Session 05

Part 01
Avian/Human pandemic
Influenza
Rapid Response Team

What is a Rapid Response

Team?
A team of professionals that
investigates suspected cases of avian
influenza and supports the first 72
hours of a response

Rapid Response Objectives

Assess the possibility of

human-to-human transmission

Stop or slow the spread of pandemic

influenza at the source

Minimize global mortality and

morbidity

Key Terms
Pandemic
An epidemic occurring over a wide
geographic area and affecting a large
proportion of the population.

Outbreak
A sudden, localized increase in the
occurrence of disease that is greater than the
expected occurrence of that disease.

Team Member Roles and

Responsibilities

Selection of The Team

The Ministry of Health and Family Welfare

will designate National and District Rapid
Response Team

Who is on the Team?

Core team members of DRRT
(proposed in national Plan):

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Civil Surgeon (team leader)

DCS/UHFPO sadar
Medical officer (CS Office) Member Secretary
RMO of the Sadar Hospital
Consultant Medicine
Consultant Pediatrics
Consultant (Pathology/Microbiology/Virology)
District Health Education Officer
SMO/DIMO (WHO)
Chief laboratory technician
An officer nominated by CS

What Does The Team Do?

Verify any rumor of disease outbreak
Carry out the outbreak investigation
Propose ways to stop epidemics
Initiate epidemic prevention and control
Provide technical support

Factors Essential to All Teams

Every team must have effective:
Leadership
Responsibility
Communication
Decision making

How To Work in A Team

Know what is expected
Team member responsibilities
Team member expertise
Resources available for tasks

Know your role

Know who is in charge

How To Work in A Team

Be able to problem solve when faced
with unexpected issues including:
Transportation
Communication
Cooperation

Who is on the Team?

Expanded team members:
Logisticians / Administrators
Interviewers
Communication specialist
Veterinarian or Ministry of Livestock
representative

Core Team Member Roles

Team Leader Role

The Team Leader. . .
Presents available information
Outlines investigation plans
Assigns roles and responsibilities
Oversees team member roles
Communicates with media
Conducts international reporting
Communicates with other officials

Epidemiologist Role
The Epidemiologist. . .
Verifies the outbreak
Establishes a case definition
Conducts case finding
Identifies risk factors
Identify and coordinate control measures
Institute case management measures
Supervises data collection and data analyses

Clinician Roles
The Consultant (Medicine/Pediatrics). . .
Advises and assists in managing patients
Educates, implements, and supervises
infection control measures
Knows area hospital bed capacity and
medical capability

The Chief Laboratory Technician. . .

assists in collection of clinical specimens
from case-patients

Scientist Roles
Microbiologists or Senior lab
technicians
Advise and assure proper specimen
collection, transportation, and storage
Verify proper avian influenza laboratory
diagnosis to help refine a case definition
Know area laboratory capability

Expanded Team
Member Roles

Expanded Team Members

Veterinarians

Provide expertise in bird reservoirs

Advise on control of avian flu in birds
Facilitate identification of the birds with avian flu
Advise and supervise control measures

Administrator / Operations Manager

Manage supplies
Work with security officer
Monitor finances
Arrange transportation
Monitor communications

Expanded Team Members

Interviewers
Visit patients, doctors
Collect data, either in person or by phone

Security Personnel

Team Composition is
Country-Specific
In practice, teams will reflect countrys:
capacity (human resources)
organization of governmental public health
circumstances of investigation

Knowledge and skills of team members

is critical

Enhancing Coordination And

Communication among
Team Members

Coordination and
Communication
Coordination
Delegation
Stress management
Coordination with
international teams

Communication
Contact information
Communication
channels
Disclosure of interest
Documentation
Daily review of
investigation activities
After action
discussions

Delegation
Team leader will delegate tasks to
appropriate team members
Other team members may also need to
delegate tasks when overwhelmed
Assign an alternate team leader as a
back-up

Stress Factors
Unexpected event
Intense pressure to investigate quickly
Working with multiple agencies
Security concerns
Team member(s) experiences trauma

Stress Factors
Local sensitivities
Legal concerns
Demands on team members time
Long hours, lack of rest
Personal health and safety concerns

Coordination with
International Teams
May differ depending on outbreak
Require flexibility and adaptability

Coordination with
International Teams

Communicate about these issues:

Roles and responsibilities of each team
Leadership
Reporting
Logistics
Language

Establishing Effective
Communication Channels
Teams meet or talk daily
Team leaders provide feedback to updates
Team member(s) fluent in local language
One team member designated to
communicate with agencies, the media, and
national and international health officials

Disclosure of Interest
For patients / cases:
Tell the cases who you are, what
organization you work for, what the
information will be used for

For team members:

Inform other team members of any special
interests you have for using the data

Documentation
Keep a daily log of activities:
Notes
Data
Photographs

Back up electronic data

Information for
Documentation and Review
All steps taken in the investigation
Decisions made and rationale
Contacts: name, position, contact information
Meeting Documentation
Minutes
Follow up actions and those responsible

After-action Discussions and

Reports / Evaluation
Identifies what worked
Identifies what did not work
Creates a record
Can be used as a reference
Informs IEDCR/DGHS/MOHFW

Ethical Conduct for Case

Investigations
Adopt a code of ethics
Maintain confidentiality
Protect the publics health
Be sensitive to cultural and religious
context

Code of Ethics
Ethical investigation oversight:
Avoids breaches in confidentiality
Helps the public understand
surveillance
Protects sensitive surveillance efforts
Balances public health welfare with
individual rights

Confidentiality
Maintain confidentiality of case patients full
names
Maintain confidentiality of the names of
anyone involved in the investigation
Photos of case patients, relatives, and
friends should be prohibited or allowed only
with consent

Protecting Public Health

Examine farmers and
villagers to find all cases
Assure that control
measures and education are
accomplished
Thailand example
Radio messages about safe
poultry handling
At Kamphaeng Phet Hospital, a
man-sized reminder of the
threat

Cultural and Religious Context

Thai government
limits cockfighting
to stop the spread of
bird flu

Only a few humans

have been infected -at least one owner of
a fighting cock

Viet Nam example

Viet Nam govrnment imposed
nationwide ban on duck and goose
farming (2005)

Customs & Religion

(Thailand)

Feeding pigeons

Freeing birds for good luck

Customs and Religion

Consider religious beliefs or cultural
customs when interacting with
communities
Caring for the sick
Handling of corpses
Raising chickens at home

Part 02
Case Investigation of Avian
Influenza

Part 02_Overview
Pre-Investigation
Planning the Response

Investigation

Case Definition
Specimen Collection
Case Finding
Interviewing
Contact Identification

After the Investigation

Evaluate Performance

Reporting
Data Management
Creating an Epidemic Curve
Assessing Transmission
Writing a Summary Report

Pre-Investigation
Before you leave to investigate

Pre-Investigation:
Gather Preliminary Information
Assess the situation
Information to collect:

Number of suspected cases

Geographic location of cases
Date of onset of cases
Signs and symptoms
Exposure history contact with birds, travel, occupational
Lab tests

Consider the law and order situation in the area

Pre-Investigation:
Plan the Response
Bring RRT together
Refer to Team Composition module for
roles and responsibilities of RRT members

Discuss each persons roles and

responsibilities

Pre-Investigation:
Documentation
Information already
gathered
Location of case, date of
illness onset, clinical or
exposure details

List of contacts
Case reporting forms
questionnaires

Pre-Investigation: Resources
People

Local health Officers caring for case-patient

clinical experts
Veterinarians
laboratory experts
support personnel

Ministry of Health
Advice, guidance, additional personnel (DGHS, IEDCR)
World Health Organization (WHO)
Avian influenza references

Others

Transportation
Communication devices
Money
Security (if needed)

Pre-Investigation:
Supplies
Epidemiological
Reporting forms
Notebook for recording data

Medical
Antiviral medication (if available)

Laboratory
Swabs, needles, cooler, ice, viral transport
media (VTM)

Pre-Investigation:
Supplies
Educational
Brochures, posters, with influenza safety
information
Easy to read
Guidelines for contacts, family members

PPE
Masks, gloves, gown, cap, goggles

Decontamination
Solution for decontaminating homes or
hospital rooms

Pre-Investigation:
Communication
Upazila Livestock office
Concerned Government agencies
Health Care personnel
Community
Non-governmental organizations
Laboratory ( Sentinel sites and IEDCR)

Rapid Response Team

(RRT) Investigation

Objectives of a RRT
Investigation

Assess the possibility of human-to-human

transmission

Stop or slow the spread of pandemic

influenza at the source

Minimize mortality and morbidity

Steps in Rapid Response

Investigation
1.
2.
3.
4.
5.
6.
7.

Conduct active case finding

Identify and follow-up with contacts
Collect samples for laboratory tests
Characterize illness and provide descriptive
epidemiology
Investigate reservoir or source of infection
Report cases to district and central authorities
Implement immediate containment measures

Investigating a Suspect Case

Evidence for H5N1 infection based on
Clinical findings
Epidemiological evidence
Laboratory testing

Case Definitions

Case Definitions
why we need case
definition?
Standardizes the investigation
Clear criteria for being a case (symptoms or lab
results)
Is unique to outbreak but is based on objective
measures

Case Definition
Categories of case definitions for avian
influenza A/H5
Patient under Investigation
Possible Case
Probable Case
Confirmed Case

Case Definitions for Influenza

A/H5
Patient Under Investigation
Any individual reporting:
Fever (temperature above 38 C)

And one or more of these symptoms

Cough
Sore throat
Shortness of breath

Case Definitions for Influenza

A/H5
Possible Case
A patient under investigation who ALSO has one or
more of the following:
Lab test for Influenza A (not including subtype)
Contact in past 14 days with confirmed case of Influenza A/H5
Contact in past 14 days with sick birds
Worked in lab where there is processing of samples from
persons/animals with Influenza A

Case Definitions for Influenza

A/H5
Probable Case
Any patient under investigation or
possible case who ALSO has
In-country laboratory evidence for influenza
A/H5

Case Definitions for Influenza

A/H5
Confirmed Case
Laboratory testing demonstrates 1 or more of
following
Positive viral culture for A/H5
Positive PCR for A/H5
IFA Test positive for A/H5
At least 4-fold rise in A/H5 in paired serum samples

Specimen Collection
Confirm the Diagnosis

Review Laboratory Module

How to safely and correctly collect
specimens
Who to collect from
What samples to collect
What to wear
How to transport specimen
Procedures for diagnosis

What to Collect
Preferred specimens
Nasal swabs
Throat swabs
When possible: Nasopharyngeal aspirates
Other specimens
Nasal washes
Acute and convalescent serum
Collect the sample on several different days

Laboratory Testing
If positive test for Influenza A and/or suspicion
of avian influenza:
Sub-type at in-country laboratory
Non-approved laboratories
Forward samples to National Influenza Centre
Inform WHO Office in country

Confirmatory testing should be conducted at

a WHO approved laboratory

Case Finding

Why is Case Finding Important?

Ensure you have identified as many
cases as possible
Case finding may provide information
about human-to-human transmission
Any cases related in time and space to
initial cluster or case

How to Find Cases

Consider all possible symptomatic
persons as cases at the beginning of
an investigation
Visit health facilities, homes of neighbors
and adjacent communities
Public information messages in the
affected communities

Common Challenges to Case

Finding
Even with case finding, all cases may
not be identified
Physician may not suspect avian influenza
Some infected persons may not seek
medical attention
What are some other potential barriers to
finding cases in community?

Case Finding Interview

Who to Interview
Case-patient
Family members/Household contacts
Health care providers/Lay health
workers

Interview Tips
Collect as much information as
possible
Unstructured interviews
Generate list of contacts

Repeat critical questions for accuracy,

validity and additional details

Interview Tips
Be friendly, but professional
Identify yourself and your institution
Explain purpose of interview
Stress importance of information you will collect
Inform respondents that all information will be kept
confidential
If appropriate, conduct interview in private

Type of Information to Collect

Demographic information: age, sex
contact details
Clinical information: signs &
symptoms, physical exam, vitals, date
of onset, hospital admission
Exposure history: occupational
exposure, travel, animal exposure

Contact Identification

What is Contact Identification?

The identification and diagnosis of
persons who may have come into close
contact with an infected individual

Purpose of Contact Identification

Find new cases that meet case
definition
Provide interventions for exposed
individuals to decrease risk of illness
and interrupt further transmission
Antivirals (Oseltamivir)
Precautionary Information

How to Identify Contacts

1. Review patients activities for the 7
days before onset of symptoms
2. Based on activities, identify all close
contacts (within 1 meter)
3. Verify all information collected

Key Information to Gather

Who did case come into close contact with?

What activities was case doing?
Where did this take place?
When did case come into contact with this
person?
Contacts Address and Phone Number
Contacts Health Status
Contacts Gender, Occupation, Age

General Guidelines for

Interviewing Contacts
Do not alarm contacts
Communicate precautionary information
Refer symptomatic individuals to clinic
Consider if Personal Protective Equipment is
necessary

Information to Gather from

Contact
Demographic and contact information
Name, Address
Occupation, age, gender

Exposure History
Contact with case-patient
Other high-risk exposures

Physical Exam and Clinical information

Temperature
Presence of sore throat, coughing
Signs and symptoms

Monitoring and Managing

Contacts
Monitor for signs of illness for at least 7 days
after contact with case
Encourage self-health monitoring
Instruct to report onset of symptoms
Visit or phone daily to monitor for illness

Request voluntary home quarantine of all

contacts for at least 7 days
Consider antiviral prophylaxis

Prioritize Contact Identification

If number of contacts is large focus on:
Contacts of laboratory confirmed cases
Contacts with extended duration and
closeness to case
Contacts that are at high risk, such as
those involved in unprotected care of case
Contacts from large gatherings and/or
school that case attended

Reporting:
Informing Those who Need
to Know

Inform Those who Need to Know

Local Level
National Level
International Level

Inform Those who Need to Know

Local and/or National Reporting Requirements
(Bangladesh)

Director, Disease Control, DGHS

Director, IEDCR

Inform Those who Need to Know

International Health Regulations (IHR)
Compulsory notification of highly-pathogenic
strains of avian influenza
Vaccination and food safety of poultry products

Compliance with these standards is required

to strengthen early detection, reporting, and
response

Managing Data on Cases

and Contacts

Data Management
Line listing
Record keeping
Validation and Cross-Checking

Line Listing
An organized way to view all cases in an investigation
Case Age Sex Status
#

Occupation

Probable

Child

Yes

7 July

55

Possible

Caretaker of
case #1

Yes

9 July

48

Possible

Poultry Farmer

No

7 July

Information included:

Difficult
Date of Onset
breathing

Demographic
Clinical
Exposure

How to Create a Line List

Add new cases as they are identified
Update case information throughout
the investigation
Number of variables to include will
depend on available data, nature of
investigation

How to Create a Line List

Always include:
Components of case definition
Case name, identifying number
Date of symptom onset, specimen collection
date
May also include additional information:
Age, gender, occupation, risk factors

How to Create a Line List

Create a table in which each row represents
a case and each column represents a
variable of interest
Variables: Demographics (age), symptoms,
exposures

Cases
Case 1
Case 2
Case 3

Variable 1 Variable 2

Variable 3

Record Keeping
Where will records be kept?
How will records be kept?
Who is assigned to record keeping?
Maintain confidentiality

Validation and Cross-Checking

Check line lists against medical charts
and interviews
Validation
Ask same question in different ways
Ask same question at different times
Ensure answers are consistent

Creating an Epidemic
Curve

What is an Epidemic Curve and

How Can it Help in an Outbreak?
An epidemic curve
(Epi curve) is a
graph or picture
of the number of
cases of illness
by the date of
illness onset

What is an Epidemic Curve and

How Can it Help in an Outbreak?
Provides information characteristics of an
outbreak:
Magnitude
Pattern of spread
Outliers (case outside expected time frame)
Time trend
Exposure and/or disease incubation period

How do I Make an Epi Curve?

Plot the number of
cases of disease
reported during an
outbreak on the yaxis
Plot the time or date
of illness onset on
the x-axis

How do I Make an Epi Curve?

Technical tips
Time unit for x-axis depends upon the time from
exposure to illness onset (incubation period)
Begin with a unit approximately one quarter the
length of the incubation period
If the incubation period is not known, graph
several epi curves with different time units

How do I Make an Epi Curve?

Usually the day of illness onset is the
best unit for the x-axis
If the incubation period is very short, hour
of onset may be more appropriate
If the incubation period or outbreak is very
long, week or month may be more
appropriate

How do I Make an Epi Curve?

No space between
categories on the x axis
Label each axis
Provide a descriptive title
Include the pre-epidemic period to show the
baseline number of cases

Summary of Data
Date of Onset

Number of Cases

(When symptoms began)

July 7th
July 8th
July 9th
July 10th
July 16th

1 confirmed (Case #3)

1 confirmed (Case #1)
2 possible (Cases #5 & #6)
1 probable (Case #7)
1 confirmed (Case #4)

Discussion Questions
Based on this epi curve:
1. What is the estimated incubation
period?
2. When did the outbreak peak
according to the epi curve?
3. Are there any outliers? If so, what
might explain them?

Epi Curve for Outbreak

Assessing Human to Human

Transmission

Current Status of H5N1

Transmission
Now
Human-to-human transmission of Influenza A/H5
highly ineffective
Has occurred only among very close contacts

In the future
Virus could mutate and pass between humans
Global outbreak could occur

Assessing Human to Human

Transmission
Cases occur close together in time and
place among individuals who had close
contact with a human case
Family members or health care workers

Onset between two cases falls within

the incubation period
No alternative source of exposure is
found

Epidemic Curves and

Transmission
Assess whether human-to-human
transmission is occurring
Epi curve pattern for infectious agent
transmitted between people
Epi curve pattern for infectious agent
transmitted from one source to people

Example Epi Curve for Human to

Human Transmission

Example Epi Curve for Human

Cases from Single Source

Writing a Summary Report

Why communicate the findings?

A document for action

Control and prevention measures

To share new insights

Documents the investigation
To assist other nations districts or
countries with investigation
Inform the public
Prevents future outbreaks

Content of a Summary Report

Summary
Introduction and Background
Outbreak Description
Methods and Results
Discussion
Lessons Learned
Recommendations
Acknowledgements
Supporting Documentation

After the Investigation

Evaluate Performance

Why Evaluate the Investigation

To summarize the events that occurred
To learn from experience
Make recommendations for future
investigations
Take lessons from what worked well
Take lessons from mistakes

What to Evaluate
Timeliness of response
Completeness of the investigation
Accuracy of the data