Preparing responses to human infections with

Avian Influenza A(H7N9)

Background

On 31 March 2013, the National Health and Family Planning Commission, China (NHFPC) notified WHO of three

cases of human infection with avian influenza A(H7N9) from Shanghai and Anhui. This was a new influenza

subtype, not previously known to have infected humans, and therefore prompted immediate action from Chinese

authorities and WHO. A total of 432 laboratory-confirmed cases including 146 deaths have been reported to date

(as of 9 May 2014).

Although the exact source and mode of transmission are not yet known, available evidence supports animal,

particularly poultry, or contaminated environments as the potential primary source of infection. As a result, the

national and provincial authorities in China initiated several control measures including the closure of live poultry

markets.

Purpose of the document

This document is produced as a framework for action to provide Member States with a summary of information

for assessment of their specific situation and assist to focus national efforts on preparedness and response. This

document does not intend to replace previous pandemic preparedness guidelines or procedures countries may

already have in place to respond to public health emergencies. It is also not exhaustive, rather it is meant to

highlight areas where H7N9 requires specific or supplemental action.

Framework for action

A number of key components, listed below, are required for countries and areas to prepare for a response to

human cases of H7N9. These are based on preparedness as set out in the Asia Pacific Strategy for Emerging

Diseases (APSED 2010) and in line with obligations required under the International Health Regulations (IHR

2005). They also align with the WHO Interim Guidance on Pandemic Influenza Risk Management. Relevant

technical documents and papers are also listed below (as of 6 May 2014).

Possible scenarios

Since the human infection with avian influenza virus A(H7N9) was detected in 2013, concern remains over the

potential for the H7N9 virus to adapt further and become readily transmissible between humans. It is also

possible that the recent decrease of cases observed in China could be due to seasonality and that transmission

may increase next winter/spring (December-May). The resumption of live animal trading in affected areas may

result again in sporadic cases, some with clusters. There have been several cases reported in outside of Mainland

China since 2013 thus far virus spread to new areas remains a possibility. From the perspective of a given country

conducting preparedness actions and risk assessment, an H7N9 outbreak would take the form of one of the

following scenarios:

Scenario 1: No locally acquired case(s) of human infection with avian influenza A(H7N9) in country

Scenario 2: Sporadic and/or limited human-to-human cases of avian influenza A(H7N9) infection in

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country

Scenario 3: Sustained human-to-human transmission of avian influenza A(H7N9) with or without sporadic

cases in country

The objectives in preparing for response to human infection with H7N9 include:

Early detection of human case/s of avian influenza A(H7N9) (all scenarios).

Early detection of avian influenza A(H7N9) in poultry (scenario 1 and 2).

Identification of the source and reservoir of infection by conducting appropriate epidemiological and

virological investigations in humans and animals (scenario 2).

Reduction of preventable deaths by improving clinical management and infection control practices

(scenario 2 and 3).

Reduction of the transmission of the virus by instituting appropriate public health interventions (scenario

2 and 3).

Adopt risk communication strategy that positions health authorities as a reliable and trustworthy source

of information by providing timely and transparent information and proactive dissemination of

prevention messages (all scenarios)

Minimization of social disruptions and other negative consequences, where possible (scenario 2 and 3).

A way of applying the framework for response can be found in Annex 1 through considering the three

possible scenarios for H7N9 cases in the future. Each scenario includes key trigger points, an overarching

strategy and examples of response measures to take. Scenario 2 is particularly broad as it includes

everything from one or more sporadic case/s up until the time just before sustained human-to-human

transmission. The preparation and responses within this scenario are also broadly applicable across the

spectrum.

Keeping up-to-date

Table 1 provides links to general and H7N9 specific guidance, risk assessments and recommendations available at

the time of this publication. Updates specific to H7N9 can be found at

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/en/index.html.

Surveillance, risk assessment and response

Effective surveillance through enhancement of current influenza-like-illness (ILI) and severe acute respiratory

infection (SARI) systems in addition to unusual occurrences detected through event-based surveillance (EBS) will

maximize the early detection and reporting of human cases of H7N9. Risk assessment which incorporates this

information helps guide proportionate response. It should be undertaken on a continual bases, particularly as

new critical information becomes available.

Laboratory investigations

Laboratory systems and response networks have provided protocols for detection and biosafety advice specific

for H7N9. Detection can either be through a national laboratory or WHO can assist Member States to access

testing internationally if the need arises.

Human animal interface/zoonoses

Being a zoonotic disease, the human-animal interface is a key component for preventing human disease.

Coordination with the animal sector will ensure investigations to identify the source of infection and optimize

appropriate public health interventions associated with the animal source of the virus.

Clinical management and Infection prevention and control

Infection prevention and control measures already practiced for influenza are appropriate for H7N9. Specific

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guidance based on evidence of H7N9 cases treated can be found in the link below.

Public health intervention and emergency preparedness

In addition to areas listed, preparedness for human cases of infection with H7N9 can be achieved through

reviewing of the pandemic plan, including practical steps to operationalize it through an event management

system. WHO does not recommend travel or trade restrictions.

Risk Communication

Developing of a strategy and communicating information in an accurate and timely manner serves to harness

public trust and enhance appropriate behaviour during public health emergencies. Reporting of cases in a timely

manner to WHO assists with international communication and is in line with country obligations under IHR (2005).

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General H7N9 specific

Keep up-to-date

WHO web page with links for technical guidelines and current status

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/en/

Background and summary, as of 31 January 2014

http://www.who.int/influenza/human_animal_interface/latest_update_h7n9/en/

Overview of the emergence and characteristics of the avian influenza A(H7N9)

virus, 31 May 2013

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/WHO_H7

N9_review_31May13.pdf?ua=1

Surveillance A guide to establishing event-based surveillance http://www.wpro.who.int/emerging_diseases/documents/docs/eventbasedsurv.pdf

WHO interim global epidemiological standards for influenza surveillance

http://www.who.int/influenza/resources/documents/INFSURVMANUAL.pdf

H5N1 investigation guidelines

http://www.who.int/influenza/resources/documents/WHO_CDS_EPR_GIP

_2006_4r1.pdf

Interim revised surveillance recommendations – H7N9, 10 May 2013

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/InterimSu

rveillanceRecH7N9_10May13.pdf?ua=1

H7N9 situation update as of 21 April 2014

http://www.wpro.who.int/outbreaks_emergencies/H7N9/en/

Risk assessment and response

Rapid risk assessment of acute public health events, WHO http://whqlibdoc.who.int/hq/2012/WHO_HSE_GAR_ARO_2012.1_eng.pdf

WPRO Internal - Practical guide: Rapid Risk Assessment for event based

surveillance World Health Organization, Western Pacific Regional Office,

December 2012

WHO risk assessment updated 28 Feb 2014 http://www.who.int/influenza/human_animal_interface/influenza_h7n9/140225_H7N9RA_for_web_20140306FM.pdf?ua=1

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Laboratory Laboratory PCR testing for H7N9, updated on 15 April 2013 http://www.who.int/influenza/gisrs_laboratory/cnic_realtime_rt_pcr_protocol_a_h

7n9.pdf?ua=1

Bio-risk management interim recommendations, H7N9 as of 10 May 2013

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/InterimRe

cLaboratoryBioriskManagementH7N9_10May13.pdf

Laboratory serology testing for H7N9 as of 20 December 2013

http://www.who.int/influenza/gisrs_laboratory/cnic_serological_diagnosis_hai_a_

h7n9_20131220.pdf?ua=1;

http://www.who.int/influenza/gisrs_laboratory/cnic_serological_diagnosis_micron

eutralization_a_h7n9.pdf; and

http://www.who.int/influenza/gisrs_laboratory/cnic_serological_diagnosis_hai_a_

h7n9.pdf

Clinical management and Infection prevention and control

Infection prevention and control guidance for influenza

http://www.who.int/csr/resources/publications/swineflu/WHO_CDS_EPR_

2007_6/en/index.html and

http://www.doh.state.fl.us/rw_Bulletins/WHO_AvianFlu_control_practice

s.pdf

Clinical management of human infection with avian influenza A (H5N1)

virus, 15 August 2007

http://www.who.int/influenza/resources/documents/ClinicalManagement

07.pdf

Post-exposure antivial chemoprophylaxis of close contacts of H7N9 patient. 17

January 2014

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/13_Janua

ry_2013_PEP_recs.pdf?ua=1

Public health intervention and emergency preparedness

Asia Pacific Strategy for Emerging Disease (2010)

http://www.wpro.who.int/emerging_diseases/documents/docs/ASPED_20

10.pdf

Pandemic influenza risk management interim guidance http://www.who.int/influenza/preparedness/pandemic/GIP_PandemicInfluenzaRiskManagementInterimGuidance_2013.pdf

International Health Regulations (2005) http://whqlibdoc.who.int/publications/2008/9789241580410_eng.pdf

Reducing transmission of pandemic (H1N1) 2009 in school settings

Vaccine preparation

WHO recommendation on influenza A(H7N9) vaccine virus. 26 September 2013

http://www.who.int/influenza/human_animal_interface/influenza_h7n9/20130

9_h7n9_recommendation.pdf?ua=1

WHO provisional recommendation on influenza A(H7N9) vaccine virus as of 31

May 2013

Candidate vaccine viruses for avian influenza A(H7N9). 13 February 2014

http://www.who.int/influenza/vaccines/virus/candidates_reagents/summary_a

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http://www.who.int/csr/resources/publications/reducing_transmission_h1n1_2009.pdf

Interim planning considerations for mass gatherings in the context of pandemic (H1N1) 2009 influenza http://www.who.int/csr/resources/publications/swineflu/cp002_2009-0511_planning_considerations_for_mass_gatherings.pdf

Public health preparedness H1N1 review document (mass gathering_travel_risk comms) http://whqlibdoc.who.int/hq/2011/WHO_HSE_GIP_ITP_2011.3_eng.pdf Advice on the use of masks in the community setting in Influenza A (H1N1) http://www.who.int/influenza/preparedness/measures/Adviceusemaskscommunityrevised.pdf

_h7n9_cvv_20140213.pdf?ua=1

Update of WHO biosafety risk assessment and guidelines for the production and quality control of human influenza vaccines against avian influenza A(H7N9) virus

Development and distribution of candidate vaccine viruses for avian influenza A(H7N9)

Risk communication

WHO media handbook

http://www.who.int/csr/resources/publications/WHO%20MEDIA%20HAND

BOOK.pdf

WHO media field guide

http://www.who.int/csr/resources/publications/WHO%20MEDIA%20FIELD

%20GUIDE.pdf

WHO outbreak communication planning guide http://www.who.int/ihr/elibrary/WHOOutbreakCommsPlanngGuide.pdf

Frequently asked questions H7N9 infections http://www.who.int/influenza/human_animal_interface/faq_H7N9/en/

Standardization of the influenza A (H7N9) virus terminology http://www.who.int/influenza/human_animal_interface/influenza_h7n9/H7N9VirusNaming_16Apr13.pdf?ua=1

China-WHO joint mission on human infection with avian influenza A(H7N9) virus, 18-24 April 2013, mission report http://www.who.int/influenza/human_animal_interface/influenza_h7n9/ChinaH7N9JointMissionReport2013u.pdf?ua=1

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Annex 1: Possible scenarios and framework for response Scenario 1: No locally acquired human case of avian influenza A(H7N9) in country Key trigger points for the scenario:

No evidence of locally acquired human infection with H7N9

Detection of H7N9 infection with a recent history of travel to the affected area

No evidence of H7N9 in animals Overarching strategy for the response:

Ensure systems are in place to detect, report, manage and prevent infections from animal or environmental sources.

Ensure systems are in place to undertake epidemiological and virology investigations.

Ensure systems are in place to recognize and manage clinical cases and implement infection prevention and control in healthcare facilities.

Ensure systems are in place for the timely and full reporting to WHO in line with IHR (2005).

Regularly reassess and communicate the public health risk of human cases of H7N9 in country.

Review preparedness and readiness for a change in risk. Key technical areas Preparedness and Response measures for country

Surveillance, risk

assessment and

response

Monitor and strengthen existing ILI and SARI surveillance including awareness raising with healthcare workers and at points of entry

Monitor and strengthen event-based surveillance and reporting mechanisms

Ensure risk assessment mechanism is in place to assess incoming information and ensure a proportionate response

Review rapid response team field investigation mechanism/guideline

Laboratory Ensure mechanisms in place for laboratory diagnostics, shipping of specimens and reporting for surveillance

Human-animal

interface/zoonoses Establish a multi-sector joint working mechanism

Establish close cooperation with agriculture/animal authorities to share details of each other’s investigations, particularly about the potential of human exposure from animals

Clinical management

and infection prevention

and control

Alert hospitals and community medical practitioners to symptoms, diagnosis, clinical management and Infection, prevention and control procedures

Public health

interventions and

emergency

preparedness

Review pandemic plan, including how to operationalize it e.g. activating an event management system

Review all response systems including readiness of event operations center (EoC), logistics, equipment and standard operating procedures

Review the status of oseltamivir and PPE stockpile and examine mechanisms for distribution

Investigate the status of vaccine preparedness and policies for vaccine distribution

Risk communication Ensure that a risk communication strategy is set up for H7N9 with a system for developing messages and clearance procedures established, coordination arrangements agreed and spokespersons appointed and trained.

Agree on mechanism for timely development, release and updating of information on H7N9 to the public and appropriate distribution arrangements are in place (talking points, FAQs, web pages press releases, etc.)

Ensure roles and responsibilities are agreed for international cooperation and communication including timely reporting in line with IHR (2005)

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Scenario 2: Sporadic &/or limited human-to-human case/s of avian influenza A(H7N9) in country Key trigger points for the scenario:

This scenario has a wide spectrum o From one or more sporadic case/s of H7N9 reported in country, without history of travel to a

country with known H7N9 in the previous 14 days. o Including limited human-to-human transmission. o To just prior to sustained human-to-human.

Detection of H7N9 infection in animals. Overarching strategy for the response:

Ensure systems are in place to detect, report, manage, and prevent further infections from animal or environmental sources.

Ensure systems are in place to undertake epidemiological and virology investigations.

Ensure systems are in place to recognize and manage clinical cases and implement infection, prevention and control measures in healthcare facilities.

Ensure timely and full reporting to WHO in line with IHR (2005).

Regularly reassess and communicate the public health risk of further human cases of H7N9 in country.

Consider public health interventions to help limit spread through sustained human-to human transmission (e.g. preliminary consideration of rapid containment)

Key technical

areas

Preparedness and Response measures for country

Surveillance, risk

assessment and

response

Implement time-limited enhanced ILI and SARI surveillance in geographic location of each sporadic case

Enhance event-based surveillance, particularly for cluster reports

Apply risk assessment mechanism for proportionate response (including determination of potential sustained human-to-human cases and rapid containment)

Ensure timely field investigation including contact tracing, detailed history of travel and animal contact and rapid reporting in place for each suspected/probable and confirmed case

Laboratory Ensure timely laboratory diagnostics, shipping of specimens and reporting for surveillance occurring

Human-animal

interface/zoonoses Ensure Ministry of Health and Ministry of Agriculture are in communication regarding

surveillance for H7N9 in animals, particularly in locations surrounding with human cases

Based on the results of surveillance in animals and epidemiological investigations of human cases, decide about control strategies in consultation with the agriculture/animal authorities

Clinical

management and

infection

prevention and

control

Alert hospitals and community medical practitioners to symptoms, diagnosis, clinical management and IPC procedures

Ensure hospitals where cases have been detected have appropriate facilities and expertise in place

If case numbers indicate, consider policy and practice of triage at healthcare facilities

Public health

interventions and

emergency

preparedness

Consider activating event management system and event operations centre

Determine the status of oseltamivir and PPE stockpile and examine mechanisms for distribution, including pre-positioning once case numbers indicate the need

Investigate the status of vaccine preparedness and policies for vaccine distribution

Review preparedness and readiness for immediate response surge if level of risk were to change (EOC capability; response logistics capacity, business continuity plan).

Risk

communication Proactively provide accessible information on H7N9 to stakeholders and the public, e.g.

health prevention advice, talking points, FAQs, press releases of cases

Listen to the public and gather feedback through a systematic media monitoring and analysis of issues. Ensure a system for dealing with rumors and misinformation.

Report cases in a timely manner to WHO in alignment with IHR (2005).

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Scenario 3: Sustained human-to-human transmission of avian influenza A(H7N9) with or without

sporadic cases in country Key trigger points for the scenario:

Rapid risk assessment suggests or concludes that sustained human-to-human transmission of H7N9 is occurring in country.

Overarching strategy for the response:

Assess the feasibility of rapid containment and implement if feasible.

Reduce clinical attack rate

Reduce burden on health care facilities

Support and maintain business continuity.

Ensure timely and full reporting to WHO in line with IHR (2005).

Regularly reassess and communicate the public health risk of further human case H7N9

Regularly review preparedness and for a change in risk. Key technical areas Preparedness and Response measures for country

Surveillance, risk

assessment and

response

Adjust surveillance system appropriate to case number and time following reporting of sustained human-to human transmission including:

o Undertake time-limited enhanced ILI and SARI surveillance in country o Review case definition and testing strategy for understanding overall

number of cases o Normalize H7N9 surveillance into seasonal system already in place

Laboratory Review laboratory testing recommendations as more cases are reported (consider only testing a subset of suspected cases)

Ensure surge capacity in place to backup testing strategy

Human-animal

interface/zoonoses Continue sharing information between Ministry of Health and Ministry of

Agriculture regarding surveillance in animals and H7N9 cases in humans

Clinical management

and infection prevention

and control

Alert hospitals and community medical practitioners to symptoms, diagnosis, clinical management and IPC procedures

Ensure hospitals where cases have been detected have appropriate facilities and expertise in place (including surge capacity at peak times)

Put in place triage practice in healthcare facilities

Public health

interventions and

emergency

preparedness

Activate MOH EOC, institute event management system, prepare stockpile for deployment and/or deploy needed items, ensure sure capacity in place

Review and activate measures, including: provision of prophylaxis to targeted groups; school closure; mass gatherings; border control measures (entry and exit screening); quarantine and isolation measures; vaccine availability and distribution; and Business continuity guidelines.

Risk communication Proactively provide accessible information on H7N9 to stakeholders and the public, e.g. health prevention advice, talking points, FAQs, press releases of cases.

Listen to the public and gather feedback through a systematic media monitoring and analysis of issues. Ensure a system for dealing with rumours and misinformation.

Develop and disseminate evidence-based health messages for behavior change and community-level prevention.

Report cases in a timely manner to WHO in alignment with IHR (2005).