Case management of suspect influenza a h5n1 infection in humans
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Case Management of Suspect Influenza A (H5N1) Infection in Humans. Learning Objectives. Recognize clinical features of H5N1 in humans Treatment of cases Public health action. Clinical Features. General Information. Signs and Symptoms. Laboratory Findings.

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Learning Objectives

  • Recognize clinical features of H5N1 in humans

  • Treatment of cases

  • Public health action

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Laboratory Findings

Commonly associated with avian influenza H5N1:

  • Drop in white blood cell count (lymphocytes)

  • Mild to moderate drop in blood platelet count

  • Increased aminotransferases (liver enzymes)

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Exposure to Avian Influenza

  • Infected poultry, particularly contact with respiratory secretions

  • Infected wild or pet birds

  • Other infected animals (e.g., pigs, cats)

  • Wild bird feces, poultry manure and litter containing high concentrations of virus

  • Contaminated surfaces

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Exposures Continued

  • Under- or uncooked poultry meat or eggs from infected birds

  • Contaminated vehicles, equipment, clothing, and footwear at affected sites, such as poultry farms with outbreaks

  • Contaminated air space (e.g., a barn, hen-house, or the air space proximal to barn exhaust fans)

  • Bodies of water with infected bird carcasses

  • Close contact with (within 3 feet of) confirmed cases

    Cultural context can produce unique exposures

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Clinical Specimens for Testing Influenza A (H5N1)

  • Lower Respiratory Tract*

    • Broncheoalveolar lavage

    • Tracheal aspirate

    • Pleural fluid tap

    • Sputum

  • Upper Respiratory Tract

    • Nasopharyngeal swab/aspirate

    • Oropharyngeal swabs*

    • Nasal Swab

* Preferred specimens

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Clinical Specimens for Testing

  • Serology

    • Acute and convalescent serum specimens

      • Acute collected within 1 week of symptom onset

      • Convalescent collected 2-4 weeks after symptom onset

    • Other infections or concurrent illness

  • Specimens should be collected within 3 days of symptom onset

  • Collect all possible specimens, serial collection

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Avian Influenza H5N1 Chest X-Ray

Chest x-ray of an avian influenza H5N1 patient, shown by day of illness

Day 5

Day 7

Day 10

Tran Tinh Hien, Nguyen Thanh Liem, Nguyen Thi Dung, et al. New England Journal of Medicine. 18 March, 2004. vol. 350 no. 12. pp 1179-1188.

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Treatment Options

  • Antivirals

  • Antibiotics

  • Supportive care

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Neuraminidase Inhibitor

  • Two drugs available

    • Oseltamivir (Tamiflu®) and Zanamivir (Relenza ®)

    • Should be given as soon as possible

    • Effective for treatment and prevention

    • Used for seasonal and avian influenza

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Other Treatments?

  • Amantadine and Rimantadine

    • H5N1 resistant in some isolates

    • Not as effective as neuraminidase inhibitors

  • Corticosteroids

    • Low dose for sepsis

    • Unclear if high dose useful

    • Risk of side effects

  • Ribavirin

    • Ineffective against influenza viruses

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Response Overview

  • Collect Case Information

    • Classify case according to case definition for surveillance

  • Facilitate specimen collection and laboratory testing

  • Information on avian influenza illness

  • Infection control measures in the home

  • Active case follow up

  • Identify close contacts and recommend chemoprophylaxis

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Case Definitions

  • Confirmed

  • Suspect

  • Report under investigation

  • Non-case

  • Refine for outbreaks

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Active Follow Up

  • Reasons for follow up

    • Specimens for testing

    • Timely notification of results

    • Monitor delivery of antiviral therapy

    • Secure antivirals if shortage

    • Note unusual clinical presentations or complications

  • Follow up by telephone

    • Patient

    • Healthcare provider (when available)

    • Surrogate (e.g. spouse)

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Identifying Close Contacts

  • List of contacts from patient’s case report form

  • Close contact = Within 3 feet

    • Sharing utensils, close conversation, direct contact

  • Follow Up

    • Characterize exposure

    • Identify signs and symptoms

  • Those with symptoms treated as potential avian influenza case

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Recommendations to Contacts

No symptoms

  • Receive current influenza vaccine

  • PEP for close contacts of a confirmed avian influenza H5N1 case

    • Antiviral (neuraminidase inhibitor) and dosage information in Background section

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Instruction to Contacts

No symptoms (continued)

  • Self monitor for 10 days after last exposure

    • Fever, respiratory symptoms, diarrhea, and/or conjunctivitis

    • Seek medical care if symptoms present

    • Notify public health authorities

  • Follow infection control measures in the home

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  • For suspect cases, ask about recent exposure and contact with humans or animals that may have had avian influenza H5N1 infection

  • Important appropriate clinical specimens need to be collected and tested

  • Begin treatment with neuraminidase inhibitor immediately! Do not wait!

  • Case management also means identifying contacts