Transcript Influenza A(H5N1) in Humans: Outbreak Investigation in an

Influenza A(H5N1) in Humans:
Outbreak Investigation in an
International Setting
Case Study 2: Part 1
1
Learning Objectives
• Describe key outbreak management issues that
need to be addressed related to supplies, team
composition, WHO policy and epidemiologic data
management during an internationally located
A(H5N1) outbreak investigation.
• Identify critical coordination priorities involving
the interface between animal and human health
sectors, key stakeholders such as WHO, CDC and
Ministries of Health and communication processes
between CDC field staff, CDC Headquarters and
relevant subject matter experts.
2
Learning Objectives (cont.)
• List appropriate practices and procedures for:
 Specimen collection and transport
 Epidemiologic investigation
 Identification of transmission mechanisms
 Contact tracing
 Isolation/quarantine policy
 Treatment/control policy
 Risk communication priorities
 Recommended laboratory specimen protocols methods
 Ethical considerations
3
Outline
• Review of the preparation for an outbreak investigation
• Description of the situation and available details on the
•
case, surrounding events/history and environment
Engage in outbreak investigation activities:





Case definition
Clinical / laboratory findings, samples, recommendations
Line listing
Contract Tracing
Treatment options/ recommendations
Principles are applicable to outbreaks from other known
or newly emerging pathogens
4
Introduction
Be sure to have materials needed to
take notes and create a line list
5
Republic of Pegu: Setting
• Developing country
• Southeast Asia
• 21 provinces
• Population: 50 million
6
Epidemiologic Setting
•
•
•
Mass deaths in chicken, geese, and waterfowl flocks
 Five months ago (March)
 Southeastern region
Ministry of Agriculture (MOA) reported 3 test results “weakly
positive” for avian influenza A(H5N1)
 Came from three dead chickens sent to national lab in
Anawrahta (April)
No systemic surveillance exists for H5N1 in poultry, wild bird
or animal populations
7
Question 1
To respond to trigger event #1, you need to put together a Rapid
Response Team (RRT) - Which of the following skills or
persons should be represented in this RRT?










Team Leader
Epidemiologist
Veterinary Liaison
Respiratory Therapist
Medical Officer / Clinician
Data Manager
Marketing Assistant
Laboratorian or Lab tech
Logistician
Communications Specialist
8
Question 2
Match who should be notified about the investigation on the left
with the reason they should be notified on the right.
1. Veterinary Health
Authority
a.
So they can raise concerns and
be aware of possible cases
b.
To be ready for samples that will
be coming
c.
So they can undertake enhanced
surveillance for sick or dying
poultry
d.
So they know you are coming to
investigate, can have medical
records ready to review, and
have appropriate staff available
e.
So they can leverage resources
such as medical supplies or
additional staff
2. Healthcare personnel
3. The community
4. Non-governmental
organizations
5. The laboratory
9
Question 2 Answers
Answer:
1. Veterinary health = c. Evaluate diseased poultry
2. Healthcare personnel = d. Knowledge that you will
investigate
3. Community = a. Can raise concerns
4. NGOs = e. Medical personnel/supplies and resources
5. Laboratory = b. Prepare for incoming samples
10
Question 3
Below are 6 categories of supplies needed when you go to the
field. Match the list of supplies to the general category.
Categories: Epidemiological, Medical, Laboratory, Educational
& Communications, PPE, Decontamination
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Case definitions
Antiviral medication
Goggles
Gloves
Graph paper
Solution for decontaminating
homes or hospital room
Transportation containers
Pens
Gown and cap
Reporting forms
k. Specimen collection
materials
l. Ice
m. Guidelines for contacts,
family members, and
healthcare workers
n. Notebook/laptop
o. Portable GIS unit
p. Viral transport media
q. Simple messages
r. Respirators
11
Question 3 Answers
Answer:
•
•
•
•
•
•
Epidemiological: a. Case definitions, j. reporting forms, n.
notebook/laptop, h. Pens, e. graph paper, o. portable GIS unit
Medical: b. Antiviral medication
Laboratory: k. Specimen collection materials, g. Transportation
containers, l. Ice, p. Viral transport media
Educational materials: q. Simple messages, m. Guidelines for
contacts, family members, and healthcare workers
Personal Protective Equipment (PPE): r. Respirators, d. gloves, i.
gown and cap, c. goggles
Decontamination: f. Solution for decontaminating homes or hospital
rooms
12
JULY 15
•
•
Trigger Event
July 15th
Dava Ghar hospital has admitted 2 patients
with SARI
 Reported to District Health Office
 They suspect avian influenza due to poultry
outbreaks in area
Patients are related
 65 year old grandmother (JAM)
 10 year old grandson (AAJ)
13
JULY 15
Character Details
• 65 year old grandmother • Grandfather = AWM
= JAM
• Mother = NJC
 Chronically ill
 Caretaker of grandson
starting July 11
• 10 year old grandson =
AAJ
 Onset July 10
•
Uncle = JRO
 Caretaker of son (AAJ)
Setting: Small, mountain
village in Pelu Jaghai
province
14
JULY 15
Exposure & Onset Details
July 8th
• AAJ, NJC, & JRO
attended live-market
(“Murg Market”)
• AAJ becomes
ill on July 10th
Murg Market in Pelu Jaghai:
Local market with live animals
and location of A(H5N1)
confirmed poultry outbreaks
• JAM cares for him
starting July 11th
• July 13th AAJ brought to
hospital with: fever (38.7),
cough, diarrhea and shortness
of breath
Dava Ghar hospital: 60
km away from village
15
JULY 15
AAJ Clinical Presentation
and Further Evidence
• Arrived in unstable condition
on the night of 13th
• Admitted early on 14th
• Rapidly deteriorated
 Respiratory distress led to
endotracheal intubation and
ventilatory support
10 year old child (AAJ)
CXR on Admission
 Cefriaxone treatment started
16
JULY 15
Caretaker Health
Status at Hospital
• Mother (NJC) and grandfather (AWM) are
•
asymptomatic or deny symptoms
Grandmother (JAM) reports respiratory condition
suddenly worsened on about July 9th
 JAM symptoms: fever, cough
and dyspnea = SARI
 JAM admitted to hospital
on July 14th
JAM denied contact with Murg Market or poultry
17
JULY 15
Rumor Surveillance Update
from Local Health Authorities
• May be additional sick persons with respiratory
symptoms in Pelu Jaghai
• May continue to be wide-spread chicken deaths
18
Question 4
How would you classify AAJ into the WHO influenza
A(H5N1) case definition? Information on AAJ is given
for your reference.
Clinical: Fever, cough, diarrhea and
a.
b.
c.
d.
Under investigation
Suspected
Probable
Confirmed
shortness of breath, Chest x-ray
positive for pneumonia
Epidemiological: Exposure to livemarket on July 8th where influenza
A(H5N1) infections in animals were
confirmed in the last month.
Laboratory: No lab specimens
available.
Answer: The Chest X-ray and clinical deterioration extend the
‘suspected A(H5N1) status’ to C, a probable case designation.
19
Question 5
How does patient JAM fit into the WHO influenza
A(H5N1) case definition?
a. Under investigation
b. Suspected
c. Probable
d. Confirmed
Clinical: Fever, cough, and shortness of
breath
Epidemiological: Close contact (within 1
meter) with a person who is a suspected,
probable, or confirmed H5N1 case. Close
contact with probable case occurred 2 days
after “onset of symptoms”.
Laboratory: No lab specimens collected at
time of questioning.
Answer: The above information is supportive of a designation of
a. person under investigation
20
Create a Line List
What variables should be included?
ID
Age
Gender
• ID #
• Demographics: (age, gender,
patient contact)
• Possible exposure to infected
animals within 7 days of
symptoms
• Possible contacts with suspect or
confirmed human case within 7
days
• Occupation
• Symptom onset
• Date of onset
• Hospital test results
• H5 Laboratory diagnosis
• Antivirial treatment
• Status (Case or Contact)
• Disposition (Hospitalized,
deceased, etc)
21
Suggested Line List Format
ID
#
Initials
Village
Age
Sex
Possible
exposures
and date
EPI
relation
Syx
Onset
Lab
date- July Status
Case
status
Outcome
22
Update the Line List
JULY 15
Update the line list with the cases as of July 15th mid-day
ID
#
Initials
Village
Age
Sex
1
AAJ
DG
10
M
Live Mkt: July 8th
Grandmother: July9th
Child (exposed at
live market)
F,C,S
10
2
JAM
DG
65
F
Caretaker of #1
Timing unknown
Grandmother of #1
(AAJ)
F,C,S
9
ID
#
Initials
Lab
Status
Case status definition
(Case v. Contact)
Outcome
1
AAJ
No lab specimen
Probable Case
Hospitalized on ventilator, pneumonia,
respiratory failure
2
JAM
Pending
Person under invest.
Hospitalized
Possible exposures
and date
EPI relation
F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx
DG: Dava Ghar
PJ: Pelu Jaghai
Syx
Onset
date- July
23
Question 6
Which of the following would be considered contacts of
AAJ?
a. JAM
b. A teacher who last spoke to him 2 weeks ago
c. A tuk-tuk driver who drove him to a friends home on the
6th
d. A neighbor who walked by AAJ but didn’t say anything
to him on the 10th
Answer: a.
24
Question 7
Note whether the following statements used to define who
is a close contact of this probable case are true or false.
Answers:
1. Anyone who came within 1 meter of the case patient
2. Anyone who had shared space within 1 meter of the case
patient
3. Close contact 1 day before through 14 days after onset of
symptoms
4. Close contact 7 days before through 14 days after the onset
of symptoms
5. Someone who kissed, embraced or shared utensils with the
case patient
6. Someone who spoke with or touched the case patient
False
True
True
False
True
True
25
Review: Identifying Contacts
• Potential contacts
 Household members
 Friends
 Healthcare providers
 Pharmacists
 Traditional healers
 Workplace contacts
• Contact tracing
activities
 Prioritize high
probability of influenza
A(H5N1) case patients
 Prioritize contacts by
duration, proximity, and
intensity of exposure to
the case patient
26
Question 8
Assuming that neuraminidase inhibitors are available:
1.Should AAJ be given anti-viral treatment?
2.Should JAM be given anti-viral treatment?
Answer:
1.Yes
2.Maybe
Hint: If antiviral drugs are available,
treatment doses should be provided to
suspected, probable and confirmed
cases as classified according to the
WHO case definition.
27
Question 9
1. Should JAM receive anti-viral prophylaxis?
2. Should asympomatic close contacts of AAJ be given
anti-viral prophylaxis?
3. Should close contacts of JAM receive antiviral
prophylaxis?
Answer:
1. Yes
2. Yes
3. No
Hint: The WHO Rapid Advice Guidelines on
pharmacological management of humans
infected with avian influenza A (H5N1) virus
suggests that prophylaxis doses should be
provided to all identified close contacts of
confirmed cases, and if resources allow, to
close contacts of “strongly suspected” cases
as well.
28
Question 10
If there are not enough antiviral resources for everyone, persons in the
community should be prioritized for antiviral prophylaxis. Match the
Risk Group on the left with the description on the right.
1. High Risk
2. Moderate Risk
3. Low Risk
a. Personnel culling likely non-infected animals
b. Personnel handling sick animals or decontaminating
environments using insufficient PPE
c. Personnel handling sick animals or decontaminating
environments using adequate PPE
d. Unprotected close/direct exposure to H5N1 infected
animals
e. Healthcare or laboratory personnel in close contact with
strongly suspected or confirmed patients or their samples
with insufficient PPE
f. Healthcare workers not in close contact
g. Healthcare workers with close contact using adequate
PPE
h. Close household contact of strongly suspected or
29
confirmed patients
Question 10 Answers
High and Moderate Risk Groups
High risk exposure groups
h. Household or close family contacts of a strongly suspected or
confirmed H5N1 patient
Moderate risk exposure
b. Personnel involved in handling sick animals or decontaminating
affected environments
d. Individuals with unprotected and very close direct exposure to
sick or dead animals infected with the H5N1 virus
e. Health care or laboratory personnel with unprotected close
contact with strongly suspected or confirmed H5N1 patients or
their clinical samples
30
Question 10 Answers:
Low Risk Groups
Low risk exposure groups
f. Health care workers not in close contact
g. Health care workers using adequate PPE
a. Personnel involved in culling non-infected or likely noninfected animal populations
c. Personnel involved in handling sick animals or
decontaminating affected environments using adequate PPE
Explain (tactfully!) to contacts the scarcity of antivirals, and that they will be
monitored.
NOTE: Drug allocation plans for treatment and prophylaxis should be made in
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advance
Update: July 16th
JULY 16
The RRT arrives at Dava Ghar
AAJ Update
• Admission
•





Fever 39 °C
Heart rate 120
34 breaths/minute
Blood pressure 90/60
O2 saturation 88%
Outcome




Intubated Jul 14
Hypotensive with renal failure
Died on the 16th
Respiratory and sputum
samples of poor quality
JAM Update
• Admission




•
Temperature 38.5 °C
28 breaths/minute
Blood pressure 160/95
O2 saturation 90%
Initial laboratory findings
 High lymphocyte count
 High leukocyte count
32
JULY 16
•
•
Specimens Needed
You will need to quickly determine whether
you’re dealing with H5N1 or some other
communicable pathogen
You send respiratory specimens from the
grandmother to the National laboratory for
testing.
33
Question 11
What specimen type is the top priority to be collected from
JAM for laboratory testing for influenza?
a.Endotracheal fluid
b.Broncho-alveolar lavage
c.Throat swab (oropharyngeal)
d.Nasal swab (nasopharyngeal)
e. Blood
Remember! It is vital to use
proper safety equipment
including eye protection and
PPE for the protection of the
individual(s) carrying out the
procedure(s). Treat all clinical
samples as though they are
potentially infected with
avian influenza!!!
Answer :
c. Throat swab
Comment: Nasal swabs should be collected to rule out seasonal
influenza. In general, collect multiple samples on multiple days.
34
Question 12
Which of the following statements about specimen collection is
NOT true?
a.It should begin as soon as possible after symptoms begin
b.It should begin before antiviral medications are administered
(but treatment should not be delayed for specimen collection)
c.Sample should be collected even if symptoms began more than
one week ago
d.Multiple samples should be collected on multiple days if possible
e.None of the above (all statements are true)
Answer: e.
Remember – it is better to collect too many specimens than not
enough
35
JULY 15
 Collection vials
with VTM
 Polyester fibertipped
applicators
 Sterile saline
which is 0.85%
NaCl
 A sputum or
mucus trap
Specimen
Collection Kit
 Tongue
depressors
 Specimen
collection cups
or Petri dishes
 Transfer pipettes
 A secondary
container
 Ice pack
 Items for
collection of blood
 Personal
Protective
Equipment (PPE)
 Field collection
forms
 A pen or marker
for labeling
samples
36
Question 13
Answers
Put the following steps for collecting an
oropharyngeal specimens in the proper order
3.
•
•
4.
•
2.
•
5.
•
1.
Done appropriate PPE
Slowly remove the swab while
slightly rotating ; the patient should
try to resist gagging and closing the
mouth
Swab oropharyngeal area behind
tonsils
Have the patient open his/her mouth
wide open
Put tip of swab into vial containing
VTM, breaking/cutting applicator’s
stick
37
Question 14
Here is an image of a properly packed specimen. Label the
packaging using the answer choices given.
1) 3 layers of _________
2) Absorbent _________
3) Labeling of the
_________ as UN3373
diagnostic specimens
4) Itemized
list of ______
5) Specimen______
6) _______ label
Answer choices:
a. contents
b. packing material
c. identification
d. outer package
e. packaging
f. biohazard
38
Question 15
Here is an image of a properly packed specimen. Label
the packaging using the answer choices given.
1) 3 layers of e. packaging.
2) Absorbent b. packing
material
3) Labeling of the d. outer
package as UN3373
diagnostic specimens
4) Itemized
list of
a. contents
5) Specimen c. identification
6) f. Biohazard label
39
Question 16
Determine whether the following statements about storing
specimens in VTM are true or false.
Answers:
1.
Specimens can be stored at 4 °C within 48 hours of
collection both before and during transportation.
True
2.
Store specimens at -70 °C beyond 48 hours (if you will not
be able to immediately transport specimen to laboratory)
True
3.
Never store specimens on dry ice
False
4.
Specimens may be stored in standard freezer
False
Avoid freeze – thaw cycles. It is better to keep a sample on ice even for a
week, than to allow the sample to freeze and thaw multiple times.
40
Question 17
When transporting specimens from potential human
cases of influenza A(H5N1) infection from the field to
the laboratory, you should follow which sets of
regulations?
a. WHO guidelines for safe transport of infectious
substances and diagnostic specimens
b. Local regulations on the transportation of infectious
material
c. Neither a nor b
d. Both a and b
Answer: d.
41
JULY 16
•
Epidemiologic and
Specimen Tracking for
Transportation
Documents to include
 Itemized list of specimens with identification numbers
 Instructions for the laboratory
•
Information to maintain
 Identification numbers, linking to epidemiologic data forms
 Case demographics
 When and where a specimen was collected
 Type of specimen
Coordinate shipment with the laboratory so they are prepared
when the specimens arrive
42
JULY 16
Contact Identification
• You have finished collecting patient specimens and
have sent them off to the national laboratory
• You want to identify all potentially exposed
individuals who have had contact with the probable
case (AAJ)
• You determine that close contacts are
 Mother (NJC)
 Uncle (JRO),
 Grandparents (JAM & AWM)
43
Update the Line List
Below is shown the line list from mid-day, July 15th. Update the line
listing with all known contacts as of July 16th a.m.
ID Initials Vill- Age Sex Possible EPI relation Syx Onset Lab
#
age
date Status
exposures
and date
Case
status
Outcome
1
AAJ
DG
10
M
Live Mkt:
July 8th
Grandmothe
r: July9th
Index case
F,C,
S
Jul 10
No lab
specimen
Probable
Case
Hospitalized
on ventilator,
pneumonia,
respiratory
failure
2
JAM
DG
65
F
Caretaker of
#1
Timing - ?
Grandmother
of #1 (AAJ)
F,C,
S
Jul 9
Pending
Person
under
invest.
Hospitalized
44
Line List as of July 16th a.m.
ID Initials Vill- Age Sex
#
age
Possible
exposures
and date
Syx
EPI
relation
Onset
date
1
AAJ
DG
10
M
Live-Mkt: July
8
‘index’
case
F, C,
D, S
10
2
JAM
DG
65
F
Caretaker of #
1
Grandm
other (#
1)
Grandfa
ther (#
1)
Mother
(# 1)
F, C,
S
9
3
AWM
DG
70
M
Caretaker of #
1
4
NJC
DG
36
F
5
JRO
DG
27
M
Caretaker of #
1; Live-Mkt:
July 8
Live-Mkt: July
8
Uncle
(# 1)
Lab
Status
Case
status
Outcome
No lab
specime
n
Pending
Probable
CASE
Died (7/16)
PUI/
Hospitalized
Contact
Contact
Contact
Contact
F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx
DG: Dava Ghar
45
PJ: Pelu Jaghai
Beyond the Given Scenario
Also think beyond the nuclear family
Village health workers
Traditional healers
Taxi drivers
Other people that may have had close contact with
the case during the infectious period
46
Question 18
You want to know whether there are more contacts that you should be
concerned about. Which of the following places would NOT be one
that you would visit at this point to determine if there are more cases
and/or contacts?
a.Health care facilities (hospitals, clinics, traditional healers)
b.Patient (or family proxy)
c.Patient’s village/neighborhood
d.Patient’s school/workplace
e.None of the above
Answer:
e. Depending on the places visited by a case, any of these places could
be important places to undertake additional contact tracing activities
47
Question 19
Which of the following scenarios does NOT list the appropriate PPE measure?
1. You will interview a symptomatic person that could be infected with influenza A(H5N1):
 Interview from more than 1-2 meters away and wear no PPE
2. You will be within 1-2 meters of a symptomatic person that could be infected with influenza
A(H5N1)
 Wear a fit tested respirator and eye protection
3. You physically examine a person that could be infected with influenza A(H5N1)
 You need to wear droplet and contact precautions
4. You are entering an environment where poultry products or feces may be contaminated,
 Wear droplet and contact precautions including boots and undertake appropriate
biosecurity/decontamination measures before leaving the premises
Answer: Scenario 2. Respirators are used for aerosol-generating procedures.
48
Question 20
Match the information source on the left with the contract tracing
activities that should be conducted there on the right.
1. Hospital or other
medical facility
2. Patient (or proxy)
3. Patients home and
village
Answer: 1. b
a.
Administer case finding questionnaire to
determine if the interviewee knows of
anyone else who is sick, to ask about
possible exposures, and to ask about
possible contacts
b.
Retrace the steps of the patient in the
facility and try to determine if there were
any close contacts without adequate PPE
c.
Find out more details about suspected
exposures, conduct an environmental
survey, and determine if there are any
outbreaks among animals. Look for
additional cases
2. a
3. c
49
Question 21
Questions to ask the case patient/case patient’s family regarding
potential H5N1 exposures should cover which of the following?
Contact with confirmed , suspect, or probable human H5 cases
Exposure to sick or dying animals, wild birds, other animals, or their
environment
Exposure to environments that may be contaminated with influenza
A (H5N1)
Exposure to cooked chicken products
Handling/preparation of raw poultry and other animal products
50
Question 22
Questions to as the case patient/case patient’s family regarding
additional case finding/H5N1 circulation in the community
include which of the following?
 Awareness of additional cases of severe respiratory illness
in family, friends and co-workers
 Awareness of H5N1 outbreaks occurring outside of the
country
 Awareness of illness or deaths in birds, cats, swine, or other
animals in the household and neighboring area
51
Question 23
When in a patient’s home or their village, what are important
contextual factors to observe?
 Poultry in and around the house
 Construction material of the home
 Mapped location or photograph of house and surroundings
 Possible unique and culturally-specific mechanisms of
exposure
 Annual community festival days
 Live bird markets or other occupationally related exposures
52
JULY 16
Case Finding Results
• Child with unexplained respiratory illness
reported in nearby province, Pelu Jaghai
• Director of Epidemiology orders your team
to
meet the Ministry of Health field workers there
and make site visits to hospitals and villages
53
JULY 16
•
New Case
and Contact
11-year-old boy, TMU
 Fever, cough shortness of breath , date of onset July 12
 Admitted July 15
 Critically ill, not intubated
You and your team don PPE, evaluate the patient, review
medical chart, and interview available family members
•
Mother (ACM)
 Reports boy visited Murg market on July 8
54
Update the line list with the current
information as of the afternoon of
July 16.
55
Line List as of July 16th p.m.
ID Initials Vill- Age Sex
#
age
1
AAJ
DG
10
M
2
JAM
DG
65
F
3
AWM
DG
70
M
4
NJC
DG
36
F
5
JRO
DG
27
M
6
TMU
PJ
11
M
7
AMC
PJ
29
F
EPI relation Syx Onset Lab
date Status
Case
status
Outco
me
Live-Mkt:
July 8
Caretaker of
#1
Caretaker of
#1
Caretaker of
# 1; Live-Mkt:
July 8
Live-Mkt:
July 8
Live-Mkt:
July 8
‘index’ case
Probable
CASE
PUI/
Contact
Contact
Died
(7/16)
Hospital
ized
Caretaker of
#6
Mother of # 6
Possible
exposures
and date
Grandmother
(# 1)
Grandfather
(# 1)
Mother (# 1)
F, C,
D, S
F, C,
S
10
9
No lab
specimen
Pending
Contact
Uncle (# 1)
Playmate (#
1)
Contact
F, C,
D,
M
12
Pending
Suspect
CASE
Hospital
ized
Contact
F: Fever; C: Cough; D: Diarrhea; S: Shortness of breath; M: Myalgias; URI – upper respiratory syx
DG: Dava Ghar
56
PJ: Pelu Jaghai
Differential Diagnoses
Human influenza
• Commonly an upper
respiratory infection
• Fever, headache, cough,
sore throat
• Muscle ache, exhaustion
• Other respiratory symptoms
• Recovery: 2-7 days
• Can progress to pneumonia
and respiratory failure in
some cases
Influenza A(H5N1)
•
•
•
•
•
•
•
•
•
Commonly a lower respiratory
infection
Fever, headache, cough, sore
throat
Muscle ache, exhaustion
Difficulty breathing,
respiratory distress
Crackling on inhalation
Leukopenia, lymphopenia
Increased respiratory rate
Sputum production, possibly
with blood
Limited data: diarrhea
An animal virus that is adapting to humans may have a
mixed picture of clinical presentations.
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Non-Influenza Differential
Diagnoses
Viral
•
•
•
•
•
•
•
•
•
•
Human influenza viruses
Parainfluenza viruses
Respiratory syncytial virus
Adenovirus
Rhinovirus
Flaviviruses (e.g. Dengue)
Coronaviruses (including
SARS-CoV)
Human metapneumovirus
Hantavirus
New / emerging viruses, such
as bocavirus
Bacterial
•
•
•
•
•
•
•
•
•
•
Mycobacteria tuberculosis
Yersinia pestis (pneumonic
plague)
Streptococcus pneumoniae
Staphylococcus aureus
Hemophilus influenzae
Burkholderia pseudomallei
Legionella spp.
Chlamydia pneumoniae
Mycoplasma pneumoniae
Coxiella burnetii
(Q fever)
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Clinical signs and
symptoms alone cannot
distinguish the severe
complications of seasonal
influenza from influenza A
(H5N1) infection in
humans:
Examine the
epidemiology and collect
specimens!
59
Move on to Outbreak
Investigation, Part 2
60