MANAGEMENT OF POSSIBLE
AVIAN INFLUENZA IN PRIVATE HEALTHCARE FACILITIES

Coordinated by:

Communicable Disease Surveillance Section,
Disease Control Division
MINISTRY OF HEALTH MALAYSIA

February 2004

Management of Possible cases of Avian Influenza in
Private healthcare facilities

1.0 INTRODUCTION

1.1 Background

Fowl plague was first described in 1878 as a serious disease of chickens in Italy. It was determined in 1955 that fowl plague virus is actually one of the influenza viruses (Beard). Highly pathogenic avian influenza (HPAI) viruses have periodically occurred in recent years in Australia, England, and Pakistan with H7 subtype; and South Africa, Scotland, Ireland, Mexico and the United States with H5 subtype. In 1961, a strain designated H5N1 was discovered in some birds from South Africa but it was harmless to human (Love, 1998). Recent outbreak of avian influenza occurred in February 2003 in Netherlands involving the H7N7 strain.

1.2 Introduction to Avian Influenza

Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. Migratory waterfowl ? most notably wild ducks ? are the natural reservoir of avian influenza viruses, and these birds are also the most resistant to infection. Domestic poultry, including chickens and turkeys, are particularly susceptible to some of the highly pathogenic avian influenza viruses. There are 15 subtypes of avian influenza virus. These viruses do not normally infect species other than birds and pigs. However, the H5N1 subtypes have demonstrated a capacity to directly infect humans in Hong Kong in 1997, and have done so again in Viet Nam and Thailand since January 2004.

Published information about the clinical course of human infection with H5N1 avian influenza is limited to studies of cases in the 1997 Hong Kong outbreak. During that outbreak, patients developed symptoms of fever, sore throat, cough and, in several of the fatal cases, severe respiratory distress secondary to viral pneumonia. Previously healthy adults and children, and some with chronic medical conditions, were affected. The current outbreak have seen a higher mortality among children

The reported symptoms of avian influenza in humans have ranged from typical influenza-like symptoms (e.g., fever, rhinitis, non-productive cough, sore throat and myalgia) to eye infections, pneumonia, acute respiratory distress and other severe and life-threatening complications. The illness tends to have an abrupt onset and can progress rapidly with the peak severity seen within 2-3 days. In children, otitis media, nausea, and vomiting are more commonly reported.

The incubation period for influenza is 1-4 days, with an average of 2 days. Respiratory illness caused by avian influenza is difficult to distinguish from illness caused by other respiratory pathogens on the basis of symptoms alone (ref: to guidelines on laboratory screening for avian influenza).

It is important to remember that among persons with concurrent illnesses (e.g., pulmonary or cardiac disease) influenza can exacerbate the underlying medical conditions, lead to secondary bacterial pneumonia or primary influenza viral pneumonia, or occur as part of a co infection with other viral or bacterial pathogens.

1.3 Transmission to Humans

There is no documented evidence that showed human-to-human transmission during this current outbreak. However additional mutations in the virus or re assortment of genetic elements with its human influenza counterpart might produce a highly virulent and contagious virus (?mixing vessel? phenomena). Currently, the mode of transmission is thought to be through contact with body fluids (including feces) of infected birds and poultry.

1.4 Clinical Case Definition & management:

The case definition is as drafted by WHO (SEARO, 2004)

1.4.1 Possible case of Influenza A (H5N1)

Person with acute respiratory illness, characterized by fever (temperature ≥38 0 c) and cough and / or sore throat AND EITHER recent (less than a week) visit to a poultry farm in an area known to have outbreak of HPAI OR contact with a confirmed case of Influenza A (H5N1) during the infectious period OR worked in a laboratory that is processing samples from persons or animals that are suspected from HPAI.

1.4.2 Probable case of Influenza A (H5N1)

Possible case AND limited laboratory evidence for Influenza A (H5N1) such as IFA positive using HF5 monoclonal antibodies OR no evidence for another cause of the disease.

1.4.3 Confirmed H5N1 case

Positive viral culture for Influenza A (H5N1) OR positive PCR for Influenza (H5) OR a four-fold rise in H5 specific antibody titre.

1.5 Management of Avian Influenza case (s) at Private Healthcare facilities

For clinical case description and managing of possible cases.

1. Patients with the following criteria should be treated as suspected cases of avian influenza:

• Recent (< 7 days) history of direct exposure* to diseased or dying poultry or birds (* direct exposure: direct contact or close proximity e.g. within 3 feet or contact with case: see case definition above)
• Fever > 38ºC
• Respiratory symptoms (e.g. cough, sore throat, shortness of breath)
• Chest radiograph may show pneumonic infiltrates, which are often patchy (rather than lobar) in distribution. Chest X-rays, however, maybe normal initially.

2. All patients with suspected avian influenza should be referred to the designated government hospitals (see attached 
   appendix 1). No private hospital /clinics are allowed to treat a suspected case of avian influenza.

3. The A&E Department of the receiving hospital should be notified after which a designated ambulance from that hospital is sent to pick up the patient.

4. While awaiting transfer, the patient should be stabilized and isolated in a single waiting / examination room or area. He/she should be provided with a surgical mask (if not contraindicated).

5. The attending doctor and other healthcare personnel (kept to smallest possible number to minimize possible exposure) should don personal protective equipment (PPE) at all times while attending to the patient. The PPEs include; 3-ply surgical mask, gloves, water- proof gown and face shield (if splashes are expected). If intubations or other invasive procedures are performed, a N-95 respirator mask should be used instead.

6. All healthcare workers involved should comply with strict infection control. Adequate hand washing must be performed after all procedures. If hand washing is not immediately possible, alcohol hand rubs maybe used. (However, alcohol hand rubs should not be a substitute for hand washing in cases of visible hand soiling.)

7. All objects in direct contact with the patient and spillages should be decontaminated as in the SARS protocol.

8. Notification of possible cases will be done by the receiving government hospital, however the referring hospital /clinic should inform the State Operations Room concerning the case.

9. The referring hospital/ clinic must provide contact numbers (telephone or fax numbers) for further clarification and information.

10. For any queries or clarification, please contact:

PENGARAH KAWALAN PENYAKIT,
KEMENTERIAN KESIHATAN MALAYSIA.
Telephone no: 03-26946601, Fax: 03-26983211
Email: survelan@dph.gov.my

_________________________________________
Infectious Diseases Unit, Hospital Kuala Lumpur

Appendix 1

STATE	DESIGNATED HOSPITALS
PERLIS	Hospital Kangar
KEDAH	Hospital Alor Star
	Hospital Langkawi
PULAU PINANG	Hospital Pulau Pinang
PERAK	Hospital Ipoh
SELANGOR	Hospital Tengku Ampuan Rahimah Klang
NEGERI SEMBILAN	Hospital Seremban
MELAKA	Hospital Melaka
JOHOR	Hospital Sultanah Aminah Johor Bahru
PAHANG	Hospital Tengku Ampuan Afzan Kuantan
TERENGGANE	Hospital Kuala Terengganu
KELANTAN	Hospital Kota Bahru
WILAYAH PERSEKUTUAN	Hospital Kuala Lumpur
	Pusat Perubatan Universiti Malaya
SARAWAK	Hospital Umum Kuching
	Hospital Sibu
	Hospital Miri
	Hospital Bintulu
SABAH	Hospital Queen Elizebeth Kota Kinabalu
	Hospital Sandakan
	Hospital Tawau
WILAYAH PERSEKUTUAN LABUAN	Hospital Labuan

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