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CDC Update for Clinicians on Avian Influenza A (H7N9) Virus

Moderators:Loretta Jackson Brown

Presenters:Alicia M. Fry, MD, MPH and David Kuhar, MD

Date/Time:April 18, 2013 2:00 pm ET

NOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to coca@cdc.gov

Coordinator:
Welcome and thank you for standing by. At this time all participants are in a listen-only mode until the question and answer session of today's conference. At that time you may press star 1 if you'd like to ask a question. Today's conference is being recorded. If you have any objections you may disconnect at this time. I'd now like to turn the call over to your first presenter Ms. Loretta Jackson Brown. Ma'am you may begin.

Loretta Jackson Brown:
Thank you (Jidan). Good afternoon. I'm Loretta Jackson Brown, and I'm representing the Clinician Outreach and Communication Activity -- COCA -- with the Emergency Communications System at the Centers for Disease Control & Prevention.

I'm delighted to welcome you to today's COCA Call -- CDC Update for Clinicians on Avian Influenza A (H7N9) Virus. We are pleased to have with us today Dr. Alicia Fry and Dr. David Kuhar -- here to provide an update on the current H7N9 situation in China and discuss interim clinical guidance and recommendations for clinicians.

There's no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA website at emergency.cdc.gov/coca under the call webpage.

At the end of the presentation you will have the opportunity to ask the presenters questions. On the phone, dialing star 1 will put you into the queue for questions.

Our first presenter is Dr. Fry. She joined CDC in 1999 as an Epidemic Intelligence Service Officer. She's currently a Medical Officer and Team Lead for the Influenza Prevention and Control Team and the Epidemiology and Prevention Branch of the Influenza Division within CDC's National Center for Immunization and Respiratory Diseases.

Our second presenter is Dr. David Kuhar. He is a Medical Officer in CDC's Division of Health Care Quality Promotion. At this time please welcome Dr. Fry.

Dr. Alicia Fry:
Thank you, Loretta. So this is an update about the situation related to human infections with avian influenza A (H7N9). I'll review the epidemiology of the virus and virus infection, how we are monitoring for human infections in the U.S., and treatment guidance. And then I'll hand it over to Dr. Kuhar who will review the infection control guidance.

Let's talk a little bit about the virus. The avian influenza A (H7N9) virus is a new reassortant avian influenza virus. Genetically, it is a low pathogenic virus in birds which means that it doesn't kill them or necessarily make them sick. It has been identified in several bird species in China, but the actual source populations has not been identified yet.

The sequences of the first few viruses were posted to GISAID by China and are publicly available. Some of the genetic changes have been associated with increases transmissibility of other avian influenza viruses to mammals based on animal studies involving ferrets in the past. So far all three viruses (are) susceptible to the influenza antiviral drugs oseltamivir and zanamivir, but they are resistant to the adamantanes, which include amantadine and rimantadine. Efforts are ongoing to learn as much as possible about this new virus.

I'm going to switch to the EPI (epidemiology) here. Since February 2013 there have been 87 cases. And all of them have been in China. There have been no cases outside of China, including no cases in the United States. Among the reported cases most have had severe disease, although 12 have been reported to have mild illness. The median age is 63 years, and 68% of cases have been male. All cases have presented with respiratory symptoms, and many have progressed to severe respiratory illness and respiratory failure. 17 cases have died.

Most cases have had some type of exposure to poultry and have been no epidemiological links between the cases. And at this time bird to human transmission appears to be the most common way this virus is transmitted to humans.

Over 1300 close contacts of confirmed cases have been followed to date in China. And there have been very few suspect cases of human to human transmission. Some of these contacts also had exposure to poultry, so it's difficult to tease out. So at this time there's evidence of very limited human to human transmission, and this is similar to human infections with avian H5N1 viruses.

At this point we are closely monitoring the situation in China, and we're looking for cases in the United States. Clinicians should consider the possibility of (H7N9) in persons with an illness compatible with influenza and with an appropriate travel history or exposure history.

Before I go into the specifics I want to remind you that much of the information that both Dr. Kuhar and I will be presenting today is available on the CDC (H79N) webpage. And I'll try to highlight documents as I go.

The information I'll begin with was posted in the April 5th HAN. The exposure criteria includes exposure to a confirmed or probable human case of (H7N9) or recent travel to a country where human cases of (H7N9) infection have recently been detected or where (H7N9) viruses are known to be circulating in animals.

Currently China is the only country that meets these criteria. Although the majority of (H7N9) cases in China have resulted in severe respiratory illness in adults, infection with this virus has been mild in some, and there are a few children who have been confirmed with (H7N9). Therefore we ask that clinicians also consider the possibility of (H7N9) infection in both severe and mild illnesses and in children if the person has the appropriate exposure history.

Clinicians should obtain a respiratory specimen from suspect patients, place it in viral transport medium, and contact their state or local health department to arrange for transportation and testing of the specimen. Respiratory specimens may include either nasopharyngeal or nasal swabs. In a patient with lower respiratory infection clinicians should consider getting a lower respiratory track specimen such as a BAL or ET aspirate.

It's important for clinicians to contact their state health department if they have a suspect case. And the state health departments are encouraged to contact CDC. Suspected infections with novel influenza A (H7N9) viruses in the United States should be reported to CDC within 24 hours of initial detection.

Let me summarize the diagnostic testing for this virus. At this time, CDC is the only U.S. lab that can confirm (H7N9) infection with RT-PCR. This is a new assay made specifically for this virus. CDC is working to make diagnostic kits available to state laboratories, but at this point I anticipate that CDC will need to be involved with confirmation of (H7N9) infection in the United States for a while.

Please be aware that commercially available rapid tests may not detect avian viruses. And at this time we do not know how other diagnostic tests perform to detect this virus as influenza A.

Now I'd like to review the case definitions that will be used for case investigation. And this is information that is available on the web and is titled "Interim Guidance on Case Definitions".

A confirmed case is an RT-PCR confirmed case at a CDC or CDC approved laboratory. Like I said, right now all testing is at CDC.

A probable case is an RT-PCR confirmed influenza A virus infection that is negative for both seasonal H1, pandemic H1, H3N2 viruses, and B viruses by PCR.

A case under investigation is a person with illness compatible with influenza meeting either one of the exposure criteria and for whom laboratory confirmation is either not known or pending. Again let me remind you what the exposure criteria is -- recent contact with a confirmed or probable case or recent travel within 10 days of illness onset to China.

Let me switch over to treatment now. Our interim treatment guidance just went live. So after this call you can go to the website, and you should be able to find it. It's interim, and it's based on current information. And it will be revised as more information is available.

At this time we do not have information on antiviral effectiveness specifically for this new virus. We used the evidence from clinical trials and observational studies of seasonal flu, pandemic H1N1, and humanH5 infections to inform our guidance. Also remember that current laboratory testing shows that the virus is susceptible to oseltamivir and zanamivir and resistant to the adamantanes.

Because of the potential severity of illness associated with (H7N9) virus infections, it's recommended that all confirmed, probable, and (H7N9) cases under investigation receive antiviral treatment with a neuraminidase inhibitor as early as possible.

While early treatment is optimal, treatment should be initiated even if it is more than 48 hours after onset illness.

Laboratory testing and initiation of antiviral treatment should occur simultaneously. Treatment should never be delayed while waiting for laboratory confirmation of influenza or (H7N9) infection.

Hospitalized Patients

Hospitalized patients and patients with severe or complicated influenza should be treated with oseltamivir. We don't have data on inhaled zanamivir works for severely ill patients. Therefore, oseltamivir should be used for hospitalized patients.

Treatment should be started even if it's initiated after 40 hours of illness onset. And as many of you probably know, there were several observational studies that support this recommendation for hospitalized patients.

Also the optimal duration of treatment is not known for severe illness. However, clinicians should consider a longer duration of treatment -- for example, 10 days -- for severely ill persons. This recommendation is not different from our current recommendation for seasonal influenza.

Outpatients and patients with uncomplicated illness

For patients with uncomplicated illness seen as outpatients, we are recommending treatment with either oseltamivir or zanamivir for all persons -- including patients who were previously healthy. Now this recommendation is different than for seasonal influenza where we only recommend outpatient treatment for persons who are at increased risk for complications.

For (H7N9) we're recommending treatment for all patients regardless of underlying conditions. In addition, treatment should be started even if it's initiated after 48 hours of illness onset. The benefit for antiviral treatment of uncomplicated flu has been demonstrated if treatment is started within 48 hours of illness onset. However, given the severity of illness and the fact that several patients in China appear to have progressed from mild to severe illness over more than a week, the anticipated lack of underlying immunity, and low adverse event profile of both of the neuraminidase inhibitors, we are recommending initiation of treatment no matter what the timing (of presentation for care), even in uncomplicated illness.

Laboratory testing should occur simultaneously, and once the results are available the clinician can stop treatment for negative tests if they were able to obtain a good specimen.

Now if the outpatient presents with an illness that is resolving at the time of the outpatient visit -- for example fever -- and most of the symptoms have completely resolved by the time they seek clinical care then of course the clinician can use his or her clinical judgment to make a treatment decision. But we would advise that untreated persons should be monitored for any worsening of illness.

And that concludes the - my presentation. And now I'd like to turn this over this over to Dr. Kuhar so he could update you on the infection control guidelines.

Dr. David Kuhar:
The Interim Guidance for Infection Control Within Healthcare Settings When Caring for Patients with Confirmed, Probable, or Cases Under Investigation of (H7N9) Infection is based upon current available information and the following considerations -- lack of a safe and effective vaccine, a suspected high rate of morbidity and mortality among infected patients, unknown potential for human-to-human transmission, and the absence of confirmed or probable (H7N9) cases in the United States.

It is anticipated that if these conditions change this interim guidance will be evaluated and updated based on the new information. It is important to note that facilities should already be familiar with many of the recommendations contained in this interim guidance as they are the same as CDC's guidance for seasonal influenza. A link is provided in the interim guidance to the seasonal guidance for reference.

For this call I am going to highlight important similarities and differences between these guidances. For (H7N9) we still emphasize that preventing transmission of influenza within healthcare settings requires a multi-faceted approach including minimizing potential exposures -- including the use of source control, such as placing a face mask on a symptomatic patient upon entry into a facility --, appropriate management of ill health care personnel, adherence to infection control precautions for all patient care activities, implementing environmental infection control with similar cleaning and disinfection procedures as for seasonal influenza, and managing visitor access and movement within the facility.

Among the important differences from seasonal influenza guidance are that a higher level of infection control measures is recommended for (H7N9) than is currently recommended for seasonal influenza. In addition to standard precautions, contact and airborne precautions are recommended for confirmed, probable, or cases under investigation of (H7N9) virus infection at this time.

We recommend that personnel adhere to appropriate hand hygiene practices. And upon entry into a patient room or care area personnel should wear gowns, gloves, eye protection, and respiratory protection that is at least as protective as a fit tested NIOSH certified disposable N95 filtering face piece respirator.

Also as I mentioned, a patient with confirmed, probable, or case under investigation of (H7N9) virus infection should be placed in an airborne infection isolation room. We are aware that placing patients in an airborne isolation rooms might not be feasible in all settings or if cases are widespread. While larger respiratory droplets are thought to be the main mode of influenza transmission, transmission via small particles might be possible. In the context of a virus with unknown potential for human-to-human transmission, no available vaccine, suspected high morbidity and mortality for those infected, and the potential for unexpected, unrecognized and/or frequent aerosol generating procedures performed on critically ill patients, a conservative approach should be taken until more information is known.

If airborne isolation rooms are unavailable we recommend that patients be placed in private rooms with the door closed, and transferred to a facility where one is available, when feasible. Pending transfer, a face mask should be placed on the patient for the purpose of source control.

Let me close this update with saying that these recommendations will be revisited as additional information on (H7N9), its transmissibility, epidemiology, available treatment, or vaccine options become available.

That concludes my presentation. And I will hand things back to our moderator.

Loretta Jackson Brown:
Thank you, Dr. Fry and Dr. Kuhar. We will now open up the lines for the question and answer session.

Coordinator:
Thank you. At this time if you would like to ask a question please press star 1. Please make sure you unmute your phone and record your name clearly when prompted so I may introduce your question. If you'd like to remove your question you may press star 2. And we'll take a few moments to see if we have any questions at this time. We do have a few questions in the queue at this time. Our first question comes from (Warner Hudson). Your line is open.

(Warner Hudson):
Hi, this question is directed to Dr. Fry. I'm from UCLA. And I spoke with Tim Uyeki a year ago about H5N1 prophylaxis regarding researchers. And as a hospital we might see potential cases coming from China.

Do you have recommendations about prophylaxis of individuals exposed to known cases of (H7N9)? I think the - dose that Tim told me a year ago was 150 milligrams BID for seven to ten days for prophylaxis of an exposed person to an H5N1 case. I just haven't heard or seen what it would be in your judgment for (H7N9).

Dr. Alicia Fry: Yes, thanks. We have not posted any guidance for chemoprophylaxis for this virus yet. I anticipate that we will have something from the web in the next week or two.

At this point if anyone had a suspect case what we are advising is that they consult with us, and we can walk through them basically on a case by case basis to discuss the need for chemoprophylaxis for these cases - for the context of these cases. Sorry to defer your question.

(Warner Hudson):<<br /> Oh, that's okay. That would be true even if we had a travelling researcher professor whatever over in Shanghai that called us up via travel medicine kind of text.

Dr. Alicia Fry:
Yes, I think that would probably be the best.

(Warner Hudson):
Okay, thank you.

Coordinator:
Our next question comes from (Richard Denali). Your line is open.

(Richard Denali):
Thank you. My question was just answered. It was about prophylaxis as well.

Coordinator:
Our next question comes from (Faye Ching). Your line is open.

(Faye Ching):
Hi, this is question is for Dr. Fry. I'm just wondering do you have any EPI profile for those 17 fatal cases. So you just mentioned the 63 years old is kind of the median for the - all 87 cases. Any kind of more detail EPI profile for 17 fatal cases?

Dr. Alicia Fry:
Thanks, that's a really good question. Part of the issue is we don't have complete information on all of the cases. So it's hard to give any - a profile with any confidence.

You're right they tend to be older and -- as you might expect -- many of the fatalities have had underlying conditions. But the information on underlying conditions is incomplete from most of the patients. And for some of the newer patients we're still waiting to get information. So at this time I really don't have any more information that I can share. I'm sorry about that.

(Faye Ching):
It's okay. So a follow up question, do we have the age range for those 17 - 87 cases?

Dr. Alicia Fry:
Do I have the age - median age?

(Faye Ching):
Age range.

Dr. Alicia Fry:
No, actually I don't have that.

(Faye Ching):
Okay.

Dr. Alicia Fry:
But I could probably get it out. I'll keep looking for it and if you send an email I can to the COCA Call I can give it to you.

(Faye Ching):
Okay, thank you.

Loretta Jackson Brown:
Yes, we - this is Loretta. We can follow up if you email us at coca@cdc.gov -- C-O-C-A @cdc.gov. We will get that answer and that information to you.

(Faye Ching):
Thank you.

Coordinator:
Our next question comes from (Margo Erming). Your line is open.

(Margo Erming):
Good afternoon. This is (Margo Erming) from Ohio, and I have a question for exposed contacts. Are the recommendations for quarantine the contacts like we initially did with pandemic H1N1 or SARS?

Dr. Alicia Fry:
This is Alicia. I'm going to let Dr. Kuhar respond for - are you talking about healthcare workers or are you talking about any contacts?

(Margo Erming):
I'm talking about any contact -- household community contacts.

Dr. Alicia Fry:
Okay, we are going to have a very detailed guidance for that that we will put on the web for you. But we don't have it yet. So again same with chemoprophylaxis, at this point I think the best thing for you to do -- and we don't have any cases yet in the U.S. -- is to call us and we can walk through it with you.

(Margo Erming):
Thank you.

Coordinator:
The next question comes from (Carl). Your line is open.

(Carl):
Yes, just curious regarding the use of the N95 mask, is this with the swine flu where we use the - one time and discarded -- was not reused? Is that - would that be the same in this case?

Dr. David Kuhar:
Yes, the - I mean respirators should be used according to FDA instructions and regulations. Some are single-use respirators that should be used and disposed of after a single use. Some are reusable and should be disinfected as per instructions.

(Carl):
Thank you.

Dr. David Kuhar:
No problem.

Loretta Jackson Brown:
Operator, do we have other questions?

Coordinator:
Our next question comes from (Barbara). Your line is open.

(Barbara):
Yes, my question is regarding the contact with poultry, is that live poultry or were people sick who ate poultry?

Dr. Alicia Fry:
No it's - if you eat poultry it should be safe as long as it's cooked. The exposures were with the live bird market and uncooked poultry.

Coordinator:
Our next question comes from (Diane). Your line is open.

(Diane):
Hello, I'm (Diane) from New Hampshire Hospital, and my question relates to what type of information is being shared in postings at the airport to warn individuals in regards or - for prevention in regards to passengers that are coming from China?

Dr. Alicia Fry:
Passengers - well I'll tell you, right now we don't have any -- as far as I'm aware -- signs posted at the airport. However we do have some guidance on the web for travelers to China and for Americans living in China that you can access.

And essentially it's very simple. It's do not touch birds, pigs, or other animals, eat food that's fully cooked, practice good hygiene -- washing your hands often -- not touching your eyes and nose, and then of course seeing a doctor if you become sick during or after your trip to China.

And if anyone from the Division of Global Migration and Quarantines are on the phone, they can pipe in and respond more fully if they'd like.

(Diane):
My question really is when H1N1 arrived we did do a lot of promotion and making notations in the airports and for any Trans-Atlantic flights. And so that's what I was wondering if we were being proactive in doing the same for this.

Dr. Alicia Fry:
At this point, given the current situation and what we know about it, we have not started to do anything like that yet. But of course we are actively planning for all sorts of future steps.

(Diane):
Thank you.

Loretta Jackson Brown:
And that link to the travel health is on the COCA Call Webpage for this call. And what they are calling it is "Level 1 Practice Usual Precautions". So again if you go to COCA -- our webpage for this call -- you can link over to "Travelers Health".

(Diane):
Thank you.

Coordinator:
Next question comes from (Melissa). Your line is open. Please check your mute button.

(Melissa):
Hello.

Loretta Jackson Brown:
Go ahead. We can hear you.

(Melissa):
Oh, I'm sorry. I just wanted to see if you could clarify a set of questions for students and patients that were traveling from China that are presenting with flu like illness.

Can you give me any idea of what questions we should ask, like for instance what areas in China are you looking at and if there are other questions we should be asking? Thank you.

Dr. Alicia Fry:
Yes, thanks. I think asking them about areas that they've travelled to. First of all the time is very important. So illness onset and the dates of their travel, where they travelled in China -- that would be important -- and whether or not they were - visited any bird or poultry markets or they had any other exposure to any other animals which would include wild birds, poultry, and pigs. Does that help?

(Melissa):
Thank you.

Coordinator:
Next question comes from (April). Your line is open.

(April):
Yes, this is (April). I was just on the website for the COCA Call that is occurring right now. And the link to the CDC Interim Guidance on case definitions to be used for the (H7N9) is broken. It's not sending us to the information.

Dr. Alicia Fry:
Okay, thanks.

Loretta Jackson Brown:
Yes, we'll fix it. Thank you.

(April):
Thank you.

Coordinator:
Next question...

Dr. Alicia Fry: If you go to the CDC webpage for (H7N9) it's working. You can find it there.

(April):
Okay.

Coordinator:
Next question comes from (Dr. Ganary). Your line is open.

(Dr. Ganary):
Yes, in worst case pandemic scenario what's the current guidance for critical industries such as public safety, electrical generation, et cetera stockpiling their own supplies of Tamiflu as opposed to the strategic reserve?

Dr. Alicia Fry:
Well, you know, this is - pandemic planning - we have been in many industries have been working on pandemic preparedness plans for many years -- even before the H1N1 pandemic. And I knew their - I don't know the specifics. But there is - there has been quite a bit of preparedness on that. I - do you have any specific question related to it other than...

(Dr. Ganary):
Your advice as to whether critical industries should have their own supply of Tamiflu or whether in a pandemic situation we can rely upon the governmental agencies to distribute it or purchase it from individual pharmacies.

Dr. Alicia Fry:
Well I, you know, I don't know what the best thing to do is. I can't - I could - you could talk about this maybe more offline. But I think it totally depends on what your company is most comfortable with.

I think there's quite a bit of commercially available oseltamivir and there is some oseltamivir in the stockpile. However, for sure, if we have a severe pandemic we would be stretching the limits of all the available supplies. So I think, you know, drugs expire. They have to be, you know, carefully stored. So it's - I think - I can't give you a specific answer to that.

(Dr. Ganary):
Thank you.

Dr. Alicia Fry:
I'm happy - if you want to contact the EOC and ask to talk to someone about that I think we could probably talk to you about it.

(Dr. Ganary):
Thank you.

Coordinator:
Next question comes (Karen Wilkins).

(Karen Wilkins):
Yes, I think my first one's been answered. If a person has a layover in the Beijing Airport and has no contact with any birds potential contact is greatly decreased?

Dr. Alicia Fry:
Yes, it seems like that's probably true.

(Karen Wilkins):
Okay. And my second question is should - would a swab - a rapid influenza swab be adequate enough to pick up the (H7N9) or should we send a culture?

Dr. Alicia Fry:
Okay, at this point I would not trust any of the commercially available rapid diagnostic tests that are out there to detect any avian viruses. Also - the only assays that we are absolutely sure can detect this is the PCR assay that CDC has developed and at this time is only performed in the CDC laboratory. But eventually more state laboratories will have it.

So if you suspect this virus you need to collect the specimen, put it in viral transport media, and immediately call your local or state health department so that they can help get this specimen to the proper place to be tested. Does that answer your question?

(Karen Wilkins):
Yes.

Dr. Alicia Fry:
Thank you.

(Karen Wilkins):
Thank you.

Coordinator:
Next question comes from (Desmond). Your line is open.

(Desmond):
Okay, my question is given that the source right now is China and only China, given the history of the Chinese have not been particularly transparent in these types of situations. We know from past history. Are they doing anything and are we sure that they are doing what they say they may be doing in terms of any outbound flights from China that are bound to the United States, especially to the west coast?

Dr. Alicia Fry:
I'm sorry. I missed the question. Are they doing what in regards to those flights?

(Desmond):
Are they doing any precautions to reduce the spread or the risk of the virus coming here with the outbound air flights coming from China to parts of the United States like the west coast for example, which is a very heavy trafficked area from China to the United States.

Dr. Alicia Fry:
No, at this time there's nothing like that. Remember, at this time this is zoonotic infection. This is all - almost all of the cases are from bird to human. There has been very limited human to human transmission. And so at this point we are treating this like a zoonotic infection. It has not - there has been nothing like that that has been done.

(Desmond):
Okay, the second question which is linked to that one, know that we have a high volume of Chinese ethnic stores actually sell food that was prepared in China in places like, you know, Chinatown, New York City and Chinatown, Los Angeles. Do we have any contingency plans should things get worst in terms of how we may seek to reduce the spread given if that situation should arise?

Dr. Alicia Fry:
Okay, if anyone has poultry -- and that could be chickens or any kind of bird -- from China that isn't already cooked somehow they should cook it very thoroughly before they eat it.

Anything that's cooked should not be infectious. Otherwise I can't imagine how someone would get something like that on a plane legally.

(Desmond):
Well you wouldn't believe it but it happens anyway.

Dr. Alicia Fry:
Yes.

(Desmond):
Okay, thanks.

Coordinator:
Our next question comes from (Amy). Your line is open.

(Amy):
Oh, thank you. Quick comment on management and a quick non-management question. First there was a comment earlier regarding respiratory protection and whether or not to reuse a N95 respirator. I just want to clarify that these people should also be on contact precautions all of the equipment be it disposable or not for respiratory protection should be handled for contact.

And the second is just a quick non-management question. Do you believe that there's any relationship between the ongoing situation in the previous massive pig death reported from Shanghai?

Dr. Alicia Fry:
Thanks, at this time I probably know as much about this as you do. The information we've received from China is that they tested some of the pigs and that they were negative for this virus. And that's really all we know.

(Amy):
Thank you.

Loretta Jackson Brown:
Hi, operator. Do we have any additional questions?

Coordinator:
Yes we do have a few more. Our next one comes (Angela Batali). Your line is open.

(Angela Batali):
Hi, I believe (Amy) answered the previous question or asked my question about N95 respirators. I am curious though, we've sort of seen an experience like this with H1N1 a few years ago where we were asked to dispose of N95s, and then quickly our nation ran out of supply. Have there been thoughts or initial conversations with manufacturers at this time yet?

Dr. David Kuhar:
Yes, we are currently having discussions about this and planning for that right now.

(Angela Batali):
Great, thank you.

Coordinator:
The next question comes (Jodi Langa). Your line is open.

(Jodi Langa):
Hi, I think you answered this question when you mentioned that it was mostly a zoonotic illness, but has there been any talk of issuing a recommendation of avoiding non-essential travel to China?

Dr. Alicia Fry:
No, not at this time. And I just want to go back to what messages have been posted at the airport. And I was - I've been informed that the - there are electronic messages in the arrival areas on the CBP monitors of that basically direct people to the CDC travel webpage.

So it says "health advisory avian flu (H7N9) in China updated information go to the webpage". And so that has been posted in the airport at the arrival centers for some of these flights.

(Jodi Langa):
Thank you.

Coordinator:
Next question comes from (Jeanette). Your line is open.

(Jeanette):
Great, thank you. And thanks for taking the time for this call. So I have one more question regarding the N95 respirators. So for older hospitals that don't have an anti-room, what would be the appropriate way to remove the masks if it's contact plus airborne isolation?

So in other words would you remove it inside the room just before leaving the room?

(Dr. David Kuhar):
I understand your question. The time to remove it is after leaving the room. And it should be the last thing removed. So you would remove your other protective equipment within the room and the respirator's the final thing once you've left the room.

(Jeanette):
And is there any special processing that - or do you just have a garbage can - a covered garbage can outside of the room?

(Dr. David Kuhar):
Whatever our current standard practice is...

(Jeanette):
Great.

(Dr. David Kuhar):
...in that facility.

(Jeanette):
Thank you.

Coordinator:
Next question comes from (Sabia). Your line's open.

(Sabia):
Thank you so much. My question is for Dr. Fry. At this point, Dr. Fry, do you recommend travelers to China carry Tamiflu with them?

Dr. Alicia Fry:
No, we haven't formally recommended that that's what they do. Instead we ask that they protect themselves by avoiding the potential exposures and practicing good hygiene.

(Sabia):
Thank you so much.

Coordinator:
Next question comes from (Jessica). Your line is open.

Hi, can you tell me or verify if you are aware of what biosafety level conditions are recommended to culture the virus? Just so you know I'm calling on behalf of the Department of Defense Laboratories that do have enhanced BLS 3 and 4 conditions. Thank you.

Dr. Alicia Fry:
I should know that, and I am pretty - I'm 95% sure of my answer. But why don't you email the COCA site and I will get you the - I will check with the laboratory and I will tell you exactly.

(Jessica):
Thank you.

Dr. Alicia Fry:
Okay?

Loretta Jackson Brown:
Again that email address is C-O-C-A@cdc.gov -- coca@cdc.gov .

Coordinator:
Next question comes from (Patrick Capeely). Your line is open.

(Patrick Capeely):
Yes, Dr. Fry at this point do you know if there are any vaccine preparations underway?

Dr. Alicia Fry:
Yes, thanks. They - at this point we have begun the initial process of identifying a virus and working up a virus that would appropriate for vaccine and then going through all the initial stages that need to happen to make a vaccine. So all of those have been initiated.

(Patrick Capeely):
Would you say that it would take the usual four six months timeframe?

Dr. Alicia Fry:
No, what we're doing is we're at the very beginning here and there's an initial set of testing that has to been done to basically say, "okay this is a good virus and this would work for a vaccine." And then this next stage is okay we're going to produce a vaccine on a mass scale.

And so I think the - we're in the initial phase where we're making small amounts to test it. But the decision to make a large amount of this has not been made yet.

(Patrick Capeely):
Okay, thank you.

Coordinator:
Next question comes from Brunswick, Colorado CDC. Your line is open.

(Francisco Rado):
Oh, hi. This is (Francisco Rado), Alicia, from Global Management Quarantine. I think you already addressed the issue of the messaging at the airports. I would also point out that there's entering guidance for airline crew that I can send through the COCA address that can be available for the clinician audience. Thank you.

Dr. Alicia Fry:
Thanks (Francisco).

Loretta Jackson Brown:
Hi operator, do we have additional questions?

Coordinator:
The next question comes from (Lisa). Your line is open.

(Lisa):
Hi, I'm calling because in California we have the CAL OSHA ATD standards which requires -- for flu --that you wear an N95 or greater if you're doing aerosolizing procedures. And I’m understanding that you're saying that you should be using that for any procedures.

(Dr. David Kuhar):
It should be used for patient contact as well as aerosol generating procedures.

(Lisa):
Okay, so with that the contact precautions require that you discard the respirator after use -- just to clarify.

(Dr. David Kuhar):
If it is - I mean you're correct. If it is a disposable single-use respirator... If you are using a reusable respirator, they should be disinfected according to manufacturer instructions.

Okay, and so if they're using PAPRs that would just discard the lens cover?

(Dr. David Kuhar):
Yes.

(Lisa):
Okay, thank you.

Coordinator:
Our next question comes from (Dr. Watson). Your line's open.

(Dr. Watson):
Yes, I think you probably answered my question already. I just wanted to know whether or not a prototype vaccine was already in process. And I think you might've alluded to that already.

Dr. Alicia Fry:
Yes, the initial steps toward vaccine production have been initiated.

Coordinator:
Our next question comes from (Elizabeth). Your line is open.

(Dr. David Kuhar):
Just one moment... I'm not sure if I misspoke about PAPRs and disposal. If you could please email your question to the COCA email site, I will get back to you on appropriate handling of a PAPR and disinfection or disposal.

Coordinator:
(Elizabeth) your line is open.

(Elizabeth):
Hi, thank you. This is (Elizabeth) and I'm actually Communicable Disease for Alameda County. My question is what is the likelihood of live foul importation from China that we might have to worry about.

Dr. Alicia Fry:
I have to tell you I have no idea. I'm sorry. I don't know if we have anyone from USDA on the line who knows that kind of information but I just don't know, and I'm sorry.

Coordinator:
And there are no other questions at this time. Should you happen to have a question please press star 1 and record your name.

Loretta Jackson Brown:
While we're waiting for questions from the phone, Dr. Fry, Dr. Kuhar we did have a question come through the COCA box, and I'm not totally sure what they're asking. But it came from a county public health department and it is in regards to assessment of the quantity of antivirus currently available in the U.S. Has there been an assessment of that? Do you have any idea?

Dr. Alicia Fry:
Yes, hi thank you. This is Dr. Fry. I can tell you we have a group of people in the strategic national stockpile who monitor the commercial levels of available for antiviral drugs very closely. And so we are monitoring them. So when we make our guidance or anything we do we have an estimate of how much is both commercially available and how much we have in our stockpile. I don't have the numbers off the top of my head, but we do follow that closely here at CDC.

Loretta Jackson Brown:
Thank you. Operator, do we have any more questions from the phones?

Coordinator:
Yes we do. Our next question comes from (Kevin). Your line is open.

(Kevin):
Yes I just want to follow up on the vaccine question. Since this is going to be a new vaccine, will all participants or individuals who are given this vaccine have to be given at least two shots in order to get the immunity that we would need to see in individuals?

Dr. Alicia Fry:
So first of all I'll tell you there have been no guidelines made and there would be very well vetted guidance before we've made any kind of recommendations. But I can tell you that there have been a couple H7 viruses - vaccines -- excuse me -- that have undergone like phase two trial in the past. And that in general these H7 vaccines tend to be poorly immunogenic.

So in other words even with a booster - boosters help. One dose is very poor response to the booster those past studies. I think - I don't have any information about this virus and what we might find in our preliminary testing.

Coordinator:
Next question comes from (Amy Wishner). Your line is open.

(Amy Wishner):
Another question on the vaccine, you know, potential vaccine. Given current technologies which have you know not every - we know we don't have to use eggs for all flu vaccines anymore. So given current technologies what would be the best case scenario of when, you know, if the vaccine were needed and if the approvals were given to go ahead with it, what is the best case scenario of when the vaccine would be available?

Dr. Alicia Fry:
Well I have to tell you I haven't gotten any of those estimates yet. And I think it's because we really have to understand how well the virus grows and other things before we can start making projections like that.

But you know, all of our - any new vaccine takes months to make a large quantity of it. And while some of the new cell based technology reduces the time it still takes several months. So I don't have a specific answer for you, but I think it would- not going to be that much different than in the past.

Coordinator:
Our next question comes from (Patrick). Your line is open.

(Patrick):
Yes, it was more of a response to some of the questions about avian smuggling into the U.S. Yes, first of all my service does catch people far too frequently trying to smuggle live and smuggled birds into the country. As recent as March of this year they're some items posted. So just be aware that that does happen.

Dr. Alicia Fry:
Thanks, I'm going to sleep a little bit less well tonight.

Coordinator:
Our next question comes from (Daniel) your line is open.

(Dan Fields):
Hi this is (Dan Fields) from (Northridge) Hospital. I think I recall the past avian flu had spread following the poultry industry. And in screening patients for travel to China I was thinking that perhaps facilities that are nearby large poultry industries might consider screening for contact with birds. (Unintelligible).

Dr. Alicia Fry:
Yes, thanks. At this point we haven't really identified the source population. But I mean your point is well taken. I think as we learn more, you know, that's a good idea. At this point we haven't really identified the source - the animal source for this outbreak.

(Dan Fields):
Okay, thank you.

Coordinator:
Next question comes from (Danny). Your line is open. Hello (Danny) your line is open. Please check your mute button. We can go onto our next question -- one moment. Our next question comes from (Veronica). Your line is open.

(Veronica):
Yes, so thank you. I'm going to be succinct for the sake of - from a homeland security for the health care delivery infrastructure and emergency management stance, what is the recommendation now for forming perhaps a small subcommittee on that?

I ask that because when we were dealing with H1N1 it didn't have the virulence that we expected and so there was alot of pandemic response fatigue and it almost got the point of crying wolf. And in order to get the attention of executive leadership, are there any suggestions about how we can approach this at this moment or do you advise just watching and waiting?

Dr. Alicia Fry:
Well I think everyone should - I think that you should have your pandemic plans ready. And the fact that the H1N1 pandemic was less severe it - still your pandemic plans I'm hoping helped with your response to that. But at least the initial pandemic plans that I know many state health departments put out together were thinking through an H5N1 that sort of 1918 like pandemic.

And so I think it's best to be prepared. Now whether you should, you know, do something different right now or, you know, that it's a little bit harder for me to answer because I'm not 100% sure I understand exactly the level of preparedness and details that you're talking about. But I think it's always a good idea to be prepared for a pandemic.

Coordinator:
Next question comes from (Leann).

(Leann):
Yes, you talked about having non negative pressure rooms, you know, putting somebody in a room that's not an Aii room. And does that then - are you suggesting that the patient would then be masked perpetually while they're in the room?

(Dr. David Kuhar):
If while they're in a non-airborne infection isolation room, they can be masked until they can be transferred to an airborne isolation room. Yes. The idea is that they would be transferred to an airborne isolation room as soon as possible.

(Leann):
Thank you.

Coordinator:
Next question comes from...

Loretta Jackson Brown:
Yes, I'm sorry operator. Let me tag onto that. So Dr. Kuhar we had a question through the box also related to masks and it is whether or not a surgical mask could be placed over the N95 mask to extend the life of it. And they are stating that this was done with SARS where there were shortages of N95 masks. What's CDC's guidance and recommendations for placing a surgical mask over the N95?

Dr. David Kuhar:
At this time that is not recommended, and we are having discussions about, you know, the potential for shortages down the road. But at this time there's, you know, no disease in the United States, and it is not widespread.

Loretta Jackson Brown:
Thank you. Operator.

Coordinator:
Next question comes from (Barbara). Your line's open.

(Barbara):
Yes, I've already had questions from our animal services, and I would like to know if there are any recommendations for PPE at this point for those who work a lot with birds, fighting cocks, wild birds?

Dr. Alicia Fry:
No, there isn't anything like that right now. Certainly we are going to - everyone will be ramping up surveillance for this virus in other places outside of China. But at this point we don't have any information that it has been detected anywhere outside of China.

(Barbara):
Okay, thank you.

Coordinator:
Next question comes from (Dr. Bresley). Your line is open.

(Dr. Faye Bresler):
Hi, this is (Dr. Faye Bresler). I was formally with USDA, and I did a very quick search on the animal and plant health inspection service page on live poultry. It does indicate that there is no importation from the People's Republic of China. And quite a few other countries are also listed there. So I understand that there's a concern of smuggling, but in terms of authorized entry there is none.

Dr. Alicia Fry:
Thank you for helping me with that.

Coordinator:
Next question comes from (Margo). Your line is open.

(Margo):
Two questions -- one, are there plans to test birds particularly migrating birds from the Far East for (H7N9)? And also do we know anything about the mechanism of depth for critical illness? Are they dying of pneumonia, ARDS?

Dr. Alicia Fry:
Thanks, I'm going to answer your second question first. The patients are progressing to severe respiratory disease and respiratory failure. And some of them have had ARDS. So yes, it seems to be a respiratory infection that is progressing and resulting in a death due to that severe respiratory process.

You know, as far as the - I'm tempted to go back and ask my USDA contact out there to answer (the surveillance set up. And so I am sure this virus, - you know, they've been monitoring it for H5N1 for several years now. And so I'm sure this virus would be added to that list. But if anyone from USDA's on the line and can elaborate on that I would let them do that.

Loretta Jackson Brown:
And if you can't get through on the line, if you could send us a reply through the COCA box we could either state it on the call or it will - we can include it in the Q and A for the transcript on the Call page.

Operator, how many questions do we have in the queue?

Coordinator:
We have one more question at this time.

Loretta Jackson Brown:
Okay.

Coordinator:
Next question comes from (Lisa). Your line is open.

(Lisa):
I was just going to ask some more clarification on the human to human transmission. You said very little or do we have like a number of cases or...?

Dr. Alicia Fry:
Yes, I can tell you. And once again remember part of the problem here is that often the contact of the confirmed case has some of the same exposure to the birds.

So there have been two suspect cases -- those are two cases that have never been tested with a PCR but had illness. And there are two contacts that were confirmed by PCR out of more than 1300.

(Lisa):
Thank you.

Coordinator:
Our next question comes from (Josie Cap). Your line is open.

(Josie Cap):
Hello, my call is from the perspective a local public health department where we may get a report on somebody in the community who is mildly ill and not hospitalized. So a couple of questions -- one is what is the isolation guidelines for a mildly ill person in the community?

And the other is in terms of infection control if we're going to send that person to their clinician who isn't going to have a negative pressure room who may not be able to implement all those airborne precautions, what would be your thoughts on that?

Dr. Alicia Fry:
David do you want to take that or you want me to take it?

(Dr. David Kuhar):
I could chime in here on the engaging health care piece. You know, perhaps ideally if you're going to send them to a healthcare facility you try to choose one that's able to implement a higher level of infection control precautions. If not, once again, they could be placed in a single patient room with the door closed wearing a surgical face mask for source control for the duration of their visit.

And I can't really speak to the community measures.

Dr. Alicia Fry:
Yes, I think - and this is Dr. Fry. You know, while the case is under investigation and this is assuming the patient is still ill so of course you want to get a specimen like you suggested and you asked about begin them on empiric oseltamivir or zanamivir. And then the ill patient should be advised to, you know, avoid contact with other people as, you know, much as possible so that this can be limited -- the spread of this.

And what I - it sounds a little onerous but I - we have been turning around our PCR tests pretty rapidly. So I think we can rule out these cases pretty quickly. So it shouldn't be that long that the patient has to stay isolated until we know for sure. And of course if they are a (H7N9) case then we all would have been happy that they did stay home and not transmit this to anybody else.

(Josie Cap):
Thank you, how long is it taking to turn around a test?

Dr. Alicia Fry:
Well PCR can be done very quickly once we get it here. But it has to get here. And so I think it depends on how long it takes to get the specimen to actually then ship it. And once we actually get it we can, you know, it's hours. It doesn't take us that long. And the other thing is we will have more information about how to approach your case investigation up on the web in the future. So we'll have more clear guidance that will walk you through some of the steps that you've been asking about hopefully soon.

(Josie Cap):
Okay, thank you.

Loretta Jackson Brown:
And Dr. Fry, we have the Florida Department of Health. They want to emphasize the importance of contacting state and local health departments if there are any cases that are suspected, including for specimen collection and laboratory testing. So are you wanting folks to directly send their specimens to CDC or to their state? What's the procedure?

Dr. Alicia Fry:
Thank you. I try to emphasize that if a clinician has a suspect case they need to collect a specimen and contact their local or state health department right away. The state health department will work with them to transport the specimen. In some cases transporting to the state health department is going to be the best thing to do.

And in other situations it may be that the state health department would prefer that it ship directly to CDC. But that decision needs to be made with the state health department. We work very closely with all of our state health departments, and we're partners with them. And they are really your first line. So if you have suspect case you really need to be contacting your state health department. Thanks to Florida for pointing that out.

Coordinator:
We do have one more question. Did you want to take it at this time?

Loretta Jackson Brown:
Yes, operator. This will be our last question.

Coordinator:
It comes from (Lt. Coronel Riley). Your line is open.

(Lt. Coronel Riley):
Is it open? Yes, this is (Lt. Coronel Riley). I just arrived at Dover Air Force Base from (PACAF) -- the pacific region. And I was wondering while I think it's very good that we are prepositioning and preplanning for this potential problem, how much engagement do we have right now with OIE and the other veterinary entities out there who are actually monitoring the animal population for signals.

Because it seems to me that we can stop this or we can mitigate the exposure rate at the chicken level then we could probably mitigate the problem at the human level.

Dr. Alicia Fry:
Thanks, I have to speak in generalities here, because I'm an epidemiologist and I'm really am only mostly aware of what's happening here at CDC. But there has been huge outreach and quite a bit of international cooperation both in the human health side and the animal health side related to this. So I don't - like I said, I don't know the specifics but I do know that both sides -- human and animal -- have been doing a lot in preparing for this.

(Lt. Coronel Riley):
Okay, because I have some people I know who at OIE who could probably get some information that's real time that would give us some kind of a situational awareness as if this level of infection is changing in China when it comes to chicken population and if there's any indication of sustained transmission of the human population.

Dr. Alicia Fry:
That sounds great. Maybe you can reach out and contact us at the influenza division directly.

(Lt. Coronel Riley):
I can do that.

Dr. Alicia Fry:
Thanks.

Loretta Jackson Brown:
Thank you. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenters Dr. Fry and Dr. Kuhar.

If you have additional questions for today's presenters please email us at coca@cdc.gov. Put April 18 COCA Call in the subject line of your email, and we will ensure that your question is forwarded to the presenter for a response. Again that email address is C-O-C-A@cdc.gov.

The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days.

There were no continuing education credits for this call. (H7N9) resources for clinicians are available on the COCA Call webpage. Go to emergency.cdc.gov/coca. Click COCA Calls, and then follow the link for the (H7N9) call.

To receive information on upcoming COCA Calls subscribe to COCA by sending an email to coca@cdc.gov and write subscribe in the subject line.

CDC launched a Facebook page for health partners. Like our page at facebook.com/cdchealthpartnersoutreach to receive COCA updates.

Thank you again for being a part of today's COCA Call. Have a great day.

Coordinator:
Thank you for participating in today's conference. You may disconnect at this time.

END

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