Avian Influenza Responder Monitoring ELC Epidemiology Workshop IRIDVPD

Avian Influenza Responder Monitoring ELC Epidemiology Workshop IRID/VPD Breakout Session February 25, 2016 Lesley Brannan, MPH IRID Team Leader

Novel and Avian Influenza • What is Novel Flu? • Influenza A subtypes that do not normally circulate in humans, e. g. , avian and swine origin strains —H 5, H 7, H 3 N 2 v, etc. • Why do we care? • Immunologically naïve population • Epidemics or pandemics can arise if viruses adapt to spread efficiently from person-to-person • Will illness be mild? Severe? Who will it affect? • Current avian viruses of concern • H 5 N 1, H 7 N 9, H 5 N 6, H 9 N 2, etc. • Highly pathogenic avian influenza (HPAI) and low pathogenic avian influenza (LPAI) subtypes • Both may cause disease in humans • Who is at risk? • Infection typically associated with close contact with poultry

Avian Influenza Outbreaks

HPAI H 5 and H 7 Avian Outbreaks, 2015 -2016

Avian Influenza in the United States 1997 -2014 • Only a handful of LPAI outbreaks in domesticated birds • Only one outbreak of HPAI in the US • Avian influenza A (H 5 N 2) detected February 23, 2004 • 6, 600 broiler chickens in Gonzales County, TX • Some of these birds were sold to supply 5 live bird markets in Houston

HPAI Outbreaks – US – 2015 • Dec 2014 – Jan 2015 • USDA reports HPAI infections in US • All H 5 subtypes (H 5 N 2, H 5 N 8, H 5 N 1 North American reassortant) • (No known human infections from these subtypes prior to outbreaks) • Overall… • 15 states affected • Commercial poultry premises • Backyard flocks • Wild birds • No novel/avian human cases detected • No cases in Texas flocks

HPAI & LPAI H 7 N 8 – 2016 • Turkey flocks in Dubois Co, Indiana • HPAI H 7 N 8 detected in first flock on 1/14/16 • LPAI H 7 N 8 detected in 8 additional flocks on 1/16/16 • Outbreak response • USDA-APHIS response involved USDA employees and contractors • Depopulation of • Commercial turkeys: 258, 045 • Commercial chickens (layers): 156, 178 • Outbreak response ended 2/22/16 • States asked to monitor human health: • Outbreak state to monitor mobilized persons and other responders (e. g. , farm owners, operators, state employees with outbreak duties) during response • States of residence (or destination) to monitor demobilized persons • No human H 7 N 8 cases detected

Demobilized Responder Monitoring – The Plan

Notification and Monitoring Process for Demobilized Responders • TX plan based on USDA-ASPHIS/CDC monitoring plan • USDA contractors and subcontractors send CDC daily lists of demobilizing responders • Includes contact information • CDC notifies states via Epi-X of all responders intending to arrive in a state after demobilization • In Texas, responders are assigned to their local jurisdiction based on information in Epi. X notifications • Local health departments contact the responders, get contact information, assess risk, and monitor accordingly - PUM (Person Under Monitoring) • Monitoring for symptoms of influenza-like illness is done for 10 days following last possible exposure to avian influenza viruses • Low risk responders are monitored at initial contact, day 5, and day 10 • Some/high risk responders are monitored once daily

Testing Symptomatic Responders • • Fever or feeling feverish and/or chills Cough Runny or stuffy nose Eye tearing, redness, irritation Sneezing Sore throat Difficulty Breathing Shortness of breath • • Fatigue Muscle or body aches Headaches Nausea Vomiting Diarrhea Seizures Rash • Symptomatic PUMs are called PUIs – Patients Under Investigation • Same as CUI: Case Under Investigation • Any PUMs reporting symptoms above are tested or offered testing for influenza • Decisions/prioritization of testing based on symptoms and risk level • Testing must be performed at a Texas Laboratory Response Network (LRN) lab or DSHS Austin • Same day testing recommended for PUIs

If a Responder Reports Symptoms • LHD should: • Notify DSHS Austin immediately • Decide if testing is warranted • Collect specimens or coordinate specimen collection • Coordinate specimen submission to public health lab for influenza testing • And… • Recommend antiviral treatment and possibly assist with obtaining it • Recommend that the PUI self-isolate if not ill enough to need medical care • Follow up with medical facilities to ensure infection control precautions in use

Demobilized Responder Monitoring – The Reality H 7 N 8 Outbreak Responders from Texas

Monitored Responders • 87 demobilized responders from Texas – “far more than any other state” • Most (82%) demobilized responders in Region 6/5 S • 2 contract companies from Texas • Timeline of responder movement • Responders from TX began arriving in IN on 1/14/2016 • The first responder returning to TX arrived on 1/19/2016 • The last responder associated with this outbreak returned to TX on 2/3/16

Timeline of Events 1/14/16 Responders start arriving in IN 1/19/16 1 st responder released to TX 1/27/16 Epi-X (n=1) 1/26/16 Epi-X (n=1) 1/29/16 Epi-X (n=10) 1/28/16 2/3/16 Epi-X (n=16) (n=55) 2/3/16 (Last responders released to TX) 2/13/16 Last TX responder finishes monitoring 2/10/16 Epi-X (n=4) 2/1 1/14/16 First flock HPAI H 7 N 8+ (IN) 1/16/16 8 flocks LPAI H 7 N 8+ (IN) 1/29/16 LRN test (Hou) 1/31/16 LRN test (Hou) 2/4/16 2/5/16 LRN test (Hou) (Har) 2/5/16 LRN test (Har) 2/22/16 All farms released from quarantine (IN)

Contact Success Rate [PERCENTAG E] Not Contacted [PERCENTAG E] Contacted

Demobilized Responders by Risk Category Low Risk: • Part of AI response with no contact with birds/bird farms 5% Some Risk: • Part of AI response with contact with birds/bird farms AND WITHOUT any breach in PPE High Risk • Part of AI response with contact with birds/bird farms AND potential or confirmed breach in PPE. Low Some/High 95%

X SOB/DB Seizures Rash Muscle aches Eye symptoms HA Diarrhea N/V Sneezing Fatigue Runny nose ST Cough Fever or feverish Symptomatic responders/PUIs X X • 12 (14%) responders reported symptoms X X • Some said symptoms started in IN X X X • Variety of symptoms reported X X X • Testing for influenza X X • 7 tested (5 at Houston LRN, 2 Harlingen LRN) negative X X • 1 refused X X • 1 LTF X X X • 1 declined (given option for testing) • 2 not recommended for testing (no respiratory symptoms) X X X X

Persons Under Monitoring (PUMs) and Patients Under Investigation (PUIs) for Avian Influenza by Texas Health Service Region (HSR), January 2016 – February 2016 80 Number of Persons 70 60 50 40 30 20 10 0 HSR 6/5 S HSR 8 PUMs HSR 9/10 PUIs HSR 11

Texas Monitoring Documents Website • https: //www. dshs. state. tx. us/ AIResponder. Monitoring. aspx

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