H7N9 influenza

[Michael Wishart]

[Forwarded on behalf of Claire Boardman – Moderator]
>
> Information for clinicians
>
> As you’d be aware, human cases of H7N9 influenza has been reported in
> China. Some information for clinicians (received from Dr Gary Lum at
> Office of Health Protection and summarized with permission), current
> as of Friday 5 April.
>
> 1. The number of confirmed patients is 11, including 5 fatalities.
>
> 2. There continues to be no evidence of human-to-human transmission
> and no epidemiological links between patients have been found.
>
> 3. All the patients detected to date have been seriously unwell.
>
> 4. Cases have been clustered in the central eastern provinces (3
> Shanghai; 1 Anhiu; 4 Jiangning and 3 Zhejiang). These are the
> provinces around the cities of Shanghai and Nanjing.
>
> 5. Analyses indicate that this virus is resistant to adamantanes but
> susceptible to oseltamivir.
>
> 6. This virus is subtyped as LPAI (for birds) H7N9 and appears to be
> an assortment of 3 avian viruses; the first 3 strains have been
> sequenced and appear to be closely related genetically.
>
> Testing
>
> PCR protocols have been developed and web-based publication is
> planned. Export of the virus to allow validation is also planned.
> Testing of suspected cases in Australia should be performed in
> consultation with jurisdictional public health units and reference
> laboratories.
>
> Further information for clinicians is being developed by CDNA.
>
> Historically
>
> No previous cases of H7 in humans have been reported in China (or
> Asia) prior to these cases
>
> Infection with H7 viruses is rare in humans, but viruses from both
> lineages (North American and Eurasian) have caused infection
> previously. Observed symptoms include conjunctivitis and mild
> respiratory symptoms. One fatal case (pneumonia) with HPAI H7N7 was
> reported in the Netherlands in 2003.
>
> Most human cases of H7 have been linked to occupational exposure (i.e.
> contact with poultry or laboratory exposure)
>
> The virus appears resistant to amantanes (e.g., amantadine) and
> susceptible to neurominidase inhibitors (oseltamivir and zanamivir).
>
> Further information is also available on the WHO website:
> http://www.who.int/influenza/human_animal_interface/faq_H7N9/en/index.html
>
> Allen
>
> —
> Allen Cheng
> Associate Professor in Infectious Diseases Epidemiology
> Department of Epidemiology and Preventive Medicine
> Monash University
>
> Infectious Diseases Physician
> Alfred Hospital
>
> Honorary Principal Research Fellow
> Menzies School of Health Research
>

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Michael Wishart
Infection Control Coordinator
St Vincent's Private Hospital Northside & St Vincent's Private Hospital Brisbane
Brisbane, QLD
michael.wishart@svha.org.au

[Anonymous]

Hi Michael
The WHO address came up as page not found.
Any chance you may be able to check same?
Thanks
Emmajane

Emmajane O’Donoghue

Infection Control Consultant
HICMR Pty Ltd
(Healthcare Infection Control Management Resources)
Level 1, 123 Camberwell Road, Hawthorn East 3123
Ph: (03) 98119923 Fax: (03) 98824534
National pager number: 1300-657-359
http://www.hicmr.com.au

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Saturday, 6 April 2013 10:47
To: AICALIST@AICALIST.ORG.AU
Subject: H7N9 influenza

[Forwarded on behalf of Claire Boardman – Moderator]
>
> Information for clinicians
>
> As you’d be aware, human cases of H7N9 influenza has been reported in
> China. Some information for clinicians (received from Dr Gary Lum at
> Office of Health Protection and summarized with permission), current
> as of Friday 5 April.
>
> 1. The number of confirmed patients is 11, including 5 fatalities.
>
> 2. There continues to be no evidence of human-to-human transmission
> and no epidemiological links between patients have been found.
>
> 3. All the patients detected to date have been seriously unwell.
>
> 4. Cases have been clustered in the central eastern provinces (3
> Shanghai; 1 Anhiu; 4 Jiangning and 3 Zhejiang). These are the
> provinces around the cities of Shanghai and Nanjing.
>
> 5. Analyses indicate that this virus is resistant to adamantanes but
> susceptible to oseltamivir.
>
> 6. This virus is subtyped as LPAI (for birds) H7N9 and appears to be
> an assortment of 3 avian viruses; the first 3 strains have been
> sequenced and appear to be closely related genetically.
>
> Testing
>
> PCR protocols have been developed and web-based publication is
> planned. Export of the virus to allow validation is also planned.
> Testing of suspected cases in Australia should be performed in
> consultation with jurisdictional public health units and reference
> laboratories.
>
> Further information for clinicians is being developed by CDNA.
>
> Historically
>
> No previous cases of H7 in humans have been reported in China (or
> Asia) prior to these cases
>
> Infection with H7 viruses is rare in humans, but viruses from both
> lineages (North American and Eurasian) have caused infection
> previously. Observed symptoms include conjunctivitis and mild
> respiratory symptoms. One fatal case (pneumonia) with HPAI H7N7 was
> reported in the Netherlands in 2003.
>
> Most human cases of H7 have been linked to occupational exposure (i.e.
> contact with poultry or laboratory exposure)
>
> The virus appears resistant to amantanes (e.g., amantadine) and
> susceptible to neurominidase inhibitors (oseltamivir and zanamivir).
>
> Further information is also available on the WHO website:
> http://www.who.int/influenza/human_animal_interface/faq_H7N9/en/index.
> html
>
> Allen
>
> —
> Allen Cheng
> Associate Professor in Infectious Diseases Epidemiology Department of
> Epidemiology and Preventive Medicine Monash University
>
> Infectious Diseases Physician
> Alfred Hospital
>
> Honorary Principal Research Fellow
> Menzies School of Health Research
>

Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

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[Michael Wishart]

[Further information on H7N9 Influenza Moderator]

Update from Gary Lum, Office of Health Protection today

* The number of confirmed cases has increased to 21, including 6 fatalities (WHO update 7 April).
* Cases have now been detected across the disease spectrum from mild (3 cases) through to deaths. Median age of all cases is 59 years (range 487).
* There continues to be no evidence of human-to-human transmission (based on active surveillance of 530 close contacts)
* Cases have been clustered in the central eastern provinces around Shanghai/Nanjing (9 Shanghai; 2 Anhui;7 Jiangning and 3 Zhejiang)
* H7N9 virus has been detected in pigeon and chicken and environmental samples collected at three separate market places in Shanghai and in quail samples (Hangzhou Farmers market).
A more complete document for clinicians (including testing and infection control recommendations) is being worked on and will be disseminated widely today or tomorrow.
Allen

Allen Cheng
Associate Professor in Infectious Diseases Epidemiology
Department of Epidemiology and Preventive Medicine
Monash University

Infectious Diseases Physician
Alfred Hospital

Honorary Principal Research Fellow
Menzies School of Health Research

—
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[Michael Wishart]

[Further information shared from asid-ozbug Moderator]
Further information (particularly regarding requirements to notify and where to refer for testing) will be available from your state/territory public health units.

This information from CDNA and PHLN provides details of testing (pneumonia with recent travel to China, although testing may be considered in milder cases) and infection control policies (airborne/contact until further information is available about transmission).
Allen Cheng

H7N9 Influenza
Important information for Clinicians and Laboratories

Summary: As of 7 April, 2013, 21 cases of H7N9 influenza have been reported in China, including 6 deaths. Although the environmental source has not yet been definitively determined, some of the confirmed cases have been associated with contact with chickens or poultry or an animal wet market environment.
In patients with acute pneumonia or pneumonitis with a history of travel to China within 7 days of illness onset, or contact with known confirmed or probable cases, the following is recommended:
1. Place the patient in a single room with negative pressure air-handling, or a single room from which the air does not circulate to other areas, and implement standard and transmission-based precautions (contact and airborne), including the use of personal protective equipment (PPE).
2. Investigate and manage the patient as for community acquired pneumonia. Appropriate specimens should also be collected for influenza PCR testing.
3. Arrange testing of any suspected or probable cases (see case definition) in accordance with the instructions below. Notify any suspected, probable or confirmed cases promptly to your local public health authorities.
What is the H7N9 influenza?
Influenza (A)H7 viruses are a group of influenza viruses that normally circulate among birds. H7N9 is a reassortant derived from three different avian influenza viruses. This strain is distinct from the H1N1/09 (that caused the 2009 pandemic in humans) and H5N1 influenza. H7N9 that is genetically similar to that detected in infected humans has been detected in pigeon and poultry samples collected at a live animal market in Shanghai. Unlike other influenza strains, including highly pathogenic avian influenza H5N1, this new virus is hard to detect in poultry because this novel virus causes little to no signs of disease in animals.
Although there is no evidence of human-to-human transmission of H7N9 to date, sequence analysis indicates the virus has properties to infect mammalian cells; therefore, the potential for avian-human and human-human transmission exists but requires further investigation. Sequences previously associated with high virulence of A(H7) in humans (PB2 gene) have been detected in isolates in the current outbreak.
What is the current situation?
See WHO website on the current situation, including epidemiological updates, Q&A and guidance documents:
Disease Outbreak News http://www.who.int/csr/don/en/index.html
Influenza at the Human-Animal Interface http://www.who.int/influenza/human_animal_interface/en/

A total of 21 cases have been reported from China, including six deaths. To date cases have been reported from four eastern provinces of China (Shanghai, Anhui, Jiangsu and Zhejiang).
There continues to be no evidence of human-to-human transmission with medical observation of over 530 contacts ongoing. In Jiangsu, investigation is ongoing into a contact of an earlier confirmed case who developed symptoms of illness.
The incubation period is not precisely known.
There is currently no vaccine available for H7N9 influenza. Laboratory testing conducted in China has shown that the influenza A(H7N9) viruses are sensitive to neuraminidase inhibitors (oseltamivir and zanamivir). When these drugs are given early in the course of illness, they have been found to be effective against seasonal influenza virus and influenza A(H5N1) virus infection. However, at this time, there is no experience with the use of these drugs for the treatment of H7N9 infection.
From 1996 to 2012, human infections with H7 influenza viruses (H7N2, H7N3, and H7N7) were reported in Netherlands, Italy, Canada, USA, Mexico and the United Kingdom. Most of these infections occurred in association with poultry outbreaks.

What are the symptoms?
H7N9 was initially identified in patients with severe pneumonia and/or Acute Respiratory Distress Syndrome (ARDS) but 3 recent cases have been mild. Symptoms include fever 38C, cough and shortness of breath. However, information is still limited about the full spectrum of disease that infection with influenza A(H7N9) virus might cause.
Symptoms and signs of A(H7) infections during previous outbreaks mainly resulted in conjunctivitis and mild upper respiratory symptoms, with the exception of one death, which occurred in the Netherlands.
Are health workers at risk from H7N9 influenza?
The routes of transmission to humans of the H7N9 influenza have not yet been fully determined, but there is currently no evidence that this strain can spread from human to human. Infection control recommendations in this document for suspected, probable and confirmed cases aim to provide the highest level of protection for health care workers, given the current limited state of knowledge.
Has WHO recommended any travel or trade restrictions related to this new virus?
The number of cases identified in China is very low. WHO does not advise the application of any travel measures with respect to visitors to China nor to persons leaving China. There is no evidence to link the current cases with any Chinese products. WHO advises against any restrictions to trade at this time.
Who do I test for H7N9 influenza?
Testing should be considered for:
1. Individuals with acute pneumonia or pneumonitis and history of travel to, or residence in China within the previous 7 days.
2. Individuals with acute pneumonia or pneumonitis and history of contact with those in point 1 above.
3. Health care workers with acute pneumonia, who have been caring for patients with severe acute respiratory infections, particularly patients requiring intensive care, without regard to place of residence or history of travel.
How do I test for H7N9?
Where H7N9 infection is suspected, samples should be referred to the jurisdictional PHLN laboratory for testing. Specimens can be handled and transported routinely. They should be clearly identified as requiring urgent testing for influenza A/H7N9, and separated from non-urgent specimens. The reference laboratory should be notified.
Collect combined nose and throat swabs (usually from adults) or nasopharyngeal aspirates (usually from children) and place in viral transport medium. Sputum is strongly recommended wherever possible. Bronchoalveolar samples and lung biopsy should also be sent if available.
Gloves, gown, surgical mask and eye protection should be worn as a minimum when collecting samples from patients. For invasive samples (nasopharyngeal aspirates, BAL and other samples where aerosols may be produced) a P2 respirator mask is recommended. If a negative pressure room is unavailable, the patient should be placed in a single room with the door closed.
Testing for other infectious causes can be undertaken at the referring laboratory using PC2 precautions, processing of samples in a biosafety cabinet and use of PPE including a surgical mask and eye protection. Routine tests for acute pneumonia should be performed where indicated, including bacterial culture, serology, urinary antigen testing and tests for influenza viruses.
The laboratory carrying out the influenza testing should immediately refer all unsubtypeable or presumptive H7 influenza A virus to one of the National Influenza Centres or the WHOCC in Melbourne.
Laboratory staff should handle specimens under enhanced PC2 conditions, with handling of open samples in a biosafety cabinet and the use of gloves, gowns, masks and eye protection. PC3 conditions are required for virus culture.
What are the recommended isolation and PPE recommendations for patients in hospital?
While further information is accumulating, current recommendations are for airborne transmission precautions for suspected, probable or confirmed cases.
These recommendations on isolation and PPE for probable and confirmed cases take a deliberately cautious approach by recommending measures that aim to control the transmission of pathogens that can be spread by the airborne route. These measures are detailed in NHMRC: Australian Guidelines for the Prevention and Control of Infection in Healthcare 2010 (particularly section B2.4).
In summary, transmission-based precautions for probable and confirmed cases should include:
Placement of confirmed and probable cases in a negative pressure room if available, or in a single room from which the air does not circulate to other areas
Airborne transmission precautions, including routine use of a P2 respirator, disposable gown, gloves, and eye protection when entering a patient care area
Standard and contact precautions, including close attention to hand hygiene
If a single or negative pressure room is not available (eg in primary care settings), or if transfer of the confirmed or probable case outside the negative pressure room is necessary, asking the patient to wear a surgical face mask, if tolerated, while they are being transferred and to follow respiratory hygiene and cough etiquette.
Triage areas should have signs asking that patients with severe respiratory tract infections with a recent history of travel to China should make themselves known so that appropriate arrangements can be made.

Case Definitions

1. Suspected case (under investigation)*
A person with an acute febrile respiratory infection with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g. pneumonia, pneumonitis or Acute Respiratory Distress Syndrome (ARDS))
AND
With one or more of the following exposures during the 7 days prior to the onset of symptoms:
Travel to a country where human cases of H7N9 influenza have recently been reported, especially if there was recent direct or close contact with animals (e.g. wild birds, poultry or pigs).
Close contact with a laboratory-confirmed case.
2. Probable Case
A person fitting the definition of a Suspected Case but with no possibility of laboratory confirmation for H7N9 influenza, either because the patient or samples are not available for testing AND
Not already explained by any other infection or aetiology, including all clinically indicated tests for community acquired pneumonia according to local management guidelines.
3. Confirmed Case
A person with laboratory confirmation of infection with H7N9 influenza at a WHO National Influenza Centre.

* Although most of the cases to date have presented with a severe acute respiratory illness, mild cases have been reported. If doctors are concerned about patients presenting with milder illness, they should discuss this with the local public health authorities.
Currently, China (excluding Hong Kong) is the only country that has recently reported human cases of H7N9 influenza.
Close contacts include:
Any person who provided care for the patient or who had other similarly close physical contact while not wearing appropriate PPE in the 7 days before symptom onset; this includes health care workers or family members.
Any person who stayed in the same household as a probable or confirmed case while the case was symptomatic.

Advice for contacts of cases
Contacts of cases should be directed to the local public health unit for advice.
Advice for travellers to China
At this time, it is advisable that travellers to China keep away from sick and dead poultry and livestock and avoid visiting live animal markets.
Advice for returned travellers
At this time, if returned travellers meet the exposure criteria for the case definition but have a less severe respiratory illness, advice regarding further management should be sought from the local public health unit
Other useful links
UN Food and Agriculture Organization of the United Nations (FAO) http://www.fao.org/news/story/en/item/173655/icode/

—
Allen Cheng
Associate Professor in Infectious Diseases Epidemiology
Department of Epidemiology and Preventive Medicine
Monash University

Infectious Diseases Physician
Alfred Hospital

Honorary Principal Research Fellow
Menzies School of Health Research

—
WARNING : This email contains information, which is CONFIDENTIAL, and that maybe subject to LEGAL PRIVILEGE. This e-mail and any attachments to it (the “Communication”) is confidential and is for the use only of the intended recipient, and may not duplicated or used by any other party without the express consent of the sender. The Communication may contain copyright material of St Vincent’s Health & Aged Care(“SVHAC”), or any of its related entities or of third parties. If you are not the intended recipient of the Communication, please notify the sender immediately by return e-mail, delete the Communication, and do not read, copy, print, retransmit, store or act in reliance on the Communication. Any views expressed in the Communication are those of the individual sender only, unless expressly stated to be those of SVHAC. SVHAC does not guarantee the integrity of the Communication, or that it is free from errors, viruses or interference. Thank-you.

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