case management of suspect avian influenza a (h5n1) virus infection in humans part 1: background...
TRANSCRIPT
Case Management of Suspect Avian Influenza A
(H5N1) Virus Infection in Humans
Part 1: Background information on clinical features of human infection with avian
influenza A (H5N1) virusesMay, 2007
Learning Objectives
• Recognize clinical features of avian Influenza A (H5N1) virus infection in humans
• Understand how information about the patient before onset of illness can help you suspect H5N1 virus infection
Illness Scenario
• Alex sick for three days– Fever– Headache– Cough– Shortness of breath– Muscle aches– Watery diarrhea
• No one else sick• Works at poultry farm and handles poultry
Question: Is avian Influenza A (H5N1) the most likely cause of Alex’s symptoms?
General InformationHuman
influenza
Avian Influenza A (H5N1)
Affected
Age Groups
• All ages affected
• Highest attack rate in children <5 years
• Most complications in elderly >65 years and persons with chronic medical conditions
• Children of all ages
• Healthy young adults
• Highest CFR in adolescents.
Estimated Incubation Period
• Mean: 2 days
• Range: 1 – 4 days
• Mean: 2 – 5 days
• ≤7 days
Signs and Symptoms
Avian Influenza A (H5N1)Type of infection Lower respiratory
Symptoms Fever, Cough, Headache
Shortness of breath, difficulty breathing
Diarrhea in some cases
Hospitalized Patients Pneumonia
Hypoxia requiring oxygen and respiratory failure requiring intubation and mechanical ventilation
Acute Respiratory Distress Syndrome (ARDS)
Laboratory Findings
Commonly associated with human infection with avian influenza A (H5N1) viruses:
– Drop in white blood cell count (leukopenia)• Drop in lymphocytes, a kind of white blood cells
(lymphopenia)
– Mild to moderate drop in blood platelet count
– Increased aminotransferases (liver enzymes)
Unusual Clinical Manifestations and Outcomes
• Knowledge of avian influenza A (H5N1) virus infection in humans is still evolving
• Unusual symptoms– Southern Vietnam – encephalitis and diarrhea– Fever and diarrhea can be the only early signs
and symptoms before pneumonia occurs later with H5N1 virus infection
Complications
Seasonal Influenza • Ear infections, sinusitis• Bronchitis, bronchiolitis• Pneumonia
– viral or secondary bacterial• Exacerbation of chronic
conditions• Muscle inflammation• Neurologic Disease
– Seizures– Encephalopathy and
encephalitis– Reye syndrome
H5N1 Virus Infection in Humans • Most cases develop
pneumonia• Acute Respiratory Distress
Syndrome (ARDS)• Multiorgan failure• Encephalitis• Cytokine storm
Exposure to Avian Influenza (H5N1) Virus
1. Infected poultry, particularly coming in contact with respiratory secretions
2. Infected wild or pet birds
3. Other infected animals (e.g., pigs, cats, dogs)
4. Wild bird feces, poultry manure and litter containing high concentrations of virus
5. Fecally contaminated surfaces
H5N1 Virus Exposures Continued
6. Under- or uncooked poultry meat or eggs from infected birds
7. Contaminated vehicles, equipment, clothing, and footwear at affected sites, such as poultry farms with outbreaks
8. Contaminated air space (e.g., a barn, hen-house, or the air space proximal to barn exhaust fans)
9. Bodies of water with infected bird carcasses
10. Close contact with (within 3 feet of) confirmed human cases
Local Customs - Unique Exposures
• Cock fighting
• Swan defeathering
• Playing with dead chickens
• Duck blood pudding, local customs
• Hunting practices
Alex
Question:
Do you think Alex could have been exposed to highly pathogenic avian influenza A (H5N1) virus?
Alex’s Situation
• 24 year old Alex sick for three days– Fever– Headache– Cough– Shortness of breath– Muscle aches– Watery diarrhea
• No one else sick
• Alex works on poultry farm where he handles poultry
Part 1 Summary
• Individuals with avian influenza A (H5N1) virus infection may have non-specific lower respiratory symptoms, or (rarely) none at all
• Ask about recent exposure and contact with humans or animals that may have had avian influenza A (H5N1) virus infection
Case Management of Suspect Avian Influenza A (H5N1) Virus Infection in
Humans
Part 2: Case Management of Suspected Human Cases of Avian Influenza A
(H5N1) Virus Infection
Learning Objectives
• Testing available for diagnosing– Clinical specimens
• Current treatment options
• Infection control measures
Part 2 Session Overview
• Laboratory Testing
• Treating Suspected Patients
• Infection Control in the Healthcare Setting
Avian Influenza A (H5N1) VirusLaboratory Tests
• RT-PCR– Detects viral RNA– Diagnose H5N1 in
humans– BSL-2 conditions– Results within hours
• Viral culture – Only in enhanced
BSL-3 laboratory– Results in 2-10 days
• Serologic Testing– Rise in H5N1 specific
antibodies – Testing only in
enhanced BSL-3 laboratory
Clinical Specimens for Detecting Avian Influenza A (H5N1)
• Lower Respiratory Tract* – Broncheoalveolar lavage fluid– Endotracheal aspirate – Pleural fluid – Sputum
• Upper Respiratory Tract– Oropharyngeal swabs* – Nasal Swab
• Collect multiple specimens from the same suspect H5N1 patient on different days for RT-PCR testing * Preferred specimens
Clinical Specimens for Testing
• Serology– Acute and convalescent serum specimens
• Acute collected within 1 week of symptom onset• Convalescent collected 2-4 weeks after
symptom onset
– Other infections or concurrent illness
• Collect all possible specimens, serial collection
Clinical Specimens for Testing
• Autopsy Specimens– Eight blocks or fixed-tissue specimens from each
of the following sites• Central (hilar) lung with segmental bronchi• Right and left primary bronchi• Trachea (proximal and distal)• Pulmonary parenchyma from both right and left lung
– Major organs• Myocardium (right and left ventricle)• CNS (cerebral cortex, basal ganglia, pons, medulla, and
cerebellum)• Organ with significant gross or microscopic pathology)
Rapid Influenza Diagnostic Tests
• NOT RECOMMENDED TO DETECT AND DIAGNOSE H5N1 VIRUS INFECTION– Many commercial kits available– Results in 15-30 minutes– Low sensitivity (FALSE NEGATIVES LIKELY)– Positive result cannot differentiate seasonal
influenza A from avian influenza A (H5N1) virus infection
– Negative result does not rule out avian influenza A (H5N1) virus infection as diagnosis
Laboratory Diagnostics
• CDC’s influenza laboratory is nation’s influenza reference laboratory
• Capable of performing additional tests– Immunohistochemical testing on autopsy
specimens
• CDC’s Emergency Response Hotline– 770.488.7100
Imaging
Chest X-ray changes of pneumonia are common in the lungs of H5N1 patients
• Non-specific changes
• Diffuse or patchy infiltrates
• Fluid in the space surrounding the lungs
• Cavities forming in the lung tissue
BBC News. http://bbb.co.ukSaturday, 3 December 2005
Avian Influenza A (H5N1) Virus Patient’s Chest X-Rays
Chest x-ray of a patient with avian influenza A (H5N1) virus infection, shown by day of illness
Day 5 Day 7 Day 10
Tran Tinh Hien, Nguyen Thanh Liem, Nguyen Thi Dung, et al. New England Journal of Medicine. 18 March, 2004. vol. 350 no. 12. pp 1179-1188.
Neuraminidase Inhibitors
• Two drugs available– Oseltamivir (Tamiflu®) and
Zanamivir (Relenza ®)
– Should be given as soon as possible
– Effective for treatment and prevention
– Used for seasonal influenza and infection with avian influenza A (H5N1) viruses
OseltamivirDosage for seasonal influenza
Adults: 75 mg twice a day for 5 days
Children:
• <1 year, not recommended
• If < 15 kg: the dose should be 30 mg twice a day for 5 days
• If >15 kg to <23 kg: the dose should be 45 mg twice a day for 5 days
• If >23 kg to <40 kg: the dose should be 60 mg twice a day for 5 days
• If >40 kg: the dose should be 75 mg twice a day for 5 days
OseltamivirTreatment for H5N1 patients
• Best dosage for H5N1 patients unknown– Consider longer treatment (7 to 10 days) OR– Higher doses (150 mg)– Begin as soon as possible
• Dosage for prevention– Once daily for 7 to 10 days after last exposure
• Side Effects– Nausea and vomiting– Skin rash– Neurological problems
Oseltamivir• Effectiveness in seasonal influenza
– Reduces influenza symptoms by 1 day– Reduces some complications of influenza
• Cautions- Consider Risk versus Benefits– People with kidney disease (adjust dose)– Pregnant or nursing females
• Contraindication– <1 year of age– Hypersensitivity to any component of product
• Resistance – Detected in some H5N1 patients
Zanamivir
• Inhaled by mouth via special device
• May be used for treatment of influenza >7 years of age
• Treatment dosage– Once in morning and night, 5 days
• Side effects– Wheezing, and breathing problems
Zanamivir• Effectiveness in seasonal influenza
– Reduces influenza symptoms by one day– Reduces lower respiratory tract complications
• Consider Risk vs. Benefit– People with chronic respiratory disease – Pregnant or nursing females
• Resistance– Very rare in human cases of avian influenza A
(H5N1) virus infections– Active against Oseltamivir resistant H5N1 viruses
Other Treatments?
• Amantadine and Rimantadine– Some H5N1 viruses are resistant
• Corticosteroids– Not recommended– Only for worsening sepsis with adrenal
insufficiency
Treating Children
• Different Oseltamivir dosage– Based on child’s weight– Not approved in children <1 year
• No aspirin for children <18 years of age– Use Acetaminophen or Ibuprofen
• Children potentially infectious for longer periods than adults– If child cannot remain hospitalized, educate family about
infection control
– Source: WHO Writing Group, Emerging Infectious Diseases, Vol. 12, No. 1, January 2006.
Antibiotics
• Broad-spectrum– Do not use as a prophylactic– Give empiric therapy for suspected
bacterial pneumonia
• Secondary bacterial infection therapy – Treat with intravenous antibiotics as
recommended
Supportive Care
Hospital care for suspected or confirmed avian influenza A (H5N1) cases should include:
• Isolating the patient
• Supplemental oxygen and ventilation
• Intensive care support for organ failure
Infection Control Measures
• Patients hospitalized for clinical monitoring, diagnostic testing, and antiviral therapy
• Droplet/airborne precautions – Isolation– N95 respirators or more protective
• Eye protection (within 3 feet)– Goggles or face shields
Infection Control Measures
• Standard Precautions– Hand washing before and after contact with patient
or potentially contaminated items
• Contact Precautions– Gloves and gown worn– Dedicated equipment used
• CDC recommendations http://www.cdc.gov/flu/avian/professional/infect-control.htm
Managing Corpses
• No known 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
Part 2 Summary
1. Important appropriate clinical specimens are collected and tested
2. Begin treatment with neuraminidase inhibitor (oseltamivir) immediately! Do not wait!
Case Management of Suspect Avian Influenza A
(H5N1) Virus Infection in Humans
Part 3: Public Health Action
Learning Objectives
• Understand case management from public health perspective
• Recognize opportunities for public health authorities to effectively communicate avian influenza A (H5N1) information
Part 3 Session Overview
1. Collect Case Information • Classify case according to case definition for
surveillance2. Facilitate specimen collection and
laboratory testing3. Information on avian influenza A (H5N1)
illness4. Infection control measures in the home5. Active case follow up 6. Identify close contacts and recommend
antiviral chemoprophylaxis (oseltamivir)7. Enhance surveillance
Pandemic Influenza Plan
• Know your role and responsibilities as outlined in your health department’s plan
• Identify key collaborators before and during investigation
Case Information
Name and contact Information
Unique IdentifierOccupation (address)DemographicSymptoms Test Results
TreatmentOutcomeTravel history Potential exposures Close contacts
• Name of person reporting• Healthcare facility name and location
• Patient information:
Updated Interim Guidance for Laboratory Testing
of Persons with Suspected Infection with Avian
Influenza A (H5N1) Virus in the United States
Testing for avian influenza A (H5N1) virus infection is recommended for
a patient who has an illness that:
• requires hospitalization or is fatal; AND
• has or had a documented temperature of ≥100.4° F; AND
• has radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established; AND
• has at least one of the following potential exposures within 10 days of symptom onset:
A) History of travel to a country with influenza H5N1 documented in poultry, wild birds, and/or humans, AND had at least one of the following potential exposures during travel:• direct contact with (e.g., touching) sick or dead domestic poultry;
• direct contact with surfaces contaminated with poultry feces;
• consumption of raw or incompletely cooked poultry or poultry products;
• direct contact with sick or dead wild birds suspected or confirmed to have influenza H5N1;
• close contact (approach within 1 meter [approx. 3 feet]) of a person who was hospitalized or died due to a severe unexplained respiratory illness;
B) Close contact (approach within 1 meter [approx. 3 feet]) of an ill patient who was confirmed or suspected to have H5N1;
or
C) Worked with live influenza H5N1 virus in
a laboratory.
Case by Case Considerations!
• Mild or atypical disease (hospitalized or ambulatory) with one of the exposures listed above
• Severe or fatal respiratory disease whose epidemiological information is uncertain, unavailable, or otherwise suspicious but does not meet the criteria above
Proposed Influenza Division/CDC Case Definitions
• Confirmed• Suspect• Report under investigation• Non-case
• To be used for reporting purposes• A separate CDC Health Alert Network was
released that includes criteria for who should be tested for Influenza A (H5N1)
Confirmed Case (symptoms, exposure, laboratory confirmation)– Documented temperature >38 C (>100.4 F) and one of the
following: cough, sore throat, and/or respiratory distress
AND
– One of the following exposures within 10 days of onset• Direct exposure to sick or dead domestic poultry• Direct exposure to surfaces contaminated with poultry feces• Consumption of raw or partially cooked poultry or poultry
products• Close contact (within 3 feet) of an ill patient with confirmed or
suspected avian influenza A (H5N1) infection• Works with live HPAI (H5N1) virus in a laboratory
AND…
Proposed Influenza Division/CDC Case Definitions
Confirmed Case (Continued)
– Positive for avian influenza A (H5N1) virus by one of the following methods
• Isolation of H5N1 from viral culture• Positive RT-PCR for H5N1• 4 fold rise in H5N1 specific antibody titer by
microneutralization assay in paired sera• Positive IFA for H5 antigen using H5N1
monoclonal antibodies
Proposed Influenza Division/CDC Case Definitions
Suspect Case– Documented temperature >38 C (>100.4 F) and one of the
following: cough, sore throat, and/or respiratory distress AND
– One of the following exposures within 10 days of onset• Direct exposure to sick or dead domestic poultry• Direct exposure to surfaces contaminated with poultry feces• Consumption of raw or partially cooked poultry or poultry
products• Close contact (within 3 feet) of an ill patient with confirmed or
suspected avian influenza A (H5N1) virus infection• Works with live HPAI (H5N1) virus in a laboratory
– Laboratory test for avian influenza A (H5N1) is pending, inadequate or unavailable
Proposed Influenza Division/CDC Case Definitions
• Report Under Investigation– Additional information needed on clinical
and exposure information
• Not a Case– Negative avian influenza A (H5N1) virus
testing result from a sensitive laboratory testing method using adequate and appropriately timed clinical specimens
Proposed Influenza Division/CDC Case Definitions
Reporting
• Report through normal channels
• Information shared with WHO—probable and confirmed cases according to WHO case definition
• Help determine pandemic phase in US
Local PH
State PH
CDC
Specimen Collection
• Best specimens– Lower respiratory tract
• Broncheoalveolar lavage fluid• Endotracheal aspirate • Pleural fluid
– Upper respiratory tract• Oropharyngeal swabs
• Have supplies stocked for timely collection of appropriate specimens
Laboratory Testing
• Be familiar with testing available in your area
• Know which laboratories can perform which tests
• Know tests available at CDC
Avian Influenza A (H5N1) Virus Infection
• Emerging disease with evolving knowledge
• Empathy with public concerns
• Provide consistent and up to date literature to healthcare providers– Appropriate reading level– Translation for non-English speaking community
members
• Information such as clinical features, exposure, and treatment options
Infection Control Measures• Give consistent and up to date
literature to healthcare providers
• Hand washing – Soap and water for 15-20 seconds– Alcohol based sanitizer, >60%
alcohol
• Limit close contact with patient
• CDC Guidance on Community Mask Use During a Pandemic. www.pandemicflu.gov
Infection Control Measures• Seek medical care if condition
worsens
• Stay home for 24 hours after symptoms resolve
• CDC’s recommendation for in-home isolation– http://
www.cdc.gov/ncidod/sars/guidance/i/pdf/i.pdf
Active Follow Up
• Reasons for follow up– Specimens for testing– Timely notification of results– Monitor delivery of antiviral therapy– Secure antivirals if shortage– Note unusual clinical presentations
or complications
• Follow up by telephone– Patient– Healthcare provider (when available)– Surrogate (e.g. spouse)
Definition of Close ContactsThe definition of close contact is household and other
contacts in work, school, and community settings who had close unprotected (i.e., not wearing PPE) contact in the 1
day before through 14 days after the case patient’s symptom onset. Examples of close contact (within 1 meter)
with a person include providing care, speaking with, or touching. *
http://www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_4r1.pdf
* Depending on the specific circumstances suspect or confirmed cases that have completed isolation for at least 7 days, and who are no longer
symptomatic, may not be considered a source of exposure to others.
Identifying Close Contacts
• List of contacts from patient’s case report form
• Close contact = within 3 feet or 1 meter– Sharing utensils, close conversation, direct contact
• Follow Up– Characterize exposure – Identify signs and symptoms
• Those with symptoms treated as potential case of infection with avian Influenza A (H5N1) virus
Recommendations to Contacts
No symptoms• Post-exposure prophylaxis for close
contacts of a strongly suspected or confirmed human case of avian influenza A (H5N1) virus infection – WHO “high” and “moderate” risk
categories, poultry depopulators, and responders who have been on infected premises should receive post exposure prophylaxis
Instruction to Contacts
No symptoms (continued)• Self monitor for 10 days after last
exposure– Fever, respiratory symptoms, diarrhea,
and/or conjunctivitis– Seek medical care if symptoms present– Notify public health authorities
• Follow infection control measures in the home
Enhance Surveillance during an Animal or Human Outbreak of Avian Influenza A
(H5N1) Virus Infections• Active case finding among occupationally
exposed• Sensitization of community to report illness• Expand SARI and/or ILI surveillance to local
hospitals, private practice etc... – Screening in hospitals
• Training on procedures and reporting• Door-to-door community surveillance • Telephone hotlines for reporting
Part 3 Summary
• Public health authorities serve as protectors of their community’s health
• Important that public health authorities provide clear and consistent messages to patients and contacts
• Case management also means identifying contacts
GlossaryAvian Influenza A VirusesInfluenza A viruses that cause infection of wild birds and poultry.
ContraindicationA specific circumstance when the use of a certain treatment could be harmful.
Seasonal InfluenzaExpected rise in influenza occurrence among humans living in temperate climates; occurs during the winter season with strains of human influenza viruses that have minor changes from season to season.
References and Resources• CDC Guidance for State and Local Health Departments for Conducting
Investigations of Human Illness Associated with Domestic Highly pathogenic Avian Influenza Outbreaks in Animals (Draft).
• Preliminary clinical and epidemiological description of influenza A (H5N1) in Viet Nam. 12 February 2004. http://www.who.int/csr/disease/avian_influenza/guidelines/vietnamclinical/en/index.html
• Tran Tinh Hien, et al. Avian Influenza A (H5N1) in 10 Patients in Vietnam. N Engl J Med March 18, 2004: 350(12), p 1179-1181.
• WHO interim guidelines on clinical management of humans infected by influenza A(H5N1), 2 March 2004. http://www.who.int/csr/disease/avian_influenza/guidelines/clinicalmanage/en/index.html
• WHO pandemic influenza draft protocol for rapid response and containment. Updated draft 30 May 2006. http://www.who.int/csr/disease/avian_influenza/guidelines/protocolfinal30_05_06a.pdf