Pat Nair

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Managing Human health aspects in Avian Flu
Pat Nair NSC HPU
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HPUs in Eastern region
NSC
2.2 m
Beds/Herts
1.5m
1.6m
Essex
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Incident Day 26th April 2006

• DEFRA Teleconference held in the afternoon HPA
  alerted at 1830 hours
• HPA Teleconference scheduled for 2115 hours
• Teleconference Participants
• ERD Duty Officer
• Centre for Infections
• LaRS Regional Team
• Regional Director
• Regional Health Emergency Planning Advisor
• Regional Epidemiologist
• Regional Communications Manager
• Health Protection Unit Director
• CCDC

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The story so far

• Outbreak in laying flock at Infected Premises
  1(IP1) located in Dereham,
• Flu A, confirmed as H7, N subtype not known and
  not known if High or Low Pathogenic Avian
  Influenza
• Information about the Unit
• 35,000 birds. in 4 sheds, shared corridor
• High security premises, staff shower in shower
  out
• Dropped egg production sheds 3 4, Mortality
  increased from 14-15/day to 80/day.
• DEFRA restrictions placed on the farm from
  previous night- 25th April

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DEFRA Response

• Blood, cloacal samples, brain and carcass sent to
  Veterinary Laboratory Agency at Weybridge
• Flu A Serology positive for H7, Negative for H5
• DEFRA Exotic Animal Disease Contingency Plan
  escalated from Amber 3 to Red
• National Disease Control Centre activated next
  day at Page Street London
• Local Disease Control Centre to be activated the
  following day at State Veterinary Service Bury
  St Edmunds
• DEFRA Intervention
• 3 Km Protection Zone Established around IP1
• 10 Km Surveillance Zone Established IP1
• Flock to be culled

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Interventions for humans Discussed Day 0

• Low Path risk to humans negligible
• High Path risk to human health
• Low Path in birds can mutate to high path
• Recent experience in Humans with H7N7,
  Respiratory symptoms less prominent, mainly
  conjunctivitis
• Need to treat as potentially High Path
• Modify algorithm E3

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Results of HPA 2115 Teleconference
Interventions

• Oseltamivir
• Pre and Post exposure prophylaxis
• Treatment dose if symptoms in exposed, Exposure
  7 days from date of confirmation in birds
• Seasonal Flu vaccine
• to prevent re-assortment
• Serology
• Acute Blood Sample and
• Convalescent Blood sample at 28 days
• Follow up for 7 days from last exposure for
  symptoms of conjunctivitis and ILI

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Interventions Day 0

• Communication to those who live on Farm And staff
• Information to GPs And others
• Information tom Public
• Risk assess those who were exposed- local CCDC
• Declared Local Major incident
• EOC to be set up at Norfolk HP office next day

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HPA Command Structure
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HPA Coordination
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Incident Day 1

• 26th April 8 am Local EOC at Norfolk Health
  protection
• Members HPA, PCT, Ambulance
• 9 am Post exposure Oseltamivir to close contacts
  (Suffolk team)
• Lunch time LDCC at Bury
• Afternoon -More contacts mainly farm workers
  CCDC/HPN
• One case of conjunctivitis in a worker- Swabs,
  treatment dose
• Enhanced local surveillance though GPs
• Prolonged and frequent teleconferences
• EOC open till 8 pm. Local GP phoned re worker in
  slaughterhouse with conjunctivitis at 8 pm.
  Treatment dose, swabs

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Incident Day 2

• 27th April 6 am Pre exposure prophylaxis to
  Cullers, Catchers and Rat catchers PCT DPH and
  HPN
• Difficulty in getting cullers to come to infected
  farm
• Cullers who fit
• Cullers who are unfit
• Cullers who faint
• Cullers who are covered in bird feathers
• SVS staff with needle stick injury the day before
• ..and the little girls who live down the lane,
  who caught the dog which caught the chicken-
  Treatment dose,

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Index Case

• 29 year old male
• Works at IP also worked on 4 other farms previous
  7 days
• Home contact wife, pregnant, no oseltamivir
• ??Vaccine, Offered but not given
• Hygiene advice to prevent spread
• Sequential swabbing from case and contact
• Treatment for 10 days
• Acute and Convalescent blood from both
• 2 negatives before sending back to work

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Incident Day 2 - April 27th

• Incineration Transport of carcasses in leak
  proof lorry (lessons from FMD) to usual plant
• No license so to other places in Bradford and at
  Kings Lynn
• Interventions to drivers, Staff at Incinerator
  plants
• Meanwhile Slaughterhouse Portuguese migrant
  workers /hostel, How many contacts?
• Has not had swabs, no treatment yet but claims
  colleagues with symptoms
• Slaughter house owned by same company. Meat used
  for pet food. But no supply from IP1 in last 6
  months ?Further spread
• EOC closed at 9 pm

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Further Development- Day 3 and 4

• Day 3,
• EOC at Ambulance HQ
• Slaughter house workers finally turned up.
• 3 people, all living at home. Treatment dose,
  swabs, full works
• H7N3 confirmed on 28th April, possibly Low Path
• Two other free range farms infected with H7N3
• Date of infection March,
• EOC closed at 6 pm. Handover to different team
• Day 4
• Free range farms confirmedLow Path H7N3 strain
• EOC closed in the afternoon
• Restriction zone around farm, Culling and
  disinfection on Day 5 (Bank holiday Monday)
• follow up- those on the farm, Vets, cullers and
  catchers

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Source DEFRA
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Source DEFRA
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H7 N3

• Day 6 Norfolk team back. No EOC, normal working
• This incident Low Path H7
• Previous H7 in UK a number of years ago, One case
  of conjunctivitis
• Dutch Outbreak in 2003 H7N7, 89 cases 1 death in
  immune compromised individual, (H7N3 British
  Columbia 2004)
• Now cleaning in progress on free range farm
• June Conjunctivitis in framer's wife on free
  range farm, On treatment dose of oseltamivir,
  Flu A PCR negative

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Incident contd

• One case of human conjunctivitis from IP1
• 3 cases of conjunctivitis unconnected to IP
• Second Infected premises
• Follow up of individuals Farm staff, DEFRA Occ
  Health Case definition, Flow chart
• Surveillance, short term/ long term
• And Finally, Clean Up operations on IP1 When?
• Can we not plan it?

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Recognised Hazards on the farm

• All enclosed (indoor) laying / rearing areas
• Primary (on-farm) sorting, grading and egg
  storage facilities
• Where free-range rearing / grazing occurs
  (including a 1 metre cordon)
• Storage area for untreated poultry litter (incl
  a 1 metre cordon if outdoors)
• Care and management of poultry in enclosed sheds
• Catching culling of infected poultry
• Collecting and loading of culled infected
  poultry for transport to disposal
• Poor hygiene / contamination is likely / others
  judged to be hazardous

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Issues to resolve during incident

• Paramyxovirus vaccine strain form culture from
  slaughter house worker (Newcastle Disease Virus)
• ?Oseltamivir induced conjunctivitis
• Follow up of people for 7 days DEFRA staff/ Non
  DEFRA staff, who pays
• Bloods at 28 days who does it
• Conjunctivitis in school 25 miles away
• Conjunctivitis in two journalists who filmed in
  Swaffham

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Criteria for follow up

• Conjunctivitis OR Fever (38C) for at least
  24hrs
• AND
• muscle/body pains OR Cough and shortness of
  breath
• Take history of exposure
• High-risk if exposure 7 days before
  identification of the outbreak
• Offer Oseltamivir vaccination and follow-up for
  7 days
• from last exposure

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Potential sources

• Unknown
• Wild birds?
• Farm workers?
• Domestic birds?

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Issues

• Alert Phase Notfication to HPUs/HPA generally
• Who has overall responsibility,
  HPU/Region/Centres/PCT/NHS?
• What Plan did we follow? HPAs PCTs ?DFRAs
  ?DEFRA Plan doers not include NHS
• Expectations on the capacity of HPU
• Intervention and its delivery- HPA/PCT/Ambulance
• Culture of swabs and arrival of Newcastle disease
  
• On Call rota, mutual aid
• Communication with professionals

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Issues

• Storage and release of Oseltamivir/Vaccine
• Availability of EOC, Admin support, log keeping,
  staff officer
• Communication to professionals who, when, what
  etc
• Media
• Who produces sitreps, who clears it?

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Lessons for me

• Good relationship with local PCTs key to
  successful intervention
• Support from Ambulance staff
• Larger HPUs provide surge capacity
• Representation of HPA at LDCC Epidemiologist
  best placed to do this. RD at strategic and CCDC
  at EOC
• Log Keeping, Admin and IT Support, Cover for EOC
• Have a staff officer to work with you
• Take some breathing space, have enough sustenance
  
• Need some one to fight your corner.

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Teleconference Time limited, ?30 minutes, od,
bd, .or taken sparingly? Limit off line chats
in between to 5 minutes Try to keep your head
even if all around you loose theirs
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THEN and NOW
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Ongoing issues

• Cleaning up process on IP1
• Serology follow up
• Extended Public health surveillance
• Representation at LDCC
• Issues around storage of Oseltamivir and vaccine