1. 1 Case Management of Suspect Human Avian Influenza Infection Part 3: Triage of Suspected Avian Influenza Cases

2. 2 Learning Objectives Define triage Know the function of each of the four steps in a triage approach Recognize the utility of triage in avian influenza case management

3. 3 Session Outline Triage and pneumonia severity ratings Assess the level of care needed Assess available healthcare facilities Advise on referral and transport of patients Assess illness in contacts, determine whether to recommend treatment or isolation of cases, contacts

4. 4 Triage Defined Triage is a system of carefully using medical resources where they are needed most –Decisions about who is the most ill –Decisions about who will respond best to care

5. 5 Steps for Triage of All AI Cases StepsExample Determine type and severity of illness Patient has pneumonia Assess level of care needed Does the patient need Antivirals? Oxygen? A ventilator? Assess available health care resources Does the health care facility have a ventilator? Advise on patient referral and transport Does a nearby facility have a ventilator? Can the patient make the trip? 1.1. 2.2. 3.3. 4.4.

6. 6 Triage Step 1 Determine Type and Severity of Illness

7. 7 Determining Severity of Illness For avian influenza, prioritize by severity of pneumonia Systems for rating pneumonia severity –Pneumonia Severity Index –CRB-65 –Pneumonia Severity Scoring System Scores assigned to show urgency of hospital admission

8. 8 CRB-65 Developed the British Thoracic Society One point each for: –Confusion (new disorientation in person, time or place) –Respiratory rate >= 30 breaths/min –Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic –Age >= 65 years

9. 9 CRB-65 Interpretation Score 0: Low risk of death; may be suitable for home treatment Score 1: Increased risk of death; consider for short inpatient treatment or supervised out patient Score >=2: High risk of death; Require urgent hospital admission Score01234 Predicted Mortality (%) 0.95.212.032.425* * low numbers and very broad confidence interval

10. 10 Severity Assessment( Children) BTS MildSevere InfantsTemp. 38.5 C RR 70/min Mild recessionModerate- severe recession Taking full feedsNot feeding Nasal flaring Cyanosis Intermittent apnea Grunting respiration

11. 11 Severity Assessment( Children) BTS MildSevere Older childrenTemp. 38.5 C RR 50/min Mild breathlessnessSevere Breathlessness No VomitingNasal flaring Cyanosis Grunting respiration signs of dehydration

12. 12 Pneumonia Severity Ratings Do not rely solely on scores –Scores serve as a guideline –Consider the patient’s clinical information –Use best judgment based on expertise Adapt rating systems to local capacity –Pulse-oximetry to measure oxygen in blood –Availability of blood pressure monitors

13. 13 Case Report

14. 14 Case Scenario Female, 32 years old Presents at hospital November 7 Symptoms –Trouble breathing –Cyanosis (blue-colored skin) –Fever 38.8°C –Pulse 118 beats / minute –Respiratory rate 37 breaths / minute –Lymphocyte count 608 / mm 3 –Chest x-ray shows diffuse infiltrates in the lower part of both lungs

15. 15 Rate Pneumonia Severity CRB-65 Category Points Given Confusion 0 Respiratory rate >= 30 breaths/min 1 Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic [Pulse > 125 beats / min] 1 Age >= 65 years 0 Total Points for modified CRB-65 2 Moderate risk of death; consider hospital admission

16. 16 Triage Step 2 Assess Level of Care Needed

17. 17 Hospitalization Not Needed Patient may be cared for at home Administer appropriate antiviral if avian influenza suspected Teach patient and family –Wash hands –Ill person uses a surgical mask –Limit social contacts –Symptoms in patient or family members that require prompt medical care If possible, follow-up with home visits or by telephone

18. 18 Hospitalization Required Illness is not an emergency –Monitor for changes in status –Treat with antiviral –Treat as necessary with Antibiotics Oxygen Severe illness –Patient admitted to intensive care unit –Ventilation or advanced medical support for organ failure may be necessary

19. 19 Triage Step 3 Assess Available Healthcare Resources

20. 20 Healthcare Facilities Station Hospital Outpatient services limited laboratory capacity Limited Inpatient services Township/District Hospital Outpatient services More laboratory capacity Inpatient services State/Division Hospital Outpatient services More laboratory capacity Inpatient services Isolation rooms ICU Service? Referral Hospital Yangon& Mandalay Advanced medical care Advanced Laboratory diagnosis Isolation rooms ICU services

21. 21 Healthcare Facilities Know your area facilities: –Location –Capability –Capacity

22. 22 Healthcare Facilities Question 1 What healthcare facilities are available in your area? Question 2 What level of care can be provided at these facilities?

23. 23 Triage Step 4 Advise on Referral and Transport of Patients

24. 24 Referring Patients to Another Facility Logistical considerations Treat all patients at one versus a few sites? When to transport patients to higher level facilities How to transport patients to higher level facilities Staff availability Availability of overflow areas Treatment considerations Access to antivirals and antibiotics Access to a laboratory for diagnosis Access to radiology (x-ray) Availability of isolation rooms

25. 25 Patient Transport Example Female patient, with pneumonia admitted to primary level hospital The only patient suspected of avian influenza Symptoms: fever, high pulse and respiratory rate, crackles heard in lungs Primary hospital can administer oxygen and antibiotics, but has no access to x-ray or antivirals Tertiary hospital can x-ray patient and place on ventilator support, if needed, but has no antivirals

26. 26 Patient Transport Example Question 1 Would you recommend transporting the patient to the tertiary care hospital? Question 2 What if the patient was one of many severe pneumonia patients at the primary hospital? Question 3 What do you think are the most important criteria for deciding to transport a patient?

27. 27 Problem Solving Exercise

28. 28 Public Health Steps for Managing Cases

29. 29 Additional Steps Necessary 1. Assess presence of illness among contacts 2. Advise on management of corpses with possible avian influenza 3. Determine need for isolation and quarantine 4. Document data on standardized forms and report to relevant authorities

30. 30 Assess Contacts Assess contacts quickly –Incubation period only 2 to 3 days Contact - anyone who has touched or talked with (=<1 meter) the patient up to 2 or 3 days prior to the patient’s onset of illness –Household members –Fellow workers Assess contacts for influenza-like illness –Fever –Cough, shortness of breath –Muscle aches –Diarrhea

31. 31 Manage Corpses No risk of transmission from dead bodies Autopsy procedures could result in transmission –Use appropriate protective equipment You should know –Where corpses may be sent for disposal –Cultural or religious beliefs to respect when handling corpses

32. 32 Advise on Isolation and Quarantine Isolation Separate or limit movement of people who are ill to prevent them from infecting healthy people Often occurs in a healthcare setting For use when illness is fairly rare Quarantine Separate people who have been exposed to an illness (may not be ill themselves) For use when illness is widespread May cancel public gatherings, large events

33. 33 Advise on Isolation and Quarantine Length of time for isolation and quarantine depends on incubation period and infectious period Goals: –Prevent additional human cases early –Slow pandemic spread (gain time for preparing) –Reduce the impact of the first wave of a pandemic

34. 34 Document and Report Cases Help identify and describe old and new strains of avian influenza Know where avian influenza is being transmitted Track and count illness due to avian influenza Provide information for influenza control Help officials make public health decisions

35. 35 Document and Report Cases Local Level District or State/Division Level Ministry of Health World Health Organization

36. 36 Document and Report Cases “WHO Guidelines for Global Surveillance of Influenza A/H5” Annex 5 “Template for Case Report Form” http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf

37. 37 Document and Report Cases Information to include Name of person reporting Healthcare facility name and location Patient information: DemographicsTravel history SymptomsAvian flu in area animals Test ResultsPotential exposures Treatment givenOutcomes

38. 38 Document and Report Cases http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf

39. 39 Document and Report Cases When should you report? As soon as possible! Do not wait for laboratory confirmation Do not wait to observe patient outcome

40. 40 Summary Patients needing advanced care may need to be transported to a higher level facility, while patients with mild illness may be able to stay at home Medical treatment and care of patients will depend on the facilities available in your geographic area People who have contact with a suspected avian influenza case should be assessed for illness, and may be given preventive treatment or put in isolation

41. 41 Case Study & Scripted Role Play

42. 42 Glossary Triage A system of carefully using medical resources where they are needed most.

43. 43 References and Resources WHO interim guidelines on clinical management of humans infected by influenza A(H5N1), 2 March 2004. http://www.who.int/csr/disease/avian_influenza/guideline s/clinicalmanage/en/index.html http://www.who.int/csr/disease/avian_influenza/guideline s/clinicalmanage/en/index.html Tran Tinh Hien, et al. Avian Influenza A (H5N1) in 10 Patients in Vietnam. N Engl J Med March 18, 2004: 350(12), p 1179-1181. WHO pandemic influenza draft protocol for rapid response and containment Updated draft 30 May 2006. http://www.who.int/csr/disease/avian_influenza/guideline s/protocolfinal30_05_06a.pdf http://www.who.int/csr/disease/avian_influenza/guideline s/protocolfinal30_05_06a.pdf