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A Influenza A (H1 N1) Master Update Ver 9.3 June 11 2009 (Emergency Medical Management and Response)

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A Influenza A (H1 N1) Master Update Ver 9.3 June 11 2009 (Emergency Medical Management and Response) - Presentation Transcript

  1. Influenza A (H1N1)qr (Quadruple Reassortment) “The Emerging Pandemic!” By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  2. Mission of Presentation “To provide the people of Ireland a universal teaching aid to respond to Influenza A (H1N1).” Medical Management of Biological Casualties 6/11/2009 2 Revised and Modified 25/05/2009
  3. Virus Names Associated with Recent Outbreak • Swine-Origin Influenza Virus (S-OIV) • North-American Influenza • Swine Influenza A(H1N1) • A(H1N1) • Novel Influenza A(H1N1) • Nouvelle Grippe A (H1N1) Spanish • A(H1N1)-SOIV • Influenza A(H1N1)swl (Swine like) • Influenza A (H1N1)v May 3 2009 • Influenza A(H1N1) May 8 2009 ( • Influenza A(H1N1)qr (Quadruple Reassortment) – May 29 2009-new name suggested by author! Virus will be referred to at different points of Presentation! Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  4. Influenza A(H1N1) Objectives • Identify Who pandemic Phases In relation to too European and Irish Alert Levels • Identify Global Health Regulation for Ireland • Biological triage • Identify global and Irish Influenza Surveillance Systems • Influenza A(H1N1) Worldwide Epidemiology • Surveillance processes and systems • Zoonosis of Swine Influenza Virus (SIV), Signs and Symptom Post- mortem findings, Past Outbreaks and differences of SIV and S- OIV/Novel Influenza Virus • Influenza virus antigenic shift and drift • Categorizing Influenza Virus “Viral Nomenclature • Emergence of Some Influenza Viruses in Humans • Swine Influenza (SIV) Reassortment • Swine Influenza Host Range • Pathogenesis of Triple Reassortment and Quadruple reassortmentCasualties Medical Management of Biological 6/11/2009 Revised and Modified 25/05/2009
  5. Influenza A(H1N1) Objectives Continued • Epidemiological Risk Factors Influenza A(H1N1) • Specific Investigational Triggers Influenza A(H1N1) • Irish resources for Influenza A(H1N1) • Influenza A(H1N1) Transmission, Personal Prevention, Human Signs and Symptoms, High Risk Groups, Diagnosis, Case Definitions • Recommended Initial PPE Protection Levels for all levels of response • Handling Human Remains (HHR) • Reporting Suspect Influenza A (H1N1) Virus Infection Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  6. Influenza A(H1N1) Objectives Continued • Influenza A(H1N1) Antivirals Treatment Schedule,Adverse Effects • Special Considerations for Children • Pregnancy • Typical Antiviral Clinic Process Flow Chart • Post Exposure Prophylaxis (PEP) Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  7. Influenza A(H1N1) Objectives Continued • Influenza A(H1N1) Irelands Laboratories Overview, Specimen Collection, Laboratory Precautions, • Shipping Infectious Substances • Infection Control In Health Care Setting • Environmental Waste • Vaccine • Antiviral treatments and considerations ,(PIEG) On Antivirals Algorithms • Bioethics • Quarantine • Infection Prevention and Control Guidance for the Ambulance Service • Influenza A(H1N1) Business Continuity with checklist • Case Studies Spain. England, and Mexico “Estimated Ratio” • IFPRI Pandemic Theory (“Pandemic Systems Model”) – Under development • Closing Discussion 6/11/2009 Medical Management of Biological Casualties Revised and Modified 25/05/2009
  8. World Health Organization (WHO) Pandemic Phase Advisories 11 June 2009 Influenza pandemic alert raised to Phase 6 The Director-General of WHO Dr Margarat Chan has On April 27 2009 The World therefore decided to raise the level of influenza On April 29, the Emergency Health Organisation raised its pandemic alert from phase 5 to phase 6. Committee had their third pandemic alert level to 4, verifying human-to-human \"The world is now at the start of the meeting, and decided to raise the pandemic alert level to five, swine flu, hours after the first British cases of the disease were 2009 influenza pandemic,\" the second-highest level, confirmed. April 28 2009 indicating that a pandemic is WHO flu expert Keiji Fukuda \"imminent,\" and that human- pointed out that it is too late to to-human transmission cases contain the swine flu have been recorded in multiple \"Containment is not a feasible countries.[ operation. Countries should now focus on mitigating the effect of the virus,” 3 to 4 Phase 4 to 5 Phase April 27 2009 April 29 2009 Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009 Avian Influenza H5N1 Phase 1-3
  9. World Health Organization (WHO) Pandemic Phase Advisories Phase 6 Rationale • World Health Organization has raise the H1N1 flu virus pandemic alert level from Phase Five to Phase Six. In doing so the WHO underscored: • The decision is based on the spread of the virus and not the severity of illness it causes. The virus has caused sustained community level outbreaks in more than three countries across two WHO regions • In general, the H1N1 flu virus continues to cause moderate illness globally with most people affected recovering at home without medical treatment. • For instance in Ireland most infections to date have been mild! • Future severity assessments would reflect one or a combination of the following factors: – changes in the virus – underlying vulnerabilities – limitations in health system capacities 6/11/2009 9
  10. International Health Regulations • Following 2003 SARS, the World Health Organization (WHO) revised the International Health Regulations • IHR contain operational definition of a “public health emergency of international concern” that triggers increased control responsibilities for nations • 194 countries worldwide Medical Management of Biological Casualties 6/11/2009 10 Revised and Modified 25/05/2009
  11. International Health Regulations (IHR) 2005 • New influenza virus sub‐types and clusters of unknown and unusual disease are notifiable to WHO in accordance with the Annex 2 decision instrument of the IHR (2005) Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  12. Global Pandemic Curve First confirmed Case in Spain was the catalyst in WHO activating phase 5 Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  13. MADRID -- Spain Became the First Country in Europe Influenza A (H1N1) • MADRID --In Catalonia Spain, officials confirmed the first European case of an infection in a person who had not (recently) travelled to Mexico, in a person whose girlfriend had done so, the second WHO region to experience transmission of this strain of H1N1 Medical Management of Biological Casualties 6/11/2009 13 Revised and Modified 25/05/2009
  14. Who Pandemic Phases and Recommended Actions Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  15. Who Pandemic Phases and Irelands Recommended Actions Medical Management of Biological Casualties 6/11/2009 Revised and Modified 25/05/2009
  16. Bioevent Disasters SEIRV Triage Model Categories • Susceptible • Exposed • Infectious • Removed • Vaccinated Medical Management of Biological Casualties 6/11/2009 16 Revised and Modified 25/05/2009
  17. “Biological Triage” Mitigation High Transmissibility • Influenza Mitigation: Susceptible • Identify & treat primary infections Exposed Infectious • Preventative Goal: • Prevent and delay secondary Removed infections Vaccinated  Prevent and delay clustered in-country transmissions  Keeping in mind the severity of the influenza virus country by New ECDC “containment vs delayed” article) country (High Transmissibility = Low or no containment therefore “delay” transmissions in WHO phase 4-6 ) According to WHO: Influenza A(H1N1) Secondary attack rate of 22-33% 6/11/2009 compared to 5-15% for seasonal influenza Medical Management of Biological Casualties
  18. EU Alert Levels in WHO Phase 6 EU alert level Description EU Alert Level One No confirmed human cases infected with the pandemic virus in any EU Member State EU Alert Level Two One or more confirmed human case(s) infected with the pandemic virus in any EU Member State EU Alert Level Three A confirmed outbreak (transmission) with the pandemic virus in any EU Member State EU Alert Level Four Widespread transmission in EU Member States Medical Management of Biological Casualties 6/11/2009 Revised and Modified 29/04/2009
  19. Influenza A(H1N1) Epidemiology 6/11/2009 19 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  20. Influenza A(H1N1) Health Service Executive • The Health Service Executive is advising anyone from Ireland who has recently returned from Mexico, California or Texas (within seven days), and develops an influenza-like illness, to telephone their family doctor for advice. • May 21 2009 Dr. Kevin Kelleher, head of Health Protection with the HSE said: • ‘Ireland has been preparing for situations like this for several years, and we have robust and detailed plans in place to respond. The H1N1 swine flu virus is sensitive to the antiviral drugs of which we have in place ample stockpiles for Ireland. • We are and will continue to closely follow the emerging situation. ' 6/11/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  21. 2009 Influenza A(H1N1) Outbreak In Ireland as of June 10 2009 Country Confirmed In-country cases of human Transmission swine influenza Ireland 12 2 (April 30 2009 1st case) NI 7 NA Influenza A(H1N1) Infection May 1 2009 June 11 2009 Weekly Surveillance Report DOHC Report As of June 10 2009 June 11 2009 Dr Tony Holohan, Chief Medical Officer of the Department of Health & Children said : • “notwithstanding the increase in level by the WHO, people in Ireland can be reassured that there is no increase in the risk to them. Irish cases are low in number and are regarded as mild. The Department and the HSE are satisfied that the actions we are taking are proportionate in the current circumstances but contingency plans are in place, if required. However, again, we would like to remind people to help themselves avoid infection through personal health protection measures, including washing their hands thoroughly and sneezing into a tissue and disposing of it immediately’” 6/11/2009 21 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  22. 2009 Influenza A(H1N1) Outbreak In Ireland By Age, Gender and Transmission Mode Age Male Female Total Antiviral In-Country Out-of- Homecare Hospitalizations Treatment Transmission Country Transmission 0-9 1 0 1 1 0 1 1 0 10-19 0 0 0 0 0 0 0 0 20-29 1 3 4 4 1 3 4 0 30-39 2 2 4 4 0 4 4 0 40-49 0 1 1 0 0 1 1 0 50-59 1 0 1 1 0 1 1 0 60-69 0 0 0 0 0 0 0 0 70-79 1 0 1 1 0 1 1 0 Total 6 6 12 8 1 11 12 0 Resource :Influenza A(H1N1) Infection Weekly Surveillance Report (June 3 2009) Update as of June 10 2009 June 4 2009 DOHC Report 6/11/2009 22
  23. WHO Influenza A(H1N1) “Confirmed Cases” June 10 2009 • 11 June 2009 -- As of 14:00 GMT, 11 June 2009, 74 countries have officially reported 28,774 cases of influenza A(H1N1) infection, including 144 deaths. 6/11/2009 25
  24. Influenza A(H1N1) (EU) and EFTA ECDC June 10 2009 Hot Spots in Red Medical Management of Biological Casualties 6/11/2009 27 Revised and Modified 25/05/2009
  25. Distribution of confirmed cases of influenza A(H1N1) virus infection by date of reporting, EU and EFTA countries, 27 April to June 11 2009 6/11/2009 29
  26. Influenza A(H1N1) Outside (EU) and EFTA ECDC Progression Maps and tables June 11 2009 2009 Hot Spots in Red 6/12/2009 30
  27. Influenza A(H1N1) Americas Outbreak 2009 • As of 9 June 2009, 23,427 confirmed cases of the new virus influenza A (H1N1) infection, including 141 deaths June 9 2009 Medical Management of Biological Casualties 6/11/2009 31 Revised and Modified 25/05/2009
  28. 2009 Influenza A(H1N1) Outbreak In The United States The date of the onset of symptoms of the first confirmed case was 28 March 2009 in the United States. U.S. Human Cases of H1N1 Flu Infection June 5, 2009, 11:00 AM ET 13,217 case 27 deaths Update Fridays Medical Management of Biological Casualties 6/12/2009 32 Revised and Modified 25/05/2009
  29. 2009 Influenza A(H1N1) Outbreak In The United States 6/12/2009 33
  30. Influenza A(H1N1) Outbreak in Canada June 10 2009 • As of June 10 2009, a total of 2,978 laboratory-confirmedcases of H1N1 flu virus have been reported in 9 provinces and 3 territories in Canada except Newfoundland Yukon - 1 Nunavut - 96 North West Territories - 2 Newfoundland - 0 British Columbia- 151 Prince Edward Island - 3 Alberta- 195 Nova Scotia - 78 Saskatchewan - 221 New Brunswick - 2 Manitoba - 56 PHAC is reporting Ontario – 1,562 Quebec- 611 every MWF Medical Management of Biological Casualties 6/11/2009 37 Revised and Modified 25/05/2009
  31. 2009 Influenza A(H1N1) Outbreak in Canada The following graph, also known as JuneJune 8th, 2009. Theup to date as 8 2009 graph an epidemic curve, is of illustrates the coursegraph, also The following of the current H1N1 flu virus outbreak in known as an epidemic Canada. It shows either the date when symptoms of H1N1 fluas of curve, is up to date virus began or, 1,this date The not June if 2009. was graph illustrates the course of available, the date when a specimen was collected, for each the current H1N1 flu virus of the laboratory-confirmed cases. outbreak in Canada. It shows the date when symptoms of H1N1 flu virus began for each of the laboratory-confirmed cases. Medical Management of Biological Casualties 6/11/2009 38 Revised and Modified 25/05/2009
  32. Influenza A(H1N1) United Kingdom Outbreak 2009 822 Confirmed Cases as of June 11 2009 Scotland- 311 Northeast - 16 Northern Ireland - 7 Yorkshire and Humberside - 15 North West - 16 East Midlands - 12 East of England - 44 Wales - 2 London - 135 West Midlands - 171 South West - 14 South East - 79 6/11/2009 39
  33. Influenza A (H1N1) Australia Outbreak 2009 Northern Territory- 8 Queensland - 77 Western Australia - 35 New South Wales - 115 Australian Capital Territory - 22 South Australia - 26 Tasmania - 13 Victoria – 1,011 6/12/2009 40
  34. Influenza A (H1N1) Japan Outbreak 2009 • A of June 10 2009 Japan has reported 518 confirmed cases of Influenza A(H1N1) • As of June 11 2009 Number of cases rises to 532, including 9 students at a Tokyo Privately run Seisoku High School 6/12/2009 41
  35. Influenza A(H1N1) Outbreak in Japan 2009 • May 21 2009 Japan notified 67 new confirmed cases in past 24 hours, representing a 32% increase in cases according to ECDC Medical Management of Biological Casualties 6/11/2009 42 Revised and Modified 25/05/2009
  36. Estimates of the Basic Reproductive Rate (Ro) • There have already been several estimates of the basic reproductive rate (Ro), which all lie between 1 and 2; the range 1.4 to 1.9 being most probable. • The basic reproduction number is the mean number of secondary cases a typical single infected case will cause in a population with no immunity to the disease in the absence of interventions to control the infection. • It is often denoted R0. When R0 < 1 the infection will die out in the long run (provided infection rates are constant); but if R0 > 1 the infection will be able to spread in a population • See case study “How to they Do it” Influenza A (H1N1) Estimates of the Basic Reproductive Rate in Mexico” Medical Management of Biological Casualties 6/11/2009 43 Revised and Modified 25/05/2009
  37. ECDC June 3rd 2009 Cumulative Epidemic Curve: ECDC SITUATION REPORT Influenza A(H1N1) infection Update 03 June 2009, 17:00 hours CEST “The trend analysis using a semi-logarithmic scale, shows a rapid increase in the number of cases in the Americas (AMRO) as well as in the European region (EURO) since end of April 2009. The increase in the Western Pacific WHO Region (WPRO) was initially less significant but showed a sharp increase in the third week of May, in relation with cases reported from Japan. The trend in the WPRO Region suggests faster increase in the reported cases in the past 8 days, when compared with the AMRO and EURO Regions, due to the rapid spread of the infection in Australia. The South East Asian WHO Region (SEARO) reported the first cases three weeks after the alert of WHO on 25 April and the Eastern Mediterranean Region (EMRO, which is including some countries of the African continent) four weeks after the 25 April. The trend in the number of reported cases from SEARO seems to be similar to the one from WPRO during the last week.” Wikipedia: A semi- logarithmic chart of laboratory-confirmed A(H1N1) influenza cases by date according to WHO reports Medical Management of Biological Casualties 6/12/2009 44 Revised and Modified 29/04/2009
  38. Irish Alert Levels In WHO Phase 6 Irish Alert Level Description Irish Alert Level 1 Cases only outside Ireland (in a country or countries with or without extensive Irish travel/trade links Irish Alert Level 2 New virus isolated in Ireland June 11 2009 Irish Alert Level 3 Outbreak(s) in Ireland Irish Alert Level 4 Widespread activity in Ireland First Confirmed case In Dublin Ireland April 3 2009 Medical Management of Biological Casualties 6/12/2009 Revised and Modified 29/04/2009
  39. Zoonosis Swine Influenza Virus (SIV) “Zoonotic diseases are those diseases transmitted between animals and people and thus compromising public health as well as endangering livelihoods by affecting their livestock.” 6/12/2009 46
  40. Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS) • The Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS) is a joint FAO, World Organisation for Animal Health (OIE) and WHO initiative to improve the early warning capacity to animal disease threats for the benefit of the international community • Certain animal health events with potential public health implications are included in the scope of the International Health Regulations (2005) (IHR(2005)) • Intersectoral collaboration, including between the veterinary, food safety and public health sectors is needed to effectively address the prevention of zoonotic diseases 6/12/2009 47
  41. (GLEWS) Zoonotic and Non-Zoonotic Diseases • Zoonotic • Non zoonotic • Anthrax • African Swine Fever (ASF) • Bovine Spongiform Encephalopathy (BSE) • Classical Swine Fever (CSF) • Brucellosis (B. melitensis) • Contagious Bovine Pleuropneumonia (CBPP)* • Crimean Congo Hemorrhagic Fever • Foot and Mouth Disease (FMD)* • Ebola Virus • Peste des Petits Ruminants (PPR) • Foodborne diseases • Rinderpest – Stomatitis/Enteritis • Highly Pathogenic Avian Influenza (HPAI) • Japanese Encephalitis • Marburg Hemorrhagic Fever • New World Screwworm • Nipah Virus • Old World Screwworm WHO States : • Q Fever GLEWS is a joint system that builds on the added value of • Rabies combining and coordinating the alert mechanisms of FAO, • Rift Valley Fever* (RVF) OIE and WHO for the international community and stakeholders to assist in prediction, prevention and control of • Sheep Pox*/Goat Pox animal disease threats, including zoonoses, through sharing • Tularemia of information, epidemiological analysis and contribute to • Venezuelan Equine Encephalomyelitis joint field missions to assess and control the outbreak. • West Nile Virus 6/12/2009 48
  42. Irelands Governmental Lead Agencies, Groups and Committees Emergency/Incident Type Lead Lead Response Principal Other Potential Remarks Government Agency as per Support Support Roles Department Framework Role Animal Infectious Diseases DAFF DF (DOD) Local Authorities HSE role relates Diseases (Animal) HSE (DEHLG) to zoonotic AGS (DJELR) diseases; DFA infectious animal CD (DOD) diseases with a DTRANS human health (IRCG/MSO/Shipping) dimension DAST • Strategic Emergency Planning Guidance – Lead, Principal and Other Support Roles: • DAFF (Department of Agriculture Fisheries & Food) • DEHLG (Department of the Environment Heritage & Local Government) • DOD (Department of Defence) • HSE (Health Service Executive) • DTRANS (Department of Transport) • IRCG (Irish Coast Guard) • MSO (Marine Service Office)DAST (Department of Arts, Sport & Tourism) 6/11/2009 49
  43. Swine Influenza (SIV) Past Outbreak History • 1918 (H1N1) – Spanish flu (H1N1viruses like swine flu) Possible emergence from swine or an avian host of a mutated H1N1 virus Pandemic with >20 -40 million deaths globally • 1976 (H1N1) – United Sates/New Jersey Virus enzootic to US swine herds since or before 1930 – One Adult with Severe Pneumonia • 1988 Swine Influenza United States/Wisscosin Swine Virus – Pregnant Women dead after exposure to infected pig (Emergency c-section performed and saved baby) • 1993 Swine Influenza ((H3N2) The Netherlands Swine Influenza-ressortant between old human H3N2(1973-75 similarities) and avian H1N1 – 2 Children with mid disease. Father suspected into have transmitted the virus from close contact with pigs • 1958-2005 Case report summary – 19 US, 6 Czechoslovakia, 4 nether land, 3 Russia, 3 Switzerland ,1 Canada (17% mortality rate) Case report summary • 2005-2009- 11 sporadic cases of infection in humans with triple-reassortant swine influenza A H1 • 2009 Novel H1N1 Strain influenza A virus Pig to Human/Human to Human transmission • 2 009- Novel H1N1 Strain influenza virus – Human-to-Pig Transmission of the Novel H1N1 Strain influenza virus in a swine herd 6/11/2009 50 in Alberta Medical Management of Biological Casualties Revised and Modified 29/04/2009
  44. Swine Influenza (SIV) Past Outbreak • 1976 U.S. outbreak • In early 1976, the novel A/New Jersey/76 (Hsw1N1) influenza virus President Ford receives swine caused severe respiratory illness in flu vaccination 13 soldiers with 1 death at Fort Dix, New Jersey A/Victoria/75 (H3N2) spread simultaneously, also caused illness, and persisted until March Video from 1976 Swine Influenza • 230 soldiers were infected with Outbreak the A/New Jersey virus 6/11/2009 51 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  45. Zoonosis Swine Influenza Virus (SIV) • Two types of virus have been isolated in Ireland : 1. H1N1 was isolated for the first time in November 1991 – The H1N1 isolated in Ireland, is different from the strains circulating in Europe and elsewhere, and probably represents a separate introduction of an avian strain into Irish pigs. It is serologically related to Weybridge 79 and OMS/2899/82 2. H3N2 was isolated for the first time in June 1993 – The H3N2 virus isolated is serologically related to OMS/3633/84 • No evidence for the existence of H1N2 in Swine influenza virus. Colorized transmission electron micrograph (37,800X) of the A/New Jersey/76 (Hsw1N1) virus under plate magnification. Irish pigs has so far been detected Image taken during the virus' first developmental passage through a chicken egg. Courtesy of the CDC/Dr. E. Palmer; R.E. Bates. 6/11/2009 Medical Management of Biological Casualties 52 Revised and Modified 29/04/2009
  46. Swine Influenza in Pigs Virus Subtypes • Influenza A was first recognized as a clinical illness in pigs in 1918, which coincided with the 1918-1919 influenza pandemic in humans • H1N1 influenza A virus was first isolated from pigs in the United States in 1930. • H1N2 viruses that resulted from reassortant between the triple reassortant H3N2 viruses and classical H1N1 swine viruses have been isolated occasionally in the United States. • Avian H4N6 virus was recognized in pigs in Canada in 1999, but spread beyond the original farm of detection was not identified. • A novel H3N1 influenza virus was isolated from pigs in the United States in the mid 2000s; this virus may have risen from reassortment of an H3N2 turkey isolate, a human H1N1 isolate, and currently circulating swine influenza viruses 6/11/2009 53 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  47. Swine Influenza (SIV) Signs and Symptoms In Swine • Symptoms of infected pigs include: – Fever (102-106°F) – Depression – Coughing (barking) – Sneezing – Difficulty breathing – Red or inflamed eyes – Lack of appetite – Discharge from the nose or eyes – Reduced fertility or abortion (boars and sows) – Mortality up to 15% Medical Management of Biological Casualties 6/11/2009 Revised and Modified 26/04/2005
  48. Swine Influenza (SIV) Differential Diagnosis In Swine • The following diseases must be considered in the differential diagnosis: – Aujeszky's disease – Atrophic rhinitis – Enzootic (mycoplasmal) pneumonia – Actinobacillus pleuropneumoniae • (serotype 1-2-4-7-9-11, serotype 2, serotype 1-9-11 or serotype 4-7) – Bacterial pneumonia due to Pasteurella or Haemophilus spp. 6/11/2009 55 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  49. Swine Influenza (SIV) Porcine Diagnostic • Veterinary diagnostic kits: • Influenza A Antibody Competition ELISA kit • Influenza A Antigen Capture Kit • The kit detects antibodies directed against the A nucleoprotein in a wide range of species (avian, porcine, equine), including wild and zoo animals. 6/11/2009 56
  50. Swine Influenza (SIV) Post-mortem findings In Swine • Post-mortem findings include: • The lesions are confined to the respiratory system and are not very specific. • Hyperaemic of the mucosa of the respiratory tract • Excess production of mucus • Atelectasis and emphysema of the cardiac and apical lobes of the lungs, • Enlarged bronchial and mediastinal lymph nodes • In fatal cases there may be an acute interstitial pneumonia 6/11/2009 57 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  51. Swine Influenza (SIV) Examples of Vaccines For Porcine! • Schering-Plough Animal Health Corporation: MaxiVac Excells • Novartis : PneumoSTAR® SIV Swine Vaccine • Pfizer Animal Health: FluSure vaccine 6/11/2009 58
  52. National Biosecurity Importation of Swine In Ireland Directives • Swine- are prohibited to be imported from non-EU countries, except in compliance with Directive 72/462/EEC. • Licence issued in accordance with the Importation of Livestock Orders, 1970 to 1992 (S.I. No. 296 of 1970 and S.I. 298 of 1992). 6/11/2009 59 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  53. Influenza A(H1N1) Food Safety of Pork “INFOSAN” • Paris, 7 May 2009 • Joint FAO/WHO/OIE Statement on influenza A(H1N1) and the safety of pork • Influenza viruses are not known to be transmissible to people through eating processed pork or other food products derived from pigs. • Heat treatments commonly used in cooking meat (e.g. 70°C/160°F core temperature) will readily inactivate any viruses potentially present in raw meat products. Authorities and consumers should ensure that meat from sick pigs or pigs found dead are not processed or used for human consumption under any 6/11/2009 circumstances.! 60 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  54. Influenza A (H1N1) Prevention Department of Agriculture and Food and Fisheries (DAFF) • Agriculture and Food and fisheries (DAFF) will institute biosecurity measures • These control measures focus on animal health issues and aim to prevent any further spread of the disease among animals 6/11/2009 61
  55. Irish BIosecurity Measures For Pig Farms: • Normal biosecurity measures on pig farms Include: • Limit the access to essential personnel (farm employees, veterinarians and essential service people) • Implement policies that prevent employees who present signs of flu-like illness from having contact with the pigs or other people on the holding • Prevent access of international visitors or people who have recently returned from international travel, particularly from swine influenza affected regions, into your holding • Implement a shower-in/shower-out procedure and the use of farm- specific clothing and footwear for employees entering the holding • At minimum, employees should don farm footwear and completely wash hands and arms before having contact with the pigs • Enforce heightened personal hygiene practices including frequent hand washing for all people in contact with pigs 6/11/2009 62 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  56. Biosecurity On Pig Farms $ Profits $ QUALITY ASSURANCE REDUCED MEDICATION REDUCED MORTALITY IMPROVED REDUCED ZOONOSIS REDUCED DISEASE PERFORMANCE BIOSECURTY 6/11/2009 63
  57. Swine Influenza Transmission • Swine diseases can be spread in a number of ways, including: • Through diseased swine or healthy swine incubating disease • Through animals other than swine (farm animals, pets, wild birds and other wildlife, vermin and insects) • On the clothing and shoes of visitors and employees moving from farm-to-farm • In contaminated feed, water, bedding and soil • From the carcasses of dead animals • On contaminated farm equipment and vehicles • In airborne particles and dust blown by the wind An Egyptian policeman wears a mask as he stands guard in front of a pick up truck full of pigs at the main slaughterhouse in Cairo April 30, 2009 6/11/2009 64 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  58. Zoonosis Swine Influenza Virus (SIV) How Can Pigs Be protected? • The following actions can potentially prevent swine influenza: • Vaccinating animals • Ensuring farm workers maintain good hygiene • Following strict biosecurity practices • Providing adequate ventilation in barns • Identifying and segregating sick animals as early as possible 6/11/2009 65 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  59. Limit the Risk of Transmission SIV On Pig Farms 1. Decreasing the spread of SIV includes: 2. Traffic control 3. Isolation 4. Sanitation 5. Herd health management 6. Program maintenance 7. Ensue Personal Protection Equipment(PPE) onsite and an active fit testing program 8. Application of HACCP (Hazard Analysis of Critical Control Points) 6/11/2009 66 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  60. Swine Influenza (SIV) Traffic control: • Traffic control: • Anyone exhibiting signs of respiratory illness should avoid contact with animals • Workers in swine facilities who have been exposed to influenza or someone diagnosed with influenza should avoid contact with animals until they have been checked by a healthcare worker • Avoid contact with swine outside regular employment • Control and restrict visitors' access to the herd • Require all visitors to wear clean boots, clothing and gloves and wash hands thoroughly on entry and exit • Prevent other animals from coming into contact with the herd • Maintain records of the movement of people, animals and equipment on and off the premises 6/11/2009 67 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  61. Swine Influenza (SIV) Isolation: • Isolation: • Only obtain new animals from reputable sources and limit the frequency of introducing new pigs to the herd • House newborn, weaned, feeder, and breeding pigs separately • Move pigs in groups during each production stage, in an all-in-all-out manner 6/11/2009 68 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  62. Swine Influenza (SIV) Sanitation: • Sanitation: • Routinely clean and disinfect buildings, barns, equipment, clothing and footwear • Designate a cleaning area for vehicles and equipment • Promptly dispose of dead pigs in a manner that minimizes the chance of spread of any disease • Implement a manure management program • Avoid borrowing equipment and vehicles from other farms 6/11/2009 69 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  63. Swine Influenza (SIV) Herd Health Management: • Herd health management: • Monitor herd health daily and employ veterinary services • Uniquely identify all groups of animals for traceability purposes (where they came from and where they are sold to) • In consultation with a veterinarian, consider vaccinating animals • Isolate sick pigs and immediately report any signs of illness to your veterinarian or the nearest Department of Agriculture office A Litter-Bed Pigpen for Breeding and Growing-Finishing Pigs. 6/11/2009 70 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  64. Swine Influenza (SIV) Program Maintenance: • Program maintenance: • Train all staff on your biosecurity program and monitor its effectiveness • Be aware of any diseases in your area and adjust your biosecurity program accordingly • Recommend farm workers discuss an annual flu vaccination with their doctor. – Vaccination may reduce the amounts of virus shed if infected during human influenza outbreaks, and limit the potential for human influenza virus infection of pigs. Full View of the The effectiveness of current human Litter-Bed Pig vaccines against this new strain is not known at this time Farm. 6/11/2009 71 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  65. HACCP (Hazard Analysis of Critical Control Points) On PIG Farms • Application of HACCP (Hazard Analysis of Critical Control Points) procedures will help to identify areas of greatest risk to the business and allow for development of preventative strategies 6/11/2009 72 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  66. A General Biosecurity Checklist For Swine 6/11/2009 73 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  67. Veterinary Surveillance • This disease is a scheduled and notifiable disease in Ireland (Class B) • Porcine surveillance: The Department of Agriculture and Food and Fisheries (DAFF) (in collaboration with the porcine industry undertakes active and passive surveillance for porcine • Notification procedures is agreed between the department of Agriculture and Food and Fisheries the HSE in the event of Influenza being identified or highly suspected from porcine 6/11/2009 74
  68. Swine Influenza (SIV) Pharmacovigilance for Veterinarians • EU Veterinary Suspected Adverse Reaction form for Veterinary and Health Professionals 6/11/2009 75
  69. Swine Influenza (SIV) Preplanning for Veterinarians Visits: • The veterinarians should: • Prepare and plan the visit by Veterinarians Porcine log Book 2009 contacting the producer beforehand • Park in designated areas or as far as possible from animals • Keep a log book of farms visited 6/11/2009 76 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  70. Swine Influenza (SIV) Interim Recommendations For Veterinarians: • Use appropriate personal protective equipment: – FFP 2-3 respirator masks, gloves, impermeable coveralls, protective clothing and footwear and eye protection • Wash hands thoroughly after handling animals • Leave as you arrived and clean and sanitize vehicles and equipment • Dispose of protective equipment in a safe manner: – either leave it on the farm to be appropriately disposed or – remove it and place it in “contaminated materials” containers for transport to the office • Prioritize work by attending low-risk jobs first and then observe animals for concerns • Avoid or minimize contact with manure storage, feed supplies, and water supplies • Until more is known about how this illness affects swine, if swine influenza is suspected – do not travel to another swine farm for 48 hours 6/11/2009 77 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  71. Swine Influenza (SIV) Personnel Protection • On arrival at a site, personnel should: • Disinfect footwear in foot-bath • Put on washable or disposable protective clothing (footwear and overalls) • Wash hands • Before departure personnel should: • Disinfect footwear and protective clothing (or leave on site if disposable) • Wash hands • Contacts who work on pig farms should remain off work for 7 days as soon as diagnosis is suspected! 6/11/2009 78
  72. Veterinarians Donning and Doffing PPE 6/11/2009 79 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  73. Department of Agriculture Local District Veterinary Offices (DVO) COUNTY ADDRESS TELEPHONE Carlow Athy Road, Carlow 059 9170022 Cavan Farnham St., Cavan 049 4368200 Clare Government Offices, Kilrush Road, Ennis, Co. Clare 065 6866042 Cork North Hibernian House, 80A South Mall, Cork 01 4149900 Cork Central Hibernian House, 80A South Mall, Cork 01 4149900 Cork West Darrara, Clonakilty Co. Cork 023 36200 Donegal Meeting House St, Raphoe, Co. Donegal 074 9145298 Dublin/ St John’s House, High St, Tallaght, Co. Dublin 01 4149900 Wicklow East Galway Dockgate Building, Merchants Rd., Galway 091 507600 Kerry Spa Road, Tralee, Co. Kerry 066 7145052 Kildare/ Poplar House, Poplar Square, Naas, Co. Kildare 045 873035 Wicklow West Kilkenny Hebron Road, Kilkenny 056 7772400 Laois Abbeyleix Road, PortLaoise, Co. Laois 057 8674400 Leitrim Cranmore Road, Sligo 071 9682000 Limerick Houston Hall, Ballycummin Avenue, 061 500900 Raheen Industrial Estate, Raheen, Co. Limerick Longford Ballinalee Road, Longford 043 50020 Louth North Quay, Drogheda, Co. Louth 041 9838933 Mayo Michael Davitt House, Castlebar, Co Mayo 094 9035300 Meath Athlumney, Kilcairn, Navan, Co Meath 046 9082900 Monaghan Main Street, Ballybay, Co. Monaghan 042 9748800 Offaly Clonminch, Tullamore, Co. Offaly 057 9346037 Roscommon Convent Road, Roscommon 090 6630100 Sligo Cranmore Road, Sligo 071 9142023 Tipperary North St Conlon’s Road, Nenagh, Co. Tipperary 067 50014 Tipperary South Government Offices, Davis Street, Tipperary 062 80100 Waterford Govt. Offices, The Glen, Co. Waterford 051 301700 Westmeath Bellview, Dublin Road, Mullingar, Co. Westmeath 044 9339300 Wexford Vinegar Hill Lane, Enniscorthy, Co Wexford 053 9242008 6/11/2009 80
  74. EU Possible Quarantine Zones for Infected Influenza A(H1N1) Pig Farms Surveillance zones Surveillance zone (minimum of 10 km radius from the infected premises) Inplace for 30 days Protection Zone Quarantined Pig Farm Restricted zone (minimum of 1 -3 km radius from the infected premises) Controls must be kept in place for at least 21 days Infected Premises Restricted Zone Contaminated Porcine Farm There are no controls on people visiting the Zone Zone A Adapted from EU Quarantine for Avian Flu DAFF:Information on Avian Influenza Control Measures Buffer Zone 6/11/2009 81 Zone B
  75. Risk vs. Benefit Analysis for Decontamination Decontamination is defined as : What are the outcomes of “The process of removing or neutralising a hazard from the environment, property or life form. Its objectives are to prevent further harm and optimise the chance for natural stabilization? full clinical recovery or restoration of the object exposed to the contaminant”. Yes Can I change the outcomes No Do nothing except protect of natural stabilization by exposures! the intervention? What are the cost of the Risk intervention in terms of risk EXCEEDS Do nothing except protect versus benefit? benefit exposures! Benefit “Decontamination Process” EXCEEDS Refers to removal of clothing, neutralization of contaminate, verification of contaminate neutralization, and isolation of all contaminated waste. benefit Engage in intervention operations as long as the benefit exceeds the risk
  76. Quarantine Zones for Infected Influenza A(H1N1) Pig Farms Agriculture and Food (DAF) will institute biosecurity measures . These control measures focus on animal health issues and aim to prevent any further spread of the disease among animals. Pending confirmation of the outbreak, if deemed necessary, all the porcine in the holding may be culled and destroyed. • Zone A : Infected premises • Buffer Zone: Surveillance zone • Risk vs. Benefit Analysis • The Surveillance Zone must stay in place for at least 30 days after the preliminary cleaning and disinfection of the infected • The Protection Zone must stay in place for at least 21 premises has been carried out. days after the preliminary cleaning and disinfection of • Identification of all porcine holdings the infected premises has been carried out, and then the • Prohibition on porcine fairs, markets, shows or other Zone becomes part of the Surveillance Zone gatherings • Killing and disposal of all porcine • Prohibition on the release of porcine, porcine products • Cleaning and disinfection of the premises Checkpoints will be • Destruction or treatment of manure, slurry and bedding put in place to control movements of • Tracing and destruction of porcine meat and carcasses vehicles transporting porcine or porcine produced during risk period related products • Epidemiological investigation and tracing of high-risk into/out of the Zones. contacts • Prohibition on porcine entering or leaving • Controls on people, vehicles and other things entering or leaving • Zone B: Free from Disease • Controls on re-stocking • A Further Restricted Zone may be declared outside the Surveillance Zone if this is considered necessary to control the disease. The measures to be applied in this Zone will be determined depending on a risk assessment 6/11/2009 carried out at the time. 83 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  77. Maximum Decontamination Infected Premises Footbath Layout Level C & D Protection Boot Cover Tape & (PPE) Reduction Outer Glove Removal Glove Wash Segregated Removal (Hypothetical example ) Equipment Stripper/ 6 5 4 3 2 1 Drop Bagger Boot Cover Boot Cover & Removal Glove Rinse Zone A 7 Suit/Safety Boot Wash Canister or 9 8 Suit/Safety Boot Rinse Mask Change and Redress - Boot Cover/ Outer Gloves 10 Safety Boot Removal 11 Splash Suit Removal CONTAMINATION 12 Inner Glove Wash REDUCTION The contamination hazards at hazardous sites Inner Glove Rinse vary greatly, the methods of decontamination ZONE 13 may be adjusted by omitting, adding, or changing the stations identified to reflect the 14 Face Piece Removal contamination hazards at a site! 15 Inner Glove Removal These figures are adapted from the, NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for 16 Inner Clothing Removal Hazardous Waste Site Activities. CONTAMINATION CONTROL LINE SUPPORT Dryer/ 17 18 Field Dresser ZONE Wash
  78. Minimum WIND DIRECTION Decontamination Layout 20 Levels C & D Protection Redress: Boot Covers and Outer Gloves Zone A Decon 20 Solution Tank Change-Over Point (If needed) Infected Premises Remove Water Boots/Gloves and Decon Outer Outer Equipment Garments Garments Drop (For Disposal Remove and Off Site Boot Covers Decontamination) and Outer Gloves Footbath Plastic Sheet Can Zone A (10 gallon) Remove SCBA (If needed) Contamination Reduction Corridor
  79. Basic Personnel Decontamination Vehicle decon “Contamination Reduction Corridor” Setup Vehicle decon Decon Water Solution Inner Washer Rinser Stripper Zone A Equipment glove Drop bagger removal Zone Contaminated Porcine Farm Entry Wash Rinse Can PPE Removal Exit (10 gallon Support Footbath Can Can Can Zone A 10 gallon 10 gallon 10 gallon Footbath if no Decon pools CRC setup Storage and Garbage Plastic (Tarp or Visqueen) Barrier tape and pylons Contamination Reduction Corridor 6/11/2009 86
  80. Vehicle Decontamination • Only allow essential vehicles onto the site. Staff, service vehicles etc. should be parked outside the perimeter. Insist that all vehicles that have to enter the site have been cleaned and disinfected beforehand • Vehicle cleaning and disinfection: • On arrival at the farm, wheels, wheel arches, outside and underside must be disinfected • Before leaving the farm, wheels, wheel arches, outside and underside must be washed and disinfected, ensuring that the World Trade Center/Ground Zero Vehicle Decontamination Wash surfaces are visibly ccontact with lean (must be dry) • Wash and disinfect all surfaces which may have come into contaminated material, such as: – Wheels, wheel arches, outside and underside – Trailer – Equipment (e.g. trolleys, crates, modules, delivery pipes, sheeting, covers) – Wipe areas of the driver’s cab that may have been contaminated, with disinfectant – Drivers should avoid contact with porcine or other porcine on premises outside the infected area for at least 3 days (72 hours) A list of approved disinfectants can be found at: http://www.agriculture.gov.ie 6/11/2009 87
  81. Swine Influenza and Influenza A(H1N1) Virus Swine influenza Influenza A(H1N1) Virus • Swine influenza is • The Influenza Virus contains commonly transmitted genes from pig, bird and through direct contact or human influenza viruses, in close proximity with pigs. a combination that has never been observed before Secondary cases following anywhere in the world human-to-human • 2009 Quadruple transmission have been reassortment of three reported in the past but viruses—a human virus, an they have been very rare avian virus , and 2 porcine • 1998 Triple reassortment viruses 6/11/2009 88 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  82. Influenza A(H1N1) : Microbiology • Influenza A viruses are negative-sense single-stranded RNA viruses • Family: Orthomyxoviridae • Genus: Influenza virus A • Enveloped virions are 80 to 120 nm in diameter, are 200 to 300 nm long, and may be filamentous – They consist of spike-shaped surface proteins, a partially host- derived lipid-rich envelope, and matrix (M) proteins surrounding a helical segmented nucleocapsid (6 to 8 segments) – The virus envelope glycoproteins (hemagglutinin [HA] and neuraminidase [NA]) are distributed evenly over the virion surface, forming characteristic spike-shaped structures; antigenic variations in these proteins form the basis of the classification system for influenza A virus subtypes – There are 16 different HA antigens (H1 to H16) and nine different NA antigens (N1 to N9) • Human disease historically has been caused by three subtypes of HA (H1, H2, and H3) and two subtypes of NA (N1 and N2) • More recently, human disease has been recognized to be caused by additional HA subtypes, including H5, H7, and H9 (all from avian origin) 6/11/2009 89 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  83. Phylogenetic Comparison To Other Negative-sense RNA Viruses • Influenza strains are subtyped A, B, or C • Based on the relatedness of the matrix (M1) and nucleoprotein (NP) antigens 6/11/2009 90 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  84. Influenza Virus Influenza Type A and Its Subtypes 3 integral membrane proteins that coordinate fusion are : 1. NA Pink - 2. HA Hemagglutinin 3. M2 Yellow - Neuraminidase CDC 6/11/2009 Medical Management of Biological Casualties
  85. Influenza Virus Influenza Type A Influenza A viruses are pleomorphic virions (that is, they vary in shape) They have negative-sense, single-stranded HA - hemagglutinin RNA and an RNA genome that is SEGMENTED There are eight RNA segments in influenza A NA - neuraminidase The nucleocapsid is helical Virions contain RNA polymerase packaged within the virus particle helical nucleocapsid (RNA plus These viruses are enveloped and have two NP protein) membrane glycoproteins: lipid bilayer membrane 1. HA - hemagglutinin - This is the attachment and fusion protein polymerase complex 2. NA - neuraminidase - This is important in release. It removes sialic acid from proteins of the virus and the host cell M1 protein M1 protein unnderlies the lipid bilayer, is the most abundant protein Genome organized in 7 or 8 segments. 3 integral membrane proteins that coordinate fusion are NA, HA, and M2 (not shown) NP protein important for subtyping NS protein, not shown, important for virulence 6/11/2009 92
  86. ORTHOMYXOVIRIDAE Influenza Type A (H1N1) PROPERTY ORTHOMYXOVIRIDAE Influenza A(H1N1) Genome segmented RNA synthesis nuclear Need for mRNA primer yes Hemagglutinin,neuraminidase Influenza A and B have both but on 2 different proteins (HA and NA) Syncytia formation no (HA functions at acid pH) 6/11/2009 93 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  87. Replication of Influenza A virus • 1. A virion attaches to the host cell membrane via HA and enters the cytoplasm by receptor-mediated endocytosis • • HA2 promotes fusion of the virus envelope and the endosome membranes • 2.The major envelope protein M1 dissociates from the nucleocapsid and viral RNA segments are translocated into the nucleus • 3. In the nucleus, the viral polymerase complexes transcribe (STEP 3a) and replicate (STEP 3b) the viral RNA segments • 4. Newly synthesized mRNAs migrate to cytoplasm where they are translated into viral proteins • 5a. Newly synthesised M1 viral proteins move to the nucleus - bind freshly synthesized 21 y y copies of viral RNA segments. • 5 b. Posttranslational processing of HA, NA, and M2 includes transportation via Golgi apparatus to the cell membrane • 6. The newly formed nucleocapsids migrate into the cytoplasm - interact via M1 with a region of the cell membrane where HA, NA and M2 have been inserted • 7. Then the newly synthesized virions bud from infected cell. NA destroys the sialic acid moiety of cellular receptors, thereby releasing the progeny 6/11/2009 virions 94 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  88. Influenza A (H1H1) 2009 Genetic Origins • HA (or H1): Hemagglutinine type 1 , swine, also in the 1918 influenza Catch host's cell receptors • NA (or N1): Neuraminidase type 1, swine, Eurasian, help start the infection • PA: avian, north America • PB1: human, likely from the 1993 H3N2 influenza • PB2: avian, from north America • NP: swine, north America • M: swine, Eurasia • NS: swine, north America – Non-structural proteins NEP (Nuclear Export Protein):, swine North America 6/11/2009 95 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  89. Definition of Pandemic • The word “pandemic” comes from the Greek “pan-“, “all” + “demos”, “people or population” = “pandemos” = “all the people.” • A pandemic affects all (nearly all) of the people. • By contrast, “epi-“ means “upon.” An epidemic is visited upon the people. And “en-“ means “in.” An endemic is in the people. Technical report - Pandemic influenza 6/11/2009 96 preparedness in the EU/EEA
  90. Timeline of 2009 Hybrid “quadruple reassortant” new influenza A(H1N1)—a human virus, an avian virus , and 2 porcine viruses Swine Emergence of Some No Vaccine Influenza H1 Quadruple Reassortment Result Influenza Viruses in 2009 Influenza A (H1N1) (Swine Origin) 144 deaths Avian Humans Influenza Pandemic vaccines 1997: In Hong Kong, avian influenza A (H5N1) H5 Total of 256 Deaths 2009 WHO Russian H9 1997-2009:avian influenza A (H9N2) Influenza H7 1980- 2003: Avian influenza A (H7N7) B Russian Flu (H2N2) 1889/1890 1 million Russian Flu (H2N2 A/USSR/90/77 (H1N1). 2002 Severer Acute Respiratory Virus (SARS-CoV) 1900 Old Hong Kong Influenza H3N8? Asian 774 deaths Influenza Old Hong Kong Regular vaccines Influenza H2 1957 (Asian Flu) 1-4 million deaths H2N2 Spanish “Triple reassortment” Influenza H3 H2 1968 (Hong Kong Flu) 1-4 million deaths H3N2 Aggressive H3N2 Hong Kong H1 1918 (Spanish Flu) 20-40 million deaths H1N1 Influenza Swine to Human 1998/9 1918 1957 1968 1977 1993 1997 2003 2009 6/11/2009 By 1993, a bird flu virus had adapted to pigs, grabbed a few human flu 98 Medical Management of Biological Casualties US 1976 Swine Influenza virus genes, and infected two young Dutch children, even displaying evidence of limited human-to-human transmission. Revised and Modified 29/04/2009
  91. Past & Potential Flu Pandemics Summary Epidemics, Subtype Year Approx Approx Deaths Approx Estimated Severity of Pandemics/ Infected Mortality % Reproductive the Number (Ro) Pandemic Russian Flu H2N2 1889/1890 unknown 1 million unknown Unclear Moderate Spanish flu H1N1 1918/1919 500 million 20-50 /?50 million 2.5 -10% 1.5-1.8 Severe + 2nd Wave 3.0-3.5 Asian flu H2N2 1956-58 45 million 1-4 million <0.2% 1.5 Severe Hong Kong H3N2 1968-69 50 million 1-4 million >0.2% 1.3-1.6 Moderate flu Avian flu H5N1 1990-today 421 257 61% 2.14 Severe Ongoing (still researching) SARS SARS-CoV 2002-03 8,096 774 9.6% 0.44-2.29 Severe 1,17 med Swine flu H3N2 1976 250-300 1 0.3% Mild Influenza H1N1 2009 28,774 144 <0.55% 1.2.-1.8 Moderate A(H1N1) Ongoing Med 1.5 Seasonal Flu A/H3N2, Yearly 1 Billion 250,000-500,000 <0.05% A/H1N1, 6/12/2009 and B 99 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  92. Epidemiology of Ireland Spanish Influenza 1818-1819 • Ireland: 10,651 influenza • The deaths per 100,000 deaths registered by age group: (Unconfirmed 20000) under 5 years 295 – Male : 5,591 5-10 years 120 – Female: 5,060 10-15 years 103 • Mortality Rate: of 243 per 15-20years 223 100,000 population 20-25 years 329 – The mortality rate 25-35 years 380 varied by region: 35-45 years 239 • Leinster: 304 per 45-55 years 222 100,000 • Ulster: 302 per 1918 Flu Pandemic In 55-65 years 226 100,000 Ireland 65-75 years 221 • Munster: 159 per < 75 years 256 100,000 • Connaught: 114 per 100,000 6/12/2009 100 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  93. Irelands Road to Pandemic Preparedness • 1999 -World Health Organisation (WHO) – “Influenza Pandemic Plan” • 2001- Ireland Developed – “A Model Plan for Influenza Pandemic Preparedness” • 2002- Plan was revised • 2004- Influenza Pandemic Preparedness Plan • 2005- WHO published – “WHO Global Influenza Preparedness Plan” • 2007 –Ireland Developed – “National Plan for Pandemic Influenza” 6/11/2009 101 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  94. Scientific Models of the Impact of an Influenza Pandemic • USA: Pandemic Severity Index • United Kingdom: Empiric HPA Model Irelands “National Pandemic Influenza Plan” uses the HPA Model Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie Gani and Meltzer Model are also used See Website for download for to predict ICU rates and Ro rates in the National Pandemic Plan clinicians 6/11/2009 102 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  95. Pre-Pandemic Planning: The Pandemic Severity Index 6/11/2009 103 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  96. Pandemic Severity Index • The pandemic severity index levels are: • Category 1, CFR of less than 0.1% • Category 2, CFR 0.1% to 0.5% • Category 3, CFR 0.5% to 1% • Category 4, CFR 1% to 2% • Category 5, CFR 2% or higher 6/11/2009 104 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  97. Pandemic Severity Index • Class I • A Class I pandemic is characterized by a widespread novel infection that, while it may cause sickness, does not create large scale deaths or economic impacts. The 1968 Flu is a good example of a Class I pandemic. Also, the current outbreak of Chikungunya could be considered a Class I pandemic. The observed death rate worldwide would not increase significantly from a Class I pandemic. • Class II • A Class II pandemic is characterized by a novel infection that has a low infection rate or a minimal case fatality rate and thus any serious effects on economies or overall mortality rates is minimized. The current HIV/AIDS pandemic can be considered a Class II pandemic. In any one year, a Class II pandemic would kill up to 1 million people. • Class III • A Class III pandemic is characterized by novel infection that spreads quickly but has a low total mortality rate. The 1918 pandemic would be considered a Class III pandemic. Note: between 50 - 100 million people died during the 1918 pandemic. A class III pandemic would kill approximately 2% of all humans or 120 million people. • Class IV • A Class IV pandemic is characterized by a novel infection that spreads quickly but has a medium level of mortality rates. The Black Death of 1347 - 1350 would be considered a Class IV pandemic. A Class IV pandemic would directly kill 40% of humans. A Class IV pandemic would kill 2.4 billion people. If Influenza A (H1N1) acquires the ability to easily infect humans to humans at the current CFR, it would be a Class IV pandemic. • Class V • A Class V pandemic is characterized by a novel infection that spreads quickly, has a high infection rate and a high mortality rate. There are no documented records of a Class V pandemic, but some experts believe that the new world indigenous peoples were affected by old world diseases in a Class V manner. A class V pandemic would directly kill off approximately 90% of living humans. A 6/11/2009 V pandemic would kill 5.4 billion people. class 105 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  98. Community Mitigation Strategy by Example on Pandemic Severity Scale 6/11/2009 106 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  99. Irelands Pandemic Mitigation “Empiric HPA Model” • The Empiric HPA model outlines a single wave pandemic over 15 weeks with a peak of clinical cases and deaths occurring weeks six and seven . According to this model, just over 20% of cases and deaths occur in each of these weeks. 6/11/2009 107
  100. Irelands Mitigation Strategies • The following scenario has been adopted for planning purposes: • A cumulative clinical attack rate of between 25% and 50% of the population • A hospitalisation rate of between 0.55% and 3.70% • A case fatality rate of between 0.37% and 2.50% (equivalent to the 1957 and 1918 pandemics respectively) • Calculations are based on the Census 2006 Preliminary Report, which puts the Irish population at 4,234,925 6/11/2009 108 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  101. Irelands Assumed Clinical Attack Rate: Scenario 1 • Scenario 1 • Irish population at 4,234,925 • Considers: – Clinical Attack Rate of 25% 1,058,731 cases – Hospitalisation Rate of 0.55% 5,823 over the 15 wks – Mortality Rate of 0.37% 3,917 deaths • Weekly number of cases, hospitalisations and deaths as predicted by the empirical model. 6/11/2009 109 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  102. Irelands Assumed Clinical Attack Rate: Scenario 2 • Scenario 2 • Irish population at 4,234,925 • Considers : – Clinical attack rate of 50%: 2,117,463 cases – Hospitalisation rate of 3.7%: 78,346 over 15 wks – Mortality rate of 2.5%.: 52,937 deaths 6/11/2009 110 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  103. WHO Phases 4 and 5 Irelands National Objectives • To assess the extent of human-to-human transmission and determine pandemic risk • To detect, notify and characterise additional clusters (including the identification of risk factors and other data concerning transmission as requested by WHO) • To assess the threat to human health and the impact of any control measures, and identify resources required for enhanced control • To determine and monitor public health resources required for pandemic response • Monitor the global situation (vaccine, antiviral availability, best practice recommendations) and estimate the impact of antiviral programmes (and vaccination programmes if used) 6/11/2009 111 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  104. WHO Phase 4-6, Irish Alert Level 1 (Ireland Not Yet Affected) • 1.Establish surveillance of clinical conditions which have been linked to the novel virus abroad, but which are not necessarily part of the clinical criteria for routine influenza investigation • 2.Travellers returning from areas with pandemic activity should be provided with information and advised to seek medical attention if they become unwell. • 3.All doctors should be advised to ask patients presenting with respiratory illnesses about overseas travel • Samples should be collected for influenza detection and sent to the NVRL from all patients with respiratory illness who have: – Fulfilled the case definition for pandemic influenza orBeen hospitalised with viral pneumonia or – Travelled to areas of known or potential pandemic influenza activity in the week preceding onset of illness or;Have a flu-like illness and are family members or other close contacts of either of the above • 4.Departments of Public Health must immediately be notified of: – All cases who have been hospitalised with viral pneumonia (or other particular clinical features associated with the pandemic strain that form part of the case definition); and who have travelled to areas of known or potential influenza activity in the week preceding onset of illness and – Those who have a flu-like illness and are family members or other close contacts of a person in either of these categories Medical Management of Biological Casualties 6/11/2009 Revised and Modified 29/04/2009
  105. WHO Phase 4-6, Irish Alert Level 1 Once Ireland Is Affected! • As soon as the first cases of pandemic influenza are detected in the country the surveillance activities will be focused on: • Detecting community outbreaks • Tracking trends in influenza disease activity and identifying populations that are severely affected • Real-time reporting between he following is essential: – Healthcare institutions – Clinicians – Public Health – Sentinel General Practitioners – NRVL and Laboratories – Pharmacists – Etc. 6/11/2009 113 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  106. Irelands Governmental Lead Agencies, Groups and Committees Emergency/Incident Type Lead Government Lead Principal Support Role Other Potential Support Remarks Department Response Roles Agency as per Framework Influenza Pandemic Influenza and DOHC HSE HSE Local Authorities Pandemic Other Public Health All members of the (DEHLG) Emergencies Interdepartmental CD (DOD) Steering Committee on Revenue Commissioners Public Health Emergency FSAI7 (DHC) Planning Current Pandemic Influenza Emergency Planning Roles and Responsibilities for Influenza A (H1N1) 6/11/2009 114
  107. Irelands Mitigation Strategies Current Pandemic Roles • “A national plan for pandemic influenza was put in place in January 2007, describing the health system’s response to a possible worldwide pandemic • Additionally The National Pandemic Expert Group has produced Expert Influenza Guidance in November 2008 which is currently being followed. It has met regularly, since an outbreak was first confirmed in Mexico, to assess the public health and clinical guidance to ensure an appropriate level of preparedness and response for Ireland • The Department is in close contact with the World Health Organisation, the European Centre for Disease Prevention and Control and our counterparts in the North of Ireland” Slide Cited From FAQs At DOHC Daily Report 6/11/2009 115
  108. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • The Department of Health and Children continues to be in close contact with the HSE and the National Pandemic Expert Group • The Department of Health and Children and the HSE participate in regular teleconference meetings with the European Centres for Disease Control, public health officials in other European Member States and the WHO • The Department of Health and Children is the lead government department for public health emergencies and works closely with the HSE in response to pandemic influenza • The National Public Health Emergency Team (NPHET) has been meeting since the outbreak was first confirmed to coordinate the response to this threat – (This is the forum for managing responses between DOHC and the HSE during the planning and response phases of a public health emergency) • NPHET is chaired by the Secretary General of the Department of Health and Children and has been meeting frequently throughout the current situation” Slide Cited From FAQs At DOHC Daily Report 6/11/2009 116
  109. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • The Government Interdepartmental Committee has been meeting to deal with health emergency planning involving transport, foreign affairs, education, security, etc. • An information leaflet has been printed and distributed to households • Posters and leaflets have been placed in air and sea ports • Ireland have accumulated anti-viral stockpiles to treat half of the population • Anti-viral medication has been distributed through public health departments to treat initial cases as they arise • Advertising will be placed on TV and other media” Slide Cited From FAQs At DOHC Daily Report 6/11/2009 117
  110. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • Information is being updated on HSE and DOHC websites • We have heightened surveillance – we will be seeking to pick up cases early • The National Virus Reference Laboratory (NVRL) have in place the capacity to carry out all diagnostic testing in relation to this virus • Professionals have received communications outlining their role in managing cases of influenza” Slide Cited From FAQs At DOHC Daily Report 6/11/2009 118
  111. Surveillance System: EU Surveillance Networks • Enter-net • EuroHIV Eurosurveillance • European Surveillance System (TESSy) • EuroTB • European Antimicrobial Resistance Surveillance System (EARSS) • European Influenza Surveillance Scheme (EISS) • European Programme for Intervention Epidemiology Training (EPIET) • European Scientific Working Group on Influenza (ESWI) • European Surveillance of STIs (ESSTI) • European Working Group for Legionella Infections (EWGLI) • FluNet Global Salm-Surv (GSS) • International Network of Paediatric Surveillance Units 6/11/2009 120
  112. International Surveillance System • International • Europe • – The European Union United Kingdom – EU Public Health Eurosurveillance British Paediatric Surveillance Unit (BPSU) – Health and Consumer Protection DG • Communicable Disease Surveillance – World Health Organisation: Europe Centre, (NI) • Department of Health (UK) • Worldwide – Australia: Communicable Diseases • Department of Health, Social Services and Australia Public Safety (NI) – Australia: Immunise Australia • Faculty of Public Health Medicine (UK) Programme • Health Promotion Agency (NI) – Canada: Health Canada • Scottish Executive Health Department – New Zealand: Ministry of Health, • Welsh Assembly Government New Zealand • – USA: Centers for Disease Control – World Health Organisation: 6/11/2009 International 121 •
  113. Surveillance System: National Surveillance Institutes in Europe • Belgium: l'Institut scientifique de Santé • Netherlands: Rijksinstituut voor Publique Volksgezondheid en Milieu (RIVM) • Norway: Folkehelseinstituttet • Czech Republic: Centrum Epidemiologie a • Poland: Panstwowy Zaklad Higieny (PZH) Mikrobiologie (CEM) • Portugal: Direcção-Geral da Saúde • Denmark: Statens Serum Institut (SSI) • Slovak Republic: Úrad Verejného • Estonia: Tervisekaitseinspektsioon Zdravotnictva (UVZ) • Finland: Kansanterveyslaitos (KTL) • Slovenia: Inštitut za varovanje zdravja (IVZ) • Spain: Instituto de Salud Carlos III • France: Institut de Veille Sanitaire (InVS) • Sweden: Smittskyddsinstitutet (SMI) • Germany: Robert Koch Institut (RKI) • UK (England & Wales): Health Protection • Greece: Hellenic Center for Infectious Agency (HPA) Diseases Control (KEEL) • UK (Northern Ireland): Communicable Disease Surveillance Centre (CDSC) • Hungary: Országos Epidemiológiai Központ • UK (Scotland): Health Protection Scotland (OEK) (HPS) • Iceland: Landlæknir • U.S. Department of Health and Human • Italy: Istituto Superiore di Sanità (ISS) Services • (DHHS) • Latvia: Sabiedribas veselibas agentura (SVA) • Luxembourg: Direction de la Sant 6/11/2009 122
  114. Influenza A(H1N1) Surveillance Systems • Reporting of clinical data by sentinel GPs • Hospital Surveillance • Enhanced surveillance • Surveillance of absenteeism rates in sentinel schools • Mortality Surveillance • Regional influenza activity by Influenza A(H1N1) Infection Weekly Surveillance Report HSE area As of June 10 2009 • Weekly Notifications of Influenza 6/11/2009 123
  115. Influenza A(H1N1) Surveillance in Ireland • Since the public health emergency was declared by WHO, HPSC and the HSE have implemented a number of surveillance initiatives to monitor the situation including: • Enhanced influenza A(H1N1) case based reporting on the Computerised Infectious Disease Reporting system (CIDR) • Contact tracing surveillance for contacts of influenza A(H1N1) cases • Expanded outbreak reporting of influenza and influenza-like illness on CIDR • An interim protocol on outbreak/cluster surveillance to detect early cases of influenza A(H1N1) • A protocol for surveillance of influenza-like illness in healthcare workers during Pandemic Phase 5. • Increased virological surveillance by the sentinel GP influenza surveillance system and recruitment of additional sentinel GPs • Expanded sentinel hospital influenza surveillance to capture information on the age breakdown of respiratory admissions Cited from Epi-insight • Sentinel paediatric hospital influenza surveillance systems have been implemented at two sites • Work is ongoing in the establishment of pilot sites for the sentinel surveillance of persons with influenza A(H1N1) who are admitted to intensive care units • Mortality surveillance has also been augmented with weekly monitoring of all cause mortality and deaths from pneumonia and influenza. HPSC will participate in a European mortality surveillance project (Euro MoMo) from early June 2009. Computerised Infectious Disease Reporting (CIDR) Adapted from Dr Jaon O'Donnell PTT From HPSC ICGP NRVL DPH/MOH Other Sentinel GP ILI consultations Hospital admissions GRO Mortality data Sentinel specimens School absenteeism HSE Influenza antiviral/vaccine uptake Non-Sentinel specimens Enhanced influenza surveillance GP Co-Ops ILI (Cluster) outbreaks Contact tracing International EISS, HPA, etc Influenza notification Health Protection Surveillance Centre (HPSC) European Influenza WHO Global Outbreak and Department of Public Health Weekly surveillance report Surveillance System (EISS) Alert Response Network and Children (GOARN)
  116. Influenza Irelands Surveillance Systems • The role of HPSC as influenza surveillance co-ordinator is to: • Maintain and develop the current sentinel influenza surveillance network • Oversee enhancements as outlined e.g. year round surveillance, surveillance of hospitalised cases • Promote year round surveillance of influenza • Maintain close working relationship with the National Virus Reference Laboratory (NVRL) and the Irish College of General Practitioners (ICGP) 6/11/2009 126
  117. Influenza A(H1N1) Irelands Surveillance Systems • World Health Organization “GOARN” • European Influenza Surveillance System (EISS) • Irish • The National Influenza Surveillance System • 1. Reporting of clinical data/influenza-like illness (ILI) by sentinel GPs • 2. Virological reporting (NVRL) • 3. Hospital surveillance comprising weekly data on total admissions, total Emergency Department (A&E) admissions and total respiratory admissions (upper respiratory tract infection, lower respiratory tract infection, pneumonia, asthma, chronic bronchitis, and exacerbations of chronic obstructive pulmonary disease) from sentinel hospitals • 4. Surveillance of absenteeism rates in sentinel schools • 5. Reports on outbreaks due to influenza or ILI • 6. Mortality data (weekly review of all cause and pneumonia and influenza registered deaths (uncoded)) from the General Registrar’s Office (GRO) • 7. Weekly regional influenza indices based on clinical activity, virological activity and outbreak activity. This is defined as no report, no activity, sporadic activity, localised activity, and widespread activity – Computerised Infectious Disease Reporting (CIDR) – Hot Line: • The Flu Information Line is available 24 hours a day and is your primary source of information on Influenza A(H1N1). • Freephone: 1800 94 11 00 6/11/2009 127 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  118. Computerised Infectious Disease Reporting (CIDR) Dissemination Pathway 6/11/2009 128 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  119. The statutory requirement to notify all cases of swine influenza A/H1N1 to the regional Director of Public Health/Medical Officer of Health (DPH/MOH) Under the Infectious Diseases (Amendment) (No.3) Regulations 2003 (SI No.707 of 2003) laboratory and clinical notification of swine influenza A (H1N1) is mandatory 6/11/2009 129 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
  120. Influenza A(H1N1) “The Emerging Pandemic!” This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. 6/11/2009 130 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  121. Influenza Antigenic Changes- Drift • Antigenic Drift • Minor change, same subtype – Caused by point mutations in gene – May result in epidemic • Example of antigenic drift – In 1997, A/Wuhan/359/95 (H3N2) virus was dominant – A/Sydney/5/97 (H3N2) This colorized image, released by the U.S. Centers for Disease Control and appeared in late 1997 and Prevention April 24, 2009, depicts the influenza A H1N1 \"swine flu\" virus from became the dominant virus an outbreak in 1976 in 1998 6/11/2009 131 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  122. Influenza Antigenic Changes - Shift • Antigenic Shift – Major change, new subtype – Caused by exchange of gene segments – May result in pandemic • Example of antigenic shift European Surveillance – H2N2 virus circulated in 1957-1967 Network for Influenza in – H3N2 virus appeared in 1968 and Pigs (ESNIP) completely replaced H2N2 virus 6/11/2009 132 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  123. Categorizing Influenza Virus “Viral Nomenclature” Type of nuclear material Neuraminidase Hemagglutinin A/California/04/2009(H1N1)swl Virus Geographic Strain Year of Virus type origin number isolation subtype Try These Two! A/Brevig Mission/1/1918(H1N1) 6/11/2009 133 Medical Management of Biological Casualties A/New Jersey/76 (Hsw1N1) Revised and Modified 29/04/2009
  124. Emergence H3N2 Viruses Antigenetic Shift 6/11/2009 134 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  125. Emergence H3N2 Viruses 6/11/2009 135 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  126. Influenza A(H1N1) Reassortment Diamond 6/11/2009 136 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  127. Influenza A(H1N1) Host Range 6/11/2009 137 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  128. Influenza A(H1N1) Antigenic Shift Pathogenesis 6/11/2009 138 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  129. Origins Overview 2009 Influenza A (H1N1) 6/11/2009 139 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  130. Influenza A(H1N1) Lineage “The Emerging Pandemic!” Human H1N1 Cases From Human H1N1 Cases From California Triple -Reassortment Swine 1998 Quadruple Reassortment 2009 PB2 PB2 PB1 PB1 PA PA HA NP NA ? HA NP NA M M NS NS “Quadruple Reassortment” Classical swine, North American Lineage Avian, North American Lineage Seasonal H3N2 Eurasian swine Lineage 6/11/2009 140 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  131. 6/11/2009 141
  132. Phylogenetic Analysis of Sequences of all Genes Identified in A/California/04/2009 • Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team 10.1056/NEJMoa0903810, May 7, 2009 NML Winnipeg, Canada 6/11/2009 142 Medical Management of Biological Casualties Has Breakthrough! Revised and Modified 29/04/2009
  133. Emergence of a Influenza A (H1N1) Virus in Humans Using “BLAST” Supplement to: Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine origin influenza A (H1N1) virus in humans. N Engl J Med 2009;361. DOI: 10.1056/NEJMoa0903810 (BLAST) Basic Local Alignment Search Tool 6/11/2009 143
  134. Influenza A (H1N1) CDC Influenza Laboratory Images • Images below of the newly identified H1N1 influenza virus were taken in the CDC Influenza Laboratory. 6/11/2009 144 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  135. Laboratory Images Influenza A (H1N1) • This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. • This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. • Comparison to; • Swine influenza virus. Colorized transmission electron micrograph (37,800X) of the A/New Jersey/76 (Hsw1N1) virus under plate magnification. Image taken during the virus' first developmental passage through a chicken egg. Courtesy of the CDC/Dr. E. Palmer; R.E. Bates. • Negative stained transmission electron micrograph of recreated 1918 influenza virions. Courtesy of CDC/ Dr. Terrence Tumpey E-medicine resource 6/11/2009 145
  136. Influenza A(H1N1) Epidemiological Risk Factors • Epidemiological risk factors that should raise suspicion of swine influenza A(H1N1) include: • Close contact to a confirmed case of swine influenza A(H1N1) virus infection while the case was ill • Recent travel to an area where there are confirmed cases of swine influenza A (H1N1) • Close contact: having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a probable or confirmed case of swine influenza A(H1N1) 6/11/2009 146 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  137. Influenza A(H1N1) Specific Investigational Triggers • The primary focus of early investigation is to trigger the initial investigation include: • Clusters of cases of unexplained ILI or acute lower respiratory disease • Severe, unexplained respiratory illness occurring in one or more health care worker(s) who provide care for patients with respiratory disease • Changes in the epidemiology of mortality associated with the occurrence of ILI or lower respiratory tract illness, an increase in deaths observed from respiratory illness or an increase in the occurrence of severe respiratory disease in previously healthy adults or adolescents • Persistent changes noted in the treatment response or outcome of severe lower respiratory illness 6/11/2009 147 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  138. Influenza A(H1N1) Infectious Period: • The infectious period for a confirmed case of swine influenza A (H1N1) virus infection is defined as 1 day prior to the case’s illness onset to 7 days after onset. • The swine flu in humans is most contagious during the first five days of the illness although some people, most commonly children, can remain contagious for up to ten days ,immunocompromised up to 0-3 months has been documented • Remember: if signs and symptoms of influenza persist past this incubation period consider yourself contagious • May 20 2009 : WHO Technical Consultation on the severity of disease Report 20,05 May Teleconferencex • Ranging between – 1–5 days (Spain) – 4–6 days (UK) – 2–7 days (US ) 6/11/2009 148 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  139. Influenza A(H1N1) Transmission: • Direct and indirect contact – Pig to human • asymptomatic carrier pigs – Human to human – Human to Pig • Droplet transmission • Aerosol generating procedures (AGPs) • Not transmissible by consumption of pork 6/11/2009 149 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  140. Influenza A(H1N1) Human Signs and Symptoms: Exacerbation of underlying chronic medical conditions Includes: Upper respiratory tract disease (sinusitis, otitis media, croup) lower respiratory tract disease (pneumonia, bronchiolitis, Fever (greater status asthmaticus) Cardiac (myocarditis, than 100°F or pericarditis) 37.8°C) Musculoskeletal (myositis, rhabdomyolysis) EU > 38 °C Neurologic (acute and post- *NOTE: Some people, infectious encephalopathy, such as the elderly, encephalitis, febrile seizures, and people who are status epilepticus) immunocompromised, Toxic shock syndrome may not develop a Secondary bacterial fever. pneumonia with or without sepsis. 6/11/2009 150 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  141. Influenza A(H1N1) High Risk Groups: • There are insufficient data available at this point to determine who is at higher risk for complications of swine-origin influenza A (H1N1) virus infection • Therefore considerer higher risk for swine-origin influenza complications if: 6/11/2009 151 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  142. Groups at High Risk for Complications From Influenza A(H1N1): • High Risk groups include: • Infants aged 12–24 months • HIV-infected persons • Adults aged >65 years • Residents of any age of nursing homes or other long-term care institutions • Asthmatics or other chronic pulmonary diseases, such as cystic fibrosis in children or • Chronic obstructive pulmonary disease in Five-year-old Edgar adults Hernandez, known as • Hemodynamically significant cardiac disease \"patient zero\" survived the • Immunosuppressive disorders or who are earliest documented case receiving immunosuppressive drugs of swine flu. “April 2 2009” • Sickle cell amenia and other hemoglobinopathies • Diseases that requiring long-term aspirin therapy 152 Medical Management of Biological Casualties 6/11/2009 Revised and Modified 29/04/2009
  143. Influenza A(H1N1) High Risk Group Age According to ECDC • High risk age 20-29 according to ECDC as of June, 2, 2009 Age Male Female Total Not Travel Total travel Related related >2 4 2 6 1 3 4 2-9 26 28 54 33 6 39 10-19 46 42 88 51 27 78 20-29 83 74 157 25 128 153 30-39 26 12 38 4 31 35 40-49 12 21 33 12 18 30 50-59 13 10 23 7 15 22 >60 6 4 10 4 7 11 Total 216 193 409 137 235 372 6/11/2009 153 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  144. Influenza A(H1N1) Travel Related Hotspots • Distribution of travel-related cases of new influenza A(H1N1) virus infection by country of travel reported in 21 EU, EEA and EFATA countries, returning from Mexico, USA and the United Kingdom by date of onset, EU, 16 April – 1 June 2009 (n=219) 6/11/2009 154
  145. Age distribution by gender and Travel Related among new influenza A(H1N1) cases reported by 21 EU, EEA and EFTA countries (date of onset from 16 April to 2 June 2009) • Number of travel-related (and non travel-related) cases of new influenza A(H1N1) virus infection by date of onset, in 21 EU, EEA and EFTA countries, 16 April – 2 June 2009 (n=375) • Age distribution by gender among new influenza A(H1N1) cases reported by 21 EU, EEA and EFTA countries (date of onset from 16 April to 2 June 2009) • Age distribution by travel-related (and not travel-related) infection of new influenza A(H1N1) reported by 21 EU countries (date of onset from 16 April to 2 June 2009) 6/11/2009 155
  146. Influenza A (H1N1) EU Specific Clinical Signs and Symptoms by Systems Frequency of Number of cases % Percentage symptoms (n=302) Generalised Fever or history of fever 263 87% Headache 125 41% Muscle pain 116 38% Joint pain 68 23% Respiratory Dry cough 148 49% Productive cough 50 17% Sore throat 149 49% Runny nose 100 33% Sneezing 63 21% Shortness of breath 29 10% Gastro-intestinal Diarrhoea 35 12% Vomiting 47 16% Nausea 52 17% Other Conjunctivitis 17 6% Nose bleed 7 2% Altered consciousness 1 0% Other (various) 101 25% 6/11/2009 156
  147. México, United Sates, Canada Age and Gender Summary: Influenza A (H1N1) • The Mexican Ministry of Health published an epidemiological update on May 7, 2009, on their website: • Out of the 1204 confirmed cases studied, 49.5% are females and 72% are in persons under the age of 29 years of age. • The Public Health Agency of Canada reported epidemiological information of the confirmed cases on May 20, 2009 – The majority of the cases (97%) are under the age of 50 – The median age of Canadian cases is 22 years – As of May 20, 2009, half the cases are 21 years of age or younger (median: 21 years; range: <1 – 86 years) – The majority of cases are linked to travel to Mexico 6/11/2009 157 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  148. Influenza A (H1N1) Mexico, United Sates, Canada Age Summary: In Mexico In United States: As of 20 May 2009, 16:30 AM ET, 48 states of the United States have reported a total of 5,764confirmed cases including 247 hospitalizations and 8 deaths. Median age: 17 years, range 1 month- 87 years Gender: 51% female, 49% male Underlying medical conditions (n=44): 63% (median age: 18 years) Median time from illness onset to hospital admission (n=32): 4 days (range: 1-13 days) Median length of hospital stay (n=32): 5 days (range 2-31) In Canada: As of May 28, 2009, the average age reported is 22 years or younger (median: 17 years; range: <1 – 86 years). In Europe: Median age 33 6/11/2009 158 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  149. Influenza A (H1N1) México Age Specific Attack Rate May 20 6/11/2009 159
  150. Influenza A (H1N1) Summary of Age Specific Clinical Signs and Fatality Rate June 2 2009 6/11/2009 160
  151. Influenza A (H1N1) General Diagnosis • A Confirmed case of swine influenza A(H1N1) virus infection is defined as an individual with laboratory confirmed swine influenza A(H1N1) virus infection by one or more of the following tests: • Real‐time RT‐PCR ICycler® from • Viral culture BioRad • Four‐fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies 6/11/2009 162 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  152. WHO Case Definitions to be Used For Investigations of Swine Influenza A (H1N1) Cases • Clinical case description • Acute febrile respiratory illness (fever >38°C ) with the spectrum of disease from influenza‐like illness to pneumonia. • 1. A Confirmed case of swine influenza A(H1N1) virus infection is defined as an individual with laboratory confirmed swine influenza A(H1N1) virus infection by one or more of the following tests*: – real‐time RT‐PCR – viral culture – four‐fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies. • 2. A Probable case of swine influenza A(H1N1) virus infection is defined as an individual with an influenza test that is positive for influenza A, but is unsubtypable by reagents used to detect seasonal influenza virus infection OR • A individual with a clinically compatible illness or who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case. 6/11/2009 163 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  153. CDC Case Definitions to be Used For Investigations of Swine Influenza A (H1N1) Cases • Case Definitions for Infection with Swine Influenza A (H1N1) Virus – A Confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: • real-time RT-PCR • viral culture • four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies – A Probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with an influenza test that is positive for influenza A, but H1 and H3 negative by RT-PCR – A Suspected case of swine influenza A (H1N1) virus infection is defined as: • A person with an acute respiratory illness who was a close contact to a confirmed case of swine influenza A (H1N1) virus infection while the case was ill OR • A person with an acute respiratory illness with a recent history of contact with an animal with confirmed or suspected swine influenza A (H1N1) virus infection OR • A person with an acute respiratory illness who has travelled to an area where there are confirmed cases of swine influenza A (H1N1) within 7 days of suspect case's illness onset. • Infectious period for confirmed cases = 1 day before onset to 7 days after onset of illness • Day before onset = Day -1 • Onset day = Day 0 • Days after onset = Days 1-7 6/11/2009 164 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  154. CDC Case Definitions to be Used For Investigations of Swine Influenza A (H1N1) Cases Update • A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: – real-time RT-PCR – viral culture • A probable case of S-OIV infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR • A suspected case of S-OIV infection is defined as a person with acute febrile respiratory illness with onset – within 7 days of close contact with a person who is a confirmed case of S-OIV infection, or – within 7 days of travel to community either within the United States or internationally where there are one or more confirmed cases of S-OIV infection, or – resides in a community where there are one or more confirmed cases of S-OIV infection. 6/11/2009 165 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  155. CDC Influenza A (H1N1) Case definition of Close Contacts • The definition of close contacts is: Household members of confirmed or probable cases • Close workplace contacts of a confirmed or probable case, including sharing an office or cubicle area (sitting within one metre for at least 15 minutes) • Members of a confirmed or probable case’s class or child care group and their teacher/child care supervisor, where the case is a child aged between 0-12 years old • Others identified by a confirmed or probable case, household members or workplace contacts as having been in close physical contact (hugging, kissing, sitting within one metre for at least 15 minutes) with the confirmed case • Passengers and crew travelling on aircraft with a confirmed or probable case as defined below: – Passengers seated in the same row, and within two (2) rows in front of and behind the case; – Any passengers who moved from elsewhere in the aircraft to spend more than 15 minutes near the case – Airline staff (unless they did not visit the section of the plane in which the case was seated) 6/11/2009 166 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  156. NDSC Case Definition Influenza (Influenza A and B virus) (EU) • Clinical description • Clinical picture compatible with influenza i.e. sudden onset of disease, cough, fever > 38 °C, muscular pain and/or headache. • Laboratory criteria for diagnosis • One of the following: – Detection of influenza antigen, or influenza virus specific RNA – Isolation of influenza virus – Demonstration of a specific serum antibody response to influenza A or B (four fold or greater rise).** • Case classification • Possible: Clinically compatible case with epidemiological link* • Probable: N/A Case Definitions for Notifiable Diseases Infectious Diseases (Amendment) • Confirmed: Clinical case that is laboratory confirmed. (No. 3) Regulations 2003 (SI No. 707 of 2003) • Note: Influenza of a new or re-emergent subtype is defined as influenza caused by a novel or re-emerging influenza virus which is capable of infecting humans and causing human illness, and to which a large 6/11/2009 167 proportion of the human population has little or no immunity. Medical Management of Biological Casualties Revised and Modified 29/04/2009
  157. EU Case Definition Novel Influenza Virus A(H1N1) April 30 2009 • Clinical criteria • At least one of the • Any person with one of the following three: following three in the • — fever > 38 °C AND signs and symptoms seven days before disease of acute respiratory infection, • — pneumonia (severe respiratory illness), onset: • — death from an unexplained acute • — a person who was a close contact to a confirmed case of novel influenza A(H1N1) virus infection while the case was ill, respiratory illness. • — a person who has travelled to an area where sustained human- • Laboratory criteria to-human transmission of novel influenza A(H1N1) is documented, • At least one of the • — a person working in a laboratory where samples of the novel influenza A(H1N1) virus are tested. following tests: • — RT-PCR, • Case classification • — viral culture (requiring BSL 3 facilities), • A. Case under investigation Any person meeting the clinical and epidemiological criteria. • — four-fold rise in novel influenza virus A(H1N1) specific neutralising antibodies • B. Probable case (implies the need for paired sera, from • Any person meeting the clinical AND epidemiological criteria AND acute phase illness and then at with a laboratory result showing positive influenza A infection of an convalescent stage 10-14 days later unsubtypable type. minimum). • C. Confirmed case • Epidemiological criteria • Any person meeting the laboratory criteria for confirmation. 6/11/2009 168
  158. Influenza Activity Index Irish Influenza Activity Code, Name and Description Index Index Name Index Description* Code 0 No Report No reports received. 1 No Activity No ILI or laboratory confirmed influenza cases and no influenza/ILI outbreaks in a HSE-Health Area. 2 Sporadic Activity Isolated case(s) of ILI or laboratory confirmed influenza case(s) in a HSE-Health Area, or an influenza/ILI outbreak in a single nstitution. 3 Localised Activity Increases in ILI in local areas (such as a city, county, or district) within a HSE-Health Area, or outbreaks in two or more institutions within an area, with laboratory confirmed cases of influenza infection. Levels of activity in the remainder of the HSE-Health Area would be sporadic or have no activity 4 Regional Activity Increases in ILI in one or more regions with a population comprising less than 50% of the HSE-Health Area’s total population, with laboratory confirmed influenza cases in the ffected region(s). Levels of activity in the remainder of the HSE-Health Area would be sporadic or have no activity. 5 Widespread activity Increases in ILI in one or more regions with a population comprising 50% or more of the HSE-Health Area’s total population, with laboratory confirmed influenza infections 6/11/2009 169
  159. Influenza-like illness (ILI) –Definition Surveillance of Clusters/Outbreaks • Influenza-like illness (ILI) -definition for interim surveillance of clusters/outbreaks • Three or more cases of ILI arising within the same 72 hour period which meet the same clinical case definition and where an epidemiological link can be established • ILI symptoms include: – Acute onset of fever (temperature≥38oC) – OR history of fever – AND flu-like illness (two or more of the Influenza-like following symptoms: cough, sore throat, Illness/Influenza/Influenza A myalgia, headache, rhinorrhea or (H1N1) Outbreak Reporting Form vomiting/diarrhoea) 6/11/2009 170
  160. Influenza A(H1N1)–Definition Surveillance of Clusters/Outbreaks 6/11/2009 New May 29 2009 171
  161. Reporting Suspect Influenza A (H1N1) Virus Infection • Clinicians must contact their state public health department to report suspected cases of Influenza A (H1N1) virus infection and to obtain information on what clinical and epidemiological data to collect and specimen shipment protocols in their region. 1.Health and Safety regulations on biological hazards (Safety, Health and Welfare at Work Act 2005 (No. 10 of 2005) 2.European Agreement concerning the International Carriage of Dangerous Goods by road (ADR) Regulations (2007 edition). 3.S.I. No 29 of 2004 - Carriage of Dangerous Goods by Road Regulations, 2004. 6/11/2009 172 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  162. Public Health Management of Influenza A(H1N1) Contacts • Management of Contacts • Household contacts: request to go into home quarantine until test result • If positive, remain in voluntary home quarantine for 7 days. • All other actions wait until the test result comes back as Influenza A unsubtypable (probable). • If A unsubtypable: • Chemoprophylaxis for close contacts as defined above (1 course = 10 days) • Surveillance: Active - contacts to self-monitor for symptoms for 7 days, check temp twice daily. – Staff from local office of Director of Public Health will make contact daily to ensure asymptomatic. • No ongoing quarantine for non household contacts of a positive case • Health care workers who have worn appropriate PPE don’t need chemoprophylaxis; they should self monitor for symptoms and will be followed daily by Public Health • Taking serology may be relevant in certain circumstances in order to better understand transmission. In these circumstances paired samples should be taken (first sample when identified as a contact and second sample 14 days later). • Contacts who are workers on pig farms should not work for 7 days following contact with a case to reduce the risk of human-to-pig transmission. 6/11/2009 173
  163. Public Health Management of Influenza A(H1N1) Contacts Update • Close Contacts Definition • Household members of a case • Roommates of cases in hospitals or institutions such as nursing homes, • People occupying the same room with a case (<1metre) for at least 4 hours • People who have contact with fomites contaminated with respiratory secretions (e.g. those handling tissues recently used by others or touching the hands of infectious persons who have handled tissues or touched their nose) • Travellers by plane sitting in the same row or in the 2 rows ahead or behind on a long haul flight (at least four hours duration) of a case that was symptomatic either on the flight or within 24 hours of the flight (only symptoms generating droplets such as sneezing and coughing count here) • Persons caring for a sick traveller, as described above • Health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient without wearing appropriate Personal Protective Equipment (PPE) for Standard, Droplet and Contact Precautions: – Surgical mask, Plastic Apron, Gloves (and goggles if risk of splashing or spraying) for staff for all routine care (including taking nasal and throat swabs for viral testing) – 6/11/2009 Additionally, FFP2 or FFP3 mask, goggles, gloves and long sleeved gown for aerosol generating 174 procedure
  164. Public Health Management of Influenza A(H1N1) Contacts Update June 5 2009 • • Management of Contacts · The following actions commence on receipt of test result of a probable or confirmed case: – Chemoprophylaxis for close contacts as defined above (1 course = 10 days) – Surveillance: Active - contacts to self-monitor for symptoms for 7 days, check temp twice daily. Staff from local office of Director of Public Health will make contact daily to ensure asymptomatic • Health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient and who WERE wearing appropriate Personal Protective Equipment (as above) are not considered to be close contacts. However, given the potential for nosocomial transmission (e.g. inadvertent exposure to aerosols, or lack of formal fit testing of respirators, or failure to implement hand hygiene following contact with contaminated surfaces or after removing PPE), such workers – Do not need chemoprophylaxis but – Should self-monitor for symptoms and report immediately to their Occupational Health Department (or local Public Health if no Occupational Health Department is available) any symptoms suggestive of influenza • Taking serology may be relevant in certain circumstances in order to better understand transmission. In these circumstances paired samples should be taken (first sample when identified as a contact and second sample 14 days later) • Contacts who are workers on pig farms should not work for 7 days following contact with a case to reduce the risk of human-to-pig transmission • If there are school contacts, these should be urgently discussed with HPSC 6/11/2009 175
  165. Influenza A(H1N1) Public Health Management Update June 11 2009 HPSC Form Update June 11 2009 http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforH ealthProfessionals/PublicHealth/Guidance/File,3617,en.pdf 6/11/2009 176
  166. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 • Post exposure prophylaxis is indicated for close contacts that were exposed to a probable or confirmed case during the period when the case was symptomatic and for 24 hours before onset of symptoms AND the contact’s last exposure occurred no more than 7 days previously. • Any probable or confirmed human case of influenza A(H1N1)should be notified to the local DPH as soon as possible. 6/11/2009 177
  167. Influenza A (H1N1) Case Surveillance Form • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInflue nza/AdviceforHealthProfessionals/PublicHealth/File,3606,e n.pdf • 1-6 pages 6/11/2009 178 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  168. Surveillance Form for Contacts of Influenza A(H1N1) • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInflue nza/AdviceforHealthProfessionals/PublicHealth/File,3607,e n.pdf • 1-7pages 6/11/2009 179 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  169. Influenza A (H1N1) Dispatchers Guide Infection Prevention and Control Guidance for the Emergency Dispatcher • Recommendations for 999 • It is important for the Emergency Operators to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H1N1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources • Emergency Operators should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health 6/11/2009 180 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  170. Influenza A (H1N1) Dispatchers Guide Infection Prevention and Control Guidance for the Emergency Dispatchers Interim recommendations: • Call takers should screen all callers for any symptoms of acute febrile respiratory illness. – Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms – If the emergency operator call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” before the responders arrive on scene 6/11/2009 181 Medical Management of Biological Casualties Adapted from “Dispatchers Guide to CBRNE” Revised and Modified 29/04/2009
  171. Confirmed Influenza A(H1N1) in The Geographic Area • Step 1: Address scene safety: – If emergency operator advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPE for suspected cases of swine-origin influenza prior to entering scene. – If emergency operator has not identified individuals with symptoms of acute febrile respiratory illness on scene, EMS personnel should stay more than 6 feet away from patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza. • Step 2: • Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough). – If no symptoms of acute febrile respiratory illness, provide routine EMS care. – If symptoms of acute febrile respiratory illness, don appropriate PPE for suspected case of swine-origin influenza if not already on. 6/11/2009 182 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  172. Influenza A(H1N1) Infection Prevention and Control Guidance for the Ambulance Service • If the ambulance service is informed that a patient is suspected or confirmed to have swine influenza (A/H1N1) the following precautions should be taken: • 1.On arrival to the house – Ambulance staff to decontaminate hands (alcohol gel), don gloves, gowns/aprons, FFP3 masks (fit check to ensure good seal) and eye protection if splashing anticipated. Wash hands before donning and after removing gloves. • Inform the hospital of admission of potentially infectious person Before leaving the house • Request patient to wear a surgical mask An ambulance driver • A patient with suspected or confirmed flu wearing a face mask drives in Hospital La Fe in should not travel with any other patients Valencia, Spain 6/11/2009 183 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  173. Influenza A(H1N1) Infection Prevention and Control Guidance for the Ambulance Service In ambulance: • Change gloves and decontaminate hands after every patient procedure • Use single use or single patient use medical equipment where possible • Use disposal linen if available 6/11/2009 184 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  174. Influenza A(H1N1) Infection Prevention and Control Guidance for the Ambulance Service • Arrival to hospital • Ensure arrangements in place for receipt of the patient before the patient leaves the ambulance • Transfer patient to the care of hospital staff • Remove PPE in the following order 1. Gloves 2. Apron/gown 3. Decontaminate hands 4. Eye wear (if applicable) 5. Mask (do not touch front of mask when removing) 6. Decontaminate hands 6/11/2009
  175. Influenza A(H1N1) Infection Prevention and Control Guidance for the Ambulance Service • Before ambulance is used again • Cleaning and disinfecting – Surfaces (stretcher, chair, door handles etc) should be cleaned with a detergent and a hypochlorite solution 1000pmm • Laundry – Place reusable blankets in an alginate bag, then into a red laundry bag and sent for laundry • Medical equipment – Follow manufacturer’s instructions for cleaning/disinfecting reusable equipment • Management of waste – Waste contaminated with blood or body fluid should be disposed of as Healthcare Risk waste – Management of sharps – as per Standard Precautions – Management of spillages – as per Standard Precautions 6/11/2009 186 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  176. Guidance for the Ambulance Service with Suspected /Probable or Confirmed Case • Post Exposure Prophylaxis “PEP” form 6/11/2009 187
  177. Influenza A (H1N1) Triage Initial Patient Management • Should be managed as follows: • Physical barrier (i.e. window or plexiglass barrier) or the receptionist should maintain a 2 metre (6 foot) distance from all patients whenever possible • In settings where such a separation is not possible, healthcare workers are advised to maintain whatever separation is feasible. • If there is no barrier, and a 2 metre (6 foot) distance cannot be achieved, a fit tested FFP 2-3 respirator and eye protection should be worn by the receptionist • Alcohol-based hand rub (ABHR) should be readily available for both staff and patients • Patient should be asked to perform hand hygiene using an ABHR and given a surgical mask to put on covering their nose and mouth • Patient should be placed in a separate area of the office (i.e. examination room). If an examination room or separate room is not available, the patient should remain masked • Provide hands-free garbage and laundry receptacles. • Remove magazines and toys from the waiting rooms to reduce potential contact exposures 6/11/2009 188
  178. Influenza A (H1N1) Triage Health Care Setting Screening • All patients who present to a health care setting should be screened for fever and respiratory symptoms. • This should include: • Passive screening: visual alerts posted at the entrances to all health care settings asking patients to report whether they have fever and any new or worsening respiratory symptoms, and • Active screening: At first contact, staff asks about fever and respiratory symptoms • Respiratory symptoms include cough, sore throat, coryza (runny nose), and myalgias (general body aches) • Routine practices ,contact and droplet precautions for clinicians • Additional precautions Influenza-like Illness/Influenza/Influenza A (H1N1) Outbreak Reporting Form 6/11/2009 189
  179. Influenza A (H1N1) Triage Health Care Setting Guidelines • The following infection control practices are indicated when assessing patients with fever and respiratory symptoms: • Before a clinical assessment: • Ensure patient is still wearing a surgical mask • Perform hand hygiene (alcohol based hand rub or soap and water) before and after patient assessment • Put on gloves • A gown is needed only when there is a risk of clothing or skin contamination (such as when examining young children who may have difficulty controlling their secretions) • Consider most appropriate respiratory protection 6/11/2009 190
  180. Influenza A (H1N1) Triage Health Care Setting Guidelines • Wear a surgical mask: • If the patient is compliant with respiratory hygiene practices (e.g. wearing a surgical mask) or If the patient has a weak or no cough. • Wear an FFP2-3 respirator: – If conducting an aerosol-generating medical procedure (e.g, obtaining a nasopharyngeal swab) on a suspect ILI case – All individuals in the room should wear an FFP2-3 respirator – When the patient is coughing forcefully and is unable or unwilling to comply with respiratory hygiene (e.g., coughing patient who is unable or unwilling to wear a surgical mask) 6/11/2009 191
  181. Influenza A (H1N1) Triage Health Care Setting Guidelines • After a clinical assessment: • Eye or face protection should be removed after leaving the case’s room and disposed of in either a hands-free waste receptacle (if disposable) or in a separate receptacle to go for reprocessing (if reusable) • The surgical mask or FFP2-3 respirator should be removed by the straps, being careful not to touch the mask or respirator itself, after leaving the case’s room and disposed of in a hands-free waste receptacle • HCWs should perform hand hygiene after removing the respiratory protection and after leaving the case’s room • Affected surfaces that may have been contaminated with droplets need to be cleaned. Routine office cleaning products are effective for respiratory viruses including influenza; no special cleaning products are needed. • There is no indication for use of personal air-purifying respirators (PAPRs) in the care of a suspect ILI/Influenza A(H1N1) case 6/11/2009 192
  182. WHO-Patient Care Checklist New influenza A (H1N1) June 2009 6/11/2009 193
  183. ECDC-Influenza A (H1N1) Triage Health Care Setting Guidelines Resource 6/11/2009 194
  184. Influenza A(H1N1) Advice to General Practitioners on Management of a Possible Case Resources • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians 6/11/2009 195 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  185. HPSC References for Patient Care Checklist for Hospitals as of June 10 2009 • 10th June 2009, Version 1.0 • 1. Respiratory Hygiene and Cough Etiquette Poster • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/InfectionControl/File,3599 ,en.pdf • 2. Guidance on hand hygiene • http://www.ndsc.ie/hpsc/A‐Z/Gastroenteric/Handwashing • 3. Pandemic Influenza Preparedness for Ireland: Advice of the Pandemic Influenza Expert Group, Chapter 9, Appendix 1 • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/Guidance/PandemicInfluenzaPreparednessforIreland/File,3261,en.pdf • 4. Taking specimens for influenza virus testing from patients with suspected influenza A(H1N1) • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/PublicHealth/File,3604,en. pdf • 5. Algorithm for the management of persons with acute febrile respiratory illness who may have influenza A(H1N1) • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/HospitalClinicians/File,358 5,en.pdf • 6. Infection Prevention and Control Guidance for the Ambulance Service for suspected or confirmed cases of Influenza A(H1N1) • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/AmbulanceStaff/File,3601 ,en.pdf • 7. Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed Influenza A(H1N1) • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/InfectionControl/File,3628 ,en.pdf • 8. Donning and Removing Personal Protective Equipment (PPE) • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/InfectionControl/File,3627 ,en.pdf • 9. Aerosol Generating Procedures • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/InfectionControl/File,3625 ,en.pdf • 10. Taking care of a sick person with Flu • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdvicefortheGeneralPublic/File,3660,en.pdf • 11. Information and medical advice for the public on Influenza A(H1N1) Leaflet • http://www.hpsc.ie/hpsc/A‐Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdvicefortheGeneralPublic/File,3653,en.pdf • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/HospitalClinicians/File,3778,en.pdf 6/11/2009 196
  186. Influenza A (H1N1) National “Acute Febrile Respiratory Illness” Algorithm • Algorithm for the management of persons with acute febrile respiratory illness who may have influenza A(H1N1) 6/11/2009 197
  187. Influenza A(H1N1) Who's Summary of Clinical Guidelines Modalities Strategies Antibiotics In case of pneumonia, empiric treatment for community acquired pneumonia (CAP) per published guidelines pending microbiologic results (e.g. 2-3 days); tailored therapy thereafter if pathogen(s) identified. Antiviral therapy If treatment needed, oseltamivir or zanamivir. The new influenza A (H1N1) virus is currently resistant to amantadine and rimantadine. Corticosteroids Moderate to high dose steroids are NOT recommended. They are of unproven benefit and potentially harmful. Infection control Standard plus Droplet Precautions. For aerosol-generating procedures use particular respirator (N95, FFP2 or equivalent), eye protection, gowns, gloves, and an airborne precaution room, that can be naturally or mechanically ventilated, per WHO guidance NSAIDS, Paracetamol or acetaminophen given orally or by suppository. Avoid antipyretics administration of salicylates (aspirin and aspirin containing products) in children and young adults (< 18 years old) due to risk of Reye’s syndrome. Oxygen therapy Monitor oxygen saturation and maintain SaO2 over 90% (95% for pregnant women) with nasal cannulae or face mask. 6/11/2009 198
  188. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 6/11/2009 199 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  189. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) • Standard Precautions require all HCWs to: • A. Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. • B. Apply a set of work practices to blood, all body fluids (except sweat), mucous membranes and non intact skin: – Hand hygiene – Use of personal protective equipment – Management of spillages of blood and body fluids – Appropriate patient placement – Management of sharps – Safe injection practices – Respiratory hygiene and cough etiquette – Management of needle stick injuries – Management of waste – Management of laundry – Decontamination of reusable medical equipment – Decontamination of the environment. 200 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  190. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.2 Occupational Health Programme Standard Precautions  HCWs should self monitor their own health for influenza like symptoms  HCWs with symptoms should not attend work and should immediately report symptoms to their line manager 2.3 Patient Placement Standard Precautions Home  Assess the patient with suspected or confirmed influenza A(H1N1) by phone at home if possible GP/Primary care/Community Droplet Precautions  Place in a single room and avoid communal areas if possible. Otherwise do not place within approximately 1 metre of other patients Contact Precautions Hospital  Place patient with suspected or confirmed influenza A(H1N1) in a single room preferably with ante room and en-suite facilities  Emergency departments without single rooms must have interim arrangements in place to prioritise transfer to an appropriate single room  Avoid communal areas and placing patient within approximately 1 metre of other patients  Ambulance Refer to ambulance advice document 2.4 Hand Hygiene Standard Precautions Hand hygiene using liquid soap or alcohol hand gel/rub must be performed before and after all patient care procedures 2.5 Patient Movement and Transfer Standard Precautions External transfer Patient should wear a surgical mask outside their room It is the responsibility of the transferring facility to inform staff of the precautions required Droplet Precautions  Refer to ambulance advice document Contact Precautions Internal transfer  Minimise movement of patient from single room  Patient should wear a surgical mask outside their room  Staff should be informed of the precautions required in the receiving departments (e.g. diagnostic departments)  Avoid holding patients in communal areas (radiology etc)  HCW PPE: Wear a surgical mask and observe hand hygiene 6/11/2009 Medical Management of Biological Casualties 201 Revised and Modified 29/04/2009
  191. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.6 Respiratory Hygiene & Cough Standard Precautions Infections should be: Etiquette  Identified promptly in primary care and emergency departments  Offered masks (and other symptomatic persons e.g., persons who accompany ill patients should also be offered masks) Droplet Precautions  Encouraged to maintain spatial separation, ideally a distance of approximately 1 meter, from others in common waiting areas Emergency departments and primary care facilities should:  Ensure that supplies of tissues, foot operating waste bins and hand hygiene facilities are available in all departments including waiting areas throughout the facility  Educate patients/visitors/carers on Respiratory Etiquette and Cough Hygiene using some or all of the following:  Patient information leaflets  Posters in all departments especially waiting areas  If influenza A(H1N1) is suspected place patient & persons who accompany ill patients in a single room  See Appendix A for respiratory hygiene and cough etiquette poster. The poster can be downloaded from the following website http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Factsheets/RespiratoryHygiene/File,35 99,en.pdf 6/11/2009 202
  192. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.7 Personal Standard Precautions The following applies to all settings: Protective Droplet Precautions GP/Primary care/Ambulance transfer/Hospital Equipment Contact Precautions Patient should wear: (PPE)  A surgical mask when outside their single room HCWs must wear the following for: 1. Routine care  Surgical mask, Plastic Apron/Gown, Gloves (& Goggles if splashing/spraying risk) 2. Aerosol Generating Procedures  FFP2 or FFP3 mask (correctly fitted), Goggles, Long sleeved disposable gown, Gloves Refer to Aerosol Generating Procedures document and to PPE poster Masks  Change mask if it becomes damp, wet or torn  Change and discard mask when leaving the room or patient care area HCW’s when putting on and removing PPE must :  Put on and remove in the correct sequence (refer to PPE poster)  Remove gloves & apron/gown inside the single room  Remove mask in the ante room or immediately outside the single room if there is no ante room. Ensure door is closed.  Decontaminate hands immediately after removing PPE 6/11/2009 203
  193. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.8 Environmental Decontamination Standard Precautions In addition to Standard Precautions: Only take essential equipment and supplies into the room. Droplet Precautions  Do not stockpile as unused stock will have to be discarded on cessation of additional precautions  Patient charts/records should not be taken into the single room Contact Precautions  The frequency and intensity of cleaning may need to be increased based on the patients level of hygiene and the level of environmental contamination  HCW’s must wear surgical mask, gloves, apron for cleaning the patients room  Thoroughly clean the environment and furniture and all patient care equipment daily with a neutral detergent and disinfectant (hypochlorite solution 1000 ppm) paying special attention to frequently touched sites and equipment close to the patient  On patient discharge/transfer cleaning and disinfection of the environment  Prior to initiating environmental cleaning and disinfection, all privacy, shower and window curtains must be removed and sent for laundering All disposable items including paper towels and toilet paper should be discarded All sterile and non-sterile supplies in the patient room to be discarded on patient transfer/discharge Dishes and Eating Utensils  Cutlery and crockery - No additional measures are required for cutlery and crockery washed in a dishwasher or wash with liquid detergent and water 2.9 Patient Care Equipment & Standard Precautions In addition to Standard Precautions: Decontamination of Medical Devices  Dedicate patient care medical devices (e.g., thermometers, sphygmomanometers, stethoscopes, glucometers) to single Droplet Precautions patient use  Use disposable equipment whenever possible Contact Precautions  Manufacturer’s instructions should be followed for cleaning and disinfecting of reusable medical equipment after use  Single use items should be disposed of after use  Bedpan/Commodes  Use a working washer disinfector at 80°C for one minute  Dedicate a commode to single patient use if no en suite available  Decontaminate commode surface after each patient use with a hypochlorite solution 1000 ppm 6/11/2009 204
  194. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components STANDARD Key Elements of Clinical Practices and Measures PRECAUTIONS 2.10 Linen/Laundry Standard Precautions  No additional precautions necessary  As per Standard Precautions all contaminated laundry should be carefully placed in an alginate stitched or water soluble bag and then placed into a laundry bag clearly identified with labels, colour-coding or other methods prior to transport to an approved laundry capable of dealing with contaminated linen 2.11 Management of needle stick injuries (NSI) and Standard Precautions  No additional precautions necessary blood and body fluid exposure 2.12 Management Standard Precautions  No additional precautions necessary for Non Healthcare Risk and Healthcare Risk Waste of Waste  Dispose of all PPE as Healthcare Risk Waste (e.g. used masks) 6/11/2009 205
  195. Influenza A(H1N1) Clinical Diagnostics 6/11/2009 206
  196. Guidance on Laboratory procedures when pandemic influenza is present outside Ireland (Irish Alert Level 1) • Samples should be collected for influenza investigation (including viral culture when advised by WHO) from all patients who: 6/11/2009 207 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  197. Taking Specimens for Influenza Virus Testing From Patients with Suspected Swine Influenza • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians 6/11/2009 208 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  198. Guidance on Laboratory procedures when pandemic influenza is present outside Ireland (Irish Alert Level 1) • 1. Samples should be collected for influenza investigation (including viral culture when advised by WHO) from all patients who: • Have been hospitalised with viral pneumonia; – Have travelled to areas of known or potential influenza activity in the week preceding onset of illness and have symptoms associated with the pandemic influenza strain – Have a flu-like illness and are family members or other close contacts of either of the above. • 2. All samples from “highly suspicious cases” must be promptly referred to NVRL for investigation, as per agreed procedures. Any influenza strains detected should be provisionally characterised at the NVRL urgently and referred with available phylogenetic data urgently to the WHO Collaborating Centre in London for confirmation and sub typing. • 3. NVRL should validate any novel diagnostic tests to ensure that “best practice” methodologies are utilised and can be introduced immediately • 4. NVRL should monitor the developments regarding the laboratory diagnosis and “bedside” diagnosis of the new influenza strain. 6/11/2009 209 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  199. Influenza A(H1N1) Irelands Laboratories Overview • Approximately 34 (BL3) laboratories distributed among the universities an biotechnology companies in Ireland. • These predominantly handle up to Category 3 pathogens or conduct genetic manipulations under regulation of the Environmental Protection Agency. • High containment Class 3 (+) laboratory has been commissioned at the University College Dublin National Virus Reference Laboratory (UCD NVRL) • Environmental and clinical specimens are investigated in a Class 3 containment laboratory at Cherry Orchard Hospital, Dublin. • Novel Influenza A H1N1 in BSL-3 practices (enhanced BSL-2 conditions) 6/11/2009 210 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  200. Influenza A(H1N1) National Virus Reference Laboratory • Postal address: Medical Microbiology, CRID Building, University College Dublin, Belfield, Dublin 4, Ireland. Telephone Number: +353-1-716 1325/1236 Fax Number: +353-1-716 1239 Email: margaret.brindley@ucd.ie 6/11/2009 211 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  201. Influenza A(H1N1) Specimen Collection • Clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer). – A diagnosis of confirmed swine flu requires laboratory testing of a respiratory sample (a simple nose and throat swab) – Collected during the first five days • Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a public health laboratory • Laboratories should send all unsubtypable influenza A specimens as soon as possible to NRVL • Spill containment measures should be in place! 6/11/2009 212 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  202. Influenza A(H1N1) Laboratory Precautions • Viral isolation on clinical specimens from patients who are suspected cases of swine influenza A (H1N1) virus infection should be performed in a BSL2 laboratory with BSL3 practices (enhanced BSL2 conditions) • Additional precautions include: Recommended Personal Protective Equipment (based on site specific risk assessment ) – Respiratory protection – fit-tested FFP 2-3 respirator or higher level of protection – Shoe covers – Closed-front gown – Double gloves – Eye protection (goggles or face shields) 6/11/2009 213 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  203. Influenza A(H1N1) Laboratory Precautions • Routine laboratory procedures, including diagnostic work and PCR analysis: • Biosafety Level 2 (BSL2), as detailed in the WHO Laboratory biosafety manual, 3rd edition. • Examples of routine laboratory procedures that require BSL2 include: • Diagnostic testing of serum, blood (including haematology and clinical chemistry), respiratory tract specimens, or other specimens • Manipulations involving neutralized or inactivated (lysed, fixed, or otherwise treated) virus particles and/or incomplete, non-infectious portions of the viral genome • Routine examination of mycotic and 6/11/2009 214 bacterial cultures Medical Management of Biological Casualties Revised and Modified 29/04/2009
  204. Influenza A(H1N1) Laboratory Precautions • Viral isolation on clinical specimens from patients who are suspected or confirmed cases of influenza A (H1N1) infection should only be performed in laboratories capable of meeting the following additional essential (minimal) containment Bio containment :BL3(+) Two microbiological safety cabinets requirements: (msc ) class I and class I/ III) at • Practices recommended for NVRL containment laboratories — Biosafety Level 3 in the WHO Laboratory biosafety manual, 3rd edition 6/11/2009 215 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  205. Influenza A(H1N1) Laboratory Precautions • A controlled ventilation system maintains directional airflow into the laboratory room • Exhaust air from the laboratory room is not recirculated to other areas within the building – Air should be HEPA filtered, if reconditioned NRVL BL3(+) Has and recirculated within the laboratory. two microbiological – When exhaust air from the laboratory is safety cabinets (class discharged to the outdoors, it must be I and class I/ III) dispersed away from occupied buildings and air intakes. – This air may be discharged through HEPA filters • All manipulations of infectious or potentially infectious materials must be performed in appropriately maintained and validated BSCs. (Ireland: NRVL Uses msc class I and class I/ III) • Access to the laboratory is restricted when work is in progress 6/11/2009 216 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  206. Influenza A(H1N1) Laboratory Precautions • Viral isolation on clinical specimens : • Biosafety Level Three plus (BL3+) containment laboratory • PPE • Laboratory workers should wear protective equipment, including: – Disposable gloves NRVL Layout of Bio – Solid front or wrap-around gowns Containment :BL3(+) – Scrub suits – Coveralls with sleeves that fully cover the forearms – Head coverings – Shoe covers or dedicated shoes – Eye protection (goggles or face shield) – Respiratory protection (fit-tested particulate respirator, e.g. EU FFP2, US NIOSH-certified N95 or equivalent, or higher protection), because of the risk of aerosol or droplet exposure 6/11/2009 217 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  207. Influenza A(H1N1) Laboratory Precautions Summary • Clinical laboratory testing • Viral isolation (laboratory diagnostic work) • Diagnostic laboratory work on • Growth of the virus in cell culture clinical samples from patients or embryonated eggs should be who are suspected cases of novel performed in a BSL-2 laboratory influenza A H1N1 virus infection with BSL-3 practices. should be conducted in a • All viral manipulations should be biosafety level 2 (BSL-2) done inside a microbiological laboratory. safety cabinets (msc ) class I and • All sample manipulations with class I/ III) that is certified the potential for creating an annually. aerosol should be done inside a microbiological safety cabinets (MSC) that is certified annually. Bio containment :BL3(+) Two microbiological safety cabinets (msc ) class I and class I/ III) at NVRL 6/11/2009 218
  208. Influenza A(H1N1) Laboratory Precautions • Animal work • The following activities require animal facility — Biosafety Level 3 facilities and work practices, as detailed in the WHO Laboratory biosafety manual, 3rd edition. – Inoculation of animals for potential recovery of the agent from influenza A (H1N1) specimens – Any protocol involving animal inoculation for confirmation and/or characterization of putative influenza A (H1N1) agents – Bio containment :BL3(+) At NRVL/Cherry Orchard 6/11/2009 219 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  209. Influenza A(H1N1) Laboratory Precautions • Waste • All waste disposal procedures should be followed as outlined in your facility standard laboratory operating procedures. • Appropriate disinfectants • 70% Ethanol • 5% Lysol • 10% Bleach • Influenza viruses can survive on environmental surfaces and can infect a person for up to 2 to 8 hours after being deposited on an environmental surface • Commonly used surfaces such as door handles, handrails, table surfaces etc. should be cleaned first and then disinfected with a chlorine releasing disinfectant (1000 ppm) twice daily Detailed information on • Disinfectants with proven activity against enveloped viruses disinfectants and their recommended use can be include chlorine, alcohol, peroxygen, quaternary ammonium found in Laboratory biosafety manual, 3rd compounds and phenolic compounds and should be adequate if ed., Geneva, World Health Organization, 2004 used according to manufacturer’s recommendations. 6/11/2009 220 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  210. Influenza A(H1N1) Laboratory Precautions • Personnel should self monitor for fever and any symptoms Never place knee on • Accidental exposure: floor – Antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days( See PEP slide) Center for Disease Control and Prevention, shows a negative-stained image of the swine flu virus. 6/11/2009 221 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  211. NRVL Testing for Influenza A(H1N1) • Preferred Respiratory Specimens • Swabs – Nasopharyngeal Aspirates • Storing Clinical Specimens • Shipping Clinical Specimens • Recommended Tests HSE :Taking • Other Influenza Tests specimens for influenza virus testing – Rapid Influenza Antigen Test from patients with – Immunofluorescence (DFA or IFA) suspected swine influenza – Viral Culture 6/11/2009 222 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  212. NRVL Testing for Influenza A(H1N1) • Taking specimens for influenza virus testing from patients with suspected influenza A (H1N1): • As with all respiratory viruses, diagnosis of influenza virus depends on the collection of high-quality specimens, their rapid transport to the virology laboratory and appropriate storage before laboratory testing • Virus is best detected in specimens containing infected cells and secretions • Specimens should ideally be taken preferably during the first 5 days after onset of clinical symptoms 6/11/2009 223 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  213. NRVL Testing for Influenza A(H1N1) • Before taking specimens: • Before a specimen is taken, it should first be discussed with the Director or Public Health as outlined in the national algorithm for the management of persons with possible influenza A (H1N1) • Infection prevention and control precautions • While not strictly an aerosol generating procedure it is recommended that the same National Algorithm precautions are followed when taking nasal and throat viral swabs to out rule influenza A (H1N1) 6/11/2009 224 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  214. NRVL Testing for Influenza A(H1N1) • Infection prevention and control precautions: • While not strictly an aerosol generating procedure it is recommended that the following PPE is used when taking nasal and throat viral swabs to out rule influenza A (H1N1) • The following personal protective equipment (PPE) should be taken: – Hand hygiene – Standard Precautions – Surgical – Eye protection (i.e. goggles) – Plastic apron (single use only) – Gloves (some of these procedures require sterile gloves) – Hand hygiene post procedure • Refer to donning and removal of PPE document 6/11/2009 225 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  215. Aerosol Generating Procedures According to WHO And HPSC • Aerosol generating procedures: • Nebulisation • Intubation and related • Non-invasive positive procedures, e.g. manual pressure ventilation(NIV) ventilation • Bi-level positive airway • Respiratory and airway suctioning pressure (BiPAP) ,CPAP, (including tracheostomy care) • High frequency oscillating • Nasopharyngeal aspiration ventilation • Cardiopulmonary resuscitation • Bronchoscopy • Nasopharyngeal aspirate • Transtracheal aspirate • Bronchoalveolar lavage • Biopsy of lung or tracheal tissues • Autopsy procedures – i.e.. (Oscillating saws) 6/11/2009 226
  216. Influenza A(H1N1) Infection Prevention and Control Precautions Personal Protective Equipment (PPE) Summary • Nasal and throat viral swabs: • Nasopharyngeal aspirate, transtracheal aspirate, • The following precautions should be bronchoalveolar lavage and biopsy taken: of lung or tracheal tissues at post- mortem, nebulizers , • Hand hygiene BIPAP/CPAP/NIV are all considered • Surgical mask aerosol generating procedures: • Goggles (if risk of splashing or spraying) • The following precautions should be • Plastic apron taken: • Gloves • Hand hygiene • Hand hygiene post procedure • FFP2 or FFP3 respiratory mask • Goggles • Long sleeved disposable gown • Gloves (some of these procedures require sterile gloves) • Hand hygiene post procedure Update June 9 2009 6/11/2009 227
  217. NRVL Testing for Influenza A(H1N1) • Respiratory specimens to take: • A. Upper respiratory tract – Nasopharyngeal (NP) and oropharyngeal (OP) swab – Nasopharyngeal aspirate – Sputum (if ordered) • B. Lower respiratory tract – Where clinically indicated, invasive procedures can be performed for the diagnosis of viral lower respiratory tract infections: – Transtracheal aspirate (TA) – Bronchoalveolar lavage (BAL) – Post-mortem lung or tracheal tissue 6/11/2009 228 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  218. NRVL Testing for Influenza A(H1N1) • Swabs to use: – Specific viral swab (contains viral transport medium in the container of the swab) – Regular swab – after taking the specimen the swab should be broken off into a bottle containing virus transport medium – Nasopharyngeal secretions should be aspirated into a sterile plastic mucous extractor. Transport the mucous extractor with the secretions – A transtracheal aspirate/ broncho-alveolar lavage should be transported in a sterile container 6/11/2009 229 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  219. Influenza A (H1N1) Nasopharyngeal Swabs • According to PHAC And CDC : Nasopharyngeal Swabs • Ideally, swab specimens should be collected using (COPAN flocked swab) swabs with a synthetic tip (eg, polyester or Dacron) and a plastic shaft • Optimal specimens continue to be Nasopharyngeal Swabs (COPAN flocked swab) but Starplex non- flocked swabs are also acceptable for nasopharyngeal and nasal samples. • Do not use wired shaft pertussis swab as it interferes with the test and give a false negative result • Swabs with cotton tips and wooden shafts are not recommended • Specimens collected with swabs made of calcium alginate are not acceptable • The swab specimen collection vials should contain 3 mL of VTM (eg, containing protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution), such as M4RT or the BD Universal Viral Transport System 6/11/2009 230 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  220. Influenza A(H1N1) Flocked Swabs and Copan-Manufactured VTM for Influenza A(H1N1) • CDC Recommends Flocked Swabs and Copan-Manufactured VTM for H1N1 Influenza A(H1N1): Optimal specimens continue to be Nasopharyngeal Swabs (COPAN flocked swab) 6/11/2009 231
  221. Influenza A(H1N1) Nasopharyngeal Flocked Swabs Procedure • “Specimens for the laboratory diagnosis of Novel A (H1N1)Influenza should be collected in the following order of priority: 1. Nasopharyngeal aspirates 2. Acute serum 3. Convalescent serum 6/11/2009 232 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  222. Influenza A(H1N1) Nasopharyngeal (NP) , Oropharyngeal (OP) Swab • Nasopharyngeal (NP) and oropharyngeal (OP) swab collection: • Collect specimen with a sterile Dacron/nylon swab with a non-wooden shaft (do NOT use calcium alginate swabs or swabs with wooden sticks) • For NP swab, insert swab into each nostril parallel to the palate and leave in place for a few seconds to absorb secretions. Swab both nostrils • For OP swab, swab the posterior pharynx and tonsillar areas, avoiding the tongue • Place swab immediately into sterile vials containing 2 ml of viral transport media • Label each specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport at 4°C (but not frozen) • Should not be kept un-refrigerated for more than 12 hours 6/11/2009 233
  223. Novel A (H1N1)Influenza Nasopharyngeal Aspirates Overview • Ideally, swab specimens should be collected using swabs with a synthetic tip (eg, polyester or Dacron) and an aluminium or plastic shaft • Swabs with cotton tips and wooden shafts are not recommended • Specimens collected with swabs made of calcium alginate are not acceptable • The swab specimen collection vials should contain 3 ml of VTM (eg, containing protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution), such as M4RT or the BD Universal Viral Transport System 6/11/2009 234 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  224. Novel A (H1N1)Influenza Nasopharyngeal Aspirates Procedure • Hierarchy “Specimens for the laboratory diagnosis of Novel A (H1N1)Influenza should be collected in the following order of priority: 1. Nasopharyngeal aspirates 2. Acute serum 3. Convalescent serum 6/11/2009 235 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  225. Influenza A(H1N1) Nasopharyngeal Aspirates Collection • Nasopharyngeal wash/aspirates collecion: • Have the patient sit with head tilted slightly backward • Instill 1ml-1.5ml of nonbacteriostatic saline (pH 7.0) into one nostril • Insert the tubing into the nostril parallel to the palate • Aspirate nasopharyngeal secretions. Repeat this procedure for the other nostril • Rinse the catheter into viral transport medium (syringe or bulb) or aspirate viral transport media through catheter into collection trap • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport • Do not freeze 6/11/2009 236
  226. Influenza A(H1N1) Bronchoalveolar Lavage (BAL) Collection • Bronchoalveolar lavage or tracheal aspirate: • During bronchoalveolar lavage or tracheal aspirate, use a double-tube system to maximize shielding from oropharyngeal secretions • Centrifuge half of the specimen, and fix the cell pellet in formalin • Place the remaining unspun fluid in sterile vials with external caps and internal O-ring seals • If there is no internal O-ring seal, then seal tightly with the available cap and secure with Parafilm® • HPSC ; broncheoalveolar lavage should be transported in a sterile container 6/11/2009 237
  227. Influenza A(H1N1) Sputum Collection • Sputum collection: • Educate the patient about the difference between sputum and oral secretions • Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile screw-cap sputum collection cup or sterile dry container. • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport • Do not freeze 6/11/2009 238
  228. Influenza A(H1N1) Stool Collection • In the USA, gastrointestinal symptoms (nausea, vomiting and/or diarrhoea) have occurred in up to 38% of outpatients with confirmed influenza A(H1N1) • Diarrhoea has been uncommon in hospitalised cases • SOP (Standard operating procedure) on collection • Full PPE (in case of splashes) • Place in Biological Bag • Do not freeze! • For all specimens Contact DPH/MOH/NVRL for shipping instructions accordance to national and international standards 6/11/2009 239
  229. Influenza A(H1N1) Influenza A(H1H1) Serology Suites • Acute Serum Suites • Convalescent Serum Suites • Immediate • 14 days after • Specimens: • Specimens: – Blood in clotted tube (red top) – Blood in clotted tube (red top) – Blood in EDTA (purple top) – Blood in EDTA (purple top) • {Full blood count) – {Full blood count) • Additional routine blood work according to physicians orders or follow pre ordered Influenza-like illness ,Influenza A(H1H1) suites as institutional protocols 6/11/2009 240
  230. Influenza A(H1N1) Serology Acute and Convalescent Serum Sample • Acute and Convalescent serum samples: • Collect 5-10 ml whole blood in a serum separator or red top tube Allow the blood to clot, centrifuge briefly, and collect all resulting sera in vial with external caps and internal O-ring seals • Refrigerate at 4°C • The minimum amount of serum needed for testing is 200 ml, which can easily be obtained from 5 ml of whole blood • A minimum of 1 cc of whole blood is needed for testing of paediatric patients • If possible, collect 1 cc in an EDTA tube and in a clotting tube • If only 1 cc can be obtained, use a clotting tube • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type 6/11/2009 241
  231. Influenza A(H1N1) and Blood Safety • 2009 H1N1 Influenza Virus and Blood Safety: • Bld cultures Aerobic No case of transfusion transmitted seasonal influenza has ever then anaerobic been reported in the United States or elsewhere, and, to date, no cases of transfusion transmitted H1N1 flu have been reported! • Safety of Plasma Derivatives • The newly emerging 2009 H1N1 Influenza Virus is a large lipid- enveloped virus. Validation studies performed by the product manufacturers have shown that viruses with similar characteristics to this agent are effectively inactivated and/or removed by the manufacturing processes in place for these products • Individuals who are not in good health are not suitable to donate blood and blood establishments must defer these potential donors therefore…. • Blood donor screening procedures currently in place at blood establishments should identify persons with symptoms of H1N1 flu infection 6/11/2009 242
  232. Influenza A(H1N1) and Blood Safety • Irish Blood Transfusion Service advisory • Swine Flu Important Information • “We are asking all donors who have returned from Mexico or the United States of America in the last 14 days NOT to attend any blood donor clinic at this time. This situation is under review on a daily basis and further updates will be available here. Please note that this precaution is in the interest of donor and recipient safety. Your patience and cooperation is greatly appreciated” 6/11/2009 243
  233. Influenza A(H1N1) Diagnostics - Chest X-ray • Approximately 2-5% of confirmed cases in the US and Canada as well as 6% in Mexico have been hospitalised • In Mexico – One-third of those hospitalised required mechanical ventilation • Of those hospitalised in California – 15 of 25 (60%) tested had radiographic changes suggestive of pneumonia including ten with multilobar infiltrates – Four (13%) required mechanical ventilation 6/11/2009 244
  234. Swine Influenza Virus Real-time RT-PCR Detection Panel (Swine Flu Test Kit) • Countries with the PCR Capacity in Place to Diagnose Influenza A(H1N1) Virus Infection in Humans Doc Available at WHO • 23 EU and EFTA countries are currently able to perform PCR to diagnose influenza A(H1N1) virus infection in humans 6/11/2009 245 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  235. Influenza A(H1N1) Laboratory Tests Molecular Diagnostics: • Molecular diagnostics: • S-OIV assay The swine-origin influenza virus (S-OIV) assay (National Virus Reference Laboratory, NVRL, Dublin) is a real-time one-step RT-PCR assay containing primers and a dual-labelled hydrolysis probe targeting the M gene of influenza A viruses other than seasonal A(H1N1) and A(H3N2) viruses • HPA (H1)v assay The influenza A(H1)v specific assay of the Health Protection Agency (HPA) contains primers and a dual-labelled TaqMan MGB probe (Applied Biosystems) targeting conserved sequences in the HA gene of A(H1N1)v viruses, and the positive control swine A(H1N1) virus A/Aragon/3218/2009, in a 1-step TaqMan PCR assay [3]. The advantage of using a genetically distinct positive control virus (A/Aragon/3218/2008) is that false positives can be differentiated by sequence from true positives • CDC (H1)v assay The Centers for Disease Control and Prevention (CDC) real-time RT-PCR kit designed for the detection and characterisation of influenza A(H1N1)v viruses contains a panel of oligonucleotide primers and dual-labelled hydrolysis probes [4]. The CDC (H1)v primer and probe set evaluated in this study has been designed to specifically detect A(H1)v influenza in a one-step RT-PCR assay. • HPA (N1)v assay The influenza A(N1)v real-time assay (HPA) is a two-step TaqMan PCR assay incorporating oligonucleotide primers and a dual-labelled MGB TaqMan probe for the detection of the NA gene of influenza A(H1N1)v viruses and the positive control virus A/Aragon/3218/2008 [5]. The assay has been designed to be performed in conjunction with the influenza A(H1)v specific assay, to provide confirmation of diagnosis of influenza A(H1N1)v virus infection 6/11/2009 246
  236. Swine Influenza Virus Real-time RT-PCR Detection Panel (Swine Flu Test Kit) • Instructions how to obtain CDC real time RT-PCR Kits for detection of Influenza A( H1 N1) • Thr rRT-PCR kits includes the following primers /probes: – Universal Influenza A(Infa) – Swine Influenza A(swIfa) – SwineH1 (swH1) – RNaseP (Control)( RP) • The rRT-PCR kits can also include detailed procedures CDC-developed PCR as well as positive control materials diagnostic test to detect novel H1N1 virus • Send the following e-mail to flouder@cdc.gov • I would like to request a rRT-PCR primers/probe kit for Swine A/H1 Flu • Contact name: • Institution Name: • Contact phone #: • 6/11/2009 Institution Shipping Address(No PO Box): 247 Medical Management of Biological Casualties • Preferred Shipping carrier: Revised and Modified 29/04/2009
  237. Influenza A(H1N1) Virus Real-time RT-PCR Detection Panel • INTENDED USE: The Influenza A(H1N1) Virus Real-time RT-PCR Detection Panel is intended for use in real- time RTPCR assays on an ABI 7500 Fast Dx Real-Time PCR instrument in conjunction with clinical and epidemiological information • Test from nasopharyngeal or nasal swab BinaxNOW® Real-time PCR Biosystems 7500 Influenza A & B detection of Mexican Real-Time PCR Test Swine Flu Kit A C B 6/11/2009 248
  238. Influenza A(H1N1) Laboratory Tests • Real-time RT-PCR for influenza A, B, H1, H3 – swine-origin influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR • Rapid influenza antigen test • Immunofluorescence (DFA or IFA): • Viral culture: • Please Read below in narration! • Emergency Use Authorization of Swine Flu Test Kit : NML Winnipeg • Centers for Disease Control and Prevention (CDC) has developed the Swine Influenza Virus Real-time RT-PCR Detection Panel (Swine Flu Test Kit) for the presumptive presence of swine influenza A (H1N1) virus from the nasal or nasopharyngeal swab. • Swine Influenza Test Kit will be made available on the CDC Swine Flu website. 6/11/2009 249 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  239. Influenza A(H1N1) Recommended Tests • Real-time RT-PCR for influenza A, B, H1, H3 at a state health department laboratory is recommended • Currently, S-OIV will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR • If reactivity of real-time RT-PCR for influenza A is strong (eg, Ct <30), it is more suggestive of a novel influenza A virus • Confirmation of Novel Influenza is performed at the NRVL currently, but may be available in public health laboratories 6/11/2009 250 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  240. CDC Rt-PCR Testing Algorithm and Results Interpretation The overall approach to influenza virus detection by RT-PCR should be considered in the context of the national situation, e.g., how many swl = swine like specimens can be handled (throughput), what gene sequence to target for RT-PCR, and whether to use concurrent or sequential testing for RT-PCR of PCR Assays AIV = Avian Influenza virus M, NP and HA genes. PCR = Polymerase chain reaction Influenza A-swl subtype specific Influenza type A (universal) PCR (H1 gene) Matrix gene PCR (other genes targets are optional Test for Seasonal influenza H1-and N3 using specific Confirmed Positive Positive Positive PCR H1N1 swl And tested negative Positive Negative for seasonal influenza H1 or H3 specific PCR Check for lab Negative Positive confirmation by Influenza A Negative retesting from original Other than H1N1 swl sample Negative for influenza A viruses (check for Positive Check for lab other pathogens confirmation by Positive retesting from original Negative Confirmed Positive sample Test for H5N1 or other AIV or H1 or H3 Influenza B 6/11/2009 251
  241. Submission of Tissue Specimens for the Pathologic Evaluation of Influenza A(H1N1) • Central (hilar) lung with segmental bronchi, right and left primary bronchi, trachea (proximal and distal) • Representative pulmonary parenchyma from right and left lung • For patients with suspected myocarditis, encephalitis, or rhabdomyalysis, myocardium (right and left ventricle), central nervous system (cerebral cortex, basal ganglia, pons, medulla, and cerebellum), and skeletal muscle, respectively • Any other organ showing significant gross or microscopic pathology 6/11/2009 252 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  242. Influenza A(H1N1) Submission of Specimens • General Guidelines for Shipping Pathology Specimens: • Packaging and Shipping Guidelines Layout of Bio Containment :BL3(+) – Formalin-fixed wet tissues OL: Outer lobby S: Shower – Formalin-fixed paraffin- IL: Inner Lobby LAB: Laboratory embedded blocks – Glass slides with sections from paraffin-embedded blocks – Fresh frozen tissue 6/11/2009 253 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  243. Influenza A(H1N1) NRVL Submission of Specimens • Postal address: Medical Microbiology, CRID Building, University College Dublin, Belfield, Dublin 4, Bio containment :BL3(+) Two microbiological safety cabinets Ireland. (msc ) class I and class I/ III) at NVRL Telephone Number: +353-1-716 1325/1236 Fax Number: +353-1-716 1239 Email: margaret.brindley@ucd.ie 6/11/2009 254
  244. Influenza A(H1N1) Who Submission of Specimens • All samples from “highly suspicious cases” must be promptly referred to NVRL for investigation, as per agreed procedures. • Any influenza strains detected should be provisionally characterised at the NVRL urgently and referred with available phylogenetic data urgently to the WHO Collaborating Centre in London for confirmation and sub typing • Dr A. Hay • WHO Collaborating Centre for Reference and Research on Influenza • National Institute for Medical Research • Mill Hill, London NW7 1AA, United Kingdom • Fax: +44 208 906 44 77 • Email: whocc@nimr.mrc.ac.uk • http://www.nimr.mrc.ac.uk/wic/ 6/11/2009 255 Medical Management of Biological Casualties 255 Revised and Modified 29/04/2009
  245. NRVL Testing for Influenza A(H1N1) • 1. Health and Safety regulations on biological hazards (Safety, Health and Welfare at Work Act 2005 (No. 10 of 2005) • 2. European Agreement concerning the International Carriage of Dangerous Goods by road (ADR) Regulations (2007 edition) • 3. S.I. No 29 of 2004 - Carriage of Dangerous Goods by Road Regulations, 2004 • Biosafety: “Directive 90/679/EEC in S.I. No. 248/1998 — Safety, Health and Welfare At Work (Biological Agents) (Amendment) Regulations, 1998.” 6/11/2009 256 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  246. Influenza A(H1N1) Shipping Clinical Specimens • Clinical specimens should be shipped on dry ice in appropriate packaging • All specimens should be labelled clearly and include information requested by the appropriate public health laboratory or NRVL • Suspect case specimens shipped from the public health laboratory to the NRVL should include all information required for seasonal influenza surveillance isolate or specimen submission 6/11/2009 257 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  247. Influenza A(H1N1) International Shipment Protocol As with all clinical specimens, respiratory specimens should be packaged and transported to the virology laboratory in accordance with national and international guidelines. Contact the National Virus Reference Laboratory or local laboratory for advice if concerned! 6/11/2009 258
  248. Influenza A(H1N1) Who Shipment Protocol Adapted from WHO E-tool-Intro Shipping requirements for influenza A (H1N1) specimens are described under: http://www.who.int/csr/resources/publications/swineflu/in structions-shipments/en/index.html All Shippers Must take the E-tool-intro coarse to be able to ship Infectious Substances “Category A” 6/11/2009 259 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  249. Influenza A(H1N1) Who Shipment Protocol • If the shipment also includes other dangerous goods (such as liquid nitrogen or dry ice), shippers must be trained appropriately in the transport of those goods. • Additional information can be found in the WHO document “Guidance on regulations for the transport of infectious substances”, available at: • http://www.who.int/csr/resources/publications/ biosafety/WHO_HSE_EPR_2008_10/en/index.ht ml 6/11/2009 260 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  250. Influenza A(H1N1) Who Submission of Specimens • Shippers should note: • Specimens collected directly from humans or animals that are suspected or confirmed to be infected with the swine influenza A(H1N1) virus, including specimens from the respiratory tract (swabs) and blood specimens, should be shipped as: • \"BIOLOGICAL SUBSTANCE, CATEGORY B\" and assigned to UN 3373. • Swine influenza A(H1N1) virus cultures (i.e. virus isolates) must be shipped as: • Category A \"INFECTIOUS SUBSTANCE; AFFECTING HUMANS\" and assigned to UN 2814. 6/11/2009 261 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  251. Influenza A(H1N1) Who Shipment of Specimens • Category A , Category B, Or Exempt • Packaging Samples • All samples must be packaged using triple packaging. • Triple packaging provides three layers of containment to protect the substances being shipped. • These layers are primary, secondary, and outer containers. • The following diagram shows the basic concept of triple packages. Must be packaged using triple packaging 262 6/11/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  252. This Packaging is Used For Category A Infectious Substances 6/11/2009 263 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  253. Category A: Markings and Labels MARKINGS • All shippers must properly mark and label Category A packages. The following is a list of markings and labels for Category A packages: Markings • Shipper’s name, address, and telephone number u 4G/CLASS 6.2/02 • Receiver’s name, address, and telephone number n F/BVT 312103 • Name and telephone number of responsible person (who is available 24 hours a day until shipment arrives) INFECTIOUS SUBSTANCE, AFFECTING HUMANS • UN Specification Marking UN2814 • Proper Shipping Name and UN Number LABELS Labels • Infectious substance label • Package orientation label (only used when primary container exceeds 50ml) 6/11/2009 264 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  254. Influenza A(H1N1) Category A Packing Requirements • Primary container is leakproof • Secondary container is leakproof • Outer container is rigid Triple Packaging Example • Pressure tested at 95kPa • Drop tested from 9m • Puncture tested at 7kg • UN specification marking • Shipper must be trained 6/11/2009 265 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  255. Steps For Packaging Category A Samples Swine influenza A(H1N1) 1. Open secondary container. virus cultures (i.e. virus isolates ) must be shipped 2. Insert absorbent material. as: 3. Don gloves. Category A \"INFECTIOUS SUBSTANCE; AFFECTING 4. Cushion primary container. HUMANS\" and assigned to UN 2814. 5. Place primary container in secondary container. Needs 6. Doff gloves. Dangerous Goods Declaration 7. Close secondary container. 8. Place secondary container in outer container. 9. Insert laboratory test instructions and description of materials. 10.Close outer container. 6/11/2009 266 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  256. Dangerous Goods Declaration • All shipments of Category A pathogens require a properly completed Dangerous Goods Declaration. This declaration must be signed by the shipper and serves as a legal contract between the shipper and operator. • Samples classified as Category B or Exempt do not require this form. Completed Form 6/11/2009 267 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  257. Air Waybill • All goods being shipped by air must have a completed Air Waybill. 6/11/2009 268 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  258. This Packaging is Used For Category B Infectious Substances 6/11/2009 269 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  259. Category B Packaging Requirements • Primary container is leakproof • Secondary container is leakproof • Outer container. Either secondary or outer container is rigid – If the shipment is transported by air, the outer container must be rigid. • Pressure tested at 95kPa • Drop tested from 1.2m 6/11/2009 270 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  260. Category B: Markings and Labels • All shippers must properly mark and label MARKINGS Category B packages. The following is a list of markings and labels for Category B packages: Markings • Shipper’s name, address, and telephone number UN 3373 BIOLOGICAL SUBSTANCE, CATEGORY B • Receiver’s name, address, and telephone number • UN Number • Proper Shipping Name Labels • None are required (unless shipping with dry ice) 6/11/2009 271 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  261. Steps For Packaging Category B Sample Specimens collected directly 1. Open secondary container. from humans or animals that are suspected or confirmed to 2. Insert absorbent material. be infected with the swine influenza A(H1N1) virus, 3. Don gloves. including specimens from the respiratory tract (swabs) and 4. Cushion primary container. blood specimens, should be shipped as : 5. Place primary container in secondary container. \"BIOLOGICAL 6. Doff gloves. SUBSTANCE, CATEGORY B\" 7. Close secondary container. and assigned to UN 3373. 8. Place secondary container in outer container. Does Not Need Dangerous Goods 9. Insert laboratory test instructions and description of Declaration materials. 10. Close outer container. 6/11/2009 272 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  262. Exempt Packaging Requirements • Primary container is leakproof • Secondary container is leakproof • Outer packaging must be of adequate strength 6/11/2009 273 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
  263. Exempt Packaging Requirements Primary container (leakproof) Secondary container (leakproof) Absorbent and cushioning material Outer packaging 6/11/2009 274 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  264. Exempt Marking Labels • All shippers must properly mark and label MARKINGS Exempt packages. The following is a list of markings and labels for Exempt packages: • Markings • Shipper’s name, address, and telephone number EXEMPT HUMAN SPECIMEN • Receiver’s name, address, and telephone number • Proper Shipping Name EXEMPT ANIMAL SPECIMEN Labels • None are required (unless shipping with dry ice) 6/11/2009 275 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  265. Steps For Packaging Exempt Sample 1. Open secondary container. 2. Insert absorbent material. 3. Cushion primary container. 4. Place primary container in secondary container. 5. Close secondary container. 6. Place secondary container in outer container. 7. Insert laboratory test instructions and description of materials. 8. Close outer container. 6/11/2009 276 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  266. Health Protection Agency (HPA) Cat B Packaging Poster 6/11/2009 277
  267. Biosaftey : Spill Clean-up Procedure 1. Wear gloves and protecting clothing, including face and eye protection if indicated. 2. Cover the spill with a cloth or paper towels to contain it. 3. Pour an appropriate disinfectant over the cloth or paper towels and the immediately surrounding area (5% bleach solutions are generally appropriate, but for spills on aircraft, quaternary ammonium disinfectants should be used). 4. Apply the disinfectant concentrically beginning at the outer margin of the spill area, working towards the centre. 5. After about 30 min, clear away the materials. If there is broken glass or other sharps are involved, use a dustpan or a piece of stiff cardboard to collect the materials and deposit them into a puncture-resistant container for disposal. 6. Clean and disinfect the area of the spillage (if necessary, repeat steps 2–5). 7. Dispose of contaminated materials into a leak-proof, puncture- resistant waste disposal container. 8. After successful disinfection, report the incident to the competent authority and inform them that the site has been 6/11/2009 278 Medical Management of Biological Casualties decontaminated Revised and Modified 29/04/2009
  268. Post-exposure Prophylaxis (PEP) for close contacts of probable1 or confirmed2 human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 (Update June 11 2009) 6/11/2009 279
  269. Influenza A(H1N1) Vaccine 6/11/2009 280
  270. Canadian Lab Working on Influenza A(H1N1) Vaccine • No Vaccine available at this time! NML Winnipeg • Late on May 6, Canada's National Microbiology Laboratory first completed the sequencing of the virus, publishing the result to GenBank • Samples from Mexico, Nova Scotia and Influenza A H1N1 virus is seen in an image taken using an electron Ontario had the same sequence, ruling microscope, at PHAC's National Microbiology Laboratory. (Public out genetic explanations for the greater Health Agency of Canada, National Microbiology Laboratory) severity of the Mexican cases 6/11/2009 281 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  271. Influenza A(H1N1) Vaccine Resource Update • For more Information: • Recommendations of the Strategic Advisory Group of Experts (SAGE) on Influenza A (H1N1) vaccines 19 May 2009 • http://www.who.int/csr/r esources/publications/swi neflu/SAGEH1N1vaccinere commendation2009_05_ 19.pdf 6/11/2009 282
  272. Influenza A (H1N1) Vaccine Development Process Seasonal 1. Collection of specimens and disease/epidemiology data (All year round) A(H1N1) 2. Diagnosis and virus isolation ,preliminary analysis (Hrs to 3 wks) 2a. Virus Isolation in eggs (1-3 wks) 3. Ferret antisera production Vaccine development (3-5 weeks) Approx 6 -12 months 4. Thorough antigenic and genetic analysis (1-3 wks) 4a. Serological Studies (3-16 wks) 5.Review and selection of candidate viruses for vaccine use (1-3 wks) 6a. Classical Reassortment of 6b. Reassortment of high high growth viruses growth using reverse genetics (3-4wks) and full safety testing (8 wks) 7a. Antigenic and genetic 9a. Development of 9b. Development of 7b. Antigenic and genetic characterizations of 8. Evaluation of growth standardized reagents standardized reagents characterizations of reassortments property fir inactivated vaccines for inactivated ressortment (3 wks) (4wks) (6wks) vaccines (3 wks) (4wks) Availability of vaccine virus and standardised reagents Adapted from WHO H5N1 vaccine development
  273. Influenza A (H1N1) Vaccine Development Process Glossary • Novel (new) subtype of human influenza A virus. This term refers to human influenza viruses that have haemagglutinin and neuraminidase antigens that are distinct from seasonal influenza viruses and have the potential to cause a pandemic. • Clinical specimens (original). These are materials collected from humans, generally in order to confirm a diagnosis. For influenza, most commonly, clinical specimens are taken from the respiratory tract (for example, swabs and aspirated fluid) but they can be from other locations. Clinical specimens can be frozen and stored for later use • Influenza reference viruses. These are wild-type influenza viruses that WHO has selected as representative of important groups of influenza viruses on the basis of extensive antigenic and genetic studies and comparisons with viruses from many countries. As the influenza viruses evolve in nature, new reference viruses are selected. • Wild-type influenza viruses (synonym: virus isolates). These are influenza viruses that have been cultured either in eggs or cells (i.e. isolated) directly from clinical specimens and have not been modified. • “Classical” reassortment. This is a non-patented laboratory technique that is often used to make (seasonal) candidate vaccine viruses • Genetic reassortment. In this process genes from two or more influenza viruses are mixed in different combinations, resulting in hybrid viruses with genetic characteristics of each parent virus. This process occurs in nature but can also be done in a laboratory using “classical” reassortment or reverse genetics • High-growth reassortant viruses. These are influenza viruses that have been genetically modified to grow better in eggs for optimal vaccine production. • Reverse genetics. This is a laboratory technique that is used to construct or modify influenza viruses and is protected by patents in several countries. It is used to render highly pathogenic H5N1 viruses less dangerous. • Reagents for influenza vaccine standardization. These reagents are used to standardize the amount of haemagglutinin protein in influenza vaccines as required by regulatory agencies. The reagents have to be produced in large quantities so that all vaccine batches can be tested. • Seed viruses. These are influenza viruses prepared from candidate influenza vaccine viruses by individual manufacturers for the manufacturer’s specific vaccine-production process. 6/11/2009 284
  274. The H1N1 flu virus is seen in an image taken using an electron microscope, at PHAC's National Microbiology Laboratory. (Public Health Agency of Canada, National Microbiology Laboratory Influenza A (H1N1) Vaccine Virus Development Summary Candidate vaccine viruses using reverse Candidate vaccine viruses using classical Development of vaccine potency reagents Wild type viruses have been/ are being sent genetics technology are being developed by: reassortment technology are being for inactivated vaccines against Influenza to vaccine manufacturers on request developed by: A(H1N1) is planned in: including: Centers for Disease Control and Prevention NIBSC, UK, from NIBSC, UK Baxter (CDC), Atlanta USA A/California/7/2009(H1N1)swl, an egg virus isolate National Institute for Biological Standards New York Medical College, USA, from CBER FDA, USA CSL Limited and Control (NIBSC) A/California/7/2009(H1N1)swl Centre for Biologics Evaluation and Research CSL Limited, Australia, from Therapeutic Goods Administration GlaxoSmithKline Biologicals (CBER) A/California/7/2009(H1N1)swl St. Jude Children’s Research Therapeutic Goods Administration (TGA), MedImmune Hospital,Memphis USA Australia National Institute of Infectious Diseases Microgen (NIID), Japan Nobilon International Novartis Omninvest Vaccines Sanofi Pasteur Solvay and Vivaldi Adapted from WHO vaccine policy May 18 2009
  275. Influenza A (H1N1) International Vaccine Candidates • Wild type influenza virus: • Traditional reassortant viruses are derived only from wild type viruses isolated and grown in hens’ eggs, or in a validated clean cell culture system. • A/California/7/2009 (egg isolate) – classical reassortment and reverse genetics • A/England/195/2009 (MDCK cell isolate) – reverse genetics • A/California/4/2009 (MDCK isolate) – reverse genetics • A/Texas/5/2009 (MDCK isolate) - reverse genetics • A/Ohio/7/2009 (MDCK isolate) - reverse genetics • A/New York/20/2009 (MDCK isolate) - reverse genetics 6/11/2009 286
  276. Influenza A (H1N1) International Vaccine Candidates Candidate influenza Parental H1N1 virus Laboratory vaccine viruses NYMCX-179A conventional A/California/7/2009 NYMC, USA reassortant virus IVR-153 conventional A/California/7/2009 CSL, Australia reassortant virus IDCDC –RG15 reverse A/Texas/5/2009 CDC, USA genetics virus NIBRG-121 reverse A/California/7/2009 NIBSC, UK genetics virus 6/11/2009 287
  277. Influenza A (H1N1) NIBSC Candidate Vaccine Viruses Candidate Parental H1N1 NIBSC code Availability influenza vaccine virus viruses NIBRG-121 A/California/7/2009 09/122 Now 27/05/09 NYMCX-179A A/California/7/2009 09/124 W/C 8/06/09 IVR-153 A/California/7/2009 VI 1525 Now 2/06/09 6/11/2009 288
  278. Influenza A (H1N1) Vaccine Development: NIBRG‐121 27 May 2009 • NIBRG‐121 (NIBRG‐121 reassortant virus) • A candidate reassortant vaccine virus (NIBRG‐121) has been developed, using reverse genetics technology, from an A/California/7/2009(H1N1)v virus, by the National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom. • The haemagglutinin (HA) and neuraminidase (NA) sequences of the A/California/7/2009(H1N1)v virus can be found on the public web site of GenBank via the following links: • HA sequence – http://www.ncbi.nlm.nih.gov/nuccore/227977171?ordinalpos=1&itool=Ent rezSystem2.PEntrez.Sequence.Sequence_ResultsPanel.Sequence_RVDocSu m • NA sequence – http://www.ncbi.nlm.nih.gov/nuccore/229396468?ordinalpos=1&itool=Ent rezSystem2.PEntrez.Sequence.Sequence_ResultsPanel.Sequence_RVDocSu m 6/11/2009 289
  279. Influenza A (H1N1) NIBRG‐121 (NIBRG‐121 Reassortant Virus) • Now Available from: • Division of Virology • National Institute for Biological Standards and Control • Blanche Lane, South Mimms, Potters Bar • Hertfordshire, EN6 3QG, United Kingdom • E‐mail: enquiries@nibsc.hpa.org.u • k or standards@nibsc.hpa.org.uk • http://www.nibsc.ac.uk/flu_site/viruses_reagents.html • The candidate reassortant vaccine virus contains infectious materials and should be handled only in appropriate containment facilities (until completion of the above‐mentioned safety tests, it is recommended to use biosafety level 2 plus *BSL‐2 plus+ facilities with biosafety level 3 *BSL‐3+ practices)3 6/11/2009 290
  280. Influenza A (H1N1) Gene sequences of the currently available reassortant candidate vaccine viruses • X-179A • The accession numbers of the HA and NA gene sequences of X-179A in GenBank is: • HA: GQ214335 • http://www.ncbi.nlm.nih.gov/nuccore/238623303 • NA: GQ214336 • http://www.ncbi.nlm.nih.gov/nuccore/238623305 • IDCDC-RG15 • The accession numbers of the HA and NA gene sequences of IDCDC-RG15 in GenBank is: • HA: GQ219781 • http://www.ncbi.nlm.nih.gov/nuccore/238623307 • NA: GQ219782 • http://www.ncbi.nlm.nih.gov/nuccore/238623309 • IVR-153 • The accession numbers of the HA and NA gene sequences of IVR-153 in GISAID is: • HA: EPI181843 • http://platform.gisaid.org/dante-cms/live/struktur.jdante?aid=1131 • NA: EPI181844 • http://platform.gisaid.org/dante-cms/live/struktur.jdante?aid=1131 6/11/2009 291
  281. Influenza A(H1N1) Antiviral Medications 6/11/2009 292
  282. Influenza A(H1N1) Antiviral Purpose in Pandemics 6/11/2009 293 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  283. Influenza A(H1N1) Antiviral Medications 2 Classes of Medications Available • M2 Inhibitors :Adamantanes – Amantadine, Rimantadine – Activity only against influenza A viruses • Neuraminidase inhibitors – Oseltamivir, Zanamivir. (Primivir experimental) – Activity against influenza A and B viruses Class Effective Against Drug Name (INN) Brand Name Year Approved Manufacturer M2 inhibitors Influenza A Amantadine Symmetrel 1976 Endo (adamantane Pharmaceuticals derivatives Rimantadine Flumadine 1994 Forest Laboratories Neuraminidase Influenza A & B Zanamivir Relenza 1999 GlaxoSmithKline inhibitors Hoffmann-La Oseltamivir Tamiflu 1999 Rochene 6/11/2009 294 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  284. Influenza A(H1N1) Antivirals Oseltamivir, Zanamivir • Chemically related • Different routes of administration – Oseltamivir (Tamiflu): Tablet, suspension – Zanamivir (Relenza): Orally inhaled powder • Mechanism of action: – Block active site of neuraminidase – Reduce the amount of viral particles released from infected cells • Decrease shedding of influenza A and influenza B viruses 6/11/2009 295 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  285. 6/11/2009 296
  286. Influenza A(H1N1) Neuraminidase Inhibitor Resistance • Cross-resistance • Frequency – 5.5% in oseltamivir pediatric treatment study (U.S.) The Strategy for the – 18% in oseltamivir pediatric Control of treatment study (Japan) Antimicrobial Resistance in Ireland • Global Neuraminidase Inhibitor Susceptibility Network 6/11/2009 297 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  287. Influenza A(H1N1) Antivirals • Director Schuchat said that the virus was resistant to Amantadine and Rimantadine • Susceptible to Oseltamivir (Tamiflu) and Zanamivir (Relenza) OSELTAMIVIR (TAMIFLU) for the prevention of Influenza A (H1N1) 6/11/2009 298 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  288. Influenza A(H1N1) Antiviral Resistance • This swine influenza A (H1N1) virus is sensitive (susceptible) to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir. • It is resistant to the adamantane antiviral medications amantadine and rimantadine 6/11/2009 299 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  289. Pandemic Influenza Expert Group (PIEG) On Antivirals • According to the Pandemic Influenza Expert Group (PIEG) • Treatment with NAI (within 48 hours) for seasonal influenza leads to reduction of: • 0.4 -1 days in duration of symptoms • 25-43% of complications requiring antibiotics • 55% in Lower Respiratory Tract Infections • 34% in need for antibiotics • 59% in hospitalisations • 44% in otitis in children 6/11/2009 301 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  290. Influenza A(H1N1) Antiviral Chemoprophylaxis • Antiviral chemoprophylaxis (pre-exposure or post-exposure) with either oseltamivir or zanamivir is recommended for the following individuals: • Household close contacts who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) of a confirmed or suspected case • School children who are at high-risk for complications of influenza (persons with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed or suspected case • Travellers to Mexico who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) • Border workers (Mexico) who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) • Health care workers or public health workers who had unprotected close contact with an ill confirmed case of swine influenza A (H1N1) virus infection during the case’s infectious period 6/11/2009 305 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  291. Influenza A(H1N1) Antiviral Treatment • Only 2 antiviral medications are equally efficacious when used for early treatment – Decrease the duration and symptoms of uncomplicated influenza by approximately 1 day – Decrease viral shedding • Early treatment with neuraminidase inhibitors can reduce some complications – Otitis media, lower respiratory tract complications, antibiotic use, hospitalizations 6/11/2009 307 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  292. Influenza Antiviral Treatment • Oseltamivir: ≥1 year; Zanamivir: ≥7 years – Dosage varies by age and weight • Early treatment of Swine influenza – Begin within 48 hours of illness onset • Duration: 5 days 6/11/2009 308 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  293. Influenza A(H1N1) Empiric Antiviral Treatment Medication Dosing Recommendations 6/11/2009 309 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  294. Table: Recommended Daily Dosage of Seasonal Influenza Antiviral Medications for Treatment and Chemoprophylaxis for the 2008-09 Season—United States 6/11/2009 310 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  295. Antiviral Adult Recommended Dosages Summary 6/11/2009 311 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  296. (PIEG) On Antivirals Treatment Schedule: • Adults - Oseltamivir 75mg every 12 hours for 5 days – (Dose to be reduced by 50% if creatinine clearance is less than 30ml/minute i.e. 75mg od) • Children Children Dose Child aged >1yr; body weight Oseltamivir 30mg 12-hourly 15kg or lower (>1yr-<3yrs) 16-23kg (3yr-<7yrs) Oseltamivir 45mg 12-hourly 23-40kg Oseltamivir 60mg 12 hourly Child 40kg or over Oseltamivir 75mg 12-hourly 6/11/2009 312 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  297. EMEA Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir • Age Recommended prophylaxis dose for 10 days : • <3 months – Not recommended unless situation judged critical due to limited data on use in this age group • 3-5 months 20 mg once daily • 6-11 months 25 mg once daily • During a pandemic, if Tamiflu is prescribed to children under the age of one, the recommended dosage is 2 to 3 mg per kg body weight • 6/11/2009 (EMEA May 8 report) 313 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  298. Emergency Use Authorization of Tamiflu (Oseltamivir) In US • Oseltamivir is not licensed for use in children less than 1 year of age in US • If used Oral suspension 6/11/2009 314
  299. Influenza A(H1N1) Antiviral Treatment • Suspected Cases • Empiric antiviral treatment is recommended for any ill person suspected to have swine influenza A (H1N1) virus infection. • Antiviral treatment with either zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine should be initiated as soon as possible after the onset of symptoms. • Recommended duration of treatment is five days. • Recommendations for use of antivirals may change as data on antiviral susceptibilities become available. • Adults Antiviral doses and schedules recommended for treatment of swine influenza A (H1N1) virus infection are the same as those recommended for seasonal influenza: Except fpr children! 6/11/2009 315 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  300. Influenza A(H1N1) Oseltamivir (Tamiflu) Adverse Effects • Metabolized by liver, excreted in • Dosage reduction: urine – Kidney disease • Adverse effects • Severe Effects • Gastrointestinal (nausea, vomiting) Other side effects may include: • 1. Hallucinations • headache 2. Delusional behaviour 3. Loss of contact with reality • diarrhoea 4. Convulsions • nausea 5. Nausea and vomiting • vomiting 6. Psychosis • nasal irritation 7. Suicidal behaviour 8. Death of both adults and • bronchitis children • cough • sinus inflammation • ear, nose and throat infections • dizziness 6/11/2009 316 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  301. Oseltamivir (Tamiflu) Children Dosing Fact Sheets 6/11/2009 317 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  302. Oseltamivir (Tamiflu) Children Fact Sheets 6/11/2009 318 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  303. Influenza A(H1N1) Zanamivir (Relenza) Adverse Effects • Not metabolized, excreted – headache unchanged – diarrhea • Adverse effects – nausea – Gastrointestinal (nausea, – vomiting diarrhea) – nasal irritation – Headache – bronchitis – Cough (bronchospasm in – cough persons with pulmonary – sinus inflammation disease: not recommended – ear, nose and throat infections for persons with underlying pulmonary disease) • dizziness 6/11/2009 319 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  304. Influenza A(H1N1) Zanamivir (Relenza) 10 Steps • The Diskhaler has three parts: • Don’t take it apart until you have looked at the step-by-step guide • The Rotadisk fits into the Diskhaler • The Rotadisk fits onto the wheel of the Diskhaler • Each of the four blisters on the Rotadisk contains a single dose of Relenza 6/11/2009 320
  305. Influenza A(H1N1) Zanamivir (Relenza) Application Steps 1 Remove the blue cover – Check that the mouthpiece is clean, inside and outside 2 Hold the white sliding tray as shown and pull it out until it stops 3 Gently squeeze the finger grips on the sides of the white tray. Remove the tray from the main body – The white tray should come out easily 4 Place a new Relenza Rotadisk on the wheel – Make sure the printed side is up, with the blisters facing downwards. The blisters fit into the holes in the wheel. 5. Push the white tray back into the main body If your not ready replace the blue cover 321 6/11/2009
  306. Influenza A(H1N1) Zanamivir (Relenza) Application Steps 6. Hold the Diskhaler horizontally • To get your dose ready to inhale: • Do this just before you inhale a dose a) Flip the lid up as far as it will go b) The lid must be fully vertical, to make sure that the blister is pierced completely c) Push the lid back down. • Your Diskhaler is now ready for use. Keep it horizontal until you have inhaled your dose • Use diskhaler immediately after set up! 6/11/2009 322
  307. Influenza A(H1N1) Zanamivir (Relenza) Application Steps 7. Don’t put the Diskhaler into your mouth yet Breathe out as far as is comfortable, keeping the Diskhaler away from your mouth – Don’t blow into the Diskhaler. If you do,you’ll blow the powder out of the Rotadisk • To prepare the next blister (the second part of your dose): 8. Pull the white tray out as far as it will go (don’t remove it completely), then push it back in again • This will turn the wheel so the next blister will appear – Repeat if necessary until a full blister is positioned under the piercing needle. – Repeat steps 6 and 7 to inhale the medicine. 9. After you’ve inhaled the full dose (normally two blisters): • Wipe the mouthpiece with a tissue and replace the blue cover. It’s important to keep the Diskhaler clean. • To replace the Rotadisk: 10. When all four blisters are empty, remove the Rotadisk from the Diskhaler and insert a new one, using steps 1 to 5. 6/11/2009 323
  308. Zanamivir (Relenza) Fact Sheets 6/11/2009 324 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  309. Guidelines for Reporting Suspected Adverse Reactions to Antiviral Medicines an Influenza Pandemic “Pharmacovigilance” • How to report? The most efficient way to report adverse reactions to the IMB in a pandemic situation is via our online reporting system at www.imb.ie 1. On-line at www.imb.ie and follow the links to ‘On-line Reporting’ to complete a Human Medicines Adverse Reaction Report 2. ‘Freepost system’ – Adverse Reaction Report Forms (yellow cards) can be obtained directly from the Pharmacovigilance Unit of the IMB or downloaded from the website under the ‘Publications section’. A supply of yellow cards/Adverse Reaction Report Forms may be requested by telephoning the Pharmacovigilance Unit of the IMB at 01-676 4971 6/11/2009
  310. Guidelines for Reporting Suspected Adverse Reactions to Antiviral Medicines an Influenza Pandemic “Pharmacovigilance” Yellow card Pharmacovigilance Section, Irish Medicines Board, ) Kevin O'Malley House, Earlsfort Centre, Filled out by Public Health Earlsfort Terrace, Dublin 2, Ireland. Tel :353-1-676 4971 Fax: 353-1-634 3514 Email: 326 imbpharmacovigilance@imb.ie 6/11/2009
  311. Influenza A(H1N1) Special Considerations for Children • Aspirin or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol) should not be administered to any confirmed or suspected ill case of swine influenza A (H1N1) virus infection aged 18 years old and younger due to the risk of Reye syndrome. • For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs. 6/11/2009 327 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  312. Influenza A(H1N1) Antivirals “Pregnant Women” • Oseltamivir, zanamivir, amantadine, and rimantadine are all “Pregnancy Category C\" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women • EU: Following a review of the available data for Tamiflu and Relenza, the CHMP concluded that the benefits of using these medicines in pregnant or breastfeeding women outweigh the risks in case of an Influenza A/H1N1 pandemic 6/11/2009 328 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  313. Influenza A(H1N1) Irelands National Antiviral Stockpile (INAS) • Mobilization plans to be Irish Alert Level Description tested for National Stock Pile Irish Alert Level 1 Cases only outside Ireland (in during this Swine-Origin a country or Influenza Virus (S-OIV ) countries with or outbreak if the Irish Alert without extensive Irish travel/trade Level Hits 2 links • Surveillance and monitoring Irish Alert Level 2 New virus isolated must be In place for future in Ireland exercise improvements for Irish Alert Level 3 Outbreak(s) in Ireland mobilizations of Irelands Irish Alert Level 4 Widespread National Antiviral Stockpile activity in Ireland Alert levels will increase in Phase 6 declaration by WHO 6/11/2009 329 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  314. Pandemic Influenza Expert Group (PIEG) On Antivirals Irelands National Antiviral Stockpile • One million treatment packs of Oseltamivir (Tamiflu) are stockpiled • This quantity is sufficient to treat 25% of the population and is in line with international trends • 63kg of the API has also been purchased – Active Pharmaceutical Ingredient (API), oseltamivir phosphate powder, should be purchased to treat young children between the ages of one and five years – Arrangements have been put in place so that API powder will be converted to paediatric capsules, which will be used for all children aged one to 11 years of age • 706,000 packs of zanamivir (Relenza) have now been ordered • This is sufficient to cover 20% of the population over the age of seven • 500,000 surgical masks, five million pairs of disposable gloves and 150,000 surgical gowns for health care providers 6/11/2009 330 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  315. Influenza A(H1N1) WHO Country Antiviral Distribution Plan 6 May 2009 • WHO headquarters stocks distributed to – – Honduras Indonesia countries. Regional stock distribution is – Kenya not included here so this is not the full list of – – Kiribati Kyrgyzstan countries receiving antivirals from WHO – Lao People's Democratic Republic globally – – Lesotho Liberia – Afghanistan – Madagascar – Angola – Malawi – Armenia – Mali – Azerbaijan – Mauritania – Bangladesh – Benin – Mexico – Bhutan – Mongolia – Bolivia – Mozambique – Burkina Faso – Myanmar – Burundi – Nepal – Cambodia – Nicaragua – Cameroon – Niger – Central African Republic – Nigeria WHO/Tom Moran – Chad – Pakistan – Comoros – Papua New Guinea WHO staff prepare boxes of – Congo – Republic of Moldova antiviral drugs for countries – Cote d´Ivoire – Rwanda – Cuba – Sao Tome and Principe May 8 2009 – Democratic People's Republic of Korea – Senegal – Democratic Republic of the Congo – Sierra Leone – Democratic Republic of Timor-Leste – Solomon Islands – Djibouti – Somalia – Eritrea – Sri Lanka – Ethiopia – Sudan – Gambia – Georgia – Tajikistan – Ghana – Togo – Guinea – Uganda – Guinea-Bissau – Ukraine – Guyana – United Republic of Tanzania – Haiti – Uzbekistan – Viet Nam 331 6/11/2009 – Yemen – Zambia – Zimbabwe
  316. Typical Antiviral Clinic Process Flow Chart Queue Medical Assessment (screeners) Antivirals/ Contraindication Require Antiviral Triage Vaccination (to EXIT) Med Consult Home, hosp, MD Antiviral/Vaccination Area Medical Orientation Post Antiviral/Vaccination Evaluation and Education Education Form collection EXIT Registration 332 Medical Management of Biological Casualties 6/11/2009 Revised and Modified 29/04/2009
  317. Guidance for Pharmacy Staff Influenza A (H1N1) • Full Tamiflu info @ http://www.emea.europa.eu/humandocs/PDFs/EPAR/tamiflu/H-402-PI-en.pdf 6/11/2009 334
  318. Influenza A(H1N1) Standard Precautions • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians 6/11/2009 335 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  319. Influenza A(H1N1) Irish Universal Respiratory Hygiene • Pandemic Influenza Preparedness for Ireland: Advice of the Pandemic Influenza Expert Group • The following are components of a universal respiratory hygiene strategy to be adopted in all health care facilities • Read in Narration! Breaking the Chain of Infection 6/11/2009 336 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  320. Influenza A(H1N1) Transmission-Based Precautions • Contact Precautions • Contact precautions should be applied in addition to Standard Precautions to prevent transmission of highly transmissible organisms that are transmitted from person to person via the contact route (e.g. Methicillin resistant Staphylococcus aureus) • Airborne Precautions • Airborne Precautions should be applied, in addition to Standard Precautions, to prevent transmission of highly transmissible organisms that are transmitted via the air from one person to another (e.g. Tuberculosis) • Droplet Precautions • Droplet Precautions should be applied, in addition to Standard Precautions, to prevent transmission of highly transmissible organisms that are transmitted via respiratory secretions from one person to another (e.g. Influenza) 6/11/2009 337
  321. Influenza A(H1N1) YOUR 4 MOMENTS FOR HAND HYGIENE (Canadian) 1. Clean your hands when entering before touching the 2, Clean your hands immediately before any patient or any object or furniture in the patient’s aseptic procedure. environment. To protect the patient To protect the patient/ patient against harmful organisms, environment from harmful including the patient’s own organisms carried on your organisms, entering his or hands her body. 4. Clean your hands when 3. Clean your hands leaving after touching immediately after an patient or any object or exposure risk to body fluids furniture in the patient’s (and after glove removal). environment. To protect yourself and the To protect yourself and the health care environment from health care environment harmful patient organisms. from harmful patient See WHO Hygiene Protocol organisms witch has 5 Steps Irish has 6 Steps 6/11/2009 338 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  322. The “My 5 Moments for Hand Hygiene” Approach (WHO) Medical Management of Biological Casualties Revised and Modified 29/04/2009
  323. 6 Step Irish Hygiene Protocol • Ireland In 2006-7, Ireland organised a national campaign called ‘Clean Hands Save Lives’. • Same as the following! • All have 6 Steps in essence! A doctor checks patients presenting symptoms of the swine flu virus, now named influenza A(H1N1), kept in isolation at the National Institute of Respiratory Diseases (INER) in Mexico City on May 5, 2009. (LUIS ACOSTA/AFP/Getty Images) 6/11/2009 340 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  324. Guidelines for Hand Hygiene in Irish Health Care Settings • Audit: In 2008 (Q1-3) the median rate of alcohol hand rub consumption increased to 17.9 litres per 1,000 bed-days used, from 10.5 and 15.0 in 2006 and 2007 respectively This represents a 19.3% increase since 2007 Good Resource But needs Updating 6/11/2009 341
  325. Pandemic Planning “Hand Washing” 6/11/2009 342
  326. Influenza A(H1N1) Protocol for Surveillance of Influenza-like Illness in Healthcare Workers during Pandemic Phase 5 • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians 6/11/2009 343 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  327. Influenza A(H1N1) Surveillance of Healthcare Workers • Healthcare worker (HCW) • Porters includes: • Domestic staff • Hospital clinician teams • Receptionists • General practitioners • Administration staff • Public health doctors • Ambulance staff • Laboratory scientists • Mortuary workers • Physiotherapists • Professional support staff Safety, Health and Welfare at Work Act 2005 6/11/2009 344 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  328. Healthcare Workers with Probable Influenza A(H1N1) • Unusual clusters or syndromes • If there are unusual clusters of disease or syndromes among HCWs • The DPH/MOH will immediately inform HPSC of any unusual clusters of disease or syndromes among HCWs Definition of a healthcare cluster: A cluster is defined as two or more healthcare workers in the same healthcare facility/unit with unexplained acute respiratory illness and with fever ≥38°C, or with severe lower respiratory tract infection or pneumonia, and with onset of illness within a period of 14 days of each other. 6/11/2009 345 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  329. Influenza A(H1N1) Surveillance of Healthcare Workers Clinical criteria • Acute onset of fever (temperature > 38 °C or history of fever and two or more of the following: • Cough • Sore throat • Myalgia • Headache • Rhinorrhoea or • Vomiting/Diarrhoea • Pneumonia • Febrile respiratory illness • Acute respiratory illness (ARI) HPSC May 21 Update 6/11/2009 346 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  330. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 (Update June 11 2009) 6/11/2009 347
  331. Healthcare Workers with Probable Influenza A(H1N1) • Report to occupational health department • The relevant line manager should notify the occupational health department: • If there is an apparent increase in absenteeism rates among a particular group of HCWs or in a particular area • If there is an apparent cluster of acute respiratory illness among a particular group of HCWs or in a particular area • If a HCW becomes ill with a severe lower respiratory tract infection or pneumonia 6/11/2009 348 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  332. Healthcare Workers with Probable Influenza A(H1N1) • Single cases • If a HCW is admitted to hospital with respiratory symptoms including pneumonia (severe respiratory illness) and they have at least one of the following in the seven days before disease onset: – Been a close contact of a confirmed case of swine influenza A (H1N1) virus infection while the case was ill – Have travelled to an area where sustained human-to-human transmission of swine influenza A (H1N1) is documented Update June 11 2009 – Worked in a laboratory where samples of the http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianP swine influenza A (H1N1) virus are tested andemicInfluenza/SwineInflu enza/AdviceforHealthProfessi onals/GPs/File,3724,en.pdf 6/11/2009 349 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  333. Healthcare Workers with Probable Influenza A(H1N1) Occupational Health Role • If a HCW has been involved in caring for or examining a symptomatic patient with swine influenza A (H1N1) infection the following actions should be taken: • 1.Inform the regional DPH/MOH if the HCW provided direct clinical or personal care or examined the symptomatic patient without appropriate Personal Protective Equipment (PPE). Discuss contact management with DPH/MOH. • 2.For HCWs who did not wear PPE* while caring for symptomatic patient: institute post-exposure prophylaxis with oseltamivir (Tamiflu) as soon as possible unless more than 7 days have elapsed since the last exposure. The dose of oseltamivir is 75mg daily for 10 days following last exposure. • 3.Provide all HCW contacts with clear public health recommendations and information on swine influenza A (H1N1) (available at www.hpsc.ie/hpsc/). 6/11/2009 350 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  334. Healthcare Workers with Probable Influenza A(H1N1) Occupational Health Role • 4. Request that any febrile respiratory or other unexplained illness within 7 days of last contact be reported • 5. If the HCW contact becomes unwell they should be investigated and treated (liaise with DPH/MOH). They should also be advised to discontinue work immediately • 6. Advise all contacts to strictly adhere to all infection control and prevention precautions as follows: – Avoid touching their faces, including their eyes and nose and mouth with their hands – Wash hands frequently. This means washing with soap and running water for a minimum of 15-20 seconds or the use of an alcohol-based hand sanitiser if the hands are not visibly soiled – Cover their mouth with a tissue when they cough and/sneeze, and dispose carefully in a bin afterwards 6/11/2009 351 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  335. Healthcare Workers with Probable Influenza A(H1N1) Occupational Health Role Update June 11 2009 • “Close contacts in the health care setting are defined as: health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient (including taking nasal and throat swabs for viral testing) without wearing appropriate personal protective equipment (PPE) for Standard, Droplet and Contact Precautions: – Routine care (including taking nasal and throat viral swabs): surgical mask, gloves, plastic apron (and goggles if risk of splashing or spraying) – Aerosol generating procedures: FFP2 or FFP3 masks, goggles, long-sleeved gown and gloves. – Failure to implement hand hygiene following contact with contaminated surfaces or after removing PPE is also considered to pose risk of infection. – Casual contact with the ill person for example, passing them in the corridor at work or waving to them etc. does not mean you are a contact and does not require any further action. • The following groups of healthcare workers caring for patients with probable/confirmed influenza A(H1N1) will require a risk assessment and consideration of chemoprophylaxis: – Healthcare workers who have not worn appropriate PPE – Healthcare workers who have worn PPE without formal fit testing – Healthcare workers who have worn surgical masks but who have been unwittingly exposed to patient generated aerosols” 6/11/2009 Cited from HPSC 352
  336. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • The Occupational Health team (or as per local arrangements) will inform Public Health about details of contacts • A Public Health Doctor will contact you to ask you a number of questions about your health and the amount / type of contact which you had with the sick person, and will advise on what precautions you need to take • In hospitals, where there is an Occupational Health Department, this will be carried out by Occupational Health staff 6/11/2009 353
  337. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • Health or social care workers who provided direct clinical/personal care or who or who examined a symptomatic patient without wearing appropriate PPE** – Those who were wearing appropriate PPE should self monitor for one week and report symptoms as explained in Public Health Management of Contacts PEP Phase 6 Update June 11 2009 6/11/2009 354
  338. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • All healthcare workers at this time should be self monitoring for flu- like symptoms and should report the development of same to their line manager promptly. • HCW contacts of suspected or confirmed Influenza A (H1N1) should • check their temperature twice a day and look out for flu-like symptoms for a period of 7 days: – Fever (38.0°C C or 100.4 °F or higher) – Flu like symptoms (cough, runny nose, sore throat, headache or aches and pains) – Diarrhoea, vomiting • Please report the development of any flu like symptoms to public health staff and to your line manager promptly. You will also be asked to contact Occupational Health. 6/11/2009 355
  339. Healthcare Workers “Fitness for Work” Occupational Health Role • Fitness for Work • Occupational health advice on fitness for work (or on the need for work restrictions at a given time) should be sought by: • Healthcare workers who develop symptoms of ILI (Influenza Like Illness), who should report to their line manager in the first instance • Healthcare workers recovering from ILI • Healthcare workers who have been in unprotected contact with suspect or confirmed cases of ILI (either in the community or at work) • Healthcare workers who have been prescribed antiviral therapy by their GP or a Public Health Doctor • Healthcare workers who have pre-existing medical conditions which might increase their risk of severe influenza complications • Pregnant healthcare workers • Healthcare workers who cannot achieve an adequate ‘seal’ with the PPE provided by their employer 6/11/2009 356
  340. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed Influenza A(H1N1) 6/11/2009 357 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  341. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) • Standard Precautions require all HCWs to: • A. Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. • B. Apply a set of work practices to blood, all body fluids (except sweat), mucous membranes and non intact skin: – Hand hygiene – Use of personal protective equipment – Management of spillages of blood and body fluids – Appropriate patient placement – Management of sharps – Safe injection practices – Respiratory hygiene and cough etiquette – Management of needle stick injuries – Management of waste – Management of laundry – Decontamination of reusable medical equipment – Decontamination of the environment. 358 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  342. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.2 Occupational Health Programme Standard Precautions • HCWs should self monitor their own health for influenza like symptoms • HCWs with symptoms should not attend work and should immediately report symptoms to their line manager 2.3 Patient Placement Standard Precautions Home • Assess the patient with suspected or confirmed influenza A(H1N1) by phone at home if possible Droplet Precautions GP/Primary care/Community • Place in a single room and avoid communal areas if possible. Otherwise do not place within Contact Precautions approximately 1 metre of other patients Hospital • Place patient with suspected or confirmed influenza A(H1N1) in a single room preferably with ante room and en-suite facilities • Emergency departments without single rooms must have interim arrangements in place to prioritise transfer to an appropriate single room • Avoid communal areas and placing patient within approximately 1 metre of other patients Ambulance Refer to ambulance advice document 2.4 Hand Hygiene Standard Precautions Hand hygiene using liquid soap or alcohol hand gel/rub must be performed before and after all patient care procedures 2.5 Patient Movement and Transfer Standard Precautions External transfer Patient should wear a surgical mask outside their room Droplet Precautions It is the responsibility of the transferring facility to inform staff of the precautions required Refer to ambulance advice document Contact Precautions Internal transfer Minimise movement of patient from single room Patient should wear a surgical mask outside their room Staff should be informed of the precautions required in the receiving departments (e.g. diagnostic departments) Avoid holding patients in communal areas (radiology etc) HCW PPE: Wear a surgical mask and observe hand hygiene 6/11/2009 Medical Management of Biological Casualties 359 Revised and Modified 29/04/2009
  343. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.6 Respiratory Hygiene & Cough Standard Precautions Infections should be Etiquette • Identified promptly in primary care and emergency departments Droplet Precautions • Offered masks (and other symptomatic persons e.g., persons who accompany ill patients should also be offered masks) • Encouraged to maintain spatial separation, ideally a distance of approximately 1 meter, from others in common waiting areas Emergency departments and primary care facilities should: • Ensure that supplies of tissues, foot operating waste bins and hand hygiene facilities are available in all departments including waiting areas throughout the facility • Educate patients/visitors/carers on Respiratory Etiquette and Cough Hygiene using some or all of the following: • Patient information leaflets • Posters in all departments especially waiting areas • If influenza A(H1N1) is suspected place patient & persons who accompany ill patients in a single room • See Appendix A for respiratory hygiene and cough etiquette poster. The poster can be downloaded from the following website http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Factsheets/RespiratoryHygiene/File,35 99,en.pdf 6/11/2009 360
  344. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.7 Personal Standard Precautions The following applies to all settings: Protective Droplet Precautions GP/Primary care/Ambulance transfer/Hospital Equipment Contact Precautions Patient should wear: (PPE)  A surgical mask when outside their single room HCWs must wear the following for: 1. Routine care  Surgical mask, Plastic Apron/Gown, Gloves (& Goggles if splashing/spraying risk) 2. Aerosol Generating Procedures  FFP2 or FFP3 mask (correctly fitted), Goggles, Long sleeved disposable gown, Gloves Refer to Aerosol Generating Procedures document and to PPE poster Masks  Change mask if it becomes damp, wet or torn  Change and discard mask when leaving the room or patient care area HCW’s when putting on and removing PPE must :  Put on and remove in the correct sequence (refer to PPE poster)  Remove gloves & apron/gown inside the single room  Remove mask in the ante room or immediately outside the single room if there is no ante room. Ensure door is closed.  Decontaminate hands immediately after removing PPE 6/11/2009 361
  345. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.8 Environmental Decontamination Standard Precautions In addition to Standard Precautions: Only take essential equipment and supplies into the room. Droplet Precautions  Do not stockpile as unused stock will have to be discarded on cessation of additional precautions  Patient charts/records should not be taken into the single room Contact Precautions  The frequency and intensity of cleaning may need to be increased based on the patients level of hygiene and the level of environmental contamination  HCW’s must wear surgical mask, gloves, apron for cleaning the patients room  Thoroughly clean the environment and furniture and all patient care equipment daily with a neutral detergent and disinfectant (hypochlorite solution 1000 ppm) paying special attention to frequently touched sites and equipment close to the patient  On patient discharge/transfer cleaning and disinfection of the environment  Prior to initiating environmental cleaning and disinfection, all privacy, shower and window curtains must be removed and sent for laundering All disposable items including paper towels and toilet paper should be discarded All sterile and non-sterile supplies in the patient room to be discarded on patient transfer/discharge Dishes and Eating Utensils  Cutlery and crockery - No additional measures are required for cutlery and crockery washed in a dishwasher or wash with liquid detergent and water 2.9 Patient Care Equipment & Standard Precautions In addition to Standard Precautions: Decontamination of Medical Devices  Dedicate patient care medical devices (e.g., thermometers, sphygmomanometers, stethoscopes, glucometers) to single Droplet Precautions patient use  Use disposable equipment whenever possible Contact Precautions  Manufacturer’s instructions should be followed for cleaning and disinfecting of reusable medical equipment after use  Single use items should be disposed of after use  Bedpan/Commodes  Use a working washer disinfector at 80°C for one minute  Dedicate a commode to single patient use if no en suite available  Decontaminate commode surface after each patient use with a hypochlorite solution 1000 ppm 6/11/2009 362
  346. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components STANDARD Key Elements of Clinical Practices and Measures PRECAUTIONS 2.10 Linen/Laundry Standard Precautions  No additional precautions necessary  As per Standard Precautions all contaminated laundry should be carefully placed in an alginate stitched or water soluble bag and then placed into a laundry bag clearly identified with labels, colour-coding or other methods prior to transport to an approved laundry capable of dealing with contaminated linen 2.11 Management of needle stick injuries (NSI) and Standard Precautions  No additional precautions necessary blood and body fluid exposure 2.12 Management Standard Precautions  No additional precautions necessary for Non Healthcare Risk and Healthcare Risk Waste of Waste  Dispose of all PPE as Healthcare Risk Waste (e.g. used masks) 6/11/2009 363
  347. Influenza A(H1N1) Infection Control In Health Care Setting • For visible soiled hands WHO recommends the following technique 6/11/2009 367
  348. Influenza A(H1N1) HealthCare Environmental Waste • In aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) SOP must be in place • Appropriate disinfectants – 70% Ethanol – 5% Lysol – 10% Bleach • According to PIEG: Commonly used surfaces such as door handles, handrails, table surfaces etc. should be cleaned first and then disinfected with a chlorine releasing disinfectant (1000 ppm) twice daily. 6/11/2009 368 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  349. Aerosol Generating Procedures According to WHO • Aerosol generating procedures: • Nebulisation • Intubation and related • Non-invasive positive procedures, e.g. manual pressure ventilation ventilation • Bi-level positive airway • Respiratory and airway suctioning pressure (BiPAP) ,CPAP,NIV (including tracheostomy care) • High frequency oscillating • Nasopharyngeal aspiration ventilation • Cardiopulmonary resuscitation • Bronchoscopy • Nasopharyngeal aspirate • Transtracheal aspirate • Broncheo-alveolar lavage • Biopsy of lung or tracheal tissues • Autopsy procedures – i.e.. (Oscillating saws) 6/11/2009 369
  350. Recommended Initial PPE Protection Levels AGENT CATEGORY MINIMUM LEVEL OF PROTECTION UNKNOWN LEVEL A NERVE LEVEL A(1) BLISTER LEVEL A(2) BLOOD LEVEL B(3) CHOKING LEVEL B(3) BIOLOGICAL High Efficiency Particulate Air FILTER w/LEVEL C RADIOLOGICAL High Efficiency Particulate Air FILTER w/LEVEL C (1) High concentrations may result in nerve agent poisoning (2) Sufficient vapor will cause blisters (3) Level A may be required in an enclosed area 6/11/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  351. Influenza A(H1N1) Personal Protective Equipment PPE • PPE = Personal Protective Equipment • PPP = Personal Protective Practices • PPE + PPP = Prevention Personal Protection is not just “personal”: It is also about preventing spread of disease to others! 6/11/2009 371
  352. Influenza A(H1N1) Personal Protective Equipment PPE • Avian flu indicated that using a face mask with a rating of N99, N100 or P100 in the United States • A rating of FFP3 in Europe should be effective in protecting against transmission – 99% efficiency FFP3 Respirator Mask • N95 or FFP2 face masks provide about 94% efficiency – 94% efficiency Particle Recent work by Viscusi5 suggests that most N95 Respirator N95 (FFP2) respirators stored in warehouse and laboratory conditions are likely to maintain there filtration capacity for up to 10 years 6/11/2009 372 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  353. HPA-Recommendations For Extending The Lifespan Of Masks: • Use out-of-date facemasks and respirators to the extent available • Use lower grade respirators to the extent available (where a respirator is indicated) • Out-of-date but in-grade respirators are preferred to incorrect grade but in-date stock • Layered facemasks might be considered as a last resort when no respirators (of any grade) are available for the performance of aerosol generating procedures however this will impact on the supply of facemasks for other uses • Re-use of any device is not recommended except as absolute last resort • Decontamination of facemasks is not recommended • Experimental work suggests that high efficacy respirators can be decontaminated without degradation using certain regimens, but these are unlikely to prove practical and there are insufficient data to be certain of a reliable effect. This should only be considered if practical and then as a measure of last resort • Hospitals can perform individual risk assessments to minimise all but essential non-pandemic use of facemasks and determine whether alternatives measures could be adopted • Masking patients with a facemask as an alternative to masking HCWs might be a more efficient use of limited quantities of masks in certain circumstances • Any other nose/mouth covering could be considered once facemask are exhausted, but there are no data in support of specific items other than the DIY 6/11/2009 373 cotton mask described by Dato et al
  354. Influenza A(H1N1) Personal Protective Equipment PPE • Disposable particulate respirators (e.g. NIOSH N95 or European EN149: 2001 • FFP2; NIOSH N99 or European EN149: 2001 FFP3; or NIOSH N100) • Must have Fit Testing Program FFP2 9300 valved disposable respirator FFP3 valved moulded cup mask 6/11/2009 374 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  355. Influenza A(H1N1) Respiratory Protection Programme • Example 6/11/2009 375
  356. Influenza A(H1N1) Respiratory Protection Programme • A respiratory protection programme for staff advised to wear respirators should be provided by each healthcare facility to ensure compliance with the following health and safety legislation and standards:  Safety, Health and Welfare at Work Act, 2005  Safety, Health and Welfare at Work (General Application) Regulations 2007 (S.I. No. 299 of 2007). Chapter 3 of Part 2: Personal Protective Equipment  Safety, Health and Welfare at Work (Biological Agents) Regulations 1994 (S.I. No. 146 of 1994) (as amended by S.I. 248 of 1998).  IS EN 529:2005 (Irish Standard on Respiratory Protective Devices) 6/11/2009 376
  357. Influenza A(H1N1) Respiratory Protection Programme • Governance: • Identify department responsible to deliver the respiratory protection programme • Identify personnel responsible for the implementation of the respiratory protection programme • Allocation of resources to deliver the programme • Selection, purchase and supply of suitable masks to each healthcare facility • Storage and maintenance of equipment • Disposal of used equipment • Record keeping 6/11/2009 377
  358. Influenza A(H1N1) Respiratory Protection Programme • Theoretical information, training and instruction including: • Types of risk • Knowledge and understanding of respiratory equipment including limitations • Personal factors including medical conditions, improper fitting • Fit testing and fit checking • Practical training including: • An initial fit test using qualitative/ quantitative methods • Ongoing fit check to confirm the seal each time the mask is donned • Donning, removing and disposing of mask 6/11/2009 378
  359. Influenza A(H1N1) Respiratory Protection Programme • Persons with excessive facial hair, the following options may be considered: • HCW agrees to remove the beard / facial hair • HCW agrees to be otherwise deployed • Pre-exposure prophylaxis (with antiviral medication) be considered • Use of powered air respirator be considered • If none of these options is deemed Types of respirators that can be fit tested with this method include: appropriate or possible (and only in • Filtering facepieces FFP1, FFP2, FFP3; exceptional circumstances) a bearded HCW • Half facemask respirators fitted with a particulate or combined filter may proceed in the clinical care of such patients, only having been fully informed of the risks and in the knowledge that an FFP2 or FFP3 respirator cannot ensure adequate protection 6/11/2009 379
  360. Influenza A(H1N1) Personal Protective Equipment (PPE) • Influenza A (H1N1) • Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 6/11/2009 380 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  361. How To Perform a Particulate Respirator Seal Check 6/11/2009 381 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  362. Donning and Doffing Personal Protective Equipment (PPE) Donning PPE Doffing PPE 6/11/2009 382 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  363. Influenza A(H1N1) First Responders (PRAs) Personal Protective Equipment (PPE): • Interim recommendations: • When treating a patient with a suspected case of swine-origin influenza as defined above, the following PPE should be worn: – Fit-tested disposable FF3 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the patient. • When treating a patient that is not a suspected case of swine-origin influenza but who has symptoms of acute febrile respiratory illness, the following precautions should be taken: – Place a standard surgical mask on the patient, if tolerated. If not tolerated, EMS personnel may wear a standard surgical mask. – Use good respiratory hygiene – use non-sterile gloves for contact with patient, patient secretions, or surfaces that may have been contaminated. Follow hand hygiene including hand washing or cleansing with alcohol based hand disinfectant after contact. • Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible. • 6/11/2009 383 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  364. Secondary Responders Health Professionals (PPE) • Pending clarification of transmission patterns for this virus, personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested FFP2 9300 valved disposable disposable FFP2-3 respirator respirator mask • Fit-tested disposable FF3 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the swine influenza 6/11/2009 FFP3 valved moulded cup mask 384 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  365. Tertiary Responders Mortuary (PPE) • However, for people who must directly handle remains, such as recovery personnel, or persons identifying remains or preparing the remains for burial or cremation, there can be a risk of exposure to such viruses or bacteria. • Fit-tested disposable FF3 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the fatalities • Increase level of protection if needed! 6/11/2009 385 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  366. Influenza A(H1N1) Handling Human Remains (HHR) • Potentially contaminated human remains must be segregated from the general population of a hospital or other facility as soon as the risk is recognized. • Only those wearing the appropriate level of PPE should perform segregation of contaminated human remains • Segregation involves: • Placing the human remains along with all personal effects and clothing into an impermeable body bag (double bagged if possible) • Attaching available identifying information to the body and bag • Decontaminating the outside of the body bag (HAZMAT teams may assist with determining the most appropriate agent to use), using extreme care to avoid tearing the body bag during handling, • Moving the bagged human remains to a secure holding area • Notifying the medical examiner of the circumstances of the death, and releasing the human remains to personnel designated by the medical examiner 6/11/2009 386 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  367. Influenza A(H1N1) Handling Human Remains Health Care setting • Influenza A (H1N1) handling of Human Remains Civil Registration Act 2004. Pt.5 Provision of particulars, and registration, of deaths. 6/11/2009 387 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  368. Influenza A(H1N1) Handling Human Remains (HHR) • Family Contact with the Deceased in Health Care Settings • For deceased persons with confirmed, probable, or suspect novel influenza A (H1N1), consider limiting contact with the body in health care settings to close family members • Direct contact with the body is discouraged; however, necessary contact may occur as long as hands are washed immediately with soap and water 6/11/2009 388
  369. Influenza A(H1N1) Handling Human Remains • Transport of Deceased Persons • Transport of deceased persons does not require any additional precautions when bodies have been secured in a transport bag • Hand hygiene should be performed after completing transport • Standard precautions should be used when handling deceased individuals, and preparing bodies for autopsy or transfer to mortuary services • Standard Precautions apply, and appropriate use of personal protective equipment (PPE) (e.g., gowns, gloves, masks, and/or eye protection) is recommended • After PPE is removed, hand hygiene should be performed 6/11/2009 389
  370. Influenza A(H1N1) Handling Human Remains Medical Examiner • Influenza A (H1N1) handling of Human Remains 6/11/2009 390 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  371. Influenza A(H1N1) Handling Human Remains Medical Examiner • Personal protective equipment (PPE) • Standard autopsy PPE, which includes: – Scrub suit worn under an impervious gown or apron – Goggles, face shield – Double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves – Surgical mask or respirator – Shoe covers • Aerosols generated procedure: use of oscillating saws – FPP 2-3 disposable particulate respirators – Powered Air Purifying Respirator (PAPR) • Autopsy personnel who cannot wear a disposable particulate respirator because of facial hair or other fit limitations should wear a loose-fitting (e.g. helmeted or hooded) PAPR • Remove PPE before leaving the autopsy suite and dispose in accordance with facility policies and procedures 6/11/2009 391
  372. Influenza A(H1N1) Handling Human Remains Medical Examiner: Environmental Precautions for Autopsies • Autopsies on human remains infected with novel influenza A (H1N1) in autopsy settings that have adequate air-handling system • Airborne infection isolation rooms (AIIRs): • Minimum of six (old construction) to twelve (new construction) air changes per hour (and direct exhaust of air to the outside or passed through a HEPA filter if air is recirculated • For autopsies, local airflow control (e.g., laminar flow systems) can be used to direct aerosols away from personnel; however, this safety feature does not eliminate the need for appropriate PPE • Use biosafety cabinets for the handling and examination of smaller specimens • Use vacuum shrouds for oscillating saws to contain aerosols and reduce the volume released into the ambient air environment 6/11/2009 392
  373. Influenza A(H1N1) Handling Human Remains Funeral Service • Influenza A (H1N1) handling of Human Remains 6/11/2009 393 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  374. Influenza A(H1N1) Handling Human Remains Funeral Service • Influenza A(H1N1) ; Cat B for HHR • There should be minimal contact/handling of the body • When there is a need to do so, the following precautions are recommended: – When handling dead bodies, do not smoke, eat or drink and avoid contact with their own mouth, eyes or nose with their hands – Avoid direct contact with blood or body fluids from the dead body – Make sure that any cuts, wounds or abrasions are covered with waterproof bandages or dressings – Put on disposable gloves and protective clothing/uniform when handling dead bodies – Hands must be washed after removing gloves and protective clothing – Embalming should not to be done, but if so Minimize environmental contamination during embalming – Viewing of the face without physical contact may be permitted – Relatives who are worried about having already been exposed to the infection should contact the physician – Cremation is recommended for the deceased’s body 6/11/2009 394
  375. Influenza A(H1N1) Bioethics 1. Equity of access to antivirals and vaccines 2. Transparency, honesty and good communications 3. Individual autonomy v. public good  Freedom vs. Quarantine 4. Imperatives of urgency in outbreak Dr. Darina situations O’Flanagan 5. Duty of care of healthcare workers and value of reciprocity of employers 6/11/2009 395
  376. Influenza A(H1N1) Global Migration and Quarantine The WHO has no free-standing international quarantine authority “Quarantine” is still a country-by- country power! QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 396 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  377. Influenza A(H1N1) Preventive Methods 1. Isolation Suspected swine flu patient (left) is escorted by a quarantine officer to 2. Quarantine Ambulance 3. Social Distancing 4. EU and Irish Quarantine Statue hard to find therefore US example Used! 5. In Ireland voluntary quarantine measures are presented in HPSC Post Exposure Prophylaxis “PEP” form QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 397 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  378. Influenza A(H1N1) Irish Post-Exposure Prophylaxis (PEP) • Post-Exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic 6 Updated PEP June 11 2009 6/11/2009 398
  379. Influenza A(H1N1) Preventive Methods • Definitions: • Isolation • The separation of an individual, or individuals, infected with a communicable disease from non infected individuals either in the home or hospital • Quarantine • The separation of an individual, or individuals, exposed to a communicable disease, from non infected and non-exposed individuals • Social distancing: • Refer to a range of non quarantined measures that might serve to reduce contact between persons, such as, closing of schools or prohibiting large gathering QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  380. Influenza A(H1N1) New Definition of Quarantine • “Means the physical separation, including confinement or restriction of movement, of an individual or individuals who are present within an affected area, as defined herein, or who are known to have been exposed or may reasonably be suspected to have been exposed to a communicable disease of public health threat and who do not yet show signs or symptoms of infection with the communicable disease of public health threat in order to prevent or limit the transmission of the communicable disease of public health threat to other unexposed and uninfected individuals.” QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  381. Rationale for Isolation & Quarantine • Isolation is a fairly common infection control measure used to prevent the spread of disease to non-infected family, healthcare professionals, patients, etc. • Quarantine in an extreme public health Hong Kong Hotel Quarantined Due measure used to prevent the spread of to Swine Flu Case disease to the community 300 people at a Hong Kong hotel have been placed under quarantine after a guest there became China's first confirmed swine flu case. QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  382. When might Isolation & Quarantine be Considered? • Isolation is used primarily in health care facilities with highly infectious patients (e.g., varicella, measles, TB) • Quarantine is used in extreme circumstances when disease spread cannot be prevented by other means, such as by post-exposure prophylaxis (e.g. ,SARS)) • Quarantine is also used when exposed individuals refuse other disease prevention means, such as vaccination (e.g., smallpox) QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  383. Preconditions to Imposition of Quarantine or Isolation • Any quarantine or isolation is implemented in the least restrictive environment necessary to contain the communicable disease of public health threat • Any quarantined persons shall be confined separately from any isolated persons Metropark Hotel • Upon determining that any quarantined person Wanchai after a can be reasonably believed to have become Mexican traveller infected with a communicable disease of public was determined to health threat, the infected person shall be have the virus promptly removed from quarantine and placed in isolation QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  384. Preconditions to Imposition of Quarantine or Isolation • The health and disease status of any quarantined and isolated persons shall be monitored regularly to determine if such persons require continued quarantine or isolation • Any quarantined or isolated persons shall be immediately released from quarantine or isolation upon a determination that such quarantined or isolated persons pose no risk of transmitting the communicable disease of public health threat to other persons • The site of any quarantine or isolation shall be, to the extent practicable, safely and hygienically maintained with adequate food, clothing, health care, and other essential needs made available to the persons who are subject to any order of quarantine and isolation Movie media QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  385. Influenza A(H1N1) Preventive Methods “Order of Quarantine” US Example • Ex parte-prepared by the Commissioner: • Sets forth: • Nature of the Public Health Threat including the specific disease if practical • Reasons why quarantine is required – Voluntary Compliance has failed or would be ineffective • Sufficient information to provide notice • Means by which the quarantine to be Biohazard implemented warning: • Geographic parameters (if any) This building • Duration of quarantine Under • Penalty for non-compliance Quarantine until • Provided to those covered individually if possible, further notice otherwise by a means determined by the Commissioner QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  386. Influenza A(H1N1) Isolation “Order of Isolation” US Example • Order of Isolation • Ex parte-issued by the Commissioner • Sets forth: – Identity of isolated persons – Bases for the isolation – Specific communicable disease – Site of the isolation – Date and time when isolation commences – Any conditions of the isolation QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER Medical Management of Biological Casualties Revised and Modified 29/04/2009
  387. Influenza A(H1N1) International Quarantine • BEIJING, May 6 (Xinhua) -- Passengers quarantined in the Chinese mainland who took the same flight with a Mexican national later diagnosed with influenza A/H1N1 in Hong Kong will be out of quarantine on Thursday if they display no flu-like symptoms, China's Ministry of Health said Wednesday QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 407 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  388. Influenza A(H1N1) Quarantine Airports • Quarantine Triage “Red” passenger could get escorted to restricted area RED (Terminal) • There will be a documentation, and a qualified medical expert about the situation and the upcoming procedures. QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 408
  389. Influenza A(H1N1) International Quarantine Reporting • Potential Quarantine Database (THAD)(Canadian) • International Health Regulations • Border Health Initiatives • Security and Prosperity Partnership • Global Public Health Information Network (GPHIN) • Passive and Active Surveillance ICU of the Jinan Infectious Disease Hospital in Jinan,China QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 409 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  390. Influenza A(H1N1) Quarantine Ethics • Targeting versus stigmatizing • Care in all communications • Public health officials, clinicians & the community must combat fear, stigma and discrimination through health education and communication QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 410 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  391. Influenza A(H1N1) In-Shelter Isolation Biohazard warning: This House Has been self quarantined until further notice Please keep Clear by 20 feet QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 411 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  392. Influenza A(H1N1) International Quarantine Recommendations • Quarantine is a net not a shield • Enhance communication strategies • Use traveller data to inform syndromic definitions • Create port risk assessment tool • Identify essential key partners for training – Border Services – Cruise Lines and Airlines – Cargo Ships • Establish International Quarantine Working Group QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 6/11/2009 412 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  393. Public Health Management for Contacts of Probable or Confirmed Case of Influenza A (H1N1) on a Aircraft (Update June 2 2009) 6/11/2009 413
  394. Influenza has a 72% attack rate in exposed persons in a 4.5 hour plane flight Communicability is highest 1-2 days before to 4-5 days after onset REMEMBER – SOCIAL DISTANCING IS 6 FEET! 6/11/2009 414 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  395. Influenza A(H1N1) Management OF Passengers Or Crew Members With Symptoms Of Influenza • Minimize the number of personnel directly exposed to the ill person Separate the ill person (6 feet) from others as much as possible without compromising flight safety • Have the ill person wear a facemask, if it can be tolerated, to reduce the number of droplets coughed or sneezed into the air • If a facemask can not be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing along with a plastic bag for proper disposal of contaminated tissues • Gloves are not intended to replace proper hand hygiene. Gloves should be carefully removed and discarded and hands should be cleaned immediately following activities involving contact with body fluids. Gloves should not be washed or reused • Personnel having close contact with an ill person should wear a facemask at a minimum or, ideally, a NIOSH-certified particulate respirator rated N- 95 or better Leaflets warning passengers of possible • Dispose of soiled material, gloves, items contaminated with body fluids, and disposable respirators in a sturdy plastic bag that is tied shut and not swine flu symptoms reopened, and disposed of according to state solid waste regulations 6/11/2009 415 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  396. Influenza A(H1N1) Irish Port Health Travel Alert Resources • 29 April, 2009, notices were put in place at Irish ports and airports 6/11/2009 416 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  397. Influenza A(H1N1) Risk Travel Advisories • HSE/DOHC Travel advisory June 8 2009 Chinese health workers in protective outfits examine passengers http://www.dohc.ie/issues/swine_influ onboard an AeroMexico flight AM 98 that landed at Pudong international airport in Shanghai from Mexico Thursday, April 30, 2009 enza/travel_advisory.pdf?direct=1 6/11/2009 417 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  398. Irish Embassy in México • Embassy • Ambassador His Excellency Dermot Brangan Travel Advisory • Address: First Secretary Security Status Embassy of Ireland Sarah Mangan May 18 2009 Secretary Cda. Blvd. Avila Camacho, 76-3 Myles Doherty Col. Lomas de Chapultepec Honorary Consulate 11000 Mexico D.F. • Address: Mexico Honorary Consulate of Ireland Telephone: Av. Coba 15 Mza.8 +52 55 5520 5803 SM22 Fax: Cancún Security Status + (52 55) 55 20 58 92 77500 Quintana Roo June 8 2009 Telephone: Exercise Caution Email: +52 998 112 5436 Submit your query here Fax: Website: +52 998 884 9940 www.irishembassy.com.mx Email: consul@gruporoyale.com Honorary Consul: Anthony Leeman 6/11/2009 418
  399. Influenza A(H1N1) Advice for Travellers to Ireland Update 6/11/2009 419
  400. Influenza A(H1N1) Passenger Health Questionnaire 6/11/2009 420 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  401. Influenza A(H1N1) Aircraft Cleaning Guidance 6/11/2009 421 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  402. Cabin Air Quality – Risk of Contagious Viruses Suspected SARS Passenger coming into Frankfurt Airport 6/11/2009 422 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  403. Influenza A(H1N1) Ship Cleaning Guidance 6/11/2009 423 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  404. Influenza A(H1N1) Irish Marine Notice May 8 2009 6/11/2009 424
  405. Influenza A (H1N1) Sydney Harbour Cruise Ship Quarantine? • The Pacific Dawn has already been blamed for a spike in Australian swine flu cases after authorities last week allowed 2,000 passengers to disembark in Sydney despite a suspected swine flu outbreak aboard • At least 46 passengers and crew aboard a previous Pacific Dawn cruise that docked at Sydney a week ago have been infected with the virus • June 1 2009 A cruise ship carrying three crew infected with swine flu agreed not to dock in northern Australia • Pacific Dawn: Passengers line the upper deck of the P&O Cruises Pacific Dawn ship as it docks at Darling Harbour in Sydney 3 days later • Embarked to emergency medical teams testing for Influenza A(H1N1)! 6/11/2009 425
  406. EU SHIPSAN TRAINET • EU SHIPSAN TRAINET project which started in 2008 and will be completed in May 2011 • This project foresees the development of: a) Harmonised communicable diseases surveillance including ILI syndrome by using standardised reporting forms b) A manual providing hygiene standards (e.g. for disinfection and cleaning), and outbreak management guidelines for airborne diseases c) Training of port health personnel and crew members on hygiene issues and outbreak management d) A communication network for collection and sharing of surveillance and ship inspection data among competent authorities • Eurosurveillance, Volume 14, Issue 21, 28 May 2009 • Perspectives • Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication 6/11/2009 426
  407. Influenza A(H1N1) Surveillance • A quarantine officer monitors passengers walking through a temperature screening checkpoint at Suvarnabhumi airport in Bangkok on April 24 Thermal Scanning 6/11/2009 427 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  408. Influenza A(H1N1) Surveillance • Monitor ... a thermal camera monitors the body temperature of passengers to identify possible swine flu infections at Incheon International Airport, South Korea / AP 6/11/2009 428 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  409. Influenza A(H1N1) Surveillance Around the World • A passenger goes through a disinfection process at the arrival terminal at the Juanda airport in Surabaya, in Indonesia's East Java province April 27, 2009 6/11/2009 429 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  410. Influenza A(H1N1) Travel Advisories 6/11/2009 430 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  411. What are the differences between Influenza A (H1N1) and the Common cold? Symptoms Influenza A(H1N1) Common Cold Onset Suddenly Slowly Fever Characteristically High (≥38oC or Rare 100oF) Headache Prominent Rare General aches and pain Usual, often severe Rare Fatigue, weakness Can be prolonged for a number Quite mild of weeks Extreme exhaustion Early and prominent Never Stuffy nose Sometimes Common Sneezing Sometimes Usual Sore throat Sometimes Common Chest discomfort, cough Common, can be severe Mild to moderate, hacking cough Diarrhoea, vomiting Commonly Not associated with the common cold in adults 6/11/2009 431 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  412. Personal Steps To Take If you Experience Flu-like Symptoms • Contact hospital or healthcare facility prior to going to allow phone triage and allow time to have precautionary measures in place before arrival! 432 6/11/2009
  413. Influenza A (H1N1) Adult Emergency Warning Signs for Re-consult • In adults, emergency warning signs that need urgent medical attention include: • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting 6/11/2009 433 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  414. Influenza A (H1N1) Children Emergency Warning Signs for Re-consult • In children emergency warning signs that need urgent medical attention include: • Fast breathing or trouble breathing • Bluish skin colour • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough • Fever with a rash 6/11/2009 434 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  415. Influenza A (H1N1) in Educational Institutions/Schools 6/11/2009 435
  416. Influenza A(H1N1) Ambulatory Care Clinics • In elective ambulatory care clinics (e.g. physiotherapy clinics, Well Baby and Well Woman clinics, outpatient follow-up clinics), where patients present for appointments: • It is suggested that clinic visits for patients who are ill with ILI symptoms be deferred until they are well. • This may be facilitated by reminder calls to patients to reschedule their appointments if they have ILI and by signage at the entrance to the clinic reminding patients to not attend clinic and to reschedule for when their symptoms have resolved. • The Well Women Centre • 67, Pembroke Road,Ballsbridge, Dublin 4. (near Jury's Hotel) Tuesday / Wednesday 10.00 am - 7.30 pm Monday / Thursday / Friday 8.00 am - 7.30 pm Saturdays 10.00 am - 4.00 pm Tel: (01) 660 9860 / 668 1108 / 6683714 Fax: (01) ) 660 3062 • info@wellwomancentre.ie 6/11/2009 436
  417. Influenza A(H1N1) Breastfeeding Mothers • The risk for influenza A (H1N1) transmission through breast milk is unknown – However, reports of viremia with seasonal influenza infection are rare • Suspected or confirmed ill mothers – Should continue breastfeeding and increase feeding frequency • Rational: – Infants who are not breastfeeding are particularly vulnerable to infection and hospitalization for severe respiratory illness • Mothers should wear a mask! • Mask not tolerated, have tissues available 6/11/2009 437
  418. Influenza A(H1N1) Infection Control for Parents • Instruct parent and caretakers on how to protect their infant from the spread of germs that cause respiratory illnesses like influenza A (H1N1): • Wash adults’ and infants’ hands frequently with soap and water, especially after infants place their hands in their mouths • Keep infants and mothers as close together as possible and encourage early and frequent skin-to-skin contact between mothers and their infants • Limit sharing of toys and other items that have been in infants' mouths. Wash thoroughly with soap and water any items that have been in infants' mouths • Keep pacifiers (including the pacifier ring/handle) and other items out of adults' or other infants' mouths prior to giving to the infant • Practice cough and sneeze etiquette 6/11/2009 438
  419. Influenza A (H1N1) HPSC On Personal Resources • Women who are Pregnant or Breastfeeding: http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicI nfluenza/SwineInfluenza/Adviceforthe GeneralPublic/File,3732,en.pdf 6/11/2009 439
  420. Influenza A(H1N1) Personal Prevention HSE Leaflet http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Educationaland 6/11/2009 440 Childcaresettings/File,3653,en.pdf Medical Management of Biological Casualties Revised and Modified 29/04/2009
  421. Influenza A(H1N1) Personal Prevention • First and most important: wash your hands – Try to stay in good general health – Get plenty of sleep – Be physically active – Manage your stress – Drink plenty of fluids – Eat nutritious food • Try not touch surfaces that may be contaminated with the flu virus • Avoid close contact with people who are sick. 6/11/2009 441 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  422. Influenza A(H1N1) Personal Prevention From Spreading the Virus Preventing the spread of Swine Influenza includes: • If you are sick, limit your contact with other people as much as possible • Do not go to work or school if ill • Cover your mouth and nose with a tissue when coughing or sneezing • I t may prevent those around you from getting sick • Put your used tissue in the waste basket • Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze 6/11/2009 442 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  423. Influenza A(H1N1) Personal Prevention From Spreading the Virus • Washing your hands often will help protect you from germs • Wash with soap and water or clean with alcohol- based hand cleaner • We recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 30 seconds • When soap and water are not available, alcohol- based disposable hand wipes or gel sanitizers may be used • You can find them in most supermarkets and drugstores • If using gel, rub your hands until the gel is dry. – The gel doesn't need water to work; the alcohol in it kills the germs on your hands 6/11/2009 443 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  424. Correct Hand-washing Protocol 1st step: 2nd step: 3rd step: Palm to palm Palm of right hand over Palm to palm with Attention: including back of left hand and palm fingers wrists (30 sec). of left hand over back of Interlaced(30 sec). right hand(30 sec). 4th step: 5th step: 6th step: Back of fingers to Rotational rubbing o fright Rotational rubbing, backwards opposing palms with thumb clasped in left palm and forwards with clasped fingers interlocked(30 and vice versa (30 sec). fingers of right hand in left sec). palm and vice versa (30 sec). 6/11/2009 444 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  425. Influenza A(H1N1) Personal Prevention From Spreading the Virus • Alcohol-based disposable hand wipes or gel sanitizers may be used 6/11/2009 445 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  426. Influenza A(H1N1) Personal Prevention From Spreading the Virus • Cover your mouth and nose with a tissue when coughing or sneezing • No Tissue 6/11/2009 446 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  427. Influenza A(H1N1) Personal Prevention From Spreading the Virus • Respiratory Etiquette/ Cough Etiquette Breaking the Chain of Infection 6/11/2009 447
  428. Information Leaflet on Influenza A (H1N1) • The HSE has produced an information leaflet for the public on A(H1N1) 'swine' Flu and Pandemic Flu. • Contains Hotline! • The Flu Information Line is available 24 hours a day and is your primary source of information on Influenza 1-8 pages A(H1N1). Will be Distributed throughout • Freephone 1800 94 11 00 Ireland 6/11/2009 448 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  429. Guidance For Caring For Persons At Home With Influenza A(H1N1) 6/11/2009 449
  430. Influenza A (H1N1) Personal Resources • People with specific medical conditions: 6/11/2009 450
  431. Influenza A (H1N1) Personal Resources • People with HIV AIDS: 6/11/2009 451
  432. European Union Hand Hygiene Campaigns 6/11/2009 452 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  433. Internet Address of National Campaigns 6/11/2009 453 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  434. Many Countries Worldwide Are Committed To Improve Hand Hygiene You are part of a global movement! Countries committed in 2005, 2006, 2007 and 2008 Current status, March 2009 Countries planning to commit in 2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  435. Influenza A (H1N1) UK Mass Media Video Swine Flu Information - NHS 24 http://www.nhs24.com/content/default.asp? page=home_SwineFlu 6/11/2009 455
  436. Influenza A(H1N1) Business Continuity • An outbreak of swine flu dampened tentative hopes for the global economy, sending markets lower on Monday and analysts fear a possible pandemic could force countries further into recession. • The World Bank estimated in 2008 that a flu pandemic could cost $3 trillion and result in a nearly 5 percent drop in world gross domestic product, damaging prospects of recovery in a world economy deep in financial crisis. 6/11/2009 456 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  437. Influenza A(H1N1) Business Continuity • Excellent resource for Business Continuity Planning • Business Continuity Planning Checklist Responding to an Influenza Pandemic available inside! 6/11/2009 457 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  438. Influenza A(H1N1) Checklists • Hospital Pandemic Influenza Planning Checklist • Home Health Care Services Pandemic Influenza Planning Checklist • Health Insurer Pandemic Influenza Planning Checklist • Travel Industry Pandemic Influenza Planing Checklist • Business Pandemic Influenza Planning Checklist • Law Enforcement Pandemic influenza Planning checklist • Child Care AND Preschool Pandemic Influenza Planning Checklist • School District (K-12) Pandemic Influenza Planning Checklist • Colleges And Universities Pandemic Influenza Planning Checklist • State And Local Pandemic Influenza Planning Checklist • CDC website for download! 6/11/2009 458
  439. US Summary of Ten Lessons Learned from the Influenza A(H1N1) Outbreak 1. Investments in pandemic planning and stockpiling antiviral medications paid off 2. Public health departments did not have enough resources to carry out plans 3. Response plans must be adaptable and science-driven 4. Providing clear, straightforward information to the public was essential for allaying fears and building trust 5. School closings have major ramifications for students, parents, and employers 6. Sick leave and policies for limiting mass gatherings were also problematic http://www.upmc- biosecurity.org/website/resources/pu blications/2009/pdf/2009-06-04- 7. Even with a mild outbreak, the health care delivery system was tfah2009-pan-flu-06.pdf overwhelmed 8. Communication between the public health system and health providers was not well coordinated 9. WHO pandemic alert phases caused confusion 459 10. International coordination was more complicated than expected
  440. Influenza A(H1N1) Case ! Studies The purpose of these case studies is to give a better picture of the interrelationships of pandemic preparedness and mitigation efforts in foreseeing and managing an emerging pandemic on a global scale ! 6/11/2009 460
  441. Influenza A(H1N1) Overview of Case Studies from Spain and England Added feature “How do they do it!” Estimation of the Reproduction Ratio for influenza A(H1N1) in Mexico Overview of Euro Surveillance Articles By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 11/06/2009 461
  442. Influenza A(H1N1) Case Studies Objectives • Review Spain's Case Study • Review England's case Study • Review preliminary estimation of the reproduction ratio for new influenza A(H1N1) from the outbreak in Mexico 11/06/2009 462
  443. Influenza A(H1N1) Spain Case Study Overview New influenza A(H1N1) virus infections in Spain, April-May 2009 http://www.eurosurveillance.org/ViewArticl e.aspx?ArticleId=19209 Overview of Euro Surveillance Articles By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 11/06/2009 463
  444. Influenza A(H1N1) Spain Surveillance Teams • Coordinating Centre for Health Alerts and Emergencies, Spanish Ministry of Health and Social Policy, Madrid, Spain • National Centre for Epidemiology and National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain • Regional Surveillance and Alert Teams from the Autonomous Communities in Spain • National Influenza Laboratory Network, Spain 11/06/2009 464
  445. 2009 Influenza A(H1N1) Outbreak in Spain • April 25 2009: – First case: The man, aged 23, had returned from Mexico on April 22 and had been quarantined on the 25th • May 17 2009 – I01 cases • June 2 2009 – 180 cases • June 8 2009 6/11/2009 465 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  446. Influenza A(H1N1) Spain's Outbreak Initial Timeline 11/06/2009 466
  447. Case definition and case classification, new influenza A(H1N1) infection, Spain, 25 April-7 May, 2009 11/06/2009 467
  448. Influenza A(H1N1) Spain's Confirmed Cases • Confirmed cases of new influenza virus A(H1N1) • As of 11 May, 98 laboratory-confirmed cases of infection with the new influenza virus A(H1N1) have been reported in Spain out of 640 possible cases investigated. The geographical distribution of reported cases by region is shown in 11/06/2009 468
  449. Spain's Geographical distribution Confirmed Cases • Seventy-six confirmed cases (78%) acquired the infection abroad; all these cases had a history of travel to Mexico. Of the 45 cases for whom this information was available, 16 (36%) were symptomatic during the inbound flight from Mexico. Dates of return from affected areas were available for 70 confirmed cases and ranged from 20 to 29 April 11/06/2009 469
  450. Cases of laboratory-confirmed new influenza virus A(H1N1) infection • Cases of laboratory-confirmed new influenza virus A(H1N1) infection, by date of travel return to Spain, as of 11 May, 2009 (n=70) Information on disease onset was available for 93 cases. The first of the 93 cases reported onset of illness (any symptom) on 19 April, and the most recent case reported onset on 4 May 11/06/2009 470
  451. Geographical distribution • Geographical distribution of cases of laboratory- confirmed new influenza virus A(H1N1) infection, Spain, as of 11 May 2009 11/06/2009 471
  452. Influenza A(H1N1) “Spain” Demographic and Clinical Features • Cases ranged in age from 14 to 55 years, with an average of 24 years (standard deviation (SD) 6.3) and a median of 22; 50 (51%) cases were male. • The most frequently reported symptoms were fever (96%) and cough (95%). Four cases did not have fever. Among 41 cases for whom this information was available, 17 (41%) reported diarrhoea 11/06/2009 472
  453. Influenza A(H1N1) “Spain” Specimens • Nose and throat swabs from cases who met clinical and epidemiological criteria were taken and referred to the national influenza reference laboratory (WHO National Influenza Centre) at the Instituto de Salud Carlos III for confirmation • Two independent assays have been used for diagnosis • Reverse transcription (RT)-nested PCR designed for typing the nucleoprotein gene and another one for subtyping the haemagglutinin gene • An alternative RT-PCR was done in case the first two PCR gave contradictory results • The strain identified in all cases was confirmed as genetically similar to viruses previously isolated from cases in California (A/California/04/2009 11/06/2009 473
  454. Influenza A(H1N1) “Spain” Discussion • Spain was the first country in Europe to report a laboratory- confirmed case of new influenza A(H1N1) virus • Several factors may have contributed: • Intense air traffic and contacts with Mexico • Timely alert with high media coverage that raised early awareness among public health and healthcare professionals, as well as among the public. • Extremely efficient surveillance system and a sensitive case definition that was distributed early in the event made it possible to detect cases at the very beginning of the outbreak and to trace more than 2,000 close contacts 11/06/2009 474
  455. Influenza A(H1N1) “Spain” Conclusion • Conclusion • The evolution of this outbreak of influenza A(H1N1) in Spain is difficult to predict. Though notification of new confirmed cases has decreased and the disease seems mild, they will continue to monitor changes in the epidemiology and/or clinical severity of new influenza A(H1N1) virus infections in Spain in order to implement appropriate prevention and control measures. 11/06/2009 475
  456. References Epidemiology of new influenza A(H1N1) in the United Kingdom, April - May 2009 http://www.eurosurveillance.org/View Article.aspx?ArticleId=19213 11/06/2009 476
  457. Influenza A(H1N1) England Case Study Epidemiology of new influenza A(H1N1) in the United Kingdom, April - May 2009 http://www.eurosurveillance.org/View Article.aspx?ArticleId=19213 By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 11/06/2009 477
  458. Influenza A(H1N1) England's Surveillance Teams • Health Protection Agency and Health Protection Scotland new influenza A(H1N1) investigation teams: • Health Protection Agency, London, United Kingdom • Health Protection Scotland, Glasgow, United Kingdom 11/06/2009 478
  459. Influenza A(H1N1) United Kingdom Outbreak 2009 822 Confirmed Cases as of June 11 2009 Scotland- 311 Northeast - 16 Northern Ireland - 7 Yorkshire and Humberside - 15 North West - 16 East Midlands - 12 East of England - 44 Wales - 2 London - 135 West Midlands - 171 South West - 14 South East - 79 6/11/2009 480
  460. Cases of laboratory confirmed swine-lineage influenza A H1N1 by day of onset and assumed mode of transmission, June 08 2009 • Cases of laboratory confirmed swine-lineage influenza A H1N1 by day of onset and assumed mode of transmission, 08 June 2009 (n=360*), United Kingdom 6/12/2009 481
  461. Cases of laboratory confirmed swine-lineage influenza A H1N1 by age-group and gender, 02 June 2009 United Kingdom 6/11/2009 482
  462. United Kingdom Transmission Mode Summary • Of those assumed acquired in the UK: • Cases assumed to have acquired their infection as a result of travel – 128 Cases assumed to have acquired their infection in the UK – 254 Data is still being followed up on 239 cases • The majority of cases are in school age children and young adults 6/11/2009 483
  463. HPA Swine Influenza Case Definition 9th May 2009 version 2.0 • The Health Protection Agency is using the • Epidemiological criteria following case definition for swine flu. • At least ONE of the following: • Clinical criteria – Onset of symptoms within seven days of visiting areas where sustained human to human transmission of • Any person with ONE of the following: swine influenza A/H1N1 is occurring* • Fever *≥38°C] OR a history of fever, AND – Onset of symptoms within seven days of close contact with a probable or confirmed case swine flu A (H1N1) • flu-like illness (TWO O R MORE of the following virus infection. symptoms: cough, sore throat, rhinorrhea, limb / joint pain, headache, vomiting / diarrhoea) OR • Case classification: • Severe / life-threatening illness suggestive of an • A. Possible case infectious process. – Any person meeting the clinical and epidemiological criteria • B. Probable case • Laboratory criteria – Any person meeting the clinical and epidemiological • At least ONE of the following tests: criteria AND with a positive influenza A infection which – Specific PCR for swine influenza is untypable – Four-fold rise in swine influenza A (H1N1) virus specific • C. Confirmed case antibodies (acute phase sera and convalescent >10-14 – Any person with laboratory confirmation days later) • D. Discarded case – Any suspect case not fulfilling the possible case definition, a possible case that tests flu A negative or a probable case that tests swine influenza H1N1 negative. 6/11/2009 484
  464. Influenza A(H1N1) England Case Study Overview • On 27 April, the first two confirmed United Kingdom cases of new influenza A(H1N1) virus infection were reported in Scotland, in a couple returning from travel to Mexico. • Health Protection Agency (HPA) and the Devolved Administrations strengthened national surveillance of respiratory illness amongst travellers returning from affected areas 11/06/2009 485
  465. Cases of laboratory confirmed new influenza A(H1N1) • Cases of laboratory confirmed new influenza A(H1N1) by day of report and travel history, United Kingdom, 11 May 2009 (n=65) 11/06/2009 486
  466. Cases of laboratory confirmed new influenza A(H1N1) by age group and sex • Cases of laboratory confirmed new influenza A(H1N1) by age group and sex, United Kingdom, 11 May 2009 (n=65) 11/06/2009 487
  467. Influenza A(H1N1) Confirmed Travel history • 65 cases, twenty-four reported a history of recent travel from Mexico and five from the US • 36 (56%) cases report no recent overseas travel and acquired their infection through secondary transmission in the United Kingdom • Cases are mainly affecting 10-19 year olds • Secondary cases are linked to transmission in different household/close contact settings and schools 11/06/2009 488
  468. Influenza A(H1N1) Clinical picture • The First Few Hundred (FF100 project) aims to collect information about a limited number of the earliest laboratory confirmed cases of new influenza A(H1N1) and their close contacts • Purpose: • Gain an early understanding of some of the key clinical, epidemiological, and virological parameters of the new influenza A(H1N1) virus • To facilitate real-time modelling efforts to make predictions of the future course of the United Kingdom epidemic 11/06/2009 489
  469. Influenza A(H1N1) Clinical signs and Symptoms • Signs and symptoms • Children were more likely to include: have: • Fever (94%), – Dry cough (83% vs. 55% OR = 5.7 95% CI: 0.97-34.2) • Sore throat (82%) – Malaise (89% vs. 69% OR = • Headache (81%) 8.1 95% CI 0.78-85.0) • Chills (80%) – Epistaxis (24% vs. 6% OR = 4.9 95% CI: 0.46-52.4) than • Malaise (80%) adults. • Diarrhoea (28%) – Females were more likely to • Arthralgia (56%) were vomit than males (40% vs. 11%, OR=6.7; 95% CI: 1.1- moderately frequently 41.1) and have diarrhoea reported. (39% vs. 14%, OR = 4.0 95% • Epistaxis and one a seizure CI: 0.8-19.8). (Five cases) 11/06/2009 490
  470. Influenza A(H1N1) England Case Study Conclusions • United Kingdom continues to observe sporadic importations of new influenza A(H1N1) virus from affected areas predominately Mexico • Healthy young adults and children are being proportionately more affected than other parts of the population • Based on the limited United Kingdom case series to date; the clinical presentation of cases continues to be relatively mild. • Further work is on-going to describe more fully the emerging epidemiological, virological and clinical characteristics of this new influenza A(H1N1). 11/06/2009 491
  471. Estimation of the Reproduction Ratio for influenza A(H1N1) from the Outbreak in Mexico “How do They do It” Boëlle PY, Bernillon P, Desenclos JC. A preliminary estimation of the reproduction ratio for new influenza A(H1N1) from the outbreak in Mexico, March-April 2009. Euro Surveill. 2009;14(19):pii=19205. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?Article Id=19205 Overview of Euro Surveillance Articles By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 11/06/2009 492
  472. Influenza A(H1N1) México 6/11/2009 493
  473. Influenza A(H1N1) México 6/11/2009 494
  474. 2009 Influenza A(H1N1) Outbreak in México (PAHO Epi Alert) Black=Deaths Red=Confirmed Cases 6/11/2009 495 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  475. Influenza A (H1N1) México Age Specific Attack Rate May 13 6/11/2009 496 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  476. México • Figure shows the number of confirmed (N = 97) and probable (N = 260)* cases of swine-origin influenza A (H1N1) virus (S-OIV) infection, by date of illness onset, in Mexico, during March 15 to April 26, 2009. • From March 15 through April 17, the daily number of confirmed and probable cases combined did not exceed five cases. However, the start of a substantial increase is indicated on April 18. This increase peaks at approximately 55 cases on April 22 and 23, before declining to fewer than 10 cases on April 26. 6/11/2009 497
  477. Influenza A (H1N1) Summary of Age Specific Clinical Signs and Fatality Rate May 20 2009 6/11/2009 498
  478. Influenza A (H1N1) México Age Specific Attack Rate May 20 6/11/2009 499
  479. México's Age Specific Case Fatality Rate 6/11/2009 500
  480. México Current Situation 6/11/2009 501
  481. HPA Case Study Mexico's Hospitalization and Deaths 6/11/2009 502
  482. Estimation of the Reproduction Ratio in México • Purpose: • Sustained human-to-human transmission is necessary to trigger influenza pandemic and estimating the reproduction ratio (average number of secondary cases per primary case) is necessary for forecasting the spread of infection and forecasting mitigation measures 11/06/2009 503
  483. Estimation of the Reproduction Ratio In México • Two parameters must be estimated for this new virus using mathematical and computational models: 1. The reproduction ratio (R), which measures the average number of secondary cases per primary case 2. The generation interval, which measures the average time between infection in a primary case and its secondary cases 11/06/2009 504
  484. Estimation of the Reproduction Ratio for Influenza A (H1N1) Methods for Estimating R • Two different approaches were used to estimate R: • M1 - Intrinsic growth rate • M2 - Real time estimation 11/06/2009 505
  485. Methods for Estimating Generation Interval Distribution • The two methods require full specification of the generation interval distribution • As no information regarding the actual generation interval in Mexico is available, they used three plausible candidate values of the generation interval (denoted GI) derived from different approaches: • 1. (denoted as PAN) obtained from household studies from the 1957 and 1968 pandemics • 2. Derived from viral excretion in experimental influenza infection (denoted as VIR) • 3. Hypothetical distribution introduced in Elveback (denoted ELV) 11/06/2009 506
  486. Methods for Estimating Generation Interval Distribution • Their values with mean standard deviation (SD) were the following: • PAN = 3.1 +/- 1.9 days • VIR = 2.6 +/- 1 day • ELV = 4.6 +/- 1.5 days 11/06/2009 507
  487. Estimation of the Reproduction Ratio for influenza A(H1N1) M1 - Intrinsic Growth Rate • When using M1, the period starting on 9 April and ending on 24 April yielded the best fit for exponential growth, with daily rate r = 0.30 [CI95% 0.28-0.34] 11/06/2009 508
  488. Estimation of the Reproduction Ratio for Influenza A(H1N1) M2 - Real Time Estimation • With method M2: • Estimates of the daily reproduction ratio R(t) in the outbreak of new influenza A(H1N1) in Mexico, calculated with method M2 (see Methods) using three generation interval values: PAN GI (top), VIR GI (middle) and ELV GI 11/06/2009 509
  489. Epidemic Growth Rates and Reproduction Ratio Estimates • Epidemic growth rates estimated for the new influenza A(H1N1) epidemic in Mexico and corresponding reproduction ratio estimates calculated with method M1 11/06/2009 510
  490. Results and Conclusion • A comprehensive analysis of all available data has independently led to the range of 1.4-1.6 • Early estimates show that the reproduction ratio in Mexico was in a range similar to that of past influenza pandemics of 1967-68 11/06/2009 511
  491. Pandemic System Model Coming soon! Performance Improvement in Preparing for Pandemics 6/11/2009 512
  492. References See Narration! 11/06/2009 513
  493. Influenza A (H1N1) Further information and References • Further information: • International http://www.hse.ie/eng/ • CDC, US http://www.dohc.ie • PHAC http://www.who.int/en http://www.cdc.gov/swineflu/ • PAHO http://ecdc.europa.eu/en/ • ECDC • http://www.nathnac.org/pro/swinefl • HPA, UK u.htm • WHO • Links • Irish • Health Service Executive (HSE) • Department of Health and Children • Department of Foreign Affairs • Department of Agriculture • Irish College of General Practitioners (ICGP) 6/11/2009 514 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  494. Disclaimer: • The opinions expressed by authors contributing to this PPT do not necessarily reflect the opinions of The Irish First Point Responder Institute or the Editorial team or the institutions with which the authors are affiliated. • Neither the Irish First Point Responder Institute nor any person acting on behalf of the IFPRI is responsible for the use which might be made of the information in this PPT. 11/06/2009 515
  495. The End of Influenza A (H1N1) By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 6/11/2009 516 Medical Management of Biological Casualties Revised and Modified 29/04/2009

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