Surveillance for Human Cases of Avian Influenza

Managing Human Avian Influenza: Strategies at a Glance

Animal Health Deptt.
Quarantine of bird Culling of bird Mopping-up Disinfection & sanitisation Vaccination of bird Poultry surveillance Other aspects

Human Health Deptt.

Quarantine of human populations Surveillance: Active (0-3 km & 3-10 km) Passive (0-10 km) Health monitoring Chemoprophylaxis Case management: Isolation Antivirals Ventilatory support Lab investigation Control room set-up IEC Logistics

Event Based Human Surveillance

Outbreak Outbreak Outbreak Outbreak

Outbreak Outbreak

Outbreak Outbreak

Trigger Point for Central RRT

Report of detecting HPAI from HSADL Bhopal; NIV, Pune Report of influenza like illness with travel history or contact history suggestive of avian influenza exposure

Report of bird death from District Animal Husbandry Officer/Chief Veterinary Officer

AVIAN INFLUENZ A MONITORI NG CELL, NICD, Delhi

Rapid Response Team

Media or other report

What is Surveillance?
Surveillance of disease is the continuing scrutiny of all aspects of occurrence and spread of a disease that are pertinent to effective control Keeping a close watch

Components of Surveillance
1. 2. 3. 4. 5. 6. Collection of data Compilation of data Analysis of data Interpretation Action/Intervention Feedback

Data Collection Procedures

1. 2. 3. 4. 5. Passive surveillance Active surveillance Sentinel surveillance Outbreak investigation Surveys

Surveillance for Human Cases of Avian Influenza

Fever with ARI + history of contact with dead/sick poultry Passive: any in no. of cases in OPDs of health facilities/private practitioners Active: house to house 0-3 km & 3-10 km About 95% of targeted population covered in 0-3 km daily up to 10 days after last culling 3-10 km: one round completed in 3-4 days 500 popn=1HW; 4 HW=1 HS; 4 HS=1 MO

Active Surveillance
Proforma: line list format

Name of affected area No. of surveyed villages No. of houses: Total & visited Population: Total & visited No. of fever & ARI cases No. of fever & ARI cases, who handled dead birds No. of houses having birds & observed death of birds in last 10 days

Contact tracing

Avian Influenza Outbreak Daily Reporting Format

Avian Influenza Outbreak Daily Reporting Format

Active Surveillance Line List of Cases

Case Investigation Sheet

Name __________________________ Sex ______ Age in Years/months______ Current contact details______________________ Full address ____________________________ Telephone ____________________________ Nationality __________________________ Ethnicity_______________________
Signs and symptoms: Body temperature higher than 38C Yes No Cough Yes No Unknown Sore throat Yes No Unknown Shortness of breath Yes No Unknown Date of onset of illness (dd/mm/ yyyy) ____/____/____ History of travel................................................................................... History of occupational exposure......................................................... History of exposure to affected poultry................................................ History of exposure to wild / domestic animals................................... History of exposure to possible human cases...................................... Unknown

Active Surveillance: Population Surveyed & Incidence Rates of Fever-ARI Cases, Avian Influenza Outbreak, Jargon, 2006
3000000 0.41% 2500000 Total Population & Surveyed 2156847 2000000 0.35% 0.30% 0.45% 2525087

85.42%

0.40%

80.4% 1622879
1500000

0.25% 0.21% 0.20% 0.15% 0.10%

94.5%
1000000 902208 852563

1304284

500000

0.08% 0.05%

0 0-3 Km 3-10 km Area Total Popn SUV Popn % Fever-ARI cases Total

0.00%

% Fever-ARI cases

Contact Tracing
When the signal is received: Contact tracing must be aggressively implemented Tracing efforts should focus on persons who had close unprotected (i.e. not using PPE) contact with the case patient from 1 day before through 14 days after the case patients onset of illness Must include identification of extended social networks and travel history of all cases and contacts during the preceding 14 days Contacts of cases should be traced and followed up for evidence of respiratory illness for at least 7 days

Contact Tracing
Information about close contacts can be obtained from:

interviews of patient, family members, workplace or school associates, or others with knowledge about the patients recent activities and travels

If no. of contacts requiring investigation is large or personnel resources are limited - focus on contacts with the highest risk of infection or exposure

Contact Tracing
Priority groups should be based on:

Heightened probability of infection, such as contact with a laboratory confirmed case Duration, spatial proximity and intensity of exposure to the case patient (e.g. HCW, household contacts sharing same sleeping/eating space, persons providing bedside care)

Exposure in settings that could accelerate spread to large numbers of contacts, e.g. when a confirmed case worked in a school or attended a large gathering

Likelihood that human-to-human transmission has resulted from contact with the case patient

Contact Tracing
Whenever possible, cases should be isolated in health facilities for strict infection control Contacts should be advised to remain at home (voluntary home quarantine) for at least 7 to 10 days after the last contact with a person under investigation Should evidence of spread beyond the initial containment zone emerge:

containment areas designated for antiviral prophylaxis should be re-defined decision to be made in collaboration with local & national authorities and WHO

Contact Tracing
Line-listing of all contacts and co-exposed persons should be maintained:

demographic information date of last common exposure or date of contact with the case patient daily temperature check date of onset if fever or respiratory symptoms develop, and receipt of antiviral prophylaxis

Contact Tracing
For symptomatic persons:

refer persons with fever & respiratory illness for: collection and laboratory testing of specimens and appropriate medical care including antiviral therapy

depending on the severity of illness and availability of hospital beds, contacts that are ill may be isolated at a healthcare facility or at home while awaiting test results

Contact Tracing
For asymptomatic contacts:

initiate active monitoring (e.g. daily visits or telephone calls) for the development of fever or respiratory symptoms for 7 days after the last exposure to the case patient

self-health monitoring with daily supervision may be advised administration of antiviral chemoprophylaxis should be guided by an exposure risk assessment

Important Terms
Isolation: Separation (for the period of communicability) of infected persons from others in such places and under such conditions so as to prevent or limit the direct or indirect transmission of the infectious agent from infected to non-infected persons or who may spread the agent to others Quarantine: Restriction of the activities of apparently healthy persons who have been exposed to a case of communicable disease during its period of communicability to prevent disease transmission during the incubation period if infection should occur Social distancing: public health practice of encouraging people to keep physical distance from each other during disease outbreaks in order to slow the spread of infection

Self Health Monitoring Proforma

Cluster Reporting Format

Contact Tracing
Cases

Family Contacts

Social Contacts Workplace School Others

Travel Contacts Flight Train Others

Symptomatic Contacts Isolation Lab test(s) Treatment

Asymptomatic Contacts Quarantine Health monitoring Chemoprophylaxis

Training of Staff
Who Medical officers Health supervisors Health workers On What Case definition Active surveillance Proforma Chemoprophylaxis IEC

Other Important Issues in Surveillance

Deputation of health teams (MO, HS, HW) Preliminary strategic meeting - briefing Chemoprophylaxis & Health monitoring of staff IEC & risk communication Logistics & supplies Reporting, supervision, monitoring & coordination Control room

Chemoprophylaxis & Health Monitoring

To Whom:

Cullers Helpers Poultry farm workers Household contacts Surveillance teams Others at risk

Oseltamivir, 75 mg OD On DOTS pattern Daily monitoring: temperature & any flu like symptoms Any side effects

Chemoprophylaxis Risk Groups

Antiviral chemoprophylaxis be considered according to risk stratification:

High risk exposure groups Moderate risk exposure groups Low risk exposure groups

High Risk Exposure Groups

Household or close family contacts of a strongly suspected/ confirmed H5N1 patient:

Potential exposure to a common environmental or poultry source Exposure to the index case

Moderate Risk Exposure Groups

Personnel involved in handling sick animals, decontaminating affected environments (including animal disposal), if PPE not used properly Individuals with unprotected & very close direct exposure to sick/dead H5N1 infected animals/birds Healthcare personnel in close contact with strongly suspected/confirmed H5N1 patient Laboratory personnel might have unprotected exposure to virus containing samples

Low Risk Exposure Groups

HWs not in close contact with a strongly suspected/ confirmed H5N1 patient HWs who used appropriate PPEs during exposure to H5N1 patients Personnel involved in culling (likely) non-infected animal populations Personnel involved in handling sick animals or decontaminating affected environments (including animal disposal) who used proper PPEs

Thank You