Emerging Infectious Respiratory Diseases
(EIRD): the Role of the Family Physician
OCFP Annual Scientific Assembly
Brian Schwartz, MD, MScCH, CCFP(EM), FCFP
Chief, Emergency Preparedness, Public Health Ontario
November 28, 2013
Faculty/Presenter Disclosure
• Faculty: Brian Schwartz
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– Not applicable
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Disclosure of Commercial
Support
• No commercial support
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Mitigating Potential Bias
• Not applicable
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Acknowledgements
• PHO
• MOHLTC – Emergency Management Branch
• Dr. Doug Sider
• Anne Winter
• Dr. Maureen Cividino
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Objectives of presentation
After this presentation you should be able to:
1. Describe the global emergence of infectious respiratory
diseases and their relevance to Ontario practice
2. Identify suspect cases of EIRD and institute appropriate
infection prevention and control
3. Identify and treat local infectious respiratory diseases (e.g.
seasonal influenza)
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Public Health Ontario
GOALS
1. Better
information
for better
public health
decisions and
actions
2. Generate and
accelerate
application of
knowledge for
better public health
decisions and
actions
3. Support the Ontario
public health system
in its daily business
and enhance capacity
in emergencies
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1. PHO monitoring for emerging diseases
• Monitoring of global surveillance reports
• Enhance provincial and local detection (e.g.
awareness, screening, lab testing)
• Collaboration and information sharing with
national, provincial and local stakeholders
• Proactive development of containment/
management/response strategies
• Risk assessment
• Monitoring of seasonal respiratory diseases
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Breaking news, June 2012
• Newspaper headlines
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“There is nowhere in the world from
which we are remote and no one
from whom we are disconnected”
Microbial threats to health in the US. IOM 1992
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www.publichealthontario.ca
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Types of coronaviruses
l ha
-
eta
amma
elta
-
-
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MERS-CoV cases reported WHO, September 20, 2013,
by month of illness onset
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MMWR, September 27, 2013 / 62(38);793-796
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Location of MERS-CoV cases by reporting
country, September 25, 2013
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http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20596
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Virus origin?
• Dromedary camels found
positive for MERS-CoV using
serologic testing
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• Genetically identical virus
fragment from bats
• Intermediate host?
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Hajj October 13-18, 2013
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Destinations of Air Travelers Departing MERS-CoV Source
Countries and Origins of Hajj Pilgrims
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http://currents.plos.org/outbreaks/article/assessing-risk-for-the-international-spread-of-middle-eastrespiratory-syndrome-in-association-with-mass-gatherings-in-saudi-arabia/
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www.ontario.ca/novelcoronavirus
MERS-CoV
• Mild to severe illness (role of asymptomatic infection)
• Limited person to person transmission has occurred
• Individuals with underlying illnesses at greater risk of
complications
• Nosocomial transmission (patients and HCWs) has
occurred, however adherence to recommended IPAC
measures unknown
• Screening and surveillance are key
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Avian influenza A/H7N9
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www.cdc.gov/flu/avianflu/h7n9-images.htm
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Background
• On March 31, 2013 China notified WHO that a novel
influenza A/H7N9 infection was causing severe illness in
humans
• Human infections with other subgroups of H7 influenza
viruses (H7N2, H7N3, and H7N7) reported previously. The
infections mainly resulted in conjunctivitis and mild upper
respiratory symptoms
www.cdc.gov/flu/avianflu/h7n9-images.htm
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http://www.uq.edu.au/vdu/VDUInfluenza_H7N9.htm
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www.ontario.ca/avianinfluenza
Avian Influenza A/H7N9
• Mild to severe illness (role of asymptomatic
infection)
• Limited person to person transmission has occurred
• Individuals with underlying illnesses at greater risk
of complications
• Disease reservoirs: ?poultry markets?
• Screening and surveillance are key
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2. Initial
Decision
Making and
Management
of Patients
Who May Have
an EIRD
www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/mers_decision.pdf
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2. Screening and IPAC: key points
1. Acute respiratory infection (ARI): Routine Practices
and Additional Precautions
2. Exposure history: add N95 respirator
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Laboratory: how to test?
MERS-CoV
Avian influenza A (H7N9)
NP swab/ BAL if indicated
NP swab/ BAL if indicated
EDTA blood tube
Viral throat swab if
hospitalized
urine
Stool if GI symptoms
Acute and convalescent (21 to
28 days later) serology
Acute and convalescent (21 to
28 days later) serology
www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/guidance.aspx
www.health.gov.on.ca/en/pro/programs/emb/avian/workers.aspx
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Principles of Routine Practices (RP)
• Based on premise that all patients are potentially
f
…
f
fp
l
be used routinely to prevent exposure to blood, body
fluids, mucous membranes or contaminated environment
• Infection control measures used to prevent and control
transmission of microorganisms from patient to patient,
patient to HCW, HCW to patient and HCW to HCW
• Perform a risk assessment before every encounter with
the patient or their environment. Note this will be a
dynamic
p
’
changes
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Principles of Additional Precautions (AP)
• Additional Precautions are used in addition to Routine
Practices for patients known or suspected to be infected or
colonized with certain microorganisms to interrupt
transmission
• AP include the use of barriers, personal protective equipment
(PPE) and control of the environment
• In some instances specialized engineering controls may be
required (e.g. referral of a patient with active tuberculosis or
in this case PUI for MERS-CoV or avian influenza A(H7N9) virus
for admission into an airborne infection isolation room)
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Personal Protective Equipment (PPE)
• PPE includes one or more of the following: gloves,
gowns, masks, respirators and eye protection
• Clean PPE is applied immediately before providing care,
removed and disposed of immediately after, and hands
cleaned
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Facial and Eye Protection
• It is important to protect the mucous membranes of the HCW
• Eye protection is often forgotten but very important
• Eye protection can be goggles, glasses with proper side
coverage or face shield
• Important to be comfortable; to fit; to ensure no splash or spray will
contact eye
• Can be disposable or reusable; ensure proper cleaning procedure that
will not contaminate the worker
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Face Protection: N95 Respirator
• N95 respirator must be fit-tested at least every 2 years as
part of a respiratory protection program
• Must be seal-checked with each use
• Must be disposed of after each use
• Take great care not to self-contaminate while removing
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Hand Hygiene
• Perform hand hygiene as per
the JCYH 4 moments of hand
hygiene
• Alcohol-based hand rub
(ABHR) at point of care is
preferred
• Should be 70% concentration
of alcohol with emollients
• Hand washing with soap and
water if hands visibly soiled
Image source: M. Ashcroft
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New England Journal of Medicine Jan 15 2009
Curtis Donskey
After using ABHR
MRSA growth
HCW hand imprint after abd exam
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Summary of IPAC
• Follow usual Routine Practices
• Use Additional Precautions for Droplet/Contact
• +N95 when history of symptoms and exposure indicate so
• Remember proper sequence for donning and doffing PPE
• Surgical mask on patient for transport (if tolerated)
• Normal cleaning practices for equipment, environment
• Normal safe handling practices for linens, sharps
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3. on’t forget
seasonal influenza
• ILI with or without travel history
• Follow PHO influenza bulletins and information from your
local health unit
• When influenza and are “going around” (i.e. significant
laboratory positivity) consider early antiviral treatment for
patients at risk for complications:
Cardiac/pulmonary
Renal/metabolic
Malignancy
Neurological disease Aboriginal
Immunocompromise Age <5 or >65
Morbid obesity
Pregnancy
FY Aoki, UD Allen, HG Stiver, GA Evans. The use of antiviral drugs for influenza: Guidance for
practitioners 2012/2013. Can J Infect Dis Med Microbiol 2012;23(4):e79-e92.
www.ammi.ca/media/48038/14791_aoki_final.pdf.pdf
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www.publichealthontario.ca/en/ServicesAndTools/SurveillanceS
ervices/Pages/Ontario-Respiratory-Virus-Bulletin.aspx
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Influenza Treatment
Oseltamivir: adults, children > 40 kg.
Children > 12 months:
23-40 kg.
75 mg. bid
15-23 kg.
<15 kg.
Children 3-12 months
Zanamivir (>7 years)
45 mg. bid
30 mg. bid
3 mg./kg. bid
2- 5mg puffs bid
60 mg. bid
FY Aoki, UD Allen, HG Stiver, GA Evans. The use of antiviral drugs for influenza: Guidance
for practitioners 2012/2013. Can J Infect Dis Med Microbiol 2012;23(4):e79-e92
www.ammi.ca/media/48038/14791_aoki_final.pdf.pdf
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Summary
• Screen for acute respiratory illness in your practice and use
IPAC routine practices and additional precautions
• 2013: include a travel/exposure question if relevant (e.g.
Middle East and China
• Watch for seasonal influenza and treat ILI with oseltamivir
when activity is high
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Resources
• Local public health unit
• MOHLTC:
• www.ontario.ca/novelcoronavirus
• www.ontario.ca/avianinfluenza
• PHO’s res iratory virus re orts (seasonal virus circulation)
• Ontario Respiratory Virus Bulletin
www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServices/Pages
/Ontario-Respiratory-Virus-Bulletin.aspx
• Laboratory Based Respiratory Pathogen Report
www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/
PHO-Laboratories-surveillance-updates.aspx
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Questions
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