Initial Decision Making and Management of Patients Who May Have an Emerging Infectious Respiratory Disease

Middle East Respiratory Syndrome (MERS-CoV) and Avian Influenza A(H7N9) Virus

Always initiate care using Routine Practices

Screening

  • Do you have a new / worse cough or shortness of breath?
  • Are you feeling feverish?

If yes to both questions, proceed to Assessment and Treatment / Precautions in parallel.

If no to either or both screening questions, initiate care using routine practices.

Assessment

Treatment / Precautions

Initiate appropriate Droplet and Contact Precautions

(hand hygiene, facial protection, gloves + gown)

Exposure risk assessment :

  • Have you travelled in the last 14 days to a country where transmission of avian influenza A(H7N9) virus has been confirmed or where H7N9 is known to be circulating in animals?
  • Have you travelled to or resided in the Arabian Peninsula or neighbouring countries within 14 days of illness onset? ** [investigate for MERS-CoV].
  • Have you had close contact with a probable or confirmed case with avian influenza A(H7N9) in the last 14 days?
  • Have you had close contact in the last 14 days with a person with a new/ worse cough or shortness of breath and feeling feverish who has travelled or resided in the Arabian Peninsula or neighbouring countries within 14 days before illness onset [investigate for MERS-CoV].
  • Is this part of a cluster that occurs within a 14-day period, without regard to place of residence or travel? [investigate for MERS-CoV].
  • Are you a health worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, without regard to residence or travel (unless another aetiology has been identified)? [investigate for MERS-CoV].
  • Has your illness taken an unexpectedly severe clinical course despite appropriate treatment, without regard to travel or residence, even if another aetiology has been identified which does not fully explain the illness? [ investigate for MERS-CoV].

If yes to any exposure question, proceed to reporting.

If no to all exposure questions, initiate appropriate Droplet and Contact Precautions (hand hygiene, facial protection, gloves + gown)

If positive for H7N9 or MERS-CoV, proceed to Additional Treatment H7N9 or MERS-CoV

  • If yes to having a new / worse cough or shortness of breath and feeling feverish, ask patient to :
    • Clean his / her hands
    • Wear mask while waiting to be seen, if tolerated
    • Wait in separate area if possible or keep two metre distance from other patients / HCWs
  • Postpone elective procedures that generate droplets (e.g. dental care).
  • Use appropriate precautions if the procedure is required (i.e., non-elective).

Additional Treatment H7N9 or MERS-CoV

  • Initiate airborne precautions (use of airborne infection isolation rooms (AIIR) when possible; fit-tested and seal-checked N95 respirators on health workers; mask on patients not in AIIR.

Additionally for H7N9

  • Treat with antiviral medication in accordance with AMMI Canada recommendations for H7N9***

Additionally for MERS-CoV

  • Treat the symptoms

Reporting

  • Report immediately to public health by phone
  • Report occupationally acquired infection to the Ministry of Labour****

References

* Elderly people and people who are immunocompromised may not have a febrile response to a respiratory infection, so the presence of new onset cough/shortness of breath may be enough to trigger further precautions.
** For a list of countries with known relation to MERS-CoV, see: http://www.phac-aspc.gc.ca/eri-ire/coronavirus/case-definition-cas-eng.php.
For a list of countries with known relation to avian influenza A(H7N9), see http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=113.
***  Interim Guidance for Antiviral Prophylaxis and Treatment of Influenza Illness due to Avian Influenza A(H7N9) Virus www.ammi.ca/media/54869/revised_h7n9_antiviral_guidance_july_16_2013_final.pdf
For additional recommendations, including laboratory testing, visit http://www.ontario.ca/avianinfluenza and http://www.ontario.ca/novelcoronavirus.
**** See http://www.labour.gov.on.ca/english/hs/incident.php