HIGHLY PATHOGENIC AVIAN

Dr Siti Zaleha Suleiman

INFLUENZA: CASE MANAGEMENT Pakar Perubatan Keluarga
IN PRIMARY HEALTH CARE KK Ayer Keroh
 outline
• Introduction
• Pathogenesis
• Symtoms & Signs
• Case management in primary care
- Case definition : suspected, probable and confirmed case
-Triaging at primary care setting
-Referral
• Personal Protective Equipment
• Precautionary Measure
• Staff monitoring
Avian influenza (AI) is caused by INTRODUCTION
influenza virus type A usually infects
birds but can infect human exposed to
infected birds
The first documented infection of humans with an
Highly pathogenic (HP) avian influenza avian influenza virus occurred in Hong Kong in
(AI) (HPAI) is an extremely contagious, 1997, where the H5N1 strain caused severe
multi-organ systemic disease of poultry respiratory diseases in 18 humans of whom 6 died
leading to high mortality, and caused by
some H5 and H7 subtypes of type A
influenza virus, family
Orthomyxoviridae Avian influenza A viruses are designated as
highly pathogenic avian influenza (HPAI) or
Highly pathogenic avian influenza low pathogenicity avian influenza (LPAI) based
viruses have been documented to arise
on molecular characteristics of the virus and the
from MPAI viruses through mutations
in the haemagglutinin surface protein. ability of the virus to cause disease and
mortality in chickens in a laboratory setting
 INTRODUCTION
From an epidemiology report of the 48 human confirmed cases
of influenza A(H5N1) reported to WHO during 2010.
-All cases occurred as sporadic cases, with no clusters reported
-Egypt (29 cases), Indonesia (9), Viet Nam (7), China (2) and
Cambodia (1)
-case fatality rate (CFR) 50%
-women has higher CRF than men ( 56% vs 38%)
-CFR higher in those admitted >/= 2 days compared < /=2 days
( 25%vs 65%)
In Malaysia, up to year 2017 no local AI in human reported
except one imported H7N9 case reported in 2014.
PATHOGENESIS OF THE
DISEASE
The waterfowls act as reservoirs for the Avian Influenza virus.
Migrating waterfowls carrying the viruses in their intestinal tract and shedding them
in their feces
The birds contaminate the water and environment of their resting places; especially
along their migrating routes
Viruses in feces and water can remain viable for up to 32 days
The domestic poultry can be infected when they drink the contaminated water.
The infected poultry shed virus in saliva, nasal secretion and faeces in the first two
weeks of infection .
Influenza A can infect other mammals
PATHOGENESIS OF THE
DISEASE
The exact mode of transmission of AI virus to human is not known.
Limited studies in Hong Kong during 1997 outbreak showed that human was
infected through close contact with the infected poultry.
Man inhales the influenza virus from the infected poultry and reproduces it in
the lining of the lungs.
Young children and old people are at a higher risk of getting symptoms and
complication because their immune system are slower to respond to the
replication rate of the virus.
 SYMPTOMS OF AVIAN INFLUENZA
IN HUMAN
The illness progresses rapidly
with the peak severity seen
within 3-4 days of onset
-Among persons with comorbidities
(e.g., pulmonary or cardiac disease)
influenza can exacerbate the
underlying medical conditions lead to
bacterial pneumonia
-primary influenza viral pneumonia
-occur as part of a co-infection with
other viral or bacterial pathogens
Incubation period for AI is 1-4 days, with
an average of 2 days.
Reported symptoms
-typical influenzalike symptoms (e.g.,
fever, cough, sore throat and myalgia)
-eye infections
-pneumonia acute respiratory distress and
other severe and life-threatening
complications
-In children otitis media, nausea, and
vomiting are more commonly reported
AI can be associated with
encephalopathy, transverse
myelitis, Reye syndrome,
myositis, myocarditis, and
pericarditis.
CASE MANAGEMENT
Avian Influenza cases must be notify within 24 hours to the nearest district
health office and should be entered in E notification apps MOH
Mandatory notification for :
1) Suspected
2) Probable
3) Confirmed
CASE DEFINITION :SUSPECTED
CASE
CASE DEFINITION :SUSPECTED
CASE
CASE DEFINITION :PROBABLE
CASE
CASE DEFINITION:
CONFIRMED CASE
 TRIAGING AT PRIMARY HEALTH CARE

Patient presented with T 38 AND one or more of:

Cough/sore throat/shortness of breath

Direct contact with dead/ill

birds/poultry under DVS Ix
Work in/visit poultry with
No YES
suspected/confirmed case HPAI
Work in lab processing sample
suspected HPAI
Sejarah keluar negara dgn kes Isolation room :
Fever Center: (within 10 days of onset of Case definition
Assess & treat symptoms) Severity assessment
Fullfill criteria Not fullfill
accordingly
Suspected case criteria
Suspected case
Refer for admission to
designated hospital & Treat accordingly
notify
SEVERITY ASSESSMENT

*rujukan : taklimat pengurusan pengurusan pesakit Avian Influenza A

H7N9 (2013)
REFERRAL OF PATIENTS
All patients with suspected avian influenza should be referred and admitted to
the designated hospital.
If the number of suspect cases is large, for logistics purposes, the patients may be
isolated and managed in the nearest district hospital. Only patients who are too ill to
be managed at district hospital without specialists, should be referred for
management in the designated hospital.
For patients who are referred, they should be sent to the hospital in an ambulance.
The health care worker accompanying the patient should wear a surgical mask and
gown.
The ambulance and other items used during transportation should be disinfected on
returning to the district hospital/clinic.
PERSONAL PROTECTIVE
EQUIPMENT (PPE)
Though there is no documented human-to-human transmission, stringent infection
control measures should be instituted.
The fact that this virus can undergo re-assortment of genes if a person is infected
with both human and avian influenza virus could enable this new strain to have the
ability to transmit among human
SUMMARY PPE
RECOMMENDED STANDARDS
OF PPE (HCW)
High-risk patient areas (Fever triage wards / cubicle, cohort wards, avian influenza screening
areas)
a)No direct patient contact
- Surgical mask
- A linen or disposable gown
Optional: Eye shield / Full-face shield, Disposable cap
b) Direct patient contact or activities with risk of exposure to blood, body fluids, secretions, excreta
and contaminated items
-3-ply surgical mask
-A linen or disposable gown
-Full-face shield or eye shield
- Latex gloves
STANDARD PPE (HCW)
Procedures with high risk of generating aerosols e.g. resuscitation, high flow
oxygen) and requiring prolonged very close contact with affected patients
-N95 respirator
- A linen gown if no uniform / working clothes
-Disposable gown
-Latex gloves
-Full-face shield
-Goggles
-optional: Disposable cap
PROVISIONAL ADVISORY FOR HEALTH CARE
WORKERS IN THE FIELD FOR PROTECTION
AGAINST AVIAN INFLUENZA
Health care workers going into the field should be adequately protected at all
times by the following methods:
-PPE: 3 ply surgical mask should be worn at all times during ACD
-Boots must be worn at all times during ACD
- Full body gown and N95 mask must be worn during culling operation
- Apron is optional
 PROVISIONAL ADVISORY FOR HEALTH CARE
WORKERS IN THE FIELD FOR PROTECTION
AGAINST AVIAN INFLUENZA
Disinfection of the following articles must be done
-boots must be disinfected before entering the vehicle during ACD
-the tyres of the vehicle must be disinfected before leaving the operation area
- handwashing with soap before and after the operation
All disposable items must be disposed by using biohazard bag for incineration by the hospital
All reusable items must be disinfected properly after usage
Disinfectant solution recommended are:
a. Sodium hypochlorite 1% in dilution, 5% solution to be diluted 1:5 in clean water
b. Bleaching powder 7g/litre with 70% available chlorine
c. Alcohol (70%) Isopropyl, ethyl alcohol, methylated spirit.
PRECAUTIONARY MEASURES
AT OUT-PATIENT SETTING
(DURING OUTBREAK)
Avoid overcrowding in the waiting areas, schedule patient appointment and remind
patients to adhere to it.
Require all patients and accompanying persons to wear surgical masks if they have
respiratory symptoms.
Request patients and accompanying patients to notify staff when the have fever,
cough or running nose and arrange medical assessment accordingly.
Clean and disinfect the environment at least once daily or more frequently as
indicated for places such as patient lavatories.
STAFF MONITORING
The monitoring of the health status of the following staff should be carried out:
staff involved in culling activities,
staff involved in surveillance activities in poultry / birds,
laboratory staff involved with processing of clinical specimens of suspect AI cases
in human and poultry / birds,
health staff involved in ACD activities and
medical staff involved in managing suspect AI cases in the ward.
The monitoring should be carried out for 14 days from the last date of doing the
related activities.
01/25/2024 25