Filariasis Isabelita M.

Samaniego MD Session Objectives To describe the epidemiology/ health situationer of filariasis  To discuss the goals, objectives and strategies of the programs of DOH and WHO for filariasis To describe the following about filariasis: Life cycle Pathogenesis and pathology Clinical features Diagnosis Management Prevention Treatment Epidemiology  1.2 billion people in 80 endemic countries are at risk of lymphatic filariasis. > 120 million people are currently living with the disease,  40 million who are incapacitated and disfigured by it. One third of these infected live in India, one third in Africa and most of the remainder in Asia, the Pacific and America. Among the 38 Least Developed Countries, 32 are endemic for LF. Epidemiology Epidemiology 90% of these infections are caused by Wuchereria bancrofti, and most of the remainder by Brugia malayi The major vectors for W. bancrofti are Culex mosquitoes - most urban and semi-urban areas Anopheles - more rural areas of Africa and elsewhere Aedes species - many of the endemic Pacific islands Brugian parasites are confined to areas of east and south Asia, especially India, Malaysia, Indonesia, the Philippines, and China Epidemiology Filariasis It is a parasitic infection transmitted by a mosquito Two species of the parasite that cause filariasis exist in the Philippines: Wuchereria bancrofti and Brugia malayi. Several mosquito vectors that include Aedes, Anopheles, and Mansonia species transmit the disease to humans Prevalence Although filariasis is not a killer disease, it is considered the second leading cause of permanent, long-term disability among infectious diseases

In the Philippines, an estimated number of 200,000 people are said to carry the

infection National prevalence rate is placed at 9.7 per 1000 population (1998) Prevalence In the Philippines, filariasis endemicity is categorized into three: Category 1 - 20 provinces in Regions 5, 8, 11, 4 & 9 with reports within the past 10 years establishing its endemicity. Category 2 - 25 provinces with no recent report of endemicity but were reported as endemic in the 1960 prevalence survey. Category 3 - 33 provinces without any report of endemicity and considered as nonendemic for the disease Prevalence 45 out of 78 provinces are endemic for filariasis Recent discoveries of new endemic areas reveal some of the country’s highest recorded rates: 13.6 % in Marinduque (1992) 17.7% in Cagayan de Oro City in (1998) National Filariasis Elimination Program Goal: Filariasis is eliminated as a public health problem. (Filariasis is considered eliminated as a public health problem if the prevalence rate is less than one per thousand population.) National Filariasis Elimination Program National Objectives for Health by 2004 Health Status Objectives 1. Reduce the microfilaria prevalence rate to less than one case per 1,000 population in endemic municipalities. (Baseline: 9.7 cases per 1,000 population in 1998, Filariasis in the Philippines –A Compilation of DOH Data, 1960 to 1998, CDCS) 2. Reduce microfilaria density in endemic municipalities to four microfilariae per positive case. (Baseline: 40 microfilariae per positive case in 1998, Cagayan de Oro Survey, CDCS) 3. Reduce adenolymphangitis attacks to one per year. (Baseline: 3-4 per year in 1994, Global Rate) Risk Reduction Objectives 1. Increase the percentage of the population in endemic municipalities submitting to annual mass treatment (for four consecutive years) to 80%. (Baseline: 22% of LGUs with Filariasis Control Programs includes a annual mass treatment component, BSNOH 2000) 2. Increase the enrollment of chronic cases in support or care groups to 90%. (Baseline: 33% of LGUs with Filariasis Control Programs has a component of support or care groups for chronic cases, BSNOH 2000) Services and Protection Objectives 1. Identify all endemic municipalities in the country.

(Baseline: 117 endemic municipalities, 1998 Filariasis in the Philippines, CDCS)

2. Conduct annual Filaria Health Fair for four consecutive years in all endemic municipalities. (Baseline: from BSNOH 2000) (1) 33% of LGUs with Filariasis Control Programs has a component of a Filaria Health Fair (2) No LGU had conducted a Filaria Health fair for four years 3. Issue National Certificate of Filaria Elimination to all municipalities completing four years of mass treatment and achieving a microfilaria prevalence rate of less than one case per 1,000 population. (Baseline: No LGU as of 2000, BSNOH) Filariasis A parasitic infection caused by thread-like adult filarial nematodes that live in the lymphatic system of infected individuals Filariasis The microfilaria rate and disease rates have been found increasing with age. The largest number of cases generally occur in the 15-44 years-age group, but the prevalence is highest in the 45-60 and above age group. Males are more affected than females for microfilaremia, with 20% more cases in bancroftian filariasis and 25% more cases in brugian filariasis. Economic Impact of Filariasis The estimated loses per year in man-days and in terms of pesos due to acute attacks of the disease are based on the positive cases found. In computation: Number of persons with microfilaremia x 0.34 (%with lymphangitis) x 3.5 (no. of attacks/ year) x 3 ( duration of attacks in days) = Number of annual man-days lost number of man-days lost x minimum daily wage= annual economic loss Human Filarial Parasites Wuchereria bancrofti (Bancroft’s filaria) the adults parasites are found in the lymphatics below the diaphragm; microfilariae sheathed, exhibit nocturnal periodicity and common in warm climate Brugia malayi (Malayan filariasis) the adults are found in the lymphatics above the diaphragm exhibit nocturnal periodicity and common in warm climate Loa-loa (eye worm) the adults are found in cutaneous tissues, microfilariae sheathed exhibit diurnal periodicity found in Tropical Africa Onchocerca volvulus (Convoluted filarial) the adults are found in subcutaneous tissues microfilariae sheathed rarely found in bloodstream common in Tropical Africa, Mexico, Guatemala and Venezuela Human Filarial Parasites

Dipetalonema perstan
the

adults are staying in the body cavities unsheathed non-periodic found in Tropical Africa and Tropical America Dipetalonema streptucercum The adults stay in the skin and subcutaneous tissues microfilariae unsheathed non-periodic found in Tropical Africa Manzonalla ozzardi Adults are located in the body cavities microfilariae unsheathed non-periodic found in Tropical America Life Cycle Vectors of Filariasis Filariasis Incubation Period starts from the entry of the infective larvae to the development of clinical manifestations is variable ranges from 8-16 months Asymptomatic Stage Characterized by the presence of microfilariae in the peripheral blood Some remain asymptomatic for years and in some instances for life Others progress to acute and chronic stages Microfilariae rate increase with age and then levels off Filariasis Acute Stage Starts when there are already manifestations such as: Recurrent attacks of fever Lymphadenitis (inflammation of the lymph nodes) Lymphangitis (inflammation of the lymph vessels) In some cases, the male genitalia is frequently affected leading to funiculitis, epidydimitis or orchitis (redness, painful and tender scrotum) Filariasis Chronic Stage Develop 10-15 years from the onset of the first attack Immigrants from areas where filariasis is not endemic tend to develop this stage more often and much sooner (1-2 years) than do the indigenous population of endemic areas Most of the time, microfilariae are absent in the blood The following are the chronic signs and symptoms: Hydrocoele (swelling of the scrotum) Lymphedema (temporary swelling of the upper and lower extremities) Elephantiasis (enlargement and thickening of the skin of the lower and/or upper extremities, scrotum, breast, penis, and vulva)
microfilariae

Chyluria

(‘rice-water” color of the urine which results from the excretion of chyle in the urinary tract. This is due to blockage of the retroperitoneal lymph nodes below the cisterna chili with consequent reflux and flow of the intestinal lymph directly into the renal lymphatics. This may rupture and permit flow of chyle.) Clinical Features Chronic manifestations: Hydrocoele, even though found only with W. bancrofti infections (i.e., not Brugia infections) is the most common clinical manifestation uncommon in childhood but is seen more frequently post-puberty and with a progressive increase in prevalence with age 40-60% of all adult males have hydrocoele Clinical Features Lymphoedema can develop in the absence of overt inflammatory reactions; in the early stages be associated with microfilaraemia, the development of elephantiasis (either of the limbs or the genitals) is most frequently associated with a history of recurrent inflammatory episodes Clinical Features redundant skin folds, cracks and fissures of the skin provide havens for bacteria and fungi to thrive and intermittently penetrate the epidermis to lead to either local or systemic infections Clinical Features Chyluria, another of the chronic filarial syndromes, is caused by the intermittent discharge of intestinal lymph (chyle) into the renal pelvis and subsequently into the urine Physical Examination History and Inspection A physical examination is important to detect manifestations of filariasis, which may sometimes be subtle. Treatment to alleviate pain and discomfort from signs and symptoms is often available and provides great relief and positivity for further treatment. Physical Examination 4. Ask/note the following questions: Main complaint History of the illness; ask the following: Fever and headache – how it started? how often? other related signs and symptoms? Lymphadenitis – where is it located? (axillary, inguinal, etc.) Lympangitis – present ( ) absent ( ) where is it located? Hydrocoele – painful ( ) not painful ( ) Lymphedema – is there swelling of either of the extremities? – is this temporary or permanent? – are there associated symptoms? Lymphedema can be classified as follows: GRADE I – mostly pitting edema, spontaneously reversible on elevation GRADE II – mostly non-pitting edema, not spontaneously reversible on elevation GRADE III (elephantiasis) - gross increase in volume in grade II lymphedema, with dermatosclerosis and papillomatous lesions Elephantiasis – where is the enlargement? – what is the duration of the enlargement?

Case Definition Symptomatic with microfilaremia- patients found to be positive for microfilariae in the peripheral blood with clinical signs and symptoms. Asymptomatic with microfilaremia- patients found to be positive for microfilariae in the blood without clinical signs and symptoms. Patients with chronic signs and symptoms- patients negative for microfilariae but with two major clinical signs and symptoms. Major Signs and Symptoms Lymphangitis Pain and swelling of the upper and lower extremities, scrotum, inguinal area, vulva, breasts, genitals. Minor Signs and Symptoms Fever Cough Chills Wheezing Note: The major signs and symptoms must be observed within the last three months. Differential Diagnosis Lymphatic filariasis Bacterial or fungal lymphadenitis (eg, sporotrichosis due to Sporothrix schenckii) Recurrent streptococcal lymphadenitis (relapsing erysipelas) Congenital or hereditary lymphedema (Milroy syndrome) Nonfilarial elephantiasis (Highlands of East Africa) Congenital hydrocele Epididymal cyst Carcinoma of testis and/or scrotum Lymphosarcoma Treatment Diethylcarbamazepine citrate (DEC) effective, safe, and relatively cheap Kills almost all the microfilariae and good prognosis of adult worms Effective against the L3 and L4 larval stages and a good proportion of adult worms It is advisable not to give the drug to pregnant women and care should be taken when treating people with kidney and cardiac disorders. This drug can be given as: Selective Treatment Advisable to individual with clinical manifestations and or microfilaremia. Given at a dose of 6 mg/kg body weight in 3 divided doses for 12 consecutive days after meals. Ideal for newly- established or low endemic areas. Treatment Mass Treatment

Can be given as part of an organized filariasis control campaign with a single full course of DEC being given to the whole population of endemic areas except pregnant women, infants, those with cardiac amnd kidney disorders. Given at a dose of 6 mg/kg body weight to be taken as single dose. Advantageous in areas with moderate to high endemicity. As effective as the older standard dose 12- day course of DEC. . The only contraindication is that it should not be used in areas with onchoceriasis and loiasis. Mass Biannual Treatment Given at a dose 6 mg/kg body weight top be taken every 6 months. This may increase microfilariae reduction and best given in areas with moderate to high endemic areas with small population and with efficient distribution system. Treatment DEC- fortified salt This had been shown to be simple, cheap, and effective in reducing or eliminating lymphatic filariasis. It is well tolerated and can be incorporated with iodized salt. However, it cannot be used in areas with loaisis and onchocerciasis. Ordinary salt medicated mixed with 0.2. 0.4% of DEC tablets as cooking or table salt for 9-12 months.

Ivermectin An alternative drug for filariasis, however this is not available yet in the Philippines. This drug is as effective and can be given at a dose of 400 ug/kg given once yearly for mass treatment. This appears to be equivalent to the single dose DEC regimen efficacy, safety and tolerance. Treatment Combination of DEC and Ivermectin Appears to be superior to either drug alone for long term reduction and microfilarial density and equivalence. A dose of 400 ug of Ivermectin and DEC 6 mg/kg body weight. Given once yearly as part of mass treatment scheme. Complementary Therapy Chronic manifestations such as elephantiasis and hydrocoele can be handle through surgery. Mild cases of lymphedema can be treated by lymphovenous anastomosis distal to the site of lymphatic obstruction. Chyluria is operated on by ligation and stripping of the lymphatics of the pedicle of the affected kidney while hydrocoeles can be managed by invertion or resection of the tunica vaginalis.
Filariasis patients are advised to observed personal hygiene by washing the affected

areas with soap and water at least twice a day, or prescribed antibiotics or antifungals for superior protection. Complementary Treatment

Diet Fatty foods are restricted in proven chyluria associated with lymphatic filariasis. Activity Mobilization of the affected limb in chronic lymphatic filariasis is encouraged with compression bandage support.
Vector Control Anti Adult Measures Insecticides Community Measures The frequency of human vector contact can be reduced by: Construction of better housing with mosquito screens. Bonfires near houses to drive away mosquitos. Tying of carabaos a safe distance from houses to attract mosquitos (insecticidal zooprophylaxis). Use of latrines. Personal protection such as proper clothing, mosquito nets with or without insecticide impregnation, mosquito coils, and insect repellants (water based). Vector Control Anti-Larval Measures 1. Use of Insecticide/ larvacides . Commonly used larvicides are the organophosohorus insecticides such as temephos, fenthion, chlorpyrifos and pirimiphos- methyl. The following dosages have been used against C. quiquefasciatus: Clorpyrifos- 0.1- 1.0 mg of active ingredient per liter of water, it remains highly active for 12-24 days. Methoprene: dosage 1.0 mg of active ingredient inper liter of water inhibits emergence of adults for some 21 days. 2. Biological Control Larvivorous fish- Gambusia affinis and Poicilia reticulate are the two fish most commonly used. Microbial agents- Bacillus thuringiensis H- 14, which produces a potent insecticidal exotoxin and is self- replicating in the field has been shown to be effective against larvae of Anopheles and Aedes. Management Regimens Twice-daily washing of the affected parts with soap and water Raising the affected limb at night Regularly exercising the affected limb to promote lymph flow Keeping the nails clean Wearing shoes Use of antiseptic or antibiotic creams to treat small wounds or abrasions.

Essentials of Health Education in the Prevention and Control of Filariasis
Create awareness of the early signs and symptoms of the disease. Encourage individuals to submit to early treatment to prevent the development of a

chronic disability. Promote acceptance of Diethylcarbamazine Citrate (DEC) in mass or selective treatment Promote the acceptance of diagnostic procedures. Empower people to protect themselves from getting sick of filariasis. Encourage community participation to clean breeding sites of mosquitoes. Roles of Health Workers as Health Educator Visit people in their community and listen to their health problems.  Give information on the prevention and control of Filariasis and prevailing diseases in the community. Health workers should show by their own personal example, practice healthy habits. Plan, implement, evaluate health education activities. Conduct health teachings. Help people to lead healthier lives. Help people to solve their problems through their own efforts Strategies used in Health Education Community mobilization deliberate process of involving and motivating people, health workers, and policy makers to organize and take action for a common purpose. Planned approach to influence behavior as well as social change. Advocacy Principle of communicating with people to gain their support for an issue and influence their behavior in a specified way. Advocacy creates/ prepares responsible environment. Advocacy provides a framework of involvement. Network/ Intersectoral Collaboration coordination with various sectors and working as a team on common projects. Community Organizing provide people and arena to interact coordinate the various efforts contributed Information, Education, Communication (IEC) Campaign inform educate move people for health action Tell people what to do to protect themselves from getting sick Training improve knowledge, attitudes and skills of individuals which would empower them to make healthy choices. Reporting Systems Flow Central Office Department of Health ↑ Filariasis Control Units

Regional Health Office ↑ Provincial Health Office (copy furnished) ↑______FHSIS ↑ Rural Heath Units ↑_____FHIS ↑ Barangay Health Station Referral Referral of cases is indicated for the following situations: confirmation of diagnosis of suspected filariasis cases. medical/surgical management of chronic complications of filariasis. for follow-up of cases Referral Systems Flow Central Office Department of Health _____Hospital Regional Health Office (Filariasis Control Units) ↕ Provincial Health Office ↕ Municipal Health Office ↕ Barangay Health Station Strategies Two principal goals of the Programme to Eliminate Lymphatic Filariasis: 1. to interrupt transmission of infection; 2. to alleviate and prevent both the suffering and disability caused by the disease. It is a necessity to achieve these goals in a cost-effective, socially-responsible manner ensuring appropriate health and economic benefits. Pacific Programme for the Elimination of Lymphatic Filariasis (PacELF) first regional campaign to attempt to eliminate filariasis as a public-health problem PacELF is a regional group of 22 Pacific countries and territories that are working together towards the goal of eliminating lymphatic filariasis from the Pacific by the year 2010 - 10 years before global elimination is expected to be achieved PacELF There are now two new tools to help eliminate filariasis: the recent development of antigen test kits

the combination of drugs - DEC and albendazole.

Strategies The Elimination of Lymphatic Filariasis: A Strategy for Poverty Alleviation and Sustainable Development – Perspectives from the Philippines Jaime Z Galvez Tan University of the Philippines, College of Medicine, Department of Family and Community Medicine, Pedro Gil Street, Malate, Manila, Philippines Background Within the Philippines areas endemic for lymphatic filariasis are in regions with the highest incidence of poverty. Out of a total of 79 provinces, 39 have a higher poverty incidence than the national average and 30 of these 39 provinces are endemic for lymphatic filariasis. Strategies Romblon province, which is ranked 71 out of 79 in terms of poverty incidence, has a Circulating Filarial Antigen (CFA) rate of 18.75% Oriental Mindoro province, which is ranked 76, has a microfilaria prevalence rate of 12.59% The Elimination of Lymphatic Filariasis as a means to Poverty Alleviation 1. LF surveys and mapping using ICT and community reporting of hydrocoele and elephantiasis increase the poor's access to health knowledge, health information and epidemiological data as well as access to diagnostic services. 2. Mass drug administration (MDA) with DEC and albendazole increases access to essential drugs and ensures universal coverage for treatment of LF and geo-helminths. The Elimination of Lymphatic Filariasis as a means to Poverty Alleviation 3. The establishment of morbidity reduction services for those with disabilities caused by LF will increase access to health services and rehabilitation particularly for those who live as stigmatized outcasts with such disabilities. This will also mean the poor returning to productive economic work and an active social life. 4. Increase in access to other health services with the integration of additional health services during the mass drug administration (MDA) such as bed net distribution, immunization, growth monitoring and promotion, Vitamin A and iodized salt distribution and sanitation and hygiene education. The 'Filariasis Fair' in the Philippines, organized by local governments, creates a festival out of the MDA, offering additional services to attract more people to take the DEC and albendazole. The Elimination of Lymphatic Filariasis as a means to Sustainable Development 1. Health planning technologies 2. Health logistics system with the procurement of diethylcarbamazine citrate, receipt of albendazole and their distribution, inventory procedure and accountability 3. Health research systems development with epidemiological research, basic health research, health social science research, health systems research, evaluation research, operational research and participatory action research. 4. Development of health management information systems using the latest information technology like Geographic Information Systems (GIS), FilSim and remote sensing 5. Social marketing and social mobilization methodologies The Elimination of Lymphatic Filariasis as a means to Sustainable Development

6. Setting up health referral systems, for example, using the adverse drug reaction reporting system 7. Vertical and horizontal integration system with LF elimination programs and primary health care 8. Human resource development in health through scientific and program updates 9. International and regional networking for technical assistance and resource mobilization 10. A focus for leadership and governance Conclusions Elimination of lymphatic filariasis as a public health problem is a 20-year strategic plan for the world community. Vision - all endemic communities free of transmission of lymphatic filariasis by 2020  Commitment - ensure the delivery of quality technologies and human services to eliminate lymphatic filariasis worldwide through a multi-stakeholder global alliance of all endemic countries.  Global goal of elimination of lymphatic filariasis is a significant opportunity for partnerships – a world with less poverty through sustainable development and free from the scourge of lymphatic filariasis. Summary Described the epidemiology/ health situationer of filariasis  Discussed the goals, objectives and strategies of the programs of DOH and WHO for filariasis Described the following about filariasis: Life cycle Pathogenesis and pathology Clinical features Diagnosis Management Prevention Treatment Avian and Pandemic Influenza Preparedness Dept. of Health Session Objectives •Role of the physician in Avian Flu •Describe the types of influenza subgroups. •Sources of threats & problems in control of Influenza. •Stages in Influenza transmission. •Recent advances in the treatment & control. •Phases of Influenza preparedness plan. •Four lines of defenses against avian flu. Role of the Physician

•Advocacy in Prevention- knowledge of Transmission •Reporting of Suspect Cases- knowledge of case definition •Initial management of suspect cases-knowledge in case Mx & Infection Control •Alleviation of Fear and Panic-knowledge of risk communication •Public health cooperation, coordination and Networking efforts – knowledge in
stakeholdership Influenza sub-groups •Influenza A •highly infective •infects many species •causes frequent widespread epidemics and pandemics •Influenza B •only found in humans •capable of producing severe disease •cause of regional epidemics •Influenza C •causes mild disease •humans are natural hosts but isolates also found in pigs •does not cause epidemics Type A Influenza Viruses Surface glycoproteins •Haemagglutinin •H or HA •responsible for pathogenicity of the virus •allows virus to adhere to endothelial cells in the respiratory tract •main determinant of immunity •Neuraminidase •N or NA •allows release of newly formed viruses within host •determinant of disease severity Genetic change in influenza viruses •Point mutations •minor change producing low to moderate antigenic change •Recombination •genetic exchange between animal viruses resulting in a new human pathogenic strain •Reassortment

•mixing of human and avian gene segments resulting in a human pathogenic strain
with major antigenic change Influenza Viruses Circulating in the Human Population •Influenza A/ H3N2 Influenza A/ H1N1

•Influenza B
(No subtypes ) Strain variation (e.g Fujian, New Caledonia) : basis for yearly vaccination
•H5N1

in Hongkong (1997) 18 cases with 6 deaths (high CFR) Destruction of all chickens (> 1 million) in Hong Kong, SAR and Guangdong (1999) 2 cases in Hong Kong, SAR 5 cases in Guangdong

•H9N2

•H5N1

in Hong Kong, SAR (2003) 2 confirmed cases with one death in a family Travel history to Fujian province
•H7N7

in Netherlands (2003) Human to human transmission 30 cases, 1 death
•H9N2

in Hong Kong, SAR (2003) One case

World : Areas reporting confirmed occurrence of H5N1 avian influenza in poultry and wild birds since January 2006, status as of 13.06.2006 Possible Spread of HPAI Along Major Flyways of Migrating Birds 10 Leading Causes of Morbidity 2000, FHSIS Data, Philippines Influenza Season in The Philippines Rationale for Southern Hemisphere Vaccine Recommendation

February 1998 – September 2003 Influenza Isolates Philippine Influenza Surveillance Data Fem Julia Paladin, PhD et al., - Research Institute of Tropical Medicine Signs and Symptoms among Birds •Decrease in activity •Drastic decline in egg production •Facial swelling with swollen & bluish – violet colored coombs & wattles •Hemorrhages on internal membrane surfaces •Virus isolation needed to definitive diagnosis •Gasping for breath •Muscle weakness and paralysis •Diarrhea •Sudden deaths ( MR up to 100%)

Mode of Transmission to Human •Direct & indirect contact with infected wild ducks & chickens through infected aerosols, discharges & surfaces •Inhalation of the particles from dried discharges or feces with the bird flu virus.

•Discharges can get in contact with the nose or eyes of persons handling infected
chicken •Virus is inactivated by heat .

•No human to human transmission
Transmission to humans •Close contact with live infected birds through infected aerosols, discharges and surfaces, feces •Flapping of wings hastens the transmission
•Plucking and preparing of diseased birds •Handling fighting cocks •Playing with poultry •Consumption of duck's blood or possibly undercooked

poultry

Large-Droplet and Aerosol Respiratory Transmission
•virus-laden

large droplets (particles >5 mm in diameter) from cough or sneeze predominant mechanism

•aerosol •

spread (especially in unventilated conditions)

the infectious dose for humans exposed by aerosol is lower than that seen with experimental nasopharyngeal instillation
•surgical

masks should protect against large droplets

Transmission by Contaminated Hands, Other Surfaces, or Fomites
• •

contaminated hands, other surfaces, or fomites transmission of oral secretions from patient to patient by staff who were not gloved

Clinical Signs and Symptoms In humans, it has been found that avian flu causes similar symptoms to other types of flu: •fever •cough •sore throat •muscle aches, and weakness •conjunctivitis •in severe cases of avian flu, it can cause severe breathing problems and pneumonia, and can be fatal. •Multiorgan failure and respiratory distress syndrome.

Baseline Investigation •Chest X-ray

•Total WBC and differential count •Liver function tests

•Take respiratory and blood specimens for laboratory testing for influenza and
other infections as clinically indicated

•Supportive care •Antibiotic therapy to control secondary bacterial infections as required

•No

evidence on effectiveness of ribavirin against influenza viruses such as corticosteroids should be used only in the context of

•Immunomodulators

clinical trials
•Paracetamol

or ibuprofen for management of fever Avoid salicylates (such as aspirin) in children under 18 years of age because of the risk of Reye’s syndrome
•Use

nebulizers and high-air-flow oxygen masks only if clinically justified and apply them under strict infection control, including airborne transmission precautions

Testing
•Avian •Rapid

influenza (H5N1) can be isolated by conventional viral culture methods

influenza tests, H5-specific RT-PCR, and real-time RT-PCR could aid a rapid diagnosis
•However,

rapid diagnostic tests for influenza have low sensitivity, which may limit their usefulness to reliably detect H5N1, especially if illnesses are diagnosed later in their clinical course
•Thus,

clinical findings and a history of poultry exposure may be more helpful in identifying patients with H5N1 infection than the result on rapid diagnostic tests for influenza. •Nasopharnygeal aspirates for influenza A H5 strain by two RT-PCR primers and by real-time RT-PCR. •Three sets of blood cultures, sputum cultures, and serologic tests for Chlamydia by microimmunofluorescence, mycoplasma by microparticle agglutination assay, urine Legionella antigen by enzyme-linked immunosorbent assay (ELISA), HIV by ELISA, Burkholderia pseudomallei (melioid) titer by immunohistochemical assay,

dengue titer by hemagglutination inhibition using all four serotypes, Leptospira titer by microscopic agglutination test, Widal test, Weil-Felix test, and viral culture.

•recently circulating H5N1 strains are susceptible to two antiviral drugs to treat
human influenza infections – oseltamivir (sold as Tamiflu) and zanamivir (sold as Relenza).

•need to be started early enough – usually within the first two days of infection – to
be effective

•Currently circulating H5N1 influenza viruses are resistant to two older, inexpensive
antiviral drugs, rimantadine and amantadine

Antiviral Agents Treatment Oseltamivir -75 mg BID X 5 days in adults •Children 1 year of age or older: •Adjusted twice-daily doses 30 mg for <15 kg 45 mg for > 15 to 23 kg 60 mg for > 23 to 40 kg Not recommended for children <1 y/o •higher doses (150 mg twice daily in adults) and treatment for 7 to 10 days for severe infections

Antiviral Agents Prophylaxis Oseltamivir Adults and teen-agers 13 y/o and above: 75 mg once a day for at least 7 days Children 1-13 y/o: daily doses 30 mg for <15 kg 45 mg for > 15 to 23 kg 60 mg for > 23 to 40 kg 75 mg for > 40 kg

Antiviral Agents

Prophylaxis Household contacts, including children for 7-10 days from the last day of exposure Health care workers Personnel involved in culling May be given up to six weeks

no protection against infection with the H5N1 avian virus prevent re-assortment from simultaneous infection by human influenza and avian influenza among high-risk groups

Selected groups for vaccination: • cullers involved in destruction of poultry • people living and working on poultry farms • health care workers giving daily care of H5N1 human cases • health care workers in emergency care facilities in areas where there are confirmed influenza H5N1 outbreaks in birds

•Both

sanofi pasteur (Swiftwater, PA) and Chiron (Emeryville, CA) are producing vaccines made from inactivated H5N1 viruses for NIAID to test in clinical trials.
•First

clinical trial began in April 2005

•Testing

a range of concentrations, known as dosage levels, of the sanofi pasteur H5N1 vaccine to evaluate safety and immunogenicity.
•Based

on preliminary data from 117 of the 450 participants enrolled in the trial in healthy adults, two 90-µg doses of the H5N1 candidate vaccine generated the highest immune response among those doses tested.
•A study

to determine if a smaller intradermal dose may be as effective as a larger dose administered intramuscularly.
•Studies

on the production of an H5N1 vaccine with adjuvants, ingredients that are added to improve the immune response that a vaccine produces- Alum and MF59

3 pre-requisites to start an influenza pandemic: Emergence of a new virus to which all are susceptible; Virus is able to replicate and cause disease in human; New virus is transmitted efficiently from human-to-human Genetic adaptation – antigenic variation •Antigenic drift •modification of H and N gene •very frequent, type A and B •leads to epidemic •Antigenic shift •exchange of RNA between human and animal strains inside an animal reservoir •rare event, only type A •change in H or N or both leading to a new subtype A •results in pandemic Genetic reassortment

•hard, nonporous surfaces (steel and plastic) - <24 to 48 hr •cloth, paper, and tissues - <8 to12 h at 35% to 40% humidity and a temperature of 28ºC •higher humidity shortened virus survival •Virus on nonporous surfaces could be transferred to hands 24 h after the surface was contaminated, while tissues could transfer virus to hands for 15 min after the tissue was contaminated. Elements of Influenza Pandemic Reporting •Who to report- Those fitting the case definition •What to report- The suspect case/s together with the information about them and their disease •Where to report-RITM,NEC •When to report- within 48 hrs •Why the need to report-For prompt institution of Response measures ( confinement, containment ,contact tracing, coordination, Communication)

How to report- use case investigation form to document suspect

Phases in development of influenza pandemic (WHO 2005) Individuals at risk Poultry handlers/workers Sellers/ people in live chicken sale Aviary workers/ Ornithologists Cullers People living near poultry farms Any individual in close contact with infected birds
 

•Prevention of spread from birds-to birds: early recognition and reporting, mass culling,
quarantine of affected area

•Prevention of spread from birds to humans: human protection through proper handling
of infected birds, use of protective gear by residents, poultry handlers, and response teams Community Response to sick or dead birds of exposed residents – gloves/ plastic material in handling sick or dead birds, hand washing
•Protection

•Personal protective equipment for cullers – caps, masks, goggles, gowns •Identification of exposed individuals and quarantine for 7 days •Reporting to the Barangay Health Emergency Response Team/ local health officer

•WHO: Phase three (current phase) : human infections with a novel virus subtype (H5)
are occurring, no evidence that the virus is spreading efficiently and sustainably among humans.

•H5N1 AI

remains principally a disease of birds, and not of humans.

•Human cases at present are isolated and rare, indicating a significant species barrier.

Public Health Measures In affected areas:

•vigilance for human cases in areas experiencing outbreaks in birds •immediate isolation and management of cases •treatment with antiviral agents •identification and monitoring of exposed persons and contacts of cases
Public Health Measures In unaffected areas •measures to prevent entry of the virus via poultry or wild birds, especially as this virus, once established in birds •For humans, no travel restrictions or screening measures at borders are recommended, as the risk that the virus will be carried by international travellers is considered negligible.

What should be done when there is a suspected case of avian influenza? A. Satellite Referral Hospitals – Regional Hospitals/ Medical Centers of 16 Regions B. Sub-national Referral Centers San Lazaro Hospital Lung Center of the Philippines Vicente Sotto Memorial Medical Center Davao Medical Center C. National Referral Hospital Research Institute for Tropical Medicine

•Stay at home for 10 days •Self-monitoring of fever, cough or difficulty of breathing or any sign and symptoms
of illness. •Sick persons to the Referral Hospital for SARS and other severe emerging infections.

Early Recognition, Rapid Response and Containment •Virus is progressively improving its transmissibility among humans, but is not yet spreading efficiently and sustainably. •Phase 4 – clusters of <25 cases in < 2weeks •Phase 5 – clusters of 25-50 cases for >2 weeks, but still localized •An increase in the number of clusters, closely related in time and place, is considered the likely epidemiological signal of improved transmissibility. Epidemiological signals Three or more health care workers/ patients with unexplained moderate to severe acute respiratory illness (or who died of unexplained acute respiratory illness) and with onset of illness within 7 to 10 days of each other Five to ten persons with moderate to severe acute respiratory illness (or deaths) in with evidence of human-to-human transmission AND With history of: -Travel to or residence in an area affected by avian influenza outbreaks in birds or other animals -Direct contact with dead or diseased birds or other animals in affected area -Close contact with an H5N1 patient (living or deceased) or a person with unexplained moderate-to-severe acute respiratory illness -A possible occupational exposure, including employment as an animal culler, veterinarian, laboratory worker, or health care worker Clinicians should immediately notify NEC or RESU National authorities should immediately trigger further assessment

Public health measures are aimed to reduce transmission and prevent, or at least delay, further spread
•Rapid

detection and isolation of H5N1 cases

•Tracing

of close contacts during the patient’s first two weeks of illness and voluntary quarantine of symptomatic persons for one week
•Use

of antiviral drugs for treatment of cases of exposed and other persons in the initially affected area.

•Prophylaxis •Restriction •Screening

on the movement of persons in and out of the initially affected area.

of travelers departing from areas where clusters of human cases are

occurring. Widespread human-to-human transmission of influenza (pandemic influenza)

•Workforce – sick, take care of the sick, afraid •Reduced production of goods •Disruption of delivery •Food, groceries and other basic needs will be in short supply
•Health alert notices describing symptoms and where to report should these symptoms develop to incoming travellers •Introduce exit screening measures for departing travelers –maybe disruptive, costly, not be fully efficient •For persons known to have been exposed in an aircraft or aboard a large cruise ship, daily fever checks among passengers and crew and prophylactic treatment with antiviral drugs, when available. •Health care workers and first responders should be equipped with N95 respiratory masks; If respiratory masks are not available, standard well-fitted surgical masks should be used.

•Patients and persons seeking care in areas with cases should wear surgical masks. •Persons with fever and respiratory symptoms and their contacts asked to undergo voluntary home confinement. •People in countries with cases asked to defer non-essential domestic travel to affected parts of the country.

•Patient isolation and tracing and quarantine of contacts should cease, •Shift to maintenance of essential services and public order
Persons providing •Emergency and disaster response •Maintenance of peace and order •Transportation, including air traffic controllers •Utilities – water, electricity Minimizing surge of cases in hospitals •Out-patient clinics should manage uncomplicated cases while hospitals will manage severe or complicated cases of influenza •Out-patient clinics should triage and separate respiratory from non-respiratory cases

•Additional health stations and manpower •Triage of cases - separating respiratory from non-respiratory cases - screening of cases – who should stay home, who should be referred to the hospital •Monitoring of supply and prices of antipyretics, analgesics, liniments and antibiotics •Advise not to use salicylates for children

•Should a large surge in cases occur,
health care facilities should be arranged in ways that help reduce transmission (for example, by keeping a distance between patient beds or placing adjacent beds face to foot).

Social Distancing •Reduction of unnecessary travel •Staying at home when sick •Isolation at home (separate room) •Closure of schools •Suspension of public events •Closure or limitation of people in public places or establishments

WHO does not recommend, at any phase, that individual countries be quarantined or that international borders be closed.

•Cover

your nose and mouth with tissue or handkerchief every time you sneeze, cough or blow your nose.
•Put

used tissues or plastic bags in the trash bin.

•Wash

your hands with soap and water. - Before touching your eyes, nose or mouth. - Before shaking hands with other people. If water is not available, use an alcohol-based hand sanitizer.
•Don’t •Wash •As

spit on the floor or on the road. Spit on a trash bin or on a small plastic bag. used handkerchiefs separately from clothing.

much as possible, stay at home and don’t get near with other people when you are sick.
•Do

not share eating utensils, drinking glasses, towels or other personal items.

1. First Line of Defense – Out Border Containment in affected countries

2. Second Line of Defense– Entry-Exit Management of International Passengers

•Intensified quarantine measures •Infrared thermal monitors are routine at international ports •Travelers with unknown fever and respiratory symptoms will be examined further
If WHO issues a notification of confirmed human-to-human transmission of avian flu

•Travelers will be asked to undertake self-quarantine for 10 days. •People under self-quarantine will need to check temperature twice daily, and report to
local health authorities if they have influenza symptoms. Avian influenza: •Personal hygiene •Use of Personal Protective Equipment (PPE) •Cleaning and disinfection •Anti-viral agents •Quarantine for 10 days •Immediate admission of symptomatic persons to referral hospital •Prophylaxis and monitoring of contacts 4. Fourth Line of Defense – Health Care System Avian Influenza : Referral Hospitals (21) •Clinical management of cases •Infection control Pandemic Influenza 21 Referral Hospitals, DOH-retained hospitals, local government hospitals and military hospitals •Management of surge of cases •Clinical management of cases •Infection control •Psychosocial management 4. Fourth Line of Defense – Health Care System
•Triaging

and screening of cases - Screening of cases in out-patient clinics/ health centers - Mild cases to stay at home, watch out for signs

of pneumonia and other complications - Mild to moderately severe pneumonia cases in municipal / district hospitals - Severe cases at provincial/ regional/ referral hospitals 4. Fourth Line of Defense – Health Care System

•Infection control •Additional sites for health care
- tent facilities, extension wards, schools, military barracks and others

•Manpower augmentation •Psychosocial management •Resource mobilization and logistics management