Module 4 Part 2
Facilitator Guide
Case Study Scenario
Instructions: This Case Study scenario will give you the opportunity to develop the
advice that you would give in the management of a suspect avian influenza case.
Background
A 9 year old boy from rural Thailand is brought to the local heath clinic due to several days of
illness with a high fever and cough. The patient had previously been healthy. He is without
vomiting or rashes. His parents say they raise some chickens on their property.
The local clinician must decide how to manage this patient.
Question:
1. What illnesses should the local clinician be concerned about?
Facilitator Answer: Any number of infections are possible causes, including influenza
and other viral infections. But the poultry exposure should raise suspicion of avian
influenza.
Additional Symptoms
The local clinician notes a fever, increased respiratory rate, crackles in the lungs, and a fast heart
rate (tachycardia) in the boy. The clinician also knows the family raises chickens. Finally, the
clinician knows that there has been a recent case report of avian influenza in the region.
Question:
2. What other data would be helpful if you were investigating this case as a possible
outbreak?
Facilitator Answer: 1) Whether or not the patient had any ill family members or close
contacts; and 2) Whether or not the patient has been in the presence of or in contact with
any ill or dead birds.
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At the Local Clinic
The clinician advises the parents to take the child to the hospital for further evaluation and fluid
management.
Question:
3. What information would be helpful for the local hospital?
Facilitator Answer: The local clinician hopefully would relay the relevant information
about the patient, including the family’s poultry exposure, and remind the hospital of the
regional case report of avian influenza
At the Local Hospital
At the local hospital, the patient is initially seen in the emergency department, given intravenous
fluids, and evaluated. The patient is examined, he and his family are interviewed, and doctors
begin medical testing.
Questions:
4. What would you like to know about the examination findings?
Facilitator Answer: vital signs, particularly respiratory rate, as well as lung sounds.
5. What tests might be helpful?
Facilitator Answer: Blood count, chemistries, stool studies, and chest x-ray may all be
helpful, but influenza testing is important in this scenario.
Initial laboratory studies
- Leukocyte count of 2800/mm³
- Lymphocyte count of 640/mm³
- Hemoglobin of 12.5 g/dl
- Platelet count of 125,000/mm³
Blood glucose 5.2 mmol/l
Initial Findings
Normal Values
4,300 - 10,800/mm³
1500 - 4000 / mm³
12 - 18 g/dl
150,000 - 400,000 / mm³
2.2 - 7.0 mmol/l
Liver function tests are normal
Chest x-ray is clear
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Initial testing indicates that influenza is the source of the boy’s illness, so oral Oseltamivir
administration is started. The patient is admitted to the hospital for continued hydration and
monitoring.
Questions:
6. If the patient developed vomiting, to what might you attribute it?
Facilitator Answer: The most common side effect of note for Oseltamivir would be
nausea and vomiting. Case reports do not suggest that vomiting is a common problem in
avian influenza. Oseltamivir also can cause diarrhea and abdominal pain; however, so
can avian influenza.
Facilitator follow up question: Should you repeat the Oseltamivir dose if the patient has
vomited?
7. What precautions should be taken?
Facilitator Answer: Isolation precautions to prevent the spread of influenza will be
discussed in further detail in the Infection Control module of this training. However,
students may note that some of these precautions include gloves, gowns goggles/face
shield, surgical mask; N-95 respirator if available for doing high-risk procedures;
dedicated medical equipment if possible; isolation of patient or cohorting if other suspect
cases are around; and limiting movement of the patient or putting a mask on him if
transporting him to other parts of the hospital or elsewhere.
At the Local Hospital
Over the next 2 days the patient’s respiratory rate increases, and he begins to require
supplemental oxygen to maintain normal oxygen levels. Furthermore, his chest x-ray reveals
bilateral infiltrates, his blood glucose rises to 12.6 millimoles per liter, and his liver enzymes
(AST and ALT) are elevated.
Questions:
8. What test would you hope was sent to a specialized laboratory?
Facilitator Answer: Specimens for influenza typing. A throat specimen should be sent to
the national or referral lab for H5N1 testing by RT-PCR (regular influenza testing should
not be done at a local lab, as culturing is not safe, but this will be discussed further in the
Laboratory module); pneumonia is possibly bacterial so specimens may be tested for this
as well.
9. What additional therapy might be helpful?
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Facilitator Answer: Antibiotics in case the x-ray reveals a bacterial pneumonia.
Update
The local hospital has very limited capabilities for intensive care.
Question:
10. Knowing the natural history of avian influenza, what might you recommend at this
point?
Facilitator Answer: Responses can vary. The patient is deteriorating, so getting the
patient to a higher level of care would be a primary concern. In this case, it might mean
transferring him to the ICU, or a larger referral hospital with ICU capabilities.
Update
The patient is transferred to a referral center, in an isolation room in the intensive care unit. Over
the next several days the patient’s respiratory symptoms improve, the fever and diarrhea resolve,
and he is moved out of the ICU. Less than a week later he has recovered, but is kept in isolation.
Questions:
11. What are the chances of a recovery from Avian Influenza?
Facilitator Answer: That isn’t well known, but case-fatality for the H5N1 strain of avian
influenza appears to be about 50%. This patient was recognized early and treated with
anti-influenza drugs early, which theoretically should improve the patient’s chances.
Many case reports of avian influenza have an outcome of patient death; however, few of
the case reports have been able to start anti-influenza therapy early.
12. When should the patient be allowed to go home?
Facilitator Answer: Isolation should continue for 21 days following onset of the illness,
ideally in a supervised setting, following the WHO recommendations for monitoring
children. This does not absolutely have to be in the hospital, so if the family is reliable,
and has accommodations for isolation at home, he could be allowed to go home when
medically ready in the appropriate setting.
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Module 4 Part 3
Case Management of Suspect Human Avian Influenza Infection: Triage
of Suspected Avian Influenza Cases
A. Problem Solving Exercise
Instructions
In this exercise, you will be able to practice assessing the severity of a patients’ illness
and forming advice as to where the patients should be treated.
Background
Three new patients are in the triage area of a small local hospital in a rural area of your country.
All three patients have respiratory symptoms and a fever. There has been a recent regional case
report of avian influenza, and several reports of dead domestic poultry in the local area.
The director of the hospital calls you to ask for advice on what to do with these patients.
Patient Severity: The clinical information on the 3 case patients is listed below.
Case 1
Case 2
Case 3
22 year old male
8 year old female
15 year old male
3 day history: fever, cough
1 week history: fever,
cough, diarrhea
3 day history: fever, cough,
headache
New onset shortness of
breath
No shortness of breath
No shortness of breath
Alert and coherent
Drowsy, confused
Alert and coherent
Temp:
39°C
Resp:
40/min
Heart rate:
136
Blood press: 108/62
Temp:
38.5 °C
Resp:
30/min
Blood press: 90/60
Temp:
38.2°C
Resp:
22/min
Blood press: 100/70
Bilateral infiltrates
Normal chest x-ray
X-ray pending
Low lymphocytes and
leukocytes
Depressed lymphocyte count Blood count pending
CRB-65 score: 1
CRB-65 score: 3
CRB-65 score: 0
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Questions:
1: What level of care do you think is required for Case 1?
Facilitator Answer: Hospitalization would be advisable, and access to an ICU is
important because this patient has a severely compromised respiratory system.
2: What level of care do you think is required for Case 2?
Facilitator Answer: Hospitalization would be advisable, probably in an ICU, due to the
patient’s altered level of consciousness.
3: What level of care do you think is required for Case 3?
Facilitator Answer: Outpatient management would be acceptable for this mildly ill
patient.
Facility Assessment: The next step is to assess the facilities available to care for the
patients that need hospitalization. Healthcare facilities in the region are listed below.
Local hospital
• Has oxygen, intravenous antibiotics, x-ray
• Minimal lab, no respiratory isolation rooms
• Attached outpatient clinic
• No antivirals
Regional referral hospital
• Has ICU, isolation, and full laboratory
• Access to antivirals
Questions:
4: Based on what you know about the local and referral hospitals, in which facility
would you want Case 1 to be treated?
Facilitator Answer: The regional referral center would be preferable for likely ICU care
due to the patient’s respiratory status.
5: Based on what you know about the local and referral hospitals, in which facility would
you prefer to see Case 2 treated?
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Facilitator Answer: The regional referral center would be preferable because the patient
has a deteriorating mental status.
6: Based on what you know about the local and referral hospitals, in which facility would
you prefer to see Case 3 treated?
Facilitator Answer: Either an outpatient clinic or a local hospital would be acceptable.
The acceptability of the outpatient clinic option would depend on the family’s reliability
with respect to follow up and isolation precautions.
7: Who should be considered for transport, and why?
Facilitator Answer: Both case 1 and case 2 should be considered for transport to the
regional referral hospital: case 1 for a likely ICU stay, and case 2 for further evaluation
of her mental status deterioration and potentially an ICU stay.
Transportation Assessment: Now that you have determined where cases should be
treated, you need to assess and advise on the transportation options.
It is a 4-hour drive from local hospital to the regional hospital (8 hours round-trip).
There is a single ambulance at local hospital with room for 2 patients.
Questions:
8: Based on the ambulance capacity and the estimated duration of the trip, would you
recommend transporting Case 1 and Case 2 to the regional referral hospital?
Facilitator Answer: Different opinions may be expressed. The patients would probably
be better off in the regional hospital; however they would need to be strong enough to
make the trip.
9: Is there any other information that you might want to know before making your
recommendation?
Facilitator Answer: You would want to know about other patients who may require
transport more urgently and the ability of the receiving hospital to accommodate more
patients.
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B. Aran Scenario
Instructions In this exercise you will re-visit Aran, a pneumonia patient. You will be
presented with information on Aran’s situation, and will answer questions as a group
based on what you have learned about public health action required for managing a case
of suspect avian influenza.
Assess Contacts
Background
There is a 13-year-old male patient named Aran, who has pneumonia. Aran has been admitted
to a primary level is suspected of having avian influenza. Several other suspect AI cases have
been reported in the area, and you are worried this may signal the beginning of an outbreak,
maybe even with human-to-human spread of the virus.
Questions:
1: Why do you want to assess Aran’s contacts for illness?
Facilitator Answer: To find out if they are ill, yes, but why does this matter? If there is
any evidence of a cluster of suspect avian influenza cases, we would immediately be
concerned about the possibility that human-to human transmission has occurred.
Human-to human transmission is most likely to occur among close, frequent contacts,
such as the family members and close friends of a child. If there is a cluster of cases, the
faster we can find out who is ill and who is exposed, the faster we can work to contain the
outbreak and prevent a large epidemic.
2: How do you find out who Aran’s contacts are?
Facilitator Answer: A parent or relative probably brought Aran to the hospital for care.
Ask the family member questions about the number of household members, who they are,
where they live, and frequent contacts of Aran’s. Also ask Aran about his friends or
school mates. Visit Aran’s household to assess family members who were not present at
the hospital, and educate them about signs and symptoms of avian influenza. They should
be instructed to report for medical care promptly if they experience any symptoms.
Isolation and quarantine
Aran has been placed in isolation. Some of his siblings and classmates have also
become ill with flu-like symptoms, and soon all of the available isolation rooms are
full. You advise the community to quarantine children who may have been exposed
to stop spread of the disease.
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Questions
3: Where should quarantine take place?
Facilitator Answer: Probably at home, since children should not be separated from their
parents.
4: Should children’s families also be quarantined?
Facilitator Answer: Voluntary quarantine of family members is probably recommended,
although it may be difficult to enforce. Parents and older relatives may have to leave the
home to earn money and provide for the family.
5: Should any events be canceled to reduce transmission among children?
Facilitator Answer: If children appear to be the source of infection, it may be
appropriate to cancel school, religious, or family events where people will gather and
children will be present.
Document and Report Cases
Aran’s village is affected by avian influenza, but the surrounding areas are not affected. You
are so busy with the situation that you do not have much time and you do not report cases.
Questions
6: Is this acceptable if influenza is not affecting neighboring villages?
Facilitator Answer: No, this is not acceptable. Influenza may soon spread to neighboring
villages, and the whole area, district, and country should be warned that there are a
large number of cases occurring so that they can prepare for outbreaks in their own
localities.
7: What problems might be caused?
Facilitator Answer: Most likely, this will result in the disease spreading more quickly.
Not reporting at the local level may cause the outbreak to spread out of control when it
might have been contained with national and international resources. International
resources can be used to help stem a possible pandemic.
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C. Scripted Role Play
Instructions
This exercise will require at least two people to play scripted roles. One person will be
the wife of a farmer who is ill with suspected avian influenza; the other will be a member
of the investigating rapid response team. The other members of the group can observe the
role play and participate in answering questions. Note that formal instruction on
questionnaire administration will occur later in the curriculum.
Background
A 23 year-old male farmer has fallen very ill. The local healthcare provider is concerned that the
illness might be avian influenza, so he calls the public health authorities, and a rapid response
team member is sent to investigate…
Rapid Responder: Hello Mrs. Farmer, I am with the rapid response team investigating
your husband’s illness. We are trying to prevent others from becoming ill, and it would
be very helpful if you could answer some questions.
Mrs. Farmer: OK.
Rapid Responder: I understand your husband fell ill 5 days ago. Can you recall anyone
he had been around that was ill within the last 7 to 10 days?
Mrs. Farmer: No one I can think of has been sick besides my husband.
Rapid Responder: I understand that you are farmers. Do you raise any poultry?
Mrs. Farmer: Yes, we have some chickens we keep for eggs.
Rapid Responder: Have you had any problems with the birds?
Mrs. Farmer: Well, two of them died last week; the rest seem fine.
Rapid Responder: I understand that you have children. How is their health?
Mrs. Farmer: Yes, we have a son and a daughter who are doing well, thank you.
Rapid Responder: Mrs. Farmer, does your husband sell your farm’s products?
Mrs. Farmer: Yes, he goes twice a week to the outdoor market to sell our produce and
eggs.
Rapid Responder: Does your husband have anyone help on the farm?
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Mrs. Farmer: Sometimes our neighbors nearby help out, and sometimes we help them,
but no one else recently.
Questions for the group:
1. What other questions would be important? – Does the patient have other friends? Does he have
any other activities or hobbies?
Suggested answer: Obtaining a detailed weekly routine or trying to have the family recall
events 1 week or so prior to the onset of illness would be useful.
2. How should this be documented?
Suggested answer: This should be documented on the standardized outbreak form for
your country.
Continue the Role Play:
Rapid Responder: Mrs. Farmer, did your husband socialize in the week prior to becoming
ill?
Mrs. Farmer: Yes, he had a group of friends who played cards together regularly,
including 3 days before he started feeling bad.
Rapid Responder: And did he have any other friends or relatives he saw in the week or so
before he became ill?
Mrs. Farmer: Yes, two friends who he went to market with to sell our vegetables and
eggs.
Update
Later that day, the responding team learns that one of the patient’s card playing friends has fallen
ill with something that resembles avian influenza.
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Questions:
3. What would be your concern if you learned this?
Suggested answer: Person to person transmission would be a concern.
4. What public health actions would you consider at this point?
Suggested answer: Some type of isolation or quarantine of the patient’s contacts,
including the rest of the card players, and perhaps the friends, in addition to the patient’s
family.
Continue the Role Play:
Update
The following day, the index patient dies. The family wishes to make funeral arrangements.
Rapid Responder: Mrs. Farmer, I am sorry for your loss. I understand you and the rest
of the family wish to make funeral arrangements. The ministry of health has asked me to
help you with this process to try to keep everyone healthy. Do you know your husband’s
wishes for a funeral?
Mrs. Farmer: We didn’t talk about it, but I think our families would like a traditional
ceremony and burial.
Rapid Responder: Do the traditions in your area make use of embalming?
Mrs. Farmer: I’m not sure.
Rapid Responder: Do funerals traditionally have an open casket?
Mrs. Farmer: None that I have been to.
Rapid Responder: And who will be responsible for preparation of your husband’s body
for the funeral?
Mrs. Farmer: That is usually done by our town’s only funeral home.
Rapid Responder: Thank you for your help. We will do everything we can to
accommodate your family’s wishes while trying to keep everyone healthy.
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Question:
5. From a disease transmission standpoint, what concerns could arise from a funeral?
(Note: More information on safety precautions for handling the deceased will be
presented in a later section).
Suggested answer: The body could potentially be infectious. Depending on funeral
traditions the people involved with handling the body could be at risk of contact with the
virus. Concerns for transmission will vary based on local funeral customs, so delicate
handling of any conflicts between safety and respect may be necessary.
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