Case Study Module 4 Part 2 Patient Management

Case Study Module 4 Part 2 Patient Management
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Case Study Module 4 Part 2 Patient Management Now that we have covered how a suspect avian influenza patient should be managed, we will work on a case study that will give you the opportunity to apply your knowledge. See Trainee / Facilitator Guide Module 4 Part 2 Case Study Scenario. This Case Study is fairly clinical in nature, and may best be used with health officers or others who may be involved in giving advice on how to directly manage potential avian influenza cases.

Case Management of Suspect Human Avian Influenza Infection
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Case Management of Suspect Human Avian Influenza Infection In this third and final session of the Case Management module, we will discuss the triage of suspected avian influenza cases. Part 3: Triage of Suspected Avian Influenza Cases

Learning Objectives Define triage
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Learning Objectives Define triage Know the function of each of the four steps in a triage approach Recognize the utility of triage in avian influenza case management Upon completing this session, you will be able to : Define triage Know the function of each of the four steps in a triage approach to case management Recognize the utility of triage in avian influenza case management

Session Outline Triage and pneumonia severity ratings
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Session Outline Triage and pneumonia severity ratings Assess the level of care needed Assess available healthcare facilities Advise on referral and transport of patients Assess illness in contacts, determine whether to recommend treatment or isolation of cases, contacts We will begin this session by discussing the concept of triage, and we will look at triage of severely ill patients by examining pneumonia severity ratings. Based on these ratings, you will learn considerations in assessing the level of care that a patient needs, and what type of healthcare facilities may be available in your area to provide that care. We will discuss factors to consider when advising on referring and transporting patients to other facilities. Finally, we will look at assessing illness in contacts, and determining whether to recommend treatment or isolation of cases and their contacts.

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3
Triage Defined Triage is a system of carefully using medical resources where they are needed most Decisions about who is the most ill Decisions about who will respond best to care Triage is a system of carefully using medical resources where they are needed most. Triage means that those who are in charge of the medical resources have to make decisions about who is the most ill, or who needs medical care the most. In some cases, this might be easy. Generally, patients who are the most severely ill or wounded will be given high priority for treatment. Patients who are not as severely ill can wait longer for treatment, and perhaps need less medication and do not need hospital beds or medical equipment. For example, a broken leg is more serious than a broken finger. In other cases, however, giving some patients higher priority than others can be a difficult decision. For example, a decision to use scarce medications might be made on the basis of who will respond best to treatment. This can cause moral dilemmas for healthcare workers.

Steps for Triage of All AI Cases
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Steps for Triage of All AI Cases Steps Example Determine type and severity of illness Patient has pneumonia Assess level of care needed Does the patient need Antivirals? Oxygen? A ventilator? Assess available health care resources Does the health care facility have a ventilator? Advise on patient referral and transport Does a nearby facility have a ventilator? Can the patient make the trip? 1. 2. There might be a situation where more than one patient is ill with avian influenza. Health care providers must triage patients to ensure that those who need care the most receive it and available resources are used wisely. There are several steps that a doctor can take to guide such triage decisions. Those four steps are to: Determine type and severity of illness Assess level of care needed Assess available health care resources Advise on patient referral and transport In the next few minutes, we will discuss each step in detail. But let’s first look at a quick example for a patient named Aran, who has pneumonia. To begin triage, we would first determine the type and severity of Aran’s illness; in determining severity of illness those who are more ill receive a higher priority. Next, we would assess the level of care needed. Does Aran need antivirals? Does he need oxygen to breathe? Should he be placed on a ventilator? Third, we would assess the healthcare resources that are available to care for Aran. If Aran needs to be on a ventilator, is one available for him in the facility? Finally, we should be able to advise on the referral and transport of patients, if necessary. If a ventilator is not available for Aran, is there one at another facility nearby? And would Aran be able to make the trip to receive treatment at a different facility? 3. 4.

Determine Type and Severity of Illness
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Triage Step 1 Determine Type and Severity of Illness Let’s now look in more detail at Step

Determining Severity of Illness
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Determining Severity of Illness For avian influenza, prioritize by severity of pneumonia Systems for rating pneumonia severity Pneumonia Severity Index CURB-65 Pneumonia Severity Scoring System Scores assigned to show urgency of hospital admission Most patients infected with avian influenza present with pneumonia. Because pneumonia can be a severe and life-threatening illness, it is reasonable to prioritize patients based on how severe their pneumonia is. Because it is best to have an objective measure of disease severity, there are several systems that have been designed to rank the severity of a patient’s pneumonia. They are: - The Pneumonia Severity Index - CURB-65 - The Pneumonia Severity Scoring System. System scores provide a way to measure how urgently patients need to be hospitalized. It should be noted that systems were developed and tested for bacterial causes of pneumonia, however they still may provide us with some useful considerations in viral pneumonia.

CURB-65 Developed the British Thoracic Society One point each for:
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 CURB-65 Developed the British Thoracic Society One point each for: Confusion (new disorientation in person, time or place) Urea, or blood urea nitrogen (BUN) level above 7 mmol/L (urea) or 20 mg% (BUN) Respiratory rate >= 30 breaths/min Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic Age >= 65 years Source: For example, let’s examine the CURB-65 rating system, developed by the British Thoracic Society. This system gives up to 5 points. The one point each is assigned if the patient has: - Confusion (for example, the patient is disoriented in time or place) - A high level of blood urea nitrogen - A high respiratory rate of 30 breaths or more per minute - Low blood pressure (measured by high systolic or high diastolic blood pressure) - Age of 65 years or more A modification of this scoring system considers only 4 elements – all of those listed here except for Urea. This allows easier assessment in settings with limited laboratory capacity.

CURB-65 Interpretation Score 1 2 3 4 5 Predicted Mortality (%) 0.9 1.1
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 CURB-65 Interpretation Score 1 2 3 4 5 Predicted Mortality (%) 0.9 1.1 5.2 12.0 32.4 25* * low numbers and very broad confidence interval Score 0: Low risk of death; may be suitable for home treatment Score 1: Increased risk of death; consider hospital referral and assessment or home treatment Score 2: Increased risk of death; consider for short inpatient treatment or supervised outpatient Score >=3: High risk of death; Require urgent hospital admission This slide shows the British Thoracic Society recommendations for hospital admission based on severity score. - A Score of 0 means that there is a low risk of death. The patient would not normally require hospitalization for clinical reasons. A patient with a score of 0 can be treated as having non-severe pneumonia and may be suitable for home treatment. - A Score of 1 or 2 indicates an increased risk of death. Admission to the hospital should be considered, either for a short stay or for outpatient treatment. - A Score of 3 or more means that there is a high risk of death and the patient requires urgent hospital admission. Ref: Thorax

CRB-65 Interpretation Score 1 2 3 4 Predicted Mortality (%) 0.9 5.2 12.0 32.4 25* * low numbers and very broad confidence interval CURB-65 scoring, without lab test for Urea (blood urea nitrogen) Has not been confirmed in large studies This slide shows the scores and corresponding predicted mortality for a modified version of Curb-65. It is very similar, however the lab test for urea is not required. The interpretation is also very similar, with a score of 0 indicating low risk and a possibility for home treatment, while hospital admission should be considered for any patient with a score of 2, 3, or 4. This scoring system has not been tested and confirmed in large studies.

Pneumonia Severity Ratings
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Pneumonia Severity Ratings Do not rely solely on scores Scores serve as a guideline Consider the patient’s clinical information Use best judgment based on expertise Adapt rating systems to local capacity Pulse-oximetry to measure oxygen in blood Availability of blood pressure monitors Pneumonia severity ratings can be a useful tool in the triage of patients, but no system is perfect. There may be clinical reasons why a patient should be hospitalized that are not captured by a set of standardized criteria. So healthcare providers should not base all decisions on a numeric rating score. Rather, they should use scoring systems for guidance along with their own best judgment. A standardized guideline such as this can be adapted to the local situation. For example, pulse-oximetry is a non-invasive test that can be done to measure the oxygen saturation of the blood. Often, patients with severe pneumonia have low blood oxygen, resulting in poor functioning of many body systems. Pulse oximetry can be used to determine whether a patient needs to be given supplemental oxygen. However, a pulse-oximeter may not be available in many locations, so this should not be a standard test required for admission of pneumonia patients. Another example is blood pressure monitors. In combination with other clinical signs, high blood pressure can indicate severe pneumonia. But if a facility does not have a blood pressure monitor, this should not be used as a criterion for admission, either.

Pneumonia Severity Rating Systems
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Pneumonia Severity Rating Systems Question 1 What elements of the rating systems do you think are most useful? Question 2 How might the system be adapted for your area? Question 1: What elements of the rating systems do you think are most useful? Question 2: If you have clinical experience, how might the system be adapted for your area? Facilitator Answer: Encourage trainees to share about the medical facilities in their area, what kinds of diagnostic capability that may be available for determining pneumonia severity indicators. Follow up questions: What elements of a rating system would be most useful in clinics or rural hospitals? Are there large referral hospitals in your area that would use more laboratory-based measures? Does anyone in the room have experience managing patients with severe pneumonia? If so, what are the signs and symptoms you look for?

Case Report Now let’s apply these rating scales to a case patient example.

A Patient in China Female, unknown age, 4 months pregnant
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 A Patient in China Female, unknown age, 4 months pregnant Presents at hospital November 7 Symptoms Trouble breathing Cyanosis (blue-colored skin) Fever 38.8°C Pulse 118 beats / minute Respiratory rate 37 breaths / minute Lymphocyte count 608 / mm3 Chest x-ray shows diffuse infiltrates in the lower part of both lungs A female patient presents to a city hospital in China on November 7. The patient’s age is unknown, but she is 4 months pregnant. Her symptoms include: - Trouble breathing - A blue color to her skin - A fever above 38 degrees C - A pulse of 118 beats per minute - A respiratory rate of 37 breaths per minute - A Lymphocyte count of 608 per cubic millimeter - A chest radiograph shows diffuse infiltrates in the lower part of both lungs

Rate Pneumonia Severity
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Rate Pneumonia Severity CRB-65 Category Points Given Confusion Respiratory rate >= 30 breaths/min 1 Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic [Pulse > 125 beats / min] Age >= 65 years Let’s first evaluate this patient using the modified, 4-point scale CRB-65 criteria. There was no mention of the patient being confused or disoriented, so 0 points are given. The patient’s respiratory rate was 37 breaths per minute, which is high, so one point is given. We do not have information on the patient’s blood pressure. In this case, we would need to modify the criteria, so blood pressure has been replaced with the pulse. This criteria was borrowed from the first Pneumonia Severity index we looked at. You may think that pulse alone is not a strong enough indicator, so you might want to combine it, for example, high pulse rate PLUS a positive chest x-ray. These adaptations can be made according to the diagnostic capabilities of a facility or area. However, they should be made BEFORE any patients are examined. The criteria cannot change from one patient to the next. Finally, we do not know the age of this patient, but she is of childbearing age, so she is probably less than 65 years old; so 0 points are given for age. The patient’s rating is 2 using this system; the score indicates a moderate risk of death per the predicted mortality that we reviewed earlier (Students may want to look back in their handout slides at the CRB-65 interpretation criteria). In this case, the patient was treated with antibiotics, but her condition worsened. She required intubation the evening of November 7. The following day, her chest x-ray showed extensive infiltration of both lungs. Despite intensive supportive care, she experienced multiple organ failure and died on November 10. Facilitator: Ask if there are any questions or comments on the use of pneumonia severity rating systems. Total Points for modified CRB Moderate risk of death; consider hospital admission

Assess Level of Care Needed
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Triage Step 2 Assess Level of Care Needed Now that you have learned about rating the severity of illness, the next step is to assess what level of care the patient needs.

Hospitalization Not Needed
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Hospitalization Not Needed Patient may be cared for at home Administer appropriate antiviral if avian influenza suspected Teach patient and family Wash hands Ill person uses a surgical mask Limit social contacts Symptoms in patient or family members that require prompt medical care If possible, follow-up with home visits or by telephone A patient may be assessed as not needing hospitalization. If this is the case, it may be appropriate for the patient to be cared for at home by family. If any medication is required, this can be administered to the patient, or given to him or her to take home. It is important to teach the patient and his or her family about personal hygiene and infection control measures such as washing hands, use of a paper or surgical mask by the ill person, and limiting of social contacts. Instruct the patient to seek prompt medical care if the condition worsens, and teach the patient and family about symptoms to look for in family members. If it is possible, follow up patients being cared for at home with home visits or telephone contact.

Hospitalization Required
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Hospitalization Required Illness is not an emergency Monitor for changes in status Treat with antiviral Treat as necessary with Antibiotics Oxygen Severe illness Patient admitted to intensive care unit Ventilation or advanced medical support for organ failure may be necessary If you determine that hospitalization is required, the patient may need inpatient monitoring and treatment, or the patient might be severely ill and require life support. If the patient’s illness is not emergency, administer the appropriate treatments, such as antivirals if they are available, and treat as necessary with antibiotics for bacterial infections, and oxygen, and monitor changes in the patient’s status closely. If the illness is severe, the patient will require admission into an intensive care unit. Appropriate medications should be given, and ventilation or advanced medical support for organ failure may be necessary.

Assess Available Healthcare Resources
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Triage Step 3 Assess Available Healthcare Resources Once you have assessed the severity of a patient’s illness and determined what kind of care the patient needs, the next step is to determine what healthcare resources are available.

Healthcare Facilities
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Healthcare Facilities Clinic Local level Community healthcare Outpatient services Hospital Local or district level More laboratory capacity Inpatient services Referral Hospital Larger cities Advanced medical care Laboratory diagnosis Isolation rooms The healthcare setting may play a large role in what resources are available to treat a patient. Healthcare facilities at the local level in rural settings may have very limited resources, whereas clinics in larger cities may have more access to medicine and equipment. The smallest healthcare facilities or clinics may offer only very basic community healthcare or outpatient services, such as diagnosis and treatment for minor illnesses, infectious diseases such as malaria, routine immunizations, and basic injury care. Even small hospitals in rural areas usually offer more laboratory capacity and basic inpatient services than clinics do. In some areas, these facilities may even have isolation rooms originally designed for treatment of tuberculosis patients. However, the ability of these local or rural district hospitals to provide advanced medical support is often limited. A district hospital in a larger town or city may offer more advanced medical care. The highest level of medical facility is a referral hospital. Referral hospitals are located in larger cities, and have the capability for advanced medical care including emergency departments, intensive care units, advanced laboratory diagnosis, and isolation rooms. They are staffed by experts in various medical specialties, and are often the largest facilities.

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Healthcare Facilities Know your area facilities: Location Capability Capacity As a public health responder, you need to know what facilities are available in the area that you serve. You should know their locations, whether or not they offer only basic medical services. If services available are very advanced, you should be familiar with a facility’s capacity for treatment and diagnosis – particularly of avian influenza! You should also know approximately how many patients each facility can handle at one time.

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Healthcare Facilities Question 1 What healthcare facilities are available in your area? Question 2 What level of care can be provided at these facilities? Question for discussion: What facilities are available in your area? Question for discussion: What level of care can be provided at these facilities? Facilitator Discussion Notes: Large referral hospitals may be the most well-known among class attendees, but a novel strain of avian influenza may appear first in rural populations. Where are these patients likely to present for treatment? Knowing where primary, secondary, and tertiary care hospitals are located will become important when talking about patient transportation (next). Is there a network of hospitals in the area? Is there a list that contains contact information for each healthcare facility? Define the levels of healthcare facilities where patients should ideally be treated during a pandemic situation (primary, secondary and tertiary referral).

Advise on Referral and Transport of Patients
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Triage Step 4 Advise on Referral and Transport of Patients So now you have learned how a patient is assessed for illness, level of care needed, and the level of care available. What happens if a patient needs a level of care that is not available locally? One option is to transport the patient to a different facility. In this next section, you will learn some of the issues to consider if you need to advise a doctor or hospital on whether a patient should be referred and transported.

Referring Patients to Another Facility
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Referring Patients to Another Facility Logistical considerations Treat all patients at one versus a few sites? When to transport patients to higher level facilities How to transport patients to higher level facilities Staff availability Availability of overflow areas Treatment considerations Access to antivirals and antibiotics Access to a laboratory for diagnosis Access to radiology (x-ray) Availability of isolation rooms When anticipating the referral and transportation of patients, you should consider many aspects of the process. Some considerations are logistical, while others relate to facility capability to treat patients. These issues will need to be considered in preparing for an avian influenza pandemic. If disease is widespread, there will be no time to make decisions on a case-by-case basis. So hospital staff and public health officials should develop criteria for moving patients from one facility to another. These criteria will be different for every area, depending on the resources available. If only one patient suspected of having avian influenza appears at a local hospital that has little diagnostic and treatment capability, should the patient be referred to a different hospital with more capability? What if there are many patients? Should treatment of all patients be limited to one versus a few hospital sites? And how would a patient be transported from a more basic facility to a more advanced one? Which location has the staff available to care for the patient? Finally, if the healthcare facilities fill up, are there facilities such as schools or temporary shelters that can serve as designated overflow areas? Earlier we discussed the importance of a facility’s capability for providing medical services. Therefore, before referring and transporting a patient, you should evaluate: - Access to antivirals and antibiotics (do any facilities have antivirals? Do most facilities have antibiotics?) - Access to a laboratory for diagnosis - Access to radiology (x-ray) - The availability of isolation rooms for potentially infectious patients

Patient Transport Example
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Patient Transport Example Female patient, Thuy, with pneumonia admitted to primary level hospital The only patient suspected of avian influenza Symptoms: fever, high pulse and respiratory rate, crackles heard in lungs Primary hospital can administer oxygen and antibiotics, but has no access to x-ray or antivirals Tertiary hospital can x-ray patient and place on ventilator support, if needed, but has no antivirals Let’s look at a patient transport example. A female patient named Thuy is admitted to a primary level hospital for pneumonia. Thuy is the only patient at this hospital suspected of avian influenza. She has a fever, a high pulse and high respiratory rate, and crackles can be heard in her lungs when she breathes. The primary hospital is able to administer oxygen to her, if she needs it, and can start her on antibiotics, but it does not have x-ray capabilities or access to antiviral medication. Thuy could be referred to a tertiary hospital, where she could receive a diagnostic x-ray and ventilator support, if needed. But the tertiary hospital also has no access to antiviral medication.

Patient Transport Example
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Patient Transport Example Question 1 Would you recommend transporting Thuy to the tertiary care hospital? Question 2 What if Thuy was one of many severe pneumonia patients at the primary hospital? Question 3 What do you think are the most important criteria for deciding to transport a patient? Facilitator Notes: You will now ask the large group to participate in brief discussion on patient transportation: Question 1: Would you recommend transporting Thuy to the tertiary care hospital? Why or why not? Facilitator Answer: There is no “correct” answer. Question 2: What if Thuy was one of many severe pneumonia patients at the primary hospital? Would this change your decision? Facilitator Answer: If there were many patients at the primary hospital, an outbreak would probably be more widespread. Recommending transport might depend on whether the tertiary hospital has room for more patients. Are there lines of communication established between hospitals? How is one to know if a referral hospital can take additional patients? One might decide that if antivirals are not available at either location, it is not worth transporting patients. Question 3: What do you think are the most important criteria for deciding to transport a patient? Facilitator Answer: Suggested answers include: treatments available; severity of patient’s illness; staffing to care for patients; distance to the next hospital or treatment center, how the patient will get there, and whether or not the patient can endure being transported.

Problem Solving Exercise
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Problem Solving Exercise Next we will work on a problem solving exercise to be accomplished in breakout groups. Note: If you are facilitating a small group of trainees (less than ~15), you may break out for the exercise. See “Module 4 Part 3 Facilitator Guide. A: Problem Solving Exercise.” If you are facilitating a larger group, DELETE this slide. Continue with the lecture presentation, and conduct all exercises and activities once the lecture is complete.

Public Health Steps for Managing Cases
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Public Health Steps for Managing Cases Thus far, we have discussed what decisions may occur during the assessment and treatment of a patient. As a public health practitioner, you may be called on to advise in some of these decisions. However, once a patient with suspect avian influenza has been identified, there are a number of steps that you as a public health work may need to carry out. In the next section, we will talk about these public health steps for managing suspect avian influenza cases.

Additional Steps Necessary
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Additional Steps Necessary Assess presence of illness among contacts Advise on management of corpses with possible avian influenza Determine need for isolation and quarantine Document data on standardized forms and report to relevant authorities Now you know what is involved in managing a case of avian influenza. However, your job is just beginning! You will also need to: Assess the presence of illness among a case-patient’s contacts Advise on the management of corpses with possible avian influenza Determine the need for isolation and quarantine Document data on standardized forms and report those data to relevant authorities Let’s talk about each of these responsibilities.

Assess Contacts Assess contacts quickly
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Assess Contacts Assess contacts quickly Incubation period only 2 to 3 days Contact - anyone who has touched or talked with (=<1 meter) the patient up to 2 or 3 days prior to the patient’s onset of illness Household members Fellow workers Assess contacts for influenza-like illness Fever Cough, shortness of breath Muscle aches Diarrhea The first step is to assess the presence of illness among anyone who has been in contact with the patient. Because the incubation period for influenza is only 2 to 3 days, you should assess contacts as soon as possible after the case patient presents for treatment. A contact is defined as someone who has touched or spent time talking with the ill person at a distance of 1 meter or less up to two or three days prior to the patient’s onset of illness. Contacts usually include any household members, and may include people that the ill person works with. These contacts should be assessed for influenza-like illness – the symptoms with which you are now very familiar include: fever, cough, shortness of breath, muscle aches, and possible severe diarrhea.

Manage Corpses No risk of transmission from dead bodies
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Manage Corpses No risk of transmission from dead bodies Autopsy procedures could result in transmission Use appropriate protective equipment You should know Where corpses may be sent for disposal Cultural or religious beliefs to respect when handling corpses In addition to assessing contacts of a patient, you need to be able to advise on the management of corpses with possible avian influenza. Normally, there is little or no risk of contracting avian influenza from an infected human who as died. However, some autopsy procedures performed after death may result in transmission. For this reason, if an autopsy to be performed, appropriate protective equipment should be used. We will talk more on this type of protection in a later unit. Even though dead bodies pose little or no risk of transmission, you should know where corpses may be sent for preparation and disposal. It is important to keep in mind the cultural or religious beliefs that need to be respected when handling corpses. Tradition or religion may necessitate cremation of a corpse at a temple for example, or a period of mourning before the body may be cremated, and an autopsy may not be performed.

Advise on Isolation and Quarantine
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Advise on Isolation and Quarantine Isolation Separate or limit movement of people who are ill to prevent them from infecting healthy people Often occurs in a healthcare setting For use when illness is fairly rare Quarantine Separate people who have been exposed to an illness (may not be ill themselves) For use when illness is widespread May cancel public gatherings, large events Now, let’s talk about the need for isolation and quarantine. Isolation is when we separate or limit the movement of people who are ill. The goal is to prevent them from interacting with healthy people and infecting them. Isolation usually occurs in a healthcare setting, as the ill person is likely to need medical treatment. Isolation procedures are used when illness is fairly rare in the population, as it can effectively prevent a larger number of people from becoming ill. Quarantine is when we separate people who have been exposed to an illness. People who are quarantined may not be ill themselves – they are at risk of becoming ill because we know they have been exposed. Quarantine is used when illness is more widespread. Often health authorities will ask people to voluntarily stay home if they have an ill family member, for example, to be sure that they don’t spread disease to others. Sometimes authorities may cancel public gatherings or other events. This is a way of preventing transmission by preventing those who may be developing illness from exposing healthy people.

Advise on Isolation and Quarantine
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Length of time for isolation and quarantine depends on incubation period and infectious period Goals: Prevent additional human cases early Slow pandemic spread (gain time for preparing) Reduce the impact of the first wave of a pandemic The length of time that isolation and quarantine need to be enforced depends on the incubation period and the infectious period for an illness. For adults, isolation is often about 7 days after onset of illness, while it is 21 days for children. The primary goals of isolation and quarantine are: – To prevent additional human cases caused by a virus that has not yet established efficient human-to-human transmission – To slow pandemic spread and thus gain time for strengthening preparedness measures – To reduce the impact of the first wave of a pandemic

Document and Report Cases
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases Help identify and describe old and new strains of avian influenza Know where avian influenza is being transmitted Track and count illness due to avian influenza Provide information for influenza control Help officials make public health decisions After you have taken care of logistics and implemented some control measures, you should document cases and report them to the proper health authorities on standardized forms. Why should you do this? There are several reasons: - This activity may help identify and describe current and new influenza strains - Documentation and reporting will help people know where avian influenza is being transmitted and identify any patterns in transmission - To track the number of cases of illness due to avian influenza - Documentation and reporting provide information for influenza control, and help officials make public health decisions

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases World Health Organization Ministry of Health District or Provincial Level How do you document and report cases? First, your country should have a standardized form that can be used to gather all the necessary information on avian influenza cases. At the local level, you may give this report to your district or provincial health office. At the provincial level, reports will go to the national Ministry of Health. All nations then report cases to the World Health Organization. Local Level

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases “WHO Guidelines for Global Surveillance of Influenza A/H5” Annex 5 “Template for Case Report Form” If your country does not have a standardized form for reporting, you can use a World Health Organization form. It is available in the Internet in the WHO .PDF document titled, “WHO Guidelines for Global Surveillance of Influenza A/H5”. The standardized form to which we are referring is Annex 5 of the document, titled, “Template for Case Report Form.”

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases Information to include Name of person reporting Healthcare facility name and location Patient information: Demographics Travel history Symptoms Avian flu in area animals Test Results Potential exposures Treatment given Outcomes What kind of information should be included in an avian influenza case report? First, the name of the person and facility doing the reporting are important. That way, this facility can be contacted later if there are any questions. Next, extensive information about the patient may be required, including: - Patient demographics - Patient symptoms - Results of any tests performed - Treatment given to the patient - Patient’s recent travel history - Whether avian flu is present in area animals - Potential exposures to avian influenza that the patient may have had - The patient’s current status or outcome

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases Here is an image of the demographic and symptoms information collected on the WHO standardized case report form.

Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Document and Report Cases When should you report? As soon as possible! Do not wait for laboratory confirmation Do not wait to observe patient outcome You may be wondering when you should document and report a case. This should be done as soon as avian influenza is suspected. It is not necessary to wait for the laboratory to confirm the diagnosis if there is good reason to suspect avian influenza. And do not wait to see if the patient will recover – it is important to begin the reporting process as soon as possible.

Summary Patients needing advanced care may need to be transported to a higher level facility, while patients with mild illness may be able to stay at home Medical treatment and care of patients will depend on the facilities available in your geographic area People who have contact with a suspected avian influenza case should be assessed for illness, and may be given preventive treatment or put in isolation To summarize this session, patients needing advanced care may need to be transported to a higher level facility, while patients with mild illness may be able to stay at home. The caregivers at the home should be taught how to care for the patient, and public health personnel should check with the patient daily. The medical treatment and care given to patients will depend on the facilities available in your geographic area. You should know what is available in your area, so that you can advise doctors or higher level public health officers. People who have contact with a suspected avian influenza case should be assessed for illness, and may be given preventive treatment or put in isolation to prevent illness from spreading to others.

Scripted Role Playing Activity
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 Case Study Scripted Role Playing Activity That concludes the lecture portion of Module 4. You are now going to participate in a scripted role playing activity. This activity will require at least two people to play scripted roles. One person will be the wife of a farmer who is ill with suspected avian influenza; the other will be a member of the investigating rapid response team. A third person can act as the facilitator, or one of the “actors” can perform that role also.

Glossary Triage A system of carefully using medical resources where they are needed most.

References and Resources
Modlue 4: Case Management of Suspect Human Avian Influenza Infection; Part 3 References and Resources WHO interim guidelines on clinical management of humans infected by influenza A(H5N1), 2 March Tran Tinh Hien, et al. Avian Influenza A (H5N1) in 10 Patients in Vietnam. N Engl J Med March 18, 2004: 350(12), p WHO pandemic influenza draft protocol for rapid response and containment Updated draft 30 May

Case Study Module 4 Part 2 Patient Management

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Case Study Module 4 Part 2 Patient Management

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Presentation on theme: "Case Study Module 4 Part 2 Patient Management"— Presentation transcript:

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