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Influenza A (H1 N1) Master Update May 22 2009

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    Influenza A (H1 N1) Master Update May 22 2009 - Presentation Transcript

    1. Influenza A (H1N1) “The Emerging Pandemic!” By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    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 5/22/2009 2 Revised and Modified 29/04/2009
    3. Virus Names Associated with Recent Outbreak • Swine-Origin Influenza Virus (S-OIV ) • North-American influenza • Swine Influenza A(H1N1) • A(H1N1) • Novel A (H1N1)Influenza • Influenza A (H1N1) May 3 2009 • A(H1N1) May 8 2009 Virus will be referred to at different points of Presentation! Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    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 Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    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 5/22/2009 Revised and Modified 29/04/2009
    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 5/22/2009 Revised and Modified 29/04/2009
    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 5/22/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    8. World Health Organization (WHO) • The World Health Organisation raised its pandemic alert level to 4, verifying human-to-human swine flu, hours after the first British cases of the disease were confirmed. April 28 2009 • WHO flu expert Keiji Fukuda pointed out that it is too late to contain the swine flu \"Containment is not a feasible 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 5/22/2009 Revised and Modified 29/04/2009
    9. 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 5/22/2009 9
    10. 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 5/22/2009 Revised and Modified 29/04/2009
    11. Global Pandemic Curve First confirmed Case in Spain was the catalyst in WHO activating phase 5 Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    12. 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 5/22/2009 12 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    13. Who Pandemic Phases and Recommended Actions Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    14. Irelands Recommended Actions Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    15. Bioevent Disasters SEIRV Triage Model Categories • Susceptible • Exposed • Infectious • Removed • Vaccinated 5/22/2009 15 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    16. “Biological Triage” Mitigation High Transmissibility: • Influenza Susceptible Mitigation: • Identify & treat primary Exposed infections Infectious Removed • Preventative Goal: Vaccinated • Prevent secondary infections 5/22/2009 16 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    17. EU Alert Levels in Phase 3 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 5/22/2009 Revised and Modified 29/04/2009
    18. Influenza A(H1N1) Epidemiology 5/22/2009 18 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
    19. WHO Influenza A(H1N1) “Confirmed Cases” May 21 2009 5/22/2009 20
    20. Influenza A(H1N1) (EU) and EFTA ECDC May 21 2009 5/22/2009 22
    21. Influenza A(H1N1) Outbreak in Japan 2009 Note Increase spike in Japan! 5/22/2009 23
    22. Influenza A(H1N1) Outbreak in Japan 2009 • Japan notified 67 new confirmed cases in past 24 hours, representing a 32% increase in cases according to ECDC 5/22/2009 24
    23. 2009 Influenza A(H1N1) Outbreak In The United States ay 2009 5/22/2009 26
    24. 2009 Influenza A(H1N1) Outbreak In The United States U.S Human The date of the onset Cases of of symptoms of the Swine Flu first confirmed case Updates was 28 March 2009 in the United States. 5/22/2009 27 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    25. Influenza A(H1N1) Outbreak in Canada May 20 2009 • Canada is reporting an additional 223 cases in past 24 hours, resulting in a 44% increase in confirmed cases PHAC is reporting every 3 days 5/22/2009 29
    26. 2009 Influenza A(H1N1) Outbreak in Canada 5/22/2009 30 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    27. 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” 5/22/2009 31
    28. Influenza A(H1N1) Health Service Executive (HSE) Confirmed cases 5/22/2009 32 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    29. ECDC May 8 2009 Cumulative Epidemic Curve: Medical Management of Biological Casualties 5/22/2009 33 Revised and Modified 29/04/2009
    30. 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. • Dr. Kevin Kelleher, head of Health Protection with the HSE said: 'We haven’t seen any cases in Ireland as yet, but it is important to be prepared for any possible cases that may arise. As a precaution, we have issued advice and will constantly update all hospitals and GPs nationwide on A/H1N1 human swine influenza.' • ‘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. ' 5/22/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    31. 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 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 5/22/2009 Revised and Modified 29/04/2009
    32. Zoonosis Swine Influenza Virus (SIV) 5/22/2009 36
    33. 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 5/22/2009 37 in Alberta Medical Management of Biological Casualties Revised and Modified 29/04/2009
    34. 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 5/22/2009 38 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    35. 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 Irish pigs has so far been detected 5/22/2009 39 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    36. 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 5/22/2009 40 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    37. 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 – Mortality up to 15% Medical Management of Biological Casualties 5/22/2009 Revised and Modified 26/04/2005
    38. 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. 5/22/2009 42 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    39. 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. 5/22/2009 43
    40. 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 5/22/2009 44 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    41. Swine Influenza (SIV) Examples of Vaccines For Porcine! • Schering-Plough Animal Health Corporation: MaxiVac Excell s • Novartis : PneumoSTAR® SIV Swine Vaccine • Pfizer Animal Health: FluSure vaccine 5/22/2009 45
    42. 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). 5/22/2009 46 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    43. 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 5/22/2009 circumstances.! 47 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    44. Influenza A (H1N1) Prevention Department of Agriculture and Food (DAF) • 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 5/22/2009 48
    45. 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 5/22/2009 49 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    46. Biosecurity On Pig Farms $ Profits $ QUALITY ASSURANCE REDUCED MEDICATION REDUCED MORTALITY IMPROVED REDUCED ZOONOSIS REDUCED DISEASE PERFORMANCE BIOSECURTY 5/22/2009 50
    47. 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 5/22/2009 51 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    48. 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 5/22/2009 52 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    49. 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) 5/22/2009 53 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    50. 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 5/22/2009 54 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    51. 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 5/22/2009 55 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    52. 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 5/22/2009 56 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    53. 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. 5/22/2009 57 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    54. 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. 5/22/2009 58 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    55. 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 5/22/2009 59 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    56. A General Biosecurity Checklist For Swine 5/22/2009 60 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    57. Veterinary Surveillance • This disease is a scheduled and notifiable disease in Ireland (Class B) • Porcine surveillance: The Department of Agriculture and Food (DAF) (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 the HSE in the event of Influenza being identified or highly suspected from porcine 5/22/2009 61
    58. Swine Influenza (SIV) Pharmacovigilance for Veterinarians • EU Veterinary Suspected Adverse Reaction form for Veterinary and Health Professionals 5/22/2009 62
    59. 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 5/22/2009 63 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    60. 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 5/22/2009 64 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    61. Veterinarians Donning and Doffing PPE 5/22/2009 65 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    62. EU Possible Quarantine Zones for Infected Influenza A(H1N1) Pig Farms Surveillance zones Surveillance zone (minimum of 10 km radius from the infected premises) Protection Zone Quarantined Pig Farm Restricted zone (minimum of 1 km radius from the infected premises) Controls must be kept in place for at least 30 days Infected Premises Contaminated Porcine Farm Zone A Adapted from EU Quarantine for Avian Flu Buffer Zone 5/22/2009 66 Zone B
    63. 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 • Killing and disposal of all porcine • Identification of all porcine holdings • Cleaning and disinfection of the premises • Prohibition on porcine fairs, markets, shows or • Destruction or treatment of manure, other gatherings slurry and bedding • Prohibition on the release of porcine, porcine • Tracing and destruction of porcine meat products and carcasses produced during risk period • Epidemiological investigation and tracing of high-risk contacts • Prohibition on porcine entering or leaving • Controls on people, vehicles and other things entering or leaving • Controls on re-stocking • Zone B: Free from Disease 5/22/2009 67 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    64. Swine Influenza and Novel Influenza Virus/ Swine-Origin Influenza Virus (S-OIV) Swine influenza The Novel Influenza Virus A(H1N1)EU /Swine-Origin Influenza Virus (S-OIV)US • Swine influenza is • The Novel Influenza Virus commonly transmitted A(H1N1)EU /Swine-Origin through direct contact or Influenza Virus (S-OIV)US close proximity with pigs. contains genes from pig, Secondary cases following bird and human influenza human-to-human viruses, in a combination transmission have been that has never been reported in the past but observed before anywhere they have been very rare in the world 5/22/2009 68 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    65. 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 5/22/2009 Medical Management of Biological Casualties
    66. 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 5/22/2009 70 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    67. 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 5/22/2009 71
    68. 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) 5/22/2009 72 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    69. 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 5/22/2009 virions 73 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    70. 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 5/22/2009 74 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    71. Timeline of 1998 Hybrid of three viruses—a human virus, a pig virus, and a bird virus Swine Emergence of Some No Vaccine No Vaccine Influenza H1 Triple reassortment Result Influenza Viruses in 2009 Swine Influenza A virus (Swine Flu)H1N1 Avian Humans Influenza Pandemic vaccines 1997: In Hong Kong, avian influenza A (H5N1) H5 Total of 256 Deaths 2009 WHO Russian H9 1999-2009:avian influenza A (H9N2) Influenza H7 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) Asian 774 deaths Influenza Regular vaccines H2 1957 (Asian Flu) 1-4 million deaths H2N2 Spanish 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 5/22/2009 By 1993, a bird flu virus had adapted to pigs, grabbed a few human flu 75 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
    72. 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 5/22/2009 76 preparedness in the EU/EEA
    73. Past & Potential Flu Pandemics • Disease Year Deaths • Russian Flu 1889/1890 1 million • Spanish Flu 1918/1919 20-4 ?100 0 million • Hong Kong Flu 1968 1-4 ?50 million • Asian Flu 1957 4-5 million • SARS 2003 774 • Avian Flu 2003 256 ongoing • Swine Flu 2009 767 Unconfirmed (confirmed 63) 5/22/2009 77 Medical Management of Biological Casualties
    74. Past & Potential Flu Pandemics Summary Epidemics Year Approx Approx Approx Case fatality (avail. data) Infected Deaths Mortality % Rate/ Russian Flu 1889/1890 unknown 1 million unknown 0.75–1 death per 1000 Spanish flu 1918/1919 500 million 20-40 /?50 2.5 -10% million + Asian flu 1956-58 45 million 3-4 million 0.58 deaths /1000 persons Hong Kong 1968-69 50 million 1-4 million flu Avian flu 1990-today 421 257 61% 610 SARS 2002-03 8,096 774 9.6% 96 Swine flu 1976 79 2009 Ongoing 5/22/2009 78 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    75. Epidemiology of Ireland Spanish Influenza 1818-1819 • Ireland: 10,651 influenza • The deaths per 100,000 deaths registered by age group: – Male : 5,591 under 5 years 295 – Female: 5,060 5-10 years 120 • Mortality Rate: of 243 per 10-15 years 103 100,000 population 15-20years 223 – The mortality rate 20-25 years 329 varied by region: 25-35 years 380 • Leinster: 304 per 35-45 years 239 100,000 45-55 years 222 • Ulster: 302 per 100,000 1918 Flu Pandemic In 55-65 years 226 • Munster: 159 per Ireland 65-75 years 221 100,000 • Connaught: 114 per < 75 years 256 100,000 5/22/2009 79 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    76. 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” 5/22/2009 80 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    77. 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 See Website for download for clinicians 5/22/2009 81 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    78. Pre-Pandemic Planning: The Pandemic Severity Index 5/22/2009 82 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    79. 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 5/22/2009 83 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    80. 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 5/22/2009 V pandemic would kill 5.4 billion people. class 84 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    81. Community Mitigation Strategy by Example on Pandemic Severity Scale 5/22/2009 85 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    82. 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. 5/22/2009 86
    83. 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 5/22/2009 87 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    84. 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. 5/22/2009 88 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    85. 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 5/22/2009 89 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    86. 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) 5/22/2009 90 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    87. 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 5/22/2009 Revised and Modified 29/04/2009
    88. 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. 5/22/2009 92 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    89. Influenza A(H1N1) Information On Surveillance • 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 • Links • HPA, UK • • WHO Irish • Health Service Executive (HSE) • Department of Health and Children • Department of Foreign Affairs • Department of Agriculture • Irish College of General Practitioners (ICGP) 5/22/2009 93 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    90. Surveillance System: Further Irish Sites of Interest • Central Statistics Office • Faculty of Public Health Medicine, RCPI • Health Research Board • Irish College of General Practitioners • National Salmonella Reference Laboratory • Food Safety Promotion Board 94
    91. Surveillance System: EU Surveillance Networks • Enter-net • EuroHIV Eurosurveillance • 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 5/22/2009 95
    92. 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: 5/22/2009 International 96 •
    93. 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 • Italy: Istituto Superiore di Sanità (ISS) • Latvia: Sabiedribas veselibas agentura (SVA) • Luxembourg: Direction de la Sant 5/22/2009 97
    94. Influenza Irelands Surveillance Systems Reference: Pandemic Influenza Preparedness for Ireland: Advice of the Pandemic Influenza Expert Group 15th January 2007 5/22/2009 98
    95. 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 institution. 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 affected 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 5/22/2009 99
    96. 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) 5/22/2009 100
    97. 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 5/22/2009 101 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    98. Computerised Infectious Disease Reporting (CIDR) Dissemination Pathway 5/22/2009 102 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    99. 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 5/22/2009 103 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
    100. 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 HSE area • Weekly Notifications of Influenza Influenza A(H1N1) Infection Weekly Surveillance Report 5/22/2009 104
    101. 2009 Influenza A(H1N1) Outbreak In Ireland Country Cases of human Confirmed Under swine influenza cases of human Investigation swine influenza Ireland 4 (4 neg) 1 April 3 2009 NI 67 (62 neg) 1 May 1 2009 4 • It advised people in Ireland who have travelled to the affected areas and who develop flu-like symptoms to seek medical help. • “If you develop an influenza-like illness and have recently returned – within the last 7 days – from Mexico, Texas or California, you should contact your GP,” said Dr Kelleher 5/22/2009 105 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    102. Influenza A(H1N1) “The Emerging Pandemic!” 5/22/2009 106 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    103. 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 5/22/2009 107 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    104. 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 5/22/2009 108 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    105. Categorizing Influenza Virus “Viral Nomenclature” Type of nuclear material Neuraminidase Hemagglutinin A/California/04/2009(H1N1) Virus Geographic Strain Year of Virus type origin number isolation subtype Try These Two! A/New Jersey/76 (Hsw1N1) 5/22/2009 109 Medical Management of Biological Casualties A/Victoria/75 (H3N2) Revised and Modified 29/04/2009
    106. Influenza Type A Antigenic Shifts Severity of Year Subtype Pandemic 1889 H3N2 Moderate 1918 H1N1 Severe 1957 H2N2 Severe 1968 H3N2 Moderate 1977 H1N1 Mild 2009 H1N1 ? Ribbon representation of the hemagglutinin HA0 trimer from the 1918 influenza virus. 5/22/2009 110 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    107. Emergence H3N2 Viruses Antigenetic Shift 5/22/2009 111 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    108. Emergence H3N2 Viruses 5/22/2009 112 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    109. Origins Overview 5/22/2009 113 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    110. Influenza A(H1N1) Reassortment Diamond 5/22/2009 114 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    111. Influenza A(H1N1) Host Range 5/22/2009 115 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    112. Influenza A(H1N1) Antigenic Shift Pathogenesis 5/22/2009 116 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    113. 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) 5/22/2009 117 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    114. 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 5/22/2009 118 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    115. 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 5/22/2009 119 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    116. 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 5/22/2009 120 Medical Management of Biological Casualties Has Breakthrough! Revised and Modified 29/04/2009
    117. Comparison of H1N1 Swine Genotypes in Recent Cases in the United States 5/22/2009 121 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    118. Emergence of a Influenza A (H1N1) Virus in Humans 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 5/22/2009 122
    119. 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 1-3 months 5/22/2009 123 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    120. Influenza A(H1N1) Transmission: • Inhalation via aerosol • Direct and indirect contact • Pig to human – asymptomatic carrier pigs • Human to human • Human to Pig • Not transmissible by consumption of pork 5/22/2009 124 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    121. Influenza A(H1N1) Human Signs and Symptoms: Fever Exacerbation of underlying chronic medical conditions (greater than Includes: 100°F or Upper respiratory tract disease (sinusitis, otitis media, croup) 37.8°C) lower respiratory tract disease EU > 38 °C (pneumonia, bronchiolitis, status asthmaticus) Cardiac (myocarditis, pericarditis) Musculoskeletal (myositis, rhabdomyolysis) Neurologic (acute and post- infectious encephalopathy, encephalitis, febrile seizures, status epilepticus) Toxic shock syndrome Secondary bacterial pneumonia with or without sepsis. 5/22/2009 125 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    122. 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: 5/22/2009 126 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    123. 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 127 Medical Management of Biological Casualties 5/22/2009 Revised and Modified 29/04/2009
    124. Symptoms Onset of Influenza A(H1N1) in Canada • As of May 6, 2009, half the cases are 22 years of age or younger (median: 22 years; range: 2 – 66 years) • As of May 19, 2009, half the cases are 33 years of age or younger (median: 33 years; range: <1 – 86 years). • One death in Alberta has been reported. 5/22/2009 128 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    125. Influenza A(H1N1) High Risk Group Age • High risk age 20-30 according to ECDC as of May 5 2009 • Correlates with US, Mexico and Canada statistics! • ?Why – Pre-exposure? Hand hygiene – Pandemic prevention techniques like social distancing, avoidance, hand hygiene not adhered to ? – Needs further research 5/22/2009 129 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    126. Influenza A(H1N1) Distribution of Confirmed Cases By Date Incubation ? 1-7 days Peaked 5-6 days 5/22/2009 130 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    127. Influenza A (H1N1) Mexico, United Sates, Canada Age Summary: In Mexico In United States: In Canada: As of May 19, 2009, half the cases are 33 years of age or younger (median: 33 years; range: <1 – 86 years). 5/22/2009 131 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    128. Influenza A (H1N1) México Age Specific Attack Rate 5/22/2009 132 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    129. 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 7, 2009 – The majority of the cases (97%) are under the age of 50 – The median age of Canadian cases is 22 years – There are no cases among people over the age of 66 – The majority of cases are linked to travel to Mexico • The opinion and assessment report are available on: 5/22/2009 133 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    130. 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 5/22/2009 134 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    131. 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. 5/22/2009 135 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    132. 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 5/22/2009 136 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    133. 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. 5/22/2009 137 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    134. 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) 5/22/2009 138 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    135. 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.oC, 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 5/22/2009 139 proportion of the human population has little or no immunity. Medical Management of Biological Casualties Revised and Modified 29/04/2009
    136. 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. 5/22/2009 140
    137. 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. 5/22/2009 141 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    138. 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: 5/22/2009 142 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    139. 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. 5/22/2009 143 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    140. 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 5/22/2009 144 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    141. Influenza A(H1N1) US 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. 5/22/2009 145 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    142. 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 #: • 5/22/2009 Institution Shipping Address(No PO Box): 146 Medical Management of Biological Casualties • Preferred Shipping carrier: Revised and Modified 29/04/2009
    143. 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 5/22/2009 147
    144. 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 5/22/2009 148 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    145. 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) 5/22/2009 149 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    146. 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 5/22/2009 150 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    147. 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! 5/22/2009 151 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    148. 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 N95 respirator or higher level of protection – Shoe covers – Closed-front gown – Double gloves – Eye protection (goggles or face shields) 5/22/2009 152 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    149. 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 5/22/2009 153 bacterial cultures Medical Management of Biological Casualties Revised and Modified 29/04/2009
    150. 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 5/22/2009 154 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    151. 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 5/22/2009 155 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    152. 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 5/22/2009 156 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    153. 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 5/22/2009 157
    154. 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 5/22/2009 158 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    155. 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. 5/22/2009 159 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    156. 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. 5/22/2009 160 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    157. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 5 5/22/2009 161
    158. NRVL Testing for Influenza A(H1N1) • Preferred Respiratory Specimens • Swabs – Nasopharyngeal Aspirates • Storing Clinical Specimens • Shipping Clinical Specimens • Recommended Tests HSE :Taking specimens for • Other Influenza Tests influenza virus testing from patients with – Rapid Influenza Antigen Test suspected swine – Immunofluorescence (DFA or IFA) influenza – Viral Culture 5/22/2009 162 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    159. 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 five days after onset of clinical symptoms 5/22/2009 163 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    160. 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) 5/22/2009 164 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    161. NRVL Testing for Influenza A(H1N1) • Infection prevention and control precautions: • While not strictly an aerosol generating procedure it is recommended that the same precautions are followed when taking nasal and throat viral swabs to out rule influenza A (H1N1) • The following Infection Prevention and Control Precautions should be taken: – Hand hygiene – Standard Precautions – FFP2 or FFP3 mask (correctly fitted) – Eye protection (i.e. goggles) – Long-sleeved disposable gown (single use only) – Gloves (some of these procedures require sterile gloves) – Hand hygiene post procedure • Refer to donning and removal of PPE document 5/22/2009 165 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    162. Influenza A(H1N1) Infection Prevention and Control Precautions • Nasal and throat viral swabs: • Nasopharyngeal aspirate, • The following precautions should transtracheal aspirate, be taken: bronchoalveolar lavage and • Hand hygiene biopsy of lung or tracheal tissues at post-mortem are considered • Surgical mask aerosol generating procedures: • Goggles (if risk of splashing or • The following precautions should spraying) be taken: • Plastic apron • Hand hygiene • Gloves • FFP2 or FFP3 respiratory mask • Hand hygiene post procedure • Goggles • Long sleeved disposable gown • Gloves (some of these procedures require sterile gloves) • Hand hygiene post procedure Update May 21 2009 5/22/2009 166
    163. NRVL Testing for Influenza A(H1N1) • Respiratory specimens to take: • A. Upper respiratory tract – Nose and throat swabs – Nasopharyngeal aspirate • B. Lower respiratory tract – Where clinically indicated, invasive procedures can be performed for the diagnosis of viral lower respiratory tract infections: – Transtracheal aspirate – Bronchoalveolar lavage – Post-mortem lung or tracheal tissue 5/22/2009 167 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    164. 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 5/22/2009 168 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    165. Influenza A (H1N1) Nasopharyngeal Aspirates • 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 5/22/2009 169 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    166. 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) 5/22/2009 170
    167. Influenza A(H1N1) Nasopharyngeal Aspirates 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 5/22/2009 171 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    168. Influenza A(H1N1) Storing Clinical Specimens • All respiratory specimens should be kept at 4°C until they can be placed at -70°C. • If a -70°C freezer is not available, specimens should be kept at 4°C, preferably no longer than 1 week. • Do not freeze! • Healthcare Bundle needed immediately with seminar at NRVL/HSE 5/22/2009 172 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    169. Influenza A(H1N1) Serology (Blood Work) • Acute Serum • Convalescent serum • 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 5/22/2009 173
    170. Influenza A(H1N1) and Blood Safety • 2009 H1N1 Influenza Virus and Blood Safety: • No case of transfusion transmitted seasonal influenza has ever 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. 5/22/2009 174
    171. Influenza A(H1N1) and Blood Safety • 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” 5/22/2009 175
    172. 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 state public health laboratory • Suspect case specimens shipped from the state public health laboratory to the NRVL should include all information required for seasonal influenza surveillance isolate or specimen submission 5/22/2009 176 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    173. 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.” 5/22/2009 177 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    174. 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 as Novel Influenza is performed at the NRVL currently, but may be available in public health laboratories 5/22/2009 178 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    175. Influenza A (H1N1) CDC Influenza Laboratory Images • Images below of the newly identified H1N1 influenza virus were taken in the CDC Influenza Laboratory. 5/22/2009 179 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    176. 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 5/22/2009 180 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    177. 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 5/22/2009 181 Medical Management of Biological Casualties 181 Revised and Modified 29/04/2009
    178. Influenza A(H1N1) NRVL Submission of Specimens • Postal address: Medical Microbiology, CRID Building, University College Dublin, Belfield, Bio containment :BL3(+) Two Dublin 4, microbiological safety cabinets (msc ) class I and class I/ III) at Ireland. NVRL Telephone Number: +353-1-716 1325/1236 Fax Number: +353-1-716 1239 Email: margaret.brindley@ucd.ie 5/22/2009 182
    179. 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/ 5/22/2009 183 Medical Management of Biological Casualties 183 Revised and Modified 29/04/2009
    180. Influenza A(H1N1) Who Shipment Protocol Adapted from 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” 5/22/2009 184 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    181. 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 5/22/2009 185 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    182. 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. 5/22/2009 186 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    183. 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 187 5/22/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    184. This Packaging is Used For Category A Infectious Substances 5/22/2009 188 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    185. 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) 5/22/2009 189 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    186. 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 5/22/2009 190 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    187. 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. 5/22/2009 191 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    188. 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 5/22/2009 192 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    189. Air Waybill • All goods being shipped by air must have a completed Air Waybill. 5/22/2009 193 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    190. This Packaging is Used For Category B Infectious Substances 5/22/2009 194 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    191. 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 5/22/2009 195 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    192. 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) 5/22/2009 196 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    193. 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. 5/22/2009 197 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    194. Exempt Packaging Requirements • Primary container is leakproof • Secondary container is leakproof • Outer packaging must be of adequate strength 5/22/2009 198 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
    195. Exempt Packaging Requirements Primary container (leakproof) Secondary container (leakproof) Absorbent and cushioning material Outer packaging 5/22/2009 199 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    196. 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) 5/22/2009 200 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    197. 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. 5/22/2009 201 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    198. Health Protection Agency (HPA) Cat B Packaging Poster 5/22/2009 202
    199. 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 5/22/2009 203 Medical Management of Biological Casualties decontaminated Revised and Modified 29/04/2009
    200. Post-exposure Prophylaxis (PEP) for close contacts of probable1 or confirmed2 human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 5 5/22/2009 204
    201. 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 Ontario had the same sequence, ruling out genetic explanations for the greater severity of the Mexican cases 5/22/2009 205 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    202. Influenza A(H1N1) Antiviral Purpose in Pandemics 5/22/2009 206 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    203. 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 5/22/2009 207 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    204. 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 5/22/2009 208 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    205. 5/22/2009 209
    206. 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 5/22/2009 210 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    207. 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) 5/22/2009 211 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    208. 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 5/22/2009 212 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    209. Surveillance Of Antiviral Resistant Examples of Influenza (H1N1) From 2006-2008 US 5/22/2009 213 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    210. 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 5/22/2009 214 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    211. Pandemic Influenza Expert Group (PIEG) On Antivirals Algorithms 5/22/2009 215 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    212. Pandemic Influenza Expert Group (PIEG) On Antivirals Algorithms 5/22/2009 216 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    213. Pandemic Influenza Expert Group (PIEG) On Antivirals Summary 5/22/2009 217 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    214. Influenza A(H1N1) Antiviral Chemoprophylaxis • Antiviral chemoprophylaxis (pre-exposure or post-exposure) with eithero seltamivir 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 5/22/2009 218 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    215. Pandemic Influenza Expert Group (PIEG) On Antivirals “ High Risk Groups” • Group 1: Treatment of persons hospitalised for influenza (if hospitalised within 48 hours of onset of symptoms). To be consistent with the goal of reducing morbidity and mortality and considering the optimal use of antiviral drugs in relation to onset of illness, those who are hospitalised within the first 48 hours of onset of illness should be highest priority for treatment. Treatment with oseltamivir may be considered in those who are hospitalised more than 48 hours after onset of symptoms, although its effectiveness in this situation is not established • Group 2: Treatment of ill health care and emergency services workers. Considering the essential role that health care workers and emergency service workers will have in the pandemic response, influenza infection in these groups, identified within the first 48 hours of onset of illness, should be high priority for treatment • Group 3: Treatment of ill high risk persons* in the community. Persons with underlying heart and lung conditions or those who are immunocompromised, and who present for medical care within 48 hours of onset of symptoms, will also be considered high priority for treatment since they are at high risk of complications • Group 4: Treatment of high risk residents of institutions (nursing homes and other chronic care facilities) to control outbreaks. Reducing the impact of influenza outbreaks in institutions where the most vulnerable persons reside will contribute to the objectives of reducing morbidity and mortality and reduce health care demands 5/22/2009 219 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    216. 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 5/22/2009 220 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    217. 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 5/22/2009 221 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    218. Influenza A(H1N1) Empiric Antiviral Treatment Medication Dosing Recommendations 5/22/2009 222 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    219. Table: Recommended Daily Dosage of Seasonal Influenza Antiviral Medications for Treatment and Chemoprophylaxis for the 2008-09 Season—United States 5/22/2009 223 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    220. Antiviral Adult Recommended Dosages Summary 5/22/2009 224 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    221. (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 5/22/2009 225 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    222. IMEA 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 (May 8 report) 5/22/2009 226 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    223. 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 5/22/2009 227
    224. 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! 5/22/2009 228 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    225. 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 5/22/2009 229 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    226. Oseltamivir (Tamiflu) Children Dosing Fact Sheets 5/22/2009 230 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    227. Oseltamivir (Tamiflu) Children Fact Sheets 5/22/2009 231 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    228. 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 5/22/2009 232 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    229. 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 5/22/2009 233
    230. 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 234 5/22/2009
    231. 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! 5/22/2009 235
    232. 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. 5/22/2009 236
    233. Zanamivir (Relenza) Fact Sheets 5/22/2009 237 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    234. 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 5/22/2009
    235. 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, Earlsfort Terrace, Dublin 2, Ireland. Tel :353-1-676 4971 Fax: 353-1-634 3514 Email: imbpharmacovigilance@imb.ie 239 5/22/2009
    236. 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. 5/22/2009 240 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    237. 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 5/22/2009 241 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    238. 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 5/22/2009 242 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    239. 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 5/22/2009 243 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    240. 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 244 5/22/2009 – Yemen – Zambia – Zimbabwe
    241. 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 245 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    242. Influenza Vaccination Clinic Map Example: From Nassau County US 5/22/2009 246 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    243. Guidance for Pharmacy Staff Influenza A (H1N1) 5/22/2009 247
    244. 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 5/22/2009 248 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    245. 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 5/22/2009 249 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    246. 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) 5/22/2009 250
    247. 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 5/22/2009 251 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    248. The “My 5 Moments for Hand Hygiene” Approach (WHO) Medical Management of Biological Casualties Revised and Modified 29/04/2009
    249. 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! 5/22/2009 253 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    250. 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 5/22/2009 254
    251. Pandemic Planning “Hand Washing” 5/22/2009 255
    252. 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 5/22/2009 256 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    253. Public Health Management of Influenza A(H1N1) Contacts • Close Contacts Definition (interim) • 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/social care workers who provided direct clinical, personal care or examined a symptomatic patient without wearing appropriate Personal Protective Equipment (PPE) for Standard, Droplet and Contact Precautions: • Routine Care (including taking nasal and throat swabs for viral testing) – Surgical mask, Plastic Apron, Gloves (and goggles if risk of splashing/spraying) • Aerosol generating procedures – FFP2 or FFP3 respirator mask, goggles, long sleeved gown and gloves 5/22/2009 257
    254. 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. 5/22/2009 258
    255. Post-exposure Prophylaxis (PEP) for close contacts of probable1 or confirmed2 human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 5 5/22/2009 259
    256. 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 5/22/2009 260 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    257. Influenza A(H1N1) Surveillance of Healthcare Workers Clinical criteria • Acute onset of fever (temperature ≥380C 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 5/22/2009 261 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    258. 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 5/22/2009 262 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    259. 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 – Worked in a laboratory where samples of the swine influenza A (H1N1) virus are tested 5/22/2009 263 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    260. 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/). 5/22/2009 264 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    261. 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 5/22/2009 265 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    262. 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. 5/22/2009 266 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    263. 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 (Table 1) 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 5/22/2009 267
    264. Influenza A(H1N1) Infection Control In Health Care Setting • CDC Interim recommendations: • The ill person should wear a surgical mask when outside of the patient room • Should be encouraged to wash hands frequently and follow respiratory hygiene practices • Cups and other utensils used by the ill person should be washed with soap and water before use by other persons • Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza • Wear masks outside the Room 5/22/2009 268 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    265. Influenza A(H1N1) Infection Control In Health Care Setting • CDC interim recommendations: • Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable FFP2-3 respirator mask • 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 disposable FFP2-3 respirator mask when entering the patient room. 5/22/2009 269 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    266. Influenza A(H1N1) Infection Control In Health Care Setting • CDC Interim recommendations: • Hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions • Wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure. 5/22/2009 270 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    267. Influenza A(H1N1) Infection Control In Health Care Setting • For visible soiled hands WHO recommends the following technique 5/22/2009 271
    268. 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. 5/22/2009 272 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    269. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 5/22/2009 273 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    270. 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. 274 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    271. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 5/22/2009 275 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    272. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 5/22/2009 276
    273. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 5/22/2009 277
    274. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 5/22/2009 278
    275. Aerosol Generating Procedures According to WHO • Aerosol generating • Nebulisation procedures: • Non-invasive positive • Intubation and related pressure ventilation procedures, e.g. manual • Bi-level positive airway ventilation pressure (BPAP) • Respiratory and airway • High frequency oscillating suctioning (including ventilation tracheostomy care) • Nasopharyngeal aspiration • Cardiopulmonary resuscitation • Bronchoscopy • Autopsy procedures 5/22/2009 279
    276. 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 5/22/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    277. 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! 5/22/2009 281
    278. 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 5/22/2009 282 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    279. 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 5/22/2009 283 cotton mask described by Dato et al
    280. 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 5/22/2009 284 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    281. Influenza A(H1N1) Respiratory Protection Programme • Example 5/22/2009 285
    282. 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) 5/22/2009 286
    283. 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 5/22/2009 287
    284. 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 5/22/2009 288
    285. 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 5/22/2009 289
    286. 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) 5/22/2009 290 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    287. How To Perform a Particulate Respirator Seal Check 5/22/2009 291 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    288. Donning and Doffing Personal Protective Equipment (PPE) Donning PPE Doffing PPE 5/22/2009 292 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    289. 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. • 5/22/2009 293 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    290. 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 5/22/2009 FFP3 valved moulded cup mask 294 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    291. 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! 5/22/2009 295 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    292. 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 5/22/2009 296 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    293. 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. 5/22/2009 297 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    294. Influenza A(H1N1) Handling Human Remains Medical Examiner • Influenza A (H1N1) handling of Human Remains 5/22/2009 298 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    295. Influenza A(H1N1) Handling Human Remains Funeral Service • Influenza A (H1N1) handling of Human Remains 5/22/2009 299 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    296. Influenza A(H1N1) Public Health Management of Contacts • 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 5/22/2009 300 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    297. Influenza A(H1N1) Advice to General Practitioners on Management of a Possible Case • 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 5/22/2009 301 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    298. 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 5/22/2009 302 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    299. 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 1-6 pages 5/22/2009 303 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    300. 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 5/22/2009 304 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    301. 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 5/22/2009 305 Medical Management of Biological Casualties Adapted from “Dispatchers Guide to CBRNE” Revised and Modified 29/04/2009
    302. 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. 5/22/2009 306 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    303. 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 5/22/2009 307 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    304. 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 5/22/2009 308 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    305. 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 5/22/2009
    306. 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 5/22/2009 310 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    307. Guidance for the Ambulance Service with suspected /probable or confirmed case 5/22/2009 311
    308. 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 5/22/2009 312
    309. 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 5/22/2009 313 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    310. Influenza A(H1N1) Preventive Methods 1. Isolation 2. Quarantine 3. Social Distancing 4. EU and Irish Quarantine Statue hard to find therefore US example Used! Suspected swine flu patient (left) is escorted by a quarantine officer to Amblance QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 5/22/2009 314 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    311. 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
    312. 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
    313. 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
    314. 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
    315. 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
    316. 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
    317. 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
    318. 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
    319. 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) 5/22/2009 323
    320. 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 5/22/2009 324 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    321. 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 5/22/2009 325
    322. 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 5/22/2009 326 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    323. 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 5/22/2009 327 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    324. 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 5/22/2009 328 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    325. 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 5/22/2009 329 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    326. 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 5/22/2009 330 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    327. Influenza A(H1N1) Irish Port Health Travel Alert Resources • 29 April, 2009, notices were put in place at Irish ports and airports 5/22/2009 331 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    328. Influenza A(H1N1) Risk Travel Advisories • HSE guidance for aircraft cleaning when swine influenza (Influenza A (H1N1) is suspected in a passenger or crew member 1-3 Pages 5/22/2009 332 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    329. 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 77500 Quintana Roo + (52 55) 55 20 58 92 Telephone: 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 5/22/2009 333
    330. Influenza A(H1N1) Advice for Travellers to Ireland Update 5/22/2009 334
    331. Influenza A(H1N1) Passenger Health Questionnaire 5/22/2009 335 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    332. Influenza A(H1N1) Aircraft Cleaning Guidance 5/22/2009 336 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    333. Cabin Air Quality – Risk of Contagious Viruses Suspected SARS Passenger coming into Frankfurt Airport 5/22/2009 337 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    334. Influenza A(H1N1) Ship Cleaning Guidance 5/22/2009 338 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    335. 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 5/22/2009 339 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    336. 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 5/22/2009 340 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    337. 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 5/22/2009 341 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    338. Influenza A(H1N1) Travel Advisories 5/22/2009 342 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    339. 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 5/22/2009 343 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    340. What are the differences between Influenza A (H1N1) and the Common cold? Symptoms Influenza A(H1N1) Common Cold Onset Suddenly Slowly Fever Characteristically High (102- Rare 104oF) Headache Prominent Rare General aches and pain Usual, often severe 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 Unknown but probably quite Not associated with the common common cold in adults 5/22/2009 344 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    341. 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 5/22/2009 345 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    342. 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! 5/22/2009 346
    343. 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 5/22/2009 347
    344. Influenza A(H1N1) Personal Prevention HSE Leaflet 5/22/2009 348 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    345. 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. 5/22/2009 349 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    346. 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 5/22/2009 350 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    347. 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 5/22/2009 351 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    348. 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). 5/22/2009 352 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    349. Influenza A(H1N1) Personal Prevention From Spreading the Virus Hygiene • Alcohol-based disposable hand wipes or gel sanitizers may be used 5/22/2009 353 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    350. Influenza A(H1N1) Personal Prevention From Spreading the Virus Hygiene • Cover your mouth and nose with a tissue when coughing or sneezing • No Tissue 5/22/2009 354 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    351. 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! 5/22/2009 355 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    352. Influenza A(H1N1) Personal Prevention From Spreading the Virus Hygiene • Respiratory Etiquette/ Cough Etiquette Breaking the Chain of Infection 5/22/2009 356
    353. 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 5/22/2009 357 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    354. European Union Hand Hygiene Campaigns 5/22/2009 358 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    355. Internet Address of National Campaigns 5/22/2009 359 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    356. 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
    357. Influenza A (H1N1) UK Mass Media Video Swine Flu Information - NHS 24 http://www.nhs24.com/content/default.asp? page=home_SwineFlu 5/22/2009 361
    358. 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. 5/22/2009 362 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    359. Influenza A(H1N1) Business Continuity • Excellent resource for Business Continuity Planning • Business Continuity Planning Checklist Responding to an Influenza Pandemic available inside! 5/22/2009 363 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    360. 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! 5/22/2009 364
    361. 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 ! 5/22/2009 365
    362. 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” 22/05/2009 366
    363. 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 22/05/2009 367
    364. 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” 22/05/2009 368
    365. 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 22/05/2009 369
    366. 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 5/22/2009 370 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    367. Influenza A(H1N1) Spain's Outbreak Initial Timeline 22/05/2009 371
    368. Case definition and case classification, new influenza A(H1N1) infection, Spain, 25 April-7 May, 2009 22/05/2009 372
    369. 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 22/05/2009 373
    370. 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 22/05/2009 374
    371. 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 22/05/2009 375
    372. Geographical distribution • Geographical distribution of cases of laboratory- confirmed new influenza virus A(H1N1) infection, Spain, as of 11 May 2009 22/05/2009 376
    373. 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 22/05/2009 377
    374. 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 22/05/2009 378
    375. 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 22/05/2009 379
    376. 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. 22/05/2009 380
    377. References Epidemiology of new influenza A(H1N1) in the United Kingdom, April - May 2009 http://www.eurosurveillance.org/View Article.aspx?ArticleId=19213 22/05/2009 381
    378. 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” 22/05/2009 382
    379. 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 22/05/2009 383
    380. Influenza A(H1N1) United Kingdom 5/22/2009 384
    381. 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. 5/22/2009 385
    382. 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 22/05/2009 386
    383. 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) 22/05/2009 387
    384. 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) 22/05/2009 388
    385. 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 22/05/2009 389
    386. 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 22/05/2009 390
    387. 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) 22/05/2009 391
    388. 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). 22/05/2009 392
    389. 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” 22/05/2009 393
    390. Influenza A(H1N1) México 5/22/2009 394
    391. Influenza A(H1N1) México 5/22/2009 395
    392. 2009 Influenza A(H1N1) Outbreak in México (PAHO Epi Alert) Black=Deaths Red=Confirmed Cases 5/22/2009 396 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    393. 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. 5/22/2009 397
    394. Influenza A (H1N1) México Age Specific Attack Rate May 13 5/22/2009 398 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    395. 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 22/05/2009 399
    396. 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 22/05/2009 400
    397. 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 22/05/2009 401
    398. 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) 22/05/2009 402
    399. 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 22/05/2009 403
    400. 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] 22/05/2009 404
    401. 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 22/05/2009 405
    402. 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 22/05/2009 406
    403. 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 22/05/2009 407
    404. Pandemic System Model Coming soon! Performance Improvement in Preparing for Pandemics 5/22/2009 408
    405. References 22/05/2009 409
    406. Swine-Origin Influenza Virus (S-OIV ) 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 • Links • HPA, UK • • WHO Irish • Health Service Executive (HSE) • Department of Health and Children • Department of Foreign Affairs • Department of Agriculture • Irish College of General Practitioners (ICGP) 5/22/2009 410 Medical Management of Biological Casualties Revised and Modified 29/04/2009
    407. 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. 22/05/2009 411
    408. The End of Influenza A (H1N1) By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” 5/22/2009 412 Medical Management of Biological Casualties Revised and Modified 29/04/2009

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