Influenza Exposure Medical Response Guidance for the University of Wisconsin-Madison

Transcription

1 Influenza Exposure Medical Response Guidance for the University of Wisconsin-Madison 1.0 Instructions: Information in this guidance is meant to inform both laboratory staff and health professionals about the risks and treatment in the event of an infectious agent exposure. In using this guidance, please consider that multiple routes of exposure may occur in a lab and that organism strains will sometimes be genetically modified to incorporate traits such as antimicrobial resistance. Research protocols and other available guidance such as Health Canada material safety data sheets will be provided as supporting information when available. It should be assumed that when exposures do occur, that the healthcare provider will be provided with information about the specific organism and strain involved, route of exposure, inoculum concentration, and patient vaccination and serological status, when available. This document was developed by UW Occupational Medicine in consultation with the UW Division of Infectious Disease. The information provided below is intended to provide guidance for treating physicians. Treatment and evaluation plans should be individualized to the patient based on the patient s symptoms, exposure risk, and underlying health status. If there are any questions about this document, please contact University Health Services, Occupational Medicine at Signs and Symptoms of Infection- Describe signs and symptoms associated with the agent. Symptoms of influenza include development of fever or fever with chills, headache, muscle or body aches, fatigue, sore throat, nonproductive cough, and nasal discharge. These symptoms herald the onset of infection. 3.0 Infectivity- Describe infective dose, relevant exposure routes (considering laboratory use), incubation period and potential severity of infection. The infective dose for influenza is estimated to be particles. Infection is acquired largely via droplet transmission (inhalation of the virus from particles in the air). Other modes of suspected transmission include: 1. direct skin to skin contact; or else 2. indirect contact touching a surface with influenza virus and then touching mucosal surfaces- such as eyes, mouth or nostrils. Incubation period- time to onset of illness from time of exposure to virus is 1-4 days (average 2 days) Viral shedding begins from hours before illness onset. The average duration of viral shedding is 4.8 days but can be up to 10 days in healthy adults (or up to 3-4 weeks in immunocompromised adults). 4/13/2017 Page 1 of 6

2 Most persons who develop symptoms have uncomplicated influenza and improve over 2-5 days. Individuals at risk for developing severe infection include : Children younger than 5 years Adults older than 65 years Pregnant individuals Native American Indians and Alaskan Natives Morbidly Obese individuals People with underlying medical conditions including chronic pulmonary, cardiac, renal, hepatic, hematologic or neurologic; or other disorders such as asthma, diabetes, or immunosuppression. Lab personnel should be vaccinated and hence (depending on the strain) may have some degree of protection. This may also prevent seasonal influenza being incorrectly attributed to work exposure. Antibody development after vaccination takes about 2 weeks in healthy adults. 4.0 Description of First Aid - Provide an overview of first aid treatment of exposures considering that multiple routes of exposure could occur (needlestick, aerosol, eye, skin and ingestion). Exposure to skin: wash with chlorhexidine soapor the antibacterial scrub approved for the laboratory) for 15mins Exposure to eyes- wash at eyewash station for 15 mins Exposure to oral surfaces- rinse / wash mouth for 15 mins 5.0 Urgency of Medical Care- Describe how soon medical attention should be sought, i.e. is an ER visit necessary, a visit to University Health Services, or simply schedule a visit with a personal physician. Select Agent Strains: All exposures, potential exposures, or the development of influenza-like symptoms after working with a select agent influenza virus, after initial first aide, should be immediately reported to UW-Madison RO or ARO's (Responsible Official or Alternate Responsible Official) and PI. RO/ARO's can be reached at their direct office numbers or through the UW-Madison Police Department at or by dialing RO/ARO will contact UW Infectious Disease to arrange for appropriate medical attention and notify UHS Occupational Medicine ( or ). Endemic Influenza Strains: The urgency of seeking medical attention depends on the health status of the affected individual and the type of exposure. Inhalation of large volume of likely contaminated material requires medical attention sooner than a splash in the eye that was washed immediately. A person with asthma, a chronic lung disorder, 4/13/2017 Page 2 of 6

3 or a pregnant individual will require medical attention sooner than an otherwise young and healthy person. -Medical attention should be sought typically within 24 hours. -During weekday working hours - contact the University Health Services. -During weekday after hours and exposures on Sunday, contact the University HealthServices the next morning. If afterhours on Friday or else on Saturday contact the UWHC Infectious Disease Physician/Fellow on call. If at any time, the exposed individual or else the lab supervisor is unsure, contact the UWHC Infectious Disease Physician/Fellow on call. 6.0 Description of Medical Response- Provide an overview for clinical treatment of exposures to the agent considering that multiple routes of exposure could occur (needlestick, aerosol, eye, skin and ingestion) and that strains of agents will vary and sometimes include antimicrobial resistance. It is important to establish from the PI- the strain of Influenza and the resistance profile- whether the strain is susceptible to Oseltamivir and/or Zanamivir or not. The key decision is whether to observe for development of symptoms of Influenza and start treatment if symptoms develop OR initiate prophylaxis upon exposure. The strain of Influenza, the route and degree of exposure and the underlying health of the exposed lab personnel determine the nature of the medical response. Indications for Antiviral Prophylaxis: a) Exposure to Avian Influenza H5N1 and 1918 Influenza warrants prophylaxis upon exposure irrespective of route and underlying health conditions. For other strains of Influenza (including H3N2, H7N9 (neuraminidase resistant and nonresistant strains), Pandemic H1N1, Swine Influenza, Influenza B and other influenza species): b) Individuals at risk for severe infection (as listed earlier) generally warrant prophylaxis upon exposure; for healthy individuals it is customary to wait and watch for development of symptoms and then treat if needed. c) Individuals exposed to large amounts of Influenza virus via inhalation or mucosal exposure should be considered candidates for initiation of prophylaxis as against low risk exposures such as exposure to skin or limited mucosal surfaces. 4/13/2017 Page 3 of 6

4 If a decision is made to initiate prophylaxis, choice of prophylaxis depends on the strain of Influenza virus. If chemoprophylaxis is indicated, it should be initiated as soon as possible following an exposure incident. Concomitant with prophylaxis, the quarantined individual will self-monitor for signs and symptoms of influenza infection. Development of fever greater than or equal to o Fahrenheit (38 o C ) is a criteria for the individual to be considered potentially infected, with further evaluation by UW Infectious Disease. Prophylaxis: 1. Seasonal H1N1 virus: Zanamivir 10mg once daily by inhalation for 10 days (In asthmatics or persons with underlying lung disease, Zanamivir should be used with caution. If on bronchodilators, these should be taken prior to the Zanamivir. Short acting bronchodilators (such as albuterol) should be available at hand for such patients in case they develop difficulty in breathing or bronchoconstriction after use of Zanamivir). Individuals engaged in influenza research should have a prescription of Zanamivir prior to any potential exposure. Oseltamivir should not be used as seasonal H1N1 is mostly resistant to this agent. 2. Neuraminidase-resistant H7N9: Zanamivir 10mg, by inhalation, twice daily for 5 days Caution for asthmatics as above Resistant to amantadine and oseltamivir Collection of baseline serum as soon as possible after occupational exposure Consider quarantine in place or at the UW Hospital under Infectious Disease, with transport provided by the UW Police Dept 3. Other Influenza Viruses (including H3N2, Neuraminidase sensitive H7N9, Pandemic H1N1, Avian Influenza H5N1, Swine Influenza, 1918 Spanish influenza, Influenza B and other influenza species): Oseltamivir 75mg twice daily for 7 days. Amantadine and Rimantadine are not generally recommended, due to resistance. 4. Seasonal endemic influenza virus: Oseltamivir orally 75 mg once daily for 7 days Oseltamivir is the recommended agent in pregnancy Zanamivir inhaled 10 mg (two 5 mg inhalations) once daily for 7 days; Caution for asthmatics as above) 4/13/2017 Page 4 of 6

5 Treatment: 1. Seasonal H1N1 virus : Zanamivir 10 mg twice daily for 5 days (Caution for Asthmatics/ underlying lung disease as detailed above). 2. Neuraminidase-resistant H7N9: Zanamivir 600 mg IV twice daily for 5 days. (IV Zanamivir is available through GSK and emergency IND use will be arranged through UW Infectious Disease. It is usually available within 1-2 days.) 3. Other Influenza viruses (including H3N2, Neuraminidase sensitive H7N9, Pandemic H1N1, Avian Influenza H5N1, Swine Influenza, 1918 Spanish influenza, Influenza B and other Influenza viruses): Oseltamivir 75 twice daily for 5 days. Amantadine, Rimantadine are generally not used. 4. Seasonal endemic influenza virus: Oseltamivir 75 mg orally twice daily for 5 days; Oseltamivir is the recommended agent in pregnancy Zanamivir 10 mg, by inhalation, twice daily for 5 days; (Caution for Asthmatics/ underlying lung disease as detailed above). 7.0 Description of Medical Surveillance- Describe the advisability of medical surveillance strategies (in particular baseline and annual serology) for those working with the agent. If doing so would likely improve the identification, diagnosis or treatment of exposures, please indicate so. Individuals working with influenza should receive the seasonal influenza vaccine annually. This is required of individuals working with select agent strains or neuraminidase resistant strains.. There is no role for routine medical testing such as annual testing. Testing for influenza is indicated when symptoms develop (especially if there is a question regarding the infecting strain). Generally nasopharyngeal swabs are processed by PCR to identify Influenza infection. Treatment, if indicated based on the clinician s assessment, is initiated before waiting for results of the test. 8.0 Considerations for Infection Control-Describe any special precautions required to prevent the further spread of infection. Include precautions for the healthcare, workplace, and home setting. Individuals exposed to an endemic influenza strain should monitor themselves for signs and symptoms of influenza. If they develop an Influenza-like Illness, they should selfisolate at home until they have been fever free for 24-hours and use appropriate respiratory hygiene and cough etiquette. Standard respiratory precautions for seasonal influenza should be used in the healthcare setting. 4/13/2017 Page 5 of 6

6 Individuals potentially exposed or exposed to a non-endemic strain or high risk influenza strain should immediately isolate themselves, avoiding all contact with others including family members and public transportation, and contact the RO and ARO who will contact UHS Occupational Medicine, UW Infectious Disease and public health officials. Quarantine is generally required per public health recommendations. In the event further medical care is required, isolation recommendations should be developed in consultation with infectious disease and infection control. 9.0 Reporting-Describe any public health or federal regulatory reporting requirements. Include the timing and mechanism for reporting. Public Health: Public Health: Exposure or potential exposure to any select agent strains will be reported to the state health department communicable disease section by the Responsible Official at The 24 hour WI health department clinical emergency contact number is The CDC Division of Select Agents and Toxins will also be notified by the Responsible Official. Exposure or potential exposure to any non-endemic strains which are not select agents is reportable IMMEDIATELY to by telephone or fax to the patient s local health officer. [Public Health Madison Dane County or emergency pager ] In addition to the immediate report, complete and mail an Acute and Communicable Diseases Case Report (DPH 4151) within 24 hours. Public health intervention is expected as indicated. See s. HFS (3) (a) References: 11.0 Document Revisions Revision History Revision Number Date Description of Revision Initial Approval 10/9/12 Original 1 5/8/14 Changed to new format; dosage edits 2 SVA 3/23/17 Neuraminidase resistant H7N9 added 3 ASW 4/13/17 additional edits 4/13/2017 Page 6 of 6