The data presented are per 4th of March 2017 and subject to changes. The presentation aims to provide the basic infection control requirement for healthcare facilities during large influenza epidemic or pandemic

1. INFLUENZA A
EMERGENCY
PREPAREDNESS
BY
DR. MOUSTAPHA A. RAMADAN
MD
INFECTION CONTROL DOCTOR & HOSPITAL
EPIDEMIOLOGIST

2. OBJECTIVES OF THE SESSION
I. Introduction/ Facts
II. Seasonal / Pandemic/ Zoonotic-variant Flu
III. Emergent types
IV. Risk Assessment
V. Preparedness / Infection control and prevention of
influenza

3. INTRODUCTION
 The flu is a contagious respiratory illness caused by
influenza viruses that infect the nose, throat, and
lungs. It can cause mild to severe illness, and at times
can lead to death.
 The incubation period is 1-3 days, and the period of
communicability among adults is 1 day before onset
of symptoms up to 5 days after becoming sick.
 MOT : Contact (Droplet/Direct/Indirect) Airborne

4. INTRODUCTION
 Morbidity tends to be high and mortality low (1–4%).
 Global estimates are 30-50 millions are affected
yearly, 250 000-500 000 deaths yearly
 Influenza hospitalizations rates (20.3/100,000
to 321.1/100,000, depending on age group)

5. INFLUENZA VIRUS
A/Fujian/411/2002 (H3N2)
Neuraminidase
Hemagglutinin
Type of nuclear
material
Virus
type
Geographic
origin
Strain
number
Year of
isolation
Virus
subtype

6. INFLUENZA
ANTIGENIC CHANGES
Antigenic Shift
• major change, new subtype
• caused by exchange of gene segments
• may result in pandemic
Example of antigenic shift
• H2N2 virus circulated in 1957-1967
• H3N2 virus appeared in 1968 and completely replaced
H2N2 virus

7. INFLUENZA
ANTIGENIC CHANGES
Antigenic Drift
• minor change, same subtype
• caused by point mutations in gene
• may result in epidemic
Example of antigenic drift
• in 2002-2003, A/Panama/2007/99 (H3N2) virus was
dominant
• A/Fujian/411/2002 (H3N2) appeared in late 2003 and
caused widespread illness in 2003-2004

9. SubType People Poultry Pigs Bats / Other
H1
H2
H3 Other Animals
H4 Other Animals
H5
H6
H7 Other Animals
H8
H9
H10
H11
H12
H13
H14
H15
H16
H17
H18
SubType People Poultry Pigs Bats / Other
N1
N2
N3
N4
N5
N6
N7 Other Animals
N8 Other Animals
N9
N10
N11

10. SEASONAL
INFLUENZA
 Seasonal influenza viruses circulate and cause
disease in humans every year.
 In temperate climates, disease tends to occur
seasonally in the winter months, spreading from
person-to-person through sneezing, coughing, or
touching contaminated surfaces.

11. SEASONAL
INFLUENZA
 Seasonal influenza viruses can cause mild to severe
illness and even death, particularly in some high-risk
individuals (pregnant women, the very young and
very old, immune-compromised people, and people
with chronic underlying medical conditions).

12. PANDEMIC
INFLUENZA
 A pandemic is a global outbreak when an influenza
virus which was not previously circulating among
humans and to which most people don't have
immunity emerges, infects and spreads easily
among humans in an efficient and sustained way.

13. PANDEMIC
INFLUENZA
 As the majority of the population has no immunity to
these viruses, the proportion of persons in a
population getting infected may be quite large.
 Some pandemics may result in large numbers of
severe infections while others will result in large
numbers of milder infections, but the reasons behind
these differences are not completely understood.

14. ZOONOTIC/VARIANT
INFLUENZA
 Influenza viruses that are routinely circulating in
animals, such as avian influenza virus subtypes
A(H5N1) and A(H9N2), swine influenza virus
subtypes A(H1N1) and (H3N2) and other species
including horses and dogs.
 These viruses are distinct from human influenza
viruses and do not easily transmit between humans.

15. ZOONOTIC/VARIANT
INFLUENZA
 Occasionally humans can acquire these infections
through direct contact with infected animals or
contaminated environments, and may cause
disease ranging from mild conjunctivitis to severe
pneumonia and even death.
 If such a virus acquired the capacity to spread easily
among people either through adaptation or
acquisition of certain genes from human viruses, it
could start an epidemic or a pandemic.

17. EMERGENT TYPES

18. AVIAN INFLUENZA A
(H5N1)

19. AVIAN INFLUENZA A
(H5N6)
 Since 2014, a total of 16 laboratory-confirmed cases of
human infection with influenza A(H5N6) virus, including
six deaths, have been reported to WHO from China.
 Although other influenza A(H5) subtype viruses have the
potential to cause disease in humans, no human cases,
other than those with influenza A(H5N1) and A(H5N6),
have been reported so far.
 Influenza A(H5N8) have been detected in wild birds and
domestic poultry in several countries in Africa, Asia and
Europe.

20. AVIAN INFLUENZA A
(H7N9)
 Since 2013, a total of 1223 laboratory-confirmed human
infections with avian influenza A(H7N9) virus were
reported to WHO including 380 deaths.
 Human infections with the A(H7N9) virus are unusual and
need to be monitored closely in order to identify changes
in the virus and/or its transmission behaviour to humans
as it may have a serious public health impact.
 Public health risk assessment found the risk from avian
influenza A(H7N9) viruses has not changed

21. AVIAN INFLUENZA A
(H7N9)
 Though small clusters of cases have been reported,
including those involving healthcare workers, current
epidemiological and virological evidence suggests that
this virus has not acquired the ability of sustained
transmission among humans.
 WHO advises travellers to countries with known
outbreaks of avian influenza should avoid, poultry farms,
contact with animals in live bird markets, entering areas
where poultry may be slaughtered, or contact with any
surfaces that appear to be contaminated.

22. AVIAN INFLUENZA A
(H7N9)

23. AVIAN INFLUENZA A
(H7N9)
 Experts from (WHO) and (GISRS) reviewed available
epidemiologic and virologic data related to influenza A(H7N9)
viruses to evaluate the need to produce additional CVVs to
maximize influenza pandemic preparedness.
 Two additional H7N9 CVVs were recommended for
development: a new CVV derived from an
A/Guangdong/17SF003/2016-like virus ;and a new CVV derived
A/Hunan/2650/2016-like virus.
 At this time, CDC is preparing a CVV derived from an
A/Hunan/2650/2016-like virus using reverse genetics.

24. AVIAN INFLUENZA A
(H7N2)
 Since 2002, a total of 3 laboratory-confirmed human
infections with avian influenza A(H7N2) virus were
detected in USA. ( Latest December 2016)
 In 2007, UK reported 4 human cases linked to l an
outbreak of avian influenza in poultry at a
smallholding in Wales.
 No human-to-human transmission was detected

25. AVIAN INFLUENZA A
(H7N2)
 One associated human infection in a person who
had close, prolonged unprotected exposure to the
respiratory secretions of infected, sick cats. A
Second infection was associated with exposure to
infected poultry and third was undetermined.
 Cats are not the typical host of avian influenza
viruses; however, cats have been infected in the
past with such viruses (avian and human seasonal).

26. AVIAN INFLUENZA A
(H9N2)
 Up to date around 35 cases of laboratory confirmed human
infections with avian influenza A(H9N2) virus were reported
to WHO including ONE death.
 Most human cases are exposed to the A(H9N2) virus
through contact with infected poultry or contaminated
environments.
 No case clusters have been reported.

27. SWINE INFLUENZA
 In USA since 2005, 9 laboratory-confirmed human infections
with influenza A v(H1N2) virus were detected; 4 during
2016.
 December 2016, the first human case of A/Indiana/08/2011-
like H3N2v influenza virus infection reported to WHO from
Canada.
 No human-to-human transmission was detected

28. CANINE INFLUENZA
 Also known as dog flu is a contagious respiratory disease
in dogs caused by specific Type A influenza viruses
known to infect dogs.
 No human infections with canine influenza have ever been
reported.
 There are two different influenza A dog flu viruses: one is
an H3N8 virus and the other is an H3N2 virus
 Canine influenza H3N8 virus originated in horses, has
spread to dogs, and can now spread between dogs.
 The H3N2 canine influenza virus is an avian flu virus that
adapted to infect dogs

29. BAT FLU
 Bat flu was first discovered in Guatemala during a study
conducted in 2009 and 2010.
 The surface protein coding genes were found to be
extraordinary different from know flu viruses.
 CDC had classified these genes into H17, H18 and
N10,N11.
 No human infections with bat flu have ever been reported.

30. RISK ASSESSMENT
May 2016, WHO has launched Tool for Influenza
Pandemic Risk Assessment (TIPRA) version I.
(TIPRA) is an influenza hazard assessment tool designed
to assess the likelihood and potential impact of a virus
becoming a pandemic strain.

31. TIPRA
 a standardized, streamlined, transparent hazard assessment
tool designed for influenza A viruses with pandemic potential;
 a tool to assist global and Member State pandemic influenza
planning and preparedness, particularly states affected by
viruses of concern;
 a tool for informing comprehensive influenza and public
health risk assessment, risk management and risk
communication; and
 a tool designed to allow hazard assessment with incomplete
data, providing a robust means of identifying information
gaps, which may direct surveillance and research resources.

32. TIPRA
The objectives of TIPRA are to:
support a timely, updatable virological risk assessment for
influenza viruses with pandemic potential;
 transparently document features of the virus that might
pose threats to a human population;
 identify knowledge gaps and prompt further investigations
including research and surveillance;
 facilitate information-sharing among scientists, policy-

33. TIPRA
 Initiating a TIPRA application requires a known human
case, development of a virus profile, and engagement
of appropriate expertise to score all TIPRA risk
elements.
 The availability of data and ability to infer on high-
weight risk elements should be considered prior to the
initiation of a TIPRA run.

34. TIPRA
Scoring consistency
In order to ensure comparability between viruses, it is
essential that experts score viruses consistently.
TIPRA risk element definitions and scoring strata attempt
to minimize ambiguity
Viruses assessed must be clearly defined, as risk may
vary depending on the level at which viruses are
differentiated.

35. TIPRA
Population immunity gateway
The gateway is based on preexisting population
serological immunity to the virus.
If 30% of the population aged 18 years has evidence of
cross-reactive antibodies, the virus is considered to have
low pandemic risk, so assessment of other factors of
pandemic risk is not essential.
Experts devised this gateway cut-off based on review of
previous pandemic data.

36. TIPRA
Timeliness:
To maximize utility, risk assessment outputs must be
timely.
WHO estimated that each virus profile required
approximately eight days of input -- four days
epidemiology, four days virology -- with additional time
for expert review and refinement.

37. TIPRA
National capacity:
National stakeholder awareness and involvement in
TIPRA is essential. This involves awareness among
International Health Regulations (IHR) National Focal
Points (NFPs), National Influenza Center teams, influenza
disease program managers and outbreak emergency risk
assessment and management teams.
National capacity is required to incorporate findings into
more comprehensive risk assessments that also consider
exposure and context

38. TIPRA
Documentation and Replication:
TIPRA provides a snapshot at a point in time based on
historical and the most up-to-date data. It is critical to
document when the assessment was conducted and what
information was available at the time.
TIPRA should be repeated for key viruses as new
information comes to light. This is equally true for context
and exposure assessments and risk management
strategy development and option evaluation.

39. INFECTION
PREVENTION
 The first and most important step in preventing flu is to
get a flu vaccination each year.
 There are two forms for influenza vaccine Inactivated
Form and Live attenuated Form.
 The nasal spray flu vaccine (live attenuated influenza
vaccine or LAIV) should not be used during 2016-2017.
 This is based on data showing poor or relatively lower
effectiveness of LAIV from 2013 through 2016.

40. INFLUENZA VACCINE
For 2016/2017 winter (Northern Hemispere)
an A/California/7/2009 (H1N1)pdm09-like virus;
an A/Hong Kong/4801/2014 (H3N2)-like virus;
a B/Brisbane/60/2008-like virus
++ B/Phuket/3073/2013-like virus.
For 2017 winter Season Southern Hemishpere
an A/Michigan/45/2015 (H1N1)-like virus; replace the
A/California/7/2009.

41. HEALTHCARE
PREPAREDNESS
Health-care facilities should prepare for communicable
disease emergencies by :
organizing permanent IPC activities, surveillance and
training of dedicated personnel and clinical staff;
creating a multidisciplinary group within the health-care
facility to develop a preparedness plan;
performing a plan evaluation and monitoring exercise, and
updating the plan as necessary; and
strengthening liaison with other levels of the health-care
system and public health authorities.

42. HEALTHCARE
PREPAREDNESS
The main goals of the plan are :
 identify, isolate and report early cases of a putative
epidemic or pandemic ARI virus;
keep the health-care system functioning for pandemic and
non-pandemic patients; and
reduce the risk of pandemic ARI transmission associated
with health care.

43. HEALTHCARE
PREPAREDNESS
1- Surveillance
2- Triage
3- Surge capacity
4-Access
5- Infection prevention
and control
6- Occupational health
program
7- Patient flow and
discharge plan
8- Mortuary
9- Risk communication
policy
10- Promotion of outpatient
care of ARI patients
Components of health-care facility pandemic acute
respiratory infection preparedness plan

44. INFECTION PREVENTION
AND CONTROL
 Minimize Exposures
 Implement Engineering Control
 Implement Infection Control Precautions
 Monitor and mange ill and exposed healthcare workers
 Train and Educate healthcare workers
 Implement Environmental Infection Control
 Manage visitor access and movement within the facility

45. MINIMIZE
EXPOSURES
 prompt screening and triage of symptomatic patients,
 provide space and encourage persons with symptoms of
respiratory infections to sit as far away from others as
possible
 implementation of respiratory hygiene and cough
etiquette

46. MINIMIZE
EXPOSURES
 placement of a facemask on symptomatic patients upon
entry to the facility,
 rapid implementation of airborne isolation precautions, in
additional to standard and contact precautions
 Provide supplies to perform hand hygiene to all patients
upon arrival to facility and throughout the entire duration
of the visit to the healthcare setting.

48. IMPLEMENT
ENGINEERING CONTROL
 Installing physical barriers such as partitions in
triage areas, curtains that are drawn between
patients in shared areas.
 Reducing exposures related to specific procedures
such as using closed suctioning systems for airways
suction in intubated patients.
 Ensuring that appropriate air-handling systems (with
appropriate directionality, filtration, exchange rate,
etc.) are installed and maintained in healthcare
facilities.

49. IMPLEMENT INFECTION CONTROL
PRECAUTIONS
 Patient should be isolated in AIIR, single bed room.
 Standard, Contact and Airborne precautions should be
implemented for patients with suspected or confirmed
novel influenza for the period of illness/stay.
 Remove PPE at doorway or in anteroom. Remove
respirator after leaving patient room and closing door.
 Cleaning environmental surfaces with water and
detergent and applying commonly used disinfectants
(such as hypochlorite) is effective and sufficient.

50. PRECAUTIONS FOR AEROSOL-GENERATING
PROCEDURES
 Only performing these procedures if it cannot be
postponed
 Limiting the number of HCP present during the
procedure to only those essential for patient care and
support
 Perform the procedures in an AIIR when feasible
 Consider use of portable HEPA filtration units to
further reduce the concentration of contaminants in the

51. PRECAUTIONS FOR AEROSOL-GENERATING
PROCEDURES
 Unprotected HCP should not be allowed in a room
where an aerosol-generating procedure has been
conducted
 HCP should adhere to standard and airborne
precautions including wearing gloves, a gown, a
face shield and N95
 Conduct environmental surface cleaning following
procedures

52. MANAGEMENT OF ILL
HCW
 Stop patient-care activities.
 Notify their supervisor, preventive medicine and
infection control personnel
 Excluded from work until for 10 days and monitor S/S
 Don a facemask, Perform Cough Etiquette, Hand
Hygiene
 Start treatment

53. MANAGEMENT OF ILL
HCW
 Facilities should consider dedicating HCWs caring for
suspected and confirmed cases.
 Facilities should keep track of all HCWs who care for or
enter the rooms of these patients
 Facilities should implement sick leave policies for HCWs
 Facilities should provide medical consultation and
prompt treatment for HCWs

54. TRAINING AND
EDUCATION
HCW should be knowledgeable about :
Influenza signs, symptoms, and risk factors for
complications.
Vaccination, ways to minimize exposure including
respiratory hygiene and cough etiquette.
Infection prevention and control precautions specially
during aerosol generating procedures

55. ENVIRONMENTAL
CONTROL MEASURES
 Standard cleaning and disinfection procedures are
adequate for influenza virus environmental control in
all settings within the healthcare facility.
 Management of laundry, food service utensils, and
medical waste should also be performed in
accordance with infection control policies and
standard procedures.

56. MANAGE VISITOR ACCESS
AND MOVEMENT WITHIN THE
FACILITY
 Limit visitors for patients in isolation to persons who
are necessary for the patient’s emotional well-being
and care.
 All visitors should follow respiratory hygiene and
cough etiquette precautions
 Facilities should consider tracking (e.g., log book) all
visitors who enter patient rooms.
 Visitors should not be present during aerosol-
generating procedures.
 Visitors should be instructed to limit their movement
within the facility.

57. MANAGE VISITOR ACCESS
AND MOVEMENT WITHIN THE
FACILITY
 Facilities should provide instruction, before visitors enter
patients’ rooms, on hand hygiene, limiting surfaces
touched, and use of PPE according to current facility
policy while in the patient's room.
 Visitors are advised to change personal clothes every
day
 Exposed visitors should be advised to report any signs
and symptoms of acute illness to their health care
provider for a period of at least 10 days after the last
known exposure to the sick patient.

58. REFERENCES
 https://www.cdc.gov/flu/index.htm
 http://www.who.int/influenza/en/
 Launching the tool for Influenza Pandemic Risk assessment (TIPRA)
meeting report. WHO 2016
 Infection prevention and control of epidemic-and- pandemic prone
acute respiratory infections in healthcare WHO guidelines 2014.
 Pandemic Influenza preparedness Framework for the sharing of
influenza viruses and access to vaccines and other benefits. WHO
2011.
 Occupational Safety and Health Administration (OSHA) 2009:
Pandemic Influenza Preparedness and Response Guidance for
Healthcare Workers and Healthcare Employers.
 Influenza Update N° 283 20 Feb 2017
 WHO “Influenza at the human-animal interface” last update 14 Feb
2017