	August 27, 2004 First (1) Bulletin—Avian Influenza “A” Issue


AVIAN INFLUENZA “A” IMPORTANT HEALTH NOTICE		PDF version

Alert to the Health Care System

The Office of the Fire Marshal is forwarding to the fire service important information on Avian Influenza A. The Ministry of Health and Long Term Care has distributed this alert to the health care system. (See attached)

CACCs have been asked to screen calls for influenza-like illness (ILI) using the attached updated patient-screening instrument. (See attached)

The fire service, as well, needs to be alert for any persons presenting with severe influenzalike illness (ILI) who have a history of travel (or known close contact with a person with such travel history) to Asia, in particular to an avian influenza affected country within one week of onset of ILI symptoms. Current countries are Thailand, Viet Nam, China and Indonesia.

It is recommended that the fire service utilize appropriate personal protective equipment when in contact with patients exhibiting ILI symptoms. Fire departments are encouraged to consult with their local EMS provider.

Current information on this subject can be found on the following websites:

Web Resources and Information

Ontario Ministry of Health and Long Term Care: Emergency Management Unit			www.health.gov.on.ca

Health Canada			www.hc-sc.gc.ca

World Health Organization			www.who.int

Important Health Notice

Information for Healthcare Professionals

August 23, 2004
Volume 1, Issue 10
Page 1 of 3

Update on Avian Influenza A (H5N1) in Asia and Surveillance Recommendations

Dear Colleagues:
This notice is to provide an update on the Avian Influenza A (H5N1) situation in South East Asia and also to request maintaining a high level of vigilance in identifying individuals at heightened risk of an avian influenza A (H5N1) infection.

Outbreaks of avian influenza (H5N1) are currently occurring in four countries: China, Indonesia, Thailand and Viet Nam. The frequency of outbreaks coupled with the lack of evident epidemiological links between the outbreaks suggests that the virus may have become endemic (constantly present) in birds in this area.

In the present outbreak, first reported on August 12, a number of fatal human cases of avian influenza A (H5N1) were reported by the Vietnamese government. The WHO is awaiting the receipt of viral specimens for confirmatory testing by a WHO laboratory before confirming that these cases were caused by the H5N1 strain.

As a result, Health Canada recommends increased vigilance in the surveillance of influenza-like illness (ILI) and for the recognition, reporting and prompt investigation of any unexpected outcomes of ILI.

In the winter and spring of 2003-04, widespread avian influenza A (H5N1) outbreaks among poultry were reported from several Asian countries, with human infections (34) and deaths (23) reported in Thailand and Viet Nam.

Viet Nam health authorities are also investigating cases of severe pneumonia that have been detected in children and young adults over the past three weeks, most of which have been fatal. At this time, there has been no evidence of influenza A (H5N1) infection in humans outside of Viet Nam.

On August 20, the Chinese Ministry of Health reported that the H5N1 avian influenza virus has been detected in pigs. Because pigs can harbor human flu viruses, the presence of the avian flu virus in pigs increases the risk of genetic recombination with a human flu virus. A new and easily transmissible human influenza virus could subsequently emerge with pandemic potential.

Recommended measures for individuals traveling to countries where avian influenza A (H5N1) outbreaks occur have not changed (e.g. practice good hand hygiene, avoid contact with live poultry).

Following are specific recommendations from the Ministry of Health and Long-Term Care (MOHLTC), based on Health Canada’s recommendations for increased vigilance for severe ILI. To assist healthcare providers in screening for ILI, attached is the revised Febrile Respiratory Illness (FRI) Screener, revised to reflect the current geographic area of concern. The MOHLTC continues to monitor the avian influenza situation closely and will provide updates as significant new information becomes available.

Sincerely,

(original signed by)
Dr Sheela Basrur
Chief Medical Officer of Health and Assistant Deputy Minister

(original signed by)
Allison J. Stuart
Director, Emergency Management Unit

Health Canada Alert and Recommendations re: Sporadic cases of avian influenza A (H5N1) in humans, with ongoing H5N1 outbreaks in poultry flocks in Asia

Increased vigilance is recommended for the surveillance of severe influenza-like illness (ILI*) and for the recognition reporting and prompt investigation of patients with unexpected outcomes (e.g. severe ILI** with a complication requiring hospitalization, or death, in otherwise healthy individuals).

Recommendations for health care providers:

to be alert for any persons presenting with severe ILI who have a history of travel (or known close contact with a person with such travel history) to Asia, in particular to an avian influenza affected country (currently: Thailand, Viet Nam , China and Indonesia) within one week of onset of ILI symptoms.
to collect clinical samples from patients with severe ILI, for viral culture as soon as possible, preferably within 48 hours of onset of symptoms (nasopharyngeal swabs are preferred). Note: to assist laboratory staff in prioritizing testing, please make a notation of positive travel history (e.g. recent return from Asia, in particular from an affected area, or known close contact of a person with such travel history) or other notation of increased suspicion (hospitalization, death) as a comment on the laboratory requisition form.
To report severe ILI cases to the local medical officer of health for further investigation and management.

Public health authorities should enquire as to whether those reported with severe ILI had a history of contact with live poultry (including chickens and ducks) or swine (pigs) during their stay in the affected country.

*Influenza like illness (ILI) in the general population (Flu Watch national case definition): Acute onset of respiratory illness with fever and cough and with one or more of the following – sore throat, arthralgia, myalgia, or prostration which could be due to influenza virus. In children under 5-6, gastrointestinal symptoms may also be present. In patients under 5, or 65 and older, fever may not be prominent.

** Severe ILI may include complications such as: pneumonia, Acute Respiratory Distress Syndrome (ARDS), encephalitis and other severe and life threatening complication.

Recommendations for Public Health Laboratories Involved in Influenza Virus Detection:

to be vigilant for novel influenza A viruses that are not readily identifiable using current antisera. Any difficult to identify viruses should be referred to the National Microbiology Laboratory in Winnipeg (NML), immediately.

Recommendations for Hospitals involved in Enhanced SRI Surveillance:

hospitals are being advised to be on the alert for any persons presenting with febrile respiratory illness (FRI), severe respiratory illness (SRI), including SARS-like illness or severe Influenza like illness (ILI), who have traveled to either a potential zone of reemergence of SARS for an area affected by avian influenza H5N1 within the past 30 days (or had been in close contact with a person with such travel history).
Hospitals are being advised to continue the use the Febrile Respiratory Illness (FRI) Screener, and include China, Indonesia, Thailand and Viet Nam – countries of concern for avian influenza at this time – in the travel history question. Updated FRI Screener is attached.

The latest information, released by the WHO, is available at http://www.who.int/csr/don/en/

The Health Canada Travel Advisory is available at: http://www.hc-sc.gc.ca/

If you have any questions please contact the 24-7 Healthcare Provider Hotline at 1-800-212-2272, or your local Public Health Unit. Or visit the MOHLTC Emergency Management Unit website at:
http://www.health.gov.on.ca/english/providers/program/emu/emu_mn.html

Febrile Respiratory Illness Screener

Screening Questions to be Asked of Patients as Part of an Active Screening Process

Do you have new / worse cough or shortness of breath?
• if ‘no’, stop here (no further questions)
• if ‘yes’, continue with next question:
Are you feeling feverish, have you had shakes or chills in the last 24 hours?
• if ‘no’, take temperature; if >38 C, continue with next questions, otherwise stop (no further questions)
• if yes, take temperature and continue with next questions:

Initiate droplet precautions if “yes” to 1 and 2.
Is any of the following true?
• Have you lived in or visited China, Taiwan, Hong Kong, Indonesia, Thailand or Viet Nam within the last 30 days?
• Have you had contact in the last 30 days with a sick person who has traveled to these same areas?

Patients with FRI (fever and respiratory symptoms) and answered ‘yes’ to any of these exposures / conditions may potentially have severe respiratory illness (SRI).

Initiate droplet precautions and notify infection control if “yes” to 1, 2 and 3.
Infection control to notify public health.

Additional questions to be asked of all admitted patients:

Do you work for a healthcare agency or organization?
Are you a resident of a long-term care institution?

Initiate droplet precautions and notify infection control if “yes” to 1, 2 and either 4 or 5.
Infection control to notify public health.

Droplet Precautions¹:
The use of surgical masks and eye protection or face shields on the part of healthcare workers when encountering patients who have respiratory infections especially if associated with coughing, sneezing, felt to be transmissible principally by large respiratory droplets particularly when within one metre of such a patient. Also used where appropriate to protect the mucous membranes of the eyes, nose and mouth of the healthcare worker during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions (e.g., airway suctioning).

¹ Preventing Respiratory Illnesses, Protecting Patients and Staff. Infection Control and Surveillance Standards for Febrile Respiratory Illness (FRI) in Non-Outbreak Conditions in Acute Care Hospitals, December, 2003

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