Address for Communication: Department of Communicable Disease Surveillance & Control, Directorate General of Health Affairs, Ministry of Health HQ, PO 393, Muscat PC 113, Sultanate of Oman
Sultanate of Oman
Ministry of Health
Department of Communicable Disease Surveillance & Control, DGHA
Reader information
Policy Document Purpose Title Author Other Contributors Publication Date Target Audience This is the official policy document of the Ministry of Health, Sultanate of Oman For information and action National Pandemic Influenza Preparedness Plan Department of Communicable Disease Surveillance & Control, Directorate General of Health Affairs, Ministry of Health HQ Experts from the “National Task Force on Influenza Pandemic Preparedness” November 20th, 2005 All director generals, directors, of the regions and governorates, medical superintendents, MOICs, of the hospitals including the MOICs of the health centres, extended health centres, polyclinics, public health sections (CDC), and other Ministry of Health institutions. Non-MoH health organizations viz. SQU Hospitals, AF hospital, ROP hospital, PDO clinics, Palace health services, ISS health services, all private hospitals and clinics and including those who are directly or indirectly involved in the pandemic management. This document outlines the framework of how the Ministry of Health, Sultanate of Oman would respond to an influenza pandemic. It is based on the recommendations of the World Health Organization for the national pandemic preparedness plan. Key Influenza Documents on the website Generic “National Epidemic Preparedness Plan” Currently none. N/A Dr. Ali Jaffer M. Suleiman, Director General, Directorate General of Health Affairs, Ministry of Health, PO Box 393, Muscat 113, Sultanate of Oman. dg-ha@moh.gov.om Dr. Salah Al Awaidy, Director, Department of Communicable Disease Surveillance & Control, Directorate General of Health Affairs, Ministry of Health, PO Box 393, Muscat 113, Sultanate of Oman. awadymoh@omantel.net.om
Description Cross References Superseded Docs Action required Timing Contact Details
Acronyms
AI DCDSC FAO HPAI GF TADs GLEWS ILI MoA&F MoH NADSS OIE PDO RADISCON ROP SNS SQUH WHO (OMS) Avian Influenza Department of Communicable Disease Surveillance & Control Food & Agriculture Organization (UN) Highly pathogenic Avian Influenza Global Framework for the control of Transboundary Animal Diseases (FAO/OIE) Global Early Warning System (FAO/OIE/WHO) Influenza Like Illness Ministry of Agriculture and Fisheries Ministry of Health National Animal Disease Surveillance System Organization Mondiale de la Santé Animale (World Organization for Animal Health) Petroleum Development Organization Regional Animal Disease Surveillance and Control Network Royal Oman Police Strategic National Stockpile Sultan Qaboos University hospital World Health Organization (Organization Mondiale de la Santé)
Contents
Reader Information ............................................................................................. 2 Acronyms ............................................................................................................... 2 Contents ................................................................................................................. 3 Executive Summary ............................................................................................. 4
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National Pandemic Influenza Preparedness Plan: 2006
1.
Introduction 1.1. Background ................................................................................................................. 6 1.2. The Need for Preparedness...................................................................................... 6 1.3. The Threat of AI ......................................................................................................... 7 1.4. Threat Assessment .................................................................................................... 8 1.5. Migratory Birds & AI ............................................................................................... 8 1.6. Major Migratory Flyways over Oman................................................................. 10
2. Epidemiology of Influenza ....................................................................................... 11 3. Aim and Objectives of the Plan ...............................................................................15 4. Preparedness Plan 4.1. Phases of Pandemic ..................................................................................................17 4.2. Country Specific Alert Levels ............................................................................... 18 4.3. Declaration of Pandemic ........................................................................................ 19 5. The Components of Preparedness 5.1. Influenza Surveillance ........................................................................................... 20 5.2. Veterinary Surveillance ......................................................................................... 21 5.3. Laboratory Surveillance ......................................................................................... 21 5.4. Information Dissemination ...................................................................................22 5.5. Public Health Response
5.5.1. 5.5.2. 5.5.3. 5.5.5. Medical Interventions ........................................................................... 23 Infection Control .................................................................................... 24 Influenza Vaccine ................................................................................... 26 Other Measures........................................................................................ 31
5.5.4. Antiviral agents ....................................................................................... 28
6. International Obligations ........................................................................................ 32 7. List of Annexure (1 to 12) ........................................................................................ 33 8. List of Algorithms (1 to 10) ..................................................................................... 60
Executive Summary
Influenza is one of the most common causes of febrile and respiratory illness in humans. The risk of severe illness and/or death is higher among older adults and among persons of any age with underlying chronic diseases. Influenza viruses circulating in the population are continuously evolving. Pandemics occur when novel influenza A viruses derived from animal or avian influenza viruses develop ability to spread effectively among people. Concern that an influenza pandemic due to the avian influenza strain might be imminent began in January 2004, when Thailand and Viet Nam reported their first human cases, caused by the H5N1 strain of Influenza virus A. These events supported by epidemiological and virological surveillance, have given the world an
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National Pandemic Influenza Preparedness Plan: 2006
unprecedented opportunity to enhance preparedness and prepare contingency plan to minimize impact of a potential pandemic. There is a potential risk that Highly Pathogenic Avian Influenza (HPAI) subtype H5N1 might be carried along migration routes of wild water birds to densely populated areas in the south Asian subcontinent and along migratory flyways to Africa and Europe. Bird migration routes also run across southwest Asia and some Mediterranean countries, where bird flu outbreaks could possibly occur. Many of the public heath interventions that successfully contained SARS will not be effective against HPAI that is far more contagious, has a short incubation period, and can be transmitted before the onset of symptoms. The epidemiological features of the HPAI may have a profound impact on the pandemic and will also affect the measures of intervention. Such as - most people will be susceptible and the pandemic may occur at any time of the year. If working age adults are predominantly affected this will impact more seriously on provision of services and business continuity, while illness in the very young and the elderly is likely to present a greater burden on the health services. It is highly unlikely that importation could be prevented in any country. The new virus is likely to produce more severe illness with severe prostration, rapidly fatal overwhelming viraemia/pneumonia or secondary complications. The impact of a HPAI pandemic on health and social services is likely to be intense, sustained and nation-wide. The aim of this document is to provide a national framework for an integrated countrywide response to an influenza pandemic, with clear operational plans for the response at all levels. The response is based on phases as currently defined by the World Health Organization (WHO) which trigger public health action. Preparedness is the key to effective response. Preparation requires planning and testing the plan as well as maintaining and strengthening key capacities and infrastructures such as surveillance, influenza vaccine stocks, and communications. The national authorities will provide overall direction, guidance and coordination, while provincial (Regions/Governorates) health affairs departments and the private medical clinics will form the front line with respect to management of ill persons and administration of interventions such as vaccine and antiviral medications and possibly community-level interventions such as isolation and quarantine. The World Health Organization, in 2005, defined six pandemic phases under which preparation and response can be organized and these phases provide a framework for planning. Oman has adopted these phases and the corresponding actions. As of now the world is in the initial Phase 3 of the Pandemic Alert period and there is growing evidence that Phase 4 is not far away. This transition between phases may be rapid and the distinction blurred. The WHO will announce the various phases as soon as they are confirmed, indicating the level of preparedness expected of WHO and its individual Member States. Timely surveillance information on influenza will be the key to early identification of an pandemic, and to the development of evidence based interventions at all stages. A pandemic influenza virus strain is likely to arise from re-assortment of animal and human influenza viruses. Therefore, coordination of surveillance with the Ministry of Agriculture & Fisheries is critical. Laboratories are also essential to confirm diagnosis, determining the characteristics of the virus, and to overall surveillance. The public health response includes the field investigation, handling and feedback of information from suspected incidents and outbreaks by appropriately trained personnel, using appropriate protocols and forms. The health service response requires co-ordinated local arrangements for the efficient, safe clinical management of cases (and suspected cases) and their contacts at primary, secondary or tertiary levels. In the capital region Al Nahda hospital would be utilized as influenza isolation hospital. In other Governorates and the Regions the decision would be left to the Director/Director General of Health Services to select an appropriate health institution. The points should be weighted while taking the decision would be the bed capacity about 50, preferably away from the city centre, central location in the province, good road, availability of life support system, reliable power and water supply system and a dependable communication network A vaccine specifically formulated against the pandemic virus strain, when such vaccine becomes available can be expected to achieve the greatest reduction in illness, complications and deaths, and lessening of the impact on health and other services. Antiviral agents active against influenza are the only other major medical countermeasure available. They may be used in the absence of, or as an adjunct to, vaccination. However, there are limitations to their use,
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their effectiveness in a pandemic situation has yet to be tested and anti-viral resistance may become a problem. A wide range of non-medical interventions, such as improved personal hygiene, quarantine, contact tracing and travel restrictions, can potentially reduce opportunities for transmission at the start of a pandemic and slow its international spread. The annexure with this plan enlists the national task force, inter-ministerial committee, case-definition, WHO advisory on travel, infection control guidelines and various algorithms for recommended actions etc. It is envisaged that this contingency plan will enable the Ministry of Health to undertake a coordinated response and to minimize the impact of HPAI pandemic in Oman.
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1. Introduction
1.1 Background
The first pandemic of influenza of the 20th century, the “Spanish flu,” began in 1918 and, by the time it ended the following year, by conservative estimates, had caused more than 20 million deaths worldwide. Later pandemics in 1957 and 1968 caused far fewer deaths but still posed a substantial burden on the health care system, and resulted in substantial economic costs and social disruption. Influenza is one of the most common causes of febrile and respiratory illness. The risk of severe illness and/or death is higher among adults >65 years old; among persons of any age with underlying chronic diseases including lung or heart disease, metabolic diseases, and immunosuppression; and among children <2 years old. Vaccination represents the major strategy to reduce the impact of influenza and is recommended for high-risk persons. Influenza viruses circulating in the population are continuously evolving (antigenic drift and antigenic shift), which requires that vaccines be redesigned and produced annually to provide the best match to the influenza strains that are circulating. Pandemics occur when novel influenza A viruses most probably derived from animal or avian influenza viruses develop ability to spread effectively among people. By definition pandemics involve the circulation of strains for which almost all of the world‟s population lack pre-existing immunity. Since January 2004, events affecting both human and animal health have brought the world closer to an influenza pandemic than at any time since 1968. These events supported by epidemiological and virological surveillance, have given the world an unprecedented warning that a pandemic may be imminent and also an unprecedented opportunity to enhance preparedness. The exact health care burden of an influenza pandemic cannot be predicted with certainty. Overall the burden of illness and the burden on the health care system will depend on the transmission potential and virulence of the strain, the epidemiology of the specific pandemic, and the rapidity and effectiveness of the response. The increasing amount and speed of global travel and the greater proportion of the elderly population who have chronic underlying diseases makes the situation worse. The recent outbreak of Severe Acute Respiratory Syndrome (SARS) highlighted the role of international travel in disease transmission. In an influenza pandemic where infection would be expected to spread more easily from person-to-person and may be transmitted by asymptomatic persons, the potential rate and extent of spread is likely to be much greater.
1.2 The Need for Preparedness
Resolution WHA56.19 of the World Health Assembly urged Member States to draw-up and implement national preparedness plans, and requested the Director-General to continue to provide leadership in pandemic preparedness, particularly by strengthening global influenza surveillance. During a pandemic disease often occurs outside of the usual influenza season, including the summer months, and multiple waves of disease occur before and after the main outbreak. Mortality during a pandemic is very high and is not confined to the usual risk groups: high attack rates occur in all age groups with particularly high mortality among healthy young adults. It is almost inevitable that another influenza pandemic will occur. It is however impossible to predict when this might occur, but a pandemic has the potential to cause widespread human suffering. The impact of a pandemic will be measured not only by the morbidity and mortality from influenza and its complications but also by the resulting economic and social disruption. An influenza pandemic would result in a worst global health and economic crisis. Contingency planning is therefore required to enable a coordinated response to minimize these effects as far as possible.
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1.3 The Threat of AI
Concern that an influenza pandemic due to the avian influenza strain might be imminent began in January 2004, when Thailand and Viet Nam reported their first human cases, caused by the H5N1 strain of Influenza virus A. These cases were directly linked to historically unprecedented outbreaks of highly pathogenic H5N1 avian influenza in poultry that began in 2003 and rapidly affected eight Asian nations. Massive control efforts were introduced in most countries with the aim of eliminating the virus from its poultry host. The largest outbreaks among poultry, in Thailand and Viet Nam, declined by March 2004. However, disease activity began to increase again in July, with fresh outbreaks reported in Cambodia, China, Indonesia, Thailand, Viet Nam and in August Malaysia. A third wave of avian influenza in poultry began in December 2004 in Thailand and Viet Nam, with outbreaks also detected later in Cambodia, Democratic People‟s Republic of Korea and Indonesia. Cambodia reported its first human case, which was fatal, in early February 2005. As of mid-March 2005, Viet Nam had reported 24 human cases in this third wave, of which 15 were fatal. Among all these cases, two features are striking: the overwhelming concentration of cases in previously healthy children and young adults, and the very high mortality. No explanation for this unusual disease pattern is presently available. Nor is it possible to calculate a reliable case-fatality rate, as mild or asymptomatic infection, now known to occur, may escape detection. Moreover, recent research shows that severe disease can occur in the absence of respiratory symptoms, further increasing the risk that some cases have been missed and suggesting that the burden of infection may be far greater than indicated by reported cases. Although the second and third waves of outbreaks have been far less conspicuous in the numbers of human beings and animals affected, they have demonstrated several unusual features. Confirmed by findings from recent epidemiological and laboratory studies, these features suggest that the virus may be evolving in ways that increasingly favour the start of a pandemic. Evidence indicates that H5N1 virus is now endemic in parts of Asia. The risk of further human cases will continue, as will opportunities for a pandemic virus to emerge. Evidence further suggests that H5N1 virus is expanding its mammalian host range. For example, the virus has recently been shown to cause severe disease and deaths in species, including captive tigers and experimentally infected domestic cats, not previously considered susceptible to disease caused by any influenza A virus. The present concentration of outbreaks of avian influenza in poultry in rural areas, where most households maintain free-ranging flocks and ducks and chickens mingle freely, is of particular concern, especially as households depend on these birds for income and food. Such outbreaks may escape detection, are difficult to control, and increase the likelihood of human exposures, which may occur when children play in areas shared by poultry or when families slaughter or prepare birds for consumption. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO: 17 November 2005
Date of onset 26.12.0310.03.04 19.07.0408.10.04 16.12.04to date Total Indonesia cases deaths 0 0 0 11 11 0 7 7 Viet Nam cases deaths 23 16 4 65 92 4 22 42 Thailand cases deaths 12 8 5 4 21 4 1 13 Cambodia cases deaths 0 0 0 4 4 0 4 4 China cases deaths 0 0 0 2 2 0 1 1 Total cases deaths 35 24 9 86 130 8 35
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67
Note: Only laboratory confirmed and including deaths
1.4 The Threat Assessment
Taken together, these changes in the ecology of the disease and behaviour of the virus have created multiple opportunities for a pandemic virus to emerge, either after a re-assortment event, when genetic material is exchanged between human and avian viruses during coinfection of a human being or pig, or through a more gradual process of adaptive mutation. No one can predict how the present situation will evolve. Experts readily agree, however, that H5N1 virus has demonstrated considerable pandemic potential. With the virus now endemic in the bird population, the probability that this potential will be realized has increased. The speed of international spread has no direct effect on mortality, but could compromise response capacity should large parts of the world experience almost simultaneous outbreaks. Many of the public heath interventions that successfully contained SARS will not be effective against a disease that is far more contagious, has a short incubation period, and can be transmitted before the onset of symptoms. Apart from causing a surge of cases requiring health care, such rapid contagion typically results in a crippling shortage of workers in health care and other essential services.
1.5 Migratory Birds & AI Transmission
It has long been known that wild birds represent a reservoir for avian influenza viruses worldwide. This is a concern because many of these birds are migratory and travel over long distances across international borders. Wild birds have been shown to introduce novel influenza gene segments into a population, that when re-assorted with existing viruses can generate a dissimilar virus with different antigenic and other biological characteristics. The influenza viruses are easily spread by fomites and survive and spread well in water. Furthermore, certain species of ducks are able to carry influenza viruses without exhibiting any clinical symptoms of disease. Juvenile ducks have the highest rates of infection and shedding. High titres of virus occur in latesummer, when birds leave their northern breeding areas, although these titres decrease as birds continue southwards. There is a potential risk that Highly Pathogenic Avian Influenza (HPAI) subtype H5N1 might be carried along migration routes of wild water birds to densely populated areas in the south Asian subcontinent and along migratory flyways to Africa and Europe. Bird migration routes also run across southwest Asia and some Mediterranean countries, where bird flu outbreaks could possibly occur. Highly Pathogenic Avian Influenza (HPAI), subtype H5N1 has been occurring in poultry in Southeast Asia since 2003. But since late July 2005, HPAI H5N1 has expanded in a north-westerly direction and both Russia and Kazakhstan have reported outbreaks in poultry as well as in wild birds. Mongolia reported the deaths in migratory birds in early August, 2005. The spring migration of 2006 may result in the spread of HPAI H5N1 virus further across Europe since birds migrating from southern zones will have intermingled with European Russia and Siberia-origin birds during the 2005/2006 winter nesting areas. All of the H5N1 viruses isolated from wild birds during the 2003-2004 outbreaks were from dead or dying birds which were located in the vicinity of infected poultry flocks or recently contaminated premises. It appears that the currently circulating strain of H5N1 is also highly pathogenic to wild birds including ducks, as can be shown from the
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isolation of the virus from numerous dead wild birds. Looking at the epidemiological data currently available, there is no denying the fact that wild water fowl most likely play a role in the avian influenza cycle and could be the initial source for AI viruses, which may be passed on through contact with resident water fowl or domestic poultry, particularly domestic ducks. The virus undergoing mutations could circulate within the domestic and possibly resident bird populations until HPAI arises. Evidence indicates that migratory birds probably act as carriers for the transport of HPAI over longer distances. The AI virus has adapted to the environment in ways such as: 1) The use of water for survival and to spread 2) Has evolved in a reservoir (ducks) strictly tied to water. To prevent spreading of H5N1, surveillance in domestic poultry as well as in wild birds should be strengthened in countries at immediate risk, especially along the migrating bird routes.
Major Migratory Birds Flyways over Oman
PALAEARCTIC
INDOMALAYAN
AFROTROPICAL
Major Migratory Bird Flyways over Oman
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2. Epidemiology of Influenza
(Influencing the Planning Assumptions)
2.1 Origin of the Pandemic
The pandemic will be due to a new subtype of influenza A and its emergence is inevitable. There are 15 haemagglutinins (HAs) which exist in nature and all can infect birds. So far, H1, H2 and H3 have been associated with widespread human disease and it is known that at least H5, H7 and H9 have the potential to cause human disease, and particularly severe disease from H5N1. The avian influenza viruses will infect people directly exposed to infected poultry, but they may not necessarily evolve into potential pandemic strain. A new virus may be a re-emerging previously known human virus subtype which has not recently been in circulation, or a virus of avian origin, emerging either through stepwise „adaptation‟ conferring greater affinity for humans or through a process of genetic „reassortment‟ between the genes of an avian and a human virus. A new strain is likely to transmit more easily to people if it contains genetic material from a human influenza virus. Such a strain could first emerge anywhere but is most likely to emerge in the Far East – the origin of recent pandemics because of the close proximity of humans, ducks, other poultry and domestic pigs in farming communities facilitating mingling of human and animal viruses resulting
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into a new „reassorted‟ strain. The viruses may also re-emerge from unrecognised or unsuspected reservoirs. False alarms are likely and investigations of suspect cases will inevitably consume resources.
2.2 Timing of the Pandemic
A future influenza pandemic could occur at any time. A new virus may not follow the usual seasonal pattern of influenza, and may occur at any time of the year.
2.3 Geographical spread
In the event of a novel influenza virus causing significant outbreaks of human illness elsewhere in the world, it is highly unlikely that importation could be prevented; even closing all borders is likely only to delay the importation. Spread from an origin in Asia is likely to follow the main routes of travel and trade. Spread from the source country through the movement of people is likely to take less than 3 months and experience of the spread of SARS from Hong Kong suggests modern travel may result in wide international spread even more rapidly than this estimate.
2.4 Duration of Pandemic
Based on other countries‟ experiences the influenza activity within a country may last for 3-5 months, depending on the season. There may be subsequent waves of the pandemic, weeks or months apart.
2.5 Infectivity & mode of spread
Influenza is mainly spread by the respiratory route, through droplets of infected respiratory secretions or by fine respiratory aerosols produced when an infected person talks, coughs or sneezes; it may also be spread by hand/face contact after touching a person or surface contaminated with infectious respiratory droplets (fomites). Cases are highly infectious from the onset of symptoms for 4-5 days (longer in children and people who are immunocompromised). 10% of these are likely to be infectious before the onset of symptoms. Children have been shown to shed virus from 6 days before to 21 days after the onset of symptoms. The incubation period is 1-3 days Without intervention one person infects on average about 1.4 people (basic reproduction number). This number is likely to be higher in closed communities.
2.6 The extent & severity of illness
Important differences in the age distribution, extent and severity of illness are likely compared with annual seasonal influenza, but will not be known until person-to-person transmission is taking place. Most people will be susceptible, although not all will develop clinical illness. Previous experience suggests an equal number will be asymptomatic.
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For planning purposes the most likely scenario, based on previous pandemics in the 20th Century, is a cumulative clinical attack rate of 25% of the population (figure advised by WHO) over one or more waves of around 12 weeks each, weeks or months apart. This compares with a usual seasonal influenza attack rate of 5-10%. Ten percent and 50% clinical attack rates have also been considered. The second wave may be the more severe. All ages will be affected, but children and otherwise fit adults could be at relatively greater risk. For planning purposes, a uniform attack rate has been used for all age groups. If working age adults are predominantly affected this will impact more seriously on provision of services and business continuity, while illness in the very young and the elderly is likely to present a greater burden on the health services. More severe illness than the usual seasonal influenza is likely with severe prostration and rapidly fatal overwhelming viraemia/pneumonia or secondary complications.
2.7 Mortality
Mortality due to influenza pandemic is expected to be higher than during the interpandemic period.
2.8 Impact on health & social services
The impact of a flu pandemic on health and social services is likely to be intense, sustained and nation-wide; they may quickly become overwhelmed as a result of: o o o o o o o the increased workload of patients with influenza and its direct complications the needs for high dependency care and infection control facilities a secondary burden on health due to anxiety and bereavement depletion of the workforce and of existing numbers of informal carers, due to the direct or indirect effects of flu on them and their families logistical problems due to interruption of supplies, utilities and transport delays in dealing with other medical conditions the longer term macro effects of the pandemic on the national economy and the structure of society.
Innovative approaches will be needed to many aspects of health care, including staffing, triaging of patients and coping with those patients needing more intense care than is normally possible at home but who may not be able to be admitted to hospital There will be pressure on mortuary facilities (possibly exacerbated by delays in death registrations and funerals). Total visits to health institutions for influenza-like illness could increase around six times during a pandemic Hospital admissions for acute respiratory and related conditions are likely to increase by at least 25%. Hospitalisations and deaths will be greatest if the highest attack rates are in the elderly. The lowest burden on health care would be associated with higher attack rates in adults aged 15-64 years. A short sharp epidemic would put greater strains on services than a lower level but more protracted one. Absence from work will depend on the age-related attack rate, although even if working age people are relatively spared, additional absenteeism may result from staff needing to take time off to care for family members.
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Accelerated transmission may occur in some workplaces where people work in close proximity. Influenza will spread rapidly in schools. This will impact on working parents. Closing schools has a significant impact on business continuity and maintenance of essential services, particularly health care, due to parent workers needing to stay at home for childcare. Similar spread is likely in other closed communities such as residential care facilities, barracks and prisons. In the absence of early or effective interventions, there will be a widespread effect on all other services, through staff sickness and any travel restrictions imposed. Travel will be affected through o o any explicit restrictions on travel and public gatherings as a policy option people opting not to travel (e.g. because of cancellation of work/school etc, fear of acquiring infection through travel or fear of leaving home)
There will be high public and political concern and scrutiny at all stages of an influenza pandemic. Press interest: the need for information and coverage will be intense. Managing people‟s concerns and expectations will be a key part of the response. People‟s concerns will extend to what is happening in other countries, particularly those with which they have family connections Interest and concern will also extend to national and international events and mass gatherings.
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3. Aims and Objectives of the Plan
The aim of this document is to provide a national framework for an integrated countrywide response to an influenza pandemic, with clear operational plans for the response at all levels. The response is based on phases as currently defined by the World Health Organization (WHO) which trigger public health action, starting with plans which need to be put in place, and exercised, during the inter-pandemic periods. The objectives of contingency planning for an influenza pandemic are to: Ensure optimal coordination, decision-making, and communication between national, state, and local levels Detect influenza strains through clinical and virologic surveillance of human and animal influenza disease Implement a vaccination program that rapidly administers vaccine to priority groups and monitors vaccine effectiveness and safety Deliver antiviral drug therapy and prophylaxis and avoid inappropriate use of these agents, which may result in antiviral resistance Implement measures to decrease the spread of disease guided by the epidemiology of the pandemic Provide optimal medical care and maintain essential community services Communicate effectively with the public, health care providers, community leaders and the media
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The National Preparedness Plan
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National Pandemic Influenza Preparedness Plan: 2006
4.1 Introduction
Planning and preparedness are essential to optimally achieve the goals and objectives of a pandemic response. Therefore, the purpose of this plan is to define the roles, responsibilities, and actions of key stakeholders before the pandemic. Specifically, the plan will: Describe the role of MoH in coordinating a national response to an influenza pandemic Provide guidance and tools to promote pandemic preparedness planning and coordination at national, sub-national, and local levels, including both the Government and private sectors Provide the underlying technical background and recommendations Preparedness is the key to effective response. Preparation requires planning and testing the plan as well as maintaining and strengthening key capacities and infrastructures such as surveillance, influenza vaccine stocks, and communications. It is important that planning be done at all levels of the organizations – from national to regional and to institutional levels. The national authorities will provide overall direction, guidance and coordination, while provincial (Regions/Governorates) health affairs departments and the private medical clinics will form the front line with respect to management of ill persons and administration of interventions such as vaccine and antiviral medications and possibly community-level interventions such as isolation and quarantine. Thus, information and guidance provided in this plan will serve as a platform for the development of plans at the provincial and institutional levels. Multiple stakeholders have important roles in pandemic influenza preparedness and response. Stakeholders include private health care organizations and other government departments and agencies. Each phase is associated with international and national public health actions. National actions during each phase are further subdivided according to the national epidemiological situation. For convenience, the term “not affected” is used for countries without cases/outbreaks.
4.2 Phases of Pandemic
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National Pandemic Influenza Preparedness Plan: 2006
The World Health Organization, in 2005, defined six pandemic phases under which preparation and response can be organized (WHO/CDS/CSR/GIP/2005.5; Table 1). These phases provide a framework for planning and have been modified from those published earlier in 1999. As of now the world is in the initial Phase 3 of the Pandemic Alert period and there is growing evidence that Phase 4 is not far away. Table 1: WHO influenza pandemic phases: 2005
Period
Interpandemic Period
Phase
1
Definition
No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk a of human infection or disease is considered to be low. No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial riska of human disease. Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Small cluster(s) with limited human- to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. b Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).b Pandemic phase: increased and sustained transmission in general population. b Return to interpandemic period.
2 Pandemic Alert Period 3 4 5
Pandemic Period Postpandemic Period
6
a The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction would be based on various factors and their relative importance according to current scientific knowledge. Factors may include: pathogenicity in animals and humans; occurrence in domesticated animals and livestock or only in wildlife; whether the virus is enzootic or epizootic, geographically localized or widespread; other information from the viral genome; and/or other scientific information. b The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include: rate of transmission; geographical location and spread; severity of illness; presence of genes from human strains (if derived from an animal strain); other information from the viral genome; and/or other scientific information.
4.3 Country Specific Alert Levels
The global alert levels suggested by WHO above may not translate into specific actions at the level of the country, hence have been modified as described below. These alert levels essentially apply to the HPAI in humans presuming a novel strain has emerged with an effective person-to-person transmission. However the AI outbreaks in the birds wild or domestic will also be monitored. The assumption is that an influenza pandemic starts outside the country and becomes established in one or more countries before reaching Oman. The above alert levels 1-4 then occur in WHO Phase 2 and this is where they are placed in the Plan. However, virus could newly emerge within Oman or be imported into Oman at an earlier (or even later) WHO phase. The alert levels would then apply at the earlier (or later) phase. A move to a higher alert level may be triggered, after assessing the risk, if influenza due to a pandemic strain is affecting another country geographically close to Oman or is affecting country from where a large expatriate population is resident in Oman, although technically it is still „outside the country‟. Transition between phases may be rapid and the distinction blurred. The crucial interval is between WHO Phase 3 and 4, which will determine to a large extent the response to the pandemic.
Table 2: Country Specific Alert Levels: 2005
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Global Alert Level
Description of Global Threat No human cases with the novel virus in the world Substantial risk of transmission to humans
Oman‟s Alert Level
Description of Alert Levels in Oman No threat AI outbreaks in wild birds & poultry outside Oman with a potential of transmission to humans Sporadic cases outside Oman among bird handlers or human cases in neighbouring countries
1 2 3
0 1
Human infection with new virus but inefficient transmission
2
Detection of AI amongst wild migratory birds and/or outbreak of AI in domestic poultry or other local birds Detection of laboratory confirmed human case in Oman: local or imported
4 5 6
Small clusters of cases in humans Large clusters of cases in humans Pandemic: Increased and sustained transmission
3 4 5
Small cluster of human cases in one province Large clusters or small clusters in multiple provinces Pandemic: Increased and sustained transmission all over the country
HPAI Outbreaks in Birds
Epizootic of HPAI among poultry or other birds in Oman will raise the alert level and will initiate following actions: Surveillance and follow-up of occupational contacts and their family members Strengthened surveillance amongst general population around the affected area especially by the health institution in their catchment area Heightened alert level at all levels of health care for detecting clustering of severe respiratory illnesses or mortality as a result of that.
4.4 Declaration of Pandemic
The WHO will announce the various phases as soon as they are confirmed, indicating the level of preparedness expected of WHO and its individual Member States. As the species of origin and sequence of progression of the next pandemic strain may vary and thus is difficult to predict, WHO may declare, upscale and downscale phases in a non-sequential order. If an upscaling designation skips a phase, actions in the skipped phase should also be implemented, unless they are specifically superseded by actions in the new phase. National Authorities are expected to be prepared to activate their national contingency plans following the announcement of pandemic. Before announcing this phase, WHO will normally consult internationally before confirming the onset of a pandemic Phase.
5. The Components of Preparedness
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National Pandemic Influenza Preparedness Plan: 2006
One of the lessons learned from the SARS outbreaks of 2003 was the importance, in the event of an incident on the scale of an influenza pandemic, of strong international and national leadership and coordination, and a clear national „command and control‟ structure. The appropriate people at all levels must have authority to make key decisions and act on them, and there must be a clear chain of accountability. The response to an influenza pandemic would be on a nationwide basis, and therefore clear demarcation of roles is required between all the stake holders.
5.1 Influenza Surveillance
Timely surveillance information will be the key to early identification of an influenza pandemic, and to the development of evidence based interventions at all stages. Oman contributes to internationally coordinated laboratory based influenza virus surveillance, which is co-ordinated by the World Health Organization (EMRO). The objectives of surveillance will change as the pandemic evolves and the different phases will trigger enhancements – such as closer monitoring of particular population groups, including laboratory workers – or changes in emphasis. Monitoring influenza disease activity is important to facilitate resource planning, communication, intervention, and investigation. Current influenza surveillance system will provide the foundation for surveillance during a pandemic. Recent enhancements include updating data transmission systems to provide real-time reporting on a weekly basis and monitoring data at the sub-national level. A high level of vigilance for clusters of cases of respiratory disease provides an early warning mechanism. Influenza is a common condition and has symptoms similar to those of many other viral respiratory infections. Early detection of a new virus therefore requires clinicians as well as laboratory staff to be alert to the possibly unusual, for example respiratory illness in a patient, with a link to areas where a new virus has been already identified, or to poultry farming and to report these unusual events promptly. The strategies are: Identify clusters of unusual respiratory illness that may be caused by a new virus Monitor the spread of a new virus and define its epidemiological features As a pandemic progresses, epidemiological surveillance must adapt to provide adequate information on the type and severity of illness, its spread, and the impact in different population groups, in order to inform policy and planning Monitor the causes, and antimicrobial susceptibility, of complications to inform treatment policies. Monitor the overall impact on health services and other parameters This will require collation of information outside that usually regarded as „surveillance‟, for example hospital admission data, absenteeism data, but nonetheless essential to assessing the impact of the pandemic. Monitor the uptake and effectiveness of any interventions (including possible adverse reactions) Monitor any changing characteristics of the virus In order to adapt policies (including vaccine recommendations) if necessary. Co-ordinate with veterinary surveillance to assess the risks of a new human or mammal/bird influenza virus crossing species Establish a case based field information management system that links epidemiological and laboratory data Disseminate a wide range of surveillance information, including monitoring of vaccine uptake and the impact of interventions
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National Pandemic Influenza Preparedness Plan: 2006
5.2 Veterinary surveillance
A pandemic influenza virus strain is likely to arise from re-assortment of animal and human influenza viruses. Therefore, coordination of surveillance with the Ministry of Agriculture & Fisheries is critical. Recent outbreaks in domestic poultry in Asia and Europe associated with cases of human disease highlight the importance of coordinating these surveillance activities. Surveillance for influenza viruses in poultry in the Sultanate has increased substantially since the outbreak of highly pathogenic avian influenza (HPAI).
5.3 Laboratory Surveillance
Laboratories are essential to confirm diagnosis, elucidation of characteristics of the virus, and to overall surveillance. The capability and capacity of the Central Public Health Laboratory to identify novel influenza strains will be maintained, with the ability to roll out a diagnostic capability. A proportion of isolates, including all unusual ones from the Oman, should be referred to the International Influenza Reference Laboratory, at WHO-EMR, Cairo for detailed identification. Once a pandemic is established, laboratory surveillance will map the evolution of the virus, its antiviral susceptibility, and the causes and antimicrobial susceptibility of bacterial complications. During pandemic the virological surveillance strategy would be expanded covering following areas: Maintaining laboratory methods of high standards and increasing capacity Maintaining reagents for routine and reference laboratory diagnostic tests Surge capacity for bacteriological diagnosis of complications of influenza Laboratory staff protection and compliance with all necessary biosafety and security requirements.
5.4 Information Dissemination
On being informed by the WHO of the isolation of a new influenza virus with pandemic potential (when effective person-to-person spread has been confirmed, i.e. Phase 0.3), the Focal Point (Director, Communicable Disease Surveillance & Control), on the advice of the Director General of Health Affairs (chairman) will immediately convene a meeting of the task. As soon as the WHO confirms the onset of a likely pandemic the preparedness plan will be activated and the Ministry of Health will immediately cascade the information to all levels of health care in Government and private sector. Effective communications provide the backbone for an effective and coordinated response. A wide range of groups at all levels will need accurate, timely and consistent information and advice, and rumours and misinformation will abound. Inevitably, the media will sometimes report information before it can be confirmed through official channels. The information to be exchanged will concern currently known facts, assessments of the risks and the public health relevance, and information and advice to help manage those risks, at all stages of the pandemic. The overall communications strategy covers the gathering, collation and dissemination of information for a variety of audiences, which can be divided broadly into:
5.4.1 Strategic communications
Two way strategic communications will involve the MoH, and all other governmental agencies and organisations involved in the response, including the private health establishments and the international agencies. The Government briefings and public information will be controlled and monitored once a pandemic is declared.
5.4.2 Professional information and guidance
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Regular information bulletins to the health professionals will be issued as required, and as urgency indicates, via already established routes. Up-to-date information on clinical guidance and public health advice will be maintained on the MoH website.
5.4.3 Communications with the public and the media
Communication both before and during a pandemic is a key element of the response, with emphasis in the inter-pandemic period on the uncertainties and the constraints faced by Governments in preparing their response. Clear, active engagement of the public will be a priority throughout a pandemic, through: Regularly updated information and advice Sharing the advice of expert groups with the public Briefing the specialist media on the preparations and plans Establishing focus groups to help identify public concerns Media communications will be co-ordinated initially by the MoH, PRO office. They will also co-ordinate cross government communication and depending on the scale will also coordinate the media and public communication for the other Government Departments involved.
5.5
The public health response: reducing impact of pandemic
The ability of containment strategies to substantially slow the spread of pandemic influenza may be limited by the short incubation period for influenza, the large proportion of asymptomatic infections, and the non-specific nature of clinical illness from influenza infection. These challenges may lead to difficulty in identifying infected persons, in quarantining contacts of infected person prior to onset of illness, and in marshalling the substantial resources that would be needed to initiate and monitor the use of containment measures. Nonetheless, during early stages of a pandemic, particularly if the novel influenza virus is not efficiently transmitted, use of containment measures may help to slow the spread of a pandemic influenza A virus and allow additional time for the development and use of a vaccine and the production and use of antiviral medications. The public health response includes the field investigation, handling and feedback of information from suspected incidents and outbreaks by appropriately trained personnel, using appropriate protocols and proforma, and the application of population control measures. The results of epidemiological investigations need regular review to redefine the protocols and develop or adjust the recommendations to prevent or control the (further) spread of the disease. The following control measures are aimed at reducing the health impact of an influenza pandemic: „Medical‟ interventions Immunisation Antiviral drugs Other public health or „social‟ measures to reduce transmission or slow the spread of infection
5.5.1 Medical Interventions
The health service response requires co-ordinated local arrangements for the efficient, safe clinical management of cases (and suspected cases) and their contacts in primary, secondary and long term residential care and by ambulance services, and all the logistical problems in maintaining services in the face of unprecedented demands and disruption. Health service organisations and personnel also have a
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role in supporting the public health response, and will be required to supply some of the data required locally and nationally to monitor the pandemic‟s impact and inform the response .
5.5.1.1 Isolation
National isolation ward at Al Nahda hospital is being re-equipped to serve as isolation and quarantine purpose. During the SARS threat of 2003 the same ward was used. However unlike SARS the HPAI pandemic would be widespread hence isolation facilities will also be developed at each of the regional referral hospitals. Clear guidelines are being developed and resources would be made available in due course of time.
5.5.1.2 Special isolation area/hospital:
It is envisaged that when the pandemic starts a large number of cases would require admission and management. In such situation a single isolation ward in the referral hospital will not be adequate. The entire hospital would be required to be converted into an isolation & quarantine hospital. In the capital region Al Nahda hospital would be utilized as influenza isolation hospital. In other Governorates and the Regions the decision would be left to the Director/Director General of Health Services to select an appropriate health institution. Following points should be weighted while taking the decision. Bed capacity about 50 Preferably away from the city centre Central location in the province Good road and access Availability of life support system Reliable power and water supply system Dependable communication network Recommended influenza isolation precautions in health care settings The patient should be placed in a private room or a room with other influenza-infected patients. Although airborne spread is not believed to play a major role in influenza transmission, if feasible early in a pandemic, the patient should be placed in a negative air pressure room or placed together with other patients with suspected proven influenza in an area of the hospital with an independent air supply and exhaust system. Health care personnel should wear a surgical mask when entering the room of a patient with known or suspected influenza. Health care personnel should use standard plus droplet and contact precautions, including hand washing, use of gloves, and gown and eye protection if they are apt to come into contact with body fluids or contaminated surfaces. 5.5.1.3 Case Management: The efficient and effective care of patients will require clear national and local guidance for the public as to who should self-care (and how), and who should seek medical assistance, when, how and where? This issue is under review and will take into account the experience gained as the pandemic evolves. Draft clinical treatment protocols will be developed. Health services will need to plan for the efficient dispensing of antiviral drugs within the agreed protocols, so that those recommended for antivirals are able to start them within 48 hours of onset of symptoms. It will be important to have in place a mechanism to collect information on the outcomes of the various treatment regimens being used nationally and internationally so that best practice can be built on the results of real time evaluations. 5.5.1.4 Infection Control: Clear infection control guidance for all health and social care establishments will also be required.
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Transmission and Infection Control Strategies in Healthcare Settings: The ability of one person to infect another relates, in part, to the amount of virus shed by the infected person during their acute infection. Studies in healthy persons have shown that the amount of virus shed correlates with the height of an infected person‟s temperature. However, approximately 50 percent of persons infected with influenza do not develop symptoms, but still may shed virus. The relative importance of asymptomatically or mildly symptomatic infected persons in the spread of influenza is unknown, but may allow for unrecognized transmission. Community Transmission Control Strategies Used in Past Pandemics: During prior pandemics, use of masks, closing of schools, and restrictions on large public gatherings and meetings were recommended to prevent community spread. These strategies, however, generally were not found to be effective, possibly because they tended to be instituted late in the outbreak and were not strictly adhered to, or because the control measures were not appropriate to the principle modes of transmission of influenza virus. Successful quarantines were rare.
5.5.1.5 Diagnosis: Clinical symptoms of influenza can range from mild upper respiratory tract illness with no elevation in temperature to illness characterized by high fever, constitutional symptoms, and cough. Young children may present with sepsis-like syndrome (high fevers, low blood pressure and rapid heart rate) or febrile seizures, and one-third may have diarrhea. Thus, the symptoms of influenza are often non-specific and wide-ranging, making influenza difficult to differentiate from other causes of respiratory illness based on the clinical presentation alone. Complications of influenza include viral and/or bacterial pneumonia, heart failure, muscle aches and inflammation (“myositis”), Reye syndrome, and inflammation of the brain (“encephalopathy”), among others. As a result of intensified surveillance and heightened public concern, growing numbers of people with respiratory symptoms or possible exposure to the virus will be admitted to hospital for observation. Until a conclusive diagnosis is made, these patients will be classified by the Ministry of Health as suspect cases. While many may not have symptoms compatible with a diagnosis of H5N1 infection, screening of patients‟ samples is being undertaken in national laboratories as part of the effort to ensure that no new cases are missed. Laboratory testing to confirm human infection with H5N1 avian influenza is technically difficult, some tests produce inconclusive or unreliable results. To ensure that reliable assessment of the situation is being made the samples will be sent to the WHO reference laboratories. Laboratory protocol and guidelines for sample collection is in the preparation. The list of available tests in CPHL with their sensitivity and specificity will be informed as soon as they are available.
5.5.1.6 Issues of Concern: Depending on the number of cases, the Ministry of Health will need to establish ways of caring for large numbers of patients on a scale outside their normal experience, including for those of all ages requiring high dependency care. Some of the key decisions required locally will include Provision of staff protection equipment where patients are to be seen and assessed How to „triage‟ patients, i.e. to quickly assess their needs and ensure they are directed to the appropriate care, in primary care and hospitals Where patients are to be treated and admission criteria? The provision of diagnostic services and the safe handling of specimens (following national protocols) How to maintain care for those staying in their own homes? The logistics of maintaining supply of equipment and pharmaceuticals, including the blood supply Cancellation or reorganisation of routine activity How other work is to be re-organised
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How to roster staff to minimise the spread of infection in health care premises, maintain the right skill mixes, but ensure that they all get time off How additional mortuary space is to be provided and safe practice for mortuaries How to manage the interface between primary care and Accident and Emergency Departments when primary care services are under pressure.
5.5.2 Influenza Vaccine
Vaccines are the most important intervention for preventing influenza and reducing its health consequences during a pandemic. Production of an appropriate vaccine is possible each year because of scientists‟ ability to predict the prevalent strains. Although a lot of efforts would be taken for production of a suitable vaccine for the pandemic strain, a specific vaccine is unlikely to be available in any quantity at least in the early stages of a pandemic. There will therefore be 3 stages in the public health strategy: Stage 1: No vaccine available Stage 2: Vaccine in limited supply Stage 3: Vaccine widely available Even when a good match is achieved between an influenza vaccine and the prevalent circulating virus or viruses, vaccination is not 100% effective in preventing illness and the protection afforded can vary from year to year. There is evidence to suggest that a vaccine against a new influenza strain to which no-one has been exposed before may require a larger dose, or more than one dose, to achieve optimal protection. Nonetheless, an appropriately formulated vaccine can be expected to reduce the impact of pandemic influenza, particularly by reducing complications, hospitalisations and deaths among groups at risk of serious illness and death. In a pandemic, vaccine purchase and distribution options include: MoH purchase and distribution of all pandemic influenza vaccine; or a mixed public-private system where public sector supply may be targeted to specific priority groups (e.g., health care workers and those providing essential public safety services) and those who may be underserved by the current system. Important considerations include how severity of the pandemic will influence distribution and whether and how centrally purchased vaccine can be distributed to private sector. Manufacturing capacity for influenza vaccines is concentrated in Australia, Europe, Japan and North America. Although several manufacturers would be engaged in development of a vaccine against a pandemic virus the greatest problem will be the inadequacy of supplies to meet the global needs. Manufacturing capacity is finite and cannot be expanded quickly. High priority has been given to the investigation of strategies that economize on the use of antigen viz. intradermal vaccination, inclusion of an adjuvant etc. Similarly antigen protective against the H5 virus subtype can be produced in bulk and stored.
5.5.2.1 Vaccination Strategy:
Even with advance work to improve our preparedness for vaccine production, the lead time before a new vaccine becomes available in quantity is likely to be at least 4-6 months. There may be no vaccine initially and then availability will depend on production rates. At the same time, international demand for vaccine will be high. Vaccine will have to be distributed equitably and administered to pre-determined priority groups first, according to nationally agreed recommendations (MoH-AV task force). It is possible that limited supplies of a suboptimal, and possibly experimental, vaccine may be available before a definitive licensed pandemic vaccine. This would have potential use to offer protection to the highest risk groups first, such as laboratory staff who are working directly with the new virus. The increased risk faced by health care workers treating patients, and the need to keep health and other essential services running, means that if vaccine supplies are limited, health care workers and other essential service key workers may need to take precedence over some of the risk groups prioritised for vaccine in inter-pandemic years. Following provisional recommendations are made, in the order of priority:
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Protect health care workers occupationally most at risk. Health care workers with patient contact are likely to be at increased risk of acquiring infection from their patients and passing it on to other vulnerable patients. Prevent illness, and thus absence, among workers required to keep essential services ongoing Prevent serious illness in the (anticipated or confirmed) most vulnerable groups Reduce the spread of influenza in situations where it might spread particularly rapidly, for example in closed communities such as residential care homes Reduce spread by immunising those more likely to transmit the virus, e.g. children Prevent illness in the general population
Final decisions on priority groups will be made by the MoH-HPAI task force, informed by any recommendations from the World Health Organization. Vaccine will be centrally purchased by the MoH and distributed according to the estimated local needs for the predetermined priority groups. Details such as vaccine formulation, dose and dose schedule will not be known until the vaccine is available, and so detailed arrangements for immunisation will be finalised afterwards. An important part of the communications strategy will be to inform the public about the reasons for vaccine not being generally available and to manage their expectations. The public will also need information to inform their own decisions about vaccination, for example about any possible potential for a pandemic vaccine to cause adverse reactions.
5.5.2.2 Vaccine Safety: Carefully monitoring for vaccine safety is important to assure that the
benefits of vaccination exceed the risks and, to assess the aetiology of adverse events that occur following vaccination, and to maintain confidence in the vaccination program. Influenza vaccine – like all other vaccines – occasionally causes local reactions at the site of injection and may cause mild systemic symptoms such as headache or fever. The association of swine influenza vaccine (1976) with GuillainBarre syndrome (GBS), a condition marked by progressive muscle paralysis which may result in a need for mechanical ventilation, was an unusual but highly prominent event.
5.5.2.3 Vaccine Stockpiling: In view of the pandemic potential of the H5N1 virus in Asia,
stockpiling of a vaccine for use in a pandemic caused by the H5N1 strain is an option for pandemic preparedness. This approach is being considered by some countries. Even if the actual pandemic H5 subtype virus shows mutational changes when compared with the current H5N1 strain, a vaccine that is protective against infection due to that strain could confer almost as much protection. Stockpiles of an H5N1 vaccine would be useful in the early phase of a pandemic when large-scale production of a vaccine has not yet been initiated.
5.5.2.4 Impact of Vaccination: Vaccination with a vaccine specifically formulated against the
pandemic virus strain, when an appropriate vaccine becomes available can be expected to achieve the greatest reduction in illness, complications and deaths, and lessening of the impact on health and other services. The effectiveness of a pandemic vaccine will not be known until it is in use Influenza vaccines do not offer 100% protection: in inter-pandemic years, when vaccine and circulating virus strains can be predicted and are well matched, vaccine reduces infection by around 70-80%, hospitalisations in high risk individuals by around 60% and deaths by around 40%
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5.5.3 Antiviral agents
Antiviral agents active against influenza are the only other major medical countermeasure available. They may be used in the absence of, or as an adjunct to, vaccination. However, there are limitations to their use, their effectiveness in a pandemic situation has yet to be tested and anti-viral resistance may be – or become – a problem. Manufacture of antiviral drugs takes several months, and their availability cannot be assured at the time of a pandemic, when international demand will be high. Hence countries are stockpiling the antiviral drugs against the contingency of an influenza pandemic. As with other resources, given the possible scale of a future pandemic, the drugs will need to be given in the most effective way on operational, clinical and cost-effectiveness grounds taking into account the stocks available. Information on effectiveness may not be available at the start of a pandemic. Oseltamivir (Tamiflu by Roche), a neuraminidase inhibitor is an effective medicine for preventing and curing the influenza. However, the limiting factors are the amount that would be available due to the potential demand as well as its cost. The Ministry of Health has placed order for 10,000 courses (10 tablets per course) for either prophylactic or therapeutic use to be made available for the Strategic National Stockpile (SNS) by the end December 2005. Factors that will influence the SNS include feasibility of public sector distribution during a pandemic; potential impacts, costs, and cost effectiveness of a larger stockpile; and the shelf life of stockpiled drug and other logistical issues. Antiviral agents, which can be stockpiled in advance, have important but different roles, both now and at the start of a pandemic. There are three opportunities for using antiviral medications which are considered effective against human H5N1 infection. First Opportunity: In the first such set of circumstances, these medicines can be used to treat H5N1-infected patients and to prevent infection in close contacts, including family members and health-care workers. As all antiviral agents need to be administered shortly after the onset of symptoms, a critical problem is the tendency of cases to be detected late in the course of their illness. Second Opportunity: A second opportunity to use antiviral agents arises when surveillance indicates that the transmissibility of the virus is beginning to become more efficient. Administration of medications to all members of a community in which clusters of cases are occurring might either stop the virus from further improving its transmissibility or delay its spread. Third Opportunity: The third opportunity presents once a pandemic has been declared. Pending the availability of vaccines, antiviral agents will be the principal medical intervention for reducing morbidity and mortality, which becomes the most important priority once a pandemic is under way.
5.5.3.1 The Impact of Antiviral drugs The effectiveness of antiviral drugs in a pandemic of influenza is not known, particularly their effectiveness in reducing mortality in cases of severe disease (including viral pneumonia). If treatment with antiviral drugs is as effective in a pandemic as during seasonal influenza, early treatment (within 48 hours of onset of illness) should shorten illness by around one day, may ameliorate symptoms, and should reduce hospitalisations (by an estimated 50%). More work is being done worldwide on the most effective strategies for the use of antiviral drugs. 5.5.3.2 Strategies for the optimal use of antiviral drugs Until more information becomes available, general principles are established for the optimal use of antivirals. More detailed guidance will be issued as necessary and as further information becomes available. Final decisions on priority groups and strategies for the use of antivirals will be made by the
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MoH-task force, informed by any recommendations from WHO or any relevant expert advisory mechanisms. The provisional strategies proposed are: A. POTENTIAL PREVENTION OF A PANDEMIC: Antiviral agents have a role in prevention and control of avian influenza in occupational groups exposed to dead or diseased birds. This is for personal protection but also to protect against establishment and evolution of avian influenza viruses in people. B. AT THE ONSET OF A PANDEMIC: At a stage when isolated cases or small confined outbreaks are occurring, antiviral drugs may have a place in trying to contain the infection or delay or slow its spread. This will be done on a case by case basis, and will involve treatment of a symptomatic case or cases and short term prophylaxis to prevent infection developing in those of their close contacts (including health care workers) potentially exposed. The drug would be taken for the duration of the incubation period, usually 7 days. This is likely to be a short term strategy, and not the main use of antiviral drugs. C. DURING THE PANDEMIC Treatment of cases: Once a pandemic is established, treatment is likely to be recommended following criteria consistent with those established for the vaccination strategy. Treatment would thus be offered, in order of priority, to Health care workers, if and when they develop fever or other flu symptoms (regardless of whether vaccinated) Other workers required for maintaining essential services (as above) Unimmunised people in high risk groups (or groups emerging information suggests are at special risk), to ameliorate illness and reduce complications and death Other unimmunised people Immunised people, using the same criteria as above, if emerging information suggests the vaccine being used is not effective in reducing serious illness, complications or deaths ‘Post exposure’ prophylaxis: Limited use of antiviral drugs may be recommended to limit the spread in certain defined situations for example, in a closed institution suffering an outbreak. Longer term prophylaxis on a population level i.e. in the absence of effective vaccination, taking the drug to prevent infection throughout the period of possible exposure (bearing in mind the virus may be circulating in the population for several weeks or months) is not considered likely to represent an efficient use of the drugs. It would consume very large quantities of drug if implemented on any scale, and the many people who would not have developed influenza anyway would have taken the drug unnecessarily. As with seasonal flu for maximum effect the drugs should be started as soon as possible and within 48 hours of onset of symptoms (for treatment) or exposure to infection (for post-exposure prophylaxis). Supply and distribution of antiviral drugs: Antivirals will be centrally purchased by the Ministry of Health and distributed on allocation. Use of antivirals will present challenges and issues for the configuration and capacity of primary care services. Primary care organisations‟ dispensing plans will need to meet the requirement that patients in the designated groups start treatment within 48 hours of onset of symptoms (or, for prophylaxis, exposure). Pharmacists are likely to have a role. Omani and non-Omani residents would be expected to have equal access to drugs. Monitoring effectiveness and adverse reactions: As part of the antiviral strategy, arrangements must be in place to monitor the susceptibility of the virus to antiviral drugs and assess their effectiveness in reducing complications and deaths and incidence and patterns of adverse reactions.
5.5.4 Other Measures
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A wide range of non-medical interventions, such as improved personal hygiene, quarantine, contact tracing and travel restrictions, can potentially reduce opportunities for transmission at the start of a pandemic and slow the international spread. They have relevance to all countries. Consideration of their use during a pandemic is particularly important, as they will be the principal protective tools, pending the augmentation of vaccine supplies.
Public health measures to reduce morbidity and/or contain spread
In the event that medical countermeasures are absent, in limited supply, or ineffective, other „social‟ interventions will be the only available countermeasures. During the outbreaks of Severe Acute Respiratory Syndrome (SARS) in 2003, internationally agreed measures were instituted to restrict the movement of people possibly infected with SARS and were assessed by WHO to have greatly contributed to bringing the disease under control. Influenza differs from SARS in many important respects that make it unlikely that similar interventions will do more than delay or slow the transmission of infection: it is more infectious, it is most infectious early in the course of the disease (and possibly even before symptoms begin); and it has a much shorter incubation period (1-3 days). At this time, the extent to which the spread of influenza can be delayed or slowed by measures to reduce infected and non-infected people mixing is not clear, and what may be reasonable at an early phase may not be once the pandemic is fully established. However, simple advice such as hand washing, encouraging people suffering from the disease to stay at home and reducing unnecessary, especially long distance, travel may achieve some slowing of the spread of a pandemic. The following public health measures, and the need for infection control guidelines in non-medical settings where people gather, are being reviewed. Clear guidance will be issued, based on the guidance from the WHO as the evidence evolves or as need arises: Hygiene including respiratory hygiene and hand washing Travel advisories to restrict international travel to or from affected areas Health screening at sea ports Voluntary home isolation of cases Voluntary quarantine of contacts of known cases Staff rostering to minimise contact between different healthcare teams and reduce spread within healthcare premises. This may also reduce the impact on staffing if all contacts of a case in a work team are asked to remain in voluntary quarantine Local restrictions on the movement of people, e.g. in a local community or town Restriction of public gatherings, especially international mass gatherings School closures (recognising the impact this will have on maintaining the workforce in other sectors) The use of face masks by infected people (to reduce droplet spread), by those in contact with infected people or by the general public
Some of these measures may be required as a result of staff absence or the general disruption, or may occur by default because of public concern or other considerations. Voluntary co-operation with recommended measures would be sought. Mandatory quarantine and curfews are generally not considered necessary and are not currently covered by public health legislation.
Reducing societal disruption: the civil emergency response
This plan is mainly concerned with the health response to an influenza pandemic, but health services will be looking to other Government Departments and other agencies to assist with the successful implementation of the health response, particularly to implement the „social‟ countermeasures referred to above which may be needed as public health measures. Additionally, all organisations, including
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businesses, need to consider the implications for their organisations, based on the information in this plan, and make their own plans. The civil emergency response should the scale of a pandemic warrant I will cover, for example: Maintenance of essential services such as emergency services, transport, food distribution, pharmaceutical supplies, utilities and communications Management of mass casualties Maintenance of public order The role of the police and armed forces
5.6 The international Obligation
A pandemic is, by definition, an international event. Sultanate of Oman must keep abreast of international developments and thinking. It also has certain international obligations (in particular in respect of the World Health Organization) to report disease incidents and outbreaks and the actions being taken. The Ministry of health will play its full part in contributing data, knowledge and expertise to help towards a coordinated and coherent international response.
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7. List ofAnnexure
Annexure # 1 Annexure # 2 Annexure # 3 Annexure # 4 Annexure # 5 Annexure # 6 Annexure # 7 Annexure # 8 Annexure # 9 Annexure # 10 Annexure # 11 Annexure # 12
National Task Force (MoH) Inter-Ministerial Committee on AI WHO Travel Advisory: November 2005 Case Definitions Case Notification Form Interpretation of Laboratory Investigations Collection, Handling & Transportation of Specimens Infection Control Guidelines (General) Isolation Guidelines for HPAI Cases Vaccination for HPAI Use of Antiviral Agents List of Algorithms
34 35 36 37 39 41 43 46 51 56 57 60
Annexure 1
NATIONAL TASK FORCE (MINISTRY OF HEALTH)
National Spokespersons for Ministry of Health Dr. Ali Jaffer M. Suleiman, DGHA Dr. Salah Al Awaidy, Director, DCDSC
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Provincial Spokesperson (Governorates & Regions)
Name Ministry of Health HQ Dr. Ali Jaffer M. Suleiman (Chairman) Ph. Nusaiba Habib Mohd. Dr. Salah Al Awaidy (Focal Point) Dr. Suleiman Al Busaidy Ms. Sabah Al Bahlani WHO Country Office Dr. El Fatih El Samani
Director/Director General of Health Services
Designation Office Fax Mobile
Director General of Health Affairs Director General of Medical Supplies Director, Communicable Disease Surveillance & Control Director, Central Public Health Laboratory Director, Health Education & Information
24600808 24699973 24601921 24705943 24562609
24696099 24601593 24601832 24793699
99335681 99240990 99315063 99426288 99332792
WHO Representative, Oman
24600989
24602637
--
MoH & Sultan Qaboos University Hospital Dr. Abdul Raouf Al Suwaid Dr. Mohammed Al Hosni Dr. Kamal Al Hag Dr. Firyal Al Lawatia Ms. Shaikha Al Shabani Director, Al Nahda Hospital Head of Child Health, Royal Hospital Head of Microbiology, Royal Hospital Consultant, Infectious Diseases, SQUH Head of Nursing, Al Nahda Hospital 24835746 24599552 24599730 24413355 24837511 Ext. 1112 24831578 24599173 24590298 24413419 24837522 99357987 99474441 95053125 99384896
Department of Communicable Disease Surveillance & Control, MoH HQ (Field Staff) Dr. Shyam Bawikar Dr. Hassan Al Tuhami Mr. Salem Al Mahrooqi Mr. Bader Al Rawahi Advisor Epidemiologist Epidemiology Section Head National Surveillance Supervisor National EPI Supervisor 99368327 24601832 95208040 99029195 99430689
24601921, 24607524
Annexure 2
INTER-MINISTERIAL COMMITTEE ON AVIAN INFLUENZA, SULTANATE OF OMAN
Name Designation Nature Conservation, Ministry of Regional Municipalities, Environment & Water Resources Office Fax Mobile
Mr. Ali Amer Al Kiyumi
24602285
24602283
99444808
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National Pandemic Influenza Preparedness Plan: 2006
Mr. Said Darwesh Al Alawi
Mr. Ali Said Al Hammadi Mr. Mudriq Kathiem Al Moosawi
DG of Health Affairs, Ministry of Regional Municipalities, Environment & Water Resources Director General of Planning, Ministry of Interior Director General of Commerce & Industry Director General of Animal Wealth Director, Communicable Disease Surveillance & Control Asst. Director General of Information & Press Affairs Asst. Director General of Customs, Royal Oman Police Asst. Director General of Animal Wealth & Veterinary Services Head of Veterinary Services
24692564
24692547
99389883
24707226 24774100 2469391
24790599 24812030 24694465
99420909 99418909 99382717
Mr. Nasr Ali Al Wahaibi
Dr. Salah Thabit Al Awaidy
24601921
24601832
99315063
Mr. Mubarak Khamis Al Araimi
24697677
24521034
24602928
Mr. Mussallam Salem Al Jenebi
24521204
24521204
99319131
Dr. Sultan Eissa Al Ismaili
24698512 24696300 Ext. 1510
24694465
99380316
Dr. Ali Abdullah Al Salmi
24694465
99371816
National Hotline for Information & Reporting of Deaths among Birds: 92777999 Annexure 3
WHO RECOMMENDATIONS TO TRAVELLERS COMING FROM & GOING TO COUNTRIES EXPERIENCING OUTBREAKS OF HPAI: NOVEMBER 2005
These recommendations are in line with phase 3 in the WHO 6-phase scale of pandemic alert: human infections with a novel influenza virus subtype are occurring, but the virus does not spread efficiently or in a sustainable way among humans. These recommendations may change according to the change in the epidemiological situation and related risk assessments.
Advice to Countries
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National Pandemic Influenza Preparedness Plan: 2006
WHO does not recommend any restrictions on travel to any areas affected by H5N1 avian influenza. WHO does not recommend travel restrictions to areas experiencing outbreaks of highly pathogenic H5N1 avian influenza in birds, including countries which have reported associated cases of human infection. WHO does not recommend screening of travellers coming from H5N1 affected areas. WHO does not, at present, recommend the routine screening of travellers coming from affected areas. Local authorities may, however, usefully provide information to travellers on risks, risk avoidance, symptoms, and when and where to report should these symptoms develop.
Advice to Travellers
WHO advises travellers to avoid contact with high-risk environments in affected countries. Travellers to areas affected by avian influenza in birds are not considered to be at elevated risk of infection unless direct and unprotected exposure to infected birds (including feathers, faeces and under-cooked meat and egg products) occurs. WHO continues to recommend that travellers to affected areas should avoid contact with live animal markets and poultry farms and any free-ranging or caged poultry. Large amounts of the virus are known to be excreted in the droppings from infected birds. Populations in affected countries are advised to avoid contact with dead migratory birds or wild birds showing signs of disease. Direct contact with infected poultry, or surfaces and objects contaminated by their droppings, is considered the main route of human infection. Exposure risk is considered highest during slaughter, de-feathering, butchering, and preparation of poultry for cooking. There is no evidence that properly cooked poultry or poultry products can be a source of infection. Travellers should contact their local health providers or national health authorities for supplementary information.
Annexure 4
CASE DEFINITIONS
Note: The case definitions advised by the World Health Organization will be used as and when available.
Provisional Case Definitions for Avian Influenza
For clinical management and reporting within a country or territory, case definitions with a hierarchy of case categories should be developed according to the epidemiological situation. In general, countries with reported highly pathogenic avian influenza (HPAI) in animal populations need to adopt more sensitive case definitions to initiate laboratory testing than countries without reported outbreaks of avian influenza.
The case-definitions reproduced below will be used in Oman until modified further based on epidemiological evidence:
Patient under investigation
Any individual presenting with fever (temperature >38°C) AND one or more of the following symptoms: cough;
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National Pandemic Influenza Preparedness Plan: 2006
sore throat; shortness of breath;
who is under clinical observation and laboratory investigations are under way.
Suspect influenza A/H5 case
I.
Any individual presenting with fever (temperature >38°C) AND one or more of the following symptoms: cough; sore throat; shortness of breath;
AND one or more of the following: a) laboratory evidence for influenza A by a test that does not subtype the virus; b) having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*; c) having been in contact during the 7 days prior to the onset of symptoms with birds, including chickens, that have died of an illness; d) having worked in a laboratory during the 7 days prior to the onset of symptoms where there is processing of samples from persons or animals that are suspected of having highly pathogenic avian influenza (HPAI) infection. OR II. Death from an unexplained acute respiratory illness AND one or more of the following residing in area where HPAI is suspected or confirmed; having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*.
Probable influenza A/H5 case
Any individual presenting with fever (temperature >38°C) AND one or more of the following symptoms: cough; sore throat; shortness of breath;
AND limited laboratory evidence for Influenza A/H5 (H5 specific antibodies detected in a single serum specimen).
Confirmed influenza A/H5 case
An individual§ for whom laboratory testing demonstrates one or more of the following positive viral culture for Influenza A/H5;
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National Pandemic Influenza Preparedness Plan: 2006
positive PCR for Influenza A/H5; immunofluorescence antibody (IFA) test positive with A/H5 monoclonal antibodies; 4-fold rise in Influenza A/H5 specific antibody titre in paired serum samples.
* Individuals infected with Influenza A/H5 virus are considered to be infectious starting from one day before the onset of symptoms up to 7 days after onset of symptoms. § Laboratory investigations for Influenza A/H5 may also be undertaken on deceased individuals and in the context of targeted epidemiological studies. Laboratory confirmed cases identified under these circumstances should also be reported.
Annexure 5
Hospital sticker
HPAI CASE NOTIFICATION FORM
Unique Identifier
OMA(code: country-province-hospital -case #)
Reporting Details
Reporting date Reporting Region/Governorate Reporting institution Location of reporting institute (dd/mm/yyyy)
______/
______/
______
Demographic details
Sex Date (dd/mm/yyyy) Usual country residence Nationality Ethnicity Health Care Worker If NO then occupation of Birth Male Female Unknown ___ / ___ / ______ OR Age (years) ____
Yes
No
Unknown
Sign and symptoms
Date of onset of initial symptoms (dd/mm/yyyy) Body temperature higher than 38˚ C Cough Difficulty breathing Clinical findings of Respiratory Distress Syndrome _____ / Yes Yes Yes Yes Yes ______ / No No No No No ________ Unknown Unknown Unknown Unknown Unknown
Chest X-ray
Chest X-ray performed
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National Pandemic Influenza Preparedness Plan: 2006
If yes, evidence of pneumonia or Respiratory Distress Syndrome Responds to standard antimicrobial treatment
Yes Yes Yes
No No No
Unknown Unknown Unknown
Hospital Admission History
Has the case been admitted to a Hospital whilst symptomatic If yes, Name of the hospital City Date of admission to hospital (dd/mm/yyyy) Has the case been in isolation Has the case been on mechanical ventilation If yes, is the case currently on mechanical ventilation Has the case been admitted to an Intensive Care Unit If not hospitalized, has been the case in home isolation
_____ / Yes Yes Yes Yes Yes Yes
______ / No No No No No No
________ Unknown Unknown Unknown Unknown Unknown Unknown
History of exposure
Prior to their onset on illness, did the patient have close contact with a known probable or suspect case of AI If yes, in what country City Date of first contact (dd/mm/yyyy) Date of last contact (dd/mm/yyyy)
_____ / _____/
______ / ______/
______ ______
During the 7 days preceding the onset of illness, did the case travel to an “affected area” If yes, to which area (s) During the 7 days prior to onset of illness, did the travel overseas to any country besides ones listed above?
Yes Yes
No No
Unknown Unknown
If yes, to which country / countries : (List as many as needed)
1. 2. 3. Date arrival __ / __ / __ Date arrival __ / __ / __ Date arrival __ / __ / __
(dd/mm/yyyy) Date departure __ /__ /____ Date departure __ /__ /____ Date departure __ /__ /____
For deceased patients ONLY
Unexplained respiratory illness resulting in death Autopsy examination performed If yes, did autopsy demonstrate pathology of Respiratory Distress Syndrome without an identifiable cause Yes Yes Yes No No No Unknown Unknown Unknown
Contact tracing
Has contact tracing been initiated If yes, is any contact currently residing abroad If yes, have the national Public Health Authorities of the recipient country been informed Yes Yes Yes No No No Unknown Unknown Unknown
Initial case classification
Suspect Probable Discarded
(dd/mm/yyyy) Date classified _____ / _____ / _____
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Please resubmit form when final case classification and the status is determined
Final case classification
Suspect Probable Discarded
(dd/mm/yyyy) Date of final classification ___ / ___ / ________
Final status
Recovered, if the case was admitted to hospital Died Left country while symptomatic Date of discharge Date of death Medical evacuation Date of departure Flight details Destination country Date of loss
(dd/mm/yyyy) ___ / ___ / ________ ___ / ___ / ________ Yes / No ___ / ___ / ________
Lost to follow-up
___ / ___ / ________
Name & Signature of reporting person: ________________________________________ Designation: _______________________________
Seal
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Annexure 6
INTERPRETATION OF LABORATORY INVESTIGATIONS
Positive diagnostic test findings
Confirmed positive PCR for AI virus:
Limited laboratory evidence for Influenza A (H5N1) (such as IFA + using H5 monoclonal antibodies) OR Positive viral culture for influenza A (H5N1) OR Positive PCR for influenza A (H5N1) OR Immunofluorescence antibody (IFA) test positive using influenza A/H5 monoclonal antibodies A 4-fold rise in H-5 specific antibody titre
Confirmation of positive PCR
The PCR procedure should include appropriate negative and positive controls in each run, which should yield the expected results: 1 negative control for the extraction procedure and 1 water control for the PCR run 1 positive control for extraction and PCR run the patient sample spiked with a weak positive control to detect PCR inhibitory substances (inhibition control)
If a positive PCR result has been obtained, it should be confirmed by:
Repeating the PCR using the original sample OR Having the same sample tested in a second laboratory.
Amplifying a second genome region could further increase test specificity
Laboratories testing for AI in Oman
Central Public Health Laboratory (CPHL), Darsait has been identified as reference laboratory at the national level. The ELISA/IFA testing as well as PCR would be acquired from WHO recommended sources. In the meantime the collected samples would be sent to regional reference laboratories.
PCR testing
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The sensitivity of PCR tests for AI depends on the specimen and the time of testing during the course of the illness. This may result in real cases of AI testing negative by PCR (false negative results). Sensitivity can be increased if multiple specimens/ multiple body sites are tested. The specificity of PCR tests for AI is excellent if technical procedures used follow quality control guidelines. False positive results may arise as a result of technical problems (e.g. laboratory contamination), so every positive PCR test should be verified. Strict criteria should be adopted for confirmation of positive results, especially in low prevalence areas, where the positive predictive value might be lower.
Antibody testing
ELISA and IFA tests are being developed by research laboratories. Because AI is a new disease in humans, AI antibodies are not found in general populations that have not been exposed to the virus. An antibody rise between acute and convalescent phase sera tested in parallel is a specific diagnostic criterion.
Annexure 7
WHO GUIDELINES FOR THE COLLECTION OF HUMAN SPECIMENS FOR LABORATORY DIAGNOSIS OF AVIAN INFLUENZA INFECTION: 12 JANUARY 2005
General information Respiratory virus diagnosis depends on the collection of high-quality specimens, their rapid transport to the laboratory and appropriate storage before laboratory testing. Virus is best detected in specimens containing infected cells and secretions. Specimens for the direct detection of viral antigens or nucleic acids and virus isolation in cell cultures should be taken preferably during the first 3 days after onset of clinical symptoms.
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Type of specimens A variety of specimens are suitable for the diagnosis of virus infections of the upper respiratory tract: nasal swab nasopharyngeal swab nasopharyngeal aspirate nasal wash throat swab.
In addition to swabs from the upper respiratory tract, invasive procedures can be performed for the diagnosis of virus infections of the lower respiratory tract where clinically indicated: transtracheal aspirate bronchoalveolar lavage lung biopsy post-mortem lung or tracheal tissue.
Specimens for the laboratory diagnosis of avian influenza A should be collected in the following order of priority: nasopharyngeal aspirate acute serum convalescent serum.
Specimens for direct detection of viral antigens by immunofluorescence staining of infected cells should be refrigerated and processed within 1–2 hours. Specimens for use with commercial near-patient tests should be stored in accordance with the manufacturer‟s instructions. Specimens for virus isolation should be refrigerated immediately after collection and inoculated into susceptible cell cultures as soon as possible. If specimens cannot be processed within 48–72 hours, they should be kept frozen at or below –70 °C. Respiratory specimens should be collected and transported in virus transport media. A number of media that are satisfactory for the recovery of a wide variety of viruses are commercially available. Procedures for specimen collection
Materials required
Sputum/mucus trap Polyester fibre-tipped applicator Plastic vials Tongue depressor 15-ml conical centrifuge tubes Specimen collection cup or Petri dishes Transfer pipettes
Virus transport medium
(A) Virus transportation medium for use in collecting throat and nasal swabs Add 10 g veal infusion broth and 2 g bovine albumin fraction V to sterile distilled water (to 400 ml). Add 0.8 ml gentamicin sulfate solution (50 mg/ml) and 3.2 ml amphotericin B (250 μg/ml) Sterilize by filtration.
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(B) Nasal wash medium Sterile saline (0.85% NaCl).
Preparing to collect specimens
Clinical specimens should be collected as described below and added to transport medium. Nasal or nasopharyngeal swabs can be combined in the same vial of virus transport medium. When possible, the following information should be recorded on the Field Data Collection Form: general patient information, type of specimens, date of collection, and contact information of person completing the form, etc. Standard precautions should always be followed, and barrier protections applied whenever samples are obtained from patients.
Nasal swab
A dry polyester swab is inserted into the nostril, parallel to the palate, and left in place for a few seconds. It is then slowly withdrawn with a rotating motion. Specimens from both nostrils are obtained with the same swab. The tip of the swab is put into a plastic vial containing 2–3 ml of virus transport medium and the applicator stick is broken off.
Nasopharyngeal swab
A flexible, fine-shafted polyester swab is inserted into the nostril and back to the nasopharynx and left in place for a few seconds. It is then slowly withdrawn with a rotating motion. A second swab should be used for the second nostril. The tip of the swab is put into a vial containing 2–3 ml of virus transport medium and the shaft cut.
Nasopharyngeal aspirate
Nasopharyngeal secretions are aspirated through a catheter connected to a mucus trap and fitted to a vacuum source. The catheter is inserted into the nostril parallel to the palate. The vacuum is applied and the catheter is slowly withdrawn with a rotating motion. Mucus from the other nostril is collected with the same catheter in a similar manner. After mucus has been collected from both nostrils, the catheter is flushed with 3 ml of transport medium.
Nasal wash
The patient sits in a comfortable position with the head slightly tilted backward and is advised to keep the pharynx closed by saying "K" while the washing fluid (usually physiological saline) is applied to the nostril. With a transfer pipette, 1–1.5 ml of washing fluid is instilled into one nostril at a time. The patient then tilts the head forward and lets the washing fluid flow into a specimen cup or a Petri dish. The process is repeated with alternate nostrils until a total of 10–15 ml of washing fluid has been used. Dilute approximately 3 ml of washing fluid 1:2 in transport medium.
Throat swab
Both tonsils and the posterior pharynx are swabbed vigorously, and the swab is placed in transport medium as described above. Sera collection for influenza diagnosis An acute-phase serum specimen (3–5 ml of whole blood) should be taken soon after onset of clinical symptoms and not later than 7 days after onset. A convalescent-phase serum specimen should be collected 14 days after the onset of symptoms. Where patients are near death, a second ante-mortem specimen should be collected. Although single serum specimens may not provide conclusive evidence in support of an individual diagnosis, when taken more than 2 weeks after the onset of symptoms they can be useful for detecting antibodies against avian influenza viruses in a neutralization test.
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Sample of Field Data Collection Form
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National Pandemic Influenza Preparedness Plan: 2006
Annexure 8
INFECTION CONTROL GUIDELINES (General)
Policy Outline
To ensure the use of proper procedure in handling patient suspected with AI following points are stressed: 1. Responsibility: Infection Control procedures are the responsibilities of all health care workers (HCWs) in order to minimize the hazard of cross infection when caring for patients with suspected AI. Infection control practice: All staff shall use standard universal precautions for patients with suspected AI to reduce exposure Barrier nursing for suspected/probable cases: The key features of the infection control response to a case of suspect or probable AI are isolation and barrier nursing techniques. In this sense, the infection control practices required will be similar to those for other infectious respiratory pathogens. Principles of isolation: a) As far as possible the suspect AI cases should be individually isolated. Health Care Workers should disinfect their hands and change PPE between patients. Disinfect or use separate ward equipment (tourniquets, Stethoscope etc.) b) Do not manage suspect cases in the same room as probable cases. c) An essential part of isolation involves minimizing contact with other people. Visits by family and non-essential staff should be avoided wherever possible.
2. 3.
4.
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d) All patients care devices (e.g. Tourniquets, Stethoscope) must be restricted to the patient and disposed of or cleaned and disinfected by sodium hypochlorite wipe. e) Patients on Respiratory support: Ventilator circuit should have closed system suctioning, catheter mount and HME viral and bacterial filter. f) Transport of AI patients should follow the same principles of isolation, including mask on patient, full PPE at all times for all staff, minimal contact, strict hygiene/washing and complete disinfection of all transport and equipment with sodium hypochlorite wipe
5.
Personal Protective Equipment (PPE): All health care personals should use PPE, which should include cap protective goggles, face masks, gloves, disposable gown and apron. While attending a probable case N95 mask or similar one should be worn. Use of Personal Protective Equipment (PPE): In all cases, certain principles apply: PPE reduces but does not completely eliminate the possibility of infection PPE is only effective if used correctly and at all times where contact may occur. Any contact between contaminated (used) PPE and surfaces/clothing/people outside the isolation area must be avoided. Used PPE must be sealed in appropriate disposal bags and incinerated or decontaminated. The use of PPE does not replace basic hygiene measures such as hand washing with Hibiscrub alcohol based skin disinfectant. Washing is still essential to prevent transmission. Hand washing is crucial and therefore, wash hands with Hibiscrub and clean water before and after removing the gloves. Alcohol based skin disinfectant could be used if there is no obvious organic material contamination. All sharps should be dealt with promptly and safely. Sharp box must be sealed when ¾ full and dispose finally by incineration. Linen from the patients should be prepared on site for the laundry staff. Appropriate be worn in this preparation and the linen should be put into hot water soluble bags. For disposal of masks and caps, these should be put in the yellow plastic and sent for autoclaving and finally for dumping. The room should be cleaned by staff wearing PPE using a broad spectrum disinfectant antiviral activity such as sodium hypochlorite. Exposure to the infected patient should be kept to an absolute minimum. Visit by non-staff should be avoided wherever possible.
6.
7.
Who should use PPE? The patient should be as self-caring as far as possible and the staff team assigned to care for the patient should kept to a minimum. Staff should be strictly supervised and be experienced in infection control. PPE should be used by: All doctors, nurses and health care workers who provide direct patient care to AI cases (keep to minimum necessary for patient‟s condition All laboratory staff who handle patient specimens from suspect cases (keep to the minimum necessary for laboratory procedures Family members who care for AI patients (visits should be avoided where possible) The patient(s) should wear a surgical mask (N95 preferable) when other people are in the isolation area.
-
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National Pandemic Influenza Preparedness Plan: 2006
8.
List of essential PPE and outbreak supplies: Estimate PPE stock size by the number of personnel needed to perform essential patient care, laundry, cleaning, patient transport and laboratory work and allow for one change to PPE each shift. Storage/positioning of the supplies: The PPE stock should be stored where it can be readily accessed at all times (24 hours a day) and is available for dispatch to a facility/transport where suspected AI patients are involved. The stock must be accessible after hours and on weekends.
9.
10. Exclusion from duty is recommended for a health care worker if fever or respiratory symptoms develop during 10 days following an unprotected exposure to an AI patient. Exclusion from duty should be continued for 10 days after the resolution of fever and respiratory symptoms. During this period, infected workers should avoid contact with persons both in the facility and in the community.
11. Exclusion from duty is not recommended for an exposed health care worker if they do not
have either fever or respiratory symptoms; however, the worker should report any unprotected exposure to AI patients to the appropriate facility point of contact (e.g. infection control or occupational health) immediately.
ISOLATION SPECIFICATION FOR PATIENT SUSPECTED WITH AI
1. Category of Isolation: Respiratory precaution for persons entering the room should be used in addition to contact precaution. Location: A single room preferably with negative pressure ventilation. An ante- room with hand washing facilities and toilet must be provided. The door must be kept closed except during necessary entries and exits. All unnecessary items of equipment must be removed before the patient occupies the room. Ensure that paper towels and antiseptic hand cleanser (Hibiscrub) with elbow operated dispenser are provided. A foot operated pedal bin with yellow plastic bag for clinical waste must be supplied inside the room. Mattresses and pillows should have non – permeable covers. Domestic equipment i.e., mop, bucket, wash bowl, damp dusting cloth should be kept separate for those patients. The patient‟s file and chart must be kept outside the room. The patient must not be transferred to other departments unless it is necessary. Thermometers and other necessary equipment should be used exclusively for this patient. 2. 3. Staff: The number of staff entering the room must be restricted only to that necessary. Visitors: Visitors must be kept to the minimum and must report to the Sister-in-Charge before entering the room. The visitor should be limited to immediate family. They should be instructed to wear PPE including a N-95 mask or surgical mask, gloves and gown. Visitor must be instructed to wash hand after the removal of the PPE, leave the room without touching the patient surfaces or items. Gowns: Disposable gowns with non-permeable fronts and sleeves must be worn and discarded into yellow double plastic bag before leaving the room. Masks: 3M Foldable Respiratory Valve Mask or NIOSH-95 Particulate Filter Personal Respirator Mask must be worn to protect the wearer. They should cover both the nose and the mouth. It must be put on before entering the room and removed before leaving the room and discarded into a yellow plastic bag. The mask should be removed by untying and should be handled by the ties only. Mask should be disposed in yellow double bag. Gloves: Well-fitted latex disposable gloves must be worn before entering the room and these must cover the cuffs of the long sleeved gown. They should be carefully removed before leaving the room and discarded into a yellow double plastic bag. Hand must be washed after removal of gloves. Gloves are not a substitute for hand washing. Eye protection (Goggles/ Face shield): These must be worn for any procedures that may cause splashes of blood or body fluids. must be washed with antiseptic solution (Hibiscrub or Betadine scrub) and dried thoroughly with a disposable paper towel. They must be washed after touching the patient or potentially contaminated articles (Bed-rails, bedside table) and after removing protective clothing i.e. gloves, mask, gown. After hand washing or hand decontamination, avoid touching the surfaces or items in
4. 5.
6.
7.
8. Hand Hygiene: Careful hand washing before and after leaving the room is most important. Hands
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National Pandemic Influenza Preparedness Plan: 2006
the immediate vicinity of the patient. When leaving the room, the door should be pushed open from the outside (By an assistant) in order to avoid touching the door, which may be contaminated.
2. Disposal of infected items:
i. Equipment: Disposable equipment should be used whenever possible. Any equipment that is not disposable must be kept inside the room. Reusable equipments should be sent to CSSD in appropriate plastic bag. No equipment should be used for other patients until it is thoroughly disinfected / sterilized in Central Service Department. Disposable item must be disposed in double yellow plastic bag for incineration. ii. Laundry: Disposable linen should be used whenever possible. If ordinary linen is used, it should be placed in hot water soluble bag into Red linen bag or red plastic bag and sent to the hospital laundry. The laundry used for AI patient should not be send to the private laundry outside the hospital If linen is completely soaked with blood, it should be placed into a double yellow bag for incineration. iii. CSSD Equipment: This should be placed in special CSSD bags then placed in appropriate container, sealed and sent to CSSD. The Manager should be informed before hand. iv. Dressings and Refuse: Contaminated dressings and all other refuse, partially used drugs and ointments that have been in the room should be placed in the yellow double plastic bag lining the disposal bin in the patient‟s room. The bag should be placed in a second yellow plastic bag and sealed at the door of the room, and then placed in the special area for items awaiting collection for incineration. v. Disposable Urinal and Bedpan: Urine and faeces should be emptied to the patient toilet and then place the used disposable bedpans in the yellow double plastic bags for incineration. vi. Cleaning: For daily and terminal cleaning of the room and bathroom. Sodium Hypochlorite must be used according to manufacture recommendation or consult the Infection Control nurse. vii. Waste Disposal: Each room should have foot operated pedal bin lined with yellow plastic double bag and finally disposed by incineration. viii. Catering: Disposable utensils should be used, then dispose in yellow double plastic bag for incineration. ix. Sharps: Puncture proof sharp container must be kept in each room. All sharp items must be discarded into the sharp container. When ¾ full, it must be sealed and placed in a yellow double plastic bag and sent for incineration. x. Laboratory Specimens: The policy of collecting and transportation of specimens must be followed strictly. The specimens and forms must be placed separately in a sealed plastic laboratory specimen bag. All container and request form should be labelled biohazard (HPAI) to warn the laboratory staff of potential danger. All specimens must be considered as biohazards. xi. Transporting Patients: If patient must be transported to referral Hospital the receiving department must be notified. Disposable gloves, gowns and mask (N95 or 3M foldable respiratory valve mask)) should be worn by the staff during transportation. Patient should wear NIOSH-95 mask or surgical mask only. xii. Decontamination after discharge of patient: Bed linen and curtains should be sent to the laundry as above. Special attention should be paid to cleaning and disinfection of furniture, fittings, horizontal surfaces and all medical equipment, which should be wiped thoroughly with sodium hypochlorite solution according to manufacture recommendations. Except for obvious splashing with excretions, secretions or blood, wall disinfection or washing is not indicated. Plastic mattress covers and pillow covers should be cleaned or replaced if torn. Mop heads, cleaning cloths and any residual detergent or cleaning powder should be disposed off into patient toilet. The bucket, bowl and mop handle should be cleaned with sodium hypochlorite. xiii. Last offices: All infection control measures must be taken. Any bleeding parts must be covered and the body placed in a sealed cadaver bag (Leak-proof body tag).
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Recommended Disinfectants Name of Disinfectant 1) Hypobromite Powder (Vim or Jiff) 2) Sodium Dichoroisocyanurates (NADCC) wipes or Spray or tablets (presept) 3) Isopropyl Alcohol 70% wipes 4) Chlorhexidine gluconate 4% Hibisrub 5) Chlorhexidine gluconate 0.5% in 70% spirit (Hibisol or Hydrex) When to use For cleaning sink, shower etc. For surface cleaning of bed, locker, table etc. For wiping thermometer For hand washing For hand rub after hand wash or physical hand clean. Then use Hibisol and leave to dry or to evaporate and the action takes place when the alcohol dries.
Guidelines for wearing PPE in the AI isolation ward All persons who enter the ward must change into scrub uniform/suit. All hair should be covered with head cap. At the cross line change the shoes and place the shoes in designated shoe-rack. Disinfect the hands with alcohol hand scrub 70%; Allow alcohol to evaporate. Wear the 3M Foldable Respiratory valve mask, closely fitted to cover nose and mouth and ensure proper seal. Wear face shield or goggles; if splash or body fluid is anticipated. Wear non-permeable gown with long sleeves. Wear disposable latex gloves Remove disposable latex gloves. Dispose in yellow double plastic bag. Remove the gown and hang it inside out on the hook provided further use Wash hand with Hibiscrub and dry with paper towel Leave the room Wipe hand with alcohol hand rub Remove goggles and 3M foldable respiratory valve mask. Wipe the goggles with alcohol 70%. Keep the mask and the goggles for further use. The mask should not be used more than 20 times. Change shoes when crossing the red line
a) Before entering the room
b) Before leaving the room
Note: a) 3M Foldable Respiratory Valve Mask should never be used for the patient/persons on isolation or quarantine because the valve disseminate the virus into the environment. Hence these are not suitable for bearded men. b) These mask although are re-usable, they should be handled carefully and stored in clean, dry location with cover. c) Humidity, dirty and crushing affects the efficiency of the respirator.
Annexure 9
ISOLATION GUIDELINES FOR HPAI CASES
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Guidelines for caring for H5N1 patients in isolation Patients with H5N1 should be cared for in single rooms to prevent direct or indirect transmission. Strict adherence to the infection control guidelines is essential to prevent transmission of infection between patients and form patients to health care workers and others. Care of patients in isolation units becomes a challenge when there are inadequate resources, or when the source patient has poor hygienic habits, deliberately contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission or micro-organisms (children, patients with in altered mental state, or elderly persons)
Preparation of the isolation room Ensure appropriate signs on the door Place a recording sheet at the entrance of the isolation room. All health care workers or visitors entering the isolation area should be encouraged to write their details on the recording sheet so that if follow-up/ contact is required, details are available. Remove all non-essential furniture. The remaining furniture should be easy to clean and should not conceal or retain dirt or moisture, either within or around it. Collect linen as needed. Stock the hand basin with suitable supplies for hand washing. Place a puncture-proof container for sharps in the room. Keep the patients personal belongings to a minimum. Keep water pitcher and cup, tissue wipes and all items necessary for attending the personal hygiene within the patient's reach. The patient should be allocated his/her own non-critical items of patient care equipment, e.g. stethoscope, thermometer and sphygmomanometers. Any item of patient care equipment that is required for other patients should be thoroughly cleaned and disinfected prior to use. Setup a trolley outside the door to hold personal protective equipment. A checklist may be useful to ensure all equipment is available. Place an appropriate container with a lid outside the door for equipment that requires disinfection and sterilization. Once equipment has been appropriately cleaned it can be sent to the sterilizing service department. Keep adequate equipment required for cleaning the disinfection inside the patient‟s room. Scrupulous daily cleaning of the isolation unit is important in the prevention of cross infection. If possible the air conditioning should ensure the direction of the air-flow is from the outside adjacent space (e.g. the corridor) into the room (negative pressure ventilation). Cutlery and crockery should be cleaned in hot soapy water.
Entering the room Collect all equipment needed. Wear personal protective equipment. Enter the room and shut the door.
Leaving the room
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National Pandemic Influenza Preparedness Plan: 2006
Remove personal protective equipment in the correct order: Remove gown (place in rubbish bin). Remove gloves (peel from hand and discard into rubbish bin). Use alcohol-based hard scrub or wash hands. Remove cap and face shield (place cap in bin and if reusable place face shield in container for decontamination). Remove mask – by grasping elastic behind ears – do not touch front of mask Use alcohol – based on hand scrub or wash hands. Leave the room. Once outside the room use alcohol hand scrub again or wash hands.
Alternatively wash hands using plain soap, antimicrobial agent or waterless antiseptic agent such as an alcohol – based hand gel.
Staff health management Health care workers who are involved in caring for a patient with H5N1 should receive training on the mode of transmission, the appropriate infection control precautions and the exposure protocol. Staff no involved in direct patient care should be given general advice about avian influenza.
Exposed health care workers Antiviral prophylaxis and flu vaccination. All health care workers or field investigators who are expecting to have contact with H5N1 or have had contact with an H5N1 patient or an environment that is likely to be contaminated are recommended to: o Be vaccinated with the current WHO recommended influenza vaccine two weeks prior to the event. This will not protect against H5N1, but will help to avoid simultaneous infection by human influenza and avian influenza. Take one Oseltamivir phosphate (Tamiflu) 75mg tablet each day for at least 7 days beginning as soon as possible after exposure. Antiviral therapy should begin immediately or at least within 2 days of exposure and may continue for up to 6 weeks.
o o
Self-management Check temperature twice daily and monitor self for other respiratory symptoms especially cough. Where available, daily throat swab sampling is recommended during the high risk field visits. Where at all possible keep a personal diary of contacts. The diary should not be taken into isolation areas or into farms. In the event of a fever, immediately limit interactions and exclude yourself from public areas. Notify the Ministry of Health.
Discharging the patient The patient and family should be educated about the appropriate precautions to take when in contact with chickens, wet markets etc.
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National Pandemic Influenza Preparedness Plan: 2006
Carry out appropriate cleaning and disinfection of the room
Care of the deceased The care of deceased pandemic influenza patients raises infection control issues, along with significant social and religious considerations. Detailed guidelines will be issued. In the interim, deceased pandemic influenza patients should be sealed for transportation in an impermeable body bag. If the body bag is thought to be permeable then double bagging should be done, and the zip or other openings sealed with airtight tape. Alternatively, the bag may be placed within a large thick plastic outer bag that can be sealed. Health care workers must follow standard precautions when caring for the deceased patient. Full personal protective equipment must be worn if the patient died during the infectious period (i.e. 7 days after the onset of symptoms in adult and 21 days after the onset of symptoms in children). The body should be fully sealed in an impermeable body bag prior to transfer to the mortuary as soon as possible after death. No leaking of body fluids should occur and the outside bag should be clean. If the family of the patient wishes to view the body, it may be allowed. If the patient died in the infectious period the family should wear gloves and a gown. Cultural sensitivity should be recognized and considered in situations where a patient dies.
Autopsy As general guide follow standard precautions and use the minimal amount of equipment in the autopsy Avoid using scalpels and scissors with pointed ends, Never pass instruments and equipment by hand – always use a tray If possible use disposable instruments and equipments Keep the number of staff present to a minimum
Mortuary care/funeral director's premises Staff of the mortuary or funeral home should be informed that the deceased had H5N1. It should be explained that standard precautions are all that is required in the event of exposure to the body. Embalming may be conducted as routine. Hygienic preparation of the deceased (e.g. cleaning, tidying of hair, trimming of nails and shaving) may also be conducted.
Infection control advice for community Advice about contact with chickens, ducks or other animals. Avoid contact with chicken farms, duck farms or any farm where animals have been ill, slaughtered or are thought to harbour Avian Influenza. If you inadvertently come into contact with an environment that has had sick/dead chickens – wash hands thoroughly and monitor your temperature for 7 days. If you develop a fever – consult your doctor regarding whether or not you should receive antiviral medication
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National Pandemic Influenza Preparedness Plan: 2006
If you have had contact with any dead chickens that have died from avian influenza or if have had contact with the faeces of these chickens – monitor your health for 7 days and consult your doctor for advice. If you have chickens that have died in your backyard – you should know how to decontaminate your yard. Wear personal protective equipment – at least cover your face and wear gloves or plastic bags over your hands. Bury the dead poultry to at least 2.5 meters. This must be away from water supplies. Clean area of all chicken droppings – scrape or use rake and bury the chicken droppings. Clean the chicken shed or area where a dropping has been with soap and water.
Advice about visiting friends or relative in health care facilities Avoid contact with patients known to have H5N1 during the infectious period of their illness. This is 7 days for adults and 7-21 days for children (<12 years old). If you must visit a patient who is suspected as having H5N1 or confirmed as having H5N1 follow the infection control precautions in place in the hospital for the period the patient is infectious. You will need to wear personal protective equipment if you have direct contact with the patient or the patient‟s environment. You should receive advice on the proper way to put on the personal protective equipment, especially on how to fit the mask to your face. Personal protective equipment you will need to wear includes mask, gown, gloves and goggles. When you leave the room must remove theses items and wash your hands very well. After you have been contact with the patients with H5N1 you should monitor your health for 7 days. If you develop a temperature and sore throat you should consult your doctor for advice regarding antiviral treatment. If your illness becomes severe you should see medical advice immediately and inform then you have been in contact with H5N1.
Advice about respiratory illness Anyone with respiratory type illnesses should be careful with secretions from the nose and mouth. Cover the nose and mouth when coughing or sneezing – use a tissue and dispose of after use in the waste. Always wash hands after having any contact with respiratory secretions. Be careful with respiratory secretions (e.g. coughing and sneezing) when around other people, especially small children. It may be best to avoid contact with individuals at risk (small children or people with illnesses) until respiratory symptoms have resolved. Avoid contact with secretions of people who have respiratory illnesses. Ask people to use a tissue and cover their nose and mouth when cough or sneezing. Seek medical advice if the illness is severe.
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Annexure 10
VACCINATION FOR HPAI
Guidelines will be issued as and when human vaccine against HPAI (H5N1) is manufactured and is available in the market. Vaccination policy will be in concordance with the WHO advisory.
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National Pandemic Influenza Preparedness Plan: 2006
Annexure 11 RECOMMENDED USE OF ANTIVIRALS
TAMIFLUTM (Oseltamivir phosphate) This is important information about TAMIFLU (TAM-ih-flew). Read it well before you begin treatment. This information does not replace talking with your health care professional about your medical condition or your treatment. This does not list all the benefits and risks of TAMIFLU. If you have any questions about TAMIFLU ask your health care professional. Only your health care professional can determine whether TAMIFLU therapy is right for you.
What is TAMIFLU? TAMIFLU is a drug that attacks the influenza virus that causes the flu, rather than simply masking symptoms and stops it from spreading inside your body. TAMIFLU is for treating adults and children age 1 and older with the flu whose symptoms started within the last day or two. TAMIFLU can also reduce the chance of getting the flu in people age 13 and older who have a higher chance of getting the flu because they spend time with someone who has the flu. TAMIFLU can also reduce the chance of catching the infection if there is a flu outbreak in the community.
Should you take flu vaccine? TAMIFLU is not a substitute for a flu vaccination. You should continue to get a flu vaccination every year (seasonal vaccine) according to your health care professional‟s advice.
Who should not take TAMIFLU? Do not take TAMIFLU if you are allergic to the main ingredient, Oseltamivir phosphate, or to any other ingredients of TAMIFLU. Before starting treatment, make sure your health care professional knows if you are taking any other medicines, or are pregnant, planning to become pregnant, or breastfeeding. TAMIFLU is normally not recommended for use during pregnancy or nursing, as the effects on the unborn child or nursing infant are unknown. Tell your health care professional if you have any type of kidney disease, heart disease, respiratory disease, or any serious health condition.
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National Pandemic Influenza Preparedness Plan: 2006
Recommended daily dosage of influenza antiviral medications for treatment and prophylaxis of HPAI Antiviral agent Oseltamivir (TamiFlu®) Treatment† of Influenza A & B Age group (yrs) 10-12 Dose varies With child‟s weight§
1-6 Dose varies With child‟s weight§
7-9 Dose varies With child‟s weight§
13-64 75 mg twice daily
≥65 75 mg twice daily
Chemoprophylaxis of Influenza A & B
†
NA
NA
NA
75 mg/day
75 mg/day
A reduction in the dose of Oseltamivir (TamiFlu®) is recommended for persons with creatinine clearance <30 mL/min. § The dose recommendation for children who weigh ≤ 15 kg is 30 mg twice a day. For children who weigh > 15-23 kg, the dose is 45 mg twice a day. For children who weigh >23-40 kg, the dose is 60 mg twice a day. And, for children who weigh >40 kg, the dose is 75 mg twice a day.
8. List ofAlgorithms
(RecommendedActions)
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National Pandemic Influenza Preparedness Plan: 2006
Algorithm # 1 Algorithm # 2 Algorithm # 3 Algorithm # 4 Algorithm # 5 Algorithm # 6 Algorithm # 7 Algorithm # 8 Algorithm # 9 Algorithm # 10
Influenza & ILI Surveillance Contact Surveillance Airport Surveillance Contact Management at Airport Seaport Surveillance Poultry Farm Surveillance Case Transfer Protocol Case Arrival at the Referral Hospital Laboratory Investigation Case Management
61 62 63 64 65 66 67 68 69 70
1. HPAI Surveillance Algorithm
31 October 2005
Suspect Case Health Care Institution Private or Government Primary/Secondary/Tertiary
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National Pandemic InfluenzaWhether satisfies WHO case definition? Preparedness Plan: 2006 0
Fever > 38 C AND Cough / shortness of breath AND Visit to affected area or contact with suspect/ probable case of HPAI
2. Contact Surveillance: Algorithm
31 October 2005
CONTACTS of suspect case
Regional Epidemiologist/Health Inspector (responsible for follow-up): To conduct Home visit PPE should be worn during visit (mask, gloves, gown) To enlist all information of all close contacts (address, movement & contact telephone, etc) National Pandemic Influenza Preparedness Plan: 2006 Ask & check for fever & respiratory symptoms
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3. Airport Surveillance Algorithm
31 October 2005
Port of Entry: Seeb/Salalah/Khasab International Airport To fill in Self Declaration Form Visit within last 2 weeks to areas declared by WHO to be endemic for HPAI NO YES Passengers ‘NOT’ visiting designated areas
Passengers arriving from designated areas
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National Pandemic Influenza Preparedness Plan: 2006examines for fever Airport Doctor No Action
> 380 C & respiratory symptoms NO
YES
4. Contact Management at Airport: Algorithm
31 October 2005
Contacts of Suspect Case at Seeb/Salalah/Khasab Airports
Suspect Case Identified on board
Suspect Case Identified at the Airport
Radio message to Airport Authority
Inform Doctor on Duty
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National Pandemic Influenza Preparedness Plan: 2006
Inform Cabin crew to take following actions (refer IATA guidelines):
On call doctor/ Health Inspector should Check boarding card of the suspect case to locate seat number
5. Sea Port Surveillance: Algorithm
31 October 2005
Focal Points for Sea-port Surveillance: Muscat: Mr. Suleiman Hamood (Tel. 99373322)/ Mr. Ashraf Al Hinai (Tel. 99368252) Salalah: Dr. Mahmood Shabaan (Tel. 99480881)/ Dr. Sonal (Tel. 99581387) Sur: Dr. Sharif Mohammed (Tel. 99388270)
Ship arriving from HPAI affected area Port of Entry: Muscat/Salalah/Sur
Acquire list of all crew on board before arrival of vessel (by radio) Ensure departure date of the ship from HPAI affected area is within 2 weeks of arrival Enquire whether any crew member is sick on board
Departure within 2 weeks from affected area
Departure over 2 weeks from affected area
Health team visits the vessel PPE (mask, gown & gloves) should be worn Avoid close cotact with crew Enquire whether any person is sick (fever & National respiratory symptoms) Pandemic Influenza Preparedness Plan: 2006
No Specific Action
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If a crew member is sick If NO crew member is sick
6. Poultry Surveillance Algorithm
31 October 2005
Sudden deaths in the domestic birds in the poultry farms
Fever and/or respiratory symptoms amongst the workers handling the birds in the poultry farms
NO
YES
Keep under observation for 10 days Watch for illness & respiratory symptoms
YES
Suspect Case of HPAI
NO
Designated doctor examines for fever > 380 C & respiratory symptoms if satisfies suspect case definition of HPAI NO YES
No Action
To fill-in Contact Details National Pandemic Influenza Preparedness Plan: 2006 (address & Telephone) Information sent to DCDSC & regional Epidemiologist
To inform & Consult Dr. Salah (Tel. 99315063) / Dr. Shyam (Tel. 99368327) / Dr. Hassan (Tel. 95208040)
To assess Epidemiological Compatibility
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7. Case Transfer Protocol to Referral Hospitals
31 October 2005
Quarantine Hospitals for HPAI in Oman Capital & all other regions: Al Nahda hospital Governorate of Dhofar: Sultan Qaboos Hospital Governorate of Musandam: Khasab Hospital Regional Hospitals: Sohar, Rustaq, Nizwa, Sur, Ibra, Ibri and Haima Hospitals
Suspect Case Epidemiologically & Clinically Compatible
Health Care Worker Doctor/health inspector should wear PPE - (3M respirator mask, gown, gloves) immediately Do not carry out any procedures on the case and avoid unnecessary contact Airport duty staff should not accompany the case to the hospital
Suspect case Isolate case in a room He/she should wear a surgical mask (N95) Do not allow contact with others (relatives) Patient's documents/belongings should be collected by the health inspector
To inform & Consult Dr. Salah (Tel. 99315063), Dr. Shyam (Tel. 99368327), Dr. Hassan (Tel. 95208040)
Contact Management Refer to Algorithm # 2
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National Pandemic Influenza Preparedness Plan: 2006 Instruction for transfer of case
To call designated focal point for Admission to referral Hospital Ambulance with a staff nurse escort would be organized and sent to airport
8. Case Arrival at Referral Hospital: Algorithm
31 October 2005
Suspect case of HPAI Arrival at the Referral Hospital
Ambulatory
Non-ambulatory
Case received & escorted by nurse to Triage Room on wheel chair Nurse should wear PPE
Case received & escorted by two nurses to Triage Room on stretcher Nurse should wear PPE
The Case is transferred to the quarantine ward immediately through the shortest possible route
DISINFECTION PROCEDURES (Applicable to ambulance, stretcher, wheel chair, or any other medical/non-medical equipment used for the case during transfer) Equipment used should be cleaned & disinfected according to manufacturer’s Plan: 2006 National Pandemic Influenza Preparedness instructions Clean all contaminated surfaces by using Sodium hypochlorite solution prepared according to manufacturer’s recommendations
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9. Laboratory Investigation of HPAI: Algorithm
4th Jan 2006
On admission of a suspect case of HPAI in the referral hospital focal point should inform Dr. Suleiman (Tel. 99426288)/ Dr. Said (Tel. 99248132) from CPHL Laboratory Investigation
General Investigations for Case Management at Referral Hospital Laboratory
Specific investigations for Diagnosis of HPAI at CPHL
Doctor/Nurse/Technician on duty to collect samples
Technicians on call Mr. Ali Al Abri (Tel. 99428487) Mr. Sathia Rajkumar (Tel. 99064910)
Haematology Clinical Chemistry 5 ml Blood 5 ml Blood Technician on call Technician on call Sujata (Tel. 99040243) Jessy (Tel. 99035874)
Specimens to be collected immediately by ENT specialist in Referral Hospital Nasopharyngeal aspirate/wash/swab Oropharyngeal swab Collect samples in VTM, refrigerate immediately (DO NOT FREEZE) Specimens to be collected during illness
Routine Investigations on Arrival CBC, LFT, SB, UE, CK, LDH Electrolytes, Blood gases Sputum Gram stain & culture Blood culture
by Chest specialist or Con. Physician Bronchoalveolar lavage Tracheal aspirate Collect samples in VTM, refrigerate immediately (DO NOT FREEZE)
Tissue Samples from the Deceased should be preserved in VTM & Formalin
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National Pandemic Influenza Preparedness Plan: 2006
Note: Collection bottles, swabs & VTM as well as PPE for technicians will be provided by CPHL Sample transport from Al Nahda hospital will be assisted by technicians from CPHL
10. HPAI Case Management Algorithm
15 January 2006
Suspect case HPAI arrives at the designated Referral Hospital
Focal point to Inform... Dr. XXXXX Consultants on Duty
Dr. Nasser (99370625) Dr. Hosni (99474441) Dr. Firyal (99384896)
CXR
Duty Doctor
Nursing Supervisor
Examine case in full HPAI gear Check vitals & Oxygen saturation
Technician on Duty CxR
Laboratory Technician on Duty
Nursing Duty Organization Stable Condition Deterioration
Test Results
Inform Anesthesiologist 2nd on Call in the Referral Hospital
Adult Child
Follow Laboratory Algorithm # 9
Examine the child in isolation room (in full HPAI gear) Counsel family Manage on case-to-case basis
Examine the case in isolation room (in full HPAI gear) Manage on case-to-case basis
Recommended Treatment
Recommended Treatment
Epidemiologist To assess the need of quarantine of family members & other contacts
National Pandemic Influenza Preparedness Plan: 2006
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