Surveillance for Avian Influenza among Humans and Animals

1. Surveillance for Avian Influenza among Humans and Animals

2. Learning Objectives • Understand current surveillance for avian influenza in poultry, wild birds, and humans • Understand enhanced human surveillance in response to a highly pathogenic avian influenza outbreak in poultry or wild birds

3. Presentation Overview • Federal Agencies • Human Influenza Surveillance • Routine • Enhanced • Animal Influenza Surveillance • Poultry • Wild Birds

4. Federal Agencies • US Department of Health and Human Services (DHHS) • CDC • US Department of Agriculture (USDA) • US Department of the Interior (DOI)

5. HHS Lead agency for avian influenza in humans • Tasks: • Pandemic influenza planning • Human surveillance • Rapid response to HPAI in humans

6. USDA Lead agency for avian influenza in poultry • Tasks: • International assistance • Import restrictions • Surveillance among domestic poultry • Rapid response to HPAI • Coordinates with states and industry

7. DOI Collaborating agency for avian influenza in wild birds • Tasks: • Surveillance among wild migratory birds • Protects health of employees and visitors on more than 500 million acres of federal lands • Rapid response to HPAI in wild migratory birds • Collaborates with USDA

8. Influenza Surveillance Among Humans

9. Routine National Surveillance • Virologic - laboratory reporting • Sentinel Providers Network • State and territorial epidemiologists reports • Emerging Infections Program • New Vaccine Surveillance Network • 122 Cities Mortality Reporting System • Influenza-associated pediatric mortality

10. Routine State-Level Surveillance • Monitor sentinel provider network data • Monitor laboratory data • Conduct mortality surveillance • Provide state-level assessments based on state-specific surveillance • Passive reporting of outbreaks in long-term care facilities and schools

11. Routine Local-Level Surveillance • Monitor local data from sentinel providers • Investigate and report influenza-related pediatric mortality • Investigate clusters of influenza-like illness (ILI) that are • a) outside of regular flu season, or • b) in nursing homes or healthcare facilities • Area-specific activities

12. Local Surveillance During Pandemic Alert Continue routine surveillance activities AND • Investigate clusters of influenza-like illness with a) recent travel to area with documented novel or avian flu, or b) severe morbidity and mortality • Facilitate viral testing for persons with ILI and epidemiologic risk factors

13. CDC Guidance for the Current Situation: Enhanced Surveillance Testing for avian influenza A (H5N1) virus infection is recommended for: A patient who has an illness that: • Requires hospitalization or is fatal; AND • Has or had a documented temperature of ≥38°C (≥100.4° F); AND • Has radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established; AND • Has at least one of a list of potential exposures within 10 days of symptom onset:

14. CDC Guidance: Exposures Exposures to investigate if within 10 days of illness onset • History of travel to a country with influenza H5N1 documented in poultry, wild birds, and/or humans, AND had at least one potential exposure (i.e. sick poultry) during travel • Close contact (approach within 3 feet) of an ill patient who was confirmed or suspected to have H5N1 • Worked with live influenza H5N1 virus in a laboratory

15. Enhancing Local Surveillance • Enhance surveillance and record review in hospitals • Public Service Announcements • Telephone hotlines • Door-to-door surveys • Occupational surveillance

16. Goals of Human Surveillance for Pandemic Influenza • Virologic Surveillance • Detect initial cases of pandemic strain • Track introduction of virus to local areas • Monitor changes in virus • Disease-based Surveillance • Early warning of increased ILI • Monitor health effects of pandemic • Track trends in disease activity

17. Human Surveillance Upon confirmed HPAI in animal species… • Conduct active case finding • Assess exposures • Classify and test potential cases

18. 1. Active Case (and Contact) Finding • Everyone with known or possible exposure 72 hours before bird symptoms • Known or possible exposures • Infected poultry • Under- or uncooked infected poultry • Infected wild or pet birds • Manure and litter • Contaminated surfaces, vehicles, equipment, etc • Contaminated air space • Within 3 ft of infected person

19. 2. Exposure Assessment • Characterize exposures • Define target population • Most likely to be exposed • Those involved in HPAI control and eradication • Poultry farm owners or employees, state and federal animal health agency employees

20. 3. Classify and Test • Classify the persons with severe or fatal respiratory disease as: • Suspect Case • Confirmed Case • Report Under Investigation • Not a Case • Perform laboratory testing

21. Interim Case Definition (H5N1) Suspect Case • Must meet all of the following criteria: • Temperature of 100.4°F or higher • Cough, sore throat, or respiratory distress • Exposure within 10 days of symptom onset • Laboratory test pending, inadequate, or unavailable

22. Interim Case Definition (H5N1) Confirmed Case • Meets clinical and exposure criteria for a Suspect Case, but laboratory testing is inconclusive - AND - • Positive lab test for H5N1 by one of four methods

23. Interim Case Definition (H5N1) Report Under Investigation • Exposure or clinical information is not available • Additional information is necessary to classify

24. Poultry Outbreak and Human Surveillance Activities • Limit case definition • Disseminate case definition • Health Alert Network (HAN) • Epi-X • Create and disseminate outbreak reporting questionnaire • Consider database and reporting tools • Identify and interview potential cases and contacts

25. Surveillance Activities cont. • Conduct surveillance for human illness linked to affected premises • Ensure timely reporting of cases to CDC • Characterize seasonal influenza strains • Notify other states that might receive cases or contacts • Advise contacts to monitor symptoms for 10 days post-exposure

26. Contacts Definition: Asymptomatic individuals who have potentially been exposed as defined by the exposure criteria in the suspect case definition.

27. Possible Contacts • Poultry workers • Agriculture responders • Farmers • Veterinarians • People purchasing poultry products • Farm visitors • Travelers

28. Possible Contacts Also: • Healthcare workers • Family members and other close contacts • Emergency Medical Services staff

29. Recommendations for Contacts • Self-monitor for symptoms for 10 days after last exposure • Evaluate for antiviral prophylaxis • Receive seasonal flu vaccine • Adhere to infection control procedures If symptoms develop, reclassify according to case definitions

30. Influenza Surveillance Among Animals

31. Animal Surveillance Poultry: • Live bird markets • Commercial flocks • Backyard flocks Other Birds: • Imported birds • Wild birds • Pet birds

32. Notifiable AvianInfluenza (NAI) “Avian influenza in its notifiable form (NAI) is defined as an infection of poultry caused by any influenza A virus of the H5 or H7 subtypes or by any AI virus with an intravenous pathogenicity index (IVPI) greater than 1.2 (or as an alternative at least 75% mortality) as described… NAI viruses can be divided into highly pathogenic notifiable avian influenza (HPNAI) and low pathogenicity notifiable avian influenza (LPNAI)” Protecting American Agriculture

33. Markets • Licensing • Bird testing and recordkeeping • Sanitation and biosecurity • Surveillance • Response Protecting American Agriculture

34. Live Bird Markets • Prevent and control LPAI • Markets • Production facilities • Distributors • Regular monitoring and surveillance of all facilities in volunteer states • Quarterly random testing • Quarterly closure with depopulation, cleaning, disinfection and down time • State-level monitoring in non-participating states

35. Commercial Flocks National Poultry Improvement Plan (NIPP) • USDA program • Monitor poultry production facilities • Random testing of flocks • Test all ill birds • Coordinate with states for response and containment plans

36. Surveillance: NPIP On-farm • Establishes standards for evaluation of poultry breeding stock and hatchery products • “Avian influenza free” certification for commercial companies Protecting American Agriculture

37. Surveillance: NPIP (cont.) • New LPAI program that will provide for H5 and H7 AI monitoringand indemnity for LPAI. • Program components: • “AI monitored” program • Surveillance specifications • State LPAI response and containment plans Protecting American Agriculture

38. Domestic, Non-Commercial Backyard Flocks • “Biosecurity for the Birds” program • Report sick birds to an animal health professional • Practice biosecurity • Collaborators • State Departments of Agriculture • USDA Cooperative Extension Service • Private veterinarians

39. Imported Birds • USDA mandates quarantine and testing all imported birds for avian influenza • Poultry • Pet birds • Zoo birds • Ratites (i.e. ostriches and emus) • Current ban on live or fresh birds or poultry from areas where the Asian strain H5N1 virus exists

40. Wildlife Surveillance Five components to surveillance • Investigation of morbidity and mortality • Surveillance in live wild birds • Surveillance in hunter-killed birds • Sentinel species monitoring • Environmental sampling

41. Wild Bird Surveillance – The USG Interagency Strategic Plan • Part of the President’s National Strategy for Pandemic Influenza • Partnership among: • U.S. Departments of Agriculture, Interior, Health and Human Services • Association of Fish and Wildlife Agencies • National Association of Public Health Veterinarians • State agencies • Unified national system for early detection of highly pathogenic H5N1 AI in wild birds. Provides standard procedures and strategies for sampling, diagnostics and data management. • Serves as a guide for regional and state surveillance plans. Protecting American Agriculture

42. Migratory Birds • Capture, sample, test • Monitor and test wild birds • Alaska / Pacific flyway • Mississippi (Central) flyway • Atlantic flyway • Collaborators: DOI, USDA, USGS, US Fish and Wildlife, state agencies, and others

43. Case Definition for Poultry • Surveillance at the flock level, rather than individual level (as in human surveillance) • Clinical case definition of HPAI in poultry flocks • Symptoms of illness such as drops in egg production, lack of energy and appetite, nasal discharge, lack of coordination, swollen head and legs AND/OR • Unusual mortality

44. Diagnostic Testing in Poultry • Rapid screening test: RRT-PCR • Identifies H5 or H7 viruses • Available within 4-7 hours • Confirmation by National Veterinary Services Laboratory (NVSL) • Confirmatory testing: viral isolation • Genetic sequencing • Pathogenicity test • Available within 5-10 days of receipt

45. LPAI Surveillance – National Animal Health Laboratory Network (NAHLN) Labs • More than 45 laboratories participate in the network. NAHLN labs: • Provide laboratory services nationwide • Provide laboratory data for reporting • Respond to foreign animal disease outbreaks • Focus on animal diseases Protecting American Agriculture

46. Presumptive Positive in Poultry • Sudden and significant increase in mortality • With clinical signs - or - • Post mortem lesions - and - • Decrease in egg production • Positive RRT-PCR for H5 or H7 • From NVSL, NAHLN, or other USDA-approved lab

47. Reporting HPAI in Poultry • Reporting varies by state • Industry • Backyard flocks • H5 or H7 LPAI • Presumptive positive cases reported to USDA or DOI will be immediately reported to: • OIE (World Organization for Animal Health) • Trade partners • Other Federal agencies • States • Industry

48. Response in the Event of an HPAI Outbreak Outbreak • Response actions for domestic flocks: • Surveillance • Quarantine and humane euthanasia • Cleaning and disinfection of premises • Possible use of vaccine in poultry • Indemnity payments • Communication to media and thepublic Protecting American Agriculture

49. Responding to Influenza among Poultry • Response begins with presumptive positive or positive result on HPAI screening test • Coordination between USDA, DOI, HHS, states, industry, tribes • National HPAI Response Plan goals: • Prevent contact between virus and susceptible animals • Stop virus production in infected animals • Increase disease resistance of susceptible animals through strategic vaccination

50. Responding to Influenza among Poultry • LPAI outbreak • Affected state takes the lead • Clean, disinfect, depopulate affected premises • USDA provides funding • Close attention to H5 and H7 strains • HPAI outbreak • USDA takes the lead • Quarantine, clean, disinfect, and cull the infected and exposed bird population • CDC is notified • Bird owners compensated