Friday, April 24, 2009

Severe Respiratory Illness (SRI) Advisory Date: April 21, 2009

[Full PDF Document at this LINK. EDITED.]

From the office of the Medical Officer of Health

SRI Context:

The Public Health Agency of Canada (PHAC) has advised us of two recent situations of severe respiratory illness that remind us of the need for ongoing SRI surveillance and response. The first is in south and central Mexico where clusters of severe respiratory illness are occurring, with a high case fatality rate.

Individuals primarily affected are healthy young adults 25-44 years of age, including some HCWs.

Some cases have tested positive for influenza A and B.

The second situation involves the detection of two unrelated cases of swine influenza A (H1N1) in children in California – the cases have recovered and did not require hospitalization. Human cases of avian H5N1 influenza continue to occur in Egypt, China and Vietnam (25 to date in 2009).

We are being asked by PHAC and Alberta Health & Wellness to continue to carry out surveillance for SRI as outlined below.

Phase Level: No Change
Pandemic Phase 3, SRI Phase 0

SRI Case Definition:
• Respiratory symptoms including history of fever >38°C and new onset of cough or breathing difficulty, with severe illness progression (pneumonia, acute respiratory distress syndrome (ARDS), encephalitis or other severe and life-threatening complications) and no alternate diagnosis within the first 72 hours of hospitalization;
• A positive response to one of the following questions:
o “Did you travel outside of Canada in the past 10 days?” OR
o “Do you live with or were you in close contact with someone who has a similar illness and who traveled outside of Canada in the 10 days before he/she became sick?”

Reporting Requirements: No Change
Emergency Departments, acute care facilities, urgent care centres – Please report all suspect SRI cases to the Medical Officer of Health on Call at (403)264-5615 for further investigation and management.

Laboratory Rule-Out/Rule-In Tests: No Change
Notify receiving laboratory and arrange urgent transport of specimens, marking them as high priority with positive travel history. Copy all results to the Medical Officer of Health by fax (403)955-6755.
• NP Swab (Aspirate): Order Respiratory Virus Panel (DFA, NAT) on ProvLab requisition. Send in M5 Viral Transport medium (pink) that is stored at room temperature.
• Blood: Order Aerobic/Anaerobic Culture on CLS requisition. Order Mycoplasma IgM (collected in SST tube) on ProvLab requisition.
• Sputum: Order Gram Stain, Aerobic Culture on CLS requisition; order AFB (if indicated), Legionella on ProvLab requisition.
• BAL (if clinically indicated): Order Gram stain, micro C&S on CLS requisition; order AFB (if indicated), Legionella culture, Respiratory Virus Panel (DFA, NAT), CMV and HSV culture on ProvLab requisition.

Infection Control Recommendations: No Change
EMS Setting: Droplet and Contact Precautions
Acute Care Facility Setting: Droplet and Contact Precautions
For patients presenting with fever and cough:
• Advise to: cover mouth and nose when coughing or sneezing; do frequent hand hygiene; stay 1 metre distant from others in waiting room (or isolate in private room); wear surgical/procedure mask if isolation not possible
For patients with fever/cough and more severe respiratory symptoms (e.g., shortness of breath), ask about:
• travel outside Canada within the last 10 days, or
• contact within last 10 days with a person with a similar illness who had traveled outside of Canada in the 10 days before they became ill.
If Yes to either question:
• Isolate immediately - negative pressure isolation is not required. If unable to isolate immediately, ask patient to wear a procedure/surgical mask and to minimize contact with others by staying 1 metre (3 feet) away from them.
• In addition to standard practice, staff in direct contact with the patient should don appropriate Personal Protective Equipment (PPE) for organisms spread by droplet and contact:
• Gloves, gowns, mask. [Procedure/surgical masks are considered adequate for routine care. N95 respirators should be used by staff for aerosol-producing procedures (e.g., intubation, bronchoscopy)].
• Hand hygiene must be done before and after use of gloves.
• Eye protection should be worn as standard practice to prevent exposure to respiratory droplets.

Additional References:
• Public Health Agency of Canada Travel Advisories:
• Nasopharyngeal Swab Collection: (videos on how to collect these specimens are available at Information sheet is at
hat-tip ironorehopper

1 comment:

Anonymous said...

Obviously, the diagnosis of impending swine flu hinges on the integrity of the sample obtained. A nasopharyngeal aspiration is far superior to swab in volume and quality, and yet I am amazed at how little encouragement there is by labs and even CDC to obtain this type of specimen. Makeshift techniques of aspiration is likely the reason as it has traditionally been uncomfortable to be on the receiving end. A new NP aspiration kit is out called NPak! With the use of NPak it is actually more comfortable for the patient and gives a better specimen than a NP swab ( In actual practice, rarely, do most healthcare workers get to the nasopharynx to get a true NP swab therefor resulting in a nasal swab with lower sensitivities. If were are going to go through the hassle of obtaining a specimen, we must encourage all to do the right thing--get a NP aspiration!

Kurtis Waters MD