Human Health Issues related to Avian Influenza in Canada

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Appendix I: Sample Letter for Physicians seeing Contacts of Avian Influenza Virus

Dear Doctor,

This patient is presenting because of possible exposure to avian influenza for one of three reasons: (1) to receive influenza vaccine pre-exposure; (2) to receive a prescription for prophylaxis with an antiviral drug during exposure or (3) for testing and treatment because of flu-like symptoms that have developed following exposure. The information below may assist you in managing this patient appropriately. For more information or if you have any questions, please contact the local health unit.

I. Vaccination to Prevent Illness Pre-Exposure

All poultry workers who will be exposed to live or dead avian influenza infected birds, bird products, secretions or contaminated surfaces should receive the current season's influenza vaccine at no charge to them and as early as possible before exposure (preferably, at least two weeks prior). If exposure has already occurred, vaccination is still encouraged in order to protect against future re-exposures.

Such vaccination will not protect the worker from avian influenza but will help guard against genetic reassortment between avian influenza and human influenza virus strains as a result of dual infection. This is an important public health measure to guard against introduction of novel subtypes of influenza viruses into the human population and to help avert potential pandemics. Please provide this vaccine from the publicly funded supply of influenza vaccine to patients presenting with this letter who have not already been vaccinated this season. If vaccine is unavailable in your office, please arrange for provision via the local health unit. Again, this vaccine should be provided at no charge to the patient.

II. Prophylaxis to Prevent Illness During Exposure

Antiviral prophylaxis to prevent illness during exposure is recommended for all workers. This should be taken daily during exposure and for seven days after last exposure with living or dead avian influenza infected poultry, products, secretions or contaminated surfaces. A neuraminidase inhibitor (Oseltamivir) is the first choice since the likelihood is smaller that the virus will be resistant to this class of antiviral drugs than to amantadine.

Review contraindications with the patient and if appropriate, provide a prescription for Oseltamivir for this patient. If you have concerns, consult with the local Medical Health Officer. Oseltamivir is available in limited quantities for purchase from a local pharmacy. During this outbreak, it is also available free of charge from the local health unit for poultry workers when accompanied by a doctor's prescription and this letter.

The recommended dose of Oseltamivir for anti-influenza prophylaxis is 75 mg once daily for the period of exposure and for seven days after the last exposure.

III. Testing and Treatment Post-Exposure if Symptoms Develop

If the patient is presenting with fever, respiratory symptoms, conjunctivitis or other influenza-like illness with onset within 10 days of last exposure to live or dead avian influenza infected poultry, products, secretions or contaminated surfaces, please do the following:

1. Take personal protective measures including respiratory precautions when handling the patient (isolation, mask, gloves, handwashing).

2. Notify the local Medical Health Officer immediately.

3. In consultation with the local Medical Health Officer, obtain appropriate specimens (nasal, nasopharyngeal, conjunctival swabs) in a virus specimen collection kit as well as a clotted blood specimen for acute serology followed by a second blood specimen at least two weeks later for convalescent serology.

4. Review contraindications and if appropriate, prescribe treatment. Treatment with anti-influenza drugs is most effective if given within 48 hours of onset, but more delayed treatment may be considered if the patient presents late, in consultation with the health unit. A neuraminidase inhibitor (Oseltamivir) is the first choice.

5. Dosage for treatment with Oseltamivir is: 75 mg bid for five days.

6. Oseltamivir is available in limited quantities for purchase from a local pharmacy . During this outbreak, it is also available free of charge from the local health unit for poultry workers. The worker must have a doctor's prescription and should bring this letter with him/her.

Please keep a copy of this letter on file and ensure the patient also retains a copy.

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