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Influenza A (H1 N1) Master Update Ver 30.3 July 3 2009

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  • + thokinwat thokinwat 1 week ago
    best
  • + apeotitusmanoni apeotitusmanoni 1 month ago
    thank for such alot of eye opening information
  • + Annie9321 Annie9321 1 month ago
    This is terrific info, in a format that really works. May I receive a copy to assist in educating our employees? Much thanks for sharing.
  • + indolesman indolesman 2 months ago
    Thanks for the video, I have favourite it, please send it to http://www.kamagrauk.co.uk
  • + mdecr Marcelo Ramos 2 months ago
    May I have a copy, I am a teacher at the University of Campinas, Brazil. Real nice presentation, will save me time to teach this to my students.
    thanx
  • + guestda26803 guestda26803 3 months ago

    test
  • + LabTestGuru Any Lab Test Now - Plano, Texas 3 months ago
    Great presentation. Must have taken forever to compile. My only concern with the H1N1 is that people will not get the regular flu vaccine and we notice more deaths this fall due to low income and elderly not getting the non-h1n1 flu vaccine.
  • + Bilogical Michael Fraser 3 months ago
    new mitigation update for download!
    thanks for the comments
  • + Francisco.Batista Francisco.Batista 3 months ago
    EXCELENT! May I have a copy? I´d like to use with my employees too.
    francisco.batista.rs@gmail.com
  • + dr.juan dr.juan 3 months ago
    Thank you for share. may I receive a copy?

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Influenza A (H1 N1) Master Update Ver 30.3 July 3 2009 - Presentation Transcript

  1. Influenza A (H1N1)qr (Quadruple Reassortment) “The Emerging Pandemic!” By Michael Fraser RN Of Irish First Point Responder Institute “Republic of Ireland” Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  2. Mission of Presentation “To provide the people of Ireland a universal teaching aid to respond to Influenza A (H1N1).” Medical Management of Biological Casualties 7/4/2009 2 Revised and Modified 25/05/2009
  3. Virus Names Associated Pandemic Influenza 2009 • Swine-Origin Influenza Virus (S-OIV) (US) • North-American Influenza (Mexico) • Swine Influenza A(H1N1) • A(H1N1) • Novel Influenza A(H1N1) • Nouvelle Grippe A (H1N1) Spanish • A(H1N1)-SOIV • Influenza A(H1N1)swl (Swine like) (US/CDC) • Influenza A (H1N1)v (Virus) May 3 2009 (ECDC) • Influenza A(H1N1) May 8 2009 (WHO) • Influenza A(H1N1) 09 (AUS) • Influenza A(Pandemic H1N1) virus (WHO/NRVESS) • Influenza A(H1N1)qr (Quadruple Reassortment) – May 29 2009-new name suggested by author! • Still mild confusion on Seasonal (H1N1) vs. Novel Influenza (H1N1) June 2009! Virus will be referred to at different points of Presentation! Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  4. Influenza A(H1N1) Objectives • Identify Who pandemic Phases In relation to too European and Irish Alert Levels • Identify Global Health Regulation for Ireland • Biological triage • Identify global and Irish Influenza Surveillance Systems • Influenza A(H1N1) Worldwide Epidemiology • Surveillance processes and systems • Zoonosis of Swine Influenza Virus (SIV), Signs and Symptom Post- mortem findings, Past Outbreaks and differences of SIV and S- OIV/Novel Influenza Virus • Influenza virus antigenic shift and drift • Categorizing Influenza Virus “Viral Nomenclature • Emergence of Some Influenza Viruses in Humans • Swine Influenza (SIV) Reassortment • Swine Influenza Host Range • Pathogenesis of Triple Reassortment and Quadruple reassortmentCasualties Medical Management of Biological 7/4/2009 Revised and Modified 25/05/2009
  5. Influenza A(H1N1) Objectives Continued • Epidemiological Risk Factors Influenza A(H1N1) • Specific Investigational Triggers Influenza A(H1N1) • Irish resources for Influenza A(H1N1) • Influenza A(H1N1) Transmission, Personal Prevention, Human Signs and Symptoms, High Risk Groups, Diagnosis, Case Definitions • Recommended Initial PPE Protection Levels for all levels of response • Handling Human Remains (HHR) • Reporting Suspect Influenza A (H1N1) Virus Infection Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  6. Influenza A(H1N1) Objectives Continued • Influenza A(H1N1) Antivirals Treatment Schedule,Adverse Effects • Special Considerations for Children • Pregnancy • Typical Antiviral Clinic Process Flow Chart • Post Exposure Prophylaxis (PEP) Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  7. Influenza A(H1N1) Objectives Continued • Influenza A(H1N1) Irelands Laboratories Overview, Specimen Collection, Laboratory Precautions, • Shipping Infectious Substances • Infection Control In Health Care Setting • Environmental Waste • Vaccine • Antiviral treatments and considerations ,(PIEG) On Antivirals Algorithms • Bioethics • Quarantine • Infection Prevention and Control Guidance for the Ambulance Service • Influenza A(H1N1) Business Continuity with checklist • Case Studies Spain. England, and Mexico “Estimated Ratio” • IFPRI Pandemic Theory (“Pandemic Systems Model”) – Under development • Closing Discussion 7/4/2009 Medical Management of Biological Casualties Revised and Modified 25/05/2009
  8. World Health Organization (WHO) Pandemic Phase Advisories 11 June 2009 Influenza pandemic alert raised to Phase 6 The Director-General of WHO Dr Margarat Chan has On April 27 2009 The World therefore decided to raise the level of influenza On April 29, the Emergency Health Organisation raised its pandemic alert from phase 5 to phase 6. Committee had their third pandemic alert level to 4, verifying human-to-human "The world is now at the start of the meeting, and decided to raise the pandemic alert level to five, swine flu, hours after the first British cases of the disease were 2009 influenza pandemic," the second-highest level, confirmed. April 28 2009 indicating that a pandemic is WHO flu expert Keiji Fukuda "imminent," and that human- pointed out that it is too late to to-human transmission cases contain the swine flu have been recorded in multiple "Containment is not a feasible countries. operation. Countries should now focus on mitigating the effect of the virus,” 3 to 4 Phase 4 to 5 Phase April 27 2009 April 29 2009 Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009 Avian Influenza H5N1 Phase 1-3
  9. World Health Organization (WHO) Pandemic Phase Advisories Phase 6 Rationale • World Health Organization has raise the H1N1 flu virus pandemic alert level from Phase Five to Phase Six. In doing so the WHO underscored: • The decision is based on the spread of the virus and not the severity of illness it causes. The virus has caused sustained community level outbreaks in more than three countries across two WHO regions • In general, the H1N1 flu virus continues to cause moderate illness globally with most people affected recovering at home without medical treatment. • For instance in Ireland most infections to date have been mild! • Future severity assessments would reflect one or a combination of the following factors: – changes in the virus – underlying vulnerabilities – limitations in health system capacities 7/4/2009 9
  10. International Health Regulations • Following 2003 SARS, the World Health Organization (WHO) revised the International Health Regulations • IHR contains an operational definition of a “public health emergency of international concern” that triggers increased control responsibilities for nations • 194 countries worldwide Medical Management of Biological Casualties 7/4/2009 10 Revised and Modified 25/05/2009
  11. International Health Regulations (IHR) 2005 • New influenza virus sub‐types and clusters of unknown and unusual disease are notifiable to WHO in accordance with the Annex 2 decision instrument of the IHR (2005) Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  12. Global Pandemic Curve First confirmed Case in Spain was the catalyst in WHO activating Influenza Pandemic Phase 5 Australia Phase 6 Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  13. MADRID -- Spain Became the First Country in Europe Influenza A (H1N1) • MADRID --In Catalonia Spain, officials confirmed the first European case of an infection in a person who had not (recently) travelled to Mexico, in a person whose girlfriend had done so, the second WHO region to experience transmission of this strain of H1N1 • As of June 15 2009 Europe reported its first death in June 14 2009 First and second death Scotland in a 38 year old pregnant women in Europe! – Had premature baby boy in June but the baby has died however he tested negative for Influenza A(H1N1) – 2nd death- They were an unnamed 73-year-who died on Saturday night after 15 days in intensive care June 27 2009 • As of June 27 2009, Europe has reported it 3rd death Third death in Europe! – Girl aged 9 dies in Birmingham hospital • As of June 30 2009, Europe has reported its 3rd Death June 30 2009 • A 19-year-old girl died of of the H1N1 influenza Fourth death in Europe! Tuesday in Madrid – The girl, of North African origin, who also suffered from asthma, was 28 weeks pregnant. Doctors performed a caesarean section 7/4/2009 on her on Monday due to the seriousness of her condition 13
  14. Who Pandemic Phases and Recommended Actions Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  15. Who Pandemic Phases and Irelands Recommended Actions Medical Management of Biological Casualties 7/4/2009 Revised and Modified 25/05/2009
  16. Bioevent Disasters SEIRV Triage Model Categories • Susceptible • Exposed • Infectious • Removed • Vaccinated Medical Management of Biological Casualties 7/4/2009 16 Revised and Modified 25/05/2009
  17. “Biological Triage” Mitigation High Transmissibility • Influenza Mitigation: Susceptible • Identify & treat primary infections Exposed Infectious • Preventative Goal: • Prevent and delay secondary Removed infections Vaccinated  Prevent and delay clustered in-country transmissions  Keeping in mind the severity of the influenza virus country by New ECDC “containment vs delayed” article) country (High Transmissibility = Low or no containment therefore “delay” transmissions in WHO phase 4-6 ) According to WHO: Influenza A(H1N1) Secondary attack rate of 22-33% 7/4/2009 compared to 5-15% for seasonal influenza Medical Management of Biological Casualties
  18. EU Alert Levels in WHO Phase 6 EU alert level Description EU Alert Level One No confirmed human cases infected with the pandemic virus in any EU Member State EU Alert Level Two One or more confirmed human case(s) infected with the pandemic virus in any EU Member State EU Alert Level Three A confirmed outbreak (transmission) with the pandemic virus in any EU Member State EU Alert Level Four Widespread transmission in EU Member States Medical Management of Biological Casualties 7/4/2009 Revised and Modified 29/04/2009
  19. Influenza A(H1N1) Epidemiology 7/4/2009 19 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  20. Influenza A(H1N1) Health Service Executive • The Health Service Executive is advising anyone from Ireland who has recently returned from Mexico, California or Texas (within seven days), and develops an influenza-like illness, to telephone their family doctor for advice. • May 21 2009 Dr. Kevin Kelleher, head of Health Protection with the HSE said: • ‘Ireland has been preparing for situations like this for several years, and we have robust and detailed plans in place to respond. The H1N1 swine flu virus is sensitive to the antiviral drugs of which we have in place ample stockpiles for Ireland. • We are and will continue to closely follow the emerging situation. ' 7/4/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  21. Irish Alert Levels In WHO Phase 6 Irish Alert Level Description Irish Alert Level 1 Cases only outside Ireland (in a country or countries with or without extensive Irish travel/trade links Irish Alert Level 2 New virus isolated in Ireland June 11 2009 Irish Alert Level 3 Outbreak(s) in Ireland Irish Alert Level 4 Widespread activity in Ireland First Confirmed case In Dublin Ireland April 3 2009 Medical Management of Biological Casualties 7/4/2009 Revised and Modified 29/04/2009
  22. 2009 Influenza A(H1N1) Outbreak In Ireland as of July ,3, 2009 Country Confirmed cases of In-country Deaths human swine Transmission influenza Ireland 63 4 0 (April 30 2009 1stcase) NI 34 NA 0 (May 1 2009 1st case) Influenza A(H1N1) Infection July ,3, 2009 Weekly Surveillance Report HSE Report As of July, 1, 2009 June 11 2009 Dr Tony Holohan, Chief Medical Officer of the Department of Health & Children said : • “notwithstanding the increase in level by the WHO, people in Ireland can be reassured that there is no increase in the risk to them. Irish cases are low in number and are regarded as mild. The Department and the HSE are satisfied that the actions we are taking are proportionate in the current circumstances but contingency plans are in place, if required. However, again, we would like to remind people to help themselves avoid infection through personal health protection measures, including washing their hands thoroughly and sneezing into a tissue and disposing of it immediately’” 7/4/2009 22 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  23. 2009 Influenza A(H1N1) Outbreak In Ireland By Age, Gender and Transmission Mode Update as of July ,1 ,2009 from Weekly Surveillance Report Age Male Female Total Antiviral In-Country Out-of- Homecare Hospitalizations Treatment Transmission Country Transmission 0-4 2 1 3 3 3 2 3 0 5-9 1 1 2 2 0 0 2 0 10-14 0 1 1 2 1 2 1 0 20-24 1 4 5 5 0 13 5 0 25-34 7 10 17 17 0 2 17 0 35-44 3 2 5 5 0 2 5 0 45 -54 2 1 3 3 0 1 3 0 55-65 1 1 2 2 0 1 2 0 65+ 1 1 2 2 2 Unknown NA NA 1 NA NA NA NA NA School 28 28 0 Outbreak Total 18 22 41 79(needs update) 4 22 (needs update) 79 1 7/4/2009 23
  24. WHO Influenza A(H1N1) “Confirmed Cases and Deaths ”2009 • As of 17:00 GMT, July , 3, 2009, 102 countries have officially reported 89,921 cases of influenza A(H1N1) infection, including 382 deaths. 7/4/2009 24
  25. Influenza A(H1N1) The Top Ten List as of July, 3, 2009 Top 10 Confirmed Circulating Avian Countries with Cases of Influenza H5N1 in Influenza A(H1N1) Influenza Humans A(H1N1) 1. United States 33,902 2. Mexico 10,262 3. Canada 8,883 4. England 7,447 5. Chile 7,376 6. Australia 4,568 7. Philippines 1,709 8. Argentina 1,587 9. Japan 1,502 10. Thailand 1,414 Yes 71. Ireland 63 7/4/2009 25
  26. ECDC Reported cumulative number of confirmed cases and of in-country transmission of influenza A(H1N1)v as of 3, July, 2009, 17:00 hours (CEST) in the EU and EFTA countries Country Confirmed cases Cumulative number Cumulative number Deaths among reported in the last of confirmed cases of in-country confirmed cases 24h transmission Austria 1 16 -0 Belgium 2 49 4 Bulgaria - 10 - Cyprus 25 83 - Czech Republic - 15 - Denmark 6 63 4 Estonia - 13 2 Finland - 43 - France 7 318 19 Hot Spots in Red Germany 35 505 107 Greece - 109 - Hungary 1 12 1 Iceland - 4 1 Ireland 9 63 4 Italy - 130 4 Latvia - 1 - Luxembourg 2 6 - Netherlands 1 135 21 Norway - 41 1 Poland 1 20 1 Portugal 5 28 - Romania 5 41 6 Slovakia - 18 1 Spain 20 776 127 1 Sweden 2 76 10 Switzerland 7 72 - United 518 7,447 380 3 Kingdom 7/4/2009 26 Total 650 10,103 655 4
  27. Influenza A(H1N1) Outside (EU) and EFTA ECDC Tables July, 3, 2009 7/4/2009 27
  28. Distribution of confirmed cases of influenza A(H1N1) virus infection by date of reporting, EU and EFTA countries, 27, April, to July, 3, 2009 • The values of the columns represent the day of notification (from 00:00 till 24:00). The sharp increase observed in the reports received on June 30 represents batch reporting from the UK over the past 3 days. 7/4/2009 28
  29. ECDC June 3rd 2009 Cumulative Epidemic Curve: ECDC SITUATION REPORT Influenza A(H1N1) infection Update 03 June 2009, 17:00 hours CEST “The trend analysis using a semi-logarithmic scale, shows a rapid increase in the number of cases in the Americas (AMRO) as well as in the European region (EURO) since end of April 2009. The increase in the Western Pacific WHO Region (WPRO) was initially less significant but showed a sharp increase in the third week of May, in relation with cases reported from Japan. The trend in the WPRO Region suggests faster increase in the reported cases in the past 8 days, when compared with the AMRO and EURO Regions, due to the rapid spread of the infection in Australia. The South East Asian WHO Region (SEARO) reported the first cases three weeks after the alert of WHO on 25 April and the Eastern Mediterranean Region (EMRO, which is including some countries of the African continent) four weeks after the 25 April. The trend in the number of reported cases from SEARO seems to be similar to the one from WPRO during the last week.” Wikipedia: A semi- logarithmic chart of laboratory-confirmed A(H1N1) influenza cases by date according to WHO reports Medical Management of Biological Casualties 7/4/2009 29 Revised and Modified 29/04/2009
  30. Influenza A(H1N1) Americas Outbreak 2009 • As of 3 July 2009, a total of 65,925 confirmed cases of the pandemic H1N1 2009, including 387 deaths, have been notified in 29 countries of the Americas July , 3, 2009 PAHO Reporting MWF Medical Management of Biological Casualties 7/4/2009 30 Revised and Modified 25/05/2009
  31. 2009 Influenza A(H1N1) Outbreak In The United States The date of the onset of symptoms of the first confirmed case was 28 March 2009 in the United States. U.S. Human Cases of H1N1 Flu Infection July ,3, 2009, 11:00 AM ET 33,902 confirmed cases 170 Deaths US Not reporting all cases! 2009 US Swine Flu Summary: First Death Inside the US April 27, 2009 First Death of US Citizen May 5, 2009 Number of People Hospitalized 770 (as of June 4) Fatalities 87 (as of June 19) CDC is reporting every Fridays Medical Management of Biological Casualties 7/4/2009 31 Revised and Modified 25/05/2009
  32. 2009 Influenza A(H1N1) Outbreak In The United States • Influenza Viruses Isolated by WHO/NREVSS Collaborating Laboratories 2008 - 2009 Season Week ending June 13 2009 Week 25 7/4/2009 32
  33. Influenza A(H1N1) México Outbreak 2009 As of July, 3, 2009 (PAHO) Aguascalientes - 94 Hidalgo - 242 Morelos - 95 Querétaro - 141 Baja California - 79 Jalisco - 333 Nayarit - 73 Quintana Roo - 57 Baja California Sur - 8 San Luis Potosí - 372 As of July ,1 Campeche- 38 2009 Sinaloa - 8 Laboratory Chiapas - 55 confirmed Sonora - 66 cases 10,262 Chihuahua - 58 Tabasco - 246 Deaths - 119 Tamaulipas - 68 Coahuila - 2 Tlaxcala - 69 Colima - 26 Veracruz - 321 Durango- 19 Federal District -1824 Nuevo León- 64 Yucatan - 97 Guanajuato - 79 Mexico State - 280 Oaxaca - 79 Guerrero - 214 Zacatecas - 237 Michoacán - 156 Puebla - 59 7/4/2009 33 Individual regions #’s are days behind
  34. Influenza A(H1N1) Outbreak in Canada 2009 • As of July, 3, 2009, a total of 8,883 laboratory-confirmed cases of H1N1 flu virus have been reported in all provinces and territories in Canada and with 29 deaths Yukon - 1 Nunavut - 340 North West Territories - 9 Newfoundland - 35 British Columbia - 298 Prince Edward Island - 5 Alberta- 1071 Death - 1 Nova Scotia - 171 Saskatchewan – 774 Deaths - 2 New Brunswick - 10 Manitoba - 685 Deaths - 4 Ontario – 3,464 Quebec- 2,020 PHAC is reporting Deaths - 10 Deaths - 12 every MWF Medical Management of Biological Casualties 7/4/2009 34 Revised and Modified 25/05/2009
  35. 2009 Influenza A(H1N1) Outbreak in Canada 423 hospitalizationsas June 17 2009have been Juneepidemic curve, is up to date as Canada of and 19 deaths The following graph, also known as 423 hospitalizations and 19deaths have been 423 hospitalizations and 19and 13 deaths an 8 2009 deaths have been of June 8th, 2009. Theofgraph also 394 hospitalizations reported among laboratory-confirmed cases illustrates the coursegraph, The following the reportedof July,3,laboratory-confirmed cases As among 2009 reported among laboratory-confirmed cases current H1N1 flu virus outbreak in known as an epidemic Canada. It shows either the date 663 hospitalizations when symptoms of H1N1 fluas of curve, is up to date virus began or, 1,this date The not June if 2009. was graph and 29 deaths 538 hospitalizations and 25 illustrates the course of available, the date when a specimen was collected, for each the current H1N1 flu virus of the laboratory-confirmed cases. deaths have been reported outbreak in Canada. It shows the date when among laboratory- symptoms of H1N1 flu virus began for each of the confirmed cases laboratory-confirmed cases. Medical Management of Biological Casualties 7/4/2009 35 Revised and Modified 25/05/2009
  36. Influenza A(H1N1) United Kingdom Outbreak 2009 7,447 Confirmed Cases as and 4 death of July, 3, 2009 New reporting system in UK as of Scotland- 1217 July, 2,2009 Death - 2 Northeast - 47 Northern Ireland - 34 Yorkshire and Humberside - 143 North West - 97 East Midlands - 147 East of England - 411 Wales - 34 London – 1,939 West Midlands – 2,582 Death - 1 Death - 1 South West - 198 South East - 598 7/4/2009 36
  37. Influenza A (H1N1) Australia Outbreak 2009 4,958 Laboratory confirmed cases and 10 death as of July, 3, 2009 Northern Territory - 270 Queensland - 746 Western Australia – 249 Death - 1 New South Wales – 1,157 Deaths - 1 First case: 9 May 2009 First death : Australian Capital Territory - 206 South Australia – 502 Death - 1 Victoria – 1,691 Tasmania - 92 Death - 7 7/4/2009 Reporting daily 37
  38. Influenza A (H1N1) Japan Outbreak 2009 • A of July, 3, 2009 Japan has reported 1,502 confirmed cases of Influenza A(H1N1) May 21 2009 Japan notified 67 new confirmed cases in past 24 hours, representing a 32% increase in cases according to ECDC (n-532) 7/4/2009 38
  39. Geographical distribution of Influenza A (H1N1) cases of laboratory-confirmed new influenza virus A(H1N1) infection, Spain Spain Outbreak 2009 As of July, 3, 2009, a total of 776 laboratory-confirmed cases and 127 In- La Rioja country transmissions of Influenza A(H1N1)v flu virus have been reported Asturias Cantabria Pais Vasco Galicia Navarre Castile and Leon Aragon Community of Madrid Catalonia Extremadura Castile-La Manchu Balearic islands Still updating regions on next report Valencia Community Region of Murcia Canary Islanders Melilla Andalusia 7/4/2009 39
  40. Estimates of the Basic Reproductive Rate (Ro) • There have already been several estimates of the basic reproductive rate (Ro), which all lie between 1 and 2; the range 1.4 to 1.9 being most probable. • The basic reproduction number is the mean number of secondary cases a typical single infected case will cause in a population with no immunity to the disease in the absence of interventions to control the infection. • It is often denoted R0. When R0 < 1 the infection will die out in the long run (provided infection rates are constant); but if R0 > 1 the infection will be able to spread in a population • See case study “How to they Do it” Influenza A (H1N1) Estimates of the Basic Reproductive Rate in Mexico” Medical Management of Biological Casualties 7/4/2009 40 Revised and Modified 25/05/2009
  41. Zoonosis Swine Influenza Virus (SIV) “Zoonotic diseases are those diseases transmitted between animals and people and thus compromising public health as well as endangering livelihoods by affecting their livestock.” 7/4/2009 41
  42. Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS) • The Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS) is a joint FAO, World Organisation for Animal Health (OIE) and WHO initiative to improve the early warning capacity to animal disease threats for the benefit of the international community • Certain animal health events with potential public health implications are included in the scope of the International Health Regulations (2005) (IHR(2005)) • Intersectoral collaboration, including between the veterinary, food safety and public health sectors is needed to effectively address the prevention of zoonotic diseases 7/4/2009 42
  43. (GLEWS) Zoonotic and Non-Zoonotic Diseases • Zoonotic • Non zoonotic • Anthrax • African Swine Fever (ASF) • Bovine Spongiform Encephalopathy (BSE) • Classical Swine Fever (CSF) • Brucellosis (B. melitensis) • Contagious Bovine Pleuropneumonia (CBPP)* • Crimean Congo Hemorrhagic Fever • Foot and Mouth Disease (FMD)* • Ebola Virus • Peste des Petits Ruminants (PPR) • Foodborne diseases • Rinderpest – Stomatitis/Enteritis • Highly Pathogenic Avian Influenza (HPAI) • Japanese Encephalitis • Marburg Hemorrhagic Fever • New World Screwworm • Nipah Virus • Old World Screwworm WHO States : • Q Fever GLEWS is a joint system that builds on the added value of • Rabies combining and coordinating the alert mechanisms of FAO, • Rift Valley Fever* (RVF) OIE and WHO for the international community and stakeholders to assist in prediction, prevention and control of • Sheep Pox*/Goat Pox animal disease threats, including zoonoses, through sharing • Tularemia of information, epidemiological analysis and contribute to • Venezuelan Equine Encephalomyelitis joint field missions to assess and control the outbreak. • West Nile Virus 7/4/2009 43
  44. Irelands Governmental Lead Agencies, Groups and Committees Emergency/Incident Type Lead Lead Response Principal Other Potential Remarks Government Agency as per Support Support Roles Department Framework Role Animal Infectious Diseases DAFF DF (DOD) Local Authorities HSE role relates Diseases (Animal) HSE (DEHLG) to zoonotic AGS (DJELR) diseases; DFA infectious animal CD (DOD) diseases with a DTRANS human health (IRCG/MSO/Shipping) dimension DAST • Strategic Emergency Planning Guidance – Lead, Principal and Other Support Roles: • DAFF (Department of Agriculture Fisheries & Food) • DEHLG (Department of the Environment Heritage & Local Government) • DOD (Department of Defence) • HSE (Health Service Executive) • DTRANS (Department of Transport) • IRCG (Irish Coast Guard) • MSO (Marine Service Office)DAST (Department of Arts, Sport & Tourism) 7/4/2009 44
  45. 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 (See Genetic Components of Triple-Reassortant Swine Influenza A (H1) • 2009 Novel H1N1 Strain influenza A virus Pig to Human/Human to Human transmission • 2009- Novel H1N1 Strain influenza virus – Human-to-Pig Transmission of the Novel H1N1 Strain influenza virus in a swine herd 7/4/2009 45 in Alberta Medical Management of Biological Casualties Revised and Modified 29/04/2009
  46. Swine Influenza A (Hsw1N1) Past Outbreak in United States • 1976 U.S. outbreak • In early 1976, the novel A/New Jersey/76 (Hsw1N1) influenza virus caused severe respiratory illness in 13 soldiers with 1 death at Fort Dix, New Jersey President Ford A/Victoria/75 (H3N2) spread simultaneously, also receives swine caused illness, and persisted until March flu vaccination • 230 soldiers were infected with the A/New Jersey virus • Vaccine Controversy; • 20-40 million vaccinated in US – Overall, there were about 500 cases of Guillain-Barré syndrome (GBS), resulting in death from severe pulmonary complications for 25 people, according to Dr. P. Haber – “Nachamkin et al (2008) found that inoculation of the 1976 swine flu vaccine, as well as the 1991-1992 and 2004-2005 influenza vaccines, Video from 1976 into mice prompted production of antibodies to antiganglioside (anti- Swine Influenza GM1), which are associated with the development of GBS. They proposed that further research regarding influenza vaccine Outbreak components is warranted to determine how these components elicit 7/4/2009 antiganglioside effects” (Source E-medicne) 46 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  47. Genetic Components of Triple-Reassortant Swine Influenza A (H1) • Triple-Reassortant Swine Influenza A (H1) Viruses Isolated from 11 Patients between December 2005 and February 2009 in the United States Triple-Reassortment Swine H1N1 Triple-Reassorment Swine Influenza Virus H1N2 Influenza Virus (Pts 1-6 and 8-11) (Pt 7 2009) Note Pt 8 visited a Pig Fair (genetic ressortment H1N2) PB2 PB2 PB1 PB1 PA PA HA HA NP NP NA NA M M NS NS http://content.nejm. org/cgi/reprint/NEJM oa0903812.pdf Triple -Reassortment Classical swine, North American Lineage Avian, North American Lineage Human (Seasonal )H3N2 7/4/2009 Human (Seasonal )H1N1 47
  48. 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 • Existence of H1N2 in Irish pigs has so far been scantly detected by % of seropositive sows (HI), 2002-03 *SIV subtype isolated in Ireland revealed the following: – Ireland – H1N1: 17.8* The novel A/H1N1 Influenza virus at the interface between humans and animals Swine influenza virus. Colorized – transmission electron micrograph H3N2: 4.2* What needs to be done in Europe? Brussels, 9 June 2009 (37,800X) of the A/New Jersey/76 (Hsw1N1) virus under plate magnification. Image taken during the virus' first – H1N2: 0.6 developmental passage through a chicken egg. Courtesy of the CDC/Dr. E. Palmer; R.E. Bates. 7/4/2009 48
  49. 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 7/4/2009 49 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  50. Swine Influenza (SIV) Signs and Symptoms In Swine • Symptoms of infected pigs include: – Fever (102-106°F) – Depression – Coughing (barking) – Sneezing – Difficulty breathing – Red or inflamed eyes – Lack of appetite – Discharge from the nose or eyes – Reduced fertility or abortion (boars and sows) – Mortality up to 15% Medical Management of Biological Casualties 7/4/2009 Revised and Modified 26/04/2005
  51. 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. 7/4/2009 51 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  52. 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. 7/4/2009 52
  53. 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 “An overview on swine influenza” ptt Pictures Normal Normal Normal Lungs Infiltration of Desquamation of Abnormal Lungs neutrophils epithelial cells Normal Lungs 7/4/2009 53 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  54. Swine Influenza (SIV) Examples of Vaccines For Porcine! • Schering-Plough Animal Health Corporation: MaxiVac Excells • Novartis : PneumoSTAR® SIV Swine Vaccine • Pfizer Animal Health: FluSure vaccine 7/4/2009 54
  55. Swine Influenza (SIV) European Vaccine List Name Virus strains Type Antigenic dose (company) Gripovac A/New Jersey/8/76 (H1N1) split H1N1 : ≥ 1,7 HI units (Merial) A/Port Chalmers/1/73 (H3N2) H3N2 : ≥ 2,2 HI units Suvaxyn Flu A/sw/Netherlands/25/80 (H1N1) whole virus H1N1 : 4 μg HA (Fort Dodge) A/Port Chalmers/1/73 (H3N2) H3N2 : 4 μg HA Gripork A/sw/Ollost/84 (H1N1) whole virus H1N1 : 3 x 107 EID50 H3N2 : 2,5 x 107 EID50 (Hipra) A/Port Chalmers/1/73 (H3N2) Respiporc Flu A/sw/Belgium/230/92 (H1N1) whole virus H1N1 : ≥ 256 HA units H3N2 : ≥ 256 HA units (IDT) A/sw/Belgium/220/92 (H3N2) Respiporc Flu3 A/sw/Haselunne/2617/03 (H1N1) whole virus H1N1 : ≥107 TCID50 A/sw/Bakum/1769/03 (H3N2) (IDT) A/sw/Bakum/1832/00 (H1N2) H3N2 : ≥107 TCID50 H1N2 : ≥107 TCID50 Slide List From Prof. Kristien Van Reeth Laboratory of Virology, Faculty of Veterinary Medicine “An overview on swine influenza” ptt 7/4/2009 55
  56. 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). 7/4/2009 56 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  57. 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 7/4/2009 circumstances.! 57 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  58. Influenza A (H1N1) Prevention Department of Agriculture and Food and Fisheries (DAFF) • Agriculture and Food and fisheries (DAFF) will institute biosecurity measures • These control measures focus on animal health issues and aim to prevent any further spread of the disease among animals 7/4/2009 58
  59. 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 7/4/2009 59 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  60. Biosecurity On Pig Farms $ Profits $ QUALITY ASSURANCE REDUCED MEDICATION REDUCED MORTALITY IMPROVED REDUCED ZOONOSIS REDUCED DISEASE PERFORMANCE BIOSECURTY 7/4/2009 60
  61. Swine Influenza Transmission • Swine diseases can be spread in a number of ways, including: • Through diseased swine or healthy swine incubating disease • Through animals other than swine (farm animals, pets, wild birds and other wildlife, vermin and insects) • On the clothing and shoes of visitors and employees moving from farm-to-farm • In contaminated feed, water, bedding and soil • From the carcasses of dead animals • On contaminated farm equipment and vehicles • In airborne particles and dust blown by the wind An Egyptian policeman wears a mask as he stands guard in front of a pick up truck full of pigs at the main slaughterhouse in Cairo April 30, 2009 7/4/2009 61 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  62. 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 7/4/2009 62 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  63. 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) 7/4/2009 63 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  64. 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 7/4/2009 64 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  65. 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 7/4/2009 65 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  66. 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 7/4/2009 66 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  67. 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. 7/4/2009 67 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  68. 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. 7/4/2009 68 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  69. 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 7/4/2009 69 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  70. A General Biosecurity Checklist For Swine 7/4/2009 70 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  71. Veterinary Surveillance • This disease is a scheduled and notifiable disease in Ireland (Class B) • Porcine surveillance: The Department of Agriculture and Food and Fisheries (DAFF) (in collaboration with the porcine industry undertakes active and passive surveillance for porcine • Notification procedures is agreed between the department of Agriculture and Food and Fisheries the HSE in the event of Influenza being identified or highly suspected from porcine 7/4/2009 71
  72. Swine Influenza (SIV) Pharmacovigilance for Veterinarians • EU Veterinary Suspected Adverse Reaction form for Veterinary and Health Professionals 7/4/2009 72
  73. 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 7/4/2009 73 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  74. 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 7/4/2009 74 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  75. Swine Influenza (SIV) Personnel Protection • On arrival at a site, personnel should: • Disinfect footwear in foot-bath • Put on washable or disposable protective clothing (footwear and overalls) • Wash hands • Before departure personnel should: • Disinfect footwear and protective clothing (or leave on site if disposable) • Wash hands • Contacts who work on pig farms should remain off work for 7 days as soon as diagnosis is suspected! 7/4/2009 75
  76. Veterinarians Donning and Doffing PPE 7/4/2009 76 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  77. Veterinarians Donning and Doffing PPE (HPSC Resource) 7/4/2009 77
  78. Department of Agriculture Local District Veterinary Offices (DVO) COUNTY ADDRESS TELEPHONE Carlow Athy Road, Carlow 059 9170022 Cavan Farnham St., Cavan 049 4368200 Clare Government Offices, Kilrush Road, Ennis, Co. Clare 065 6866042 Cork North Hibernian House, 80A South Mall, Cork 01 4149900 Cork Central Hibernian House, 80A South Mall, Cork 01 4149900 Cork West Darrara, Clonakilty Co. Cork 023 36200 Donegal Meeting House St, Raphoe, Co. Donegal 074 9145298 Dublin/ St John’s House, High St, Tallaght, Co. Dublin 01 4149900 Wicklow East Galway Dockgate Building, Merchants Rd., Galway 091 507600 Kerry Spa Road, Tralee, Co. Kerry 066 7145052 Kildare/ Poplar House, Poplar Square, Naas, Co. Kildare 045 873035 Wicklow West Kilkenny Hebron Road, Kilkenny 056 7772400 Laois Abbeyleix Road, PortLaoise, Co. Laois 057 8674400 Leitrim Cranmore Road, Sligo 071 9682000 Limerick Houston Hall, Ballycummin Avenue, 061 500900 Raheen Industrial Estate, Raheen, Co. Limerick Longford Ballinalee Road, Longford 043 50020 Louth North Quay, Drogheda, Co. Louth 041 9838933 Mayo Michael Davitt House, Castlebar, Co Mayo 094 9035300 Meath Athlumney, Kilcairn, Navan, Co Meath 046 9082900 Monaghan Main Street, Ballybay, Co. Monaghan 042 9748800 Offaly Clonminch, Tullamore, Co. Offaly 057 9346037 Roscommon Convent Road, Roscommon 090 6630100 Sligo Cranmore Road, Sligo 071 9142023 Tipperary North St Conlon’s Road, Nenagh, Co. Tipperary 067 50014 Tipperary South Government Offices, Davis Street, Tipperary 062 80100 Waterford Govt. Offices, The Glen, Co. Waterford 051 301700 Westmeath Bellview, Dublin Road, Mullingar, Co. Westmeath 044 9339300 Wexford Vinegar Hill Lane, Enniscorthy, Co Wexford 053 9242008 7/4/2009 78
  79. EU Possible Quarantine Zones for Infected Influenza A(H1N1) Pig Farms Surveillance zones Surveillance zone (minimum of 10 km radius from the infected premises) Inplace for 30 days Protection Zone Quarantined Pig Farm Restricted zone (minimum of 1 -3 km radius from the infected premises) Controls must be kept in place for at least 21 days Infected Premises Restricted Zone Contaminated Porcine Farm There are no controls on people visiting the Zone Zone A Adapted from EU Quarantine for Avian Flu DAFF:Information on Avian Influenza Control Measures Buffer Zone 7/4/2009 79 Zone B
  80. Risk vs. Benefit Analysis for Decontamination Decontamination is defined as : What are the outcomes of “The process of removing or neutralising a hazard from the environment, property or life form. Its objectives are to prevent further harm and optimise the chance for natural stabilization? full clinical recovery or restoration of the object exposed to the contaminant”. Yes Can I change the outcomes No Do nothing except protect of natural stabilization by exposures! the intervention? What are the cost of the Risk intervention in terms of risk EXCEEDS Do nothing except protect versus benefit? benefit exposures! Benefit “Decontamination Process” EXCEEDS Refers to removal of clothing, neutralization of contaminate, verification of contaminate neutralization, and isolation of all contaminated waste. benefit Engage in intervention operations as long as the benefit exceeds the risk
  81. Quarantine Zones for Infected Influenza A(H1N1) Pig Farms Agriculture and Food (DAF) will institute biosecurity measures . These control measures focus on animal health issues and aim to prevent any further spread of the disease among animals. Pending confirmation of the outbreak, if deemed necessary, all the porcine in the holding may be culled and destroyed. • Zone A : Infected premises • Buffer Zone: Surveillance zone • Risk vs. Benefit Analysis • The Surveillance Zone must stay in place for at least 30 days after the preliminary cleaning and disinfection of the infected • The Protection Zone must stay in place for at least 21 premises has been carried out. days after the preliminary cleaning and disinfection of • Identification of all porcine holdings the infected premises has been carried out, and then the • Prohibition on porcine fairs, markets, shows or other Zone becomes part of the Surveillance Zone gatherings • Killing and disposal of all porcine • Prohibition on the release of porcine, porcine products • Cleaning and disinfection of the premises Checkpoints will be • Destruction or treatment of manure, slurry and bedding put in place to control movements of • Tracing and destruction of porcine meat and carcasses vehicles transporting porcine or porcine produced during risk period related products • Epidemiological investigation and tracing of high-risk into/out of the Zones. contacts • Prohibition on porcine entering or leaving • Controls on people, vehicles and other things entering or leaving • Zone B: Free from Disease • Controls on re-stocking • A Further Restricted Zone may be declared outside the Surveillance Zone if this is considered necessary to control the disease. The measures to be applied in this Zone will be determined depending on a risk assessment 7/4/2009 carried out at the time. 81 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  82. Maximum Decontamination Infected Premises Footbath Layout Level C & D Protection Boot Cover Tape & (PPE) Reduction Outer Glove Removal Glove Wash Segregated Removal (Hypothetical example ) Equipment Stripper/ 6 5 4 3 2 1 Drop Bagger Boot Cover Boot Cover & Removal Glove Rinse Zone A 7 Suit/Safety Boot Wash Canister or 9 8 Suit/Safety Boot Rinse Mask Change and Redress - Boot Cover/ Outer Gloves 10 Safety Boot Removal 11 Splash Suit Removal CONTAMINATION 12 Inner Glove Wash REDUCTION The contamination hazards at hazardous sites Inner Glove Rinse vary greatly, the methods of decontamination ZONE 13 may be adjusted by omitting, adding, or changing the stations identified to reflect the 14 Face Piece Removal contamination hazards at a site! 15 Inner Glove Removal These figures are adapted from the, NIOSH/OSHA/USCG/EPA Occupational Safety and Health Guidance Manual for 16 Inner Clothing Removal Hazardous Waste Site Activities. CONTAMINATION CONTROL LINE SUPPORT Dryer/ 17 18 Field Dresser ZONE Wash
  83. Minimum WIND DIRECTION Decontamination Layout 20 Levels C & D Protection Redress: Boot Covers and Outer Gloves Zone A Decon 20 Solution Tank Change-Over Point (If needed) Infected Premises Remove Water Boots/Gloves and Decon Outer Outer Equipment Garments Garments Drop (For Disposal Remove and Off Site Boot Covers Decontamination) and Outer Gloves Footbath Plastic Sheet Can Zone A (10 gallon) Remove SCBA (If needed) Contamination Reduction Corridor
  84. Basic Personnel Decontamination Vehicle decon “Contamination Reduction Corridor” Setup Vehicle decon Decon Water Solution Inner Washer Rinser Stripper Zone A Equipment glove Drop bagger removal Zone Contaminated Porcine Farm Entry Wash Rinse Can PPE Removal Exit (10 gallon Support Footbath Can Can Can Zone A 10 gallon 10 gallon 10 gallon Footbath if no Decon pools CRC setup Storage and Garbage Plastic (Tarp or Visqueen) Barrier tape and pylons Contamination Reduction Corridor 7/4/2009 84
  85. Vehicle Decontamination • Only allow essential vehicles onto the site. Staff, service vehicles etc. should be parked outside the perimeter. Insist that all vehicles that have to enter the site have been cleaned and disinfected beforehand • Vehicle cleaning and disinfection: • On arrival at the farm, wheels, wheel arches, outside and underside must be disinfected • Before leaving the farm, wheels, wheel arches, outside and underside must be washed and disinfected, ensuring that the World Trade Center/Ground Zero Vehicle Decontamination Wash surfaces are visibly ccontact with lean (must be dry) • Wash and disinfect all surfaces which may have come into contaminated material, such as: – Wheels, wheel arches, outside and underside – Trailer – Equipment (e.g. trolleys, crates, modules, delivery pipes, sheeting, covers) – Wipe areas of the driver’s cab that may have been contaminated, with disinfectant – Drivers should avoid contact with porcine or other porcine on premises outside the infected area for at least 3 days (72 hours) A list of approved disinfectants can be found at: http://www.agriculture.gov.ie 7/4/2009 85
  86. Swine Influenza and Influenza A(H1N1) Virus Swine influenza Influenza A(H1N1) Virus • Swine influenza is • The Influenza Virus contains commonly transmitted genes from pig, bird and through direct contact or human influenza viruses, in close proximity with pigs. a combination that has never been observed before Secondary cases following anywhere in the world human-to-human • 2009 Quadruple transmission have been reassortment of three reported in the past but viruses—a human virus, an they have been very rare avian virus , and 2 porcine • 1998 Triple reassortment viruses 7/4/2009 86 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  87. Influenza A(H1N1) : Microbiology • Influenza A viruses are negative-sense single-stranded RNA viruses • Family: Orthomyxoviridae • Genus: Influenza virus A • Enveloped virions are 80 to 120 nm in diameter, are 200 to 300 nm long, and may be filamentous – They consist of spike-shaped surface proteins, a partially host- derived lipid-rich envelope, and matrix (M) proteins surrounding a helical segmented nucleocapsid (6 to 8 segments) – The virus envelope glycoproteins (hemagglutinin [HA] and neuraminidase [NA]) are distributed evenly over the virion surface, forming characteristic spike-shaped structures; antigenic variations in these proteins form the basis of the classification system for influenza A virus subtypes – There are 16 different HA antigens (H1 to H16) and nine different NA antigens (N1 to N9) • Human disease historically has been caused by three subtypes of HA (H1, H2, and H3) and two subtypes of NA (N1 and N2) • More recently, human disease has been recognized to be caused by additional HA subtypes, including H5, H7, and H9 (all from avian origin) 7/4/2009 87 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  88. 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 7/4/2009 88 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  89. 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 7/4/2009 Medical Management of Biological Casualties
  90. 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 7/4/2009 90
  91. 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) 7/4/2009 91 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  92. 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 7/4/2009 virions 92 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  93. 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 7/4/2009 93 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  94. 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 7/4/2009 94 preparedness in the EU/EEA
  95. 2009 Hybrid “quadruple reassortant” new Timeline of influenza A(H1N1)—a human virus, an avian virus , and 2 porcine viruses Swine No Vaccine Influenza Emergence of Some H1 Quadruple Reassortment Result Influenza Viruses in 2009 Influenza A (H1N1) (Swine Origin) 382 deaths Avian Humans Influenza Pandemic vaccines 1997: In Hong Kong, avian influenza A (H5N1) H5 Total of 262 Deaths 2009 WHO (Asiatic) Russian H9 1997-2009:avian influenza A (H9N2) Influenza H7 1980- 2003: Avian influenza A (H7N7) B Russian Flu (H2N2) 1889/1890 1 million Russian Flu (H2N2 A/USSR/90/77 (H1N1). 1900 Old Hong Kong Influenza H3N8? Asian 2002 Severer Acute Respiratory Virus (SARS-CoV) 774 deaths Influenza Old Hong Kong Regular vaccines Influenza H2 1957 (Asian Flu) 1-4 million deaths H2N2 Spanish “Triple reassortment” Influenza H3 H2 1968 (Hong Kong Flu) 1-4 million deaths H3N2 Aggressive H3N2 Hong Kong H1 1918 (Spanish Flu) 20-40 million deaths H1N1 Influenza Swine to Human 1998/9 1918 1957 1968 1977 1993 1997 2003 2009 7/4/2009 By 1993, a bird flu virus had adapted to pigs, grabbed a few human flu 95 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
  96. Past & Potential Flu Pandemics Summary Epidemics/ Subtype Year Approx Approx Deaths Approx Estimated Severity of Pandemics Infected Mortality % Reproductive the Number (Ro) Pandemic (Asiatic) H2N2 1889/1890 unknown 1 million unknown Unclear Moderate Russian Flu Spanish flu H1N1 1918/1919 500 million 20-50 /?50 million 2.5 -10% 1.5-1.8 Severe + 2nd Wave 3.0-3.5 Asian flu H2N2 1956-58 45 million 1-4 million <0.2% 1.5 Severe Hong Kong flu H3N2 1968-69 50 million 1-4 million >0.2% 1.3-1.6 Moderate Avian flu H5N1 1990-today 433 262 61% 2.14 Severe Ongoing (still researching) SARS SARS-CoV 2002-03 8,096 774 9.6% 0.44-2.29 Severe 1,17 med Swine flu H3N2 1976 250-300 1 0.3% 1.09 Mild Influenza H1N1 2009 89,921 382 (WHO) <0.55% 1.2.-1.8 Moderate A(H1N1)v Ongoing CFR- 0.4 Med 1.5 (Mexico) 0.2-0.004 (ECDC) Seasonal Flu A/H3N2, Yearly 1 Billion 250,000-500,000 <0.05% NA NA (Epidemic) A/H1N1, 7/4/2009 and B 96 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  97. Epidemiology of Ireland Spanish Influenza 1818-1819 • Ireland: 10,651 influenza • The deaths per 100,000 deaths registered by age group: (Unconfirmed 20000) under 5 years 295 – Male : 5,591 5-10 years 120 – Female: 5,060 10-15 years 103 • Mortality Rate: of 243 per 15-20years 223 100,000 population 20-25 years 329 – The mortality rate 25-35 years 380 varied by region: 35-45 years 239 • Leinster: 304 per 45-55 years 222 100,000 • Ulster: 302 per 1918 Flu Pandemic In 55-65 years 226 100,000 Ireland 65-75 years 221 • Munster: 159 per < 75 years 256 100,000 • Connaught: 114 per 100,000 7/4/2009 97 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  98. 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” 7/4/2009 98 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  99. Scientific Models of the Impact of an Influenza Pandemic • USA: Pandemic Severity Index • United Kingdom: Empiric HPA Model Irelands “National Pandemic Influenza Plan” uses the HPA Model Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie Gani and Meltzer Model are also used See Website for download for to predict ICU rates and Ro rates in the National Pandemic Plan clinicians 7/4/2009 99 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  100. Pre-Pandemic Planning: The Pandemic Severity Index 7/4/2009 100 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  101. 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 7/4/2009 101 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  102. 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. Influenza A(H1N1) is a Class 2 Pandemic June 12 2009 • 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 7/4/2009 V pandemic would kill 5.4 billion people. class 102 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  103. Community Mitigation Strategy by Example on Pandemic Severity Scale 7/4/2009 103 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  104. 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. 7/4/2009 104
  105. 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 7/4/2009 105 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  106. 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. 7/4/2009 106 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  107. 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 7/4/2009 107 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  108. 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) 7/4/2009 108 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  109. 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 7/4/2009 Revised and Modified 29/04/2009
  110. 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 – 7/4/2009 Etc. 110 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  111. Irelands Governmental Lead Agencies, Groups and Committees Emergency/Incident Type Lead Government Lead Principal Support Role Other Potential Support Remarks Department Response Roles Agency as per Framework Influenza Pandemic Influenza and DOHC HSE HSE Local Authorities Pandemic Other Public Health All members of the (DEHLG) Emergencies Interdepartmental CD (DOD) Steering Committee on Revenue Commissioners Public Health Emergency FSAI7 (DHC) Planning Current Pandemic Influenza Emergency Planning Roles and Responsibilities for Influenza A (H1N1) 7/4/2009 111
  112. Irelands Mitigation Strategies Current Pandemic Roles • “A national plan for pandemic influenza was put in place in January 2007, describing the health system’s response to a possible worldwide pandemic • Additionally The National Pandemic Expert Group has produced Expert Influenza Guidance in November 2008 which is currently being followed. It has met regularly, since an outbreak was first confirmed in Mexico, to assess the public health and clinical guidance to ensure an appropriate level of preparedness and response for Ireland • The Department is in close contact with the World Health Organisation, the European Centre for Disease Prevention and Control and our counterparts in the North of Ireland” Slide Cited From FAQs At DOHC Daily Report 7/4/2009 112
  113. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • The Department of Health and Children continues to be in close contact with the HSE and the National Pandemic Expert Group • The Department of Health and Children and the HSE participate in regular teleconference meetings with the European Centres for Disease Control, public health officials in other European Member States and the WHO • The Department of Health and Children is the lead government department for public health emergencies and works closely with the HSE in response to pandemic influenza • The National Public Health Emergency Team (NPHET) has been meeting since the outbreak was first confirmed to coordinate the response to this threat – (This is the forum for managing responses between DOHC and the HSE during the planning and response phases of a public health emergency) • NPHET is chaired by the Secretary General of the Department of Health and Children and has been meeting frequently throughout the current situation” Slide Cited From FAQs At DOHC Daily Report 7/4/2009 113
  114. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • The Government Interdepartmental Committee has been meeting to deal with health emergency planning involving transport, foreign affairs, education, security, etc. • An information leaflet has been printed and distributed to households • Posters and leaflets have been placed in air and sea ports • Ireland have accumulated anti-viral stockpiles to treat half of the population • Anti-viral medication has been distributed through public health departments to treat initial cases as they arise • Advertising will be placed on TV and other media” Slide Cited From FAQs At DOHC Daily Report 7/4/2009 114
  115. Irelands Mitigation Strategies Current Pandemic Roles • “What is being done currently to prepare for a possible pandemic? • Information is being updated on HSE and DOHC websites • We have heightened surveillance – we will be seeking to pick up cases early • The National Virus Reference Laboratory (NVRL) have in place the capacity to carry out all diagnostic testing in relation to this virus • Professionals have received communications outlining their role in managing cases of influenza” Slide Cited From FAQs At DOHC Daily Report 7/4/2009 115
  116. Surveillance System: EU Surveillance Networks • Enter-net • EuroHIV Eurosurveillance • European Surveillance System (TESSy) • EuroTB • European Antimicrobial Resistance Surveillance System (EARSS) • European Influenza Surveillance Scheme (EISS) • European Programme for Intervention Epidemiology Training (EPIET) • European Scientific Working Group on Influenza (ESWI) • European Surveillance of STIs (ESSTI) • European Working Group for Legionella Infections (EWGLI) • FluNet Global Salm-Surv (GSS) • International Network of Paediatric Surveillance Units 7/4/2009 117
  117. 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: 7/4/2009 International 119 •
  118. Surveillance System: National Surveillance Institutes in Europe • Belgium: l'Institut scientifique de Santé • Netherlands: Rijksinstituut voor Publique Volksgezondheid en Milieu (RIVM) • Norway: Folkehelseinstituttet • Czech Republic: Centrum Epidemiologie a • Poland: Panstwowy Zaklad Higieny (PZH) Mikrobiologie (CEM) • Portugal: Direcção-Geral da Saúde • Denmark: Statens Serum Institut (SSI) • Slovak Republic: Úrad Verejného • Estonia: Tervisekaitseinspektsioon Zdravotnictva (UVZ) • Finland: Kansanterveyslaitos (KTL) • Slovenia: Inštitut za varovanje zdravja (IVZ) • Spain: Instituto de Salud Carlos III • France: Institut de Veille Sanitaire (InVS) • Sweden: Smittskyddsinstitutet (SMI) • Germany: Robert Koch Institut (RKI) • UK (England & Wales): Health Protection • Greece: Hellenic Center for Infectious Agency (HPA) Diseases Control (KEEL) • UK (Northern Ireland): Communicable Disease Surveillance Centre (CDSC) • Hungary: Országos Epidemiológiai Központ • UK (Scotland): Health Protection Scotland (OEK) (HPS) • Iceland: Landlæknir • U.S. Department of Health and Human • Italy: Istituto Superiore di Sanità (ISS) Services (DHHS) • Latvia: Sabiedribas veselibas agentura (SVA) • Luxembourg: Direction de la Sant 7/4/2009 120
  119. Influenza A(H1N1) Surveillance in Ireland • Reporting of clinical data by sentinel GPs • Hospital Surveillance • Enhanced surveillance • Surveillance of absenteeism rates in sentinel schools • Mortality Surveillance Influenza A(H1N1) Infection • Regional influenza activity by Weekly Surveillance Report As of June 17 2009 HSE area • Weekly Notifications of Influenza 7/4/2009 121
  120. Influenza A(H1N1) Surveillance in Ireland • Since the public health emergency was declared by WHO, HPSC and the HSE have implemented a number of surveillance initiatives to monitor the situation including: • Enhanced influenza A(H1N1) case based reporting on the Computerised Infectious Disease Reporting system (CIDR) • Contact tracing surveillance for contacts of influenza A(H1N1) cases • Expanded outbreak reporting of influenza and influenza-like illness on CIDR • An interim protocol on outbreak/cluster surveillance to detect early cases of influenza A(H1N1) • A protocol for surveillance of influenza-like illness in healthcare workers during Pandemic Phase 5. • Increased virological surveillance by the sentinel GP influenza surveillance system and recruitment of additional sentinel GPs • Expanded sentinel hospital influenza surveillance to capture information on the age breakdown of respiratory admissions Cited from Epi-insight • Sentinel paediatric hospital influenza surveillance systems have been implemented at two sites • Work is ongoing in the establishment of pilot sites for the sentinel surveillance of persons with influenza A(H1N1) who are admitted to intensive care units • Mortality surveillance has also been augmented with weekly monitoring of all cause mortality and deaths from pneumonia and influenza. HPSC will participate in a European mortality surveillance project (Euro MoMo) from early June 2009. Computerised Infectious Disease Reporting (CIDR) Adapted from Dr Jaon O'Donnell PTT From HPSC ICGP NRVL DPH/MOH Other Sentinel GP ILI consultations Hospital admissions GRO Mortality data Sentinel specimens School absenteeism HSE Influenza antiviral/vaccine uptake Non-Sentinel specimens Enhanced influenza surveillance GP Co-Ops ILI (Cluster) outbreaks Contact tracing International EISS, HPA, etc Influenza notification Health Protection Surveillance Centre (HPSC) European Influenza WHO Global Outbreak and Department of Public Health Weekly surveillance report Surveillance System (EISS) Alert Response Network and Children (GOARN)
  121. 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) 7/4/2009 124
  122. 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 7/4/2009 125 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  123. Computerised Infectious Disease Reporting (CIDR) Dissemination Pathway 7/4/2009 126 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  124. 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 7/4/2009 127 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
  125. Influenza A(H1N1) “The Emerging Pandemic!” This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. 7/4/2009 128 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  126. 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 7/4/2009 129 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  127. 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 7/4/2009 130 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  128. Categorizing Influenza Virus “Viral Nomenclature” Type of nuclear material Neuraminidase Hemagglutinin A/California/04/2009(H1N1)swl Virus Geographic Strain Year of Virus type origin number isolation subtype Try These Two! A/Brevig Mission/1/1918(H1N1) 7/4/2009 131 Medical Management of Biological Casualties A/New Jersey/76 (Hsw1N1) Revised and Modified 29/04/2009
  129. Emergence H3N2 Viruses Antigenetic Shift 7/4/2009 132 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  130. Emergence H3N2 Viruses 7/4/2009 133 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  131. Influenza A(H1N1) Classic Reassortment Diamond 7/4/2009 134 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  132. Influenza A(H1N1) Host Range 7/4/2009 135 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  133. Influenza A(H1N1) Antigenic Shift Pathogenesis 7/4/2009 136 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  134. Influenza A(H1N1) Origins Overview • Nature magazine article on 11 June, 2009, about the “Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A epidemic”. 7/4/2009 137 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  135. Genetic Components of Triple-Reassortant Swine Influenza A (H1) • Triple-Reassortant Swine Influenza A (H1) Viruses Isolated from 11 Patients between December 2005 and February 2009 in the United States: Triple-Reassortment Swine Tripple-Reassorment Swine H1N1 Influenza Virus H1N2 Influenza Virus (Pts 1-6 and 8-11) (Pt 7 (2007)) Note Pt 7visited a Pig Fair (genetic ressortment H1N2) PB2 PB2 Swine PB1 PB1 Avian PA PA Human HA HA NP NP NA NA M M NS NS http://content.nejm.org/cgi /reprint/NEJMoa0903812.p df (For personal use only) Tripple Reassortment Classical swine, North American Lineage Avian, North American Lineage Human (Seasonal )H3N2 7/4/2009 Human (Seasonal )H1N1 138
  136. Influenza A(H1N1) Lineage “The Emerging Pandemic!” Human H1N1 Cases From Human H1N1 Cases From California Triple -Reassortment Swine 1998 Quadruple Reassortment 2009 PB2 PB2 PB1 PB1 PA PA HA HA NP NP NA NA M M NS NS “Quadruple Reassortment” Classical swine, North American Lineage Avian, North American Lineage http://content.nejm.org/cgi/ Seasonal H3N2 reprint/NEJMoa0903812.pdf (For personal use only) Eurasian swine Lineage 7/4/2009 139 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  137. H1N1 (Swine) H3N2 (Human) H1N1 (Avian) Influenza A(H1N1) PB2 PB2 PB2 PB1 PA HA PB1 PA HA PB1 PA HA Lineage Summary NP NP NP Classical swine, North American Lineage NA NA NA Avian, North American Lineage M M M NS NS NS Seasonal H3N2 Eurasian swine Lineage http://www.who.int/csr/resour ces/publications/swineflu/WHO _OFFLU2009_05_15.pdf First Detected in 1998 H3N2 Double Reassortant (Swine/Human) H3N2 Triple Ressortant (Swine/Avian/Human) H1N1 (Swine) ? PB2 PB2 PB2 PB2 PB1 PB1 PB1 PB1 “Large gaps in the historical global animal PA PA PA PA influenza surveillance data. “ HA HA HA HA NP NP NP NP NA NA NA NA M M M M NS NS NS NS 2009 Influenza A(H1N1) Quadruple H1N2 Triple Ressortant H1N1 Triple Reassortant Reassortant (Swine/Avian/Human) (Swine/Avian/Human) (North American and Eurasian Swine/Avian/Human) PB2 PB2 PB1 PB1 PB2 PA PA PB1 HA HA PA NP NP HA NA NA NP M M NA NS NS M 7/4/2009 NS 140
  138. 7/4/2009 141
  139. 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 7/4/2009 142 Medical Management of Biological Casualties Has Breakthrough! Revised and Modified 29/04/2009
  140. Emergence of a Influenza A (H1N1) Virus in Humans Using “BLAST” Supplement to: Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine origin influenza A (H1N1) virus in humans. N Engl J Med 2009;361. DOI: 10.1056/NEJMoa0903810 (BLAST) Basic Local Alignment Search Tool 7/4/2009 143
  141. “Molecular Clock” Method in Estimation of the Origins of Influenza A(H1N1) • Britons Andrew Rambaut of the University of Edinburgh and Oliver Pybus of Oxford University, and Yi Guan of the University of Hong Kong examined the genetic sequence of the new H1N1 swine flu virus The international team used a "molecular clock" method to compare the current virus to its relatives and estimate its age based on the mutations. – This gives a rough idea of when the new virus is likely to have emerged! "We found that the common ancestor of the (new H1N1) outbreak and the closest related swine viruses existed between 9.2 and 17.2 years ago, depending on the genomic segment, hence the ancestors of the epidemic have been circulating undetected for about a decade," 7/4/2009 144
  142. Influenza A (H1N1) CDC Influenza Laboratory Images • Images below of the newly identified H1N1 influenza virus were taken in the CDC Influenza Laboratory. 7/4/2009 145 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  143. Laboratory Images Influenza A (H1N1) • This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. • This preliminary negative stained transmission electron micrograph depicts some of the ultrastructural morphology of the A/CA/4/09 swine flu virus. Courtesy of CDC/ C. S. Goldsmith and A. Balish. • Comparison to; • Swine influenza virus. Colorized transmission electron micrograph (37,800X) of the A/New Jersey/76 (Hsw1N1) virus under plate magnification. Image taken during the virus' first developmental passage through a chicken egg. Courtesy of the CDC/Dr. E. Palmer; R.E. Bates. • Negative stained transmission electron micrograph of recreated 1918 influenza virions. Courtesy of CDC/ Dr. Terrence Tumpey E-medicine resource 7/4/2009 146
  144. 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) 7/4/2009 147 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  145. 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 7/4/2009 148 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  146. http://www. Influenza A(H1N1) Infectious Period: • The infectious period for a confirmed case of swine influenza A (H1N1) virus infection is defined as 1 day prior to the case’s illness onset to 7 days after onset. • The swine flu in humans is most contagious during the first five days of the illness although some people, most commonly children, can remain contagious for up to ten days ,immunocompromised up to 0-3 months has been documented • Remember: if signs and symptoms of influenza persist past this incubation period consider yourself contagious • May 20 2009 : WHO Technical Consultation on the severity of disease Report 20,05 May Teleconferencex • Ranging between – 1–5 days (Spain) – 4–6 days (UK) – 2–7 days (US ) 7/4/2009 149 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  147. Influenza A(H1N1) Transmission: • Direct and indirect contact – Pig to human • asymptomatic carrier pigs – Human to human – Human to Pig • Droplet transmission • Aerosol generating procedures (AGPs) • Not transmissible by consumption of pork 7/4/2009 150 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  148. Influenza A(H1N1) Human Signs and Symptoms: A(H1N1) Exacerbation of underlying chronic medical conditions Includes: • Upper respiratory tract disease (sinusitis, otitis media, croup) lower respiratory tract disease (pneumonia, Fever (greater bronchiolitis, status asthmaticus) than 100°F or  Cardiac (myocarditis, 37.8°C) pericarditis)  Musculoskeletal (myositis, EU > 38 °C rhabdomyolysis) *NOTE: Some people,  Neurologic (acute and post- such as the elderly, infectious encephalopathy, and people who are encephalitis, febrile seizures, immunocompromised, status epilepticus) may not develop a  Toxic shock syndrome fever.  Secondary bacterial - Diarrhoea pneumonia with or without sepsis 7/4/2009 151 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  149. Influenza A (H1N1) ECDC Report of Specific Clinical Signs and Symptoms by Systems Update June 17 2009 Frequency of Number of cases % Percentage symptoms (n=879) Generalised Fever or history of fever 653 74% Headache 364 41% Muscle pain 336 38% Joint pain 195 22% Respiratory Dry cough 465 53% Productive cough 157 18% Sore throat 354 40% Runny nose 295 34% Sneezing 165 19% Shortness of breath 103 12% Gastro-intestinal Diarrhoea 101 11% Vomiting 84 10% Nausea 114 13% Other Conjunctivitis 45 5% Nose bleed 25 3% Altered consciousness 12 1% Other (various) 386 44% 7/4/2009 152
  150. 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 Influenza A(H1N1) complications if: 7/4/2009 153 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  151. 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 154 Medical Management of Biological Casualties 7/4/2009 Revised and Modified 29/04/2009
  152. 2009 Influenza A(H1N1) Outbreak In Ireland By Age, Gender and Transmission Mode Update as of July ,1 ,2009 from Weekly Surveillance Report Age Male Female Total Antiviral In-Country Out-of- Homecare Hospitalizations Treatment Transmission Country Transmission 0-4 2 1 3 3 3 2 3 0 5-9 1 1 2 2 0 0 2 0 10-14 0 1 1 2 1 2 1 0 20-24 1 4 5 5 0 13 5 0 25-34 7 10 17 17 0 2 17 0 35-44 3 2 5 5 0 2 5 0 45 -54 2 1 3 3 0 1 3 0 55-65 1 1 2 2 0 1 2 0 65+ 1 1 2 2 2 Unknown NA NA 1 NA NA NA NA NA School 28 28 0 Outbreak Total 18 22 41 79(needs update) 4 22 (needs update) 79 1 7/4/2009 155
  153. Influenza A(H1N1) According to ECDC Surveillance Report • Reported number of cases of influenza A(H1N1)v infection, travel association and hospital admission, as of reports of 29, June, 2009 7/4/2009 June, 29, 2009 156
  154. Influenza A(H1N1) According to ECDC Surveillance Report • Distribution of travel-related and domestic individual case reports of influenza A(H1N1)v infection, by date of onset and country of travel, 25 EU/EEA countries, 20 April – 29 June 2009 (n=2,761) 7/4/2009 157
  155. Age distribution by gender and Travel Related among new influenza A(H1N1) cases reported by 21 EU, EEA and EFTA countries (date of onset from 16 April to 29 June 2009) • Distribution of travel-related and domestic individual case reports of influenza A(H1N1)v infection, by date of onset and country of travel, 25 EU/EEA countries, 20 April – 29 June 2009 (n=2,761) • Distribution by age and gender of individual case reports of influenza A(H1N1)v infection, 25 EU/EEA countries, 20 April and 29 June (n=3,315) • Distribution by age and travel status of individual case reports of influenza A(H1N1)v infection, 25 EU/EEA countries, 20 April and 29 June (n=3,618) 7/4/2009 158
  156. Influenza A(H1N1) High Risk Group Age According to ECDC June, 17, 2009 7/4/2009 159
  157. Influenza A(H1N1) High Risk Group Age According to ECDC • High risk age 20-29 according to ECDC as of June, 2, 2009 Age Male Female Total Not Travel Total travel Related related >2 4 2 6 1 3 4 2-9 26 28 54 33 6 39 10-19 46 42 88 51 27 78 20-29 83 74 157 25 128 153 30-39 26 12 38 4 31 35 40-49 12 21 33 12 18 30 50-59 13 10 23 7 15 22 >60 6 4 10 4 7 11 Total 216 193 409 137 235 372 7/4/2009 160 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  158. Influenza A(H1N1) High Risk Group Age According to ECDC • Distribution by age and travel status of individual case reports of influenza A(H1N1)v infection reported by 22 EU countries (date of onset from 16 April to 14 June 2009) • Distribution by age and travel status of individual case reports of influenza A(H1N1)v infection reported by 22 EU countries (date of onset from 16 April to 14 June 2009) • Proportion of symptoms reported by confirmed cases of influenza A(H1N1)v virus infection, 22 EU and EFTA countries (n=879) 7/4/2009 161
  159. Age distribution by gender and Travel Related among new influenza A(H1N1) cases reported by 21 EU, EEA and EFTA countries (date of onset from 16 April to 14 June 2009) • Proportion of individual case reports of A(H1N1)v by country visited or domestic 22 EU and EFTA countries, 16 April – 14 June 2009 (n=685) • Age distribution by gender among new influenza A(H1N1) cases reported by 21 EU, EEA and EFTA countries (date of onset from 16 April to 2 June 2009) 7/4/2009 162
  160. Cases of laboratory confirmed swine-lineage influenza A H1N1 by age-group and gender, 02 June 2009 United Kingdom • Confirmed cases with influenza A/H1N1v by age group and sex (01 July 2009), England. 7/4/2009 163
  161. México, United Sates, Canada Age and Gender Summary: Influenza A (H1N1) • The Mexican Ministry of Health published an epidemiological update on May 7, 2009, on their website: • Out of the 1204 confirmed cases studied, 49.5% are females and 72% are in persons under the age of 29 years of age. • The Public Health Agency of Canada reported epidemiological information of the confirmed cases on May 20, 2009 – The majority of the cases (97%) are under the age of 50 – The median age of Canadian cases is 22 years – As of May 20, 2009, half the cases are 21 years of age or younger (median: 21 years; range: <1 – 86 years) – The majority of cases are linked to travel to Mexico 7/4/2009 164 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  162. Influenza A (H1N1) Mexico, United Sates, Canada Age Summary: In Mexico In United States: As of 20 May 2009, 16:30 AM ET, 48 states of the United States have reported a total of 5,764confirmed cases including 247 hospitalizations and 8 deaths. Median age: 17 years, range 1 month- 87 years Gender: 51% female, 49% male Underlying medical conditions (n=44): 63% (median age: 18 years) Median time from illness onset to hospital admission (n=32): 4 days (range: 1-13 days) Median length of hospital stay (n=32): 5 days (range 2-31) In Canada: As of May 28, 2009, the average age reported is 22 years or younger (median: 17 years; range: <1 – 86 years). In Europe: Median age 33 7/4/2009 165 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  163. Influenza A (H1N1) México Age Specific Attack Rate May 20 7/4/2009 166
  164. 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 7/4/2009 168 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  165. 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. 7/4/2009 169 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  166. 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 7/4/2009 170 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  167. 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. 7/4/2009 171 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  168. CDC Influenza A (H1N1) Case definition of Close Contacts • The definition of close contacts is: Household members of confirmed or probable cases • Close workplace contacts of a confirmed or probable case, including sharing an office or cubicle area (sitting within one metre for at least 15 minutes) • Members of a confirmed or probable case’s class or child care group and their teacher/child care supervisor, where the case is a child aged between 0-12 years old • Others identified by a confirmed or probable case, household members or workplace contacts as having been in close physical contact (hugging, kissing, sitting within one metre for at least 15 minutes) with the confirmed case • Passengers and crew travelling on aircraft with a confirmed or probable case as defined below: – Passengers seated in the same row, and within two (2) rows in front of and behind the case; – Any passengers who moved from elsewhere in the aircraft to spend more than 15 minutes near the case – Airline staff (unless they did not visit the section of the plane in which the case was seated) 7/4/2009 172 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  169. NDSC Case Definition Influenza (Influenza A and B virus) (EU) • Clinical description • Clinical picture compatible with influenza i.e. sudden onset of disease, cough, fever > 38 °C, muscular pain and/or headache. • Laboratory criteria for diagnosis • One of the following: – Detection of influenza antigen, or influenza virus specific RNA – Isolation of influenza virus – Demonstration of a specific serum antibody response to influenza A or B (four fold or greater rise).** • Case classification • Possible: Clinically compatible case with epidemiological link* • Probable: N/A Case Definitions for Notifiable Diseases Infectious Diseases (Amendment) • Confirmed: Clinical case that is laboratory confirmed. (No. 3) Regulations 2003 (SI No. 707 of 2003) • Note: Influenza of a new or re-emergent subtype is defined as influenza caused by a novel or re-emerging influenza virus which is capable of infecting humans and causing human illness, and to which a large 7/4/2009 173 proportion of the human population has little or no immunity. Medical Management of Biological Casualties Revised and Modified 29/04/2009
  170. 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. 7/4/2009 174
  171. Influenza Activity Index Irish Influenza Activity Code, Name and Description Index Index Name Index Description* Code Map of influenza activity 0 No Report No reports received. by HSE area during week 20 2009 1 No Activity No ILI or laboratory confirmed influenza cases and no influenza/ILI outbreaks in a HSE-Health Area. 2 Sporadic Activity Isolated case(s) of ILI or laboratory confirmed influenza case(s) in a HSE-Health Area, or an influenza/ILI outbreak in a single nstitution. 3 Localised Activity Increases in ILI in local areas (such as a city, county, or district) within a HSE-Health Area, or outbreaks in two or more institutions within an area, with laboratory confirmed cases of influenza infection. Levels of activity in the remainder of the HSE-Health Area would be sporadic or have no activity 4 Regional Activity Increases in ILI in one or more regions with a population comprising less than 50% of the HSE-Health Area’s total http://www.hpsc.ie/hpsc/A- population, with laboratory confirmed influenza cases in the ffected Z/Respiratory/Influenza/SeasonalInfl region(s). Levels of activity in the remainder of the HSE-Health Area would be sporadic or have no activity. uenza/InfluenzaSurveillanceReports/I nterseason2009/File,3737,en.pdf 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 7/4/2009 175
  172. Influenza-like illness (ILI) –Definition Community Surveillance of Clusters/Outbreaks • Influenza-like illness (ILI) -definition for interim surveillance of clusters/outbreaks • Three or more cases of ILI arising within the same 72 hour period which meet the same clinical case definition and where an epidemiological link can be established • ILI symptoms include: – Acute onset of fever (temperature≥38oC) – OR history of fever – AND flu-like illness (two or more of the Influenza-like following symptoms: cough, sore throat, Illness/Influenza/Influenza A myalgia, headache, rhinorrhea or (H1N1) Outbreak Reporting Form vomiting/diarrhoea) 7/4/2009 176
  173. Influenza A (H1N1) National “Acute Febrile Respiratory Illness” Algorithm • Algorithm for the management of persons with acute febrile respiratory illness who may have influenza A(H1N1) • Update June,26,2009 7/4/2009 177
  174. 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. 7/4/2009 178 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  175. 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. 7/4/2009 179
  176. Public Health Management of Influenza A(H1N1) Contacts Update • Close Contacts Definition • Household members of a case • Roommates of cases in hospitals or institutions such as nursing homes, • People occupying the same room with a case (<1metre) for at least 4 hours • People who have contact with fomites contaminated with respiratory secretions (e.g. those handling tissues recently used by others or touching the hands of infectious persons who have handled tissues or touched their nose) • Travellers by plane sitting in the same row or in the 2 rows ahead or behind on a long haul flight (at least four hours duration) of a case that was symptomatic either on the flight or within 24 hours of the flight (only symptoms generating droplets such as sneezing and coughing count here) • Persons caring for a sick traveller, as described above • Health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient without wearing appropriate Personal Protective Equipment (PPE) for Standard, Droplet and Contact Precautions: – Surgical mask, Plastic Apron, Gloves (and goggles if risk of splashing or spraying) for staff for all routine care (including taking nasal and throat swabs for viral testing) – 7/4/2009 Additionally, FFP2 or FFP3 mask, goggles, gloves and long sleeved gown for aerosol generating 180 procedure
  177. Public Health Management of Influenza A(H1N1) Contacts Update June 5 2009 • • Management of Contacts · The following actions commence on receipt of test result of a probable or confirmed case: – Chemoprophylaxis for close contacts as defined above (1 course = 10 days) – Surveillance: Active - contacts to self-monitor for symptoms for 7 days, check temp twice daily. Staff from local office of Director of Public Health will make contact daily to ensure asymptomatic • Health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient and who WERE wearing appropriate Personal Protective Equipment (as above) are not considered to be close contacts. However, given the potential for nosocomial transmission (e.g. inadvertent exposure to aerosols, or lack of formal fit testing of respirators, or failure to implement hand hygiene following contact with contaminated surfaces or after removing PPE), such workers – Do not need chemoprophylaxis but – Should self-monitor for symptoms and report immediately to their Occupational Health Department (or local Public Health if no Occupational Health Department is available) any symptoms suggestive of influenza • Taking serology may be relevant in certain circumstances in order to better understand transmission. In these circumstances paired samples should be taken (first sample when identified as a contact and second sample 14 days later) • Contacts who are workers on pig farms should not work for 7 days following contact with a case to reduce the risk of human-to-pig transmission • If there are school contacts, these should be urgently discussed with HPSC 7/4/2009 181
  178. Influenza A(H1N1) Public Health Management Update June 22 2009 HPSC Form Update June 22 2009 http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforH ealthProfessionals/General/File,3617,en.pdf 7/4/2009 182
  179. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 • Post exposure prophylaxis is indicated for close contacts that were exposed to a probable or confirmed case during the period when the case was symptomatic and for 24 hours before onset of symptoms AND the contact’s last exposure occurred no more than 7 days previously. • Any probable or confirmed human case of influenza A(H1N1)should be notified to the local DPH as soon as possible. Update PEP June 22 2009 7/4/2009 183
  180. Influenza A (H1N1) Case Surveillance Form • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInflue nza/AdviceforHealthProfessionals/PublicHealth/File,3606,e n.pdf • 1-6 pages 7/4/2009 184 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  181. Surveillance Form for Contacts of Influenza A(H1N1) • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInflue nza/AdviceforHealthProfessionals/PublicHealth/File,3607,e n.pdf • 1-7pages 7/4/2009 185 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  182. 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 7/4/2009 186 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  183. 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 7/4/2009 187 Medical Management of Biological Casualties Adapted from “Dispatchers Guide to CBRNE” Revised and Modified 29/04/2009
  184. 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. 7/4/2009 188 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  185. 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 7/4/2009 189 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  186. 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 7/4/2009 190 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  187. 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 7/4/2009
  188. 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 7/4/2009 192 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  189. Influenza A (H1N1) Triage Initial Patient Management • Should be managed as follows: • Physical barrier (i.e. window or plexiglass barrier) or the receptionist should maintain a 2 metre (6 foot) distance from all patients whenever possible • In settings where such a separation is not possible, healthcare workers are advised to maintain whatever separation is feasible. • If there is no barrier, and a 2 metre (6 foot) distance cannot be achieved, a fit tested FFP 2-3 respirator and eye protection should be worn by the receptionist • Alcohol-based hand rub (ABHR) should be readily available for both staff and patients • Patient should be asked to perform hand hygiene using an ABHR and given a surgical mask to put on covering their nose and mouth • Patient should be placed in a separate area of the office (i.e. examination room). If an examination room or separate room is not available, the patient should remain masked • Provide hands-free garbage and laundry receptacles. • Remove magazines and toys from the waiting rooms to reduce potential contact exposures 7/4/2009 193
  190. Influenza A (H1N1) Triage Health Care Setting Screening • All patients who present to a health care setting should be screened for fever and respiratory symptoms. • This should include: • Passive screening: visual alerts posted at the entrances to all health care settings asking patients to report whether they have fever and any new or worsening respiratory symptoms, and • Active screening: At first contact, staff asks about fever and respiratory symptoms • Respiratory symptoms include cough, sore throat, coryza (runny nose), and myalgias (general body aches) • Routine practices ,contact and droplet precautions for clinicians • Additional precautions Influenza-like Illness/Influenza/Influenza A (H1N1) Outbreak Reporting Form 7/4/2009 194
  191. Influenza A (H1N1) Triage Health Care Setting Guidelines • The following infection control practices are indicated when assessing patients with fever and respiratory symptoms: • Before a clinical assessment: • Ensure patient is still wearing a surgical mask • Perform hand hygiene (alcohol based hand rub or soap and water) before and after patient assessment • Put on gloves • A gown is needed only when there is a risk of clothing or skin contamination (such as when examining young children who may have difficulty controlling their secretions) • Consider most appropriate respiratory protection 7/4/2009 195
  192. Influenza A (H1N1) Triage Health Care Setting Guidelines • Wear a surgical mask: • If the patient is compliant with respiratory hygiene practices (e.g. wearing a surgical mask) or If the patient has a weak or no cough. • Wear an FFP2-3 respirator: – If conducting an aerosol-generating medical procedure (e.g, obtaining a nasopharyngeal swab) on a suspect ILI case – All individuals in the room should wear an FFP2-3 respirator – When the patient is coughing forcefully and is unable or unwilling to comply with respiratory hygiene (e.g., coughing patient who is unable or unwilling to wear a surgical mask) 7/4/2009 196
  193. Influenza A (H1N1) Triage Health Care Setting Guidelines • After a clinical assessment: • Eye or face protection should be removed after leaving the case’s room and disposed of in either a hands-free waste receptacle (if disposable) or in a separate receptacle to go for reprocessing (if reusable) • The surgical mask or FFP2-3 respirator should be removed by the straps, being careful not to touch the mask or respirator itself, after leaving the case’s room and disposed of in a hands-free waste receptacle • HCWs should perform hand hygiene after removing the respiratory protection and after leaving the case’s room • Affected surfaces that may have been contaminated with droplets need to be cleaned. Routine office cleaning products are effective for respiratory viruses including influenza; no special cleaning products are needed. • There is no indication for use of personal air-purifying respirators (PAPRs) in the care of a suspect ILI/Influenza A(H1N1) case 7/4/2009 197
  194. HPSC Adaptation from WHO- “Patient Care Checklist” New influenza A (H1N1) June, 10, 2009 HPSC being proactive and showing continuous improvement through innovation ! 7/4/2009 198
  195. ECDC-Influenza A (H1N1) Triage Health Care Setting Guidelines Resource 7/4/2009 199
  196. Influenza A(H1N1) Advice to General Practitioners on Management of a Possible Case Resources • Health Protection Surveillance Centre 25-27 Middle Gardiner St Dublin 1, Ireland. t: +353 1 8765300 f: +353 1 8561299 e: hpsc@hse.ie • See Website for download for clinicians or hit hyperlink during slide show! http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInflu enza/SwineInfluenza/AdviceforHealthProfe ssionals/GPs/File,3636,en.pdf 7/4/2009 200 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  197. Influenza A(H1N1) General Practitioners Algorithm and Infection Control Resources http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInflu enza/SwineInfluenza/AdviceforHealthProfe ssionals/GPs/File,3636,en.pdf 7/4/2009 201
  198. Patient Resource for GPs Guidance For Caring For Persons At Home With Influenza A(H1N1) http://www.hpsc.ie/hpsc/A- 7/4/2009 Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfl 202 uenza/AdviceforHealthProfessionals/GPs/File,3636,en.pdf
  199. Influenza A(H1N1) Who's Summary of Clinical Guidelines Modalities Strategies Antibiotics In case of pneumonia, empiric treatment for community acquired pneumonia (CAP) per published guidelines pending microbiologic results (e.g. 2-3 days); tailored therapy thereafter if pathogen(s) identified. Antiviral therapy If treatment needed, oseltamivir or zanamivir. The new influenza A (H1N1) virus is currently resistant to amantadine and rimantadine. Corticosteroids Moderate to high dose steroids are NOT recommended. They are of unproven benefit and potentially harmful. Infection control Standard plus Droplet Precautions. For aerosol-generating procedures use particular respirator (N95, FFP2 or equivalent), eye protection, gowns, gloves, and an airborne precaution room, that can be naturally or mechanically ventilated, per WHO guidance NSAIDS, Paracetamol or acetaminophen given orally or by suppository. Avoid antipyretics administration of salicylates (aspirin and aspirin containing products) in children and young adults (< 18 years old) due to risk of Reye’s syndrome. Oxygen therapy Monitor oxygen saturation and maintain SaO2 over 90% (95% for pregnant women) with nasal cannulae or face mask. 7/4/2009 203
  200. Influenza A(H1N1) Diagnostics Summary • The following investigations are recommended “pandemic influenza expert group” in patients referred to hospital: Test Who this applies to Full blood count All patients Urea and electrolytes All patients Liver function tests All patients C-reactive protein If influenza-related pneumonia is suspected* Chest x-ray All patients Pulse oximetry All patients. If <92% on air, then arterial blood gases. ECG Patients with cardiac and respiratory complications or co-morbid illnesses. Patients with influenza-related pneumonia should also have the following bacteriological tests: Blood culture (Gold standard) (preferably before antibiotic treatment is commenced) Pneumococcal urine antigen (20 mls urine sample) Legionella urinary antigen 20 mls urine sample) Sputum Gram stain, culture Antimicrobial susceptibility tests on samples obtained from patients who: i.are able to expectorate purulent samples, and ii. ave not received prior antibiotic treatment. Paired serological examination for influenza/other agents Acute serum should be collected and a ‘convalescent’ sample obtained after an interval 10-14 days (both 5-10mLs clotted blood) 7/4/2009 204
  201. Clinical Management of Adults In The Hospital Setting • Severity assessment when presenting to hospital • Patients with uncomplicated influenza A(H1N1) infection would be expected to make a full recovery and do not require hospital care – Voluntary isolation with antivirals at home with self surveillance and follow up from PHD • Patients with worsening of pre-existing co-morbid medical conditions should be managed according to best practice for that condition with reference to published disease-specific guidelines (High risk groups) – Influenza-related Pneumonia assessment : • CURB-65 score* Bilateral pulmonary 7/4/2009 infiltrates 205
  202. Clinical Management of an Adults In The Hospital Setting Management of Influenza-related Pneumonia • *Score 1 point for each feature present: • Confusion (Mental Test Score of ≤ 8, or new disorientation in person, place or time.) • Urea > 7mmol/L • Respiratory rate ≥ 30/min • Blood pressure (SBP < 90mmHg or DBP ≤ 60mmHg) Patient admitted to ICU with severe bilateral pneumonia • New bilateral lung shadowing on CXR consistent with primary viral pneumonia should be taken as a feature of severe pneumonia regardless of CURB-65 score! • Assessment of those with Influenza-related pneumonia: • Severity assessment: (CURB-65 score) – *Score 1 point for each feature present CURB-65 score* Recommended action 0 Likely suitable for home treatment 1 or 2 Consider elective hospital stay, particularly with score 2, or hospital supervised outpatient stay 3 or more Manage in acute hospital as severe pneumonia 7/4/2009 206
  203. Clinical Management of Adults In The Hospital Setting • High Dependency or Intensive Care Unit referral: • Patients with primary viral pneumonia or a CURB-65 score of 4 or 5 should be considered for HDU/ICU referral • General indications for HDU/ICU referral include: 1. Persisting hypoxia with PaO2 <8Kpa despite maximal oxygen administration 2. Progressive hypercapnia 3. Severe acidosis (pH<7.26) 4. Septic shock 7/4/2009 207
  204. Paediatric Respiratory Distress Severity Assessment Paediatric Respiratory Distress Mild Severe Severity Assessment Infants Temperature > 38.5 °C Temperature > 38.5 °C Respiratory rate <50 breaths per min Respiratory rate >70 breaths per min Mild recession Moderate to severe recession Taking full feeds Nasal flaring Infants Cyanosis Intermittent apnoea Grunting respiration Not feeding Older children Temperature > 38.5 °C Temperature > 38.5 °C Resp rate < 50 breaths per min Resp rate > 50 breaths per min Mild breathlessness Severe difficulty in breathing No vomiting Nasal flaring Cyanosis Grunting respiration Signs of dehydration 7/4/2009 208
  205. Clinical management of Children Presenting To Hospital • Coughs and mild fevers: – Treat at home by parents with antipyretics and fluids – (Note: aspirin should not be used in children < 16 years) • High fever (> 38 °C /101.3°F) and cough or influenza like symptoms : – Seek medical advice • If there are no features which put them at high risk of complications they should be treated with oseltamivir, and given advice on antipyretics and fluids • Children at risk of complications, and all children aged less than 3 years should be seen by a GP • High fever (> 38 °C /101.3°F) and cough or influenza like symptoms PLUS at-risk group. These children should be seen by their GP or in an Emergency Department • Children may be considered at increased risk of complications if they have cough and fever (or influenza like illness) and temperature >38.0°C/101.3°F AND either chronic disease or one of following features: – Breathing difficulties – Severe earache – Vomiting > 24 hours – Drowsiness 7/4/2009 209
  206. Clinical management of Children Presenting To Hospital • Criteria for hospital referral for admission are any of the following: 1. Signs of persistent respiratory distress – markedly raised respiratory rate – grunting – intercostal recession – breathlessness with chest signs 2. Cyanosis 3. Severe dehydration 4. Altered conscious level 5. Complicated or prolonged seizure 6. Signs of septicaemia – extreme pallor, hypotension, floppy infant 7. Most children admitted to hospital are likely to need oxygen therapy and/or intravenous support as well as antibiotics and oseltamivir 7/4/2009 210
  207. Clinical management of Children Presenting To Hospital • Indications for referral to High Dependency or Intensive Care are: 1. The child is failing to maintain a SaO2 of >92% in FiO2 of >60% 2. The child is shocked 3. there is severe respiratory distress and a raised PaCO2 ( > 6.5 Kpa) 4. There is a rising respiratory rate and pulse rate with clinical evidence of severe respiratory distress with or without a raised PaCO2 5. There is recurrent apnoea or slow irregular breathing 6. There is evidence of encephalopathy 7/4/2009 211
  208. Clinical management of Children Presenting To Hospital • Microbiological/virological investigations in hospital: – WHO Phase 6, Irish Alert levels 2 and 3) • A. Virology – all children – Nasopharyngeal aspirate or nose and throat swabs – If presentation is more than 7 days after onset of illness, an ‘acute’ serum (2-5 ml clotted blood) should be collected and a ‘convalescent’ sample (2- 5 ml clotted blood) obtained after an interval of not less than 7 days. • B. Bacteriology – children with influenza related pneumonia – Blood culture (before antibiotic treatment is commenced) – Sputum samples obtained from older children – Paired serological examination for influenza/other agents 7/4/2009 212
  209. Influenza A(H1N1) Clinical Management : Discharge Checklist • Discharge and follow up Children can be safely discharged – Patients should be reviewed 24 from hospital when they: hours prior to discharge home – Are clearly improving – Are physiologically stable • Those with 2 or more of the – Can tolerate oral feeds following unstable clinical factors – Have a respiratory rate < 40/min ( should be considered for <50/min in infants) continuing care in hospital: – Have an awake oxygen saturation of >92% in air – Temperature > 37.8oC – Heart rate > 100/min – Respiratory rate > 24/min Follow up clinical review should be considered – Systolic blood pressure <90mmHg for all patients who suffered significant – Oxygen saturation < 92% on room complications or who had significant worsening air of their underlying disease, either with their – Inability to maintain oral intake general practitioner or in a hospital clinic. – Abnormal mental status or mental status not returned to baseline. 7/4/2009 213
  210. Influenza A(H1N1) Clinical Management : Hospital and Community Setting Resource Extensive clinical Practice Guidelines are available at this Hyperlink (Click during Slide show!) • http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInflu enza/Guidance/PandemicInfluenzaPrepar ednessforIreland/File,3261,en.pdf 7/4/2009 214
  211. Summary of HPSC Management of Contacts, National Algorithm, and PEP for Influenza A(H1N1) 7/4/2009 215
  212. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) 7/4/2009 217 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  213. 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. 218 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  214. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.2 Occupational Health Programme Standard Precautions  HCWs should self monitor their own health for influenza like symptoms  HCWs with symptoms should not attend work and should immediately report symptoms to their line manager 2.3 Patient Placement Standard Precautions Home  Assess the patient with suspected or confirmed influenza A(H1N1) by phone at home if possible GP/Primary care/Community Droplet Precautions  Place in a single room and avoid communal areas if possible. Otherwise do not place within approximately 1 metre of other patients Contact Precautions Hospital  Place patient with suspected or confirmed influenza A(H1N1) in a single room preferably with ante room and en-suite facilities  Emergency departments without single rooms must have interim arrangements in place to prioritise transfer to an appropriate single room  Avoid communal areas and placing patient within approximately 1 metre of other patients  Ambulance Refer to ambulance advice document 2.4 Hand Hygiene Standard Precautions Hand hygiene using liquid soap or alcohol hand gel/rub must be performed before and after all patient care procedures 2.5 Patient Movement and Transfer Standard Precautions External transfer Patient should wear a surgical mask outside their room It is the responsibility of the transferring facility to inform staff of the precautions required Droplet Precautions  Refer to ambulance advice document Contact Precautions Internal transfer  Minimise movement of patient from single room  Patient should wear a surgical mask outside their room  Staff should be informed of the precautions required in the receiving departments (e.g. diagnostic departments)  Avoid holding patients in communal areas (radiology etc)  HCW PPE: Wear a surgical mask and observe hand hygiene 7/4/2009 Medical Management of Biological Casualties 219 Revised and Modified 29/04/2009
  215. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.6 Respiratory Hygiene & Cough Standard Precautions Infections should be: Etiquette  Identified promptly in primary care and emergency departments  Offered masks (and other symptomatic persons e.g., persons who accompany ill patients should also be offered masks) Droplet Precautions  Encouraged to maintain spatial separation, ideally a distance of approximately 1 meter, from others in common waiting areas Emergency departments and primary care facilities should:  Ensure that supplies of tissues, foot operating waste bins and hand hygiene facilities are available in all departments including waiting areas throughout the facility  Educate patients/visitors/carers on Respiratory Etiquette and Cough Hygiene using some or all of the following:  Patient information leaflets  Posters in all departments especially waiting areas  If influenza A(H1N1) is suspected place patient & persons who accompany ill patients in a single room  See Appendix A for respiratory hygiene and cough etiquette poster. The poster can be downloaded from the following website http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Factsheets/RespiratoryHygiene/File,35 99,en.pdf 7/4/2009 220
  216. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.7 Personal Standard Precautions The following applies to all settings: Protective Droplet Precautions GP/Primary care/Ambulance transfer/Hospital Equipment Contact Precautions Patient should wear: (PPE)  A surgical mask when outside their single room HCWs must wear the following for: 1. Routine care  Surgical mask, Plastic Apron/Gown, Gloves (& Goggles if splashing/spraying risk) 2. Aerosol Generating Procedures  FFP2 or FFP3 mask (correctly fitted), Goggles, Long sleeved disposable gown, Gloves Refer to Aerosol Generating Procedures document and to PPE poster Masks  Change mask if it becomes damp, wet or torn  Change and discard mask when leaving the room or patient care area HCW’s when putting on and removing PPE must :  Put on and remove in the correct sequence (refer to PPE poster)  Remove gloves & apron/gown inside the single room  Remove mask in the ante room or immediately outside the single room if there is no ante room. Ensure door is closed.  Decontaminate hands immediately after removing PPE 7/4/2009 221
  217. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.8 Environmental Decontamination Standard Precautions In addition to Standard Precautions: Only take essential equipment and supplies into the room. Droplet Precautions  Do not stockpile as unused stock will have to be discarded on cessation of additional precautions  Patient charts/records should not be taken into the single room Contact Precautions  The frequency and intensity of cleaning may need to be increased based on the patients level of hygiene and the level of environmental contamination  HCW’s must wear surgical mask, gloves, apron for cleaning the patients room  Thoroughly clean the environment and furniture and all patient care equipment daily with a neutral detergent and disinfectant (hypochlorite solution 1000 ppm) paying special attention to frequently touched sites and equipment close to the patient  On patient discharge/transfer cleaning and disinfection of the environment  Prior to initiating environmental cleaning and disinfection, all privacy, shower and window curtains must be removed and sent for laundering All disposable items including paper towels and toilet paper should be discarded All sterile and non-sterile supplies in the patient room to be discarded on patient transfer/discharge Dishes and Eating Utensils  Cutlery and crockery - No additional measures are required for cutlery and crockery washed in a dishwasher or wash with liquid detergent and water 2.9 Patient Care Equipment & Standard Precautions In addition to Standard Precautions: Decontamination of Medical Devices  Dedicate patient care medical devices (e.g., thermometers, sphygmomanometers, stethoscopes, glucometers) to single Droplet Precautions patient use  Use disposable equipment whenever possible Contact Precautions  Manufacturer’s instructions should be followed for cleaning and disinfecting of reusable medical equipment after use  Single use items should be disposed of after use  Bedpan/Commodes  Use a working washer disinfector at 80°C for one minute  Dedicate a commode to single patient use if no en suite available  Decontaminate commode surface after each patient use with a hypochlorite solution 1000 ppm 7/4/2009 222
  218. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components STANDARD Key Elements of Clinical Practices and Measures PRECAUTIONS 2.10 Linen/Laundry Standard Precautions  No additional precautions necessary  As per Standard Precautions all contaminated laundry should be carefully placed in an alginate stitched or water soluble bag and then placed into a laundry bag clearly identified with labels, colour-coding or other methods prior to transport to an approved laundry capable of dealing with contaminated linen 2.11 Management of needle stick injuries (NSI) and Standard Precautions  No additional precautions necessary blood and body fluid exposure 2.12 Management Standard Precautions  No additional precautions necessary for Non Healthcare Risk and Healthcare Risk Waste of Waste  Dispose of all PPE as Healthcare Risk Waste (e.g. used masks) 7/4/2009 223
  219. Influenza A(H1N1) Clinical Diagnostics 7/4/2009 224
  220. 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: 7/4/2009 225 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  221. 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 7/4/2009 226 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  222. 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 7/4/2009 227 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  223. 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) 7/4/2009 228 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  224. 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 7/4/2009 229 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  225. 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! 7/4/2009 230 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  226. Influenza A(H1N1) Laboratory Precautions • Viral isolation on clinical specimens from patients who are suspected cases of swine influenza A (H1N1) virus infection should be performed in a BSL2 laboratory with BSL3 practices (enhanced BSL2 conditions) • Additional precautions include: Recommended Personal Protective Equipment (based on site specific risk assessment ) – Respiratory protection – fit-tested FFP 2-3 respirator or higher level of protection – Shoe covers – Closed-front gown – Double gloves – Eye protection (goggles or face shields) 7/4/2009 231 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  227. 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 7/4/2009 232 bacterial cultures Medical Management of Biological Casualties Revised and Modified 29/04/2009
  228. 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 7/4/2009 233 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  229. 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 7/4/2009 234 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  230. 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 7/4/2009 235 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  231. 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 7/4/2009 236
  232. Influenza A(H1N1) Laboratory Precautions • Animal work • The following activities require animal facility — Biosafety Level 3 facilities and work practices, as detailed in the WHO Laboratory biosafety manual, 3rd edition. – Inoculation of animals for potential recovery of the agent from influenza A (H1N1) specimens – Any protocol involving animal inoculation for confirmation and/or characterization of putative influenza A (H1N1) agents – Bio containment :BL3(+) At NRVL/Cherry Orchard 7/4/2009 237 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  233. 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 7/4/2009 238 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  234. 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. 7/4/2009 239 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  235. NRVL Testing for Influenza A(H1N1) • Preferred Respiratory Specimens • Swabs – Nasopharyngeal Aspirates • Storing Clinical Specimens • Shipping Clinical Specimens • Recommended Tests HSE :Taking • Other Influenza Tests specimens for influenza virus testing – Rapid Influenza Antigen Test from patients with – Immunofluorescence (DFA or IFA) suspected swine influenza – Viral Culture 7/4/2009 240 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  236. NRVL Testing for Influenza A(H1N1) • Taking specimens for influenza virus testing from patients with suspected influenza A (H1N1): • As with all respiratory viruses, diagnosis of influenza virus depends on the collection of high-quality specimens, their rapid transport to the virology laboratory and appropriate storage before laboratory testing • Virus is best detected in specimens containing infected cells and secretions • Specimens should ideally be taken preferably during the first 5 days after onset of clinical symptoms 7/4/2009 241 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  237. 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 Update June, 26, 2009 nasal and throat viral swabs to out rule influenza A (H1N1) 7/4/2009 242 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  238. NRVL Testing for Influenza A(H1N1) • Infection prevention and control precautions: • While not strictly an aerosol generating procedure it is recommended that the following PPE is used when taking nasal and throat viral swabs to out rule influenza A (H1N1) • The following personal protective equipment (PPE) should be taken: – Hand hygiene – Standard Precautions – Surgical – Eye protection (i.e. goggles) – Plastic apron (single use only) – Gloves (some of these procedures require sterile gloves) – Hand hygiene post procedure • Refer to donning and removal of PPE document 7/4/2009 243 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  239. Aerosol Generating Procedures (AGP) According to WHO And HPSC • Aerosol generating procedures: • Nebulisation • Intubation and related • Non-invasive positive procedures, e.g. manual pressure ventilation(NIV) ventilation • Bi-level positive airway • Respiratory and airway suctioning pressure (BiPAP) ,CPAP, (including tracheostomy care) • High frequency oscillating • Nasopharyngeal aspiration ventilation • Cardiopulmonary resuscitation • Bronchoscopy • Nasopharyngeal aspirate • Transtracheal aspirate • Bronchoalveolar lavage • Biopsy of lung or tracheal tissues • Autopsy procedures – i.e.. (Oscillating saws) 7/4/2009 244
  240. Influenza A(H1N1) Infection Prevention and Control Precautions Personal Protective Equipment (PPE) Summary • Nasal and throat viral swabs: • Nasopharyngeal aspirate, transtracheal aspirate, • The following precautions should be bronchoalveolar lavage and biopsy taken: of lung or tracheal tissues at post- mortem, nebulizers , • Hand hygiene BIPAP/CPAP/NIV are all considered • Surgical mask aerosol generating procedures: • Goggles (if risk of splashing or spraying) • The following precautions should be • Plastic apron taken: • Gloves • Hand hygiene • Hand hygiene post procedure • FFP2 or FFP3 respiratory mask • Goggles • Long sleeved disposable gown • Gloves (some of these procedures require sterile gloves) • Hand hygiene post procedure Update June 9 2009 7/4/2009 245
  241. NRVL Testing for Influenza A(H1N1) • Respiratory specimens to take: • A. Upper respiratory tract – Nasopharyngeal (NP) and oropharyngeal (OP) swab – Nasopharyngeal aspirate – Sputum (if ordered) • B. Lower respiratory tract – Where clinically indicated, invasive procedures can be performed for the diagnosis of viral lower respiratory tract infections: – Transtracheal aspirate (TA) – Bronchoalveolar lavage (BAL) – Post-mortem lung or tracheal tissue 7/4/2009 246 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  242. 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 7/4/2009 247 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  243. Influenza A (H1N1) Nasopharyngeal Swabs • According to PHAC And CDC : Nasopharyngeal Swabs • Ideally, swab specimens should be collected using (COPAN flocked swab) swabs with a synthetic tip (eg, polyester or Dacron) and a plastic shaft • Optimal specimens continue to be Nasopharyngeal Swabs (COPAN flocked swab) but Starplex non- flocked swabs are also acceptable for nasopharyngeal and nasal samples • Do not use wired shaft pertussis swab as it interferes with the test and give a false negative result • Swabs with cotton tips and wooden shafts are not recommended • Specimens collected with swabs made of calcium alginate are not acceptable • The swab specimen collection vials should contain 3 mL of VTM (eg, containing protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution), such as M4RT or the BD Universal Viral Transport System 7/4/2009 248 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  244. 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) 7/4/2009 249
  245. Influenza A(H1N1) Nasopharyngeal Flocked Swabs Procedure • “Specimens for the laboratory diagnosis of Novel A (H1N1)Influenza should be collected in the following order of priority: 1. Nasopharyngeal aspirates 2. Acute serum 3. Convalescent serum 7/4/2009 250 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  246. Influenza A(H1N1) Nasopharyngeal (NP) , Oropharyngeal (OP) Swab • Nasopharyngeal (NP) and oropharyngeal (OP) swab collection: • Collect specimen with a sterile Dacron/nylon swab with a non-wooden shaft (do NOT use calcium alginate swabs or swabs with wooden sticks) • For NP swab, insert swab into each nostril parallel to the palate and leave in place for a few seconds to absorb secretions. Swab both nostrils • For OP swab, swab the posterior pharynx and tonsillar areas, avoiding the tongue • Place swab immediately into sterile vials containing 2 ml of viral transport media • Label each specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport at 4°C (but not frozen) • Should not be kept un-refrigerated for more than 12 hours 7/4/2009 251
  247. Novel A (H1N1)Influenza Nasopharyngeal Aspirates Overview • Ideally, swab specimens should be collected using swabs with a synthetic tip (eg, polyester or Dacron) and an aluminium or plastic shaft • Swabs with cotton tips and wooden shafts are not recommended • Specimens collected with swabs made of calcium alginate are not acceptable • The swab specimen collection vials should contain 3 ml of VTM (eg, containing protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution), such as M4RT or the BD Universal Viral Transport System 7/4/2009 252 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  248. Novel A (H1N1)Influenza Nasopharyngeal Aspirates Procedure • Hierarchy “Specimens for the laboratory diagnosis of Novel A (H1N1)Influenza should be collected in the following order of priority: 1. Nasopharyngeal aspirates 2. Acute serum 3. Convalescent serum 7/4/2009 253 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  249. Influenza A(H1N1) Nasopharyngeal Aspirates Collection • Nasopharyngeal wash/aspirates collecion: • Have the patient sit with head tilted slightly backward • Instill 1ml-1.5ml of nonbacteriostatic saline (pH 7.0) into one nostril • Insert the tubing into the nostril parallel to the palate • Aspirate nasopharyngeal secretions. Repeat this procedure for the other nostril • Rinse the catheter into viral transport medium (syringe or bulb) or aspirate viral transport media through catheter into collection trap • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport • Do not freeze 7/4/2009 254
  250. Influenza A(H1N1) Bronchoalveolar Lavage (BAL) Collection • Bronchoalveolar lavage or tracheal aspirate: • During bronchoalveolar lavage or tracheal aspirate, use a double-tube system to maximize shielding from oropharyngeal secretions • Centrifuge half of the specimen, and fix the cell pellet in formalin • Place the remaining unspun fluid in sterile vials with external caps and internal O-ring seals • If there is no internal O-ring seal, then seal tightly with the available cap and secure with Parafilm® • HPSC ; broncheoalveolar lavage should be transported in a sterile container 7/4/2009 255
  251. Influenza A(H1N1) Sputum Collection • Sputum collection: • Educate the patient about the difference between sputum and oral secretions • Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile screw-cap sputum collection cup or sterile dry container • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type • Place specimen vial onto ice or in refrigerator prior to and during transport • Do not freeze 7/4/2009 256
  252. Influenza A(H1N1) Stool Collection • In the USA, gastrointestinal symptoms (nausea, vomiting and/or diarrhoea) have occurred in up to 38% of outpatients with confirmed influenza A(H1N1) • Diarrhoea has been uncommon in hospitalised cases • SOP (Standard operating procedure) on collection • Full PPE (in case of splashes) • Place in Biological Bag • Do not freeze! • For all specimens Contact DPH/MOH/NVRL for shipping instructions accordance to national and international standards 7/4/2009 257
  253. Influenza A(H1N1) Influenza A(H1H1) Serology Suites • Acute Serum Suites • Convalescent Serum Suites • Immediate • 14 days after • Specimens: • Specimens: – Blood in clotted tube (red top) – Blood in clotted tube (red top) – Blood in EDTA (purple top) – Blood in EDTA (purple top) • {Full blood count) – {Full blood count) • Additional routine blood work according to physicians orders or follow pre ordered Influenza-like illness ,Influenza A(H1H1) suites as institutional protocols 7/4/2009 258
  254. Influenza A(H1N1) Serology Acute and Convalescent Serum Sample • Acute and Convalescent serum samples: • Collect 5-10 ml whole blood in a serum separator or red top tube Allow the blood to clot, centrifuge briefly, and collect all resulting sera in vial with external caps and internal O-ring seals • Refrigerate at 4°C • The minimum amount of serum needed for testing is 200 ml, which can easily be obtained from 5 ml of whole blood • A minimum of 1 cc of whole blood is needed for testing of paediatric patients • If possible, collect 1 cc in an EDTA tube and in a clotting tube • If only 1 cc can be obtained, use a clotting tube • Label specimen container with patient’s FIRST AND LAST NAME, date of birth, medical record number, date of collection, specimen type 7/4/2009 259
  255. Influenza A(H1N1) and Blood Safety • 2009 H1N1 Influenza Virus and Blood Safety: • Bld cultures Aerobic No case of transfusion transmitted seasonal influenza has ever then anaerobic been reported in the United States or elsewhere, and, to date, no cases of transfusion transmitted H1N1 flu have been reported! • Safety of Plasma Derivatives • The newly emerging 2009 H1N1 Influenza Virus is a large lipid- enveloped virus. Validation studies performed by the product manufacturers have shown that viruses with similar characteristics to this agent are effectively inactivated and/or removed by the manufacturing processes in place for these products • Individuals who are not in good health are not suitable to donate blood and blood establishments must defer these potential donors therefore…. • Blood donor screening procedures currently in place at blood establishments should identify persons with symptoms of H1N1 flu infection 7/4/2009 260
  256. Influenza A(H1N1) and Blood Safety • Irish Blood Transfusion Service advisory • Swine Flu Important Information • “We are asking all donors who have returned from Mexico or the United States of America in the last 14 days NOT to attend any blood donor clinic at this time. This situation is under review on a daily basis and further updates will be available here. Please note that this precaution is in the interest of donor and recipient safety. Your patience and cooperation is greatly appreciated” 7/4/2009 261
  257. Influenza A(H1N1) Diagnostics - Chest X-ray • Approximately 2-5% of confirmed cases in the US and Canada as well as 6% in Mexico have been hospitalised • In Mexico – One-third of those hospitalised required mechanical ventilation • Of those hospitalised in California – 15 of 25 (60%) tested had radiographic changes suggestive of pneumonia including ten with multilobar infiltrates – Four (13%) required mechanical ventilation 7/4/2009 262
  258. Influenza A(H1N1) Diagnostics Summary • The following investigations are recommended in patients referred to hospital: Test Who this applies to Full blood count All patients Urea and electrolytes All patients Liver function tests All patients C-reactive protein If influenza-related pneumonia is suspected* Chest x-ray All patients Pulse oximetry All patients. If <92% on air, then arterial blood gases. ECG Patients with cardiac and respiratory complications or co-morbid illnesses. Patients with influenza-related pneumonia should also have the following bacteriological tests: Blood culture (preferably before antibiotic treatment is commenced) Pneumococcal urine antigen (20 mls urine sample) Legionella urinary antigen 20 mls urine sample) Sputum Gram stain, culture Antimicrobial susceptibility tests on samples obtained from patients who: i.are able to expectorate purulent samples, and ii. ave not received prior antibiotic treatment. Paired serological examination for influenza/other agents Acute serum should be collected and a ‘convalescent’ sample obtained after an interval not less than 7days (both 5-10mLs clotted blood) 7/4/2009 263
  259. 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 7/4/2009 264 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  260. Influenza A(H1N1) Laboratory Tests Molecular Diagnostics: • Molecular diagnostics: • S-OIV assay The swine-origin influenza virus (S-OIV) assay (National Virus Reference Laboratory, NVRL, Dublin) is a real-time one-step RT-PCR assay containing primers and a dual-labelled hydrolysis probe targeting the M gene of influenza A viruses other than seasonal A(H1N1) and A(H3N2) viruses • HPA (H1)v assay The influenza A(H1)v specific assay of the Health Protection Agency (HPA) contains primers and a dual-labelled TaqMan MGB probe (Applied Biosystems) targeting conserved sequences in the HA gene of A(H1N1)v viruses, and the positive control swine A(H1N1) virus A/Aragon/3218/2009, in a 1-step TaqMan PCR assay [3]. The advantage of using a genetically distinct positive control virus (A/Aragon/3218/2008) is that false positives can be differentiated by sequence from true positives • CDC (H1)v assay The Centers for Disease Control and Prevention (CDC) real-time RT-PCR kit designed for the detection and characterisation of influenza A(H1N1)v viruses contains a panel of oligonucleotide primers and dual-labelled hydrolysis probes [4]. The CDC (H1)v primer and probe set evaluated in this study has been designed to specifically detect A(H1)v influenza in a one-step RT-PCR assay. • HPA (N1)v assay The influenza A(N1)v real-time assay (HPA) is a two-step TaqMan PCR assay incorporating oligonucleotide primers and a dual-labelled MGB TaqMan probe for the detection of the NA gene of influenza A(H1N1)v viruses and the positive control virus A/Aragon/3218/2008 [5]. The assay has been designed to be performed in conjunction with the influenza A(H1)v specific assay, to provide confirmation of diagnosis of influenza A(H1N1)v virus infection 7/4/2009 265
  261. 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 #: • 7/4/2009 Institution Shipping Address(No PO Box): 266 Medical Management of Biological Casualties • Preferred Shipping carrier: Revised and Modified 29/04/2009
  262. 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 7/4/2009 267
  263. Influenza A(H1N1) Laboratory Tests • Real-time RT-PCR for influenza A, B, H1, H3 – swine-origin influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR • Rapid influenza antigen test • Immunofluorescence (DFA or IFA): • Viral culture: • Please Read below in narration! • Emergency Use Authorization of Swine Flu Test Kit : NML Winnipeg • Centers for Disease Control and Prevention (CDC) has developed the Swine Influenza Virus Real-time RT-PCR Detection Panel (Swine Flu Test Kit) for the presumptive presence of swine influenza A (H1N1) virus from the nasal or nasopharyngeal swab. • Swine Influenza Test Kit will be made available on the CDC Swine Flu website. 7/4/2009 268 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  264. Influenza A(H1N1) Recommended Tests • Real-time RT-PCR for influenza A, B, H1, H3 at a state health department laboratory is recommended • Currently, S-OIV will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR • If reactivity of real-time RT-PCR for influenza A is strong (eg, Ct <30), it is more suggestive of a novel influenza A virus • Confirmation of Novel Influenza is performed at the NRVL currently, but may be available in public health laboratories 7/4/2009 269 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  265. CDC Rt-PCR Testing Algorithm and Results Interpretation The overall approach to influenza virus detection by RT-PCR should be considered in the context of the national situation, e.g., how many swl = swine like specimens can be handled (throughput), what gene sequence to target for RT-PCR, and whether to use concurrent or sequential testing for RT-PCR of PCR Assays AIV = Avian Influenza virus M, NP and HA genes. PCR = Polymerase chain reaction Influenza A-swl subtype specific Influenza type A (universal) PCR (H1 gene) Matrix gene PCR (other genes targets are optional) Test for Seasonal influenza H1-and N3 using specific Confirmed Positive Positive Positive PCR H1N1 swl And tested negative Positive Negative for seasonal influenza H1 or H3 specific PCR Check for lab Negative Positive confirmation by Influenza A Negative retesting from original Other than H1N1 swl sample Negative for influenza A viruses (check for Positive Check for lab other pathogens confirmation by Positive retesting from original Negative Confirmed Positive sample Test for H5N1 or other AIV or H1 or H3 Influenza B 7/4/2009 270
  266. 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 7/4/2009 271 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  267. 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 7/4/2009 272 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  268. Influenza A(H1N1) NRVL Submission of Specimens • Postal address: Medical Microbiology, CRID Building, University College Dublin, Belfield, Dublin 4, Bio containment :BL3(+) Two microbiological safety cabinets Ireland. (msc ) class I and class I/ III) at NVRL Telephone Number: +353-1-716 1325/1236 Fax Number: +353-1-716 1239 Email: margaret.brindley@ucd.ie 7/4/2009 273
  269. 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/ 7/4/2009 274 Medical Management of Biological Casualties 274 Revised and Modified 29/04/2009
  270. 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.” 7/4/2009 275 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  271. Influenza A(H1N1) Shipping Clinical Specimens • Clinical specimens should be shipped on dry ice in appropriate packaging • All specimens should be labelled clearly and include information requested by the appropriate public health laboratory or NRVL • Suspect case specimens shipped from the public health laboratory to the NRVL should include all information required for seasonal influenza surveillance isolate or specimen submission 7/4/2009 276 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  272. Influenza A(H1N1) International Shipment Protocol As with all clinical specimens, respiratory specimens should be packaged and transported to the virology laboratory in accordance with national and international guidelines. Contact the National Virus Reference Laboratory or local laboratory for advice if concerned! 7/4/2009 277
  273. Influenza A(H1N1) Who Shipment Protocol Adapted from WHO E-tool-Intro Shipping requirements for influenza A (H1N1) specimens are described under: http://www.who.int/csr/resources/publications/swineflu/in structions-shipments/en/index.html All Shippers Must take the E-tool-intro coarse to be able to ship Infectious Substances “Category A” 7/4/2009 278 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  274. 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 7/4/2009 279 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  275. 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 7/4/2009 280 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  276. 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 281 7/4/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  277. This Packaging is Used For Category A Infectious Substances 7/4/2009 282 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  278. 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) 7/4/2009 283 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  279. 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 7/4/2009 284 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  280. 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. 7/4/2009 285 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  281. 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 7/4/2009 286 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  282. Air Waybill • All goods being shipped by air must have a completed Air Waybill 7/4/2009 287 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  283. This Packaging is Used For Category B Infectious Substances 7/4/2009 288 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  284. 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 7/4/2009 289 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  285. 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) 7/4/2009 290 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  286. 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. 7/4/2009 291 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  287. Exempt Packaging Requirements • Primary container is leakproof • Secondary container is leakproof • Outer packaging must be of adequate strength 7/4/2009 292 Medical Management of Biological Casualties Medical Management of Biological Casualties Revised and Modified 29/04/2009
  288. Exempt Packaging Requirements Primary container (leakproof) Secondary container (leakproof) Absorbent and cushioning material Outer packaging 7/4/2009 293 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  289. 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) 7/4/2009 294 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  290. 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. 7/4/2009 295 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  291. Health Protection Agency (HPA) Cat B Packaging Poster 7/4/2009 296
  292. 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 7/4/2009 297 Medical Management of Biological Casualties decontaminated Revised and Modified 29/04/2009
  293. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 (Update June 22 2009) 7/4/2009 298
  294. Influenza A(H1N1) Ireland Vaccine In Ireland advance purchase agreements with two manufacturers for the procurement of 7.7 million doses of pandemic vaccine have been negotiated! 1. Novartis 2. ? 7/4/2009 299
  295. Canadian Lab Working on Influenza A(H1N1) Vaccine • No Vaccine available at this time! NML Winnipeg • Late on May 6, Canada's National Microbiology Laboratory first completed the sequencing of the virus, publishing the result to GenBank • Samples from Mexico, Nova Scotia and Influenza A H1N1 virus is seen in an image taken using an electron Ontario had the same sequence, ruling microscope, at PHAC's National Microbiology Laboratory. (Public out genetic explanations for the greater Health Agency of Canada, National Microbiology Laboratory) severity of the Mexican cases 7/4/2009 300 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  296. Influenza A(H1N1) Vaccine Resource Update • For more Information: • Recommendations of the Strategic Advisory Group of Experts (SAGE) on Influenza A (H1N1) vaccines 19 May 2009 • http://www.who.int/csr/resources/publications/swineflu/SAGEH1N1vaccinere commendation2009_05_19.pdf • Influenza vaccines have been available for over 50 years. Generally, they are trivalent, i.e. they contain three different, inactivated virus strains, either whole viruses or parts or subunits of them – Because the flu virus is changing its antigenic shape constantly (either in minor drifts or in major shifts), the composition of the flu vaccine needs to be adapted to these changes regularly • The monitoring of these changes is done by the Global Influenza Surveillance Network of the World Health Organization (WHO) – At the beginning of each year the WHO makes a recommendation for the strains to be included into the vaccine for the coming influenza season 7/4/2009 301
  297. Vaccine Technology Overview • Traditional Egg-based Process (last 50 years) • Cell Culture Process (1990’s) – Grown in eggs – Mammalian (Kidney) cell culture – Moderate specific to original strain (growth of epidemic – Vaccine are not grown on the tissue but in the single cells of viruses in eggs result in variants that are antigenically distinct the tissue from the original viruses – Highly specific to original strain (strains grown in cell cultures – Low Yield (approx 1-3 eggs per dose) equal the original clinical isolates) – Allergies to egg albumin? – High Yield – Potential impurities in eggs (antibiotics, other viruses) may – Virus grown in mammalian cell culture is therefore more cause sterility problems representative of the circulating wild type virus than that – Long Process (6-12 months) grown in eggs – A flu pandemic could probably not be contained and defeated – Cell culture based systems, however, could be rapidly on egg-based procuction, because the production takes too expanded and scaled up in times of emergency long and eggs don’t grow on demand – Up -front costs for operational readiness of such plants (with – Emerging endemic viruses sometimes do not grow at all in its huge fermenters) are much higher than the costs for egg – eggs based systems – Egg-based production of flu vaccines is well established and – Ie. Polio Vaccine cost-effective – Example: Pharmaceutical company - Novarits – Example:Pharmaceutical company- Glaxo-Smith-Kline (GSK) • Transient Expression of haemagulltinin – Insect cell culture – Very High Yield – Not very well established but is cost effective – Low production time 7/4/2009 302
  298. Influenza A (H1N1) Vaccine Development Process Seasonal 1. Collection of specimens and disease/epidemiology data (All year round) A(H1N1) 2. Diagnosis and virus isolation ,preliminary analysis (Hrs to 3 wks) 2a. Virus Isolation in eggs (1-3 wks) 3. Ferret antisera production Vaccine development (3-5 weeks) Approx 6 -12 months 4. Thorough antigenic and genetic analysis (1-3 wks) 4a. Serological Studies (3-16 wks) 5.Review and selection of candidate viruses for vaccine use (1-3 wks) 6a. Classical Reassortment of 6b. Reassortment of high high growth viruses growth using reverse genetics (3-4wks) and full safety testing (8 wks) 7a. Antigenic and genetic 9a. Development of 9b. Development of 7b. Antigenic and genetic characterizations of 8. Evaluation of growth standardized reagents standardized reagents characterizations of reassortments property fir inactivated vaccines for inactivated ressortment (3 wks) (4wks) (6wks) vaccines (3 wks) (4wks) Availability of vaccine virus and standardised reagents Adapted from WHO H5N1 vaccine development
  299. Influenza A (H1N1) Vaccine Development Process Glossary • Novel (new) subtype of human influenza A virus. This term refers to human influenza viruses that have haemagglutinin and neuraminidase antigens that are distinct from seasonal influenza viruses and have the potential to cause a pandemic. • Clinical specimens (original). These are materials collected from humans, generally in order to confirm a diagnosis. For influenza, most commonly, clinical specimens are taken from the respiratory tract (for example, swabs and aspirated fluid) but they can be from other locations. Clinical specimens can be frozen and stored for later use • Influenza reference viruses. These are wild-type influenza viruses that WHO has selected as representative of important groups of influenza viruses on the basis of extensive antigenic and genetic studies and comparisons with viruses from many countries. As the influenza viruses evolve in nature, new reference viruses are selected. • Wild-type influenza viruses (synonym: virus isolates). These are influenza viruses that have been cultured either in eggs or cells (i.e. isolated) directly from clinical specimens and have not been modified. • “Classical” reassortment. This is a non-patented laboratory technique that is often used to make (seasonal) candidate vaccine viruses • Genetic reassortment. In this process genes from two or more influenza viruses are mixed in different combinations, resulting in hybrid viruses with genetic characteristics of each parent virus. This process occurs in nature but can also be done in a laboratory using “classical” reassortment or reverse genetics • High-growth reassortant viruses. These are influenza viruses that have been genetically modified to grow better in eggs for optimal vaccine production. • Reverse genetics. This is a laboratory technique that is used to construct or modify influenza viruses and is protected by patents in several countries. It is used to render highly pathogenic H5N1 viruses less dangerous. • Reagents for influenza vaccine standardization. These reagents are used to standardize the amount of haemagglutinin protein in influenza vaccines as required by regulatory agencies. The reagents have to be produced in large quantities so that all vaccine batches can be tested. • Seed viruses. These are influenza viruses prepared from candidate influenza vaccine viruses by individual manufacturers for the manufacturer’s specific vaccine-production process. 7/4/2009 304
  300. Results of Haemagglutination Inhibition Tests of Influenza A(H1N1) Viruses With Post‐infection Ferret SeraA 7/4/2009 305
  301. Viral Gene Sequences to Assist Update Diagnostics for Swine Influenza A(H1N1) - GenBank Accession Numbers 2009 Influenza A(H1N1) The WHO Collaborating Centre for influenza in CDC Quadruple Reassortant Lineage Atlanta USA has posted the full genome sequences of swine influenza (North American and Eurasian A/California/04/2009 (H1N1) influenza virus on the Swine/Avian/Human) GenBank sequence database. To access, go to: http://www.ncbi.nlm.nih.gov/sites/entrez?db=nuccore PB2 &itool=toolbar, then enter the accession number as shown below: PB1 • PB2 gene accession number is: FJ966079 PA • PB1 gene accession number is: FJ966080 HA • PA gene accession number is: FJ966081 NP • HA gene accession number is: FJ966082 • NP gene accession number is: FJ966083 NA • NA gene accession number is: FJ966084 M • M gene accession number is: FJ966085 NS • NS gene accession number is: FJ966086 Tip: to access all the gene sequence records at once, copy the following line of text and paste Classical swine, North American Lineage it into the search bar in the above GenBank web link. FJ966079,FJ966080,FJ966081,FJ966082,FJ966083,FJ9660 Avian, North American Lineage 84,FJ966085,FJ966086 Seasonal H3N2 Eurasian swine Lineage 7/4/2009 306
  302. Influenza A (H1N1) Gene sequences of the currently available reassortant candidate vaccine viruses: • X-179A – The accession numbers of the HA and NA gene sequences of X-179A in GenBank is: • HA: GQ214335 • http://www.ncbi.nlm.nih.gov/nuccore/238623303 • NA: GQ214336 • http://www.ncbi.nlm.nih.gov/nuccore/238623305 • IDCDC-RG15 – The accession numbers of the HA and NA gene sequences of IDCDC-RG15 in GenBank is: • HA: GQ219781 • http://www.ncbi.nlm.nih.gov/nuccore/238623307 • NA: GQ219782 • http://www.ncbi.nlm.nih.gov/nuccore/238623309 • IVR-153 – The accession numbers of the HA and NA gene sequences of IVR-153 in GISAID is: • HA: EPI181843 • http://platform.gisaid.org/dante-cms/live/struktur.jdante?aid=1131 • NA: EPI181844 • http://platform.gisaid.org/dante-cms/live/struktur.jdante?aid=1131 7/4/2009 307
  303. Influenza A (H1N1) International Vaccine Candidates • Wild type influenza virus: • Traditional reassortant viruses are derived only from wild type viruses isolated and grown in hens’ eggs, or in a validated clean cell culture system. • A/California/7/2009 (egg isolate) – classical reassortment and reverse genetics • A/England/195/2009 (MDCK cell isolate) – reverse genetics • A/California/4/2009 (MDCK isolate) – reverse genetics • A/Texas/5/2009 (MDCK isolate) - reverse genetics • A/Ohio/7/2009 (MDCK isolate) - reverse genetics • A/New York/20/2009 (MDCK isolate) - reverse genetics 7/4/2009 308
  304. ) Influenza A (H1N1) Vaccine Virus Development Summary Candidate vaccine viruses using reverse Candidate vaccine viruses using classical Development of vaccine potency reagents Wild type viruses have been/ are being sent genetics technology are being developed by: reassortment technology are being for inactivated vaccines against Influenza to vaccine manufacturers on request developed by: A(H1N1) is planned in: including: Centers for Disease Control and Prevention NIBSC, UK, from NIBSC, UK Baxter (CDC), Atlanta USA A/California/7/2009(H1N1)swl, an egg virus enquiries@nibsc.ac.uk rdonis@cdc.gov isolate enquiries@nibsc.ac.uk National Institute for Biological Standards New York Medical College, USA, from CBER FDA, USA CSL Limited and Control (NIBSC) A/California/7/2009(H1N1)swl zhiping.ye@fda.hhs.gov enquiries@nibsc.ac.uk zhiping.ye@fda.hhs.gov Centre for Biologics Evaluation and Research CSL Limited, Australia, from Therapeutic Goods Administration GlaxoSmithKline Biologicals (CBER) A/California/7/2009(H1N1)swl gary.grohmann@health.gov.au zhiping.ye@fda.hhs.gov gary.grohmann@health.gov.au St. Jude Children’s Research ERL NIID, Japan MedImmune Hospital,Memphis USA mtashiro@nih.go.jp richard.webby@stjude.org National Institute of Infectious Diseases Microgen (NIID), Japan mtashiro@nih.go.jp Nobilon International Novartis June 15 2007 cell cultured vaccine ready for first stage Omninvest Vaccines Sanofi Pasteur June 17 2009 Donates 10,000,000 vaccine doses to WHO (When Ready) Adapted from WHO vaccine policy May 18 2009 Solvay and Vivaldi
  305. Influenza A (H1N1) International Vaccine Candidates Candidate influenza Parental H1N1 virus Laboratory vaccine viruses NYMCX-179A conventional A/California/7/2009 NYMC, USA reassortant virus IVR-153 conventional A/California/7/2009 CSL, Australia reassortant virus IDCDC –RG15 reverse A/Texas/5/2009 CDC, USA genetics virus CBER-RG2 reverse genetics A/California/04/2009 CBER, USA virus NIBRG-121 reverse A/California/7/2009 NIBSC, UK genetics virus 7/4/2009 310
  306. Influenza A (H1N1) NIBSC Candidate Vaccine Viruses Candidate Parental H1N1 NIBSC code Availability influenza vaccine virus viruses NIBRG-121 A/California/7/2009 09/122 Now 27/05/09 NYMCX-179A A/California/7/2009 09/124 Now W/C 8/06/09 IVR-153 A/California/7/2009 09/144 Now Previously VI 1525 2/06/09 7/4/2009 311
  307. Reagents for Single Radial Diffusion Assay of Influenza A (H1N1)v Virus Vaccine Reagents for NIBSC code Availability influenza Vaccine Standardisation A/California/7/2009 NA Mid July 2009 antigen (cell derived) A/California/7/2009 NA End July 2009 antigen (egg derived) A/California/7/2009 09/142 Now antiserum 7/4/2009 312
  308. Influenza A (H1N1) Vaccine Development: NIBRG‐121 27 May 2009 • NIBRG‐121 (NIBRG‐121 reassortant virus) • A candidate reassortant vaccine virus (NIBRG‐121) has been developed, using reverse genetics technology, from an A/California/7/2009(H1N1)v virus, by the National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom. • The haemagglutinin (HA) and neuraminidase (NA) sequences of the A/California/7/2009(H1N1)v virus can be found on the public web site of GenBank via the following links: • HA sequence – http://www.ncbi.nlm.nih.gov/nuccore/227977171?ordinalpos=1&itool=Ent rezSystem2.PEntrez.Sequence.Sequence_ResultsPanel.Sequence_RVDocSu m • NA sequence – http://www.ncbi.nlm.nih.gov/nuccore/229396468?ordinalpos=1&itool=Ent rezSystem2.PEntrez.Sequence.Sequence_ResultsPanel.Sequence_RVDocSu m 7/4/2009 313
  309. Influenza A (H1N1) NIBRG‐121 (NIBRG‐121 Reassortant Virus) • Now Available from: • Division of Virology • National Institute for Biological Standards and Control • Blanche Lane, South Mimms, Potters Bar • Hertfordshire, EN6 3QG, United Kingdom • E‐mail: enquiries@nibsc.hpa.org.u • k or standards@nibsc.hpa.org.uk • http://www.nibsc.ac.uk/flu_site/viruses_reagents.html • The candidate reassortant vaccine virus contains infectious materials and should be handled only in appropriate containment facilities (until completion of the above‐mentioned safety tests, it is recommended to use biosafety level 2 plus *BSL‐2 plus+ facilities with biosafety level 3 *BSL‐3+ practices)3 7/4/2009 314
  310. Performance Improvement for Irelands Vaccination Targets Guidance on Allocating and Targeting Pandemic Influenza Vaccine 7/4/2009 315
  311. US Example of Vaccination Target Groups • Vaccination target groups, estimated populations, and tiers for severe, moderate and less severe pandemics as defined by the Pandemic Severity Index (PSI) 7/4/2009 316
  312. US Example of Vaccination Tiers • Vaccination tiers and target groups for a severe pandemic 7/4/2009 317
  313. Vaccination Tiers and Targets Performance Improvement Summary • Dissemination of the Novel Influenza Vaccine is imperative and tiers and targets is an excellent example of the possible breakdown or needs assessment of high risk groups! • Incorporating the Empirical Model (HPA Model) and Pandemic Severity Index with also interrelating tiers and targets Irelands pandemic groups and committees have the potential to target vaccination groups effectively and assess future needs when the Influenza A(H1N1) vaccine becomes available in the Autumn! • Allocation of funds for the vaccine for Irelands population should be based upon a needs assessment and not only on general assumptions of clinical attack rates in the HPA model! • Cost-effective planning is essential during the economic times! • ? How much vaccine do you really need to pre-order keeping pandemic severity in mind? • Ireland Pre ordered 7.7 million influenza A(H1N1) vaccine dosages! • 2nd wave could mutate! Difficult to find the balance! Finding the balance The priority groups recommended for H5N1 vaccine were: Pandemic Influenza Priority Group 1: Healthcare staff, with direct patient contact Pandemic Severity (including ambulance staff) and staff in residential care homes for Preparedness for Ireland: the elderly Advice of the Pandemic Priority Group 2: Providers of essential services e.g. fire, utilities, Influenza Expert Group; Gardaí, security, communications, armed forces, undertakers, and essential healthcare staff, without direct patient contact. Chapter 6 Public Health Health care workers with direct patient contact are defined as: Population Vaccine Response: Vaccines Persons who provide or assist in provision of direct health care (within 1 metre) to potential or known influenza cases with or without personal protective equipment. 7/4/2009 318
  314. Influenza A(H1N1) Antiviral Medications 7/4/2009 319
  315. 7/4/2009 320
  316. Influenza A(H1N1) Antiviral Purpose in Pandemics 7/4/2009 321 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  317. 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 7/4/2009 322 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  318. 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 7/4/2009 323 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  319. 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 7/4/2009 324 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  320. 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 7/4/2009 325 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  321. 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) 7/4/2009 326 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  322. 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 7/4/2009 327 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  323. Influenza A(H1N1) Antiviral Resistance • 29 June 2009: • In Denmark, a female contact, who initially tested negative on PCR, was given prophylaxis with oseltamivir (75mg per day) • Five days later, despite reportedly having complied with treatment, she developed flu-like symptoms and was tested positive for A(H1N1)v. • Sequencing of the virus showed a single mutation H275Y (H274Y in N2 numbering system) in the neuraminidase gene • WHO and CDC has downplayed the resistance as a minor http://www.ecdc.europa.e isolated case but must be considered for future Influenza u/en/files/pdf/Health_topi cs/0907_Influenza_AH1N1 A(H1N1) mutation surveillance as there is no evidence that v_Resistance_TA_Oseltam the resistant virus has subsequently transmitted to other ivir.pd persons • HX of Neuraminidase segment gene (position 274 in N2 numbering system). – This mutation has been described in the past, associated with so-called secondary resistance to oseltamivir acquired during treatment of both H1N1 and H5N1 virus infections 7/4/2009 328
  324. 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 7/4/2009 329 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  325. 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 7/4/2009 330 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  326. 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 for children! 7/4/2009 331 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  327. 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 7/4/2009 332 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  328. Summary for Oseltamivir and Relenza Treatment for Ireland Oseltamivir Relenza – Adult dose – Adult dose • Treatment for acute illness: 75 mg PO bid for 5 d • Treatment for acute illness: 10 mg inhaled orally bid • Prophylaxis: 75 mg PO qd for 10 d for 5 d – Paediatric dose • Prophylaxis of household contact: 10 mg inhaled • Treatment for acute illness and age <1 year orally qd for 10 d (initiate within 36 h) – <3 months: 12 mg PO bid for 5 d • Prophylaxis for community outbreak: 10 mg inhaled – 3-5 months: 20 mg PO bid for 5 d orally qd for 28 d (initiate within 5 d of outbreak) – 6-11 months: 25 mg PO bid for 5 d • Treatment for acute illness and age >1 year – Paediatric dose – <15 kg: 30 mg PO bid for 5 d • Treatment for acute illness – 15-23 kg: 45 mg PO bid for 5 d – <7 years: Not established – 23-40 kg: 60 mg PO bid for 5 d – >7 years: Administer as in adults – >40 kg: Administer as in adults • Prophylaxis and age <1 year • Prophylaxis in household contact – <3 months: Data limited; not recommended – <5 years: Not established unless situation judged critical – >5 years: Administer as in adults – 3-5 months: 20 mg PO qd – 6-11 months: 25 mg PO qd • Prophylaxis in community outbreak • Prophylaxis and age >1 year – Adolescents 12-16 years: Administer as in – <15 kg: 30 mg PO qd for 10 d adults – 15-23 kg: 45 mg PO qd for 10 d – 23-40 kg: 60 mg PO qd for 10 d – >40 kg: Administer as in adults for 10 d 7/4/2009 333
  329. Oseltamivir Tx for Ireland Treatment Schedule: Update June, 22, 2009 • Adults - The following actions commence on receipt of test result of a probable or confirmed case: – Chemoprophylaxis for close contacts as (1 course = 10 days) • Oseltamivir 75mg every 12 hours for 10 days – (Dose to be reduced by 50% if creatinine clearance is less than 30ml/minute i.e. 75mg od) Children Dose • Children Child aged >1yr; body weight Oseltamivir 2-3mg/kg twice daily for 5 days Pandemic Influenza Preparedness for Ireland: Child aged ≥1yr; body weight 15kg or Oseltamivir 30mg 12-hourly for 5 days Advice of the Pandemic lower Influenza Expert Group Chapter 9: Health system 16-23kg (3yr-<7yrs) Oseltamivir 45mg 12-hourly for 5 days response – clinical guidelines November 2008 23-40kg Oseltamivir 60mg 12-hourly for 5 days Child 40kg or over Oseltamivir 75mg 12 hourly for 5 days 7/4/2009 334 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  330. EMEA Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir • Age Recommended prophylaxis dose for 10 days : • <3 months – Not recommended unless situation judged critical due to limited data on use in this age group • 3-5 months 20 mg once daily • 6-11 months 25 mg once daily • During a pandemic, if Tamiflu is prescribed to children under the age of one, the recommended dosage is 2 to 3 mg per kg body weight • 7/4/2009 (EMEA May 8 report) 335 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  331. 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 7/4/2009 336
  332. 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 7/4/2009 337 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  333. Oseltamivir (Tamiflu) Children Dosing Fact Sheets 7/4/2009 338 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  334. Oseltamivir (Tamiflu) Children Fact Sheets 7/4/2009 339 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  335. 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 7/4/2009 340 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  336. 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 7/4/2009 341
  337. 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 342 7/4/2009
  338. 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! 7/4/2009 343
  339. 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. 7/4/2009 344
  340. Zanamivir (Relenza) Fact Sheets 7/4/2009 345 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  341. 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 7/4/2009
  342. Guidelines for Reporting Suspected Adverse Reactions to Antiviral Medicines an Influenza Pandemic “Pharmacovigilance” Yellow card Pharmacovigilance Section, Irish Medicines Board, ) Kevin O'Malley House, Earlsfort Centre, Filled out by Public Health Earlsfort Terrace, Dublin 2, Ireland. Tel :353-1-676 4971 Fax: 353-1-634 3514 Email: 347 imbpharmacovigilance@imb.ie 7/4/2009
  343. 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. 7/4/2009 348 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  344. 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 7/4/2009 349 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  345. Influenza A(H1N1) Irelands National Antiviral Stockpile (INAS) • Mobilization plans to be Irish Alert Level Description tested for National Stock Pile Irish Alert Level 1 Cases only outside Ireland (in during this Swine-Origin a country or Influenza Virus (S-OIV ) countries with or outbreak if the Irish Alert without extensive Irish travel/trade Level Hits 2 links • Surveillance and monitoring Irish Alert Level 2 New virus isolated must be In place for future in Ireland exercise improvements for Irish Alert Level 3 Outbreak(s) in Ireland mobilizations of Irelands Irish Alert Level 4 Widespread National Antiviral Stockpile activity in Ireland Alert levels will increase in Phase 6 declaration by WHO 7/4/2009 350 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  346. 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 47% of the population and is over 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 7/4/2009 351 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  347. 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 352 7/4/2009 – Yemen – Zambia – Zimbabwe
  348. 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 353 Medical Management of Biological Casualties 7/4/2009 Revised and Modified 29/04/2009
  349. Performance Improvement for Irelands Antiviral Tiers and Targets • According to ECDC : An important general principle is that having stockpiles is of limited use without the agreed objectives, protocols, administration and delivery systems to accompany them. Good resource! Finding the balance Delaying the Pandemic Population Antiviral Stockpiling (Clinical Attack Rate) Interim guidance: Public health use of influenza antivirals during influenza pandemics 7/4/2009 354
  350. Guidance for Pharmacy Staff Influenza A (H1N1) • Full Tamiflu info @ http://www.emea.europa.eu/humandocs/PDFs/EPAR/tamiflu/H-402-PI-en.pdf 7/4/2009 356
  351. 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 7/4/2009 357 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  352. 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 7/4/2009 358 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  353. 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) 7/4/2009 359
  354. 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 7/4/2009 360 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  355. The “My 5 Moments for Hand Hygiene” Approach (WHO) Medical Management of Biological Casualties Revised and Modified 29/04/2009
  356. 6 Step Irish Hygiene Protocol • Ireland In 2006-7, Ireland organised a national campaign called ‘Clean Hands Save Lives’. • Same as the following! • All have 6 Steps in essence! A doctor checks patients presenting symptoms of the swine flu virus, now named influenza A(H1N1), kept in isolation at the National Institute of Respiratory Diseases (INER) in Mexico City on May 5, 2009. (LUIS ACOSTA/AFP/Getty Images) 7/4/2009 362 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  357. 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 7/4/2009 363
  358. Performance Improvement Pandemic Planning “Hand Washing” • Author promotes this hand wash technique with incorporating times/wash • 20-30 seconds for non-soiled hands • 60 seconds for visibly soiled hands 7/4/2009 364
  359. Influenza A(H1N1) Protocol for Surveillance of Influenza-like Illness in Healthcare Workers during Pandemic Phase 5 or Greater • 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 or this hyperlink http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInflue nza/AdviceforHealthProfessionals/HospitalClinicians/ 7/4/2009 365 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  360. Influenza A(H1N1) Surveillance of Healthcare Workers • Healthcare worker (HCW) • Porters includes: • Domestic staff • Hospital clinician teams • Receptionists • General practitioners • Administration staff • Laboratory scientists • Ambulance staff • Physiotherapists and other • Mortuary workers allied health professional • Healthcare students • Health volunteers and community health workers Safety, Health and Welfare at Work Act 2005 7/4/2009 366 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  361. 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 June 24 2009 Update “WHO” 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. 7/4/2009 367 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  362. Influenza A(H1N1) Surveillance of Healthcare Workers Clinical criteria • Acute onset of fever (temperature > 38 °C or history of fever and two or more of the following: • Cough • Sore throat • Myalgia • Headache • Rhinorrhoea • Vomiting/Diarrhoea • Pneumonia • Febrile respiratory illness (FRI) • Acute respiratory illness (ARI) HPSC June ,26 ,Update 7/4/2009 368 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  363. Comparison of Community and Healthcare Cluster Definitions Definition Community Surveillance Definition of a healthcare cluster of Clusters/Outbreaks (World Health Organization) • Influenza-like illness (ILI) - • A cluster is defined as two or definition for interim surveillance more healthcare workers in the of clusters/outbreaks same healthcare facility/unit with • Three or more cases of ILI arising within the same 72 hour period unexplained acute respiratory which meet the same clinical case illness and with fever ≥38°C, or definition and where an with severe lower respiratory epidemiological link can be tract infection or pneumonia, and established with onset of illness within a • ILI symptoms include: – Acute onset of fever (temperature period of 14 days of each other ≥38°C) – OR history of fever – AND flu-like illness (two or more of the following symptoms: cough, sore throat, myalgia, headache, rhinorrhea or vomiting/diarrhoea) 7/4/2009 369
  364. Post-exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic Alert Phase 6 (Update June, 22, 2009) 7/4/2009 370
  365. 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 • In institutions where there is no Occupational Health Physician, the General Manager will consult with the Chair of the Medical Executive to assign this role to a suitable doctor. See also Supplement 10, Guidance for Pandemic Influenza: Infection Control in Hospitals, Community and Primary Care Settings available at: • http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/Guidance/PandemicInfluenzaPrepared nessforIreland/. 7/4/2009 371 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  366. Healthcare Workers with Probable Influenza A(H1N1) • Single cases • If a HCW is admitted to hospital with respiratory symptoms including pneumonia (severe respiratory illness) and they have at least one of the following in the seven days before disease onset: – Been a close contact of a confirmed case of swine influenza A (H1N1) virus infection while the case was ill – Have travelled to an area where sustained human-to-human transmission of swine influenza A (H1N1) is documented Update June 11 2009 – Worked in a laboratory http://www.hpsc.ie/hpsc/A- Z/EmergencyPlanning/AvianP andemicInfluenza/SwineInflu enza/AdviceforHealthProfessi onals/GPs/File,3724,en.pdf 7/4/2009 372 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  367. 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/). 7/4/2009 373 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  368. 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 – If visible soiled use WHO guidance for visible soiled hand wash technique – Cover their mouth with a tissue when they cough 7/4/2009 and/sneeze, and dispose carefully in a bin afterwards 374 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  369. Influenza A(H1N1) Infection Control In Health Care Setting • For visible soiled hands WHO recommends the following technique 7/4/2009 375
  370. Healthcare Workers with Probable Influenza A(H1N1) Occupational Health Role Update June, 11, 2009 • “Close contacts in the health care setting are defined as: health or social care workers who provided direct clinical or personal care or who examined a symptomatic patient (including taking nasal and throat swabs for viral testing) without wearing appropriate personal protective equipment (PPE) for Standard, Droplet and Contact Precautions: – Routine care (including taking nasal and throat viral swabs): surgical mask, gloves, plastic apron (and goggles if risk of splashing or spraying) – Aerosol generating procedures: FFP2 or FFP3 masks, goggles, long-sleeved gown and gloves. – Failure to implement hand hygiene following contact with contaminated surfaces or after removing PPE is also considered to pose risk of infection. – Casual contact with the ill person for example, passing them in the corridor at work or waving to them etc. does not mean you are a contact and does not require any further action. • The following groups of healthcare workers caring for patients with probable/confirmed influenza A(H1N1) will require a risk assessment and consideration of chemoprophylaxis: – Healthcare workers who have not worn appropriate PPE – Healthcare workers who have worn PPE without formal fit testing – Healthcare workers who have worn surgical masks but who have been unwittingly exposed to patient generated aerosols” 7/4/2009 Cited from HPSC 376
  371. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • The Occupational Health team (or as per local arrangements) will inform Public Health about details of contacts • A Public Health Doctor will contact you to ask you a number of questions about your health and the amount / type of contact which you had with the sick person, and will advise on what precautions you need to take • In hospitals, where there is an Occupational Health Department, this will be carried out by Occupational Health staff 7/4/2009 377
  372. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • Health or social care workers who provided direct clinical/personal care or who or who examined a symptomatic patient without wearing appropriate PPE** – Those who were wearing appropriate PPE should self monitor for one week and report symptoms as explained in Public Health Management of Contacts PEP Phase 6 Update June, 22, 2009 7/4/2009 378
  373. Healthcare Workers with Probable Influenza A(H1N1) Surveillance • All healthcare workers at this time should be self monitoring for flu-like symptoms and should report the development of same to their line manager promptly. • HCW contacts of suspected or confirmed Influenza A (H1N1) should check their temperature twice a day and look out for flu-like symptoms for a period of 7 days: – Fever (38.0°C C or 100.4 °F or higher) – Flu like symptoms (cough, runny nose, sore throat, headache or aches and pains) – Diarrhoea, vomiting • Please report the development of any flu like symptoms to public health staff and to your line manager promptly. You will also be asked to contact Occupational Health. 7/4/2009 379
  374. Healthcare Workers “Fitness for Work” Occupational Health Role • Fitness for Work • Occupational health advice on fitness for work (or on the need for work restrictions at a given time) should be sought by: • Healthcare workers who develop symptoms of ILI (Influenza Like Illness), who should report to their line manager in the first instance • Healthcare workers recovering from ILI • Healthcare workers who have been in unprotected contact with suspect or confirmed cases of ILI (either in the community or at work) • Healthcare workers who have been prescribed antiviral therapy by their GP or a Public Health Doctor • Healthcare workers who have pre-existing medical conditions which might increase their risk of severe influenza complications • Pregnant healthcare workers • Healthcare workers who cannot achieve an adequate ‘seal’ with the PPE provided by their employer 7/4/2009 380
  375. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed Influenza A(H1N1) 7/4/2009 381 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  376. 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. 382 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  377. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.2 Occupational Health Programme Standard Precautions  HCWs should self monitor their own health for influenza like symptoms  HCWs with symptoms should not attend work and should immediately report symptoms to their line manager 2.3 Patient Placement Standard Precautions Home  Assess the patient with suspected or confirmed influenza A(H1N1) by phone at home if possible GP/Primary care/Community Droplet Precautions  Place in a single room and avoid communal areas if possible. Otherwise do not place within approximately 1 metre of other patients Contact Precautions Hospital  Place patient with suspected or confirmed influenza A(H1N1) in a single room preferably with ante room and en-suite facilities  Emergency departments without single rooms must have interim arrangements in place to prioritise transfer to an appropriate single room  Avoid communal areas and placing patient within approximately 1 metre of other patients  Ambulance Refer to ambulance advice document 2.4 Hand Hygiene Standard Precautions Hand hygiene using liquid soap or alcohol hand gel/rub must be performed before and after all patient care procedures 2.5 Patient Movement and Transfer Standard Precautions External transfer Patient should wear a surgical mask outside their room It is the responsibility of the transferring facility to inform staff of the precautions required Droplet Precautions  Refer to ambulance advice document Contact Precautions Internal transfer  Minimise movement of patient from single room  Patient should wear a surgical mask outside their room  Staff should be informed of the precautions required in the receiving departments (e.g. diagnostic departments)  Avoid holding patients in communal areas (radiology etc)  HCW PPE: Wear a surgical mask and observe hand hygiene 7/4/2009 Medical Management of Biological Casualties 383 Revised and Modified 29/04/2009
  378. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.6 Respiratory Hygiene & Cough Standard Precautions Infections should be: Etiquette  Identified promptly in primary care and emergency departments  Offered masks (and other symptomatic persons e.g., persons who accompany ill patients should also be offered masks) Droplet Precautions  Encouraged to maintain spatial separation, ideally a distance of approximately 1 meter, from others in common waiting areas Emergency departments and primary care facilities should:  Ensure that supplies of tissues, foot operating waste bins and hand hygiene facilities are available in all departments including waiting areas throughout the facility  Educate patients/visitors/carers on Respiratory Etiquette and Cough Hygiene using some or all of the following:  Patient information leaflets  Posters in all departments especially waiting areas  If influenza A(H1N1) is suspected place patient & persons who accompany ill patients in a single room  See Appendix A for respiratory hygiene and cough etiquette poster. The poster can be downloaded from the following website http://www.ndsc.ie/hpsc/A- Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/Factsheets/RespiratoryHygiene/File,35 99,en.pdf 7/4/2009 384
  379. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.7 Personal Standard Precautions The following applies to all settings: Protective Droplet Precautions GP/Primary care/Ambulance transfer/Hospital Equipment Contact Precautions Patient should wear: (PPE)  A surgical mask when outside their single room HCWs must wear the following for: 1. Routine care  Surgical mask, Plastic Apron/Gown, Gloves (& Goggles if splashing/spraying risk) 2. Aerosol Generating Procedures  FFP2 or FFP3 mask (correctly fitted), Goggles, Long sleeved disposable gown, Gloves Refer to Aerosol Generating Procedures document and to PPE poster Masks  Change mask if it becomes damp, wet or torn  Change and discard mask when leaving the room or patient care area HCW’s when putting on and removing PPE must :  Put on and remove in the correct sequence (refer to PPE poster)  Remove gloves & apron/gown inside the single room  Remove mask in the ante room or immediately outside the single room if there is no ante room. Ensure door is closed.  Decontaminate hands immediately after removing PPE 7/4/2009 385
  380. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components PRECAUTIONS Key Elements of Clinical Practices and Measures 2.8 Environmental Decontamination Standard Precautions In addition to Standard Precautions: Only take essential equipment and supplies into the room. Droplet Precautions  Do not stockpile as unused stock will have to be discarded on cessation of additional precautions  Patient charts/records should not be taken into the single room Contact Precautions  The frequency and intensity of cleaning may need to be increased based on the patients level of hygiene and the level of environmental contamination  HCW’s must wear surgical mask, gloves, apron for cleaning the patients room  Thoroughly clean the environment and furniture and all patient care equipment daily with a neutral detergent and disinfectant (hypochlorite solution 1000 ppm) paying special attention to frequently touched sites and equipment close to the patient  On patient discharge/transfer cleaning and disinfection of the environment  Prior to initiating environmental cleaning and disinfection, all privacy, shower and window curtains must be removed and sent for laundering All disposable items including paper towels and toilet paper should be discarded All sterile and non-sterile supplies in the patient room to be discarded on patient transfer/discharge Dishes and Eating Utensils  Cutlery and crockery - No additional measures are required for cutlery and crockery washed in a dishwasher or wash with liquid detergent and water 2.9 Patient Care Equipment & Standard Precautions In addition to Standard Precautions: Decontamination of Medical Devices  Dedicate patient care medical devices (e.g., thermometers, sphygmomanometers, stethoscopes, glucometers) to single Droplet Precautions patient use  Use disposable equipment whenever possible Contact Precautions  Manufacturer’s instructions should be followed for cleaning and disinfecting of reusable medical equipment after use  Single use items should be disposed of after use  Bedpan/Commodes  Use a working washer disinfector at 80°C for one minute  Dedicate a commode to single patient use if no en suite available  Decontaminate commode surface after each patient use with a hypochlorite solution 1000 ppm 7/4/2009 386
  381. Swine influenza A (H1N1) Infection Prevention and Control Precautions for use when caring for patients with suspected or confirmed swine influenza A (H1N1) Key Components STANDARD Key Elements of Clinical Practices and Measures PRECAUTIONS 2.10 Linen/Laundry Standard Precautions  No additional precautions necessary  As per Standard Precautions all contaminated laundry should be carefully placed in an alginate stitched or water soluble bag and then placed into a laundry bag clearly identified with labels, colour-coding or other methods prior to transport to an approved laundry capable of dealing with contaminated linen 2.11 Management of needle stick injuries (NSI) and Standard Precautions  No additional precautions necessary blood and body fluid exposure 2.12 Management Standard Precautions  No additional precautions necessary for Non Healthcare Risk and Healthcare Risk Waste of Waste  Dispose of all PPE as Healthcare Risk Waste (e.g. used masks) 7/4/2009 387
  382. 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. 7/4/2009 391 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  383. Aerosol Generating Procedures (AGP) According to WHO • Aerosol generating procedures: • Nebulisation • Intubation and related • Non-invasive positive procedures, e.g. manual pressure ventilation ventilation • Bi-level positive airway • Respiratory and airway suctioning pressure (BiPAP) ,CPAP,NIV (including tracheostomy care) • High frequency oscillating • Nasopharyngeal aspiration ventilation • Cardiopulmonary resuscitation • Bronchoscopy • Nasopharyngeal aspirate • Transtracheal aspirate • Broncheo-alveolar lavage • Biopsy of lung or tracheal tissues • Autopsy procedures – i.e.. (Oscillating saws) 7/4/2009 392
  384. 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 7/4/2009 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  385. 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! 7/4/2009 394
  386. 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 7/4/2009 395 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  387. 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 7/4/2009 396 cotton mask described by Dato et al
  388. 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 7/4/2009 397 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  389. Influenza A(H1N1) Respiratory Protection Programme • Example 7/4/2009 398
  390. 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) 7/4/2009 399
  391. 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 7/4/2009 400
  392. 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 7/4/2009 401
  393. 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 7/4/2009 402
  394. 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) 7/4/2009 403 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  395. How To Perform a Particulate Respirator Seal Check 7/4/2009 404 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  396. Donning and Doffing Personal Protective Equipment (PPE) Donning PPE Doffing PPE 7/4/2009 405 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  397. 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. • 7/4/2009 406 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  398. 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 7/4/2009 FFP3 valved moulded cup mask 407 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  399. 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! 7/4/2009 408 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  400. 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 7/4/2009 409 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  401. 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. 7/4/2009 410 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  402. Influenza A(H1N1) Handling Human Remains (HHR) • Family Contact with the Deceased in Health Care Settings • For deceased persons with confirmed, probable, or suspect novel influenza A (H1N1), consider limiting contact with the body in health care settings to close family members • Direct contact with the body is discouraged; however, necessary contact may occur as long as hands are washed immediately with soap and water 7/4/2009 411
  403. Influenza A(H1N1) Handling Human Remains • Transport of Deceased Persons • Transport of deceased persons does not require any additional precautions when bodies have been secured in a transport bag • Hand hygiene should be performed after completing transport • Standard precautions should be used when handling deceased individuals, and preparing bodies for autopsy or transfer to mortuary services • Standard Precautions apply, and appropriate use of personal protective equipment (PPE) (e.g., gowns, gloves, masks, and/or eye protection) is recommended • After PPE is removed, hand hygiene should be performed 7/4/2009 412
  404. Influenza A(H1N1) Handling Human Remains Medical Examiner • Influenza A (H1N1) handling of Human Remains 7/4/2009 413 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  405. Influenza A(H1N1) Handling Human Remains Medical Examiner • Personal protective equipment (PPE) • Standard autopsy PPE, which includes: – Scrub suit worn under an impervious gown or apron – Goggles, face shield – Double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves – Surgical mask or respirator – Shoe covers • Aerosols generated procedure: use of oscillating saws – FPP 2-3 disposable particulate respirators – Powered Air Purifying Respirator (PAPR) • Autopsy personnel who cannot wear a disposable particulate respirator because of facial hair or other fit limitations should wear a loose-fitting (e.g. helmeted or hooded) PAPR • Remove PPE before leaving the autopsy suite and dispose in accordance with facility policies and procedures 7/4/2009 414
  406. Influenza A(H1N1) Handling Human Remains Medical Examiner: Environmental Precautions for Autopsies • Autopsies on human remains infected with novel influenza A (H1N1) in autopsy settings that have adequate air-handling system • Airborne infection isolation rooms (AIIRs): • Minimum of six (old construction) to twelve (new construction) air changes per hour (and direct exhaust of air to the outside or passed through a HEPA filter if air is recirculated • For autopsies, local airflow control (e.g., laminar flow systems) can be used to direct aerosols away from personnel; however, this safety feature does not eliminate the need for appropriate PPE • Use biosafety cabinets for the handling and examination of smaller specimens • Use vacuum shrouds for oscillating saws to contain aerosols and reduce the volume released into the ambient air environment 7/4/2009 415
  407. Influenza A(H1N1) Handling Human Remains Funeral Service • Influenza A (H1N1) handling of Human Remains 7/4/2009 416 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  408. Influenza A(H1N1) Handling Human Remains Funeral Service • Influenza A(H1N1) ; Cat B for HHR • There should be minimal contact/handling of the body • When there is a need to do so, the following precautions are recommended: – When handling dead bodies, do not smoke, eat or drink and avoid contact with their own mouth, eyes or nose with their hands – Avoid direct contact with blood or body fluids from the dead body – Make sure that any cuts, wounds or abrasions are covered with waterproof bandages or dressings – Put on disposable gloves and protective clothing/uniform when handling dead bodies – Hands must be washed after removing gloves and protective clothing – Embalming should not to be done, but if so Minimize environmental contamination during embalming – Viewing of the face without physical contact may be permitted – Relatives who are worried about having already been exposed to the infection should contact the physician – Cremation is recommended for the deceased’s body 7/4/2009 417
  409. Influenza A(H1N1) Bioethics 1. Equity of access to antivirals and vaccines 2. Transparency, honesty and good Ethical Dilemmas in a Pandemic Proceedings of the Irish Council for communications Bioethics Conference 17th October 2006, Dublin 3. Individual autonomy v. public good  Freedom vs. Quarantine 4. Imperatives of urgency in outbreak Dr. Darina O’Flanagan situations 5. Duty of care of healthcare workers and value of reciprocity of employers 7/4/2009 418
  410. 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 7/4/2009 419 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  411. Influenza A(H1N1) Preventive Methods 1. Isolation Suspected swine flu patient (left) is escorted by a quarantine officer to 2. Quarantine Ambulance 3. Social Distancing 4. EU and Irish Quarantine Statue hard to find therefore US example Used! 5. In Ireland voluntary quarantine measures are presented in HPSC Post Exposure Prophylaxis “PEP” form QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER QUARANTINE DO NOT ENTER 7/4/2009 420 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  412. Influenza A(H1N1) Irish Post-Exposure Prophylaxis (PEP) • Post-Exposure Prophylaxis (PEP) for close contacts of probable or confirmed human case(s) of Influenza A(H1N1) in WHO Pandemic 6 7/4/2009 Updated PEP June, 22, 2009 421
  413. 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
  414. 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
  415. 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
  416. 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
  417. 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
  418. 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
  419. 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
  420. 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
  421. 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 7/4/2009 430 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  422. 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 7/4/2009 431
  423. 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 7/4/2009 432 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  424. 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 7/4/2009 433 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  425. 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 7/4/2009 434 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  426. 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 7/4/2009 435 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  427. Public Health Management for Contacts of Probable or Confirmed Case of Influenza A (H1N1) on a Aircraft (Update June 2 2009) 7/4/2009 436
  428. 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! 7/4/2009 437 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  429. 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 7/4/2009 438 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  430. Influenza A(H1N1) Irish Port Health Travel Alert Resources • 29 April, 2009, notices were put in place at Irish ports and airports 7/4/2009 439 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  431. Influenza A(H1N1) Risk Travel Advisories • HSE/DOHC Travel advisory July, 3, 2009 Chinese health workers in protective outfits examine passengers onboard an AeroMexico flight AM 98 that landed at Pudong international airport in Shanghai from Mexico Thursday, April 30, 2009 7/4/2009 440 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  432. 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 + (52 55) 55 20 58 92 77500 Quintana Roo Security Status Telephone: July , 3, 2009 Email: +52 998 112 5436 Submit your query here Fax: Exercise Caution Website: +52 998 884 9940 www.irishembassy.com.mx Email: consul@gruporoyale.com Honorary Consul: Anthony Leeman 7/4/2009 441
  433. Influenza A(H1N1) Advice for Travellers to Ireland Update 7/4/2009 442
  434. Influenza A(H1N1) Passenger Health Questionnaire 7/4/2009 443 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  435. Influenza A(H1N1) Aircraft Cleaning Guidance 7/4/2009 444 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  436. Cabin Air Quality – Risk of Contagious Viruses Suspected SARS Passenger coming into Frankfurt Airport 7/4/2009 445 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  437. Influenza A(H1N1) Ship Cleaning Guidance 7/4/2009 446 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  438. Influenza A(H1N1) Irish Marine Notice May 8 2009 7/4/2009 447
  439. Influenza A (H1N1) Sydney Harbour Cruise Ship Quarantine? • The Pacific Dawn has already been blamed for a spike in Australian swine flu cases after authorities last week allowed 2,000 passengers to disembark in Sydney despite a suspected swine flu outbreak aboard • At least 46 passengers and crew aboard a previous Pacific Dawn cruise that docked at Sydney a week ago have been infected with the virus • June 1 2009 A cruise ship carrying three crew infected with swine flu agreed not to dock in northern Australia According to information received from SHIPSAN, there has been 5 cruise ships with influenza A(H1N1) cluster outbreaks since the beginning of the pandemic, the first one being reported on May 25, 2009 Pacific Dawn: Passengers line the upper deck of the P&O Cruises Pacific Dawn ship as it docks at Darling Harbour in Sydney 3 days later • Embarked to emergency medical teams testing for Influenza A(H1N1)! 7/4/2009 448
  440. EU SHIPSAN TRAINET • EU SHIPSAN TRAINET project which started in 2008 and will be completed in May 2011 • This project foresees the development of: a) Harmonised communicable diseases surveillance including ILI syndrome by using standardised reporting forms b) A manual providing hygiene standards (e.g. for disinfection and cleaning), and outbreak management guidelines for airborne diseases c) Training of port health personnel and crew members on hygiene issues and outbreak management d) A communication network for collection and sharing of surveillance and ship inspection data among competent authorities • Eurosurveillance, Volume 14, Issue 21, 28 May 2009 • Perspectives • Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication 7/4/2009 449
  441. 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 7/4/2009 450 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  442. 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 7/4/2009 451 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  443. 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 7/4/2009 452 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  444. Influenza A(H1N1) Travel Advisories 7/4/2009 453 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  445. What are the differences between Influenza A (H1N1) and the Common cold? Symptoms Influenza A(H1N1) Common Cold Onset Suddenly Slowly Fever Characteristically High (≥38oC or Rare 100oF) Headache Prominent Rare General aches and pain Usual, often severe Rare Fatigue, weakness Can be prolonged for a number Quite mild of weeks Extreme exhaustion Early and prominent Never Stuffy nose Sometimes Common Sneezing Sometimes Usual Sore throat Sometimes Common Chest discomfort, cough Common, can be severe Mild to moderate, hacking cough Diarrhoea, vomiting Commonly Not associated with the common cold in adults 7/4/2009 454 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  446. Personal Steps To Take If you Experience Flu-like Symptoms • Contact hospital or healthcare facility prior to going to allow phone triage and allow time to have precautionary measures in place before arrival! 455 7/4/2009
  447. 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 7/4/2009 456 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  448. 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 7/4/2009 457 Medical Management of Biological Casualties Revised and Modified 29/04/2009
  449. Influenza A (H1N1) in Educational Institutions/Schools 7/4/2009 458
  450. 2009 Influenza A(H1N1) Co Mayo , “St John's National School” • St John's National School in Breaffy near Castlebar, Co Mayo • 7 year old girl in first class has now been quarantined and is responding well to treatment at home • Transmission occurred from relative returning from abroad • Theses children meet Influenza A(H1N1) contact case definition and post- exposure prophylaxis protocol! • Therefore anti-viral medication will now be provided to 28 St John's National School in Breaffy children who were in the girl's class • The HSE said that the school remains open! Unless the Department of Public Health advises the school to close • Parents voluntarily have removed some children as a precautionary measure • All children will see there GP upon returning to school ! • Contact HPSC immediately upon probable or confirmed case in schools!  Influenza A(H1N1)virus has been identified at a National School in Co Roscommon. (July, 2, 2009) • Roxboro NS is a five-teacher school with more than 130 pupils 7/4/2009 459
  451. 2009 Influenza A(H1N1) Irish School Recommendations • This virus currently appears to be acting like seasonal influenza in terms of the severity of illness and transmission of infection. Given this information, schools can remain open with appropriate isolation of the individuals at home or close