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DECLARATION OF OUTBREAK OF HPAI IN POULTRY IN MANIPUR, INDIA

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  • Bharat Dube
    DECLARATION OF OUTBREAK OF HPAI IN POULTRY IN MANIPUR, INDIA ... On 27th July, 2007, the 3rd day after confirmation of outbreak of Highly Pathogenic Avian
    Message 1 of 1 , Aug 1, 2007
      DECLARATION OF OUTBREAK OF HPAI IN POULTRY IN MANIPUR, INDIA
      ---------------------------------------------------------------------



      On 27th July, 2007, the 3rd day after confirmation of outbreak of
      Highly Pathogenic Avian Influenza(HPAI), the pace of control and
      containment measures was further intensified. On 27th July, 2007, 34
      Rapid Response Teams (RRTs) (including of 2 teams sent in the
      afternoon as re-enforcement) were deployed for undertaking culling
      operation. A total of 22 villages/areas were covered on the 3rd day
      in the culling zone. Total number of poultry birds culled on 27th
      July 2007 was 25,094. Number of eggs destroyed was 3,277 and the
      quantity of poultry feed materials destroyed was 2,245 Kgs.

      On the 4th day of the operation i.e. 28th July, 2007, 28
      villages/areas have been identified for culling and proper
      sanitization works in the culling zone. For this work, 30 RRTs have
      been deployed.



      NATIONAL RAPID RESPONSE TEAM

      Constitution
      1. Epidemiologist (2) from NICD
      2. Microbiologist from NICD
      3. Virologist from NIV Pune/ other ICMR institutions
      4. Clinician from central govrenment hospital
      Terms of Reference:
      1. Surveillance for suspected human cases/health checkup of
      cullers/poultry worker.
      2. Advice for case management, use of PPE and chemo prophylaxis.
      3. Collection and transportation of samples from suspected case to
      designated
      laboratories.
      4. Do's/Don'ts for patients, contacts, visitors, travelers and
      health care providers

      CASE DEFINITION OF AVIAN INFLUENZA IN HUMANS
      The WHO recommendation for standard case definition of Avian
      Influenza suggests adopting
      of definition according to country situation. The cases should be
      classified as below:
      Suspected case
      1. Fever (body temperature of 380 Celsius or higher); in addition to
      2. One of the following symptoms – muscle ache, cough, abnormal
      breathing (unusual
      breathing difficulty), or suspected of pneumonia by physician, or
      influenza; in addition
      to
      3. History of direct contact with infected/dead birds in the past 7
      days or occurrence of
      unusual death of birds in the community within the past 14 days; or
      contact with a
      pneumonia patient or another patient suspected of avian influenza.
      Probable case
      The above mentioned symptoms of suspected case and:
      | Preliminary test shows infection of influenza group A, but cannot
      yet be confirmed
      whether it is influenza from humans or birds.
      | Respiratory failure
      | Death
      Confirmed case
      Suspected/ probable case with final PCR test or virus isolation
      showing H5 strain of influenza
      group A, which is a bird strain.
      Note: Diagnosis of suspected and probable cases can be changed if
      confirmation tests
      show that the patient's infection was caused by other factors.


      CHEMOPROPHYLAXIS GUIDELINES
      Four prescription medications with antiviral activity against
      influenza viruses are
      commercially available (amantadine, rimantadine, oseltamivir,
      zanamivir). The four drugs
      are classified into two categories, the adamantine derivatives and
      the neuraminidase
      inhibitors, on the basis of their chemical properties and activities
      against influenza viruses.
      Controlled clinical trials have demonstrated the efficacy of all
      four antiviral medications
      in reducing symptom duration when used for treatment of influenza
      infections. Three of the
      antiviral drugs have been approved for use as chemoprophylaxis.
      Chemoprophylaxis:
      A. Neuraminidase Inhibitors
      The neuraminidase inhibitors, zanamivir and oseltamivir, are
      chemically related drugs
      that have activity against both influenza A and B viruses.
      Oseltamivir, but not zanamivir is approved for chemoprophylaxis of
      influenza
      Oseltamivir is effective against al subtypes of influenza viruses A
      (including H5N1) indicated
      for both therapeutic and prophylactic use but is only advocated for
      persons 13 years and
      above. For prophylaxis purposes the dosage is:
      - Close contacts: 75 mg once daily for at least 7 days.
      - Community contacts: 75 mg once daily upto 6 weeks
      (Protection lasts only during the period of chemoprophylaxis)
      The only contraindication is in persons with known hypersensitivity
      to any of the
      components of the product.
      Adverse reactions:
      u Most frequent side effects in adults are nausea and vomiting.
      These are transient and
      generally occur with first dosing.
      u In children, most frequently reported side effect is vomiting.
      u Other reported events include abdominal pain, epistaxis, ear
      disorder and conjuncitivitis.
      u These events do not require discontinuation of treatment in a
      majority of cases.
      u Should be used during pregnancy or lactation only if the potential
      benefit/justified the
      potential risk to the foetus or breast-fed baby.
      B. Amantadine Derivatives
      The amantadine derivatives, amantadine and rimantadine, are
      chemically related,
      orally administered drugs that are approved for treatment and
      chemoprophylaxis of influenza
      56
      A. Amantadine and rimantadine specifically inhibit replication of
      influenza A viruses, but
      not influenza B viruses. Both drugs are approved for
      chemoprophylaxis to prevent influenza
      A in people aged 1 year and older. It has to be administered 200 mg
      daily for 5 to 8 weeks.
      When used for chemoprophylaxis, amantadine and rimantadine are
      approximately
      70% - 90% effective in preventing symptoms of influenza A illness.
      The efficacy and
      effectiveness of amantadine and rimantadine to prevent complications
      of influenza A are
      unknown. Both drugs are effective when used for chemoprophylaxis
      during outbreaks of
      influenza A in institutions, such as nursing homes.
      Side effects of the amantadine drugs:
      Chemoprophylactic use of both drugs have been associated with
      u Gastrointestinal and central nervous system (CNS) adverse effects
      in healthy adults
      and elderly persons.
      u CNS toxicity includes such as lightheadedness, difficulty in
      concentrating, nervousness,
      insomnia, and seizures in patients with pre-existing seizure
      disorders. Rimantadine
      use has been associated with fewer CNS side effects than amantadine.
      u Amantadine is teratogenic and embryo toxic in animals. Rimantadine
      has not been
      found to be mutagenic. The safety of amantadine and rimantadine when
      used during
      pregnancy has not been established.


      GUIDELINES FOR CASE MANAGEMENT FOR HUMAN CASES
      OF AVIAN INFLUENZA H5N1
      WHO Case Definition for Influenza A/H5
      Suspected case
      1. Fever (body temperature of 380 celsius or higher); in addition to
      2. One of the following symptoms – muscle ache, cough, abnormal
      breathing (unusual
      breathing difficulty), or suspected of pneumonia by physician, or
      influenza; in addition
      to
      3. History of direct contact with infected/dead birds in the past 7
      days or occurrence of
      unusual death of birds in the community within the past 14 days; or
      contact with a
      pneumonia patient or another patient suspected of avian influenza.
      Probable case
      The above mentioned symptoms of suspected case and:
      | Preliminary test shows infection of influenza group A, but cannot
      yet be confirmed
      whether it is influenza from humans or birds.
      | Respiratory failure
      | Death
      Confirmed case:
      One of the following tests is positive:
      | Positive viral culture for influenza A/H5
      | Positive RT-PCR for influenza A/H5
      | Positive IFA test using A/H5 monoclonal antibodies
      | A 4 fold rise in Influenza A/H5 specific antibody titers
      Principles of Management of Avian Influenza:
      Management of human cases of avian influenza is based on the
      following principles:
      | Management of a case with avian influenza does not differ from
      that of influenza due
      to a primary human influenza virus
      58
      | Patients should be isolated and universal precautions should be
      observed
      | Good infection control practices in health settings
      | Anti-viral drugs: H5N1 viruses have been reported to be resistant
      to amantadine and
      rimantadine, but susceptible to neuraminidase inhibitors like
      oseltamivir and zanamivir.
      Management of Human Avian Influenza cases comprises of :
      1. General and supportive treatment
      | Hospitalize and isolate cases
      | Monitor vital signs
      | Maintain airway, breathing and circulation (ABC)
      | Maintain hydration, electrolyte balance and nutrition
      | Provide oxygen therapy, when indicated
      | Manage fever symptomatically with paracetamol
      2. Specific treatment
      | Antiviral drugs: In adults, oseltamivir is to be given orally in
      the dose of 75 mg.
      BD for 5 days.
      | Broad spectrum antibiotic should be added to cover secondary
      pulmonary infection
      Do not use aspirin, ribavirin and corticosteroids
      Discharge policy:
      Infection control precautions should remain in place for seven days
      after resolution of
      fever. For children below 12 years, infection control measures
      should remain in place for
      21 days after the onset of illness. Where this is not possible, the
      family of fully recovered
      patients discharged within 21 days of onset of illness should be
      educated on personal
      hygiene and infection control measures; children should not attend
      school during this period.
      Public Health Measures:
      Report to the Local Health Authorities and the Director (EMR),
      Directorate General of
      Health Services, Nirman Bhavan, New Delhi – 110011 (Telephone No.:
      011-2306 1302
      and Fax: 011- 2306 1457) all patients for whom the diagnosis of
      influenza (H5N1) virus
      infection is being considered. Identify the contacts and follow them
      for one week. They
      should be advised to check their temperature twice daily and report
      all health events.


      SOP FOR RAPID RESPONSE
      The multidisciplinary Rapid response team would depart within six
      hours of receiving
      the information from Director (EMR), Dte GHS subject to
      transportation facilities provided
      by Deptt of civil Aviation/ Ministry of home Affairs.
      MOHFW would inform the state Government to activate its own state
      plan and rapid
      response teams to the incident site/ affected area.
      The state Health Secretary would facilitate movement of the Central
      rapid response
      team with in the state.
      The rapid response team after reaching the site would co-ordinate/
      advice/ guide the
      District Collector, District Chief Medical Officer & the District
      Animal Husbandry Officer and
      would conduct a rapid assessment of the situation.
      The geographic perimeter of the affected area would be determined.
      Demography
      data of that area would be obtained.
      Further line of action would depend on the current situation and
      evolving scenario and
      would be dealt under the following situations:
      I. Avian influenza is suspected in birds/ Poutry
      | The rapid response team of the state/ Centre would guide the
      District Collector to
      enforce quarantine guidelines.
      | All movement [in and out of the affected area] would be
      restricted. Any relaxation to
      this affect on emergency grounds would be informed to the team
      leader of the RRT.
      | The state would take adequate measures to monitor the health
      status for 10 days of
      such individuals who had been allowed to move out on emergency
      grounds.
      | The state would identify the Health worker/s (Male and Female) of
      the nearest PHC /
      sub center in the affected area who would carry out house-to-house
      survey of the
      population for fever cases. Any case of fever reported would
      immediately be brought
      to the notice of the Medical Officer identified by the District
      authorities who would
      follow the SOP as mentioned in Part II.
      | Such health workers would be sensitized by the RRT for
      identification of suspect case
      of avian flu.
      | The health care worker/s would follow infection control practices
      as per SOP.
      | The health workers would be given Chemoprophylaxis with
      Oseltamivir as per
      84
      chemoprophylaxis guidelines.
      | The health status of the cullers would be monitored as per the SOP.
      II. Where one or more cases of human avian influenza have been
      reported (as per
      standard case Definition).
      | The Identified district officer in the affected area to whom a
      suspected case has been
      reported, would inform the state and the central RRTs.
      | The state and Central RRT would visit the case/s and after review,
      the following
      measures would be instituted:
      | The case would be isolated, provided personal protective
      equipments including N95
      mask and transported in isolation to the identified health facility.
      The state health
      authorities would arrange this.
      | The ambulance driver and the attendant would also be provided PPEs.
      | After the case is isolated in the hospital, the ambulance staff
      would discard the PPE
      as per the standard waste management protocols. The ambulance would
      be disinfected
      as per SOP for infection control (SOP-IV).
      | The household immediate contacts would be provided chemo
      prophylaxis and
      monitored for 10 days for any symptoms of avain flu.
      | The household immediate contacts would be quarantined in house
      which the local
      police would ensure.
      | The affected communities would be separated from the affected
      poultry and the they
      would be informed to avoid contact with any poultry including
      healthy poultry. (in a
      scenario where culling is delayed).
      | The cullers and the health care functionaries in contact with the
      contact cases would
      be provided PPEs and chemoprophylaxis.
      | The state/ Central RRT would ensure that appropriate clinical
      samples from the affected
      cases would be collected as per SOP for collection and
      transportation of clinical samples
      for laboratory investigations (SOP-III).
      | RRT would ensure that the standard treatment protocol is being
      followed. For such
      purpose the RRT would visit the hospital where the case has been
      kept in isolation.
      | The house-to-house survey for the fever cases would continue for
      10 days (from the
      last case reported).
      85
      III. Where human-to-human transmission has been established.
      | The district authorities would strictly enforce the quarantine
      guidelines.
      | All cases would be reviewed and transported in isolation to the
      identified hospital.
      | All actions as cited in part II would be enforced.
      | All the individuals in the affected area would be provided chemo
      prophylaxis by the
      Central RRT in co-ordination with district authorities..
      | All individuals would be provided well-fitted triple layer
      surgical mask by the Central
      RRT.
      | Additional PPE, if needed would be transported and would be co-
      coordinated by
      Director, EMR, Dte GHS
      | The district health authorities would ensure that the community
      follows strict personal
      hygiene including frequent hand wash. RRT would monitor the same.
      The RRT will review the situation. The RRT would report on daily
      basis / or more
      frequently if situation warrants/ to Avian Influenza Monitoring Cell
      of NICD.












































      SOP FOR INFECTION CONTROL PRACTICES


      Infection control precautions
      Infection control for influenza A (H5N1) involves a two-level
      approach:
      | Standard precautions, which apply to ALL patients at ALL times,
      including those who have
      influenza A (H5N1) infection and
      | Additional precautions, which should include:
      . Droplet precautions,
      . Contact precautions, and
      . Airborne precautions
      A combination of these precautions will give the appropriate
      infection control. Strict adherence
      to these precautions is required to break the chain of infection
      transmission.
      Hand hygiene is the single most important measure to reduce the risk
      of transmitting infectious
      organism from one person to other.
      Hands should be washed frequently with soap and water / alcohol
      based hand rubs/ antiseptic
      hand wash and thoroughly dried preferably using disposable tissue/
      paper/ towel.
      | After contact with respiratory secretions or such contaminated
      surfaces.
      | Any activity that involves hand to face contact such as eating/
      normal grooming / smoking
      etc.
      Respiratory Hygiene
      People with respiratory infection should practice the following
      cough/ sneeze etiquettes
      whenever they are in the presence of another person.
      All symptomatic should:
      | Avoid close contacts (less than one Meter) with other people.
      | Cover their nose and mouth when coughing and sneezing
      | Use disposable masks and dispose them as per waste disposal
      protocol.
      | Immediately wash and dry their hands.
      88
      Social distancing:
      | Crowded places and large gatherings of people should be avoided.
      | Distance between at least one meter should be maintained.
      Personal Protection Equipments
      PPE reduces the risk of infection if used correctly. It includes:
      | Gloves (nonsterile),
      | Mask (high-efficiency mask),
      Steps of good hand washing
      Step 1. Step 2.
      Wash palms and fingers. Wash back of hands.
      Step 3. Step 4.
      Wash fingers and knuckles. Wash thumbs.
      Step 5. Step 6.
      Wash fingertips. Wash wrists.
      89
      Goggles N-95 Mask
      OR
      GOWN(MUST FOR LAB WORK) TRIPLE LAYER MASK
      Gloves Shoe covers
      | Long-sleeved cuffed gown,
      | Protective eyewear (goggles/visors/face shields),
      | Cap (may be used in high risk situations where there may be
      increased aerosols),
      | Plastic apron if splashing of blood, body fluids, excretions and
      secretions is anticipated.
      THE PPE SHOULD BE USED IN SITUATIONS WERE REGULAR WORK PRACTICE
      REQUIRES UNAVOIDABLE, RELATIVELY CLOSED CONTACT WITH THE SUSPECTED
      HUMAN CASE/POULTRY.
      90
      CORRECT PROCEDURE FOR APPLYING PPE IN THE FOLLOWING ORDER:
      1. FOLLOW THOROUGH HAND WASH
      2. WEAR THE COVERALL.
      3. WEAR THE GOGGLES/ SHOE COVER/AND HEAD COVER IN THAT ORDER.
      4. WEAR N-95 MASKS
      5. WEAR GLOVES
      THE MASKS SHOULD BE CHANGED AFTER EVERY SIX TO EIGHT HOURS.
      Remove PPE in the following order:
      | Remove gown (place in rubbish bin).
      | Remove gloves (peel from hand and discard into rubbish bin).
      | Use alcohol-based hand-rub or wash hands with soap and water.
      | Remove cap and face shield (place cap in bin and if reusable place
      face shield in
      container for decontamination).
      | Remove mask - by grasping elastic behind ears – do not touch front
      of mask.
      | Use alcohol-based hand-rub or wash hands with soap and water.
      | Leave the room.
      | Once outside room use alcohol hand-rub again or wash hands with
      soap and water.
      Wash hands using plain soap, anti-microbial agent or waterless
      antiseptic agent such as
      an alcohol-based hand gel.
      Used PPE should be handled as waste as per waste management protocol
      given in the
      guidelines. Repeat hand wash before leaving the infected area.
      91
      SOP FOR CASE REPORTING
      | The Team leader of the RRT would report the `suspected case' as
      per case definition.
      | The probable case reporting would depend upon the preliminary
      laboratory test report
      of infection of influenza group-A as also respiratory failure or
      death among the suspect
      cases. The hospital treating the case would be the agency to confirm
      a probable case
      in hospital settings.
      | DG, ICMR would be the nodal person to confirm laboratory finding
      for diagnosing the
      case as suspect case.
      | In either case, the information would be communicated first to the
      state health Secretary,
      Union health Secretary and DGHS who would review the case parameters
      before
      declaring the probable case.
      | The information of a case being probable would also be
      communicated to the Prime
      ministers Office, Cabinet Secretariat, Team leader of the rapid
      response team by the
      Joint Secretary/ Director, EMR.
      | For confirmation of the probable case, DG, ICMR would ensure that
      NIV, Pune conducts
      the requisite PCR test/ viral culture and sent the samples to the
      WHO designated
      global laboratory at the earliest.
      | Director (EMR) would co-ordinate with the Ministry of Home Affairs
      for airlifting of the
      samples as per standard procedure.
      | The Ministry of Health would only declare the confirmed case after
      ascertaining from
      all concerned.


      Guidelines on public health measures for avian human influenza
      (To be followed when first outbreak is reported)
      Background
      Outbreaks of avian influenza in poultry, when caused by highly
      pathogenic viruses of
      the H5 or H7 subtypes, are of great concern for the agricultural
      sector and can have
      considerable economic consequences. Such outbreaks are also of
      concern for human
      health. WHO therefore recommends, for certain avian influenza
      viruses, a series of
      protective measures aimed at preventing human infections in persons
      at high risk of
      exposures. These measures are particularly important during
      veterinary investigations and
      extensive and urgent culling operations.
      The guidelines set out below is general and in tended for adaptation
      to specific
      situations, in line with national health and veterinary polices.
      63
      Recommended public health actions:
      General advice
      Coordination of services. Multisectoral procedures should be put in
      place to coordinate
      the work of agricultural, veterinary and public health services (and
      any other sectors deemed
      appropriate in a county context) and facilitate the exchange of
      laboratory and epidemiological
      data.
      Protection of persons at risk of occupational exposure
      Persons at risk of occupational exposure on affected or at-risk
      farms should be protected.
      Personal protective equipment. : Those at risk of occupational
      exposure on affected or
      at-risk farms should wear personal protective equipment:
      1. Protective clothing, preferably coveralls plus an impermeable
      apron or surgical gowns
      with long cuffed sleeves plus an impermeable apron;
      2. Heavy-duty rubber work gloves that may be disinfected;
      3. Standard well-fitted surgical masks should be used if high-
      efficiency N95
      respiratory masks (NIOSH –certified N-95 or equivalent) are not
      available. Masks
      should be fit-tested and training in their use should be provided;
      4. Goggles;
      5. Rubber or polyurethane boots that can be disinfected or
      protective foot covers
      that can be discarded.
      Pharmaceutical prophylaxis and treatment.
      Those at risk of occupational exposure on affected or at-risk farms
      can be
      protected via antiviral prophylaxis or post-exposure prophylaxis
      (refer to annexure
      on chemoprophylaxis Annexure-IX). Antivirals should be readily
      available for the
      treatment of suspected and confirmed cases.
      Health monitoring
      Those at risk of occupational exposure should:
      1. Be aware of the early clinical signs of H5N1 infection, but also
      understand that
      many other common diseases- of far less health concern- will show
      similar early
      symptoms.
      Most patients infected with the H5N1 virus show initial symptoms of
      fever (380C
      or higher) followed in influenza-like respiratory symptoms,
      including cough,
      64
      rhinorrhea, sore throat, and (less frequently) shortness of breathe.
      Watery diarrhoea is often present in the early stages of illness,
      and may precede
      respiratory symptoms by up to one week. Gastrointestinal symptoms
      (abdominal
      pain, vomiting) may occur and headache has also been reported. To
      date, one
      report has described two patients who presented with an
      encephalopathic illness
      and diarrhoea without apparent respiratory symptoms.
      2. Check for these signs (especially fever) each day during
      potential exposure and
      for 14 days after last exposure.
      3. Communicate any symptoms to a designated local physician and
      provide
      background information on exposure history.
      Suspected cases
      1. Supected cases should be placed in isolation and managed
      according to recommended
      procedures for infection control.
      2. Suspected cases should be sampled accordingly to national
      guidelines and samples
      should be submitted to regional or national reference laboratories.
      3. Samples and viruses may be shipped to designated laboratories for
      diagnosis and
      virus characterization in accordance with national guidelines.
      4. If possible (for research aimed at identifying risk factors for
      infection), serum samples
      and epidemiological data should be collected from persons who have
      been exposed.
      Serological studies should utilize micro-neutralization tests only.

















      NATIONAL CONTINGENCY PLAN FOR AVIAN INFLUENZA
      NICD ACTION PLAN FOR RAPID RESPONSE

      1. When a case of bird flu in poultry/ birds is reported, the
      National Institute of
      Communicable Disease (NICD) shall investigate possible transmission
      of infection in
      humans in the area concerned.
      2. As information from the District Health Officer / Chief
      Veterinary Officer-District Animal
      Husbandry Officer/ any health institution and media report is
      received, the NICD will
      investigate the same by sending the Rapid Response Team (equipped
      with PPE and
      antiviral drug) and report the findings to the Directorate General
      of Health Services,
      Ministry of Health & F.W. and National Influenza Pandemic Committee.
      3. The team, accompanied by the District/ State veterinary persons
      and State RRT would
      investigate whether there is a possible case of Avian Influenza in
      the area in and
      around the site, where bird / poultry cases were reported from. For
      this the team
      would:
      a. Review Early Warning Signal (increased number of cases and death)
      generated
      by the district health authority in various health facilities
      detected in the district by
      investigating unusual increase in fever cases, any unusual event and
      death with
      acute respiratory illness.
      b. Review OPD/IPD data from local hospital/health facilities pattern
      for acute
      respiratory distress for possible cases of Influenza/ Avian
      Influenza.
      c. Review acute respiratory distress syndromes and unexplained
      deaths due to
      acute respiratory illness in the community.
      d. Review unexplained deaths due to acute respiratory illness in
      health care facilities
      of the area.
      4. All possible cases are to be examined and a line list made with
      details of history of
      travel, occupational exposure; exposure to affected poultry;
      exposure to wild / domestic
      animals and exposure to possible human cases.
      5. A case report form would be completed for every individual for
      whom a diagnosis of
      influenza A/H5 viral infection is being considered. A prototype of
      such a form is enclosed.
      6. Clinical samples of all such cases would be collected and brought
      in for examination
      at the designated laboratories for confirmation of diagnosis as per
      the guidelines in
      15
      the National Contingency Plan. Along with laboratory results
      findings of each such
      investigation by RRT shall be reported to the National Influenza
      Pandemic Committee.
      7. Cases of laboratory confirmed Avian Influenza Infection would be
      reported as:
      a. First confirmed case of influenza A/H5 viral infection.
      b. Cases with most recent dates of onset.
      c. Cases residing in an area without reported HPAI outbreaks in the
      animal
      populations.
      d. Cases in health care workers.
      e. Cases with reported contact with a confirmed case and with no
      other reported
      risk or exposure.
      f. Cases that are part of a cluster (two or more cases in an area).
      g. Sporadic cases with no reported risk or exposure.
      h. Cases among cullers.
      8. All RRT investigations shall be conducted with a full-fledged
      state team accompanying,
      so that with time the state RRT can take over investigation of
      possible Influenza Infection
      episode.
      9. Quarantine of team members.
















































      CONTINGENCY PLAN FOR MANAGEMENT OF HUMAN CASES
      OF AVIAN INFLUENZA

      INTRODUCTION
      Influenza A viruses undergo major antigenic shift at unpredictable
      intervals causing worldwide
      epidemics ("pandemics") with high morbidity and mortality. The
      present outbreak of H5N1 Avian
      Influenza in the south-east asian countries merits attention because
      of increasing evidence to suggest
      that the avian strains are getting more virulent, capable of causing
      severe disease. As of now, it has
      already caused illness in 137 humans with 70 deaths (as on
      9.12.2005) in five countries namely
      Cambodia, Vietnam, Indonesia, China and Thailand. Even though small
      numbers of human cases
      have been reported to date, the situation has features of public
      health concern. Situation could
      change very quickly as the influenza viruses are genetically
      unstable and their behavior cannot be
      predicted.
      From middle of this year the concern shifted to migratory birds as
      they were found to carry the
      virus to many countries in Europe, which included Kazakhstan,
      Romania, Turkey and Croatia. These
      migratory birds also frequent many parts of India.
      Deptt. of Animal Husbandry in co-ordination with Ministry of
      Environment and Forests has
      developed contingency plans for surveillance and containment of
      cases among birds. Any entry of
      the Avian Influenza in India would be through infected birds, which
      will manifest as clustering of
      deaths amongst birds. In that scenario, it is possible that any
      human in contact with the infected birds
      may develop the disease. In the absence of human-to-human
      transmission, the number of such
      cases will be few and localized around the geographic area where the
      birds have been affected.
      It is of paramount importance to contain the infection at this stage
      lest it provides an opportunity
      to the pathogen for re-assorting in humans/any other host and
      mutating into a new strain with potential
      of human-to-human transmission.
      Objectives
      q Surveillance of human cases of avian influenza where cases among
      birds have been reported.
      q Early detection of human cases and their management.
      q Containment of the transmission of infection.
      q Decrease social disruption and economic loss.
      Action plan:
      1. Institutional Framework
      1.1 The National Influenza Pandemic Committee would decide on the
      activation of contingency
      plan on reporting of unusual deaths among birds. The constitution of
      National Influenza
      Pandemic Committee is at Annexure-I.
      (Action: Convener, National Influenza Pandemic Committee)
      1.2 National Institute of Communicable Diseases (NICD) is the
      identified nodal agency for
      8
      managing human avian influenza whereas Department of Animal
      Husbandry is the nodal
      agency for managing bird and poultry cases. The Director, NICD would
      activate its action
      plan once suspected cases in birds/poultry is reported. [Annexure-
      II].
      (Action: Director, NICD)
      2. Surveillance
      2.1 The Department of Animal Husbandry would activate its action
      plan on receipt of any
      preliminary report regarding unusual sickness or above average
      mortality of poultry or wild/
      migratory birds at a place either from veterinary officers or from
      any other source [Wildlife
      Warden etc.]. The Chief veterinary officer (CVO) / District Animal
      Husbandry Officer (DAHO),
      accompanied by a disease investigation Officer shall visit that
      place within 24 hours and
      personally ascertain the circumstances and facts of the case. A
      report on the investigations
      carried out should be sent to Dept. of Animal Husbandry [DAH];
      Ministry of Health and
      Family Welfare (MOHFW), Director, NICD immediately. Action plan of
      DAH is at Annexure-
      III.
      (Action: Dept. of Animal Husbandry/Min. of Environment and Forest)
      2.2 The CVO/ DAHO would inform the district chief medical officer
      (CMO) / district health officer
      of its findings and also alert neighboring districts. The CVO/ DAHO
      would ensure collection
      of samples, culling and disinfections as per the action plan of the
      Department of Animal
      Husbandry.
      (Action: CVO/DAHO)
      2.3 NICD would depute a multi-disciplinary Rapid Response Team (RRT)
      to the affected area
      immediately, whenever a suspected case of avian influenza is
      reported in poultry/ wild/
      migratory birds. The RRT will conduct clinico-epidemiological
      investigation and examine
      contacts/-exposed individuals for influenza illness and report the
      same to MOH&FW.
      Composition of the RRT is at Annexure-IV.
      (Action: Director, NICD)
      2.4 The NICD RRT would undertake surveillance activities (in and
      around the identified area
      from where deaths amongst birds have been reported) along with state
      RRT in coordination
      with Director of Health Services [DHS] of the concerned state to
      identify any human case as
      per standard case definition (Annexure-V). The RRT would carry out
      field investigations
      and collect epidemiological data as well as clinical samples from
      the suspected cases. The
      guideline for collection and transportation of samples is at
      Annexure-VI.
      (Action: Team leader, RRT, State health authorities)
      2.5 The RRT will monitor the health status of the cullers on a
      regular basis at a decontamination
      zone near the culling facility which would be according to the DAH
      action plan (Annexure-
      III). The guidelines for monitoring of health status of cullers are
      at Annexure-VII. CVO/
      DAHO will identify cullers. They will be isolated for this activity
      in a separate place away
      from human dwelling for 10 days after last culling. CVO/ DAHO will
      provide them PPE. The
      disposal of PPE and other procedures would be as per DAH action plan
      (Annexure-III).
      The RRT would provide chemoprophylaxis to the cullers. In the event
      of any suspected
      9
      case among cullers, the case would be treated in the nearest
      identified health facility
      (Annexure-VIII) or any other facility subsequently identified.
      (Action: CVO/ DAHO and Team leader, RRT)
      2.6 The RRT would send daily report to the Avian Influenza
      Monitoring Cell at NICD, which
      would provide necessary technical guidance to RRT. NICD would keep
      Dte.G.H.S. MOHFW
      and the National Influenza Pandemic Committee informed.
      (Action: Team leader, RRT and Monitoring Cell)
      2.7 The RRT would identify the high-risk groups for administration
      of chemoprophylaxis. The
      guidelines for chemoprophylaxis are at Annexure-IX.
      (Action: Team leader, RRT and Monitoring Cell)
      3. Clinical Management
      3.1 The RRT/ State health authorities would identify any human case
      by using the standard case
      definition. The suspected case would be managed as per standard
      treatment protocol
      (Annexure-X)
      (Action: State Health Authorities)
      3.2 The District Collector would ensure transport of human cases
      from affected area to the
      designated hospital.
      (Action: District/ State Health Authorities)
      3.3 The cases would be managed in identified hospitals having
      isolation facilities that follow standard
      infection control practices. A state-wise list of such identified
      hospitals is at Annexure-VIII.
      The state may further identify hospitals with isolation facilities
      for such purpose.
      (Action: State Health Authorities)
      3.4 If required, all such identified hospitals would requisition for
      equipments for critical care support
      and drugs from the Central Govt. to further strengthen their case
      management facilities.
      (Action: State Health Authorities)
      3.5 Clinical samples would be sent to identify bio-safety
      laboratories. A list of such laboratories is
      at Annexure-XI.
      (Action: State Health Authorities)
      4. Public Health Measures
      4.1 Department of Animal Husbandry would ensure that the bird
      handlers/cullers in the affected
      areas/source site, use personal protective equipments. The guideline
      for use of Personal
      Protective Equipments is placed at Annexure-XII.
      (Action: Dept. of Animal Husbandry)
      4.2 The RRT in association with local health authorities will ensure
      chemo prophylaxis of high-risk
      groups including contacts of human cases as per guidelines (Annexure-
      IX).
      (Action: Team leader, RRT and State Health Authorities)
      4.3 The contact cases would be quarantined in-house. Quarantine of
      the village would be
      10
      considered on case-to-case basis. The guidelines for quarantine are
      at Annexure-XIII.
      (Action: State Health Authorities/ MHO)
      4.4 The CVO/ DAHO/ State Animal Husbandry authorities would follow
      the guidelines of Department
      of Animal Husbandry (Annexure-III) in disposing off dead birds/
      culled birds.
      (Action: State Animal Husbandry Authorities)
      4.5 Intensive IEC campaign would be undertaken in the affected area.
      Generic IEC guidelines
      do's and don'ts and FAQs are at Annexure-XIV and XV respectively.
      (Action: State Health Authorities)
      5. Logistics and supplies
      5.1 Suitable stocks of anti-viral drugs for treatment as well as
      chemoprophylaxis, personal protective
      equipment, and critical care equipment will be stockpiled at NICD.
      Initially, 100,000 courses of
      Oseltamivir and 10,000 PPE sets would be stockpiled at NICD. DAH
      will procure and stock
      PPE for their use. The necessary supplies will be rushed to the
      affected area immediately.
      (Action: NICD/ State Health Authorities)
      5.2 Mobilize additional resources in terms of manpower and material
      to affected areas.
      (Action: Director, EMR, Dte.G.H.S.)
      5.3 Ministry of Home Affairs will provide airlifting facilities to
      the RRT and other material logistics,
      if required. Director, EMR, Dte.G.H.S. will coordinate.
      (Action: MHA/ Director, EMR, Dte.G.H.S.)
      5.4 As per the provisions of revised IHR, any public health
      emergency of international concern
      would be reported to the WHO.
      (Action: NICD; MOHFW)
      6. Communications and Media Management
      6.1 NICD, the nodal agency, would communicate to all concerned
      departments regarding the
      status and other information related to Avian Flu. NICD would
      maintain a web based interactive
      public information system.
      (Action: NICD)
      6.2 The Chairman, National Influenza Pandemic Committee or any other
      officer delegated by
      him/ her would address the media.
      (Action: Chairman, NIPC)
      6.3 The Department of Telecommunications would provide satellite
      phone to RRT team, if the
      geographic quarantine area has no landline or cellular connectivity.
      (Action: Dept of Telecommunications)
      7. Miscellaneous
      The contingency plan would be circulated to all concerned. This
      would include contact numbers
      of all-important officers (Annexure-XVI).
      (Action: Director, EMR, Dte.G.H.S.)
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