathered from the patient/proxy 48

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

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

51 Question 15a Questions to ask the case patients family covering situations with potential for H5N1 exposure should include which of the following? Contact with confirmed or suspect human H5 cases Awareness of clusters of severe respiratory illness in family, friends and co-workers Awareness of H5N1 outbreaks occurring outside the country Exposure to animals and their environment Exposure to contaminated environments Exposure to cooked chicken products Inquire about illness or deaths in birds, cats, swine, or other animals in the household and neighboring area 51

52 Question 15b When interviewing at a patients home or in their village, which of the following are important contextual factors to observe and analyze? Poultry in and around the house Number of people living in the home Construction material of the home Mapped location or photograph of house and surroundings Culture-specific risk factors Annual community festival days Live bird markets or other occupationally related exposures 52

53 Case Finding Results Child with unexplained respiratory illness reported in nearby province, Pelu Jaghai Director of Epidemiology recommends that your team meet the Ministry of Health field workers there and make site visits to hospitals and villages JULY 16 53

54 New Case and Contact 11-year-old boy, TMU Fever, cough shortness of breath starting July 12 Admitted July 15 Critically ill, not intubated You and your team don PPE, evaluate the patient, review medical chart, and interview available family members Mother (ACM) Reports boy visited Murg market on July 8 54 JULY 16

55 Question 16 Update the line list with the current information as of the afternoon of July

56 Question 16 Answer 56 Line list as of July 16 th p.m. F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx DG: Dava Ghar PJ: Pelu Jaghai ID # InitialsLocAgeSexEPI relation OccSyxOnset - July Poss. Exp. Lab Status Case vs. Contact Outcome 1AAJDG10Mindex case ChildF, C, D, S 10Live-Mkt: July 8 No lab specimen Probable CASE Died (7/16) 2JAMDG65FGrandm other (# 1) RetiredF, C, S 9Caretaker of # 1 PendingPUI/ Contact Hospitalize d 3AWMDG70MGrandfa ther (# 1) RetiredCaretaker of # 1 Contact 4NJCDG36FMother (# 1) Home- maker Caretaker of # 1; Live-Mkt: July 8 Contact 5JRODG27MUncle (# 1) FarmerLive-Mkt: July 8 Contact 6TMUPJ11MPlaymat e (# 1) ChildF, C, D, M 12Live-Mkt: July 8 PendingSuspect CASE Hospitalize d 7AMCPJ29FMother of # 6 MotherCaretaker of # 6 Contact

57 Differential Diagnoses Human influenza Upper respiratory infection Fever, headache, cough, sore throat Muscle ache, exhaustion Other respiratory symptoms Recovery: 2-7 days Can progress to pneumonia and respiratory failure in some cases Influenza A(H5N1) Lower respiratory infection Fever, headache, cough, sore throat Muscle ache, exhaustion Difficulty breathing, respiratory distress Crackling on inhalation Increased respiratory rate Sputum production, possibly with blood Limited data: diarrhea 57

58 Non-Influenza Differential Diagnoses Viral Human influenza viruses Parainfluenza viruses Respiratory syncytial virus Adenovirus Rhinovirus Flaviviruses (e.g. Dengue) Coronaviruses (including SARS-CoV) Human metapneumovirus Hantavirus New / emerging viruses, such as bocavirus Bacterial Mycobacteria tuberculosis Yersinia pestis (pneumonic plague) Streptococcus pneumoniae Staphylococcus aureus Hemophilus influenzae Burkholderia pseudomallei Legionella spp. Chlamydia pneumoniae Mycoplasma pneumoniae Coxiella burnetii (Q fever) 58

59 Question 17 Do you think TMU has Influenza A(H5N1) infection? 59

60 Move on to Outbreak Investigation, Part 2 60


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