Health Establishments Preparation For Unusual Or Unexpected Cases ...
Health Establishments Preparation for Unusual or Unexpected Cases or Clusters of Severe Acute Respiratory Infection SARI
Health Establishments Preparation for Unusual or
Unexpected Cases or Clusters of Severe Acute
Respiratory Infection
(SARI)
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CONTENTS
1. Introduction
2. Purpose of the Course
3. General Objectives
4. Specific Objectives
5. Methodology
Part I–Detection of and Response to Severe Acute Respiratory Infection (SARI)
6. General Information about Influenza
6.1. Seasonal Influenza
6.2. Influenza of animal origin
6.2.1 Swine Influenza
6.2.2 Avian Influenza
6.3. Pandemic Influenza
7. International Health Regulations 2005 (IHR-2005)
7.1. Necessary Basic Capacities for Surveillance and Response
7.2. IHR and the Risk of a Human Influenza Pandemic
7.3. Operational Aspects of IHR
7.4. Public Health Emergency of International Concern
8. Preparations for an Influenza Pandemic
9. Influenza Surveillance
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9.1. Definition of ILI and SARI and Confirmed Case of Influenza
9.2. Enhanced Nationwide Surveillance
9.3. Importance of Hospital Surveillance
9.4. Reporting
10. Laboratory
10.1.
Laboratory Tests for Diagnosis of Influenza
10.2.
Sampling and Shipment to the Laboratory
11. Hospital Infection Control
11.1.
ABC of Infection Control
11.2.
Specific Orientations for SARI with Pandemic Potential
11.3.
Practical Demonstration
12. Dealing with Cases
12.1.
Triage
12.2.
Evaluation of the Required Level of Care
12.3.
Evaluation of the Availability of Medical Management Resources
12.4.
Need for Referral and Transportation of Patients
12.5.
Organization of the Healthcare Facility for Dealing with Cases
13. Vaccines and Antiviral Agents
13.1.
Vaccines
13.2.
Antiviral Agents
Part II–Hospital Response to a Pandemic
14. Preparedness Plan and Hospital Response to an Emergency with Large Number of Cases of
SARI
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14.1.
Introduction
14.2.
Organization, Command and Coordination Structure
14.3.
Ethical-Legal Aspects
14.4.
Triage
14.5.
Bed Management
14.6.
Resources Management
14.7.
Management of Excess Hospital Mortality
14.8.
Occupational Health
15. Risk Communication for Healthcare Facilities
16. Annexes
Annex 1 Seven strategic actions to guide application of IHR-2005
Annex 2 Epidemiological Surveillance Algorithm
Annex 3 Formulas for Calculating the Proportions of Cases of SARI
Annex 4 Forms for Weekly Compilation of SARI and Death by SARI
Annex 5 Form for Reporting SARI–Generic Protocol for Influenza Surveillance
Annex 6 Differential SARI Diagnostic for Laboratory Diagnosis
Annex 7 Techniques for Taking Respiratory Tract Samples
Annex 8 Packaging of Samples for Transportation
Model form for monitoring healthcare workers for detection of diseases similar to flu
Annex 9 and for health workers exposed to patients with unusual or unexpected SARI
Annex 10 Triage
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1. INTRODUCTION
Emerging respiratory-transmitted diseases pose a substantial risk for humankind due to their
very high potential for transmission. These diseases can produce high morbidity, and, in
serious forms, show high rates of hospitalization and high case-fatality rates. It is important
to emphasize that lack of previous immunity in the population to the new viruses leads to a
high number of cases and to greater severity. This potential for severity requires that
measures for patient care and control and prevention of new cases be put in place
immediately.
In the last century there have been three major pandemics: the first occurred in 1918 (type
A/H1N1 influenza) and was responsible for the death of approximately 40 to 50 million
people throughout the world, mainly young people; the second was in 1957 (type A/H2N2
influenza) and the third in 1968 (type A/H3N2 influenza), with approximately 2 and 1
million deaths throughout the world, respectively.
(1)
Currently, type A/H5N1 influenza virus has infected birds in more than 50 countries on three
continents. This H5N1 strain has rarely infected people, but could easily mutate to a strain
capable of infecting human beings. Cases in humans caused by this strain have shown high
case-fatality, about 60%. It is not possible to determine if the next influenza pandemic will be
caused by the H5N1 strain or by another strain of the influenza virus. Given this fact, world
influenza surveillance is indispensable for detecting new strains of the virus as these appear,
through sentinel surveillance of influenza-like illness (ILI) and of atypical clinical
manifestations of syndromes of severe acute respiratory infection (SARI). (2)
Due to the high risk that this situation poses for humankind, International Health Regulations
(IHR-2005), in effect from 15 June 2007, require that any case of human influenza caused by
a new viral subtype be reported immediately (within a period of 24 hours) to the World
Health Organization (WHO). (3)
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This training module was developed by the Pan American Health Organization (PAHO) with
the objective of providing professionals in healthcare facilities the necessary tools for rapid
identification and proper management of cases with pandemic potential. This rapid
identification will make it possible to set up the actions necessary for prevention and control
of new cases.
This training module is primarily directed to workers in public and private healthcare
facilities, especially those that provide hospitalization services. This includes professionals
that provide care as nurses, physicians, laboratory staff, and others. The course should also
include medical coordinators and other managers, since it contains components aimed at
management of health services.
2. PURPOSE OF THE COURSE
Strengthen the capacity of the health services to detect and respond rapidly to one or more
cases of unusual or unexpected severe acute respiratory infection (SARI), including human
influenza.
3. GENERAL OBJECTIVES
Part I
Prepare health professionals for detection and early management of cases or clusters of
SARI at the level of healthcare facilities. This will permit the early identification of
emerging agents and their investigation and control on a timely basis.
Part II
Provide tools for improvement of the response by healthcare facilities for a situation of
cases of SARI that exceed theirs capacity, in order to achieve adequate and efficient
care.
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4. SPECIFIC OBJECTIVES
PART I: Detection and Management of SARI
That the personnel of every healthcare facility be capable of detecting on a timely basis:
• Cases of unusual or unexpected SARI.
• Cluster of SARI
• Excess cases of SARI.
That the personnel of every healthcare facility be capable of responding on a timely basis to:
• Carry out treatment of cases and apply infection control standards.
• Report the cases immediately to sub-national and/or national authorities for the
mobilization of rapid response teams according to the mechanisms set up in the
country.
• Collect samples from these cases and send them to the laboratory in an adequate and
timely way.
• Know and comply with the International Health Regulations 2005 and enhance the
necessary basic skills for the tasks of surveillance and response.
PART II: Hospital Response to a Pandemic
• Train the health team in the fundamental measures for treatment response by the
healthcare facilities to emergence of Influenza-Like Illness (ILI) or SARI.
• Provide the practical tools for organization of treatment response to the increase in
expected demand from patients.
• Know the measures related to organization of services that contribute to efficient
management of cases and utilization of the resources of the healthcare facilities.
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5. METHODOLOGY
The content of the course is based on the Generic Protocol for Surveillance of Influenza
developed by PAHO and Centers for Disease Control and Prevention of the United States
(CDC) (4), on WHO guides, and on recent scientific articles on the subject. The course,
designed for groups of 40 people, will be given in short presentations of 20 to 30 minutes,
followed by a period of active and passive discussion. The material presented will be
supplemented with exercises, case studies, practical demonstrations, and simulations where
participants will act out a pandemic influenza situation, in groups (5 to 8 people). It is
important to emphasize that the course is aimed at healthcare workers who treat patients with
manifestations of unusual or unexpected SARI in healthcare facilities with hospitalization
service.
References:
1. WHO Ten things you need to know about pandemic influenza.
http://www.who.int/csr/disease/influenza/pandemic10things/en/
2. World Health Organization (WHO), Interim Protocol:Rapid operations to contain the initial emergence o
pandemic influenza. Update October 2007.
http:www.who.int/csr/disease/avian_influenza/guidelines/RapidContProtOct15.pdf
3. WHO. International Health Regulations 2005.
4. OPS-CDC. Protocolo genérico para la vigilancia de la influenza, 2006. PAHO/HDM/CD/V/411/06.
I - DETECTION OF AND RESPONSE TO UNUSUAL OR UNEXPECTED SARI
6. GENERAL INFORMATION ABOUT INFLUENZA
The influenza virus is a virus that contains RNA of the orthomomyxoviridae family. There
are three types of influenza virus (A, B and C) that can cause the disease in humans.
However, only type A and B viruses have caused outbreaks and only type A viruses, the most
mutable, have caused pandemics. Virus C tends to cause a mild disease. Influenza A viruses
are also classified by subtype according to the proteins present on their surface, the
hemagglutinin (16 subtypes), and the neuramidase (9 subtypes). (1)(2) In addition to
infecting human beings, the influenza virus infects other species of mammals, as well as wild
and domestic birds. The subtypes of the human influenza A virus that are currently
circulating A are H1N1 and H3N2.
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Influenza is a disease that has a high epidemic potential, produced by the capacity of the
virus to generate antigenic variations and by the existence of an extensive animal reservoir.
Wild aquatic birds are the natural reservoir of all known influenza subtypes. Frequent
changes in the genetic composition of type A influenza viruses are the basis of epidemics and
pandemics. Minor changes produce seasonal influenza outbreaks, for which development of
an annual vaccine that provides protection against the new strain in circulation is required.
6.1 SEASONAL INFLUENZA
Seasonal influenza is influenza or flu that people regularly get at specific times of the year,
mainly in the coldest months in countries where the seasons are more marked. In countries
with a tropical climate, the patterns of circulation are not clearly defined.
The period of incubation of the virus varies from 1 to 4 days, with an average of 2 days. The
disease is characterized by fever, headache, myalgia, prostration, runny nose, sore throat, and
cough. Cough tends to be intense and lasting. Other symptoms are limited in duration and the
patient recovers in a period from two to seven days. From the clinical standpoint, influenza
may not be distinguished from the diseases caused by other viruses of the respiratory tracts.
This virus is effectively transmitted from one person to another in various ways such as
direct contact, droplets that in general disperse up to 1 meter, by fomite through objects and
rarely by aerosols. However, disease caused by influenza can be effectively prevented with
annual vaccination. For this purpose there is a virological surveillance system, the Global
Influenza Surveillance Network (GISN), made up of National Influenza Centers (NIC) and
122 sentinel units in 94 countries, that does systematic sampling of patients with ILI, to find
out the viral profile for every year. Based on the viruses found in circulation, WHO convenes
a meeting of experts twice a year to determine the composition of the vaccine. (3) These
vaccines should be administered before the annual peak. In industrialized countries, the
influenza vaccine, when there is a good match between the antigens of the vaccine and the
viruses in circulation, provides approximately 70% to 90% protection against clinical disease
in healthy adults. Among older persons who do not live in institutions, vaccination against
influenza can reduce the number of hospitalizations between 25% and 39% and reduce
mortality between 39% and 75% during the influenza season. (4) Since 2004, PAHO has
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recommended annual vaccination for people over 60 years of age, the chronically ill, people
who are immunodeficient, health professionals, pregnant women, and children between 6 and
23 months old. (5)
The most frequent complication of influenza is severe acute respiratory infection (SARI)
with the clinical symptoms of pneumonia. This can sometimes be a primary infection due to
influenza virus or it more commonly can be secondary bacterial pneumonia (S. pneumonie,
Haemophilus influenzae, or S. aureus). During annual epidemics, the most serious cases and
deaths take place mainly among children, the elderly, and people weakened by chronic
diseases. It is calculated that annual mortality from influenza throughout the world reaches 1
million people.
In the majority of epidemics, between 80% and 90% of deaths occur in people over 65 years
of age. The monthly peak of cases of influenza varies by country according to geographical
location. In the United States of America, the CDC estimate that the peak is in the month of
February. In the countries of the Southern Cone it is estimated that the peak in general is in
the month of May, while clear evidence is still not available to determine the peak in
countries with a tropical climate.
6.2 INFLUENZA OF ANIMAL ORIGIN
The pandemic strain of the virus influenza is of animal origin, the more frequent are from
birds, pigs and other mammals.
6.2.1 Swine influenza
Swine influenza, or “swine flu”, is a highly contagious acute respiratory disease of pigs,
caused by one of several swine influenza A viruses. Swine influenza viruses are most
commonly of the H1N1 subtype, but other subtypes are also circulating in pigs (e.g., H1N2,
H3N1, H3N2). Pigs can also be infected with avian influenza viruses and human seasonal
influenza viruses as well as swine influenza viruses. Sometimes pigs can be infected with
more than one virus type at a time, which can allow the genes from these viruses to mix. This
can result in an influenza virus containing genes from a number of sources, called a
"reassortant" virus. Although swine influenza viruses are normally species specific and only
infect pigs, they do sometimes cross the species barrier to cause disease in humans.
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Outbreaks and sporadic human infection with swine influenza have been occasionally
reported. Generally clinical symptoms are similar to seasonal influenza but reported clinical
presentation ranges broadly from asymptomatic infection to severe pneumonia resulting in
death. The clinical case description is acute febrile respiratory illness (fever >38°C ) with the
spectrum of disease from influenza-like illness to pneumonia.
Swine influenza is not notifiable to international animal health authorities, therefore its
international distribution in animals is not well known. The disease is considered endemic in
the United States. Outbreaks in pigs are also known to have occurred in North America,
South America, Europe (including the UK, Sweden, and Italy), Africa (Kenya), and in parts
of eastern Asia including China and Japan. Since the implementation of IHR(2005) in 2007,
WHO has been notified of swine influenza cases from the United States and Spain. Most of
these swine influenza cases recovered fully from the disease without requiring medical
attention and without antiviral medicines.
It is likely that most of people, especially those who do not have regular contact with pigs, do
not have immunity to swine influenza viruses that can prevent the virus infection. If a swine
virus establishes efficient human-to human transmission, it can cause an influenza pandemic.
6.2.2 Avian influenza or avian flu
Avian influenza or avian flu is a disease of birds (wild or domestic), that are the natural
reservoir of the virus. The human being is not a regular part of this cycle. The H5N1 strain is
the one causing most concern at this moment because it has shown the capacity to infect
other mammals and human beings. This virus appeared originally in Asia in 1997 and
starting in 2003 has been spreading rapidly to other regions.
To date, the strains of avian influenza strains with potential for transmission for human
beings are strains H5, H7, and H9. Sporadic infections in humans in Asia since 1997 have
resulted from contact with sick or dead birds or with their secretions, since the virus is
excreted in the stools, blood, and respiratory secretions of the birds. Human cases that have
occurred to date are associated with contact with birds between 76% and 100% of the time,
depending on the country. Clusters of H5N1, with at least 2 cases with epidemiological ties,
have been identified in 10 countries, corresponding to 25% of the cases. (2) More than 90%
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of clusters have occurred among family members. In these cases, the infection was probably
acquired by a common source of exposure, such as birds, but limited person-to-person and
unsustained transmission has also been considered. This probably occurred during intimate
contacts or contact with very sick patients, without protection. (2)
The period of incubation of the virus in humans seems to be less than 7 days, in the majority
of cases from 2 to 5 days. The average age of infection by H5N1 is approximately 18 years,
and 90% of the cases are in patients less than 40 years old. General case-fatality is 61%, this
percentage being greater in the group less than 20 years old. Pneumonia occurs in 61% to
100% of the cases and the most frequent presentation of infection by H5N1 influenza in
humans is severe pneumonia that rapidly evolves to an acute state of respiratory distress
syndrome. Most frequent symptoms documented to date are fever (almost 100%), dyspnea
(37%-94%), cough (71%-98%), runny nose (14%-33%), sore throat (32%-68%), and diarrhea
(5%-52%). (2)
In Indonesia, for example, the initial diagnosis in the cases of patients with a confirmed
diagnosis of influenza A (H5N1) was pneumonia in 46%, dengue in 12%, and acute
respiratory disease in 27% of the cases. Only in 12% of the cases was the human infection by
an avian influenza virus considered as the first diagnosis. The period between the onset of
symptoms and hospitalization was from 3 to 5 days and the time between the onset of
symptoms and death was from 8 to 13 days, with an average from 9 to 10 days. For these
cases one notes that the time of the patient in the hospital is very short, with rapid evolution
toward death. Other findings are leukopenia, lymphopenia, thrombocytopenia, and increase
in lactic dehydrogenase (LDH). (2)
6.3 PANDEMIC INFLUENZA
An influenza pandemic occurs when a new viral subtype is generated by greater changes in
the virus, a subtype to which the human population has not had previous exposure. When the
new virus finds a susceptible population, epidemics can spread rapidly at the world level
among humans and can produce high mortality.
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The influenza virus should meet the following condition in order to result in a
pandemic:
• that it is capable of producing disease in humans;
• that the population is totally susceptible to the virus (that it does not have
previous immunity); and
• that the virus is capable of being transmitted efficiently and sustainably from
one person to another.
It is not possible to know when and where a pandemic will begin or which strain of influenza
will cause it or if the H5N1 virus currently in circulation will mutate so that it is transmitted
efficiently from one person to another. If H5N1 were capable of generating an influenza
pandemic, it is also not possible to know the severity that the new pandemic strain will show.
What is known is that never before there have so many opportunities to generate a pandemic
strain been documented, with so many cases in humans of infection by an avian influenza
virus. In addition, the H5N1 virus has already become an enzootic virus in Asia and Africa,
increasing the opportunities for human infection and the risk of emergence of a pandemic
strain.
Based on information provided by countries during training workshops in the use of
statistical packages for epidemic modeling developed by the CDC, (6)(7) PAHO has
estimated that, in a scenario of moderate severity—such as observed in 1968—a first
pandemic wave of 8 weeks of duration and 25% clinical case rate would produce, on
average, a potential pandemic impact equivalent to 334,163 deaths, 1,461,401
hospitalizations, and more than 76 million outpatient visits throughout Latin America and the
Caribbean. (8) The impact of such a pandemic wave on hospital capacity would reach its
maximum around the fourth to fifth weeks of the pandemic, with nearly 43,600 daily
hospitalizations, using 84% of installed capacity. In this scenario, the capacity of intensive
care units and respirators would be passed after the second week of the pandemic. These
estimates, of a conservative character, show the vulnerability of the healthcare services of the
Region of Latin America and the Caribbean to an influenza pandemic.
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This scenario makes necessary the early detection of the circulation of any virus with
pandemic potential for immediate adoption of control measures aimed at containing its
circulation. To meet this increased risk, the countries have developed, as a first step, National
Preparedness Plans for an Influenza Pandemic.
References:
1. The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza
A/H5. Avian influenza A (H5N1) infection in human. N Engl J Med 2005; 353:1374-85 [Erratum, N
Engl J Med 2006; 354:884.]
2. The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza
A/H5. Avian influenza A (H5N1) infection in human. N Engl J Med 2008; 358:261-273.
3. WHO. (http://www.who.int/csr/disease/influenza/vaccinerecommendations/en/)
4. WHO. (http://www.who.int/wer/2005/wer8033.pdf)
5. WHO.http://www.paho.org/Spanish/AD/FCH/IM/GTA16_2004_FinalReport_Spa.pdf).
6. Meltzer MI, Shoemake HA, Kownaski M, Crosby R. 2000. FluAid 2.0: Software and manual to aid
state and local-level health officials plan, prepare and practice for the next influenza pandemic (beta
test version). Centers for Disease Control and Prevention. [Online]. Available at:
http://www.cdc.gov/flu/tools/fluaid/ [accessed 1 May 2007].
7. Zhang X, Meltzer MI, Wortley P. 2005. FluSurge 2.0: Software and manual to aid state and local
public health officials and hospital administrators in estimating the impact of an influenza pandemic on
hospital surge capacity (beta test version). Centers for Disease Control and Prevention. [Online].
Available at: http://www.cdc.gov/flu/tools/flusurge/ [accessed 1 May 2007].
8. Mujica OJ, Oliva O, dos Santos T, Ehrenberg JP. Pandemic influenza preparedness: regional planning
efforts; In: Institute of Medicine (IOM) 2007. Ethical and Legal Considerations in Mitigating
Pandemic Disease. Workshop Summary. The National Academies Press; Washington DC.
7. INTERNATIONAL HEALTH REGULATIONS - 2005
International Health Regulations 2005 (IHR-2005) is a set of linked legal instruments
adopted by the Member States of WHO to contain the threats of diseases likely to spread
rapidly from one country to another, including emerging infections such as the Severe Acute
Respiratory Syndrome (English acronym SARS) or a new human influenza virus.
Furthermore, the regulations encompass other public health emergencies with possible
transborder impact, such as spills, leakages, or effluents of chemical products or nuclear
accidents.
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IHR-2005, in effect from 15 June 2007, comes from an updating of IHR-1969, which only
referred to four diseases -- cholera, plague, yellow fever, and smallpox (now eradicated) --
and contained general provisions for border control and relatively passive measures of
reporting and control..
The review in 2005 resulted in an unprecedented international agreement for public health
that foresees containment of health emergences at the point of origin where the incident is
located and not only at national borders. The new regulation encompasses all diseases and
health-related events that can constitute a public health emergency of international concern.
IHR-2005 also requires all the Member States to strengthen their capacities for surveillance
and response (Annex 1: figure 1, actions 2-5). PAHO/WHO is collaborating closely with
Member States providing them with technical guidance, especially for development of
adequately trained human resources and quality health systems infrastructure and services.
7.1 NECESSARY BASIC CAPACITIES FOR SURVEILLANCE AND RESPONSE
IHR-2005 contains a series of procedures for management of events that represent a public
health threat of international concern as well as basic requirements for national systems for
disease surveillance and response. These core competencies include the ability to detect,
investigate, confirm, communicate, and intervene in events or diseases, defined in part A of
Annex 1 of the Regulation.
7.2 IHR-2005 AND THE RISK OF A HUMAN INFLUENZA EPIDEMIC
In accordance with IHR-2005, all cases of the following diseases, smallpox, poliomyelitis
(by wild poliovirus), SARS, and human influenza caused by a new virus subtype, should be
reported immediately to PAHO/WHO. Reporting also includes the detection of influenza in
birds.
7.3 OPERATIONAL ASPECTS OF IHR-2005
IHR-2005 introduces new operational concepts, namely:
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• Specific procedures for monitoring of events and risks to public health at national
level and for reporting to WHO.
• PAHO/WHO request for verification of public health events that occur in the
countries
• Rapid risk assessment in collaboration with the countries and delivery of assistance to
them.
• Determination if an event constitutes a public health emergency of international
concern.
• Coordination of international response.
7.4 PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN
According to IHR-2005, a public health emergency of international concern is understood to
be an extraordinary public health event when, through specific procedures, it has been
determined that:
• It constitutes a hazard for public health of other states because of the international
spread of a disease, and;
• It could require a coordinated international response.
In order to facilitate timely and adequate communication with PAHO/WHO with regard to
possible public health emergencies of international scope, IHR-2005 contains in Annex 2 a
decision-making tool (Annex 1: see figure No.. 2) that establishes the parameters for
reporting by a national government to PAHO/WHO of all events that can constitute a public
health emergency of international concern, on the basis of the following criteria:
• Severity of the public health impact of the event;
• unusual or unexpected character of the event;
• possibilities of international spread of the event, and/or;
• risk of restrictions to travelers or to trade because of the event.
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In order for this tool to be used appropriately by the national government, it is required that
the network of epidemiological surveillance set up by the health services fulfill the functions
of early detection of events and immediate communication to the higher levels of each
country.
References:
1. Text adapted from information available at:
http://www.who.int/topics/international_health_regulations/es/ and
http://www.who.int/csr/ihr/es/index.html
2. The complete IHR is available at: http://www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_3-sp.pdf
3. For additional information on the Region, consult the PAHO website at:
http://www.paho.org/spanish/ad/dpc/cd/EER-IHRS.htm
8. PREPARATIONS FOR AN INFLUENZA PANDEMIC
Disturbances caused by influenza pandemics are often compared with natural disasters, but it
is probable that a pandemic causes effects that are both widespread and continuous and,
consequently, can rapidly exhaust rapidly national-level resources. The possibility that a
strain of such characteristics may arise underlines the need for all countries to prepare a
National Influenza Pandemic Preparedness Plan (NIPPP).
[stop here] The objective of preparing and implementing a NIPPP is to plan and implement
the national response to a pandemic, so that countries are prepared for detecting and handling
the effects of an influenza pandemic. Planning can help reduce transmission of the pandemic
virus strain; diminish the number of cases, hospitalizations, and deaths; maintain essential
services; and reduce the economic and social impact of a pandemic.
In the WHO Global Influenza Preparedness Plan (1) announced in 2005, WHO establishes 6
phases of increasing risks to public health caused by the appearance of a new subtype of the
influenza virus that could represent a pandemic threat. For each one of these phases, WHO
recommends measures to national authorities and describes the measures that WHO would
adopt to improve international coordination and transparency in application of the measures
at the national level. The Global Plan provides guidelines for preparation of the NIPPP
according to these phases. Every phase is associated with national and international public
health measures. The national measures during every phase are subdivided in turn according
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to the epidemiological situation of the country. In accordance with this definition, in April
2008, WHO observes that the world is in phase 3 of pandemic risk.
Table 1: WHO Pandemic Risk Phases
Interpandemic
Phase 1 No new subtype of human influenza. Low risk of infection
by virus circulating in animals
period
Phase 2 No new subtype of human influenza. New virus
circulating in animals represents a risk for humans
Period
Phase 3
of Human infection with a new subtype but without
transmission from person to person
Pandemic Alert
Phase 4 Small clusters of cases with limited transmission from
person to person
Phase 5 Larger clusters of cases with transmission from person to
person still localized
Pandemic Period Phase 6 Pandemic: increased and sustained transmission in the
general population
Since 2005, PAHO has been supporting the countries of Latin America and the Caribbean in
the preparation, evaluation, and implementation of their NIPPPs. At the same time, PAHO
has supported the countries in strengthening basic capacities required by IHR-2005. These
capacities include establishment of early warning systems within the countries that improve
their capacity to detect events that can represent public health threats, through expanding the
goals of surveillance and through strengthening of the existing virological surveillance
network. In addition, technical cooperation has aimed at strengthening mechanisms for
response to any public health emergency, which has included the training, preparation, and
equipment of rapid response teams in all the countries of the Region of the Americas.
PAHO technical cooperation has as goals that every country have a national pandemic
preparedness plan complying with the requirements of the WHO checklist (2) and that
these plans be implemented at national, sub-national, and local levels. In addition, the plans
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should be validated with simulations and drills at all administrative levels. In April 2008, all
the countries of Latin America and of the Caribbean were actively involved in activities to
prepare for an influenza pandemic and the vast majority had a NIPPP. Following the
orientations of WHO, the NIPPP should include specific actions for each phase,
classified into five categories: 1) planning and coordination; 2) monitoring and
evaluation of the situation; 3) prevention and containment; 4) response by the health
system; and 5) communications.
References:
4. OMS. Plan mundial de la OMS de preparación para una pandemia de influenza 2005
http://www.paho.org/spanish/ad/dpc/cd/vir-flu-plan-mundial-oms.htm
5. OMS. Lista de verificación de la OMS del plan de preparación para una pandemia de influenza
http://www.paho.org/Spanish/AD/DPC/CD/vir-flu-oms-lista-verificacion.htm.
9. INFLUENZA SURVEILLANCE
Influenza surveillance has as its principal objectives:
1. Identifying the seasonal strain of the virus that is circulating in a country or
region, for the purpose of determining the composition of and preparing the
seasonal vaccine.
2. Detecting early on the presence of a strain with pandemic potential and
implementing the pertinent control measures.
In order to meet these objectives the Generic Protocol for Influenza Surveillance (1)
establishes the following means of surveillance:
• Sentinel Surveillance of Influenza-Like Illness (ILI) and of Severe Acute Respiratory
Infections (SARI), in localities strategically selected by the Ministry of Health of
every country. Sentinel surveillance of ILI is carried out for ambulatory patients, and
monitoring of SARI for hospitalized patients. This should include usual and unusual
or unexpected forms, in addition to associated deaths. The objective of this form of
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surveillance is to provide data for determination of the epidemiological characteristics
of the influenza, to guide the policies and levels of action for prevention and control
of the disease.
• Enhanced nationwide surveillance is carried out in all the healthcare facilities of the
country and represents an improved system for reporting surveillance of notifiable
diseases, that is, with the sensitivity required to detect a case of unexpected or
unexpected acute respiratory infection.
Surveillance of:
• Influenza-Like Il ness (ILI) in outpatients
Sentinel
• Severe Acute Respiratory Infection in
S ur
en
veillan ce
Hospitalized SARI Patients
• Mortality due to SARI in hospitalized Patients
Surveillance (Investigation) of
Clusters/Cases:
Nation Wide
• Unusual or Unexpected SAR
I Cases
Enhenced
•
Suveillance
Mortality due to inusual SARI, in hospita
lized Patients
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The need for using different mean of surveillance comes from the fact that the clinical
manifestations of influenza are very variable, from a case without apparent infection up to
complications such as pneumonia, which can evolve to severe cases of respiratory distress
syndrome and death. Patients with SARI usually require hospitalization while patients with
ILI are treated on an outpatient basis.
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Sentinel influenza surveillance is in operation in the majority of countries. This course is aimed
at preparation of medical and auxiliary personnel of healthcare facilities to carry out enhanced
nationwide surveillance. The distinctive characteristic of the latter is that it focuses on patients
with unusual manifestations of SARI of greater severity and on deaths of people who show a
pattern of febrile acute respiratory infection, of an unknown cause.
9.1 DEFINITION OF ILI , SARI, AND CONFIRMED CASE OF INFLUENZA
Influenza-Like Illness (ILI):
→
Patient of any age with sudden appearance of fever higher than 38 ° C AND
→
Cough or sore throat
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Sever Acute Respiratory
Infection, SARI :
In the case of individuals ≥ 5 years:
→ Patient of any age with sudden appearance of fever
higher than 38° C and
→ Cough or sore throat AND
→ Dyspnea or difficult breathing AND
→ Need for hospitalization.
For children under 5 the case definition has been adopted from the integrated
management of childhood illness program (IMCI):
• Any child under 5 in whom there is clinical suspicion of the presence of
pneumonia or pneumonia which is severe or very severe, and who
requires hospitalization.
Every child suspected of pneumonia presents:
• Fever (temperature >38 C) and
• Cough or difficult breathing.
Difficult breathing is considered to be:
• Before 2 months old,: more than 60 breaths per minute;
• 2 to 11 months old: more than 50 breaths per minute;
• 12 months to 5 years old: more than 40 breaths per minute
Every child with severe pneumonia presents:
Suspicion of SARI is based on symptoms and clinical signs; a chest X-Ray is not
necessary for considering a case to be suspicious.
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Confirmed case of influenza
Any case with positive results for the influenza virus in laboratory tests.
Table summarizing Sentinel Surveillance and Enhanced Nationwide Surveillance.
Sentinel Surveillance
Enhanced Nationwide Surveillance
ILI e SARI
Unusual or unexpected SARI
The case definition is broader. These are all The case definition is more specific. This
cases of ILI and SARI
could include a single case or clusters of
outbreaks of unusual and unexpected SARI,
or show epidemiological characteristics
suggesting infection with a new influenza
strain.
Healthcare facilities strategically selected by All public and private healthcare facilities
a Ministry of Health
Systematic nasopharyngeal specimen
Systematic sampling of nasopharyngeal
sampling for influenza research
specimens for research on influenza in any
unusual case of SARI.
Useful for estimating the disease burden.
Indispensable for early detection of
Serves to isolate the virus for determining
pathogens with pandemic potential and the
the composition of the seasonal vaccine.
timely establishment of response measures.
Can detect circulation of atypical viruses Supports implementation of International
with pandemic potential
Health Regulations 2005.
9.2 ENHANCED NATIONWIDE SURVEILLANCE
9.2.1 Introduction
This module for Enhanced Nationwide Surveillance is based on three documents: the
Generic Protocol for Influenza Surveillance developed by PAHO and the CDC, the
Guidelines for Investigation of Human Cases of Avian Influenza from WHO, and
International Health Regulations 2005.
According to the Generic Protocol for Influenza Surveillance, early detection of all
outbreaks of unexpected or unexpected respiratory infections is essential for effective
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application of control measures aimed at limiting morbidity and mortality. An effective
system for surveillance of infectious diseases should have the capacity to detect and
respond to outbreaks of human influenza and atypical respiratory infections. Furthermore,
early detection of sustained person-to-person transmission of a virus with pandemic
potential is crucial for application of control measures designed to interrupt or stop the
spread of the disease.
An Enhanced Surveillance System for notifiable diseases (nationwide surveillance) can
provide an early warning for respiratory disease outbreaks with pandemic potential. Such
a system requires that there be general awareness of the factors that should trigger a
report and an effective report mechanism. (1)
This Module has been developed as a tool to facilitate compliance with International
Health Regulations (IHR) with respect to detection of influenza in humans caused by
a new subtype. Its purpose is to respond to the need to protect world public health.
As the following figure shows, the focus of this module is Enhanced Nationwide
Surveillance, corresponding to those cases with unusual and atypical manifestations of
SARI of greater severity and with deaths of people with symptoms of febrile acute
respiratory infection, from an unknown cause.
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The central subject of this module is unusual or unexpected cases and clusters of SARI.
The terms "unusual" or "unexpected" are used in IHR-2005 to distinguish those events
that deserve particular attention from national surveillance systems, so that they can be
evaluated and it can be determined whether or not they constitute events of international
concern. For enhanced nationwide surveillance, these are events that trigger further
investigation, as noted below. In order to further clarify the terms "unusual" and
"unexpected," several examples and specific situations are included, illustrating the
objective of enhanced nationwide surveillance.
An unusual case is one that is different, atypical, unusual, or uncommon and should
always be regarded as a warning signal for the professional to initiate a report; take a
sample for early diagnosis, and undertake immediate infection control measures.
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Another unusual situation is the emergence of cases of SARI at an unexpected time of
year or outside the normal season. This means that if, for example, the normal seasonal
influenza peak is at the end of spring and the beginning of winter, and cases increase in
the fall, this fact should cause us to pay attention.
An unexpected or unexpected event, according to IHR-2005, is caused by a disease or an
agent that was already eliminated or eradicated or not previously reported, such as a case
of avian influenza in humans.
9.2.2 Objectives of enhanced nationwide surveillance
Detection
• Detection on a timely basis of unusual or unexpected cases of SARI.
• Detection on a timely basis of clusters of SARI.
• Excess of cases of SARI.
Reporting
• Immediate reporting of unusual or unexpected cases or clusters of SARI to local
and/or national authorities for mobilization of the rapid response team according to
established national procedures.
Research
• Collaboration in epidemiological research, including active search for additional
suspect cases in the community, and in the initial control of the outbreak, when this is
required.
9.2.3 Early detection of unusual or unexpected SARI
Healthcare facility personnel should be alert to unusual, uncommon, or unexpected
diseases (including respiratory infections linked with epidemiological factors, for
example, clusters of SARI, cases of SARI related to travel or exposure to sick animals),
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in order to report these immediately to public health authorities and so that control
measures can be taken in a timely fashion.
There are many diseases that can manifest themselves as SARI. Among the principal
etiologic agents we have viruses, followed by bacteria. The figure below illustrates the
most common diagnoses:
9.2.4 Triggering Factors for Investigation (1) (2) (3)
Healthcare workers should be attentive to the appearance of unusual cases of severe acute
respiratory infection, since these constitute triggering factors for investigation, as noted
below:
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• Unusual (atypical or uncommon) cases of SARI
Definition of unusual (atypical or uncommon) cases of SARI:
→ In healthcare workers or others exposed in a work context who develop
unexplained SARI after close contact with people (live or dead) with SARI of
uncertain origin or that results in a positive test for avian influenza virus.
→ In people who travel to areas of circulation of the avian influenza virus H5N1.
→ Cases in previously healthy young adults.
→ Deaths by SARI of unknown cause.
→ Any case that the professional considers as an unexpected or unusual case.
→ Any unexplained case of SARI in a person that works with birds.
• Clusters (outbreaks) of SARI
Definition of Clusters of SARI:
A cluster is defined as TWO or more people with manifestations of SARI or who
died of unexplained SARI, linked social or geo-spatially within a period of 2 weeks.
(2)
→ Clusters that include two or more members of a family, social nucleus or
workers at a given site. .
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• Excess number of cases of SARI
Definition of excessive number of cases of SARI:
When the number of cases of SARI exceed the number expected for the healthcare
facility, or occur within a short time period.
This is a parameter that healthcare facilities should monitor. For this purpose, it is
necessary for the healthcare facility to have a time series, of 5 years or more, of the
number of cases hospitalized for SARI per epidemiological week. Based on these data, it
is possible to construct the endemic range for defining the epidemic threshold. Thus one
can see if the number of cases fall within the expected range or not, for the time period
being evaluated. The rate of SARI cases per epidemiological week in proportion to the
total number of hospitalized patients is one of the parameters most used for this
surveillance (% of SARI hospital cases, per epidemiological week). Another important
parameter is the rate of deaths by SARI in proportion to total deaths for the healthcare
facility (5). Annex 3 includes some rates used for monitoring SARI in the healthcare
facility. .
The epidemiological week is the time unit for reporting, tabulation, and analysis and
is established on the basis of the epidemiological schedule for each year. Once the data
have been collected and analyzed on the basis of the weekly trend, information is
generated that allows early detection of clusters for adults and children who require
medical care for SARI and reporting of an epidemiological alert. Some models for forms
to capture the data collected in routine surveillance for SARI and deaths by SARI in a
healthcare facility are found in Annex 4.
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Epidemiological history to investigate for confirming a suspicion of avian influenza:
(1) (2) (3)
[Any of the following events must be reported and an investigation begun to identify
changes in the agent or in the host and confirm its etiology. Patients with SARI who have
a background that strongly indicates possible exposure to the avian influenza virus A,
within seven (7) days prior to the appearance of symptoms, are the ones that:1 :
• Travel or reside in an area affected by influenza outbreaks in birds or other animals
(especially if they have visited livestock establishments, farms, markets for meat or
live animals or have participated in game hunting activities).
• Have a history of direct contact with animals, especially dead or sick birds, in an
affected area
• Indicate possible occupational exposure to animal products or products of animal
origin,2 including work as a butcher, veterinarian, a worker in a livestock
establishment, laboratory technician, worker in a storage or transport facility, or a
poultry worker who has been in contact with domestic fowl presumably infected by
virus H5N1, or an outbreak of SARI among poultry workers.
• Consumption of products originating from domestic or wild birds, either raw or
cooked (for example, meat, eggs, blood, liver)
Laboratory confirmation of a human case of avian influenza (H5N1), for example,
should immediately trigger a full investigation.
Epidemiological surveillance also should begin to investigate rumors:
1 It is necessary to point out that human cases of infection by influenza A (H5N1) have been diagnosed in some
areas in which there had been no previous notice of disease or death in birds..
2 Certain types of exposure imply greater risk: plucked birds, slaughtered birds, cooked birds, cleaning of cages,
living together in the home, handling of excrements used as fertilizers, etc.
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• Unofficial reports of respiratory infection outbreaks have demonstrated usefulness
in early identification of cases. Healthcare workers should be alert to such
information, which can come from communications media, the public, other
professional groups, and laboratory staff.
Other triggering factors for investigation of outbreaks can be clusters of animal deaths or
excessive absenteeism at schools and work places.
In summary, the triggering factors for an investigation, beginning with cases
detected in health facilities, are:
→
Unusual cases of SARI;
→ clusters of SARI;
→ excess number of cases of SARI..
Error! Bookmark not defined.
It is important to point out that investigation should begin immediately,
without waiting for confirmation of laboratory results identifying the causative
agent.
In situations of unusual or unexpected SARI, there should be an active search of clinical
histories to detect additional cases, as well as death notices for deaths caused by
respiratory disease in the previous period of a month or more. Always investigate travel
and other activities that took place in the 10 days preceding the appearance of symptoms.
It is important to involve all healthcare facility professionals, so that all are alert to the
appearance of new cases for them to be reported and investigated immediately.
An essential element for success of epidemiological surveillance, early detection, and
setting up control measures, is strengthening basic capacities in healthcare facilities in
these matters. One should also add the need for integration in the healthcare facility of
healthcare workers and epidemiological and laboratory professionals.
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9.3 IMPORTANCE OF HOSPITAL EPIDEMIOLOGICAL SURVEILLANCE
Both public and private hospitals are entry points into the health system, that are
important for detection of serious or unusual cases, of emerging diseases, and of
outbreaks, as well as of severe acute respiratory infection. Hospitals constitute the
principal location for detection of cases of unusual or unexpected respiratory infections,
with the possibility of pandemic potential. Thus, professionals who work in these
establishments should know the procedures required to respond to these cases, from
adequate treatment to complying with biosafety standards; immediate reporting; research
on risk factors; investigation of cases among family members, and collection of
laboratory samples, in order to make it possible for health authorities to take appropriate
control measures. Similarly, health authorities should get continuous updating from
hospital personnel on disease outbreaks and other risks occurring in the population.
9.3.1 Entry Points for Hospital Cases
The principal entry points for cases of SARI are the first aid and emergency units, from
which patients are referred to intensive care or intermediary units. All staff of these areas
should receive training on procedures to follow with these cases. All unusual events, not
only with respect to respiration, but also hemorrhagic symptoms of jaundice, or
neurological systems, should also be reported immediately to the corresponding
health authorities. In case of death of a patient without samples having been collected of
material from the oro/nasopharynx and of blood, blood samples and tissue biopsies
should be carried out when possible for the purpose of laboratory investigation of the
case and contact should be established immediately the unit responsible for local
epidemiological surveillance.
It is important to stress that adoption of measures for the interventions to follow
should be simultaneous. This means that reporting, proper management, and taking
samples should be carried out upon detection of the case or cases.
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9.4 NOTIFICATION
Immediately report to local and/or national authorities for mobilization of rapid
response teams:
→ Unusual cases of SARIs;
→ clusters of SARI;
→ excess cases of SARI.
FLOW OF REPORTS
• The healthcare facility should immediately report to the appropriate local authorities any
case or cluster of SARI that is determined to be unusual or unexpected. This report
should rapidly trigger epidemiological investigation by the epidemiological surveillance
rapid response team.
• Reporting unusual or unexpected SARI should follow the channels of information flow of
the national surveillance system. The information should pass from the healthcare facility
where it is generated up to the appropriate authorities at the central level (commonly the
epidemiology department of the Ministry of Health), following the established channels
of national surveillance for transmission of information and research.
Follow guidelines established at the national level for the flow of reports and
investigation by the rapid response team.
INVESTIGATION OF AND ACTIVE FINDING OF SUSPECT CASES
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This action is a responsibility of health secretariats at the level of the municipio, but
when the healthcare facility treating the patient is the only healthcare unit in the
municipio, it will have the responsibility for initiating epidemiological investigation,
including active case-finding of additional suspect cases and initial control of the
outbreak.
Initiating an investigation to identify additional cases beyond immediate contacts is
fundamental for prevention and control of infection. The search for active cases should
concentrate on:
• people that may have been exposed to the same source as that of the cases
identified;
• people with exposures to animals, especially sick birds;
• people with unexplained SARI or people who have died of a unexplained febrile
respiratory disease.
The strategy for case-finding in the area under investigation can focus on the community,
through house-to-house visits (carried out by municipal surveillance) or on institutions,
through telephone surveys of healthcare facilities, private physicians, and laboratories, or
through review of records.
There should also be prepared a record of all co-exposed contacts and people, with
demographic information, date of last exposure or date of contact with the case.
During the investigation, it is fundamental to prepare daily reports on the situation and
establish effective and timely communication with relevant authorities at local and
national level, and with other stakeholders (for example, the public and the
communications media).
References:
1. OPS-CDC. Protocolo genérico para la vigilancia de la influenza, 2006.
2. World Health Organization. WHO guidelines for investigation of human cases of avian influenza
A (H5N1). 2006. revised in 2007.(Accessed 9 April 2008, at
http://www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_4r1.pdf)
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3. WHO. Alerta epidémica y respuesta. Plan mundial de la OMS de preparación para una pandemia
de influenza. Función y recomendaciones de la OMS para las medidas nacionales antes y durante
las pandemias. 2005.(Accessed 9 April 2008, at http://www.paho.org/spanish/ad/dpc/cd/vir-flu-
plan-mundial-oms.pdf)
4. Centers for Disease Control and Prevention (CDC). Case studies in applied epidemiology.
Influenza A(H5-N1) in humans: Surveillance and case management (international setting),
December, 2007.
5. Centers for Disease Control and Prevention (CDC). FLU VIEW, a weeky influenza surveillance
report prepared by influenza division. (Accessed 9 April 2008 http://www.cdc.gov/flu/weekly/)
10.
LABORATORY
SARI can be caused not only by the influenza virus but also by other viruses, such as
respiratory syncytial virus (RSV), Parainfluenza subtypes 1, 2 and 3 and Adenovirus.
SARI can also be of bacterial origin. The only way of knowing with certainty the etiology
of a case of ILI or SARI is by means of laboratory diagnosis.
Laboratory diagnosis of influenza is an important public health tool, for prevention,
surveillance, containment, and therapeutic management. It is also required for identifying
the circulation of the influenza virus and formulating compatible vaccines.
The sensitivity and specificity of the diagnosis method for influenza will depend on
technical laboratory operation, the type of test used, and the specimen analyzed (the time
it is taken, the sample quality, and the sample origin).
10.1
Laboratory Tests for Diagnosis of SARI and Influenza
Samples of nasopharyngeal secretion and blood for serology and hemoculture should be
collected in all cases of SARI. Differential laboratory diagnosis of SARI is very broad.
(Annex 6)
For diagnosis of influenza, several characteristics of the specimen are very
important:
→ Collection of samples within the first 72 hours of onset of symptoms.
→ Adequate specimen collection procedures.
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→ Conditions of shipment and storage of samples before they are processed in
the laboratory
The virus influenza is replicated primarily in epithelial cells of the respiratory tract. For
this reason it is necessary to capture cells in taking samples of material and not only
secretion.
The most used respiratory specimens are:
→ Nasopharyngeal swab
→ Nasopharyngeal aspirate
→ Tracheal aspirate and broncoalveolar lavage are only used in special
situations, according to medical criteria.
Laboratory Tests (1)
• Indirect immunofluorescence
Samples are processed and are analyzed in the laboratory to detect the presence of viral
antigens (Adenovirus, Influenza virus of types A and B, Parainfluenza, and respiratory
syncytial virus) using the immunofluorescence test with monoclonal antibodies. The
sensitivity of this technique varies from 70% to 100% and its positive predictive value is
from 84% to 94%, reaching the maximum in periods of higher virus circulation. Ideally
this technique is carried out using level 2 biosafety practices. However, in suspected
cases of avian influenza, unusual or unexpected cases or outbreaks of SARI, the
processing should be at level 2 biosafety, applying level 3 practices at the national
reference laboratory. This is a test that can be carried out in some reference laboratories,
although in general it is carried out by the public health laboratory.
• Virus culture
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This is a method of high sensitivity and high utility for diagnosis of viral infections, when
the specimens are high-quality. This is the gold-standard laboratory test for influenza. It
can be carried out in a cell culture or in fertilized eggs. The test can give results in 2 to 3
days using immunological methods for reading the results, since immunofluorescence
with the conventional system can take from 7 to 10 days. The culture performed in
fertilized eggs allows isolation of the virus for vaccine production. The principal
advantage of viral isolation is that this method amplifies the virus of the initial material
and makes possible antigenic characterization with reference antibodies that is
indispensable for the selection of the virus for vaccination, as well as tests of antiviral
resistance antiviral. It is a test carried out in National Influenza Centers (NIC) or in the
Reference Centers for the Region.
• Molecular Techniques--Polymerase Chain Reaction (PCR)
The PCR detects genetic material of the virus that is present in clinical samples and in
viral cultures. The tests are based on amplification of the nucleic acid RNA. Another
technique used is RT-PCR (in real time), with a more rapid result, although few
laboratories are using this due to the cost of equipment. Sequence analyses of the virus
permit study of its evolution and of the mutations that modify the antigenic sites for strain
selection for the vaccine. This test is carried out in National Influenza Centers of
Influenza (NIC) or in the Reference Centers for the Region.
• Serological techniques
The technique used is hemoagglutination inhibition (HI). It requires two paired serum
samples from the patient (with 10 to 15 days difference among them). This allows
checking seroconversion for a given viral strain. The test is carried out making use of a
reference panel of antigens and antisera provided by the CDC.
• Rapid Influenza Test
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There are three types of tests, those that only detect influenza A, those that detect
influenza types A and B but do not distinguish between them, and those that detect
influenza A and B and distinguish between the two types.
These are useful to support the investigation of outbreaks and initiate antiviral treatment
within 48 hours of appearance of the symptoms Among the disadvantages are that they
do not permit identification of viral subtype and the fact that they have low sensitivity,
principally by comparison with viral isolation, which leads to results with false negatives
and high cost. In addition, this is a low-sensitivity test in comparison with viral isolation.
10.2
SAMPLING AND SHIPMENT TO THE LABORATORY (2)(3)(4)(5)
Collect samples of these cases, sending them to the laboratory in a proper and timely
way.
Important aspects for taking respiratory samples:
• Satisfy the definition of an unusual case of SARI
• Samples for isolation of respiratory viruses should always be taken. If possible
collected during the first 3 days from appearance of the symptoms.
• The sample should be taken before administering antiviral drugs.
• Several samples should be collected on different days.
• In children under 5, the ideal respiratory sample to take is that using the
nasopharyngeal aspirate technique.
• In adults and children over 5, the ideal respiratory sample is the nasopharyngeal
aspirate, since it is more effective. However, it can be obtained through
nasopharyngeal swab or nasal lavage. Directions for collection and management of
respiratory samples are found in Annex 7.
• After being collected, the sample should be kept in ice until placed in the refrigerator.
• If samples for viral isolation are going to be transported to the laboratory within 2
days, they should be kept at 4˚ C, and transported to the laboratory promptly.
Otherwise, the samples should be frozen to -70˚ C until they are transported to the
laboratory.
• Avoid freezing and thawing of samples. Annex 8.
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• The serum should be stored to 4˚ C for approximately a week but afterwards should
be frozen to -20˚ C (see more detail in Annex 7 and Annex 8). Group paired samples,
the 1st sample collected on the first 3 days and the 2nd sample during convalescence
(10 to 15 days after the 1st sample).
• It is important in these cases to take an additional serum sample (10ml of blood),
because of differential diagnosis with other pathologies.
References:
1.
World Health Organization WHO. Role of laboratory diagnosis of influenza.
2.
World Health Organization (WHO). Guidelines for collection of clinical specimens during field
investigation of outbreaks, 2000.
3.
Control Diseases Center (CDC). Rapid response for avian pandemic influenza. Module 5: Laboratory
Diagnostics, Specimen Collection, and biosafety issues. Training of trainers workshop Bangok,
Thailan July 17-21, 2006.
4.
World Health Organization (WHO). Guidelines for The storage and transport o human and animal
specimens for laboratory diagnosis os suspected avian influenza A infection. January 2005.
5.
World Health Organization (WHO). Guidelines for Collecting, preserving and shipping specimens
for the diagnosis of avian influenza A(H5N1) virus infection Guide for field operations, October
2006.
11. INFECTION CONTROL
11.1.
Principles of Infection Control
The model of the epidemiological chain with its three links, going from the infectious agent
up to the susceptible host, through a more or less simple transmission mechanism, helps in
understanding how infection occurs and also makes for rapid comprehension of the control
mechanisms available, by breaking any of the links of the chain.
• The first link is the infectious agent in the reservoir and/or source of infection.
• The second link of the epidemiological chain is the transmission mechanism.
Infectious agents leaving the source of infection reach the entry point to the
susceptible host through one or more transmission mechanisms.
• The third link is the susceptible host. When the infectious agent reaches the host, it
must find contributory mechanisms for producing the infection.
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11.1.1 Types of transmission
The types of transmission vary depending on the type of microorganism, and some can be
transmitted through more than one route. The three most important ways of transmission are:
• By Contact
Microorganisms are transmitted by direct or indirect contact with the patient or the
environment of the patient. Direct transmission occurs when microorganisms are
transferred from one person to another person without an object or a contaminated person
as intermediary. Indirect transmission includes transfer of an infectious agent through an
intermediary object or contaminated person. Precautions for contact also apply where
there is presence of excessive drainage from wounds, fecal incontinence, or other
discharges from the body that have greater potential for environmental pollution and a
greater risk of transmission. In addition to transmission by droplets, some respiratory
pathogens, for example, parainfluenza and respiratory syncytial virus (RSV), can be
transmitted through contact; particularly contamination of the hands and auto inoculation
in the conjunctiva or the nasal mucous membrane. Transmission by contact can also play
a role in infections by SARS and avian flu A (H5N1).
• By Droplets
Transmission by droplets implies contact with the conjunctiva or with the mucous
membranes of the nose or mouth of a susceptible person, and droplets of particles that
contain microorganisms coming from a person who has a clinical disease or is a carrier of
a microorganism. Droplets are generated mainly in the person-source when the person
coughs or sneezes or during conversation. Droplet transmission requires close contact
between the source person and the receptor person, because droplets do not remain
suspended in air and usually only travel short distances (approximately three feet or 1
meter) through the air. Respiratory pathogens that are transmitted through droplets include
adenovirus, human flu, SARS, and avian flu A (H5N1).
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Based on epidemiological patterns of transmission of the influenza virus, transmission
by droplets has been considered to be the most important transmission route.
• By air (aerosols)
Pathogens transmitted through the air are transmitted through inhalation of droplet nuclei
that continue to be infectious over a great distance (more than 1 meter), and require
special systems of air management and ventilation (for example, negative pressure
rooms). Their transmission is classified as: required airborne transmission,
Mycobacterium tuberculosis that causes lung tuberculosis and preferential airborne
transmission, referring to respiratory pathogens that can also be transmitted through
other routes (for example, measles).
Under special circumstances, the transmission of droplet nuclei over short distances could
occur with human flu, and perhaps with other respiratory viral infections, for example,
during procedures that generate aerosols in rooms that are not adequately ventilated or
that do not make adequate use of personal protective equipment (PPE) (for example,
SARS). This type of transmission has been known as "opportunistic airborne
transmission," and is not the same as the classical airborne transmission that involves
transmission over a great distance.
11.1.2 Routine precautions for infection control
Standard Precautions
Standard precautions are routine precautions for infection control, which should be
applied for ALL patients, in ALL health contexts.
These have the purpose of minimizing the spread of infection associated with healthcare
and avoiding direct contact with blood, bodily fluids, secretions, and non-intact skin of
patients. The SARS outbreak in Hong Kong in 2003 illustrated the critical importance of
basic precautions for infection control in healthcare facilities. Generally the transmission
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of SARS in a healthcare facility is associated with lack of compliance with standard
precautions.
The threat of emerging respiratory infectious diseases implies that promotion of
standard precautions is more important than ever, and should be a priority in all
healthcare facilities.
Hand hygiene
Hand hygiene is one of the most important measures for preventing and controlling
spread of disease in health facilities and it is a principal component of the standard
precautions. Although it is a simple procedure, numerous studies have demonstrated that
compliance with hand hygiene is low. The use of alcohol-based hand solutions has been
implemented in health facilities in recent years in an attempt to increase compliance with
hand hygiene. The principal points are:
• Routine hand hygiene includes washing the hands with water and liquid soap
(avoid bar soap) and using an individual towel for drying (do not use hand dryer);
alternatively, if the hands are not visibly dirty, using an alcohol-based hand
solution with 60% or 70% concentration
• If the hands are visibly dirty or spotted with blood or other bodily fluids, or if
injured skin could have been exposed to potentially infectious material, hands
should be washed thoroughly with water and soap.
Indications for hand hygiene:
• Before and after direct care of a patient.
• Immediately after taking off gloves.
• Before handling an invasive device that does not require a surgical procedure,
including central intravascular catheters, urinary catheters, or peripheral vascular
catheters.
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• After touching blood, bodily fluids, secretions, excretions, non-intact skin, or
contaminated elements, even if gloves are used.
• When going from a contaminated body part to a clean body part of the same
patient, during patient care.
• After contact with inanimate objects in the immediate proximity of the patient.
• After using the bathroom.
11.1.3 Precautions based on the type of transmission
Diagnosis of many infections requires laboratory confirmation. Since diagnostic tests
often require two or more days for their results, precautions based on transmission
should be implemented while waiting for the results, based on the clinical
presentation and on possible pathogens. The use of appropriate precautions based on
transmission at the time that the patient develops the symptoms or signs of infection, or
upon arriving at the health facility, reduces the opportunities for transmission to others.
Precautions for contact, for droplets, and for airborne transmission are elaborated in detail
in the following section.
Discontinuation of precautions based on the type of transmission:
These precautions should remain in effect over limited periods (for example: while the
risk of transmission of the infectious agent persists or during the natural history of
disease). For the majority of infectious diseases this duration reflects known patterns of
persistence and elimination of the infectious agent associated with the natural history of
the infection and its treatment.
11.1.4 Use of Personal Protective Equipment (PPE)
PPE should be used in the context of other strategies for prevention and control, and
according to recommendations for infection control (for example, standard precautions
for contact, droplet, or airborne transmission).
• Appropriate training should be given on the use of PPE.
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o Provision of adequate supplies of PPE should be a national and institutional
priority.
o Recycling of disposable PPE should be avoided. It is not known whether using
disposable PPE again gives the same efficacy and safety of protection as using
new PPE, and recycling can increase the risk of infection for healthcare workers.
If resources are limited and disposable PPE is not available, one can use material that can
be reused (for example, cotton gowns that can be disinfected), and disinfect them
adequately after each use.
In order to avoid wastage, critically evaluate the situations in which PPE is indicated
using the analysis in Table 3, and take the maximum clinical precautions during each
visit to the room of a patient.
• Selection of PPE on the basis of risk assessment
o Routinely evaluate the risk of exposure to bodily substances or contaminated
surfaces before any planned healthcare activity.
o Select the PPE on the basis of the risk assessment.
o Have adequate PPE available for the case of an unexpected emergency.
• Gloves
o Gloves should be used whenever contact is foreseen with blood, bodily fluids,
secretions, excretions, mucous membranes, or non-intact skin. Change gloves
between tasks and procedures for the same patient.
o If the supply of gloves is limited, reserve them for situations in which there is
probability of being in contact with blood, respiratory secretions or bodily fluids,
including procedures that generate aerosols associated with a defined risk of
pathogen transmission.
o Carry out hand hygiene immediately after removing gloves.
• Protection of the face
o Use face protection, including a medical mask and protection for the eyes (safety
glasses, facial protectors) to protect the conjunctiva and mucous membranes of
nose, eyes, and mouth during activities that have a possibility of generating
splatters or aerosols of blood, bodily fluids, secretions, or excretions. When one is
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treating and is in close contact with a patient with respiratory symptoms (for
example, cough or sneezing), there can be sprays of secretions and ocular
protection should be used.
• Gowns
o Use gowns to protect the skin and to avoid soiling of clothes during activities with
a possibility of generating splatters or aerosols of blood, bodily fluids, secretions,
or excretions.
o Select a gown adapted for the activity and the amount of fluid that is expected. If
the gown being used is not resistant to liquids, a waterproof apron should be used
if splatter or sprays with potentially infectious material is expected.
o If the supply of gowns for health workers is limited, their use should be
prioritized for carrying out procedures that generate aerosols associated with a
defined risk of pathogen transmission and for activities that involve being close to
the patient (for example, in a pediatric environment), or when other prolonged and
direct contacts with the patient are anticipated.
• Medical masks
o Medical masks should remain adjusted to the face of the user and should be
discarded immediately after use. If the mask is soaked or soiled with secretions, it
should be changed immediately.
• Ocular protection
o Conventional glasses are not designed to protect the ocular mucous membrane
against splatters and should not be used as protection of the eyes.
o Reusable ocular protection equipment (for example, safety glasses, facial
protectors) can be used. However, this can pose a potential risk of cross infection
if they are not adequately cleaned and decontaminated after each use according to
the manufacturer's instructions. Cleaning should precede disinfection. Hand
hygiene should be carried out after discarding or cleaning ocular protection
equipment that may be contaminated with splatters or aerosols.
PPE has the purpose of giving protection to the user but should not produce a greater risk
for other individuals nor for the environment. PPE supplies can be limited and their
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recycling may be unavoidable, but recycling should be carried out in safety conditions.
Furthermore, unnecessary use of PPE should be avoided.
11.1.5 Handling of Corpses
Removal of body from the isolation room or area
According to standard precautions, use PPE to avoid direct contact with bodily fluids.
Cultural sensitivity is required. If the family of the patient wishes to see the body after it
has been taken from the isolation room or area, this can be permitted, applying standard
precautions.
11.1.6 Structure for Infection Control in the Healthcare Facility
Infection control strategies in healthcare facilities are generally based on the following
types:
• Reduction and elimination
Examples of reduction and elimination are promotion of respiratory hygiene and cough
etiquette as well as treatment to make the patient noninfectious.
• Management controls
These include establishment of infrastructures and activities for sustainable infection
control, clear policies on early recognition of SARI of potential concern, implementation
of adequate measures for infection control, among others.
• Environmental and engineering controls
The latter include methods for reducing the concentration of infectious respiratory
aerosols (for example, droplet nuclei) in the air: adequate environmental ventilation (≥ 12
ACH), spatial separation between patients (> 1m) between patients, reduction of the
presence of surfaces and contaminated elements according to the epidemiology of the
infection.
These types of control are closely interrelated. They should be integrated to promote an
institutional climate of safety, the basis of safe behavior.
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Summary of Key Aspects of Infection Control in Healthcare Facilities
1. Isolation, and limitation of movement of cases and limitation of visitors; by means of
identifying and separating patients by symptoms; hospitalize only the severe cases. Identify the
appropriate structure: good ventilation, a single process flow. Discontinue non-essential services.
2. PPE: at the very least, standard precautions; mask, gloves, gown, eye protection, if necessary,
depending on the type of pathogen and the type of exposure (expected risk).
3. Emphasize hand hygiene.
4. Emphasize cleaning, disinfection, and sterilization.
5. Appropriate management of waste, especially of contaminated material.
6. Protection for health workers and family members who take care of the patient: prophylaxis
when indicated (example, in case of contact without protection), health surveillance, education:
respiratory hygiene, hand washing, social distancing
7. Proper management of corpses
References:
1. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings, June 2007, Centers for Disease Control and Prevention, Atlanta, Georgia. Siegel JD,
Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory
Committee, 2007
2. Infection Prevention and Control of epidemic- and pandemic-prone acute respiratory diseases in
health care, WHO Interim Guidelines. WHO/CDS/EPR/2007.
3. Control de infección. Precauciones estándar. Política de aislamientos, Infection control. Standar
precautions. Isolation policy, T. Rubio, J. García de Jalón, F. Sanjuan, M.A. Erdozain, J.I. Sainz
de Murieta, E. Escobar Anales, Universidad de Navarra, Spain 2000.
11.2
SPECIFIC PRECAUTIONS FOR UNUSUAL OR UNEXPECTED SARI
These guidelines concentrate on infection prevention and control measures of respiratory
infections that:
• cause acute respiratory tract infection, including pneumonia and acute respiratory
distress syndrome;
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• cause severe diseases in susceptible people with apparently normal immune
systems;
• can constitute a public health emergency of international concern as defined by
IHR-2005.
The fundamentals of infection control in care of patients with unusual or unexpected
SARI include:
• Early and rapid recognition of suspected cases.
• Application of standard precautions for infection control.
• Additional precautions in selected patients (on the basis of the presumed diagnosis).
• Establishing an infection control infrastructure for healthcare facilities.
11.2.1 Early recognition, isolation, reporting, and surveillance of episodes of unusual
or unexpected SARI:
These are extremely critical activities for preventing dissemination of unusual or
unexpected SARI, which have been widely covered in other sections. This section
focuses on prevention and control measures that are applied as soon as the suspected case
is identified. :
• Action algorithm: This should be established and be known to all staff who work
in entry points for patients into the healthcare facility, to ensure early recognition
and proper management of people with possibilities of having a SARI of epidemic
or pandemic potential.
• Rapidly strengthen infection control precautions when there is a suspicion of
an unusual or unexpected SARI (see Table 3).
• Isolation: all patients with suspicion or confirmation of an unusual or unexpected
SARI should be located in a room or area separated from other patients and be
evaluated as rapidly as possible.
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• During care prior to hospitalization and during transportation of these
patients there, procedures that generate aerosols should be avoided, since they
are associated with a defined risk defined of pathogen transmission (for example,
intubation), unless this is clinically necessary to preserve life. During transportation,
optimize ventilation in the vehicle to increase the volume of exchange of air (for
example, opening the window). Whenever possible, use vehicles that have separate
compartments separated for driver and patients.
The principles of infection control are the same throughout the entire sequence of
healthcare. Areas that require particular attention are the following:
Emergency and Outpatient Care Areas.
For these the following is recommended:
• Put up notices to alert people with severe acute febrile respiratory disease to
report it immediately to healthcare personnel and implement the respiratory
hygiene and cough etiquette:3
• Evaluate patients with acute febrile respiratory disease as rapidly as possible.
• Consider processing outpatients with acute febrile respiratory disease in different
locations than other patients, either totally separated, or at least ≥ 1 m (3 feet)
between every patient in the waiting room.
• Provide paper handkerchiefs in the waiting room for containing respiratory
secretions from coughing or sneezing whenever possible. Provide receptacles for
discarding used handkerchiefs (if possible, receptacles that do not need to be
touched).
• If possible, provide masks for people with acute febrile respiratory disease when
they are admitted, but if these are not available, alternatives may be used to
replace them
3 http://www.cdc.gov/flu/protect/covercough.htm
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• Promote hand hygiene after contact with respiratory secretions and provide
facilities for hand hygiene (for example, washstands equipped with water, soap
and disposable towels, alcohol-based solution with a concentration of 60% to
70%) in the waiting rooms, if possible.
• Eliminate or reduce the use of objects shared by patients, such as pens, paperclips,
telephones, etc.
• Make sure that equipment used for patient care is cleaned and disinfected between
patients.
• Healthcare workers should implement standard precautions and droplet
precautions when providing care, in close contact, to patients with acute febrile
respiratory disease.
• If a patient with confirmation or suspicion of being infected with a SARI of
epidemic or pandemic potential is referred to another healthcare facility, report
this to the reception personnel at the healthcare facility so that necessary
precautions can be taken for infection control.
If it is known that there have been cases of unusual or unexpected SARI admitted at
the facility or in other healthcare facilities in the area, in addition to the previous
measures, also implement the following:
• Establish criteria for triage for rapidly identifying people having a risk of infection
with an unusual or unexpected SARI.
• If there is suspicion of an unusual or unexpected SARI, the healthcare worker should
use the appropriate PPE (see Table 3), depending on availability.
• High-risk procedures that generate aerosols in patients with SARI should not be
carried out in an outpatient environment, unless it is necessary for saving life and
there is no alternative.
• If such as procedure is carried out, it should be in a separate and well-ventilated
room, and the healthcare worker involved should use adequate PPE.
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• After a patient with confirmed or suspected unusual or unexpected SARI has left the
outpatient care environment, clean and disinfect environmental surfaces in the
physician’s office or other areas where the patient was and clean and disinfect any
equipment used to treat the patient.
11.2.2 Isolation Precautions
When treating patients with SARI, adequate isolation precautions should be taken. In
addition to the application of standard healthcare precautions, other additional
precautions should be applied depending on:
• presence of epidemiological and clinical signs that suggest that patients have an
unusual or unexpected SARI;
• presumed or confirmed causative agents of SARI; and
• type of contact with the patient.
The majority of acute respiratory infections are transmitted mainly through droplets, but
in some cases other forms of transmission can have an important role. The type of
precautions for infection control should be adjusted accordingly (Table 3). Furthermore,
transmission of some of these infections has been associated with specific procedures
such as those that generate aerosols. The latter have the potential to increase the risk of
infection transmission. Greater personal protection is justified, at least for those
procedures with a documented increase of risk of infection transmission (see table 1).
11.2.3 Isolation and special measures for unusual or unexpected SARI
• Due to the risk of transmission, whenever possible suspect patients should be
isolated in individual rooms.
• When individual rooms are not available, groups of patients infected or colonized
with the same pathogen should be grouped in a single room or wing, whenever
possible, in order to implement isolation measures.
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• The number of people assigned to the isolation unit or area, or for special
measures, should be limited to the minimum necessary for care and support of the
patients.
• Whenever possible, the healthcare worker assigned to care for units with patients
with unusual or unexpected SARI or unexpected should be experienced and not
rotated or also assigned to other patient care areas. Monitoring the appearance of
symptoms similar to influenza in all healthcare workers exposed to these patients
is recommended, up to 7 to 10 days after the last possible exposure to a patient
with unusual or unexpected SARI (model Annex 10).
• Consider having designated portable X-ray equipment available in the assigned
areas.
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Table 1.
Procedures That Generate Aerosols:
In this document reference is made to implementation of the following procedures in patients with SARI:
• Intubation and related procedures (for example, manual ventilation, aspiration);
• cardiopulmonary resuscitation;
• bronchoscopy;
• surgery and autopsy.
Additional precautions for healthcare workers that carry out procedures that generate aerosols in patients
with SARI seem to be justified.
A.1.1 PPE for procedures that generate aerosols
The PPE should cover the torso, the arms, the hands, the eyes, the nose and the mouth, and should
include a long-sleeve gown, disposable gloves, ocular protection (for example, safety glasses,
facial protectors) and respiratory protection. The use of a cap for the hair is optional.
A particle respirator with at least N95 protection certified by the National Institute for Occupational
Safety and Health
(NIOSH), EU FFP2 or equivalent is the minimum level of respiratory
protection required for healthcare workers who carry out procedures that generate aerosols with
a greater documented risk of transmission of respiratory pathogens.
A.1.2 Environmental controls for procedures that generate aerosols
Carry out the procedure in an adequately ventilated individual room and far from other patients.
For patients with unusual or unexpected SARI who high-flow oxygen or ventilation with non-
invasive positive pressure, add an outlet with a filter for bacteria/virus (for example, HEPA
filter) to reduce emission of aerosols.
For the patients with unusual or unexpected SARI who receive ventilation with intermittent positive
pressure, filter filters for bacteria/virus (for example, HEPA filters) can be connected to the
respiratory support system, and, whenever possible, use a closed system for tracheal aspiration
to take up respiratory secretions.
ADDITIONAL PRECAUTIONS IN SELECTED PATIENTS (ON THE BASIS OF A
SUSPECT DIAGNOSIS)
11.2.4 Precaution
against
Droplets
Respiratory pathogens that are transmitted through droplets include adenovirus, human
flu, SARS and influenza type A (H5N1). During an influenza pandemic it is expected
that the circulating human virus will be transmitted just as seasonal influenza viruses, and
as a result droplet precautions should be applied in addition to standard precautions.
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Droplet precautions include:
• PPE: Use of a medical mask if working within a radio of 1 m around the patient.
For practical purposes, the use of a medical mask is recommended when entering
the room of a patient.
• Location of the patient: in individual rooms or groupings of patients with the
same etiological diagnosis. If a diagnosis of the etiology is not possible, patient
should be grouped by similar clinical diagnoses and on the basis of
epidemiological risk factors, with a spatial separation greater than or equal to 1
meter.
• Transport of patients: limit the transfer of patients; patients should use a
medical mask when outside their rooms.
11.2.5 Contact Precautions
In addition to droplet transmission, some respiratory pathogens [for example,
parainfluenza and respiratory syncytial virus (VRS), SARS, and influenza type A
(H5N1)] can be transmitted through contact; particularly contamination of the hands and
auto inoculation in the conjunctiva or nasal mucous membrane. Contacts precautions
include:
• PPE: (put on when entering the room and remove it when leaving)
• Gloves: Clean, non-sterile latex gloves should be used and discarded after
every contact with the patient. Change the gloves between tasks and
procedures for the same patient.
• Gown:
o One can use a disposable gown made of synthetic fiber, or a gown of
washable cloth. Ensure that gowns are of the size needed to completely
cover the areas to be protected.
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o Gown should preferably be used once and then placed in a receptacle for
waste or clothes to wash, as appropriate, and hand hygiene should be
observed.
o Aprons should only be used when the gown is permeable in order to
reduce penetration of fluids. They should not be used only for preventing
contamination by contact.
• Equipment and environment
o If possible, use disposable equipment or instruments or designate
instruments such as stethoscopes, blood pressure cuffs, thermometers, etc.,
for patients for whom contact precautions are being applied. If it is
necessary to share the equipment among patients, it should be cleaned and
disinfected after use with each patient.
o Healthcare workers should avoid touching their eyes, nose, or mouth with
their hands with or without gloves, since these potentially be
contaminated.
o Avoid contaminating environmental surfaces that are not directly related
to patient care (for example, door handles, light switches).
• Location of patients: using individual rooms or forming groups of patients with the
same etiological diagnosis can facilitate implementation of infection control
measures. In rooms with multiple patients, maintain a spatial separation of at least 1
meter between the beds.
• Transport of patients: limit the transfer of patients; contact with uninfected people
should be minimized.
11.2.6 Prevention of Airborne Transmission
For pathogens transmitted by air, the following should be added to the standard precautions:
• PPE: Upon entering the room or area of isolation or when treating a patient with an
infection regularly or sometimes transmitted through air in other environments, use a
particle respirator with a least a level of protection equivalent to a N95 NIOSH
certificate.
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• Patient location (Table 2):
o Place the patient in a room for prevention of airborne transmission.
o If a ventilated isolation room is not available, put patients in well-
ventilated separate rooms.
o If individual rooms are not available, form groups of patients by the same
etiological diagnosis in well-ventilated places.
o Procedures that generate aerosols with pathogen transmission should be
carried out using appropriate PPE in a room for prevention of airborne
transmission.
Transport of patients: limit the transfer of patients; Patients should use a medical mask
outside their room or area. Subsequently, the vehicle used for the transfer should be
disinfected.
Table 2
Environmental Ventilation
− The purpose of ventilation4 is to maintain good indoor air quality, that is to ensure that the indoor air is safe
to breath. The majority of respiratory diseases (for example, virus parainfluenza, RSV, influenza virus)
do not spread easily by air over great distances in a health environment, and patients can be housed
adequately without controls for ventilation of the environment.
− However, since some SARI can be airborne, especially through opportunistic airborne transmission,
airborne transmission precautions should be implemented for patients who are infected (or suspected
of infection) with a new agent causing an unusual or unexpected SARI until the mode of transmission
is clarified.
− As a result, if there are rooms with airborne transmission precautions, these patients should be placed there.
If the facility does not have this kind of room, one should consider locating these patients in adequately
ventilated individual rooms, that have ≥ 12 ACH but not necessarily controlled directional air flow.
Precautions for control of diseases that can be transmitted opportunistically through
droplet nuclei
4 Ventilation of the environment refers to the process of introducing and distributing external air, and/or treated recycled air in an
adequate way, in a building or room. Ventilation and air conditioning are two different concepts.
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For the majority of these diseases, precautions against droplets should be added to the
standard precautions, and special measures should be taken for room ventilation and PPE
during procedures that generate aerosols associated with the transmission of pathogens.
• PPE:
o At the very least, use a well adjusted medical mask (surgical mask or
procedures mask), on entering the room of the patient; the use of the mask
is compulsory if working less than 1 meter from the patient.
o When carrying out procedures that generate aerosols associated with
transmission of pathogens, use a particle respirator that satisfies at least a
protection level of N95 certified by NIOSH, EU FFP2 or equivalent, as
well as gloves, gown and ocular protection (for example, protective
glasses).
• Location of patients:
o Rooms for prevention of airborne transmission are not compulsory. If they
are available, they should be prioritized for patients with airborne
transmitted diseases;
o If possible, individual rooms should be used; if they are not available,
groups can be formed according to etiological diagnosis. If etiological
diagnosis is not possible, place the patients so that they have more than 1
meter of separation between them;
o Procedures that generate aerosols associated with transmission of
pathogens should be carried out in well-ventilated individual rooms.
o Transport of patients: limit the transfer of patients; patients should use
medical masks when they are outside their room or area.
When patents with unusual or unexpected SARI are treated, make sure that health
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workers make proper use of personal protective equipment (for example, using
supervisors).
Establish an infection control infrastructure for healthcare facilities as support for
infection control activities:
The administration of healthcare facilities should promote and provide education about
respiratory hygiene and cough etiquette for all health workers, patients, and members of the
families of patients with acute febrile respiratory disease.
Respiratory hygiene / cough etiquette
For diseases transmitted through droplets and/or droplet nuclei, all individuals with
respiratory symptoms should implement respiratory hygiene and cough etiquette. All
individuals (health workers, patients, and visitors) with signs and symptoms of respiratory
infection should:
• Cover mouth and nose upon coughing/sneezing;
• use paper or cloth handkerchiefs, cloth masks, or medical masks, if they are available,
to control respiratory secretions at the source, and discard them in waste receptacles;
• use a medical mask on a person who is coughing or sneezing if it is tolerated and
properly placed; and
• implement hand hygiene
11.2.7 Selection of Equipment for Respiratory Protection
Particle respirators:
• Healthcare workers who treat patients infected by a microorganism with an
unknown mode of transmission, or by a pathogen known to or suspected to be
capable of airborne transmission, or when procedures that generate aerosols are
carried out, should select respiratory protection equipment of the highest possible
level, preferably a particle respirator.
• Adjustment and sealing of disposable particle respirators are important for their
effective functioning. If good adjustment and sealing are lacking, particles transmitted
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through the air can be inhaled through filtrations, and the particle respirator may not
be effective.
• The people who use particle respirators should receive training on how to use the
device (for example, placement of the respirator, avoiding auto-contamination during
use and removal, and ways of achieving a better seal). Hospitals should follow local
regulations with respect to regular implementation of adjustment tests.
• The user should check the seal whenever using a disposable particle respirator.
Environmental controls: cleaning and disinfection
Cleaning MUST precede the disinfection. Objects and surfaces cannot be disinfected if they
are not cleaned first of organic matter (excretions, secretions from the patients, dirt, spots,
etc.).
• Cleaning should be carried out to avoid possible aerosol generation to avoid the
possible aerosol generation. This process significantly reduces the environmental
biological charge.
• Follow manufacturers' instructions for use/dilution, contact time, and management of
disinfectants.
• Common hospital disinfectants include:
o sodium hypochlorite (domestic bleach);
o alcohol at 60% or 70% or >60%;
o phenolic compounds;
o quaternary ammonium compounds;
o compounds of peroxygen.
Particular attention should be paid to:
• Cleaning of the patient-care environment.
• Equipment and instruments for patient care.
• Bedclothes and clothes to be washed.
• Waste management.
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• Packing and transportation of equipment for patient care, bedclothes and clothes to
wash and waste from isolation areas.
• All staff that handles equipment that has been used, dirty bedclothes, and waste
should use standard precautions and carry out hand hygiene after removing the PPE.
11.2.8 Duration of Precautions for Infection Control
The duration of precautions for infection control varies according to the known or
presumed infection period of the specific SARI. In the case of avian influenza in humans
precautions should be implemented for infection control according to the age of the
patient.
• Adults and adolescents of more than 12 years old–implement precautions at the time
of admission and continue for 7 days from resolution of the symptoms.
• Babies and children of less than 12 years old–implement precautions at the time of
admission and continue for 21 days after the beginning of the symptoms (young
children can transmit seasonal flu virus for up to during 21 days).
Note: In immunocompromised patients, production of pathogens can be prolonged and
there are no precise data to define the duration of the infection. Microbiological control is
advised to determine the absence of detectable pathogens, whenever possible.
More recently emergent SARI
Implement precautions at the time of admission and continue until a week after
symptoms have been resolved, or until there is laboratory evidence of absence of active
infection. Precautions, including their duration, should be implemented according to the
information available and recommendations of the local health authorities
11.2.9 Duration of Precautions for Infection Control
Removal of the body of the room/the area of isolation
• In accordance with the standard precautions standard, EPP will be used to avoid the
direct contact with bodily fluids.
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• Cultural sensitivity should be considered. If the family of the patient wishes to see
the body after it has been retired of the room/the area of isolation, they do it applying
the standard precautions.
Mortuary care
• The personnel of the funeral home and of burial should apply the standard
precautions. That is, to disinfected hands adequately and to use the EPP appropriate
(use of gown, gloves, protection of the face if there is risk of splatter of body
fluids/secretions of the patient to the body and the face of the personnel.
• Embalmment can be carried out in accordance with the standard routine, subject to
the regulations/ local legislation.
• A hygienic preparation of the corpse can also be carried out a (for example, clean the
body, arrange hair and nails; shave) applying standard precautions.
Transmission of lethal infectious diseases associated with the mortuary care has been reported.
However, the cultural context of the local community should also be respected. It is essential to
evaluate the risk during the process of mortuary care, giving an adequate explanation to the
family. If it is indicated, EPP should be provided to the family after instructing them about its
use. Each family should be treated individually, making a balance between its rights and of the
risks of exposure to an infection.
Postmortem examination
• Postmortem examination and the collection of samples for microbiological analyses
are crucial for a better comprehension of the ARI. However, there is the risk of
transmitting infections. Therefore, they should be carried out only when necessary
and always observing the required safety measures. The appropriate safety measures
to protect the people who conduct the examination should be implemented
beforehand.
• In the procedure, the quantity of personnel should be kept at a minimum. It should
only be carried out if:
a well ventilated room suitable for the procedure and the appropriate EPP
are available.
Engineering and environmental controls for the autopsy
• Carry out autopsies in rooms well ventilated with ACH>12.
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• Minimize aerosols in the autopsies room
avoiding the use of electric saws whenever possible;
avoiding splatters when removing, handling and/or to washing organs,
especially pulmonary tissue and intestines;
using extracted ventilation to contain the aerosols and reduce the volume
of aerosols liberated in the air of the environment. The extracted
ventilation systems around the autopsy table should direct the air and the
aerosols far from the health worker that carries out the procedure (for
example, extraction with downward direction).
• The surfaces that have been contaminated with bodily or tissue fluids should be
cleaned and be decontaminated as follows:
remove most of tissue or corporal substance with absorbent materials;
clean the surfaces with water and detergent;
apply the standardized disinfectant of the healthcare facility. If a solution
with sodium hypochlorite is used, soak the surface and allow it to act by
contact at least 10 minutes;
rinse thoroughly.
The safety procedures for people who died infected with an unusual SARI should be consistent
with those used for any autopsy procedure. In general, the recognized dangers of the work in
the autopsies room appear to arise from the contact with infectious materials, and particularly
with splatters on the body surfaces of the health worker more than by inhalation of infectious
material. However, if a patient with an unusual SARI died during the infectious period, the
lungs and other organs can still contain live viruses. Therefore, additional respiratory protection
is required during the aerosol-generating procedures of small particles (for example, use of
mechanical saws, intestines washing). As a result, the examinations postmortem of these
patients deserve special precautions with regard to the environment.
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Table 3
Pathogen
Without an
Pathogen
identified
Bacterial
Parainflue Flu virus
New flu
SARS
New agents of
pathogen
ARI
nza RSV with
virus without
ARI
no risk factor
&
sustained
sustained
of ARI of
adenoviru transmission transmission of
potential
s
of human to human to
concern (that
human (for human (for
is, disease
example,
example,
similar to flu
seasonal flu, avian flu)
but without
pandemic
risk factor of
flu)
ARI of
potential
concern)
Hand hygiene
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Gloves
Risk
Risk
Yes
Risk
Yes
Yes
Yes
assessment
assessment
assessment
Gown
Risk
Risk
Yes
Risk
Yes
Yes
Yes
assessment
assessment
assessment
Ocular protection
Risk
Risk
Risk
Risk
Yes
Yes
Yes
assessment
assessment assessmen assessment
t
Medical masks for
Yes
Risk
Yes
Yes
Yes
Yes
Not as routine
healthcare
assessment
workers and
healthcare providers
Particle
For entry No
No
No
No
Not as
Not as
Yes
respirator
to the
routine
routine
for
room
healthcare Within 1 No
No
No
No
Not as
Not as
Yes
workers
m of the
routine
routine
and
patient
healthcare
providers For proc Yes
Not as
Not as
Yes
Yes
Yes
Yes
that
routine
routine
generate
aerosols
Medical masks for
Yes
Yes
Yes
Yes
Yes
Yes
Yes
patients outside the
isolation areas
Individual room
Yes, if
No
Yes, if
Yes, if
Yes
Yes
available
available available
Precaution room for No
No
No
No
Not as
Not as
Yes
airborne transmission
routine
routine
Summary of
Standard
Standard
Standard
Standard
Standard
Standard
Standard
precautions for
precautions
precautions precaution precaution
precautions
precautions
precautions
infection control for plus
s plus
plus
plus contact
plus droplet plus
routine patient care, droplet
droplet
droplet
precautions
precautions
airborne
excluding procedures precautions
precaution precautions
plus contact transmission
that generate aerosols
s plus
precautions
precautions
contact
plus contact
precaution
precautions
s
a. Bacterial SARI represents common bacterial respiratory infections caused by microorganisms such as Streptococcus
pneumoniae, Haemophilus influenzae, Chlamydia spp., and Mycoplasma pneumoniae.
b. When a new ARI has recently been found, the mode of transmission is usually unknown. Implement the maximum level of
precautions available for infection control until the situation and the mode of transmission are clarified.
c. Take hand hygiene measures according to standard precautions.
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d. Gloves and gowns consonant with standard precautions should be used. If the demand for gloves exceeds those available,
the use of gloves should always be a priority during contact with blood and bodily fluids (unsterilized gloves), and contact
with sterile sites (sterilized gloves).
e. If splatters of blood or other bodily fluids are foreseen and the gloves are not resistant to liquid, a waterproof apron should
be used over the gown.
f. Healthcare workers should use protection for the face (medical masks and protection for the eyes) consonant with standard
precautions if there are possibilities that the activities will generate splatters or spraying of blood, bodily fluids, secretions,
or excretions onto the mucous membrane of the eyes, nose, or mouth, or if they are in close contact with a patient with
respiratory symptoms (for example, cough or sneezing) and sprayings of secretions could reach the mucous membrane of
the eyes, nose or mouth.
g. As of the date of this document, effective transmission between human beings of avian flue A is not known, and the
evidence on hand does not suggest airborne transmission from one person to another. Therefore it is adequate to use a
medical mask for routine care.
h. The current evidence suggests that transmission of SARS in a healthcare environment occurs mainly by droplet and direct
contact. Therefore, it is appropriate to use a medical mask for routine care..
i. Some procedures that generate aerosols have been associated with a greater risk of transmission of SARS and tuberculosis
(Table 6). To date, the risk of infection associated with procedures that generate aerosols in patients with SARI, SARI
caused by rhinovirus, parainfluenza, RSV, and adenovirus has not been determined. At the very least, a well adjusted
medical mask should be used.
j. If medical masks are not available, use other methods for control of the infection source (for example, cloth or paper
handkerchiefs, or the hands) in case of cough or sneezing.
k. These are common pathogens in children, who may not be capable of complying with these recommendations.
l. Form groups of patients with the same diagnosis. If this is not possible, locate the patients in beds with a separation of at
least 1 m at least from each other.
m. Rooms for prevention of airborne transmission can have natural or mechanical ventilation, with an adequate index of air
circulation of at least 12 ACH and air flow with a controlled direction.
n. Rooms for prevention of airborne transmission, if they are available, should be prioritized for patients with infections with
airborne transmission (for example, lung tuberculosis, chickenpox, measles) and for those with new microorganisms that
cause SARI.
*For further details, see original document from which this information was taken.
Infection Prevention and Control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO
Interim Guidelines. WHO/CDS/EPR/2007.
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12.
CASE MANAGEMENT
OBJECTIVE
Identify the basic actions that should be considered by the health facility for appropriate
and safe management of sudden or unexpected cases of SARI or ILI.
DESCRIPTION
The current dynamics of travel by persons and technological advances have increased the
possibility of man reaching remote locations rapidly. In addition, they have increased
potential transmission of infectious agents. The most recent example was the SARS
outbreak in 2003. In theory, this is also a latent possibility for any emerging disease. The
following variables influence management of sudden or unexpected cases of SARI due to
their potential to cause epidemics and/or pandemics:
• There is clear evidence that health workers are a high-risk group and that health
facilities can easily become locations where infections are spread. For example,
during the SARS epidemic, out of 138 cases of secondary and tertiary transmission
in Hong Kong, 85 (62%) occurred in health workers (1). Out of 144 cases in
Toronto, 73 (51%) were in health workers (2).
• The main purpose of appropriate and early case management is not only recovery
of the individual’s health. It also plays an important role in control of the
outbreak.
• Many countries have limited ability to rapidly increase their hospital capacity
(human and logistic resources) in the event of sudden emergence of a high
number of cases. Consequently, preparation is a key part of the response.
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This situation demands that the health workers in health facilities remain alert. They
should be aware that an outbreak of sudden or unexpected cases of SARI could occur at
any time and they should be prepared to manage this situation appropriately.
The sequence followed by a patient from the time of arrival at the health facility and
admission until discharge due to recovery or death is shown below. In addition, the
specific characteristics of appropriate management of a patient suspected of sudden or
unexpected SARI have also been identified in each of these steps.
12.1 TRIAGE
Triage is the first step in case management. It is a systematic process that allows a patient
to be classified based on his condition, which is then related to the type of immediate care
the patient should receive.
The overall organization of the triage process depends on the magnitude of the problem.
Treatment of a few cases is not the same as the wide-scale demand that might occur in an
epidemic or pandemic. Accordingly, during a wide-scale outbreak, in some situations
additional facilities or centers where initial screening of the patients can be conducted
may be required in order to prevent overflow of the health facilities. For example, use of
fever clinics during the SARS outbreak in Asia or hydration stations during the cholera
outbreaks.
Action protocols must be developed and circulated at the hospital-wide level in order to
separate and manage suspected patients in the emergency departments and other patient
admission areas.
There are some useful general considerations for implementation of triage in the health
facility (7):
• The physical site of "triage" should be located at the entrance to the emergency
department. Suspected cases should be differentiated as of this time.
• A map of the emergency department that clearly indicates the "triage" routes
should be prepared.
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• Suspected cases and their companions (preferably one for each case) should be
referred to a waiting room. It is advisable for the waiting room to be large and to
have its own toilet facilities, in the event of a high number of cases.
• The waiting room should be equipped with devices for use of oxygen tanks in
patients when required.
• The patient and his companion(s) should receive instructions on infection control
and have surgical masks.
• Patients should receive care in the cubicles adjacent to the waiting room.
• The number of cubicles will depend on the needs and availability of the emergency
department.
• A route to reach the diagnostic x-ray area in the emergency department should be
defined. There should also be a route for intra-hospital transfer from the emergency
department to the regular hospital floor if admission is required.
The objectives of triage are:
• Reduce the risk of transmission or contagion.
• Prioritize care, and define or assign the immediate destination of the patient (e.g.,
isolation, ambulatory management, other departments, home). All patients that
undergo triage receive some type of care.
• Assign patients according to the required level of care in order to prevent
unnecessary overload of the health facilities and inappropriate use of human and
technical resources.
• Compile information that facilitates identification or subsequent location of the
patient
• The following are the general steps of any triage. They are applied regardless of the
triage scale that is routinely used in the health facility (if any).
• Determine the type and severity of disease (differential diagnosis).
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When the patient arrives at the health facility, the following question is inevitably posed
at the emergency department, outpatient office, and the hospital wards:
Does this patient have sudden or unexpected SARI? Based on this question, a
systematic process should begin that leads to diagnosis, treatment, and the most
appropriate management of the patient in the context of a comprehensive approach to
care that includes factors such as biosafety variables, infection control, referral and
counter-referral, and resource management.
It is important to clarify that the clinical characteristics aid in the diagnostic process.
However, they are not sufficient to rule out or confirm a definitive diagnosis since the
correlation with epidemiological data is an essential element for diagnosis (4).
Management of the suspected case of SARI is a key aspect that is directly influenced by
the clinical, epidemiological, laboratory, and administrative variables of the health
facility.
At any rate, as more cases are reported (e.g., in an outbreak or pandemic), the specificity
and predictive value of the diagnostic impressions based on clinical manifestations are
expected to improve.
The case definitions aid in the triage process for conducting patient management,
particularly in outbreak situations. For this process, it is important to take into account the
concepts of SARI that have already been defined. In addition, it should be taken into
account that clinical and epidemiological criteria are fundamental variables when
defining the therapeutic behavior for each case.
Clinical symptoms of sudden or unexpected SARI
The clinical manifestations are not specific, as shown in the following table that
summarizes the case definitions. Rather, they are shared by many different infectious
diseases. Therefore, it is always important to consider the characteristic of the clinical
condition that makes it atypical, unusual, or unexpected, as described in the section on
surveillance.
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ILI
SARIa
Sudden fever >38ºC
Sudden fever >38ºC
Cough Cough
Sore throat
Sore throat
Dyspnea
Pneumoniab
a Requires hospital management
bAs criteria for IMCI in children under 5 years
Furthermore, it should be pointed out that the clinical symptoms may be accompanied by
other concurrent symptoms that can occur in either of the two conditions:
Nasal
Weakness
Loss of Appetite
Headache
Myalgia
Congestion
Diarrhea Conjunctivitis
Altered state of
Vomiting
Seizures
consciousness
Differential diagnosis
As in clinical management of any patient, in the event of unusual or unexpected SARI,
several different possible diagnoses that could lead to appropriate therapeutic behavior
should be considered. Some of the diseases to be considered in differential diagnosis are
as follows:
Viral diseases
Other Viral
Leptospirosis,
Atypical
Subacute
associated with
Diseases:
Typhoid Fever,
Pneumonia:
Bacterial
respiratory
Mononucleosis,
Tuberculosis
Mycoplasma
Endocarditis
infection:
Hantavirus,
pneumoniae,
Rhinovirus,
Dengue,
Chlamydia
Coronavirus,
Cytomegalovirus
pneumoniae,
Parainfluenza,
Chlamydia
Influenza,
psittaci,
Adenovirus,
Coxiella burnetii
Respiratory
(Q fever),
Syncytial Virus
Legionnaire’s
disease
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Preexisting conditions
Some preexisting diseases can represent clinical conditions of greater severity than ILI
and SARI. Consequently, health workers should take this into account in case
management. Some of these conditions are:
• Diabetes
• HIV/immunodeficiency
• Heart disease
• Pulmonary disease
• Pregnancy
12.2
EVALUATION OF THE REQUIRED LEVEL OF CARE
Although it is a routine practice, it is mentioned here due to its importance. During or
immediately after the triage process, the level of care required by the patient should be
determined in accordance with the initial diagnosis and the severity of the condition.
This process is of vital importance in order to locate the patient as soon as possible in the
place where the required level of care and biosafety will be received (this could be in
another facility). This evaluation is also important in order to avoid overloading the
health facility and use the health care network rationally.
12.3
EVALUATION OF THE AVAILABILITY OF MEDICAL RESOURCES
FOR MANAGEMENT
For the previous step, the resources available in the health facility should be known (e.g.,
trained human resources, isolation rooms or areas, equipment, supplies). The capacity of
other facilities in the health care network as well as the operating procedures established
for these cases by the facility management and/or the respective authorities should also
be known in order to determine the need for referral to another institution that has the
required resources.
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12.4
NEED FOR PATIENT REFERRAL AND TRANSPORT
The evaluation of the steps of triage will determine whether or not the patient should be
referred to another institution and, if so, in what conditions, according to the operating
procedures of the health care facility and the respective authorities.
12.5
ORGANIZATION OF THE HEALTH FACILITY FOR CASE
MANAGEMENT
Care for one or more cases of sudden or unexpected SARI in a health facility entails the
joint and integrated effort of many persons with responsibilities in the facility (e.g.,
clinicians, administrative staff, logistic services).
• Management of suspected cases:
The health facility should define and set aside an area exclusively for clinical
assessment and management of suspected cases that ensures application of the
infection control measures. Inpatient admission or hospitalization should ideally be
done in a respiratory isolation unit. The human and physical resources assigned to
management of the suspected case or cases should be set aside exclusively for care of
such cases insofar as that this can be achieved based on the capacity and resources of
the facility. In any case, standard and special infection control measures should
always be followed.
Special attention is required in the following situations (6)(7):
• Movement of the patient in the hospital facilities: Logistics and resources should
be available for this purpose. This implies use of a clear travel route, unobstructed
elevator or ramps, and use of a surgical mask by the patient whenever possible. In all
cases, patient transfer or movement within the hospital should be limited to that
which is strictly necessary. All of the surfaces in contact with the patient during the
transfer should be cleaned appropriately.
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• Sample collection for laboratory tests: Etiological identification is a fundamental
element for management of cases of unexpected SARI. Therefore, the health facility
should ensure availability of the resources and mechanisms required for collection
and subsequent processing of samples, either in their own laboratory or by safe and
proper shipment of the sample to a reference laboratory. It should be pointed out that,
in the event of wide-scale emergence of disease, it will no longer be necessary to
collect and analyze samples of all of the cases.
• Medical care and case treatment: The health facility should attempt to maintain an
inventory of appropriate drugs and case management protocols should be available.
• Aerosol-generating invasive procedures: In procedures such as bronchoscopy,
tracheal intubation, or respiratory nebulizers, the health workers must use the
complete personal protective equipment, including high efficiency N-95 respirators.
• Patient transfer by ambulance: Since they are narrow and poorly ventilated
environments, the vehicles used for patient transport require special attention in terms
of biosafety. Crew members should wear surgical masks at all times and persons who
come into contact with the patient should use gloves. As an additional measure, the
patient may also have a surgical mask. If the patient and the driver compartments are
separated by a window, the separation should be maintained at all times during
patient transfer and opening the window should be avoided. Only the crew members
required for patient movement and care should come into contact with the patient.
Therefore, if the driver has only been assigned to driving, he should not enter the
patient compartment under any circumstances.
• After the transfer has been completed, before it is used for another transfer, the
patient compartment and the equipment used should be cleaned and disinfected.
• Patient referral and counter-referral: It is essential to have a referral and counter-
referral system for management of sporadic suspected cases and situations that
require wide-scale care. In some situations the health facility will have to provide
treatment or referral for cases of SARS because of its level of complexity. In order to
do so, clear and timely communication about the case between the facility that makes
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Health Establishments Preparation for Unusual or Unexpected Cases or Clusters of Severe Acute Respiratory Infection SARI
the referral and the facility that receives the patient is essential. All of the
characteristics of the referral process should be specified: identification, diagnosis,
treatment introduced, required biosafety conditions, companions, transfer time, and
other items. The receiving facility will ensure the appropriate conditions for care of
the case taking into account the infection control measures. When the patient arrives
at the receiving facility, it is recommended that he/she be taken directly to the final
destination that was the reason for referral (e.g., intensive care unit, operating room,
radiology). The patient should not be stationed at transitory points that increase the
risk of contagion to other persons. This is one of the subjects to be defined by the
hospital.
• Companions: If they are symptomatic, the companions of the suspected case should
be considered to be contacts unless it has been demonstrated otherwise. Therefore,
they should be supplied surgical masks for use. Unrestricted movement throughout
the facility should be avoided until the Epidemiology Department establishes the
guidelines to be followed. The infection control measures should be applied in the
waiting rooms.
• Visiting control: The cases that have been hospitalized can receive visits from their
closest family members. Admission of visitors should be rational and visitors should
not be admitted indiscriminately. Visitors should wear a surgical mask and disposable
gloves when they enter the patient’s room. After visiting the family member, the
mask and gloves should be discarded. Visitors should wash their hands before going
through the rest of the facility.
• Isolation rooms or areas: Ideally the hospitalized cases should be located in
individual isolation rooms. However, if the facility does not have such rooms, the
patients should be assigned to individual rooms with the optimum resources nearby
(e.g., toilet, nursing station). If there are several cases, the patients should be placed in
cohorts in rooms or wards that only include these cases and a distance of at least 1
meter should be maintained between patients.
Whether they are in an individual room or a ward, natural or artificial ventilation
conditions should ensure air exchange with the door closed.
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The rooms or wards should have exclusive equipment (e.g., thermometers,
sphygmomanometers, phonendoscopes) that is not shared with other areas that manage
another type of patients.
• Recommendations for health workers: The health workers assigned to care for these
cases should not have respiratory symptoms or fever. In addition, it is recommended that
all staff be vaccinated each year with the seasonal influenza vaccine. Insofar as possible,
an exclusive group of staff should be assigned to provide care for the suspected case or
cases. Special emphasis should be placed on use of biosafety elements and hand washing.
In situations with growing outbreaks, the health workers should be screened for febrile
syndromes and their temperature should be taken when they enter the health facility.
• Patient discharge: The clinical staff of the health facility should also take into account
the clinical progress of the patient and the epidemiological variables in order to ensure
complete patient recovery and prevent the risk of contagion to other persons. Therefore,
the incubation and contagious periods for the different etiologic agents that are capable of
producing sudden or unexpected cases of SARS should be considered. For example, for
cases of pandemic influenza in patients over 12 years of age it is recommended that
infection control measures should be maintained for 7 days after resolution of the
symptoms. For cases in patients under 12 years, the measures should be maintained for
21 days.
• Mental health: Protection of mental health8 is an aspect that should not be overlooked
when managing cases of respiratory disease with epidemic or pandemic potential since
the stress, isolation, and uncertainty can easily lead to conditions that affect the patient’s
psychological structure and further complicate the cases. Consequently, a health team
should be trained to offer psychological support that modulates the patient’s condition
and contributes to improved self-care as well as precautions to prevent contagion of other
persons.
In order to simplify this situation, a case management algorithm that summarizes the
basic components the health facility should prepare and perform is shown below.
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Health Establishments Preparation for Unusual or Unexpected Cases or Clusters of Severe Acute Respiratory Infection SARI
CASE MANAGEMENT IN SARI OUTBREAKS OR ATYPICAL CASES OF SARI
Is it a sudden or unexpected
Standard precautions for
case of SARI?
infection control
Biosafety standards
NO
YES
Special precautions for
SUSPECTED CASE
infections
Report to epidemiology
Regular management
Take sample for etiological
diagnosis
Requires hospitalization
Ambulatory management
NO
YES Isolation
Infection control for
transf
er/domicile/contacts
quarantine domicile
Requires referral
Therapeutic management NO
YES Referral process
Biosafety standards for
transfer by ambulance
References:
1. Lee N, Hui D, Wu A et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N
Engl J Med 2003. Available from: http://content.nejm.org/cgi/reprint/NEJMoa030685v2.pdf.
2. Booth CM, Matukas LM, Tomlinson GA et al. Clinical features and short-term outcomes of 144
patients with SARS in the Greater Toronto Area. JAMA 2003. Available from: http://jama.ama-
assn.org/cgi/reprint/289.21.JOC30885v1.pdf.
3. Australasian College for Emergency Medicine. 2000. The Australian Triage Scale. Carlton
Vic.:Publisher. Available from: wacebnm.curtin.edu.au/workshops/Triage.pdf.
4. Call et al. JAMA 2005; 293: 987-997.
5. PAHO-CDC. Generic Protocol of Influenza Surveillance, 2006.
6. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health
care, WHO Interim Guidelines, June 2007.
7. Guía Para la Clasificación de Pacientes que Demandan Asistencia (“Triage”) Plan Nacional de
Preparación y Respuesta ante Pandemia de Gripe, Ministerio de Sanidad y Consumo, España, 2006.
8. Protección de la Salud Mental en Situaciones de Epidemias, Unidad de Salud Mental, Abuso de
Sustancias y Rehabilitación, Tecnología y Prestación de Servicios de Salud, OPS, 2006.
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13.
VACCINES AND ANTIVIRAL DRUGS
13.1 VACCINES
In the event of a possible influenza pandemic due to a new virus, the directives and
guidelines regarding use of the influenza vaccine and antiviral drugs should be known,
including general recommendations as well as treatment and prophylaxis.
Availability of vaccines and antiviral drugs would facilitate mitigation of the effects of a
pandemic. However, it is accepted that timely availability of the required amounts may
be difficult to achieve. Therefore, use and distribution should be based on well-structured
analyses and processes that are specific to each region and country.
Seasonal influenza vaccines have been available for over 60 years, especially in
developed countries (1). In this period their safety and efficacy have been demonstrated.
In populations with risk of severe complications, it is well-known that vaccination
reduces hospital admissions and deaths. Therefore, vaccination is the cornerstone of
influenza prevention. Since the influenza viruses evolve constantly, vaccines are
produced every year. Vaccine composition is based on the most important strains of the
virus that have been identified by the worldwide surveillance system. Storage of vaccines
as a preparatory measure for a pandemic is not a viable option since vaccine composition
depends on the causative virus. It is necessary to wait until the virus emerges and is
identified at the beginning of the pandemic. At this time, the vaccine supply will be
limited. In some parts of the world vaccines may not be available.
The vaccines for seasonal influenza virus are usually produced by growth of the virus
particles in fertilized chick embryos. The period from the time of identification of the
strain until the vaccine is available is approximately 6-8 months.
Twice a year, in February for the Northern Hemisphere and in September for the
Southern Hemisphere, WHO organizes a consultation with the directors of the
collaborating centers and representatives from the national laboratories in order to
provide recommendations on the composition of the trivalent vaccine, which contains a
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type A/H3N2, type A/H1N1, and type B virus. Since 1972, WHO has recommended 39
changes in the formulation of the influenza vaccine.
The PAHO Technical Advisory Group on Immunization recommends to the countries
that they vaccinate against seasonal influenza in the risk groups defined by WHO.
PAHO also promotes vaccination of children aged between 6 and 23 months. Vaccination
of these risk groups has been found to be one of the most cost-effective public health
interventions.
Another advantage of more widespread use of the seasonal vaccine is that it will help
increase the production capacity required to respond to a pandemic. In principle, the same
technology that is available would be used to produce a vaccine against a pandemic
strain.
Risk groups defined by WHO in Weekly Epidemiological Bulletin No. 33 of 19 August 2005, by order
of priority, in order to reduce incidence of severe forms of disease and premature death:
1. Residents of facilities for the elderly and disabled
2. Elderly persons who do not live in health care facilities but have chronic heart or lung
diseases, metabolic diseases, neuropathies, or immunodeficiencies
3. All persons over 6 months of age with any of the aforementioned diseases
4. Persons older than the national age limit, regardless of other risk factors
5. Other groups defined based on data and national capacity, such as the contacts of high-risk
persons, pregnant women, health care professionals and other persons responsible for
essential social services, and children aged between 6 and 23 months.
In the event of an influenza pandemic, since there are limitations on vaccination of the
entire population, the countries could consider vaccination of certain population groups to
be a priority. Evolution of the pandemic in each country should be analyzed on an
ongoing basis in order to provide for vaccination of the groups that are affected the most.
The groups to be considered are:
1. Persons responsible for essential services (in order to prevent interruption of
services during the pandemic): health workers in areas of clinical care, essential
staff for production of vaccines and drugs, workers from retirement homes and
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facilities for chronically ill patients, police, fire department, armed forces, and
personnel in charge of other public services.
2. Persons with high risk of influenza-related mortality: residents of facilities for the
elderly or the chronically ill, persons over 65 years of age with chronic heart and
lung diseases, pregnant women in the second or third trimester of pregnancy,
children from 6 to 23 months of age, persons between 6 months and 18 years of
age receiving chronic treatment with aspirin, other vulnerable groups such as
indigenous communities that live in isolation, as well as others.
3. Persons in close contact with high-risk persons: health workers and retirement
home staff, families in daily contact with high-risk persons, and persons in daily
contact with children from 0 to 5 months of age.
4. Children of preschool and school age, who are considered to spread disease in the
community.
5. Persons without risk factors for complications: This is the largest population
group, and it includes adults and healthy children. The main objective is to
reduce the demand for medical services, allow individuals to continue their daily
activities, and prevent greater social disruption. This decision depends on the
availability of the vaccine and the epidemiological situation.
13.2 ANTIVIRAL DRUGS
Although the indication of antiviral drugs for respiratory viral processes and especially
influenza has been known for several years, use and prescription of these drugs is not
widespread in the countries of Latin America and the Caribbean. The advantage of this
situation is that antiviral resistance in the Region will probably not be a major problem
when use of these drugs begins. However, on the other hand, it must also be
acknowledged that since the medical community is not very familiar with use of these
drugs, the process of introduction of use could be complicated.
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The antiviral drugs used at present would probably be effective for prophylaxis and
treatment of disease caused by a new pandemic virus. However, the reserves would be
depleted rapidly in the first part of the pandemic, when the vaccine is not yet available
and there is greater demand for an alternative control method. Once they are available,
the vaccines will continue to be the primary means of prevention of influenza. However,
antiviral drugs will be used in special situations.
Antiviral drugs can be used in prophylaxis or treatment. For treatment, they should be
administered as soon as possible (within 48 hours). This is expected to reduce the
duration of the disease by one day in healthy adults. In addition, when they are used in
prophylaxis, antiviral drugs reduce the risk of developing influenza by 60 to 90%. When
they are administered to household contacts, they prevent 80% of the cases of influenza
and reduce the severity of the symptoms.
There are two groups:
M2 ion channel inhibitors
Amantadine
Rimantadine
Neuraminidase inhibitors
Oseltamivir (Tamiflu ®)
Zanamivir (Relenza ®)
Peramivir (investigational frug)
At present use of neuraminidase inhibitors for treatment as well as prophylaxis of patients
with influenza is recommended.
If possible, antiviral treatment should be introduced within 48 hours after onset of the
symptoms. However, it can be considered after this period in persons with severe
influenza or high risk of complication.
Oseltamivir has been approved for use in patients over 1 year of age. Zanamivir has been
approved for treatment of patients over 7 years of age and prophylaxis in patients over 5
years of age.
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For effective prophylaxis, the drug should be administered daily while there is potential
exposure to the influenza virus or until post-vaccination immunity is achieved
(approximately 2 weeks in adults; over 2 weeks in children).
Some examples of use of antiviral drugs as treatment or prophylaxis in the event of
influenza virus activity in the community are as follows:
• Prophylaxis in persons that have been vaccinated within the last two weeks.
• Prophylaxis in unvaccinated and persons with high risk of contagion (health
workers, geriatric home staff, social service volunteers that provide patient care).
• Prophylaxis in persons with compromised immune systems or that can not
respond to vaccination (HIV patients or patients receiving immunosuppressive
treatment)
• Prophylaxis in persons who cannot be vaccinated against influenza due to allergy
or another contraindication.
• Treatment of persons with influenza who live with or care for the high-risk
population.
• Treatment of high-risk persons with influenza.
• Treatment of persons with influenza with less than 48 hours of evolution of
symptoms in order to reduce the duration and severity of the disease.
The following table summarizes the doses indicated for the antiviral drugs available:
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Drug
Prophylactic Dose
Treatment Dose
Main Adverse
Effect
→ Amanta → Age 1-9 years: → Age 1-9 years: 5 → CNS: anxiety,
dine
5 mg/kg po bid
mg/kg po
dizziness,
→ Age >9 years: → bid
difficulties
100 mg po bid
→ Age >9 years:
concentration
100 mg po bid
→ Rimant
→ Age 1-10 years: → Adults: 100 mg → CNS: less
adine
5 mg/kg po qid
po bid
common
→ Age >10 years:
100 mg po bid
→ Oseltam → Age >1 year: → Adults: 75 mg → Gastrointestin
ivir
75 mg /day
twice daily (up to
al: nausea,
→ Children:
150 mg twice
vomiting.
adjust for daily)
→ Should be
weight
→ Children > 1 year:
taken with
→ (For 7-10 days
adjust for weight
meals
after exposure) → (5 days), up to 10 →
days
→
→ Zanami
→ Children over 5 → Over 7 years:
→ Bronchial:
vir
years:
→ 10 mg (2 spasm
→ 10 mg (2 inhalations twice → (Other: GI
inhalations
a day)
and dizziness)
once a day)
→ (5 days)
→ (For 7-10 days
after exposure)
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References
1.
Guías de la OMS para el uso de vacunas y antivíricos en las pandemias de influenza
WHO/CDS/CSR/RMD/2004.8
2.
Consideraciones para la vacunación en caso de una pandemia de influenza. Alba Maria Ropero,
Jon Andrus MD, Unidad de Inmunización OPS/WDC
3.
Guías de la OMS para el uso de vacunas y antivíricos en las pandemias de influenza
WHO/CDS/CSR/RMD/2004.8
4.
CDC-Influenza Antiviral Medications: A Summary for Clinicians Antiviral medications with
activity against influenza viruses are an important second line of defense in the prevention and
treatment of influenza. October 23, 2007
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PART II – HOSPITAL RESPONSE TO A PANDEMIC
14. ORGANIZATION OF THE RESPONSE TO EMERGENCE OF CASES OF
SEVERE ACUTE RESPIRATORY INFECTION (SARI) BY HEALTH
FACILITIES
14.1 INTRODUCTION
When one speaks about being prepared, there is an inevitable feeling that there is time to
do so. However, time may not be in our favor and this can lead to unexpected adverse
circumstances.
There are few occasions in the history of mankind in which there has been such a high
level of expectation of an epidemic as there is now for a possible influenza pandemic. At
present, when infectious diseases are still the leading cause of death in humans and nearly
forty million people live with HIV, why is there a pronounced fear of an influenza
pandemic? This is due to the fact that the influenza virus is often fatal. It causes 1-1.5
million deaths each season and in a pandemic its effect may be even greater. It is estimated
that if the pandemic was caused by the H5N1 strain, global mortality could be between 180
and 360 million deaths.
SARS is the condition most similar to a potential influenza. However, it does not spread as
quickly. After the SARS outbreaks emerged in China, it spread to five countries within 24
hours, and to three to six continents within a matter of months (In five months, 8,000
people were infected and 10% died) (1).
The process of preparation and response to a pandemic is very complex. It is linked to
several aspects that are related not only to variables regarding disease or fatality, but also to
the productivity and sustainability of communities. As a result, its impact and response will
occur in multiple sectors and not only in the health sector. National preparedness plans in
the national and local areas should include the different segments of society.
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In addition to the response of the health services, other extremely important elements such
as epidemiological surveillance, population containment measures, and risk communication
should be considered.
The inevitable contact between the population that is ill and the health services is one of the
major challenges when considering preparation and response to wide-scale care for cases of
SARS as could occur in an influenza pandemic.
The estimates of impact on the health services clearly show that there is insufficient
installed capacity to provide care for cases in an influenza pandemic. This situation could
be more serious in areas that lack the required capacity even in regular conditions.
The clinical course of the infection tends to require complex care. Therefore, it is estimated
that there will not be sufficient intensive care units and the mechanical ventilation
equipment or staff required for case management will not be available.
At least at the beginning of a pandemic outbreak, when vaccines will probably not be
available as a preventive measure, the health facilities will have a higher burden of
morbidity and mortality.
In these conditions, there should be sufficient coordination between the health services that
must respond to this situation, including the clinical, administrative, logistic, and financial
components. In addition, information should be available in order to maintain control of the
situation in a complex and adverse scenario.
14.2
ORGANIZATION, COMMAND STRUCTURE, AND COORDINATION
In an emergency situation, it is essential to ensure the concept of control through a visible
figure or structure that makes timely and diligent rational decisions based on technical
information.
Otherwise, the second disaster could be the lack of control and coordination of the situation
in the event of a pandemic. This is this reason why the health facility should provide for a
structure that ensures control of actions, decision-making, and the authority to ensure that
decisions are implemented with assignment of responsibility to all members.
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An influenza pandemic includes several critical elements. It is an emergency that has a
major impact. Moreover, it can affect operation of the health facility since it uses the
human, material, administrative, and financial resources of the institution.
Adequate coordination with regard to preparation and response for care in the event of a
large number of cases requires that the health facility have at least four types of capacity:
Decision-making capacity: Oriented toward active participation of the directors of the
organization in order to ensure rapid and effective decision-making.
Logistic capacity: Aimed at ensuring the necessary support so that the operational actions
of the health facility can be implemented. All activities such as transport, communications,
safety, and other activities should be clearly considered in the structure.
Operational capacity: Refers to ensuring the health facility conducts its activity,
particularly its essential functions of provision of services, including the administrative
component. The medical and paramedical staff in the facility and the persons responsible
for administrative tasks should play an active role in the structure.
External liaison capacity: This is an essential condition for achievement of coordinated
actions that directly or indirectly affect the functions of the health facility (e.g., public
services, waste disposal, safety, patient referral, wide-scale mortality).
Operational actions
There are two non-exclusive approaches that can be implemented at the health facility:
activation of a hospital committee in charge of emergency preparation and response (or
creation of such a committee if there is none) and adoption of an incident management
system (IMS) structure.
The hospital committee must be developed from the preparatory phase in order to achieve
greater consolidation. The IMS could be implemented later on, even without prior
preparation, since a methodology has already been established and validated. The key
message is that, in either of the two cases, it is always be better to be prepared as soon as
possible.
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Emergency preparation and response committee
The objective of activation or creation of a committee of this type is to integrate the key
referents in the health facility in the implementation of actions that ensure effective
operation of human and physical resources in order to provide for patient demand during
the epidemic or pandemic outbreak.
The committee should meet at least the following conditions:
a)
Invite representatives from each area of the health facility so that it will be a
multidisciplinary committee.
b)
Have a coordinator who will lead planning, task orientation, and decision-making.
Insofar as possible the coordinator should be a director that is close to the
management of the facility.
c)
Formalize creation of the committee
d)
Define duties for each member
e)
Meet on a regular basis, preferably monthly. Depending on the phase of the
pandemic and the specific circumstances, the frequency of the meetings may be
changed or extraordinary meetings may be called.
Depending on the size of the health facility and, therefore, the size of the committee,
subcommittees that take on groups of related tasks may be created in order to facilitate
operation of the committee.
The committee should conduct at least the following tasks:
1.
Designate the composition of the committee
2.
Designate a coordinator
3.
Define the duties of each member
4.
Prepare, implement, and follow-up on the hospital preparedness and response plan
for cases of severe acute respiratory infection (SARI)
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Incident Management System
Incident command (or incident management) is a system of organization and terminology
that provides management tools for response and operation in the event of disasters. It was
originally designed in the United States for forest fire operations. It has been used
successfully in other circumstances that have required a robust response by the health
sector with the support of other sectors. It should be an agile structure that is responsible
primarily for the response to a crisis situation rather than preparation for this type of
situation. Its purpose is to respond to the emergency and return the facilities, in this case
the hospitals, to their regular operating status as soon as possible.
The incident management system (IMS) is based on four basic components: operations,
logistics, planning, and finance. A coordinator is in charge of administration of each of
these components. There is also an incident manager who is in charge of all the IMS tasks
that have not been delegated. The manager has four officers (management personnel) who
work directly under him:
• Liaison Officer: contact point for external agencies and inter-institutional relations
• Information Officer: responsible for preparation and delivery of information to the
media
• Security Officer: in charge of supervising all facilities and operations in order to
guarantee safe procedures. It must be highlighted that the safety officer has the
authority to immediately halt any procedure, operation, or task that poses a risk for
health workers. Therefore, an incident manager should not attempt to perform the
duties of the safety officer.
• Medical/Technical Specialist: responsible for advising the incident manager as an
expert in the specific area of the incident (e.g., a specialist in entomology/infection
control in the event of an influenza pandemic or SARS epidemic, a radiation expert in
the event of a case of radiation).
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INCIDENT
MANAGER
Information Officer
Liaison Officer
Medical/Technical Specialist
Safety Officer
PLANNING
LOGISTICS
ADMINISTRATION
OPERATIONS
Situation
Supplies
AND FINANCE
Resources
Establish
Time sheets
Action Plan
Transport
Claims/
Documentation
Communications
Compensation
Reports
Food
Costs
Safety
Procurement
Telecom-
Medical
Alerts
Medical care
munications
equipment
Signposting
Usual patient
Access to
Medicinal gases
Hazardous
care
services
Power
materials
Triage
Information
Ventilation
Fire extinction
Treatment
storage
Heating
Search
Evacuation
Relocations
Aqueduct/alcant
Safety
Admissions
Each of the four main areas (planning, logistics, administration and finance, and
operations) should have a leader that coordinates a team of persons. In order to make
incident management more effective, it is suggested that this team should include 5 to 7
members.
The IMS is based on a series of forms for practical management of the situation. These are
an important guide for preparation of an incident action plan and daily orientation. The
forms are also a source of filed information for the financial reports and the reports
prepared after the action.
In any case, whether there is a committee or an IMS (ideally both), implementation should
be adapted to the conditions, size, and specific characteristics of the health facility.
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Finally, it is important to remember that management of a situation such as an influenza
pandemic implies external actions. Therefore, liaison with the leading health unit in the
town and with other sectors should be considered. Such sectors include the security forces,
emergency agencies, humanitarian aid organizations, educational system, media, and
public utility companies.
14.3
ETHICAL AND LEGAL ASPECTS
The ethical and legal aspects are elements that theoretically have many variables in
common. However, in practice there may be slight differences that separate them or at
times they may even be opposed to one another.
In disasters, health workers often have to leave their home and closest relatives in order to
provide care at the event, and they may even put their own life at risk. In this situation
questions such as the following inevitably arise: Was it his duty? Was it his obligation? If
he had not gone, could he have been held liable? What would be the blame? Could there
have been justifiable causes? Therefore, it must be considered that it is not easy to provide
a single and irrefutable response to any of these questions.
For example, in the case of the SARS epidemic in 2003, there are registries that show that
30% of the cases reported were in health workers, many of whom died (4).
In the event of an influenza pandemic, conflicts between "obligations" and "duties" will
inevitably arise. Work, family, affective, and civic responsibilities as well as self-care will
be considered in the values scale of each person and will determine his behavior to a
significant extent. In addition, it is the duty of the individual who provides care to protect
himself and others (In this case, this refers to not infecting others or ensuring that other
persons are not subject to unnecessary exposure).
In legal matters, each country establishes standards, regulations, or codes on providing
health care. These tools can certainly be useful to guide discussions and behavior with
regard to the civil and legal responsibility of health care providers. To the extent that health
is regarded as a right, this situation will lead to a series of responsibilities for health care
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providers, including the State, health system, Social Security system, health facilities, and
even the health workers in charge of providing care.
Another key aspect with ethical implications that will occur in an influenza pandemic is
management of the high demand for services. It is estimated that there will not be sufficient
resources to provide care for all critical cases. Therefore, some type of triage will have to
be applied in order to prioritize admission to intensive care units, use of mechanical
ventilation(5), or the possibility of receiving supplies of products such as vaccines or
antiviral drugs. The physicians will clearly face difficult decisions with implications that
may extend beyond clinical aspects.
Operational actions
Both the legal and ethical aspects will depend on the specific conditions of the place, the
time when they occur, and the persons involved. Consequently, only very general actions
that can be considered within the framework of an emergency response plan for epidemic
respiratory diseases such as SARI will be mentioned.
The actions that could be considered by the health facility include:
• Discuss the subject and problems with the ethics committee of the health facility or the
authority in charge of these functions.
• Review the legal and ethical guidelines for epidemic respiratory diseases established in
the national emergency plans, and in the provincial or local plans.
• Seek legal advice on national and local regulations on subjects such as emergency care,
patient rights, rights of health care providers, care in the event of disaster, work-related
subjects, medical liability, and liability of the facilities.
• Analyze the scale of institutional values for the problems that may occur in an
emergency due to epidemic respiratory diseases taking into account factors such as
individual freedom, protecting the community from harm, proportionality, reciprocity,
transparency, privacy, protecting the community from stigmatization, responsibility to
provide care, equity, and solidarity (7).
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• Seek agreements with workers of the health facility where institutional values and legal
regulations are considered in a framework of respect and consideration as persons and
health care providers.
• Promote activities that seek to increase awareness and strengthen individual values such
as respect, trust, and solidarity.
14.4.
TRIAGE
The health facilities may receive a disproportionate demand from patients with SARI that
surpasses their response capacity. The facilities will be filled to capacity with patients that
have the epidemic infection as well as patients with other conditions, including mild
clinical symptoms that they would not usually have visited for. The impact on the
emergency departments will be especially significant. The departments will probably have
to make additional efforts when implementing mechanisms of classification and
prioritizing cases for hospital management.
In an influenza pandemic it is estimated that between 15% and 35% of the population will
have symptomatic disease. In addition, 15% of the population admitted to hospitals will
require an intensive care unit and 7.5% will require mechanical ventilation (8).
Implementation of triage mechanisms should be linked to ensuring care for all patients that
request it. Therefore, the services network should be prepared to provide care for hospital
cases and also be capable of providing alternatives to ambulatory management through
means such as primary care centers or home care. Moreover, depending on the technical
potential and sustainability of the system, telephone triage deserves special consideration
when regulating demand for health facilities. This could involve channeling cases to a call
center, as provided in the National Preparedness and Response Plan for Flu Pandemic in
Spain (9).
For an emergency situation such as an influenza pandemic, three phases of triage may need
to be implemented: an initial phase in order to separate patients with a potentially
infectious condition from patients with other conditions; a second triage of patients with
respiratory symptoms that may be related to avian influenza or infection with
epidemic/pandemic potential from patients with other diseases (e.g., RSV, adenovirus,
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parainfluenza, bacterial pneumonia, tuberculosis) in order to identify patients taking into
account the case definitions and their immediate destination; and a subsequent phase in
order to decide on patient location (e.g., home, hospitalization in a hospital ward,
hospitalization in intensive care unit).
Operational actions
• Availability of an area for triage of SARI in a location different from that set aside for
the usual triage in the emergency department.
• Take into account that due to the demand for patients, sufficient triage stations
equipped with equipment, materials, personal protective equipment, and registration
forms will be required.
• Provide adequate signposting for transit of patients and companions in the triage room
and between this room and the different departments of the health facility.
• Availability of sufficient trained human resources to conduct the triage process.
• Provide for the mechanism of immediate reporting of suspected or probable cases to the
epidemiology department of the health facility.
Tools for implementation
Triage is a measure that is especially useful for infection control and epidemiological
follow-up. Specifically, in the pandemic period, it is especially useful for rationalization
and organization of the services offered in the event that the response capacity is surpassed.
The health facilities can define the triage protocol they consider to be appropriate.
However, this protocol should be used to supplement and not to replace the judgment of the
individual clinician.
It is important to mention that some of the systems of classification that are shown in the
annexes refer to schemes to determine the severity –possible mortality– of community-
acquired pneumonia. They are not necessarily appropriate for influenza-related pneumonia
and even less so for pandemic influenza, in which the risk groups may be different.
Therefore, they may not be classified properly using the scores mentioned (e.g., possible
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increased mortality in young patients, as occurred in 1918, or pregnant women). Finally, it
is important to emphasize that the scores shown in the annexes do not replace the clinical
criteria. They are only a guide that orients the decision-making process of the clinician.
The approach to initial triage could be simplified in the following diagram:
Patient with unexpected ILI/SARI?
NO
YES
Requires hospitalization?
With complications or
chronic decompensated
disease?
NO
YES
YES
NO
Ambulatory
Consider hospitalization
Requires
Consider
management
in centers that do
ICU/AR?
ambulatory or
of disease
NOT have a high
home
number of cases of
management
SARI
Requieres
ICU/AR?
NO
YES
NO
Hospital
Consider
management of
application of
Consider hospitalization in centers with
disease
ICU admission
a HIGH NUMBER of
protocols
cases of SARI
References:
1. Osterholm, Michael T. En Previsión de la Próxima Pandemia. Salud Pública de Mexico. 2006;48:279-
285
2. Desarrollo de Sistemas de Servicios de Emergencias Médicas-Experiencia de los Estados Unidos de
América para países en desarrollo, Organización Panamericana de la Salud, Washington, DC, 2003,
3. Recommended modifications and applications of the hospital emergency incident command system for
hospital emergency management. Prehospital and disaster medicine 2005; 20 (5): 290-300
4. Debate on pandemics and the duty to care: Whose duty? Who cares? BMC Medical Ethics, 2006,7:5
5. DeveloP.M.ent of a Triage protocol for critical care during an influenza pandemnic, CMAJ, November
21, 2006,175(11) 1377:1381
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6. Commentary-Pandemic triage: the ethical challenge, Melnychuk & Kenny, CMAJ, November 21,
2006, 175(11);1393:1394
7. Clinics and SARS:lessons from Toronto, BMJ, volume 317, 6 December 2003.
8. Zhang X, Meltzer MI Flusurge 2.0, CDC,HHS,2005
9. Guía Para la Clasificación de Pacientes que Demandan Asistencia (“Triage”) Plan Nacional de
Preparación y Respuesta ante Pandemia de Gripe, Ministerio de Sanidad y Consumo, España, 2006.
14.5
BED MANAGEMENT
Catastrophes are events that usually demand high levels of hospital capacity. The
emergency and hospitalization departments receive maximum demand in any case. In a
respiratory epidemic event, there would be special circumstances due to the prolonged
duration of the event, the risk of contagion, the severity of disease, the progressive increase
in use of resources, and the limited possibilities of receiving external support. In addition to
all of the above, it must be added that many health facilities operate regularly at the limit of
their capacity, which implies a minimal possibility of capacity for expansion.
Some assumptions show that 45% of the population that contracts pandemic influenza will
not require medical care (but will need health information and advice), around 53% will
require outpatient care, and approximately 1.5 to 2% will require hospitalization (1).
For pandemic influenza the average hospital stay outside the intensive care unit (in the
main hospital ward) could be 5 days. In contrast, the ICU stay would last about 10 days. A
total of 15% of hospitalized patients would require ICU and 7.5% would require
mechanical ventilation. It is estimated that there would be a 3% daily increase in cases that
require care (1). In countries such as the Netherlands, more dramatic estimates have been
made: hospital stay times of up to 14 days, between 10% and 40% of hospitalized patients
requiring ICU, and 30% of hospitalized patients could require mechanical ventilation (2).
Appropriate and rigorous triage is the first line of containment for a sudden increase in
patients. The second line of containment would be the internal reorganization that occurs in
the hospitalization departments of the facility. Finally, the availability of inpatient care in
areas outside the facility should also be taken into account. It is essential to consider that
each hospital bed available should be related to the operational capacity of the hospital with
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regard to human resources, medical supplies, and support services (e.g., toilets, food) that
would be assigned to each bed.
A recent study in which the experience of SARS in Toronto was related to the possible
scenarios of pandemic influenza indicated that with measures restricting non-urgent
admissions, the hospital admission capacity to provide care for pandemic cases would only
be increased by 12% (3). This study also recommended implementation of additional
measures as a higher case rate would lead to an even greater gap.
Operational actions
The actions undertaken to implement a strategy of expanding capacity should be based on
the correlation between the increased number of beds and the resources required for
functionality as well as control of transmission of infection in the facility. Some general
measures that should be adapted to the specific characteristics of the health facility if they
are considered are described below.
An aspect of vital importance is the availability of environmental ventilation systems that
ensure uncontaminated air in the patient care and hospitalization areas. To this end,
mechanical ventilation or natural ventilation mechanisms that contribute to infection
control should be implemented (4).
SITUATION
SUGGESTED MEASURES
EXPECTED
SCOPE
There is a discrete tendency of
Adjust maximum hospital stays for all
Reduce hospital stay to
increased demand for beds for
patients. Promote early discharge
increase relative availability.
SARI patients, but there is
strategies in medical and surgical
availability for care in individual
hospitalization services.
isolation rooms.
The availability of beds for
Prepare new individual isolation beds.
Increase number of isolation
patients with SARI in individual
Prepare shared rooms.
beds available.
isolation rooms is at the limit of
the required demand.
The demand for beds for patients
Assign an exclusive ward or area for
Expand the internal
with SARI surpasses the existing
patients with SARI. Delay care for
hospitalization capacity for
availability of individual or shared patients with other diseases that are not patients with SARI.
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isolation rooms.
potentially fatal and do not imply
serious adverse consequences as a
result of the delay. Refer long-term stay
patients to chronic care inpatient units
as beds become available. Reconvert
beds in elective services (e.g.,
ambulatory surgical recovery, palliative
care) to operational beds for priority
services and SARI patients.
The availability of beds for
Expand and enlarge areas for
Expand the internal
patients with SARI in the wards is hospitalization in wards. Refer acute
hospitalization capacity for
at the limit of the required
hospitalized patients (e.g.,
patients with SARI.
demand.
postoperative) to continue care at home
as long as care can be provided safely
in this environment.
The demand for beds for patients
Assign an entire floor (or more if
Expand the internal
with SARI surpasses the current
necessary) to management of SARI
hospitalization capacity for
availability in the wards.
patients. Transfer patients with or
patients with SARI.
without SARI to other health care
centers in the services network with
availability of beds.
The demand for beds for patients
Prepare areas that have been closed
Reach the maximum
with and without SARI clearly
recently and are reserved for other
availability of beds for
surpasses the existing availability
purposes. Apply triage strategies for
patients with/without SARI.
in the wards.
admission of patients with and without
SARI. Prepare supplementary and
unconventional inpatient units (e.g.,
hotels, schools, auditoriums, field
hospitals).
References
1. Ontario Health Plan for Influenza Pandemic, September 2006
2. Genugten M, Scenario analysis of expected number of hospitalizations and deaths due to
pandemic influenza en Netherlands, RIVM Report 217617004
3. Schull et al. Surge Capacity Associated with Restrictions on Nonurgent Hospital Utilization and
Expected Admissions during an Influenza Pandemic, ACAD EMERG MED. November 2006, vol.
13 No 11
4. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in
health care, WHO Interim Guidelines, June 2007
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14.6 RESOURCE
MANAGEMENT
The increase in the number of cases of SARI in an epidemic entails a high demand for use
of the existing human and physical resources and supplies of the health facilities. The
supplies of personal protective equipment, oxygen therapy devices, and some drugs could
be rapidly depleted. The health workers would be overloaded with work and they may also
be affected by the disease, as indicated by estimates of the occupational impact of a
potential influenza pandemic (1). Based on the assumption that there would be patients
with different degrees of severity of disease (mild, moderate or high) in an influenza
pandemic, it has been estimated that initially only patients with moderate or severe
conditions would use the medical resources in the hospitals. Severely ill patients would
require intubation, ventilation management, and/or multiple drugs, including use of
vasopressors and intravenous fluids. Patients with moderate conditions would require at
least drugs and intravenous fluid.
Operational actions
Planning of the resources required to provide for the demand should be based on a standard
level that is appropriate and sufficient for the usual requirements. However, for many
health facilities, it is probable that the demand would be higher than the existing resources.
The establishment should plan its resources taking into account the potential scenarios for
demand such as the expected influenza pandemic case rate (e.g., 35%) or the period that the
situation is expected to remain critical (e.g., 8 weeks).
It is recommended that the facility consider the subject from two perspectives:
• Human resources planning
• Planning of need for equipment, materials, and supplies
14.6.1 Human Resources Planning
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It may be necessary to review the entire staff in the health facility in order to redistribute
tasks and reassign duties.
The key aspects that should be taken into account include the following (2):
1.
Identification of competency:
Management
Administrative and support staff
User service
Patient referral
Patients
Samples
Transport
Waste
Medicinal gases
Health workers
Health care staff
Training
Community education
Case-finding for staff with illness
Development of surveillance
programs
Infection control and occupational
Implementation of surveillance
health
programs
Logistic and psychosocial support for
health care personnel
Immunization
Care for healthy persons
Prophylaxis
Patient care
Case management
2.
Assignment of competencies or roles:
After the competencies have been identified, they can be assigned to the profiles or
positions existing in the health facility (e.g., administrators, physicians, nurses, assistants).
3.
Estimated activities:
After the competencies have been assigned, the number of activities/day assigned to each
profile or position can be determined (e.g., number of outpatient visits in each 8-hour shift).
Longer units of time such as weeks or months can also be calculated.
4.
Gap analysis:
Based on the activity estimate, the current existing human resources and the resources
required to cover the proposed requirements can be determined.
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5.
Identification of additional resources:
The alternatives to consider include:
• Reassignment of duties of current staff
• Staff use in training (universities)
• Notice to retired staff
• Recruitment of voluntary staff
6.
Strategy for hiring additional resources.
The following aspects should be taken into account:
• Identification of the activities designated for support
• Legal support
• Protection and safety conditions
• Occupational aspects
• Training and preparation
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The process can be summarized in the following diagram:
HUMAN RESOURCES PLANNING
How are the tasks and duties
Identification
of
grouped in the facility?
Competencies
Which positions
should be responsible
for these duties and
Assignment of
tasks?
Competencies
How many tasks or
activities should
Estimated
Activities
each assigned profile
How many activities
or post perform?
can not be covered
with the current
human resources?
Gap
Analysis
Id entification of
Additional
What source of human
What strategy and steps
Resources
resources will be used
will be followed to
to cover the gaps
introduce additional
identified?
human resources with
assurances of safety and
availability?
Introduce
Additional
Resources
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14.6.2
Planning of Equipment, Materials, and Supplies
In order to achieve an objective estimate of the requirements, the installed capacity
(including human resources) should be compared to the expected demand in a given period.
Consequently, plans can be made for use of medical equipment, drugs, personal protective
equipment, and other supplies.
Some of the considerations that the health facility should take into account are shown
below:
• Identify the required supplies based on the management guidelines adopted and agreed
on with the clinical group. Conduct the same procedure for infection control.
• Define a policy and a strategy to ensure availability of an emergency inventory during
the first days of the crisis.
• Define a storage and distribution strategy for supplies and drugs that ensures immediate
availability, safety, rational use, and efficient use of space.
• Define a strategy for prompt and effective replacement of supplies by the suppliers that
guarantees continuous and ongoing supply for the demand (during each pandemic
outbreak).
• Strengthen the preventive and corrective maintenance component for medical
equipment and all electromechanical devices that are expected to require increased use.
• Keep comprehensive records of consumption of supplies, medical materials, and drugs.
WHO has proposed a model scenario for calculations in the event of an influenza pandemic
(3), which is shown below:
a
Scenario for model calculation
Recommendations for infection control in
Standard precautions + precautions
routine care of patients with pandemic flu
against droplets
Main points:
strengthen respiratory/cough
hygiene
health workers use surgical masks
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when they are in close contact with
patients
strengthen hand washing
Recommendations for infection control
The PPE should include a long-
when conducting aerosol-generating sleeved gown, disposable gloves, eye
procedures (see Annex A)
protection (e.g, safety goggles, facial
protectors) and respiratory
protection.
Population
100 000 persons
Duration of pandemic outbreak
90 days
Duration of the infectious period/days of
7 days
patient hospitalization
% of the population that develops clinical
30% (30,000 persons)
symptoms
% of persons with symptoms that require
100% (30,000 persons)
care
% of persons with symptoms that require
2% (600, 480 of which are in rooms
hospital care
and 120 in intensive care units)
% of patients with symptoms that receive
98% (29 400 persons)
care at home
aNote: The PPE estimates will change if any of the individual assumptions is changed.
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Model Calculation of PPE Needs in the Health Centers According to the Previous
Scenario
Item
Assumptions
Needs
Surgical masks for patients admitted
No. of patients admitted to rooms
Patient that will use mask
3 360
= 480
outside of the isolation
room. Assign 1 mask
/patient/day for 7 days
No. of patients in intensive care =
Most patients will not be
480
120
able to use masks. All
patients will survive and use
masks for 4 days (estimate)
Masks for visits
600 inpatients receive 2 visits/day
1 surgical mask/visit;
8 400
each. No. of visits/day = 1200.
2 visits/patient/day for 7
No. of days = 7
days
Masks for health workers
Surgical masks for health workers
12 admissions of health
50 400
that care for 600 patients for 7
workers/isolation room/day
days
+ 2 aerosol-generating
procedures/patient/day
TOTAL surgical masks
62
640
Other PPE for health workers when they perform aerosol-generating procedures
Respirators
2/patient/day
8 400
Disposable facial protectors or
2/patient/day disposable
8 400
safety goggles
or
Reusable facial protectors
2/patient/day reprocessed*
or
10 times
840
Reusable safety goggles
or
or
2/patient/day reprocessed*
168
50 times
Disposable long-sleeve gowns or
cloth robes (not reusable on the
same day, washed. e.g,
2/patient/day
8 400
reprocessed up to 50 times)
or
or
2/patient/day
168
Gloves
Non-sterile, disposable gloves
2 pairs/patient/day
8 400
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References:
1. Zhang X, Meltzer MI, Bridges CB FluWorkloss 1.0 A Manual to Assist State and Local Public
Health Officials in Estimating the Impact of an Influenza Pandemic on Work Day Loss. CDC,
HHS, 2005.
2. HHS, Pandemic Influenza Plan, 2006 (adapted).
3. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in
health care, WHO Interim Guidelines, June 2007.
14.7
MANAGEMENT OF EXCESS HOSPITAL MORTALITY
Although strictly speaking management of fatalities is the responsibility of local
government agencies and it should be considered as such in the procedures in the event of
an unusually high volume of bodies, the health facilities, particularly facilities with
hospitalization capacity, could receive the first and the highest impact of mortality. It has
been estimated that 70% of the deaths in an influenza pandemic will occur in the hospitals.1
Consequently, the health facilities should make provisions for fatalities based on the
expected number with all of the biosafety, logistic, and sociocultural implications that this
entails.
Local coordination in management of a large number of corpses is especially important.
This should be the responsibility of a local agency, preferably not the hospital director or
the health workers, since they are responsible primarily for care of the living.2
With regard to the facility, a procedure should be established that considers infection
control measures as well as efficient and respectful corpse management.
Operational actions
The facility should define the protocol in accordance with the basic guidelines shown
below:
• Follow the guidelines defined in the national and local plans with regard to corpse
management in disaster situations.
• Establish liaison with the local agency in charge of fatality management.
• Adopt and provide information on the process for prompt removal of corpses from the
isolation area or room:
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o Biosafety precautions
o Use of PPE (masks, gloves)
o Use of waterproof hermetic bag for the corpse
• Driving route to the morgue
• Mechanisms for timely delivery of the corpse to the family (use of PPE)
• Special precautions if autopsy is performed
• Identification of alternative strategies for temporary storage:
o Refrigerated vans/containers
o Appropriate corpse identification (labeling)
• Comprehensive mortality registry
• Coordination with the local funeral parlors in order to improve the efficiency of the
processes and maintain biosafety conditions.
References:
1. Zhang X, Meltzer MI, Bridges CB FluWorkloss 1.0 A Manual to Assist State and Local Public
Health Officials in Estimating the Impact of an Influenza Pandemic on Work Day Loss, CDC,
HHS, 2005.
2. La gestión de cadáveres en situaciones de desastre: guia práctica para equipos de respuesta.
OPS/OMS/CICR, Washington DC, 2006
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14.8.
OCCUPATIONAL HEALTH
The risk factors that the health workers will be exposed to in the event of an emergency due
to epidemic respiratory diseases will not be different from those that are usually present.
The difference will probably be evident in the magnitude and intensity of exposure and the
potential increase in the number of occupational accidents and occupational diseases, not
only from the biological, but also from the ergonomic and psycho-occupational
perspective. There are several factors that could explain this hypothesis a priori:
1. Increased number of contacts with infected patients
2. Increased number of tasks/day
3. Longer workdays
4. Assignment of new responsibilities
5. Increased contact with critically ill patients
6. Potential limitation of current resources
These are some of the factors that can have an influence. The non-occupational conditions
that the worker may have, such as disease or death of family members, change in family
and social situation, should also be considered.
Therefore the authority in the health facility that is responsible for workers' health should
promote implementation of an internal contingency plan to deal with the situation in order
to improve worker protection from higher exposure by seeking to maintain his health and
appropriate functionality.
Operational actions
The facility can implement a contingency plan that includes actions such as the following:
• Training on use of personal protective equipment and biosafety measures
• Epidemiological surveillance system for febrile/respiratory syndromes in workers of the
facility
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• Definition of prophylaxis protocols (vaccines/antiviral drugs)
• Supervision and monitoring of staff travel
• Verification of staff disabilities associated with influenza-like illness
• Psychological and social support for staff
• Special training for additional staff
There are some important factors1 that should be taken into account when considering the
subject of occupational health:
• Timely recognition of health care professionals with SARI is essential in order to limit
spread of the infection.
• Health care professionals with SARI should be excluded from work until they recover.
• As a general principle, the health workers that provide care for SARI patients should
not care for other patients.
• Health workers with high risk of SARI-related complications should not provide care
for infected patients.
References:
1. Pandemic Influenza Guide: Infection Control in Hospitals and Primary Care Guidelines.
Department of Health, England, Agency for Health Protection, October 2005 (adapted).
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15.
RISK COMMUNICATION FOR HEALTH FACILITIES
The objective of this section is to provide basic knowledge of risk communication for
health facilities. Some basic concepts will be presented, as well as messages about skills
that allow health workers to communicate with several different audiences and involve
the general community, particularly when they work in coordination with physicians and
other administrators. The purpose of communication is to decrease emotions and negative
attitudes that could arise in the event of an epidemic outbreak, using an approach to risk
communication that is within the framework of national, subnational, and local actions
for pandemic control.
WHO (1) prepared standards for communication of epidemic outbreaks that indicate that
"the paramount goal for communication of epidemic outbreaks is to communicate with
people in a way that promotes, maintains, or recovers trust." Furthermore, the importance
of making early announcements, acting with transparency, having knowledge of different
audiences, and planning communication strategies is pointed out.
15.1 RISK COMMUNICATION
Risk communication for epidemic outbreaks is a process of exchanging information and
opinions between people, groups, and institutions. It usually includes several different
messages about the nature of the risk. Furthermore, it allows for expression of concerns,
opinions, or reactions related to the messages about risk or the legal and institutional
provisions for risk management (2). The goal is to communicate with the public in a way
that creates, maintains, or reestablishes trust.
Risk communication is implemented when the danger of an epidemic outbreak causes
strong feelings of anger. It contributes to people containing their feelings and effectively
overcoming the dangers (3). Therefore, it is different from public relations or health
education activities that are conducted in normal situations.
Risk communication is concentrated in 6 areas:
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1.
Contents of information: What do we know about the crisis? What do we want the
people to know, and how do we communicate effectively?
2.
Logistics and resources: How do we really communicate our contents to the hands
(and minds) of our audiences?
3.
Evaluation of audience: Who do we have to reach? What are these people
thinking, and how should this influence what we say?
4.
Public participation: How do we make the communication allow audience
involvement, and how do we keep them active and not passive?
5.
Meta-messages: How much security should or can we provide? How much
confidence should or can we demonstrate? How can multiple emotions be
addressed?
6.
Self-evaluation: How will values, emotions, and political problems influence our
crisis communication? What may we be mistaken about? Which are the internal
sources of resistance to doing it well and how can we counteract them?
15.2. NATIONAL COMMUNICATION STRATEGY
Most countries have a national preparedness plan for an influenza pandemic that
establishes a communications strategy, including actions such as the following when an
epidemic outbreak or pandemic begins:
Define the first announcements and when they will be made
Establish the limits of transparency
Define who will be the official spokesperson
Define the communication channels
Obtain support for training activities, preparation of messages, definition of
audiences, and selection of communication channels
The communication strategy should be written, approved, and aligned with the National
Preparedness Plan for an Influenza Pandemic.
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15.3. HEALTH FACILITY COMMUNICATION PLANS
The national communication strategies should provide guidance for development of the
communication plans of the health facilities. The activities outlined in these plans tend to
be divided into actions that will be conducted before the pandemic, the first actions at the
beginning of a pandemic, and the actions to be implemented after the pandemic has been
declared and spread internationally. Preparatory activities for the later phases are critical,
and sufficient time must be set aside for each of the activities.
Activities prior to the pandemic
Define who will be included in the communications team (including sponsors and
health volunteers).
Create or activate chains of command and assign persons responsible for each area.
Establish the information flow during a pandemic and assign persons responsible for
each area.
Make known the national communication strategy.
Select a spokesperson and a substitute based on the criteria of credibility, ability to
generate confidence, clear speech, time availability. Preferably select a person
with a high position in the department such as a hospital director.
Prepare all contact information for the communications team (e.g., address, work and
home phone, e-mail, messaging, radio) and keep the information up-to-date and
visible.
Estimate and allocate the necessary financial resources.
Prepare the health workers to communicate with the public, students, local
authorities, and others during their routine visits.
Identify the target audiences (e.g., health workers, school directors, financial
activities, unions, religious organizations, community). Segment the audiences
by district or another significant and manageable territorial unit. Identify the
significant media.
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Record everything the team knows about the different audiences (e.g., how they
reacted to previous crises). Determine whether they speak other languages or
dialects. Describe their resources (e.g., occupational health resources). For the
media, specify whether or not they are associated with the current health
system.
Discuss the emotions generated by a crisis and how they have been dealt with
previously (e.g., fear, anger, victimization, mistrust, mourning).
Design a basic set of messages. Verify their technical consistency and draft them
simply and concisely. Confirm that they are understandable to persons that are
not part of the health system.
Prepare action plans that consider the phase of the epidemic, action times, persons
responsible, forms of feedback and evaluation.
Confirm that the department action plan is consistent with the general plans of the
Ministry of Health. Send the action plan to the Ministry of Health
communication offices and obtain feedback.
Review the plan periodically and update it as appropriate.
Emergence of the pandemic: early announcement
At the beginning of a pandemic, the public will want to know about subjects such as the
following:
Am I or are we safe?
How will it affect me or my family?
Who or what caused this?
Can it be fixed? If you can not fix it, who or what can?
How can I protect myself or my family in the future?
It is important that health workers familiarize themselves with the pandemic
communication strategy in their national preparedness plan, and take into account the
following:
People have the right to information that influences their life.
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If you wait, the news may become known anyway. If this happens, you may lose trust
and credibility.
You can control the accuracy and framework of the information better if you are the
first to present it.
It is more likely that there will be time for significant audience participation in
decision-making if the information is circulated soon.
Early circulation of the information about a situation may prevent similar situations at
other sites.
Less work is needed to circulate the information soon than to respond to the
questions, attacks, and mistrust that can arise due to late circulation.
You will be better prepared to gain the trust of the public if you circulate the
information promptly.
If you wait, people may feel angry and resentful.
It is more likely that people will overestimate the risk if you withhold the
information.
Finally, the following suggestions are provided to guide the communication activities,
particularly for the spokespersons, as well as face-to-face encounters with the media and
community:
General measures:
Do not over-reassure.
Err on the alarming side.
Acknowledge uncertainty.
Share dilemmas.
Acknowledge opinion diversity.
Face the emotional aspect of the crisis:
Do not diagnose or overplan for the panic.
Do not focus your attention on eliminating all fear.
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Do not forget that emotions are different from fear.
Do not ridicule the emotions of the public.
Legitimize the fears of the public.
Tolerate early overreactions.
Recognize your own humanity.
Include the public:
Tell people what you expect and which measures should be taken.
Offer people activities to carry out.
Allow people to choose their own actions.
Ask more about people.
Errors, bad impressions, and partial truths:
Recognize the errors, deficiencies, or improper behavior.
Request often that errors, deficiencies, and improper behavior be excused.
Be explicit about changes in the official opinion, forecast, or policy.
Do not lie or tell half truths.
Focus your attention on sincerity and transparency.
Be careful when making risk comparisons.
References:
1
Normas de comunicación de brotes epidémicos de la OMS, 2006
2
HHS, Administration of Mental Health Services and Substance Abuse
3
Sandman P, Lanard J. Crisis Communication I: How Bad Is It? How Sure Are You? Available
from: http://psandman.com/handouts/sand12a.pdf
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ANNEX 1. SEVEN STRATEGIC ACTIONS FOR APPLICATION OF THE IHR
Strategic action
Objective
GLOBAL PARTNERSHIPS
1
Foster global partnerships
WHO, all countries and all relevant sectors (e.g. health,
agriculture, travel, trade, education, defence) are aware
of the new rules and collaborate to provide the best
available technical support and, where needed, mobilize
the necessary resources for effective implementation of
IHR (2005).
STRENGTH NATIONAL CAPACITY
2
Strengthen national disease
Each country assesses its national resources in disease
surveillance, prevention, control and
surveillance and response and develops national action
response systems
plans to implement and meet IHR (2005) requirements,
thus permitting rapid detection and response to the risk
of international disease spread
3
Strengthen public health security in
The risk of international spread of disease is minimized
travel and transport
through effective permanent public health measures and
response capacity at designated airports, ports, and
ground crossings in all countries
PREVENT AND RESPOND TO INTERNATIONAL PUBLIC HEALTH
EMERGENCIES
4
Strengthen WHO global alert
Timely and effective coordinated response to
and response systems
international public health risks and public health
emergencies of international concern
5
Strengthen the management of
Systematic international and national management of
specific risks
the risks known to threaten international health security,
such as influenza, meningitis, yellow
fever, SARS, poliomyelitis, food contamination,
chemical and radioactive substances. AND
MNITORING
LEGAL ISSUES AND MONITORING
6
Sustain rights, obligations and
New legal mechanisms as set out in the Regulations are
procedures
fully developed and upheld; all professions involved in
implementing IHR (2005) have a clear understanding of
and sustain the new rights, obligations, and procedures
7
Conduct studies and monitor progress Indicators are identified and collected regularly to
monitor and evaluate IHR (2005) implementation at
national and international levels. WHO Secretariat
reports on progress to the World Health Assembly.
Specific studies are proposed to facilitate and improve
implementation of the Regulations
Strategic actions 2-5 are key because they call for significantly strengthened national and global efforts.
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L CAPACITY
ANNEX 2. DECISION-MAKING INSTRUMENT FOR EVALUATION AND REPORTING
OF EVENTS THAT MAY BE A PUBLIC HEALTH EMERGENCY OF INTERNATIONAL
CONCERN
Events detected by the national surveillance system (see Annex 1)
A sudden or unexpected case of any of the following diseases that can have serious repercussions
for public health and, therefore, must be reported. a,b
- Smallpox
- Poliomyelitis associated with wild poliovirus
- Human flu caused by a new subtype of virus
- Severe acute respiratory syndrome (SARS)
The algorithm will be used for all events with potential of becoming a public health problem of
international concern, including events with causes of unknown origin or related to diseases other
than those listed in the boxes on the left and the right.
The algorithm will always be used for events related to the following diseases (it has been
demonstrated that they can have serious repercussions for public health and can spread
internationally rapidly).
- Cholera
- Pneumonic plague
- Yellow fever
- Viral hemorrhagic fevers (Ebola, Lassa, Marburg)
- West Nile Virus
- Other diseases of special national or regional importance (e.g., dengue, Rift Valley fever, and
meningococcal disease)
Does the event have a serious public health repercussion?
Yes / No
Is it a sudden or unexpected event?
Yes / No
Is there a significant risk of international spread?
Yes / No
Is there a significant risk of restrictions on travel or international trade?
Not reported at this time. New evaluation if additional information is available
THE EVENT WILL BE REPORTED TO WHO IN ACCORDANCE WITH INTERNATIONAL
HEALTH REGULATIONS
aAccording to the case definitions established by WHO
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bThis list of diseases will be used exclusively for the purposes of this regulation.
ANNEX 2. EPIDEMIOLOGICAL SURVEILLANCE ALGORITHM
Timely detection of sudden or unexpected SARI
Report
Appropriate and early
Timely sample
case management
collection
Report immediately to
the provincial
Implement measures to
Take samples and
authorities in order to
control intra-hospital
send to the
mobilize rapid response
infection
laboratory as soon
units if required
as possible using
appropriate
transport
Collaborate with the epidemiological investigation, including active case-
finding of more suspected cases and control of the initial outbreak
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ANNEX 3. CALCULATING THE PERCENTAGE OF SARI CASES IN THE HEALTH
FACILITY
In order to determine the epidemiological curve or pattern of cases of SARI in the population
that seeks care at or visits a specific health facility, the weekly percentages of cases of SARI in a
single health facility should be calculated and analyzed by age group.5
This will facilitate identification of an elevation or increase in the number of cases above the
usual levels for the facility during a given time period compared to the number of cases found in
previous years. This could indicate a SARI outbreak, which may have been caused by a virus
with pandemic potential.
Percentage of SARI-related hospital
Number of SARI cases hospitalized weekly
admissions
Total number of weekly hospital admissions
Percentage of SARI-related hospital
Number of SARI cases hospitalized weekly by age group
admissions by age group
Total number of weekly hospital admissions
Percentage of SARI-related deaths
Number of weekly SARI-related deaths
Total number of weekly deaths
Percentage of SARI-related deaths
Number of weekly SARI-related deaths by age group
by age group
Total number of weekly deaths
5 If the population coverage or population assigned to the health facility is known, the epidemiological rates can be calculated.
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ANNEX 4. WEEKLY SARI AND SARI-RELATED MORTALITY CASE REPORT FORMS
Formulario de Recolección Semanal para Casos de Infección Respiratoria Aguda Grave (IRAG)
Servicio de Salud, Departamento de Salud, Región
Semana Epidemiológica #
Hospital Centinela
Fecha de Notificación
Definición de IRAG: Persona con fiebre súbita (sobre 38°C) y tos o dolor de garganta, disnea o dificultad para respirar y necesidad de internamiento en el hospital
Número de Visitas
Total
Menos de 6 meses
6–23 meses
2-4 años
5-14 años
15-49 años
50-64 años
Más de 65 años
Visitas
Visitas
Visitas
Visitas
Visitas
Visitas
Visitas
Visitas
Total es
# IRAG
Totales
# IRAG
Totales
# IRAG
Totales
# IRAG
Totales
# IRAG
Totales
# IRAG
Totales
# IRAG
Totales
# ETI
Lunes
Martes
Miércoles
Jueves
Viernes
Sábado
Dom ingo
Total por semana
Población
Tasa de incidencia
(por 100,000)
Coordinador de vigilancia
Firma:
Severe Acute Respiratory Infection (SARI) Weekly Case Report Form
Health Unit, Health Department, Region
Sentinel Hospital
Epidemiological week no.
Training Course for Health Facility Case-Finding and Response to Sudden or Unexpected Cases of SARI
Date reported
SARI case-finding: person with sudden fever (over 38ºC) and cough or sore throat, dyspnea or breathing difficulty, and need for
hospitalization
Number of Visits
Total / Less than 6 months / 6-23 months / 2-4 years / 5-14 years / 15-49 years / 50-49 years / 50-64 years / Over 65 years
Total visits / Cases SARI
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Total weekly
Population
Incidence rate (per 100,000)
Surveillance coordinator
Signature
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Weekly Hospital Deaths Case Report Form
Health Unit, Health Department, Region
Epidemiological week no.
Sentinel Hospital
Date reported
Surveillance of Severe Acute Respiratory Infection (SARI)-Related Mortality
Less than 6
Total
6–23 months
2-4 years
5-14 years
15-49 years
50-64 years
Over 65 years
months
SARI-related
SARI-related
SARI-related
SARI-related
SARI-related
SARI-related
SARI-related
Total deaths
SARI
Total deaths
Total deaths
Total deaths
Total deaths
Total deaths
Total deaths
Total deaths
deaths
deaths
deaths
deaths
deaths
deaths
deaths
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekly total
Population
Incidence rate (per
100,000)
Surveillance Coordinator
Signature:
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121
ANNEX 5. SARI CASE REPORT FORM. GENERIC PROTOCOL FOR INFLUENZA
SURVEILLANCE
Clinical Epidemiological Registry of Sudden or Unexpected SARI
Physician: ......................................................................
Address: ........................................................................
City/Town: .....................................................................
Province: .......................................................................
Recipient Laboratory:
Tel: ......................................... Fax: ...............................
..............................................................
E-mail: ...........................................................................
Case identification number: (.......................)..............................................
First and last name.............................................................................................................
Date of birth: ....../....../...... Age: ........................
Sex:....................
Date of onset of disease: ....../....../....... Epidemiological week number: ......
Date sample taken: ....../....../..........................
Influenza vaccine: Yes
No Date of vaccination: ...../........./..........
Clinical characteristics
Yes No
Yes No
Fever >38ºC
Adenopathies
Rhinorrhea
Asthenia
Pharyngitis
Headache
Conjunctivitis
Myalgia
Otitis
Vomiting
Bronchitis
Diarrhea
Bronchiolitis
Rash
Pneumonia
Sporadic case
Cough
Onset of symptoms during the
Dyspnea
outbreak
Comments: … … … … … … … … … … … … … … … … … … … … … … … … … …
… … … … … … … … … … … … … … … … … … … …….
Treatment: Antiviral drugs
Yes
No
Type:…… … … … … … ….
Antibiotics
Yes
No
Type:
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ANNEX 6. DIFFERENTIAL DIAGNOSIS OF SARI AND DIAGNOSTIC SPECIMENS
Severe Acute Respiratory Infection
(SARI)
Possible diseases or pathogens
Influenza
Pulmonary syndrome of:
Bacterial
Diphtheria
Hantavirus
pneumonia
Streptococcus
Dengue
Pharyngitis/Scarlet fever
Leptospirosis
Pertussis
Respiratory syncytial virus
2 serum samples
Blood
Specimens
Acute phase and convalescence
Throat swab
(posterior pharynx)
Nasal or nasopharyngeal
Laboratory Tests
swab or aspirate
Culture, serotyping,
antigen detection,
antibody level,
susceptibility
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Source: Adaptation of guidelines for collection of clinical specimens during field
investigation of outbreaks. WHO/CDS/CSR/EDC/2000.4
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ANNEX 7. RESPIRATORY TRACT SAMPLING TECHNIQUES
Nasal swab
− Insert a dry polyester or Dacron swab into the nostril, parallel to the palate, using a rotating
motion. Apply pressure on the walls of the nasal septum in order to collect as many cells as
possible.
− Insert the swab into the tube that contains the transport medium:
– If a commercial medium is used, place the swab in the transport tube and press on
or apply pressure to the padding on the bottom of the tube in order to release the
medium.
– If a laboratory-prepared medium is used, break off the stick from the swab so that
only the part adhered to the swab remains in the tube. Close the tube with the cap.
The swabs should always be kept moist during shipping.
Throat swab
− Use a swab to brush the tonsils and the back of the pharynx. Then insert the swab into the
transport medium as indicated in the previous section.
− If a laboratory-prepared medium is used, both swabs (nasal and pharyngeal) can be sent in the
same transport medium.
Nasopharyngeal aspirate
− Materials
– Nasopharyngeal aspiration kit
– Test tube rack
– Cold-storage units
– Vacuum pump
– Container with disinfectant solution
− Method
– Open the envelope that contains the aspiration kit and connect the end of the tube
with smaller diameter to the aspiration tube.
– Connect the end with larger diameter to the vacuum pump.
– Insert the nasogastric tube into the nostril of the patient.
– Remove the tube with a gentle rotating motion. Then repeat the procedure in the
other nostril.
– Aspirate a volume of approximately 8-10 mL of cold buffer solution at pH 7.2
through the collector tube in order to collect all of the secretions.
– Change the cap of the sample collection tube and identify it with the patient data.
– Send the sample to the laboratory immediately with the sample shipment form. Make
sure that it is kept in the ice bath until it reaches the laboratory.
Source: PAHO/CDC Generic Protocol for Influenza Surveillance
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ANNEX 8. PACKING THE SAMPLES FOR TRANSPORT
→ Keep the samples at a temperature of 4ºC.
→ Fill a refrigerator with packs of ice or coolants.
→ Keep the samples in double packing if dry ice is used.
Include a detailed list of the samples with identification numbers and instructions for the laboratory.
Packing the samples for transport
Use three layers of packing.
The first layer should have passed the filtration test
.
Use absorbent material in all of the layers.
Do not place more than 500 mL in the packing.
Transport of samples
Take into account the WHO guidelines for safe transport of infectious substances and diagnostic
samples. Follow the local standards for transport of infectious materials.
Coordinate with the laboratory.
Transport of samples from the health facility to the laboratory
Handling infectious material in the health facility
Always use personal protective equipment. Emphasize the importance of hand washing
.
Be careful with the sharps.
Handle all of the samples as if they were infected.
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ANNEX 9. FORM FOR MONITORING HEALTH WORKERS FOR CASE-FINDING OF
INFLUENZA-LIKE ILLNESSES IN HEALTH WORKERS EXPOSED TO PATIENTS
6
WITH SUDDEN OR UNEXPECTED SARI
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Heath Establishments Preparation for Unusual or Unexpected Cases or Clusters of Sever Acute Respiratory Infection (SARI)
Name: _________________________________ Home phone: _____________________
Job: _____________________________ Workplace:_________________________
Date(s) of exposure (List all dates. Use the back of the sheet if required): ____/____/_______ ____/____/________
Type of contact with patient with serious respiratory infection of potential concern, the patient environment, or the
virus:
_____________________________________________________________________________________
Was the following personal protective equipment (PPE) used?
PPE Yes
No
Do
not
know
Gown
Gloves
Particle respirator
Surgical mask
Eye protection
Other
(Please specify)
List any non-occupational exposure (i.e., exposure to birds or persons with febrile severe acute respiratory disease):
_________________________________________________________________
Take your temperate twice daily, in the morning (AM) and the afternoon (PM), for 10 days after providing care for a
patient infected with an acute respiratory disease of potential concern (including 10 days after the last exposure) and
monitor onset of any of the following symptoms of influenza-like illness (ILI), including:
-
fever >38 °C
-
cough
-
sudden onset of respiratory disease
-
sore throat
-
arthralgia
-
myalgia o prostration
-
gastrointestinal symptoms (e.g, diarrhea, vomiting, abdominal pain)
If any symptom of ILI occurs, limit your interaction with others immediately. Do not visit public areas and report to
_______________________in _____________________
Day 1
Day 2
Day 3
Day 4
Day 5
Date
Date
Date
Date
Date
____/____/_____
____/____/_____
____/____/_____
____/____/_____
____/____/______
Temperature AM:
Temperature AM:
Temperature AM:
Temperature AM:
Temperature AM:
______________
_______________ _______________ _______________ _______________
Temperature PM:
Temperature PM:
Temperature PM:
Temperature PM:
Temperature PM:
________________ ______________
_____________
_______________ ________________
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
No ____ Yes ___
No ___ Yes ___
No ___ Yes ____
No ___ Yes ____
No ___ Yes ____
Day 6
Day 7
Day 8
Day 9
Day 10
Date
Date
Date
Date
Date
____/____/_____
____/____/_____
____/____/_____
____/____/______
____/____/______
Temperature AM:
Temperature AM:
Temperature AM:
Temperature AM:
Temperature AM:
_______________ _______________ _______________ _______________
_______________
Temperature PM:
Temperature PM:
Temperature PM:
Temperature PM:
Temperature PM:
_______________ ______________
______________
________________ ________________
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
Symptoms of ILI:
No ___ Yes ___
No ___ Yes ____
No ___ Yes ____
No ___ Yes ____
No ___ Yes ____
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6Prevention and control of acute respiratory diseases with epidemic and pandemic potential during health care. Provisional WHO guidelines. June
2007 (WHO/CDS/EPR/2007.6).
ANNEX 10: TRIAGE
TRIAGE SCALES
PATIENT CLASSIFICATION CRITERIA BY COLOR (1)
Type of Patient
Referral
Treatment
Healthy, no respiratory symptoms
Home
Biosafety measures
Respiratory symptoms not
Home
Symptomatic and biosafety
compatible with influenza
measures
Influenza-like symptoms, without
Strict home
Symptomatic and biosafety
pulmonary complications and
isolation
measures
without additional chronic disease
Clinical symptoms of influenza
Care and isolation
Symptomatic and antiviral
without pulmonary complications
centera
and/or controlled chronic disease
Clinical symptoms of influenza
Permanent or field
Compensaction of chronic
with pulmonary complications
hospital medical
disease and complications
and/or chronic decompensated
unit
disease
Death due to suspected or
Forensic medical unit
confirmed clinical symptoms of
influenza
aUnits located in alternative treatment centers (e.g., gymnasiums, hotels, schools) with capacity for
outpatient care of exclusive cases of influenza-like illness.
The United States Influenza Pandemic Preparedness Plan and Response includes other
methodologies for defining the immediate destination of the patient, which are described below (2):
For adults
• The preliminary IDSA-ATS guidelines recommend the use of severity scores or scales such as the
Pneumonia Severity Index (PSI) or PORT Score and the CURB-65 System in order to determine
which patients can be safely treated as outpatients.
For Children
• The current guidelines provide indicators for hospitalization of children with community-acquired
pneumonia. For infants the indications include temperature >38.5ºC, RR >70 breaths/minute,
thoracic retraction (inspiration), nasal inflammation, hypoxia, cyanosis, intermittent apnea, snoring,
and poor diet. The indications for hospitalization of older children include temperature >38.5ºC, RR
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>50 breaths/min, thoracic retraction, nasal inflammation, hypoxia, cyanosis, snoring, and signs of
dehydration.
As with pandemic influenza, the decision to hospitalize for community-acquired post-influenza
bacterial pneumonia during the pandemic period will be based on clinical assessment of the patient
by the physician, as well as the availability of hospital resources and staff. Although unstable
patients will be considered high priority, patients with conditions that entail high risk of
complications also require special care. Home management with follow-up may be appropriate for
young children with satisfactory appearance that only have fever.
Risk groups for influenza complications
The Advisory Committee on Immunization Practices (ACIP) currently recognizes the following
groups as those with highest risk for complications of seasonal influenza (e.g., hospitalization,
death) compared to healthy older children and young adults (3).
•
Persons aged > 65 years
•
Residents of nursing homes and other chronic care facilities that house persons of any age
with chronic medical conditions.
•
Adults and children with chronic disorders of the pulmonary or cardiovascular systems,
including asthma.
•
Adults and children who have required regular medical follow-up or hospitalization during the
previous year due to chronic metabolic diseases (including diabetes mellitus), renal
dysfunction, or immunosuppression (including immunosuppression that is caused by
medication or by human immunodeficiency virus [HIV]).
•
Children and adolescents (aged 6 months to 18 years) who are receiving long-term aspirin
therapy and, therefore, are at risk of Reyes syndrome.
•
Pregnant women
•
All children aged < 2 years
•
All persons with conditions that can affect respiratory function or respiratory secretion
management, or can increase the risk of aspiration.
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CALCULATION OF THE PNEUMONIA SEVERITY INDEX (PORT SCORE)
Characteristic of Patient
Points Assigned
Demographic Factor
Age
Male
Age
Female
Age –10
Resident of nursing home or similar institution
+10
Comorbid disease
Neoplastic disease
+30
Hepatic disease
+20
Congestive heart failure
+10
Cerebrovascular disease
+10
Kidney disease
+10
Physical examination findings
Altered mental status
+20
Respiratory rate > 30 breaths/min
+20
Systolic blood pressure <90 mm Hg
+20
Temperature <35ºC or >40ºC
+15
Pulse > 125 bpm
+10
Laboratory and/or X-ray findings
Arterial pH <7.35
+30
Blood urea nitrogen >30 mg/dL
+20
Sodium <130 mmol/L
+20
Glucose >250 mg/dL
+10
Hematocrit <30%
+10
Hypoxemia
+10
Pulse oximetry <90%
Arterial blood gas <60 mm Hg
Pleural effusion in baseline X-ray
+10
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RISK CLASSIFICATION ACCORDING TO PNEUMONIA SEVERITY INDEX (PSI)
Recommended
PSI risk class
Characteristics and points
treatment site
I
Age >50 years + no morbid conditions, Outpatient
vital signs within normal range, normal
mental status
II
<70
Outpatient
III
71–90
Outpatient/Brief
admission
IV
91–130
Inpatient
V
>130
Inpatient
CURB-65 SCORING SYSTEM
Characteristic
Points
Confusiona +1
Urea >7 mmol/L (20 mg/dL)
+1
Respiratory rate >30 breaths/min
+1
Blood pressure (systolic <90 or diastolic <60 mm Hg)
+1
Age >65 years
+1
a Based on specific mental assessment or person, time, or place disorientation
Patient score
Recommended treatment site
0 – 1
Outpatient
2
Hospital room admission
3 – 5
Hospital room or ICU admission
VERSION APRIL 2009 132
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CRITICAL CARE TRIAGE PROTOCOL
Another critical point is insufficient availability of the ventilators and intensive care units that will
be required for care of serious cases of SARI. The decision-making process can be complex when
there are too many cases with similar needs but insufficient capacity to treat them. In these cases,
more objective mechanisms of prioritization must be used that allow the clinician to make a
decision in critical situations based on scientific evidence.
The protocol that is presented is only one form of addressing the problem. There should be a
consensus between the clinicians and the administrators of the health facility that will define the
guidelines on this subject in the final analysis. The protocol is based on an adaptation of the
Sequential Organ Failure Assessment (SOFA) score (4).
TOOL USED TO ASSIGN PRIORITIES IN THE TRIAGE PROTOCOL FOR
ASSESSMENT OF PATIENTS THAT REQUIRE INTENSIVE CARE IN
AN INFLUENZA PANDEMIC (5)
Initial assessment
Triage
Criteria
Action or priority
code
Manage medically
Exclusion criteria met or SOFA score
Blue
Provide palliative care as needed
>11a
Discharge from critical care
Red
SOFA score ≤7 or single-organ failure High priority
Yellows SOFA score 8-11
Intermediate priority
Referral or discharge from critical
Green
No significant organ failure
care
Reassess if needed
aIf the patient meets the exclusion criteria or the SOFA score is >11 at any time from the initial
assessment until 48 hours later, change the triage code to blue and proceed as indicated.
48-hour assessment
Triage
Criteria
Action or priority
code
Exclusion criteria met or SOFA score Provide palliative care if needed
Blue
stable 8–11 with no change
Discharge from critical care
Red
SOFA score ≤ 11 and decreasing
High priority
SOFA score stable at <8 with no
Yellow
Intermediate priority
change
Green
No longer dependent on ventilator
Discharge from critical care
VERSION APRIL 2009 133
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120-hour assessment
Triage
Criteria
Action or priority
code
Exclusion criteria met or SOFA score Provide palliative care
Blue
>11 or SOFA score < 8 with no
Discharge from critical care
changeb
SOFA score <11 and decreasing
Red
High priority
progressively
SOFA score < 8 with minimal
Yellow
Intermediate priority
decrease
Green
No longer dependent on ventilator
Discharge from critical care
Instructions for Application of Triage Protocolc
1. Assess whether the patient meets the inclusion criteria
• If yes, proceed to step 2.
• If no, reassess the patient later to determine whether clinical status has deteriorated.
2. Assess whether the patient meets the exclusion criteria
• If no, proceed to Step 3
• If yes, assign blue triage code. Do not transfer the patient to critical care. Continue current
level of care or provide palliative care as needed.
3. Proceed with application of the protocol (initial assessment).
b If the patient meets the exclusion criteria or the SOFA score is >11 at any time between 48 and
120 hours after the initial assessment, change the triage code to blue and proceed as indicated.
c The authors suggest that this protocol be applied in all patients that could require critical care,
whether or not they have symptoms of influenza.
VERSION APRIL 2009 134
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Inclusion Criteria
The patient must have one of the following:
A. Criteria for invasive ventilatory support
• Refractory hypoxemia (SPO2 < 90% with no ventilatory mask or FiO2 > 0.85
• Refractory acidosis (pH < 7.2)
• Clinical evidence of imminent respiratory failure
• Inability to protect or maintain airway
B. Hypotension (systolic pressure < 90 mm HG or relative hypotension) with clinical evidence of
shock (altered state of consciousness, decreased urine output, or other evidence of end-organ
failure) refractory to volume resuscitation requiring vasopressor or inotropic support that cannot be
managed in a ward setting.
Exclusion Criteria
The patient is excluded from admission or transfer to a critical care unit if any of the following
criteria are met:
A. Severe trauma
B. Severe burn with one of the following criteria:
• Age > 60 years
• 40% of body surface area affected
• Inhalation injury
C. Cardiac arrest
• unwitnessed cardiac arrest
• witnessed cardiac arrest that does not respond to defibrillation or pacemaker
• recurrent cardiac arrest
D. Serious cognitive impairment
E. Advanced untreatable neuromuscular disease
F. Metastatic malignant disease
G. Advanced and irreversible immune compromise
H. Severe and irreversible neurological condition or event
I. End-stage organ failure that meets the following criteria:
• Heart
New York Heart Association (NYHA) class III or IV heart failure
• Lungs
COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mm Hg or secondary pulmonary
hypertension
Cystic fibrosis with post-bronchodilatation FEV1 > 30% or PaO2 < 55 mm Hg
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Pulmonary fibrosis with VC or TLC < 60% predicted, PaO2 < 55 mm Hg or secondary
pulmonary hypertension
Primary pulmonary hypertension with NYHA class III or IV heart failure, right atrial pressure
> 10 mm Hg or mean pulmonary artery pressure 50 mm Hg
• Liver
Child-Pugh score ≥7
J. Age over 85 years
Sequential Organ Failure Assessment (SOFA) Score
Score
Variable 0
1
2
3
4
PaO2/FIO2 mm Hg
>400
≤400
≤300
≤200
≤100
Platelet count x 106/L >150 ≤150
≤100
≤50
≤20
Bilirubin levels, mg/dL
<1.2 (<20)
1.2-1.9
2.0-5.9
6.0-11.9 (101- >12
(μmol/L)
(20-32)
(33-100)
203)
(>203)
Hypotensiona None
MABP
<70
Dop
≤ 5
Dop >5
Dop > 15
Epi ≤ 0.1
Epi > 0.1
Norepi≤ 0.1
Norepi > 0.1
Glasgow coma score
15
13-14
10-12
6-9
<6
Creatinine level, mg/dL
<1.2
1.2-1.9
2.0-3.4
3.5-4.9
>5
(μmol/L)
(<106)
(106-168)
(169-300)
(301-433)
(>434)
PaO2= Partial pressure of arterial oxygen
FIO2= Fraction of inspired oxygen
MABP= Mean arterial pressure in mm Hg
aDop (dopamine), Epi (epinephrine), Norepi (norepinephrine) doses in μg/kg /minute
NYHA Functional Classification of Heart Failure
This system relates patient symptoms and everyday activities
Class
Patient symptoms
Class I (mild)
No limitation of physical activity. Ordinary physical activity does
not cause fatigue, palpitation, or dyspnea.
Class II (mild)
Slight limitation of physical activity. Comfortable at rest, but
ordinary activities can cause fatigue, palpitation, or dyspnea.
Class III(moderate) Marked limitation of physical activity. Comfortable at rest, but
minimal ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (severe)
Unable to perform any physical activity without discomfort.
Symptoms of heart failure at rest. Any physical activity increases the
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Heath Establishments Preparation for Unusual or Unexpected Cases or Clusters of Sever Acute Respiratory Infection (SARI)
discomfort
Child-Pugh Score
The scale uses five clinical measures of liver disease, each of which established a score from 1 to 3,
with 3 as the most abnormal.
Unit of
Measure
1 point
2 points
3 points
measurement
Total bilirubin
<34 (<2)
34–50 (2-3)
>50 (>3)
μmol/l
(mg/dL)
Serum albumin
>35
28–35
<28
g/L
INR
<1.7
1.71–2.20
> 2.20
No unit
Ascites None
Responds
to
Refractory
No unit
medication
Hepatic
None
Grade I-II (or
Grade III-IV (or
No unit
encephalopathy
responds to
refractory)
medication)
Interpretation
Points Class 1 yr survival probability
2 yr survival probability
5-6 A 100%
85%
7-9 B 81%
57%
10-15 C
45%
35%
References:
1. Plan Nacional de Preparación y Respuesta a una Pandemia de Influenza, Manual Operativo, Secretaría de
Salud Mexico, 2005.
2. HHS, Pandemic Influenza Plan, 2006.
3. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 2005; 54:1-40. Available from: http:// www.cdc.gov/mmwr/pdf/rr/rr54e713.pdf.
4. Ferrerira FL, Bota DP, Bross A., et al. Serial evaluation of the SOFA score to predict outcome in critically ill
patients. JAMA 2001;286:1754-8.
5. Michael Christian et al. Development of triage protocol for critical care during an influenza pandemic, CMAJ
2006; 175(11):10.
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