Special Focus on H1N1

Novel A (H1N1) Cases and contacts management in 18 countries in Europe, during the containment phase (as of 15/05/09)
Collated by Sandra Cohuet (Epiet Cohort 12, INVS, France) and Chris Williams (Epiet Cohort 11, HPA, UK) with information sent by EAN Members and Epidemiologists across the World

Europe
A review of information regarding influenza A(H1N1) the management of cases and their contacts was performed with data available as of 15 May 2009. Cases and contacts policies were documented for 13 European countries: Cyprus, Italy, Finland, Spain, Germany, United Kingdom, Sweden, Norway, Denmark, Netherlands, Ireland, Portugal, and France) (table 1 in attachment).

Case definitions
Two groups of countries could be defined:

1. A group which classifies a case as probable with a positive PCR Flu A only: France.
2. A group which classifies a case as probable with a PCR positive Flu A non-typable (or not "seasonal influenza"), corresponding to EU recommendations: Cyprus, Denmark, Germany, Finland, Ireland, Norway, Portugal, Spain, Sweden and United Kingdom (UK).

There is no major difference in terms of definition of suspect or confirmed between these two groups of countries (Table 1).

Curative treatment and isolation of cases
The management of cases is quite heterogeneous in the 13 documented countries. Countries can be classified in 4 groups ordered by decreasing order in terms of contingency measures (Table 1).

1. Treatment with oseltamivir and systematic hospitalisation of suspect cases: France and Cyprus
2. Treatment with oseltamivir and home quarantine of suspect cases (6 countries):
   Switzerland, Italy, Finland, Spain, Germany, and Norway.
3. Treatment with oseltamivir and self-isolation for suspected cases, hospitalisation of severe cases only: Ireland, UK.
4. Treatment of probable cases by oseltamivir, home quarantine for probable cases and hospitalisation for severe cases only: Netherlands, Denmark.

Isolation and prophylactic treatment of contacts
The management of contacts of cases was very heterogeneous in countries documented. The management ranged from the treatment and compulsory home quarantine for contacts of suspect cases to treatment decided on a case by case basis tailored on individual risk factors of complications for contact persons (table 1).

1. Prophylactic treatment of contacts of suspect cases and home quarantine for contacts: Spain, Portugal
2. Prophylactic treatment for contacts of probable cases and home quarantine for contacts of suspect cases: France, Ireland
3. Prophylactic treatment for contacts of probable cases and home quarantine of probable cases: Denmark
4. Prophylactic treatment for contacts of probable cases and no home quarantine: United Kingdom
5. Prophylactic treatment for contacts of confirmed cases and no home quarantine: Netherlands
6. No prophylactic treatment for contacts and home quarantine for contact of confirmed cases: Switzerland
7. Prophylactic treatment for contacts only if people at risk of complications: Finland and Norway

The implementation of the public health response has also varied. In the UK, regional flu centres assess cases and advise on testing, treatment, isolation and other public health measures such as school closures. In Germany, H1N1 field teams have been deployed to investigate clusters of infection (see below the contribution by Helen Bernard).

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Response to H1N1 from WHO Euro
By Sabrina Bacci (Epiet Fellow Cohort 13, SSI, Denmark)
After building capacity at WHO, Sabrina wins the swine flu

One of the most wanted activities during our two year fellowship really seem to be the “mythical” international missions. For sure one of the main drives is the fact that you are able to keep your regular job while being able to visit and work in exotic places for a limited amount of time. Well, now back to my story. What is more exotic than Denmark for an Italian? Not many countries. Yes, I have been living in Copenhagen for a year and a half now, but is that enough not to think that Denmark is exotic? I do not think so. So when Roberta Andraghetti from WHO Regional Office for Europe requested support from the EPIET network I could not be more convinced that that was “the” mission I was waiting for. Everything became even more colourful when Roberta, another Italian, called me, and following our little conversation (in Italian, of course) we made arrangements for our first meeting. The Italians are everywhere around the World, but I don’t think that there are many in Copenhagen. The mission was therefore becoming even more interesting and the most exotic combination you could think of: having an Italian as a boss, in Denmark, and be at the same time on “an international mission”.
Besides that, I am not sure if you are aware of the fact that holidays in Denmark are concentrated in the month of May (3 long weekends over 5 weeks is quite interesting): apparently this is due to fact that it is much more exciting to enjoy a day of holiday outside in the nature during spring rather than a cold grey day at home (which would be the case of all other months). So can you imagine my enthusiasm when I realized I was going to skip these long weekends to work.
At WHO Copenhagen Danish holidays do not seem to exist. Amazing. This is what I was looking for: enjoy a nice spring day – one of the few – in the office. I am not going to tell you on how WHO responded to the emergency, I am sure you can have your own idea which you have build up working (directly or indirectly) with the pandemic in your own country. What I would like to share with you is my personal experience and the things, which impressed me most. I am probably banal, but I think after a few years working in “science” it was quite a change to be exposed to a different language, not so scientific, but more political correct, and to be honest, much more understandable by the crowds. I never thought about it, and believe me, I was not able at all to be proficient in a new way of writing/speaking after such a short time (of course!).
But the most interesting experience was for me dealing with the mysterious Pivot Tables. Me, the STATA expert? Yes, indeed. In my pre WHO-life I always refused to make any type of calculation with excel, yet I had to do an international mission to be faced with the fact that not everybody has Stata in his computer or even the time to think about some nice command, the perfectionism of data management, or my favourite activity, labelling variables so that you see a word and Stata reads it as a number. So here we go, next moment I find myself performing an analysis on the European cases of Influenza A H1N1 as fast as possible, learning new features, and finally mastering Pivot Tables, but most interesting, combining as much information from different countries (different variables, different codings, and different languages). What I learned is that ideally, the information should arrive to WHO in a standardized form and ideally in English (at least for me, who do not speak Russian). In reality it arrives in different forms, from emails of a couple of lines to “official case report forms of 7 pages” and the challenge is really to make the best use of as much information as possible in the most optimal way in a reasonable amount of time. Take home message: you can live without odds ratio if you struggle to have basic numbers.
Another point I could really appreciate is how difficult is to make statements, give suggestions that are valid for any country, from Tajikistan to the very rich Scandinavian countries, to the countries of the African Region. You could get a headache fairly easy just by thinking about that. And for sure I got more than one when we were discussing in one of the many conference calls with the 6 WHO Regions the forecoming Pandemic Surveillance Plan.
I was working with Roberta and Mårten (cohort 10) only for 3 weeks but I learned a lot, and most of the things cannot really be put down in words. I can just thank them for having welcomed me and found the time to explain me things in what were probably the busiest weeks since a very long time.
Oops: I realized it’s late: I have to prepare a lecture for the nurses I was asked to give some time ago - I have decided to teach them how to make Pivot Tables and to use basic information. Keep it simple. Thanks Roberta!

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‘As long as it’s not the swine flu...!’
By Helen Bernard (PAE Cohort 12, RKI, Germany) Germany
Many epidemiologists working at national public health institutes in Europe these days know what it means to be busy with H1N1 night and day. Since the Novel Influenza A(H1N1) virus, the S-OIV, the swine flu, the piggy flu and the Mexico flu became an issue in April, the Robert Koch Institute (RKI) has run an emergency operations centre and has sent 14 outbreak investigation teams* to the regions so far to investigate confirmed cases and their household contacts. After a briefing on the study protocol and on how to use the personal protective equipment, formation of the field teams and start of the mission usually take place at very short notice.
Dirk Werber (cohort 10), Michaela Spackova (cohort 13), Julia Hermes (cohort 14), and me (cohort 12) investigated a cluster of eight H1N1 case households. We visited cases at their homes to take serum and nasal wash samples from them and their close contacts. While the serum is only taken once during the investigation, the nasal washing procedure is being repeated for several days. The sampling procedure requires the patient to say ‘kakakakakakakaka’ while the saline solution is injected in the nose to prevent it from running down their throat, making them cough and aerosolizing the whole sample including the bug. Needless to say that after one day of non-stop nasal washing while wearing silly-looking protective equipment the ‘kakakakakakakaka’ sound had entered our dreams. The challenge for the field teams is not only to quickly become confident using the protective gear, doing the sampling, and coordinating the visits to the different households that are spread across the region, but also to juggle with political sensitivities (Germany is a federal state and the decisions regarding public health issues lie with the governments of the Bundesländer) and to learn to trade-off between theoretical and applied infectious disease control.
One of the main challenges when visiting case households in rural areas is to avoid attracting the fellow residents’ attention. Already during the short time period that has passed since H1N1 hit the stage, some case families were being shunned by their fellow residents and were asked to leave the village. While in some of the rural regions being a case household member does not seem to be easy, in others people’s attitude towards the swine flu is still more laid-back. So was the postman in one of the villages we visited who was just about to deliver mail to one of the case contacts sitting in front of her house having breakfast when she exclaimed: ‘Don’t get too close to me, I am ill!’. The postman replied: ‘Oh well, as long as it’s not the swine flu…!’, and delivered the mail.
The New Influenza A(H1N1) will probably keep us busy for a while. In the meantime, more outbreak team members will get the chance to discover a lot more of the country in which they are working and living than they would have discovered without the pandemic, including regional differences in food, language, habits, and landscape.
*Apart from those mentioned in the text, the following current and past EPIET fellows were involved in the field teams: Doris Radun (cohort 7), Andreas Gilsdorf, Andreas Jansen (both cohort 10), Daniel Sagebiel (cohort 11), Stefan Brockmann, Mirko Faber, Oscar Kamga Wambo, Sabine Mall, Maria Wadl (all cohort 13), Steffen Geis, Alexandra Hofmann, Niels Kleinkauf, and Stine Nielsen (all cohort 14).