Filiariasis, Avian Flu, etc.

8/14/2019 Filiariasis, Avian Flu, etc.

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FilariasisIsabelita M. Samaniego MD

Session ObjectivesTo describe the epidemiology/ health situationer of filariasis

To discuss the goals, objectives and strategies of the programs of DOH and WHO for filariasisTo describe the following about filariasis:Life cyclePathogenesis and pathologyClinical featuresDiagnosisManagementPreventionTreatment

Epidemiology1.2 billion people in 80 endemic countries are at risk of lymphatic filariasis.> 120 million people are currently living with the disease,

40 million who are incapacitated and disfigured by it.One third of these infected live in India, one third in Africa and most of the remainder

in Asia , the Pacific and America.Among the 38 Least Developed Countries, 32 are endemic for LF.

EpidemiologyEpidemiology

90% of these infections are caused by Wuchereria bancrofti , and most of the remainder by Brugia malayi

The major vectors for W. bancrofti areCulex mosquitoes - most urban and semi-urban areas

Anopheles - more rural areas of Africa and elsewhere Aedes species - many of the endemic Pacific islandsBrugian parasites are confined to areas of east and south Asia, especially India,

Malaysia, Indonesia, the Philippines, and China

EpidemiologyFilariasis

It is a parasitic infection transmitted by a mosquitoTwo species of the parasite that cause filariasis exist in the Philippines: Wuchereria

bancrofti and Brugia malayi .Several mosquito vectors that include Aedes , Anopheles , and Mansonia species transmit

the disease to humansPrevalence

Although filariasis is not a killer disease, it is considered the second leading cause of permanent, long-term disability among infectious diseases
http://www.who.int/ctd/filariasis/library/africa1.htmlhttp://www.who.int/ctd/filariasis/library/asia1.htmlhttp://www.who.int/ctd/filariasis/library/asia1.htmlhttp://www.who.int/ctd/filariasis/library/africa1.htmlhttp://www.who.int/ctd/filariasis/library/asia1.html


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In the Philippines, an estimated number of 200,000 people are said to carry theinfection National prevalence rate is placed at 9.7 per 1000 population (1998)

PrevalenceIn the Philippines, filariasis endemicity is categorized into three:

Category 1 - 20 provinces in Regions 5, 8, 11, 4 & 9 with reports within the past 10years establishing its endemicity.Category 2 - 25 provinces with no recent report of endemicity but were reported as

endemic in the 1960 prevalence survey.Category 3 - 33 provinces without any report of endemicity and considered as non-

endemic for the diseasePrevalence

45 out of 78 provinces are endemic for filariasisRecent discoveries of new endemic areas reveal some of the countrys highest recorded

rates:

13.6 % in Marinduque (1992)17.7% in Cagayan de Oro City in (1998) National Filariasis Elimination ProgramGoal: Filariasis is eliminated as a public health problem.( Filariasis is considered eliminated as a public health problem if the prevalence rate isless than one per thousand population. )

National Filariasis Elimination ProgramNational Objectives for Health by 2004Health Status Objectives1. Reduce the microfilaria prevalence rate to less than one case per 1,000 population in

endemic municipalities.(Baseline: 9.7 cases per 1,000 population in 1998, Filariasis in the Philippines ACompilation of DOH Data, 1960 to 1998, CDCS)2. Reduce microfilaria density in endemic municipalities to four microfilariae per positivecase.

(Baseline: 40 microfilariae per positive case in 1998, Cagayan de Oro Survey, CDCS)3. Reduce adenolymphangitis attacks to one per year.

(Baseline: 3-4 per year in 1994, Global Rate)

Risk Reduction Objectives 1. Increase the percentage of the population in endemic municipalities submitting to

annual mass treatment (for four consecutive years) to 80%.(Baseline: 22% of LGUs with Filariasis Control Programs includes a annual masstreatment component, BSNOH 2000)2. Increase the enrollment of chronic cases in support or care groups to 90%.

(Baseline: 33% of LGUs with Filariasis Control Programs has a component of supportor care groups for chronic cases, BSNOH 2000)Services and Protection Objectives 1. Identify all endemic municipalities in the country.


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(Baseline: 117 endemic municipalities, 1998 Filariasis in the Philippines, CDCS)2. Conduct annual Filaria Health Fair for four consecutive years in all endemicmunicipalities.

(Baseline: from BSNOH 2000)(1) 33% of LGUs with Filariasis Control Programs has a component of a Filaria

Health Fair (2) No LGU had conducted a Filaria Health fair for four years3. Issue National Certificate of Filaria Elimination to all municipalities completing four years of mass treatment and achieving a microfilaria prevalence rate of less than one case

per 1,000 population.(Baseline: No LGU as of 2000, BSNOH)

FilariasisA parasitic infection caused by thread-like adult filarial nematodes that live in the

lymphatic system of infected individualsFilariasis

The microfilaria rate and disease rates have been found increasing with age.

The largest number of cases generally occur in the 15-44 years-age group, but the prevalence is highest in the 45-60 and above age group.

Males are more affected than females for microfilaremia, with 20% more cases in bancroftian filariasis and 25% more cases in brugian filariasis.Economic Impact of FilariasisThe estimated loses per year in man-days and in terms of pesos due to acute attacks of the disease are based on the positive cases found. In computation:

Number of persons with microfilaremia x 0.34 (%with lymphangitis) x 3.5 (no. of attacks/ year) x 3 ( duration of attacks in days) = Number of annual man-days lost

number of man-days lost x minimum daily wage= annual economic lossHuman Filarial Parasites

Wuchereria bancrofti (Bancrofts filaria) the adults parasites are found in the lymphatics below the diaphragm; microfilariae

sheathed,exhibit nocturnal periodicity and common in warm climateBrugia malayi (Malayan filariasis) the adults are found in the lymphatics above the diaphragmexhibit nocturnal periodicity and common in warm climateLoa-loa (eye worm) the adults are found in cutaneous tissues, microfilariae sheathed

exhibit diurnal periodicityfound in Tropical AfricaOnchocerca volvulus (Convoluted filarial)the adults are found in subcutaneous tissuesmicrofilariae sheathedrarely found in bloodstreamcommon in Tropical Africa, Mexico, Guatemala and Venezuela

Human Filarial Parasites


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Dipetalonema perstan the adults are staying in the body cavitiesmicrofilariae unsheathednon-periodicfound in Tropical Africa and Tropical America

Dipetalonema streptucercum The adults stay in the skin and subcutaneous tissuesmicrofilariae unsheathednon-periodicfound in Tropical AfricaManzonalla ozzardi Adults are located in the body cavitiesmicrofilariae unsheathednon-periodicfound in Tropical America

Life Cycle

Vectors of FilariasisFilariasis Incubation Period

starts from the entry of the infective larvae to the development of clinicalmanifestations is variable

ranges from 8-16 monthsAsymptomatic Stage

Characterized by the presence of microfilariae in the peripheral bloodSome remain asymptomatic for years and in some instances for lifeOthers progress to acute and chronic stagesMicrofilariae rate increase with age and then levels off

Filariasis Acute StageStarts when there are already manifestations such as:Recurrent attacks of fever Lymphadenitis (inflammation of the lymph nodes)Lymphangitis (inflammation of the lymph vessels)In some cases, the male genitalia is frequently affected leading to funiculitis,

epidydimitis or orchitis (redness, painful and tender scrotum)FilariasisChronic Stage

Develop 10-15 years from the onset of the first attack

Immigrants from areas where filariasis is not endemic tend to develop this stage moreoften and much sooner (1-2 years) than do the indigenous population of endemic areasMost of the time, microfilariae are absent in the blood

The following are the chronic signs and symptoms:Hydrocoele (swelling of the scrotum)Lymphedema (temporary swelling of the upper and lower extremities)Elephantiasis (enlargement and thickening of the skin of the lower and/or upper

extremities, scrotum, breast, penis, and vulva)


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Chyluria (rice-water color of the urine which results from the excretion of chyle inthe urinary tract. This is due to blockage of the retroperitoneal lymph nodes below thecisterna chili with consequent reflux and flow of the intestinal lymph directly into therenal lymphatics. This may rupture and permit flow of chyle.)Clinical Features

Chronic manifestations: Hydrocoele , even though found only with W. bancroftiinfections (i.e., not Brugia infections) is the most common clinical manifestationuncommon in childhood but is seen more frequently post-puberty and with a

progressive increase in prevalence with age40-60% of all adult males have hydrocoele

Clinical FeaturesLymphoedema can develop in the absence of overt inflammatory reactions; in the early

stages be associated with microfilaraemia,the development of elephantiasis (either of the limbs or the genitals) is most frequently

associated with a history of recurrent inflammatory episodesClinical Features

redundant skin folds, cracks and fissures of the skin provide havens for bacteria andfungi to thrive and intermittently penetrate the epidermis to lead to either local or systemic infectionsClinical Features

Chyluria, another of the chronic filarial syndromes, is caused by the intermittentdischarge of intestinal lymph (chyle) into the renal pelvis and subsequently into the urinePhysical Examination

History and InspectionA physical examination is important to detect manifestations of filariasis, which may

sometimes be subtle. Treatment to alleviate pain and discomfort from signs andsymptoms is often available and provides great relief and positivity for further treatment.

Physical Examination4. Ask/note the following questions:Main complaintHistory of the illness; ask the following:Fever and headache how it started? how often? other related signs and symptoms?Lymphadenitis where is it located? (axillary, inguinal, etc.)Lympangitis present ( ) absent ( ) where is it located?Hydrocoele painful ( ) not painful ( )Lymphedema is there swelling of either of the extremities? is this temporary or

permanent? are there associated symptoms?

Lymphedema can be classified as follows:GRADE I mostly pitting edema, spontaneously reversible on elevationGRADE II mostly non-pitting edema, not spontaneously reversible on elevationGRADE III (elephantiasis) - gross increase in volume in grade II lymphedema, with

dermatosclerosis and papillomatous lesions

Elephantiasis where is the enlargement? what is the duration of the enlargement?


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Case DefinitionSymptomatic with microfilaremia- patients found to be positive for microfilariae in the

peripheral blood with clinical signs and symptoms.Asymptomatic with microfilaremia- patients found to be positive for microfilariae in the

blood without clinical signs and symptoms.Patients with chronic signs and symptoms- patients negative for microfilariae but withtwo major clinical signs and symptoms.

Major Signs and SymptomsLymphangitisPain and swelling of the upper and lower extremities, scrotum, inguinal area, vulva,

breasts, genitals.Minor Signs and Symptoms

Fever Cough

ChillsWheezing

Note: The major signs and symptoms must be observed within the last three months.Differential Diagnosis

Lymphatic filariasis Bacterial or fungal lymphadenitis (eg, sporotrichosis due to Sporothrix schenckii )

Recurrent streptococcal lymphadenitis (relapsing erysipelas)Congenital or hereditary lymphedema (Milroy syndrome)

Nonfilarial elephantiasis (Highlands of East Africa)Congenital hydrocele

Epididymal cystCarcinoma of testis and/or scrotumLymphosarcomaTreatmentDiethylcarbamazepine citrate (DEC)

effective, safe, and relatively cheapKills almost all the microfilariae and good prognosis of adult wormsEffective against the L3 and L4 larval stages and a good proportion of adult wormsIt is advisable not to give the drug to pregnant women and care should be taken when

treating people with kidney and cardiac disorders.This drug can be given as:Selective TreatmentAdvisable to individual with clinical manifestations and or microfilaremia.Given at a dose of 6 mg/kg body weight in 3 divided doses for 12 consecutive days after

meals.Ideal for newly- established or low endemic areas.

TreatmentMass Treatment


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Can be given as part of an organized filariasis control campaign with a single full courseof DEC being given to the whole population of endemic areas except pregnant women,infants, those with cardiac amnd kidney disorders.

Given at a dose of 6 mg/kg body weight to be taken as single dose.Advantageous in areas with moderate to high endemicity.

As effective as the older standard dose 12- day course of DEC. .The only contraindication is that it should not be used in areas with onchoceriasis andloiasis.Mass Biannual Treatment

Given at a dose 6 mg/kg body weight top be taken every 6 months.This may increase microfilariae reduction and best given in areas with moderate to high

endemic areas with small population and with efficient distribution system.TreatmentDEC- fortified salt

This had been shown to be simple, cheap, and effective in reducing or eliminatinglymphatic filariasis.

It is well tolerated and can be incorporated with iodized salt. However, it cannot beused in areas with loaisis and onchocerciasis. Ordinary salt medicated mixed with 0.2.0.4% of DEC tablets as cooking or table salt for 9-12 months.

IvermectinAn alternative drug for filariasis, however this is not available yet in the Philippines.This drug is as effective and can be given at a dose of 400 ug/kg given once yearly for

mass treatment.This appears to be equivalent to the single dose DEC regimen efficacy, safety and

tolerance.TreatmentCombination of DEC and Ivermectin

Appears to be superior to either drug alone for long term reduction and microfilarialdensity and equivalence.

A dose of 400 ug of Ivermectin and DEC 6 mg/kg body weight. Given once yearly as part of mass treatment scheme.Complementary Therapy

Chronic manifestations such as elephantiasis and hydrocoele can be handle throughsurgery.

Mild cases of lymphedema can be treated by lymphovenous anastomosis distal to thesite of lymphatic obstruction.

Chyluria is operated on by ligation and stripping of the lymphatics of the pedicle of the

affected kidney while hydrocoeles can be managed by invertion or resection of the tunicavaginalis.

Filariasis patients are advised to observed personal hygiene by washing the affectedareas with soap and water at least twice a day, or prescribed antibiotics or antifungals for superior protection.

Complementary Treatment


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DietFatty foods are restricted in proven chyluria associated with lymphatic filariasis.ActivityMobilization of the affected limb in chronic lymphatic filariasis is encouraged with

compression bandage support.

Vector ControlAnti Adult Measures

InsecticidesCommunity Measures

The frequency of human vector contact can be reduced by:Construction of better housing with mosquito screens.Bonfires near houses to drive away mosquitos.Tying of carabaos a safe distance from houses to attract mosquitos (insecticidal

zooprophylaxis).Use of latrines.Personal protection such as proper clothing, mosquito nets with or without insecticide

impregnation, mosquito coils, and insect repellants (water based).Vector ControlAnti-Larval Measures1. Use of Insecticide/ larvacides .

Commonly used larvicides are the organophosohorus insecticides such as temephos,fenthion, chlorpyrifos and pirimiphos- methyl. The following dosages have been usedagainst C. quiquefasciatus:Clorpyrifos- 0.1- 1.0 mg of active ingredient per liter of water, it remains highly active

for 12-24 days.Methoprene: dosage 1.0 mg of active ingredient inper liter of water inhibits emergence

of adults for some 21 days.2. Biological Control

Larvivorous fish- Gambusia affinis and Poicilia reticulate are the two fish mostcommonly used.

Microbial agents- Bacillus thuringiensis H- 14, which produces a potent insecticidalexotoxin and is self- replicating in the field has been shown to be effective against larvaeof Anopheles and Aedes.

Management RegimensTwice-daily washing of the affected parts with soap and water Raising the affected limb at nightRegularly exercising the affected limb to promote lymph flowKeeping the nails cleanWearing shoesUse of antiseptic or antibiotic creams to treat small wounds or abrasions.


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Essentials of Health Education in the Prevention and Control of Filariasis

Create awareness of the early signs and symptoms of the disease.Encourage individuals to submit to early treatment to prevent the development of a

chronic disability.Promote acceptance of Diethylcarbamazine Citrate (DEC) in mass or selectivetreatment

Promote the acceptance of diagnostic procedures.Empower people to protect themselves from getting sick of filariasis.Encourage community participation to clean breeding sites of mosquitoes.

Roles of Health Workers as Health EducatorVisit people in their community and listen to their health problems.Give information on the prevention and control of Filariasis and prevailing diseases in

the community.Health workers should show by their own personal example, practice healthy habits.

Plan, implement, evaluate health education activities.Conduct health teachings.Help people to lead healthier lives.Help people to solve their problems through their own efforts

Strategies used in Health EducationCommunity mobilizationdeliberate process of involving and motivating people, health workers, and policy

makers to organize and take action for a common purpose.Planned approach to influence behavior as well as social change.AdvocacyPrinciple of communicating with people to gain their support for an issue and influence

their behavior in a specified way.Advocacy creates/ prepares responsible environment.Advocacy provides a framework of involvement.

Network/ Intersectoral Collaborationcoordination with various sectors and working as a team on common projects.

Community Organizing provide people and arena to interactcoordinate the various efforts contributed

Information, Education, Communication (IEC) Campaigninform educate move people for health actionTell people what to do to protect themselves from getting sick

Trainingimprove knowledge, attitudes and skills of individuals which would empower them tomake healthy choices.Reporting Systems FlowCentral OfficeDepartment of HealthFilariasis Control Units


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Regional Health OfficeProvincial Health Office(copy furnished)

______FHSIS

Rural Heath Units_____FHIS

Barangay Health StationReferralReferral of cases is indicated for the following situations:confirmation of diagnosis of suspected filariasis cases.medical/surgical management of chronic complications of filariasis.for follow-up of cases

Referral Systems Flow

Central OfficeDepartment of Health

_____HospitalRegional Health Office(Filariasis Control Units)Provincial Health OfficeMunicipal Health OfficeBarangay Health Station StrategiesTwo principal goals of the Programme to Eliminate Lymphatic Filariasis:1. to interrupt transmission of infection;2. to alleviate and prevent both the suffering and disability caused by the disease.

It is a necessity to achieve these goals in a cost-effective, socially-responsible manner ensuring appropriate health and economic benefits.Pacific Programme for the Elimination of Lymphatic Filariasis (PacELF)

first regional campaign to attempt to eliminate filariasis as a public-health problemPacELF is a regional group of 22 Pacific countries and territories that are working

together towards the goal of eliminating lymphatic filariasis from the Pacific by the year 2010 - 10 years before global elimination is expected to be achievedPacELFThere are now two new tools to help eliminate filariasis:

the recent development of antigen test kits

the combination of drugs - DEC and albendazole.


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StrategiesThe Elimination of Lymphatic Filariasis: A Strategy for Poverty Alleviation

and Sustainable Development Perspectives from the PhilippinesJaime Z Galvez Tan

University of the Philippines, College of Medicine, Department of Family andCommunity Medicine, Pedro Gil Street, Malate, Manila, Philippines

BackgroundWithin the Philippines areas endemic for lymphatic filariasis are in regions with the

highest incidence of poverty. Out of a total of 79 provinces, 39 have a higher povertyincidence than the national average and 30 of these 39 provinces are endemic for lymphatic filariasis.Strategies

Romblon province, which is ranked 71 out of 79 in terms of poverty incidence, has aCirculating Filarial Antigen (CFA) rate of 18.75%

Oriental Mindoro province, which is ranked 76, has a microfilaria prevalence rate of 12.59%The Elimination of Lymphatic Filariasis as a means to Poverty Alleviation1. LF surveys and mapping using ICT and community reporting of hydrocoele andelephantiasis increase the poor's access to health knowledge, health information andepidemiological data as well as access to diagnostic services.2. Mass drug administration (MDA) with DEC and albendazole increases access toessential drugs and ensures universal coverage for treatment of LF and geo-helminths.The Elimination of Lymphatic Filariasis as a means to Poverty Alleviation3. The establishment of morbidity reduction services for those with disabilities caused byLF will increase access to health services and rehabilitation particularly for those who

live as stigmatized outcasts with such disabilities. This will also mean the poor returningto productive economic work and an active social life.4. Increase in access to other health services with the integration of additional healthservices during the mass drug administration (MDA) such as bed net distribution,immunization, growth monitoring and promotion, Vitamin A and iodized salt distributionand sanitation and hygiene education. The 'Filariasis Fair' in the Philippines, organized bylocal governments, creates a festival out of the MDA, offering additional services toattract more people to take the DEC and albendazole.The Elimination of Lymphatic Filariasis as a means to Sustainable Development1. Health planning technologies2. Health logistics system with the procurement of diethylcarbamazine citrate, receipt of albendazole and their distribution, inventory procedure and accountability3. Health research systems development with epidemiological research, basic healthresearch, health social science research, health systems research, evaluation research,operational research and participatory action research.4. Development of health management information systems using the latest informationtechnology like Geographic Information Systems (GIS), FilSim and remote sensing5. Social marketing and social mobilization methodologiesThe Elimination of Lymphatic Filariasis as a means to Sustainable Development


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6. Setting up health referral systems, for example, using the adverse drug reactionreporting system7. Vertical and horizontal integration system with LF elimination programs and primaryhealth care8. Human resource development in health through scientific and program updates

9. International and regional networking for technical assistance and resourcemobilization10. A focus for leadership and governanceConclusions

Elimination of lymphatic filariasis as a public health problem is a 20-year strategic planfor the world community.

Vision - all endemic communities free of transmission of lymphatic filariasis by 2020Commitment - ensure the delivery of quality technologies and human services to

eliminate lymphatic filariasis worldwide through a multi-stakeholder global alliance of allendemic countries.

Global goal of elimination of lymphatic filariasis is a significant opportunity for

partnerships a world with less poverty through sustainable development and free fromthe scourge of lymphatic filariasis.Summary

Described the epidemiology/ health situationer of filariasisDiscussed the goals, objectives and strategies of the programs of DOH and WHO for

filariasisDescribed the following about filariasis:Life cyclePathogenesis and pathologyClinical featuresDiagnosis

ManagementPreventionTreatment

Avian and PandemicInfluenza PreparednessDept. of Health Session Objectives Role of the physician in Avian Flu

Describe the types of influenza subgroups. Sources of threats & problems in control of Influenza. Stages in Influenza transmission. Recent advances in the treatment & control. Phases of Influenza preparedness plan. Four lines of defenses against avian flu.Role of the Physician


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Advocacy in Prevention- knowledge of Transmission Reporting of Suspect Cases- knowledge of case definition Initial management of suspect cases-knowledge in case Mx & Infection Control Alleviation of Fear and Panic-knowledge of risk communication Public health cooperation, coordination and Networking efforts knowledge instakeholdership

Influenza sub-groups Influenza A highly infective infects many species causes frequent widespread epidemics and pandemics Influenza B only found in humans capable of producing severe disease cause of regional epidemics Influenza C causes mild disease humans are natural hosts but isolates also found in pigs does not cause epidemics

Type A Influenza Viruses

Surface glycoproteins Haemagglutinin H or HA responsible for pathogenicity of the virus allows virus to adhere to endothelial cells in the respiratory tract main determinant of immunity Neuraminidase N or NA allows release of newly formed viruses within host determinant of disease severity

Genetic change in influenza viruses Point mutations minor change producing low to moderate antigenic change Recombination genetic exchange between animal viruses resulting in a new human pathogenicstrain Reassortment


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mixing of human and avian gene segments resulting in a human pathogenic strainwith major antigenic change

Influenza Viruses Circulating in the Human Population Influenza A/ H3N2 Influenza A/ H1N1

Influenza B (No subtypes )

Strain variation (e.g Fujian, New Caledonia) : basis for yearly vaccination

H5N1 in Hongkong (1997)18 cases with 6 deaths (high CFR)Destruction of all chickens (> 1 million)

H9N2 in Hong Kong, SAR and Guangdong (1999)2 cases in Hong Kong, SAR 5 cases in Guangdong

H5N1 in Hong Kong, SAR (2003)2 confirmed cases with one death in a familyTravel history to Fujian province

H7N7 in Netherlands (2003)Human to human transmission30 cases, 1 death

H9N2 in Hong Kong, SAR (2003)One case

World : Areas reporting confirmed occurrence of H5N1 avian influenza in poultryand wild birdssince January 2006, status as of 13.06.2006

Possible Spread of HPAI Along Major Flyways of Migrating Birds

10 Leading Causes of Morbidity2000, FHSIS Data, PhilippinesInfluenza Season in The PhilippinesRationale for Southern Hemisphere Vaccine Recommendation


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February 1998 September 2003 Influenza IsolatesPhilippine Influenza Surveillance DataFem Julia Paladin, PhD et al., - Research Institute of Tropical Medicine

Signs and Symptoms among Birds Decrease in activity Drastic decline in egg production Facial swelling with swollen & bluish violet colored coombs & wattles Hemorrhages on internal membrane surfaces Virus isolation needed to definitive diagnosis Gasping for breath Muscle weakness and paralysis Diarrhea Sudden deaths ( MR up to 100%)

Mode of Transmission to Human Direct & indirect contact with infected wild ducks & chickens through infectedaerosols, discharges & surfaces Inhalation of the particles from dried discharges or feces with the bird flu virus. Discharges can get in contact with the nose or eyes of persons handling infectedchicken Virus is inactivated by heat . No human to human transmissionTransmission to humans Close contact with live infected birds through infected aerosols, discharges andsurfaces, feces

Flapping of wings hastens the transmission

Plucking and preparing of diseased birds Handling fighting cocks Playing with poultry

Consumption of duck's blood or possibly undercooked poultry

Large-Droplet and Aerosol Respiratory Transmission

virus-laden large droplets (particles >5 mm in diameter) from cough or sneeze -predominant mechanism


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aerosol spread (especially in unventilated conditions)

the infectious dose for humans exposed by aerosol is lower than that seen withexperimental nasopharyngeal instillation

surgical masks should protect against large droplets

Transmission by Contaminated Hands, Other Surfaces, or Fomites

contaminated hands, other surfaces, or fomites transmission of oral secretions from patient to patient by staff who were not gloved

Clinical Signs and Symptoms In humans, it has been found that avian flu causes similar symptoms to other types of flu:

fever cough sore throat muscle aches, and weakness conjunctivitis in severe cases of avian flu, it can cause severe breathing problems and pneumonia,and can be fatal. Multiorgan failure and respiratory distress syndrome.

Baseline Investigation Chest X-ray Total WBC and differential count Liver function tests

Take respiratory and blood specimens for laboratory testing for influenza andother infections as clinically indicated

Supportive care

Antibiotic therapy to control secondary bacterial infections as required


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No evidence on effectiveness of ribavirin against influenza viruses

Immunomodulators such as corticosteroids should be used only in the context of clinical trials

Paracetamol or ibuprofen for management of fever Avoid salicylates (such asaspirin) in children under 18 years of age because of the risk of Reyes syndrome

Use nebulizers and high-air-flow oxygen masks only if clinically justified and apply

them under strict infection control, including airborne transmission precautions

Testing

Avian influenza (H5N1) can be isolated by conventional viral culture methods

Rapid influenza tests, H5-specific RT-PCR, and real-time RT-PCR could aid arapid diagnosis

However, rapid diagnostic tests for influenza have low sensitivity, which may limittheir usefulness to reliably detect H5N1, especially if illnesses are diagnosed later intheir clinical course

Thus, clinical findings and a history of poultry exposure may be more helpful inidentifying patients with H5N1 infection than the result on rapid diagnostic tests forinfluenza.

Nasopharnygeal aspirates for influenza A H5 strain by two RT-PCR primers andby real-time RT-PCR.

Three sets of blood cultures, sputum cultures, and serologic tests for Chlamydia bymicroimmunofluorescence, mycoplasma by microparticle agglutination assay, urine

Legionella antigen by enzyme-linked immunosorbent assay (ELISA), HIV byELISA, Burkholderia pseudomallei (melioid) titer by immunohistochemical assay,


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dengue titer by hemagglutination inhibition using all four serotypes, Leptospira titerby microscopic agglutination test, Widal test, Weil-Felix test, and viral culture.

recently circulating H5N1 strains are susceptible to two antiviral drugs to treathuman influenza infections oseltamivir (sold as Tamiflu) and zanamivir (sold as

Relenza).

need to be started early enough usually within the first two days of infection tobe effective

Currently circulating H5N1 influenza viruses are resistant to two older, inexpensiveantiviral drugs, rimantadine and amantadine

Antiviral AgentsTreatment

Oseltamivir -75 mg BID X 5 days in adults Children 1 year of age or older: Adjusted twice-daily doses

30 mg for 15 to 23 kg60 mg for > 23 to 40 kg

Not recommended for children 23 to 40 kg75 mg for > 40 kg

Antiviral Agents


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Prophylaxis

Household contacts, including children for 7-10 days from the last day of exposureHealth care workersPersonnel involved in culling

May be given up to six weeks

no protection against infection with the H5N1 avian virus prevent re-assortment from simultaneous infection by

human influenza and avian influenza among high-risk groups

Selected groups for vaccination: cullers involved in destruction of poultry people living and working on poultry farms

health care workers giving daily care of H5N1 humancases health care workers in emergency care facilities in

areas where there are confirmed influenza H5N1outbreaks in birds

Both sanofi pasteur (Swiftwater, PA) and Chiron (Emeryville, CA) are producingvaccines made from inactivated H5N1 viruses for NIAID to test in clinical trials.

First clinical trial began in April 2005

Testing a range of concentrations, known as dosage levels, of the sanofi pasteurH5N1 vaccine to evaluate safety and immunogenicity.

Based on preliminary data from 117 of the 450 participants enrolled in the trial inhealthy adults, two 90-g doses of the H5N1 candidate vaccine generated the highestimmune response among those doses tested.

A study to determine if a smaller intradermal dose may be as effective as a largerdose administered intramuscularly.

Studies on the production of an H5N1 vaccine with adjuvants, ingredients that areadded to improve the immune response that a vaccine produces- Alum and MF59


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3 pre-requisites to start an influenza pandemic:Emergence of a new virus to which all are susceptible;Virus is able to replicate and cause disease in human;New virus is transmitted efficiently from human-to-human

Genetic adaptation antigenic variation Antigenic drift modification of H and N gene very frequent, type A and B leads to epidemic Antigenic shift exchange of RNA between human and animal strains inside an animal reservoir rare event, only type A change in H or N or both leading to a new subtype A results in pandemic

Genetic reassortment

hard, nonporous surfaces (steel and plastic)-


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How to report- use case investigation form to document suspect

Phases in development of influenza pandemic(WHO 2005)

Individuals at risk

Poultry handlers/workersSellers/ people in live chicken saleAviary workers/ OrnithologistsCullers

People living near poultry farmsAny individual in close contact with infected birds

Prevention of spread from birds-to birds: early recognition and reporting, mass culling,quarantine of affected area

Prevention of spread from birds to humans: human protection through proper handling of infected birds, use of protective gear by residents, poultry handlers, and responseteams

Community Response to sick or dead birds Protection of exposed residents gloves/ plastic material in handling sick or dead birds,hand washing

Personal protective equipment for cullers caps, masks, goggles, gowns

Identification of exposed individuals and quarantine for 7 days

Reporting to the Barangay Health Emergency Response Team/ local health officer

WHO: Phase three (current phase) : human infections with a novel virus subtype (H5)are occurring, no evidence that the virus is spreading efficiently and sustainably amonghumans.

H5N1 AI remains principally a disease of birds, and not of humans.

Human cases at present are isolated and rare, indicating a significant species barrier.


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Early Recognition,Rapid Response and Containment

Virus is progressively improving its transmissibility among humans, but is not yetspreading efficiently and sustainably.

Phase 4 clusters of 2 weeks, but still localized

An increase in the number of clusters, closely related in time and place, isconsidered the likely epidemiological signal of improved transmissibility.

Epidemiological signals

Three or more health care workers/ patients with unexplained moderate to severeacute respiratory illness (or who died of unexplained acute respiratory illness)and with onset of illness within 7 to 10 days of each other

Five to ten persons with moderate to severe acute respiratory illness (or deaths) inwith evidence of human-to-human transmission

AND

With history of:- Travel to or residence in an area affected by avian influenza outbreaks in birds orother animals

- Direct contact with dead or diseased birds or other animals in affected area

- Close contact with an H5N1 patient (living or deceased) or a person withunexplained moderate-to-severe acute respiratory illness

- A possible occupational exposure, including employment as an animal culler,veterinarian, laboratory worker, or health care worker

Clinicians should immediately notify NEC or RESUNational authorities should immediately trigger further assessment


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Public health measures are aimed to reduce transmission and prevent, or at leastdelay, further spread

Rapid detection and isolation of H5N1 cases

Tracing of close contacts during the patients first two weeks of illness andvoluntary quarantine of symptomatic persons for one week

Use of antiviral drugs for treatment of cases

Prophylaxis of exposed and other persons in the initially affected area.

Restriction on the movement of persons in and out of the initially affected area.

Screening of travelers departing from areas where clusters of human cases areoccurring.

Widespread human-to-human transmission of influenza(pandemic influenza)

Workforce sick, take care of the sick, afraid Reduced production of goods Disruption of delivery Food, groceries and other basic needs will be in short supply

Health alert notices describing symptoms and where to report should thesesymptoms develop to incoming travellers

Introduce exit screening measures for departing travelers maybe disruptive, costly, not be fully efficient

For persons known to have been exposed in an aircraft or aboard a large cruise

ship, daily fever checks among passengers and crew and prophylactic treatmentwith antiviral drugs, when available.

Health care workers and first responders should be equipped with N95 respiratorymasks; If respiratory masks are not available, standard well-fitted surgical masksshould be used.


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Patients and persons seeking care in areas with cases should wear surgical masks.

Persons with fever and respiratory symptoms and their contacts asked to undergovoluntary home confinement.

People in countries with cases asked to defer non-essential domestic travel toaffected parts of the country.

Patient isolation and tracing and quarantine of contacts should cease,

Shift to maintenance of essential services and public order

Persons providing Emergency and disaster response Maintenance of peace and order Transportation, including air traffic controllers Utilities water, electricity

Minimizing surge of cases in hospitals Out-patient clinics should manage uncomplicated cases while hospitals will managesevere or complicated cases of influenza Out-patient clinics should triage and separate respiratory from non-respiratorycases

Additional health stations and manpower

Triage of cases- separating respiratory from non-respiratory

cases- screening of cases who should stay home,

who should be referred to the hospital

Monitoring of supply and prices of antipyretics, analgesics, liniments and

antibiotics Advise not to use salicylates for children

Should a large surge in cases occur,health care facilities should be arranged in ways that help reduce transmission (for

example, by keeping a distance between patient beds or placing adjacent beds face tofoot).


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Social Distancing Reduction of unnecessary travel Staying at home when sick Isolation at home (separate room)

Closure of schools Suspension of public events Closure or limitation of people in public places or establishments

WHO does not recommend, at any phase, that individual countries be quarantined or that international borders be closed.

Cover your nose and mouth with tissue or handkerchief every time you sneeze,cough or blow your nose.

Put used tissues or plastic bags in the trash bin.

Wash your hands with soap and water.- Before touching your eyes, nose or mouth.

- Before shaking hands with other people.If water is not available, use an alcohol-based hand sanitizer.

Dont spit on the floor or on the road. Spit on a trash bin or on a small plastic bag. Wash used handkerchiefs separately from clothing.

As much as possible, stay at home and dont get near with other people when youare sick.

Do not share eating utensils, drinking glasses, towels or other personal items.

1. First Line of Defense Out Border Containment in affected countries


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2. Second Line of Defense Entry-ExitManagement of International Passengers

Intensified quarantine measures Infrared thermal monitors are routine at international ports Travelers with unknown fever and respiratory symptoms will be examined further

If WHO issues a notification of confirmed human-to-human transmission of avian flu

Travelers will be asked to undertake self-quarantine for 10 days.

People under self-quarantine will need to check temperature twice daily, and report tolocal health authorities if they have influenza symptoms.

Avian influenza: Personal hygiene Use of Personal Protective Equipment (PPE) Cleaning and disinfection Anti-viral agents Quarantine for 10 days Immediate admission of symptomatic persons to referral hospital Prophylaxis and monitoring of contacts

4. Fourth Line of Defense Health Care System

Avian Influenza : Referral Hospitals (21) Clinical management of cases Infection control

Pandemic Influenza21 Referral Hospitals, DOH-retained hospitals, local government hospitals and

military hospitals Management of surge of cases Clinical management of cases Infection control Psychosocial management4. Fourth Line of Defense Health Care System

Triaging and screening of cases- Screening of cases in out-patient clinics/ health

centers

- Mild cases to stay at home, watch out for signs


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Filiariasis, Avian Flu, etc.

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