دکتر رضا وفایی نژاد treatment, prophylaxis and prevention of influenza treatment,...

نژاد وفایی رضا دکتر

Treatment , Prophylaxis Treatment , Prophylaxis and prevention of and prevention of

InfluenzaInfluenza

نژاد وفائی رضا نژاد دکتر وفائی رضا دکتر

عفونی بیماریهای عفونی متخصص بیماریهای متخصص

نژاد وفایی رضا نژاد دکتر وفایی رضا دکتر 33

symptom-based symptom-based therapy(In therapy(In uncomplicated)uncomplicated) acetaminophen for the relief of acetaminophen for the relief of

headache, myalgia and fever(use of headache, myalgia and fever(use of salicylates should be avoided in salicylates should be avoided in children<18 years of age : association children<18 years of age : association of salicylates with Reye's syndrome. of salicylates with Reye's syndrome.

Treatment with cough suppressants Treatment with cough suppressants generally is not indicated, although generally is not indicated, although codeine-containing compounds may be codeine-containing compounds may be employed if the cough is particularly employed if the cough is particularly troublesome.troublesome.

rest and maintain hydration during rest and maintain hydration during acute illnessacute illness


SpecificSpecific Antiviral Antiviral Agent for influenazaAgent for influenaza

M2 InhibitorsM2 Inhibitors Amantadine Amantadine

(symmetrol)(symmetrol) Rimantadine Rimantadine

neuraminidase neuraminidase inhibitorsinhibitors Oseltamivir (tamiflu)• Zanamivir (relenaz)


Specific antiviral Specific antiviral therapy (continued)therapy (continued) If begun within 48 h of the onset If begun within 48 h of the onset

of illness, : reduced the duration of illness, : reduced the duration of systemic and respiratory of systemic and respiratory symptoms of influenza by 50%symptoms of influenza by 50%


Specific antiviral Specific antiviral therapy (drug)therapy (drug) amantadine and rimantadine for amantadine and rimantadine for

influenza A influenza A Zanamivir and oseltamivir for Zanamivir and oseltamivir for

both influenza A and influenza Bboth influenza A and influenza B


Specific antiviral Specific antiviral therapy (therapy (M2 InhibitorsM2 Inhibitors)) amantadine and rimantadine : inhibit by amantadine and rimantadine : inhibit by

interfering with the uncoating of virus interfering with the uncoating of virus after infection of the cell , interaction after infection of the cell , interaction with the influenza A M2 matrix protein, with the influenza A M2 matrix protein, during which the ion channel function of during which the ion channel function of M2 is inhibited.M2 is inhibited.

A substitution of a single amino acid at A substitution of a single amino acid at critical sites in the M2 protein can result critical sites in the M2 protein can result in a virus that is resistant to amantadine in a virus that is resistant to amantadine and rimantadineand rimantadine


Specific antiviral Specific antiviral therapy (therapy (M2 InhibitorsM2 Inhibitors)) 5 to 10% who receive amantadine : mild CNS 5 to 10% who receive amantadine : mild CNS

side effects, primarily jitteriness , anxiety, side effects, primarily jitteriness , anxiety, insomnia, or difficulty in concentrating insomnia, or difficulty in concentrating (disappear upon cessation of the drug)( with (disappear upon cessation of the drug)( with old age , TMP/SMZ , antihistamine old age , TMP/SMZ , antihistamine anticholnegic ). anticholnegic ).

Rimantadine : equally efficacious , less Rimantadine : equally efficacious , less frequent CNS side effects than is amantadine.frequent CNS side effects than is amantadine.

In adults, the usual dose of amantadine In adults, the usual dose of amantadine (cap;100mg) or rimantadine is 200 mg/d for 3 (cap;100mg) or rimantadine is 200 mg/d for 3 to 7 days.to 7 days.


Specific antiviral Specific antiviral therapy (therapy (M2 InhibitorsM2 Inhibitors)) For prophylaxis, the compounds must be For prophylaxis, the compounds must be

administered daily for the period at risk administered daily for the period at risk (i.e., the peak duration of the outbreak). (i.e., the peak duration of the outbreak). For therapy, amantadine or rimantadine For therapy, amantadine or rimantadine is generally administered for 5 to 7 daysis generally administered for 5 to 7 days

excreted via the kidney, the dose should excreted via the kidney, the dose should be reduced to = <100 mg/d in elderly be reduced to = <100 mg/d in elderly and in renal insufficiency (creatinine and in renal insufficiency (creatinine clearance (Cr,) rate of <50 mL/min)clearance (Cr,) rate of <50 mL/min)


Specific antiviral Specific antiviral therapy (therapy (M2 InhibitorsM2 Inhibitors)) Amantadine is not metabolized Amantadine is not metabolized

and is excreted almost entirely by and is excreted almost entirely by the kidney,the kidney,

Rimantadine is extensively Rimantadine is extensively metabolized to hydroxylated metabolized to hydroxylated derivativesderivatives


Specific antiviral Specific antiviral therapy (therapy (neuraminidase neuraminidase inhibitorsinhibitors )) Both zanamivir and oseltamivir act Both zanamivir and oseltamivir act

through competitive and reversible through competitive and reversible inhibition of the activesite of influenza A inhibition of the activesite of influenza A and B viral neuraminidases (essential for and B viral neuraminidases (essential for release of the virus from infected cell) release of the virus from infected cell) and have relatively little effect on and have relatively little effect on mammalian cell enzymes. mammalian cell enzymes.

zanamivir and oseltamivir are active zanamivir and oseltamivir are active against strains resistant to amantadine against strains resistant to amantadine and rimantadine.and rimantadine.


Specific antiviral Specific antiviral therapy (therapy (neuraminidase neuraminidase inhibitorsinhibitors )) Zanamivir(has low oral bioavailability) Zanamivir(has low oral bioavailability)

(belister pack 5 mg), inhaled orally : 10 (belister pack 5 mg), inhaled orally : 10 mg twice a day for 5 days,mg twice a day for 5 days,

oseltamivir (cap: 75) , orally : 75 mg oseltamivir (cap: 75) , orally : 75 mg twice a day for 5 days,twice a day for 5 days,

Zanamivir may exacerbate Zanamivir may exacerbate bronchospasm in asthmatic patients, and bronchospasm in asthmatic patients, and oseltamivirhas been associated with oseltamivirhas been associated with nausea and vomiting, ( reduced by drug nausea and vomiting, ( reduced by drug administration with food)administration with food)


Specific antiviral Specific antiviral therapy (therapy (neuraminidase neuraminidase inhibitorsinhibitors )) Zanamivir and oseltamivir : treatment Zanamivir and oseltamivir : treatment

of influenza in adults and in children of influenza in adults and in children (those >_7 years old for zanamivir and (those >_7 years old for zanamivir and those > 1 year old for oseltamivir) who those > 1 year old for oseltamivir) who have been symptomatic for <_2 days. have been symptomatic for <_2 days.

Oseltamivir is approved for prophylaxis Oseltamivir is approved for prophylaxis of influenza in individuals > 13 years of influenza in individuals > 13 years of ageof age


Specific antiviral Specific antiviral therapy (continued)therapy (continued) Resistant viruses :Resistant viruses : frequently during treatment with frequently during treatment with

amantadine or rimantadine and amantadine or rimantadine and can be transmitted among family can be transmitted among family members.members.

resistance infrequent with resistance infrequent with zanamivir or oseltamivirzanamivir or oseltamivir


therapy (primary therapy (primary influenza pneumoniainfluenza pneumonia )) maintaining oxygenation and is most maintaining oxygenation and is most

appropriately undertaken in an intensive appropriately undertaken in an intensive care unit, with aggressive respiratory and care unit, with aggressive respiratory and hemodynamic support as needed. hemodynamic support as needed.

When an acute respiratory distress When an acute respiratory distress syndrome develops, fluids must be syndrome develops, fluids must be administered cautiously, with close administered cautiously, with close monitoring of blood gases and monitoring of blood gases and hemodynamic functionhemodynamic function


therapy (bacterial therapy (bacterial complicationscomplications )) secondary bacterial pneumonia. secondary bacterial pneumonia. Gram's staining and culture of Gram's staining and culture of

respiratory secretions, such as respiratory secretions, such as sputum or transtracheal aspirates.sputum or transtracheal aspirates.(or empirical antibiotics effective (or empirical antibiotics effective against the most common bacterial against the most common bacterial pathogens pathogens (S. pneumoniae, S. (S. pneumoniae, S. aureus, aureus, and and H. influenzae) H. influenzae)

clinical management of clinical management of human infection with human infection with

avian influenzaavian influenzaA (H5N1)A (H5N1)


Summary of treatment Summary of treatment modalities for human A(H5N1) modalities for human A(H5N1) virus infectionvirus infection

Recommended

Modalities

Strategies

Antivirals Oseltamivir is the primary treatment of choice. Consider modified regimens (150 mg twice daily for adults), longer duration and possibly combination therapy with amantadine or rimantadine (in countries where A(H5N1) viruses are likely to be susceptible to adamantanes)

in the early : reducing mortality- at a later stage of illness


Summary of treatment Summary of treatment modalities for human A(H5N1)modalities for human A(H5N1)virus infectionvirus infection

Recommended

Modalities

Strategies

Antibiotics Empiric treatment1 for community-acquired pneumonia : a β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) pluseither azithromycin or a fluoroquinolone



Recommended

Modalities

Strategies

Oxygen therapy

Monitor oxygen saturation and maintain SaO2 over 90% with nasal cannulae or face mask

IPPV(Invasive positive pressureventilation)

Early intervention recommended for ARDS. Use lung protective, low tidal volume, low pressure ventilation to prevent barotrauma and conservative fluid management



Recommended

Modalities

Strategies

Low dose systemiccorticosteroids

Appropriate for refractory septic shock complicating ARDS (e.g. hydrocortisone intra venous 50 mg every 6 hours in adults).

NSAIDs, antipyretics

Paracetamol :sufficient in most cases as an anti-pyretic



Recommended

Modalities

Strategies

Infection control

Whenever risk of infectious aerosols, use particulate respirator(N95, FFP2 or equivalent), eye protection, gowns, gloves andan airborne precaution room or negative pressure room.

Immunotherapy??

Neutralizing monoclonal antibodies or of polyclonal sera



Modalities NOT

Recommended

Strategies

Adamantane monotherapy

When neuraminidase inhibitors are available, monotherapywith amantadine or rimantadine is not recommended.Combination therapy is consideration in areas where A(H5N1)virus is likely susceptible



Modalities NOT

Recommended

Strategies

Antibioticchemoprophylaxis

NOT Recommended

Salicylates Avoid aspirin and aspirincontaining products in children and young adults (<18 yearsold) because of the risk of Reye Syndrome



Modalities NOT Recommended

Strategies

NPPV(Non-invasive positivepressure ventilation)

Generally not recommended

Systemic corticosteroids

Moderate to high doses of unproven benefit and potentiallyharmful: not recommended

PROPHYLAXISPROPHYLAXIS


PROPHYLAXISPROPHYLAXIS(vaccines)(vaccines) inactivated influenza vaccines(highly purified) inactivated influenza vaccines(highly purified)

: influenza A and B viruses circulated during : influenza A and B viruses circulated during the previous influenza season. the previous influenza season.

50 to 80% protection.50 to 80% protection. reactions. 5% of individuals low-grade fever reactions. 5% of individuals low-grade fever

and mild systemic symptoms 8 to 24 hand mild systemic symptoms 8 to 24 h one-third : mild redness or tenderness at the one-third : mild redness or tenderness at the

vaccination sitevaccination site (produced in eggs,)individuals with true (produced in eggs,)individuals with true

hypersensitivity to egg products should be hypersensitivity to egg products should be desensitized or not be vaccinated. desensitized or not be vaccinated.


PROPHYLAXISPROPHYLAXIS(vaccines)(vaccines) 1976 swine influenza vaccine ; 1976 swine influenza vaccine ;

increased frequency of Guillain-increased frequency of Guillain-Barre syndrome, ( since 1976 Barre syndrome, ( since 1976 generally have not been)generally have not been)

during the 1992–1993 and 1993–during the 1992–1993 and 1993–1994 influenza seasons, slightly 1994 influenza seasons, slightly more than one case per million more than one case per million among vaccine recipients.among vaccine recipients.


PROPHYLAXISPROPHYLAXIS(vaccines)(vaccines) recommends :for any individual >6 recommends :for any individual >6

months of age who is at an increased months of age who is at an increased risk for complications of influenza, (risk for complications of influenza, (Table). ).

inactivated ("killed"), safely to inactivated ("killed"), safely to immunocompromised patients.immunocompromised patients.

not associated with exacerbations of not associated with exacerbations of chronic nervous-system diseases such chronic nervous-system diseases such as multiple sclerosis. as multiple sclerosis.

administered early in the autumn before administered early in the autumn before influenza outbreaks occur and then influenza outbreaks occur and then annuallyannually


PROPHYLAXISPROPHYLAXIS(vaccines)(vaccines) a live attenuated influenza vaccine : a live attenuated influenza vaccine :

intranasal spray.intranasal spray. by reassortment of currently circulating by reassortment of currently circulating

strains of influenza A and B virus with a cold-strains of influenza A and B virus with a cold-adapted, attenuated master strain. adapted, attenuated master strain.

well tolerated and highly efficacious (92% well tolerated and highly efficacious (92% protective)protective)

protection against a circulating influenza protection against a circulating influenza virus that had drifted antigenically away from virus that had drifted antigenically away from the vaccine strain. the vaccine strain.

for use in healthy children and adults from 5 for use in healthy children and adults from 5 to 49years of age.to 49years of age.


PROPHYLAXISPROPHYLAXIS(vaccines)(vaccines) a live attenuated influenza a live attenuated influenza

vaccine : 0.5 ml sprayer , 5-9 years vaccine : 0.5 ml sprayer , 5-9 years – 1 or 2 doses interanasal (4-10 – 1 or 2 doses interanasal (4-10 w) , 9-49 1 2 doses interanasal w) , 9-49 1 2 doses interanasal

inactivated influenza vaccines :IMinactivated influenza vaccines :IM age> 13 years=0.5 ml age> 13 years=0.5 ml × 1 × 1 age 4-12 years=0.5 ml age 4-12 years=0.5 ml × 2 × 2 (4 w) (4 w) age 6- 48 m. =0.25 ml age 6- 48 m. =0.25 ml × 2 × 2 (4 w) (4 w)


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) amantadine or rimantadine, : 100 to 200 amantadine or rimantadine, : 100 to 200

mg/d, ( 70 to 100% against influenza A mg/d, ( 70 to 100% against influenza A infection) . infection) .

Chemoprophylaxis with oseltamivir (75 Chemoprophylaxis with oseltamivir (75 mg/d by mouth) ( 84 to 89% against mg/d by mouth) ( 84 to 89% against influenza A and B). influenza A and B).

for high-risk individuals who have not for high-risk individuals who have not received influenza vaccine or in a received influenza vaccine or in a situation where the vaccines previously situation where the vaccines previously administered are relatively ineffective administered are relatively ineffective because of antigenic changes in the because of antigenic changes in the circulating virus. circulating virus.


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) During an outbreak: antiviral During an outbreak: antiviral

chemoprophylaxis with inactivated chemoprophylaxis with inactivated vaccine,(drugs do not interfere with an vaccine,(drugs do not interfere with an immune response to the vaccine. In immune response to the vaccine. In fact, there is evidence that the fact, there is evidence that the protective effects of chemoprophylaxis protective effects of chemoprophylaxis and vaccine may be additive.)and vaccine may be additive.)

concurrent administration of concurrent administration of chemoprophylaxis and the live chemoprophylaxis and the live attenuated vaccine may interfere with attenuated vaccine may interfere with the immune response to the vaccine. the immune response to the vaccine.


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) Chemoprophylaxis : control nosocomial Chemoprophylaxis : control nosocomial

outbreaks of influenza.outbreaks of influenza. For prophylaxis, administration should For prophylaxis, administration should

be instituted promptly when influenza be instituted promptly when influenza activity is detected and must be activity is detected and must be continued daily for the duration of the continued daily for the duration of the outbreak. outbreak.

Amantadine and rimantadine are Amantadine and rimantadine are approved for prophylaxis in adults and approved for prophylaxis in adults and in children(>1years) oseltamivir is in children(>1years) oseltamivir is approved for prophylaxis in adults and approved for prophylaxis in adults and in children(>13 years old) .in children(>13 years old) .


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) Persons at High Risk Who Are Persons at High Risk Who Are

Vaccinated After Influenza Activity Vaccinated After Influenza Activity Has Begun(Has Begun(for persons at high risk for persons at high risk during the time from vaccination until during the time from vaccination until immunity has developed. Children aged immunity has developed. Children aged <9 years who receive influenza vaccine <9 years who receive influenza vaccine for the first time can require 6 weeks of for the first time can require 6 weeks of chemoprophylaxis (i.e., chemoprophylaxis (i.e., chemoprophylaxis for 4 weeks after the chemoprophylaxis for 4 weeks after the first dose of vaccine and an additional 2 first dose of vaccine and an additional 2 weeks of chemoprophylaxis after the weeks of chemoprophylaxis after the second dose).)second dose).)


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) Persons Who Provide Care to Persons Who Provide Care to

Those at High Risk (Those at High Risk (employees of employees of hospitals, clinics, and chronic-care hospitals, clinics, and chronic-care facilities; household members; facilities; household members; visiting nurses; and volunteer visiting nurses; and volunteer workers)workers)

Persons Who Have Immune Persons Who Have Immune Deficiencies (Deficiencies (HIV, chiefly those with HIV, chiefly those with advanced HIV disease)advanced HIV disease)


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) When outbreaks occur in institutions, When outbreaks occur in institutions,

chemoprophylaxis should be chemoprophylaxis should be administered to all residents, regardless administered to all residents, regardless of whether they received influenza of whether they received influenza vaccinations during the previous fall, vaccinations during the previous fall, and should continue for a minimum of 2 and should continue for a minimum of 2 weeks. If surveillance indicates that weeks. If surveillance indicates that new cases continue to occur, new cases continue to occur, chemoprophylaxis should be continued chemoprophylaxis should be continued until approximately 1 week after the until approximately 1 week after the end of the outbreakend of the outbreak


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) Chemoprophylaxis also can be offered Chemoprophylaxis also can be offered

to unvaccinated staff members who to unvaccinated staff members who provide care to persons at high risk. provide care to persons at high risk.

Chemoprophylaxis should be Chemoprophylaxis should be considered for all employees, considered for all employees, regardless of their vaccination status, regardless of their vaccination status, if the outbreak is suspected to be if the outbreak is suspected to be caused by a strain of influenza virus caused by a strain of influenza virus that is not well-matched to the vaccinethat is not well-matched to the vaccine


PROPHYLAXISPROPHYLAXIS(Chemoprophylaxis)(Chemoprophylaxis) In addition to nursing homes, In addition to nursing homes,

chemoprophylaxis also can be chemoprophylaxis also can be considered for controlling considered for controlling influenza outbreaks in other influenza outbreaks in other closed or semiclosed settings closed or semiclosed settings (e.g., dormitories or other (e.g., dormitories or other settings in which persons live in settings in which persons live in close proximity).close proximity).


Household Contact Household Contact TreatmentTreatment Frequent handwashingFrequent handwashing N95 masks/eye protection (feasible?)N95 masks/eye protection (feasible?) Monitor temperature twice daily for 7 Monitor temperature twice daily for 7

daysdays

QuarantineQuarantine

No Fever Fever

Prophylaxis Treatment


کاهش برای اولیه کاهش اقدامات برای اولیه اقداماتبیماری بیماری انتشار انتشار

زائی سرایت دوره طی در بیماران کردن زائی ایزوله سرایت دوره طی در بیماران کردن ایزوله دست بهداشت رعایت و شخصی حفاظتی وسایل از دست استفاده بهداشت رعایت و شخصی حفاظتی وسایل از استفاده

وی درمانی مراقبت یا بیمار با نزدیک تماس در که کسانی وی توسط درمانی مراقبت یا بیمار با نزدیک تماس در که کسانی توسطهستندهستند

: شده بستری مظنون افراد برای احتیاطات رعایت شده : حداکثر بستری مظنون افراد برای احتیاطات رعایت حداکثرایزوله N-95N-95ماسک ماسک اطاق ، چشم محافظ ، کش دست و گان ایزوله ، اطاق ، چشم محافظ ، کش دست و گان ،

منفی فشار منفی با فشار با مرطوب اوازم و زباله صحیح مرطوب دفع اوازم و زباله صحیح دفع ریوی عالئم یا تب بروز نظر از یافته تماس افراد کنترل و ریوی مراقبت عالئم یا تب بروز نظر از یافته تماس افراد کنترل و مراقبت بیمار با یافته تماس افراد پروفیالکسی بیمار درمان با یافته تماس افراد پروفیالکسی درمان مالقاتها کردن مالقاتها محدود کردن محدود پرسنل وامد رفت کردن پرسنل محدود وامد رفت کردن محدود


Influenza Prevention: Influenza Prevention: What What CanCan We Do? We Do?

•Stay home when sick•Respiratory & hand hygiene: Cover your cough Wash hands and/or

use alcohol hand gelAvoid touching eyes, nose, mouth

•Implement “social distancing” measures

•Masks?•Pandemic preparedness planning

نژاد وفایی رضا دکتر

Table 4. Isolation Precautions for Patients Hospitalized With Suspected or Confirmed Avian Influenza H5N1*8

Standard precaution

Strict hand hygiene before and after all patient contacts

Contact precautions

Use gloves and gown for all patient contact

Eye protection

Wear when within 3 feet (1 m) of the patient

Airborne precautions

Place the patient in an airborne isolation room (ie, monitored negative air pressure in relationship to the surrounding areas with 6 to 12 air changes per hour)

Use a fit-tested respirator, at least as protective as an NIOSH-approved N-95 filtering facepiece respirator, when entering the room

*NIOSH = National Institute of Occupational Safety and Health.


Health Care Worker Health Care Worker SurveillanceSurveillance

Record temperature twice dailyRecord temperature twice daily

Prophylaxis Normal Abnormal Symptoms

Remove from workplace

Evaluate for influenza

Treatment


Infection control Infection control considerations /Isolation considerations /Isolation facilitiesfacilities appropriate precaution measuresappropriate precaution measures wear eye protection, gowns, gloves and wear eye protection, gowns, gloves and

particulate respirators that are at least as particulate respirators that are at least as effective as the NIOSH-certified N95, EU effective as the NIOSH-certified N95, EU FFP2 or equivalentFFP2 or equivalent

an airborne precaution room an airborne precaution room (mechanically or naturally ventilated (mechanically or naturally ventilated rooms with at least 12 air exchanges/hour rooms with at least 12 air exchanges/hour and safe airflow), in a single well-and safe airflow), in a single well-ventilated room, or in a negative pressure ventilated room, or in a negative pressure room when available.room when available.


Special infection control Special infection control considerations during considerations during ventilatory support therapyventilatory support therapy endotracheal intubation, as well endotracheal intubation, as well

as possibly NPPV and oxygen as possibly NPPV and oxygen therapy, were risk factors for therapy, were risk factors for SARS nosocomial transmission, SARS nosocomial transmission, although inconsistent use of PPE although inconsistent use of PPE is a key confounding variable in is a key confounding variable in such studiessuch studies


Special infection control Special infection control considerations during considerations during ventilatory support therapyventilatory support therapy supplemental oxygen via mask : supplemental oxygen via mask :

dispersion of potentially infectious dispersion of potentially infectious aerosols aerosols

Oxygen masks with an expiratory Oxygen masks with an expiratory port and HEPA filter will reduce port and HEPA filter will reduce aerosol productionaerosol production


Special infection control Special infection control considerations during considerations during ventilatory support therapyventilatory support therapy HEPA filters should be attached to HEPA filters should be attached to

the expiratory ports of ventilators, the expiratory ports of ventilators, and a closed tracheal suctioning and a closed tracheal suctioning system used for aspiration of system used for aspiration of respiratory secretions to reduce respiratory secretions to reduce generation and spread of generation and spread of infectious aerosols. infectious aerosols.


Special infection control Special infection control considerations during considerations during ventilatory support therapyventilatory support therapy To minimize the risk of nosocomial To minimize the risk of nosocomial

infection, it is important to maintain infection, it is important to maintain adequate medical ward ventilation adequate medical ward ventilation during application of oxygen during application of oxygen therapy or NPPV. If NPPV is to be therapy or NPPV. If NPPV is to be used, a closed system with a head used, a closed system with a head helmet and an expiratory port HEPA helmet and an expiratory port HEPA filter is recommended whenever filter is recommended whenever possiblepossible

CONTROLCONTROL


VACCINATIONVACCINATION

QURANTINEQURANTINE DEPOPULATIODEPOPULATIO

CONTROLCONTROL


Transmission of AI virus A/H5N1 Transmission of AI virus A/H5N1 to humansto humans

From infected animals to humansFrom infected animals to humans– contact with respiratory secretions, faeces, contact with respiratory secretions, faeces,

contaminated feathers, blood from infected contaminated feathers, blood from infected birds.birds.

– Environmental contaminationEnvironmental contamination– Raw food consumption (?)Raw food consumption (?)

From a patient to health careFrom a patient to health care

personnel/family memberspersonnel/family members


Asia’s particularities : Live Animal Asia’s particularities : Live Animal MarketsMarkets


AI : Transmission issuesAI : Transmission issues

– Need to better understand the kind of “close contacts” with Need to better understand the kind of “close contacts” with poultry that pose a risk to public health.poultry that pose a risk to public health.

– Clear need to improve biosecurity and hygiene at live animal Clear need to improve biosecurity and hygiene at live animal marketsmarkets


Control of animal outbreaksControl of animal outbreaks

Stamping out policies:Stamping out policies:– Destruction of infected flocks and surrounding flocks.Destruction of infected flocks and surrounding flocks.– Strengthening disease surveillanceStrengthening disease surveillance– Delay of 3-6 months before restockingDelay of 3-6 months before restocking

Vaccination Vaccination – Need for biosecurity capabilities Need for biosecurity capabilities – Implications for tradeImplications for trade


Benefits of fit testingBenefits of fit testing Study: 25 volunteers, 21 models of N-95 Study: 25 volunteers, 21 models of N-95

respiratorsrespirators WithoutWithout fit testing, 95% of the tests had fit testing, 95% of the tests had

up to 33% leakageup to 33% leakage WithWith fit testing, 95% of the tests had no fit testing, 95% of the tests had no

more than 4% leakagemore than 4% leakage


فوری و اولیه فوری اقدامات و اولیه اقدامات

و مسوولین سازی و آگاه مسوولین سازی آگاهبروز با اجرائی بروز مدیران با اجرائی مدیران

بیماری به بیماری شک به شک تمام فوری تمام قرنطینه فوری قرنطینه

مشکوک مشکوک حیوانات حیوانات تشخیص اثبات تشخیص پیگیری اثبات پیگیری در جمعی دسته در انهدام جمعی دسته انهدام

در - مزارع آلوده در - مزارع مزارع آلوده مزارعمجاور - مجاور - تماس تماس


کنی ریشه و کنی کنترل ریشه و کنترل

موشها و حشرات با موشها مبارزه و حشرات با مبارزه انهدام و ها رمه انهدام کشتار و ها رمه کشتار

اجساداجساد فشار با اسپری از فشار استفاده با اسپری از استفاده

سطوح کردن پاک برای سطوح زیاد کردن پاک برای زیادبا پاشی سم و وسائل با و پاشی سم و وسائل و

پایدار ضدعفونی پایدار مواد ضدعفونی مواد


پیشگیریپیشگیری

خروج و ورود راههای کردن محدود و خروج کنترل و ورود راههای کردن محدود و کنترل شدید شدید مراقبت مراقبت بیولوژیک ایمنی و بیولوژیک مراقبت ایمنی و مراقبت

انسان - ازدحام محلهای انسان - کنترل ازدحام محلهای کنترل

با - مکانهای در ها رمه پرورش از با - خودداری مکانهای در ها رمه پرورش از خودداریدریایی پرندگان دریایی وفور پرندگان وفور

-طیور و دام صنایع کارکنان طیور- آموزش و دام صنایع کارکنان آموزش) گیریهای همه به سریع گیریهای (پاسخ همه به سریع )) MP AIMP AIپاسخ


گیری : همه اول فازبیماری: = - • کنی ریشه گیری همه طی بیماری: = - در کنی ریشه گیری همه طی در

شعاع در ضدعفونی و ها رمه شعاع کشتار در ضدعفونی و ها رمه 55کشتار ( قرنطینه ( ) کیلومتری قرنطینه ( شدید- کیلومتری شدید- اقدامات اقدامات

( – (محافظتیمحافظتی ماسک دستکش ( – (شاغلین ماسک دستکش -N100- N100شاغلینN99 - N-95N99 - N-95 – ( - - - – (عینک چکمه عینک) – - - - ) – روپوش چکمه روپوش

شعاع در ها رمه شدید شعاع مراقبت در ها رمه شدید 5050مراقبت – ( در( وانتقاالت نقل کنترل کنترل ) – کلیومتر در( وانتقاالت نقل کنترل کنترل کلیومتر

رسانی – 6060شعاع شعاع اطالع عملیالت رسانی – کلیومتر اطالع عملیالت کلیومترداروی - ( شروع داروی - (عمومی شروع OSELTAMIVIROSELTAMIVIR ( (7575عمومی

در مرغداری کارکنان برای روزانه در میلی مرغداری کارکنان برای روزانه میلیتا تائید تا صورت تائید - 77صورت ، تائید صورت در - روز ، تائید صورت در روز

تا مرغداریها شاغلین و آنها تا واکسیناسیون مرغداریها شاغلین و آنها واکسیناسیونآغشته - 55شعاع شعاع وسایل ضدعفونی آغشته - کیلومتر وسایل ضدعفونی کیلومتر

هیپوکلریت با بیماران بدن مایعات یا خون هیپوکلریت به با بیماران بدن مایعات یا خون به11 - % - %


گیری : همه بعد دوم فازبیماری • از رهائی اثبات برای

آزمایشگاهی و کلینیکی مراقبتاست الزم کنترل محدوده در

وتا 30مدت • اول ماه 5روز

کنترل : و مراقبت سوم فاز• ، مهاجر و اهلی پرندگان مراقبت

مدت به صادرات و وارداتطوالنی


REFERENCESREFERENCES Treanor J. Treanor J. Influenza Virus. Influenza Virus. In In Mandell, Douglas, and Mandell, Douglas, and

Bennett's Principles and Practice of Infectious diseasesBennett's Principles and Practice of Infectious diseases . . 6th ed. New York: Elsevier/Churchill Livingstone; 6th ed. New York: Elsevier/Churchill Livingstone; 2005:2005:chap 162chap 162

Kasper,…HARRISON`S Principles of Internal Medicine Kasper,…HARRISON`S Principles of Internal Medicine 1616thth ed.2005 : chap.171 ed.2005 : chap.171

Clinical management of human infection with avian Clinical management of human infection with avian influenza A (H5N1) virus ,Updated advice 15 August influenza A (H5N1) virus ,Updated advice 15 August 2007 ,wold health organization2007 ,wold health organization

Prevention and Control of Influenza Recommendations Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices of the Advisory Committee on Immunization Practices (ACIP) , Morbidity and Mortality Weekly Report , July 28, (ACIP) , Morbidity and Mortality Weekly Report , July 28, 2006 / Vol. 55 / No. RR-10, department of health and 2006 / Vol. 55 / No. RR-10, department of health and human services Centers for Disease Control and human services Centers for Disease Control and PreventionPrevention

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