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Emergency Planning and Preparedness

Guidance for Health Care Workers and Health Sector Employers on Asian lineage Avian Influenza A(H7N9)

Last reviewed: October 11, 2017
Last updated: October 11, 2017

This information is intended for use by health workers and health sector employers in all settings.

The Ministry of Health and Long-Term Care has also developed general information on the avian influenza A(H7N9) virus.

What's New?

  • The following updates were made on October 11, 2017:

    • The ministry revised the case definition to clarify the focus on Asian lineage avian influenza A(H7N9), the definition of a close contact, as well as the exposure criteria.
    •  The ministry provided a link to the Public Health Ontario Laboratory (PHOL) Test Information Sheet for Avian Influenza.
    • The ministry added a section on contact management.

Case Definitions

These case definitions are for surveillance purposes only. They are not intended to replace clinical or public health practitioner judgment in individual patient assessment and management.

The ministry’s case definitions for the Asian lineage avian influenza A(H7N9) virus differ from those provided by the Public Health Agency of Canada (PHAC). PHAC has provided a case definition that only includes severe acute respiratory infection, while the ministry’s case definition is broader to ensure a wider range of individuals are tested.

Person Under Investigation

A patient with acute respiratory illness or other symptoms compatible with influenza, regardless of illness severity, meeting any of the exposure criteria† and for whom laboratory confirmation is not known or pending, or for whom test results do not provide a sufficient level of detail to confirm Asian lineage avian influenza A(H7N9) virus infection.

Probable Case

A patient fitting appropriate exposure criteria and with acute respiratory illness or other symptoms compatible with influenza, regardless of illness severity, for whom laboratory diagnostic testing is positive for influenza A but un-subtypeable (i.e., negative for H1pdm09, negative for seasonal H1 and negative for seasonal H3 by real-time reverse transcriptase polymerase chain reaction).

Confirmed Case

A patient fitting appropriate exposure criteria† and with Asian lineage avian influenza A(H7N9) virus infection that is confirmed by a laboratory.

Case Definition Footnotes

† Exposure Criteria : The person has a history of travel to or residence in China within 10 days before onset of illness1 OR the person has recent close contact2 (within 10 days before onset of illness) with a confirmed or probable case with the Asian lineage avian influenza A(H7N9) virus.

1 To date, China is the only country where transmission of the Asian lineage avian influenza A(H7N9) virus to humans has been confirmed and where the Asian lineage avian influenza A(H7N9) virus is known to be circulating in animals. The ministry does not recommend testing patients who have travelled to countries with imported cases from China.

2 Close contact includes:

  • anyone with direct contact with infectious secretions while the case was likely to be infectious (the case is infectious one day prior to his/ her illness onset and until resolution of illness)
  • anyone who provided care for the patient, including a health worker or family member, or who had other similarly close physical contact
  • anyone who stayed at the same place (e.g., lived with, visited) as a probable or confirmed case while the case was symptomatic

Occupational Health & Safety and Infection Prevention & Control

The ministry recommends the use of Routine Practices and Additional Precautions (Contact, Droplet and Airborne) by health care workers at risk of exposure to a confirmed case, probable case or or PUI and/or the patient’s environment. These precautions include:

  • hand hygiene
  • use of airborne infection isolation rooms (AIIRs) when possible
  • masking the patient with a surgical mask (if tolerated) when outside of an AIIR
  • use of gloves, gowns, fit-tested, seal-checked N95 respirators and eye protection when entering the patient’s room or when transporting or caring for the patient

For more information on Routine Practices and Additional Precautions, health care workers should refer to the Provincial Infectious Diseases Advisory Committee’s (PIDAC's) Routine Practices and Additional Precautions in All Health Care Settings and Annex B: Prevention of Transmission of Acute Respiratory Infection in all Health Care Settings [PDF].

The use of Airborne Precautions is a higher level of precaution than is being recommended by PHAC. It is also a higher level of protection than normally recommended for seasonal influenza. The ministry is recommending that health care workers apply Airborne Precautions based on its application of the precautionary principle to this novel virus for which little information about transmission and clinical severity is available.

Infection Prevention & Control for Visitors

Health sector employers should implement Routine Practices and Additional Precautions (Contact and Droplet) for visitors of confirmed cases, probable cases and PUIs  in health care settings, as per PIDAC's Routine Practices and Additional Precautions in All Health Care Settings. This includes:

  • risk based education about hand hygiene and the use of personal protective equipment as described under Routine Practices
  • masks for visitors who must be within two metres of patients

Visitors should be kept to a minimum and must be informed about the reason for implementing infection prevention and control measures.

Assessment

Health care providers should assess patients presenting with acute respiratory illness or other symptoms compatible with influenza infections using the case definitions and clinical judgment.

Reporting

Health care workers must contact the local public health unit to report a PUI, probable case or confirmed case (see the case definitions).

Treatment

When indicated, antiviral treatment is most effective when started as soon as possible after symptom onset. Early initiation of treatment provides a better clinical response, although treatment of moderate, severe, or progressive disease started 48 hours after symptom onset may still provide benefit.

Health care workers can follow the Association of Medical Microbiology and Infectious Disease Canada’s Interim Guidance for Antiviral Prophylaxis and Treatment of Influenza Illness due to Avian Influenza A(H7N9) Virus [PDF] for guidance on treating PUIs, probable cases and confirmed cases with antivirals.

Genetic mutations linked to resistance to neuraminidase inhibitors have been detected in several human cases of the Asian lineage avian influenza A(H7N9); however, the majority of tested samples continue to respond well to neuraminidase inhibitors.

Laboratory Testing

The Public Health Ontario Laboratory (PHOL) conducts laboratory testing for avian influenza A(H7N9). Health care workers should review PHOL's Test Information Sheet for Avian Influenza for more information on laboratory testing.

Health care workers are encouraged to submit laboratory samples as soon as possible to PHOL.

Contact Management

Public health units and/ or health care workers should monitor any person who had close contact with a probable or confirmed case while the probable or confirmed case was ill for the appearance of respiratory symptoms. If symptoms develop within the first 10 days after contact, the individual should be considered a PUI and investigated accordingly.

In general, the ministry does not recommend the preventive use of antivirals for close contacts of cases of avian influenza A(H7N9). However, as per the Centers for Disease Control and Prevention’s Interim Guidance on Follow-up of Close Contacts of Persons Infected with Novel Influenza A Viruses Associated with Severe Human Disease and on the Use of Antiviral Medications for Chemoprophylaxis, antiviral prophylaxis may be considered in certain circumstances such as for people who are at highest risk of exposure to the virus (e.g., household or close family member contacts of a confirmed or probable case who has severe H7N9 infection). The ministry will support public heath units and/or health care workers with decisions about the use of antiviral prophylaxis in close contacts at the time that a probable or confirmed case is identified in Ontario.

Further Information

For more information, call the Ministry of Health and Long-Term Care's Health Care Provider Hotline at 1-866-212-2272.

For additional information on worker health and safety information, please visit the Ministry of Labour Health and Community Care website.

This information does not relieve employers of their legislated obligations.

For More Information

Ministry of Health and Long-Term Care
Health System Emergency Management Branch
1075 Bay Street, Suite 810
Toronto, Ontario
Canada M5S 2B1
Fax : 416-212-4466
TTY : 1-800-387-5559
E-mail : emergencymanagement.moh@ontario.ca

 

Health workers and health sector employers can call the Healthcare Provider Hotline for more information
Toll free : 1-866-212-2272

CritiCall Ontario provides a 24 hour call centre for hospitals to contact on-call specialists; arrange for appropriate hospital bed access and facilitate urgent triage for patients
1-800-668-4357