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					National Center for Disease
  Prevention and Control

  LUNINGNING E. VILLA, MD, MPH,
             DTM
             Medical Specialist IV
Program for Emerging Infectious Diseases
             Influenza: Seasonal, HPAI, Pandemic

                 Seasonal               Highly               Pandemic
                 Influenza            Pathogenic             Influenza
                                   Avian Influenza
             Influenza A (H3N2,    Pathogenic to
Etiology     H1N1)                 humans:               A new subtype
                                                         mutated H5N1
             Influenza B              H5N1, H7N7         capable of
                                                         human- to -human
                                                         transmission


Incubation
Period       2 to 3 days           3 days                        ?
             (range 1 to 7 days)   (range 2 to 4 days)
               Influenza: Seasonal, HPAI, Pandemic

                   Seasonal              Highly           Pandemic
                   Influenza           Pathogenic         Influenza
                                    Avian Influenza
               from persons                           from persons
Exposure       infected             infected birds    infected
               with the usual                         with a new virus
               circulating                            subtype
               subtype, strains
               may vary


               fever, respiratory   sustained fever   fever, respiratory
Clinical       signs                >380C             signs,
Manifestatio   and symptoms that    shortness of      severity to be
ns             may                  breath            determined
               or may not           dry, non-
               progress             productive
                                    cough, severe
                                    illness
                   Influenza: Seasonal, HPAI, Pandemic

                        Seasonal                  Highly                   Pandemic
                        Influenza               Pathogenic                 Influenza
                                             Avian Influenza

                   young children,
Who are at risk    persons                  children and adults     uncertain,

of complications   >50 y/o, persons with                            1918 pandemic- young,
                   co-morbidities e.g DM,                           otherwise healthy,
                   heart, lung, kidney                              working population
                   disease,                                         were affected
                   immunocompromised


Vaccine            yearly vaccine strains   none                    none


Treatment          supportive, antiviral    supportive, antiviral   antiviral agent, if the
                   agent within the         agent within the 1st    new subtype is not
                   1st 2 days               2 days, but shows       resistant
                                            resistance in some
    Human Public Health Implications
• High mortality of H5N1 to humans
•   Emergence of a new influenza virus with
    pandemic potential
     -Efficient human to human transmission
     -Vast majority of people have no immunity
     -No protective vaccine/ Inadequate
      quantity of developed vaccines for the
      world
     -High number of cases and deaths
      worldwide (pandemic)
Transmission to humans
• Close contact with infected birds
  and through aerosols, discharges
  and surfaces

• Virus is excreted in feces, which
  dries, pulverized and inhaled

• Flapping of wings hasten
  transmission
    Clinical Stages of AI in humans
                                                              Recovery
Exposure
                                                              in 30%
                                                              of cases


   Incubation    Prodromal Stage Lower Respiratory
   Period                            Stage


   3 days, range 0-1 days            1-7 days              Most
   2-4 days      high fever (above   early dyspnea         cases have
                 38 °C), cough and   crackles              died in spite
                 shortness of        rapid progress to     of ventilatory
                 Breath              respiratory           support after
                                     distress -            about 10
                                     respiratory failure   days
         The signs are alarming
A.   Avian influenza is endemic and probably ineradicable
     among poultry in Southeast Asia
B.   H5N1 spread at pandemic velocity amongst migratory
     birds, with the potential to reach most of the earth in
     the next year
C.   Humans and animals are mixing vessel for the virus.
•    1968-69 (most recent pandemic) : China population was 790
     million; today it is 1.3 billion the number of pigs in China was 5.2
     million; today it is 508 million, number of poultry 1968 was 12.3
     million, today it is 13 billion.
D.    Exponential multiplication of hot spots and silent
     reservoirs (as among infected but asymptomatic
     ducks)
E.   Increasing human H5N1 infections, small clusters of
     cases
F.   Rapid growth in foreign travel
  Stages of Avian and Pandemic
          Preparedness
Stage 1: Avian influenza-free   Philippines

Stage 2: Avian influenza in domestic fowl in
     the Philippines

Stage 3: Avian influenza from poultry to
     humans in the Philippines

Stage 4 - Human-to-human transmission
     (pandemic influenza) in the country
            Strategic Approaches
                               • Use of antiviral agents
                               • Infection control
                               • Quarantine of contacts




• Import ban       • Early recognition/
• Border control     reporting              •   Passenger entry-exit
• Wildlife Act     • Proper handling            management
                     of birds               •   Border control
• Early            • Protective gear        •   Quarantine of
  recognition/     • Management of              contacts
  reporting          public panic           •   Isolation
• Mass culling,                             •   Management of cases
                                            •   Social distancing
• Quarantine of                             •   Personal hygiene
  affected area                             •   Management of
• Management of                                 public panic
  public panic
Stage 1: Keeping the Philippines Bird Flu Free
             Prevention of entry of the virus:

  •   Ban of all poultry and poultry products
      from AI-infected countries
  •   Border control
  •   Ban on sale, keeping in captivity of wild
      birds
  •   Biosecurity measures
  •   Standardized footbath
  •   Confiscation and destruction of unlicensed
      cargo
  •   Surveillance of Poultry in Critical Areas
  •   Influenza vaccination for all poultry
      workers, handlers
STAGE 2: Avian Influenza in Domestic Fowl
            in the Philippines

     Individuals at risk

        Poultry handlers/workers
        Sellers/ people in live chicken
         sale
        Aviary workers/ Ornithologists
        Cullers
        People living near poultry farms
        Any individual in close contact
         with infected birds
STAGE 2: Avian Influenza in Domestic Fowl
            in the Philippines
   •   Prevention of spread from birds-to birds:
       early recognition and reporting, mass
       culling, quarantine of affected area

   •   Prevention of spread from birds to
       humans: human protection through
       proper handling of infected birds, use of
       protective gear by residents, poultry
       handlers, and response teams
STAGE 2: Avian Influenza in Domestic
      Fowl in the Philippines
 Community Response to sick or dead birds

 •   Protection of exposed residents – gloves/ plastic material in
     handling sick or dead birds, hand washing

 •   Personal protective equipment for cullers – caps, masks,
     goggles, gowns

 •   Identification of exposed individuals and quarantine for 7 days

 •   Reporting to the Barangay Health Emergency Response Team/
     local health officer
STAGE 3- Avian Influenza in Humans
 Community response
 •   Patient: face mask, in a separate area or at least 1
     meter distance from other people

 •   Protection of caregiver : face mask and goggles or
     eye glasses, hand washing, self-monitoring for
     signs and symptoms
 •   Immediate transfer to the Referral Hospital
 •   Protection of the transporting team and disinfection
     of vehicle
 •   Monitoring of contacts of the case
Referral of Avian Influenza Cases
  A. Satellite Referral Hospitals –
  Regional Hospitals/ Medical Centers of 16
    Regions

  B. Sub-national Referral Centers
  San Lazaro Hospital
  Lung Center of the Philippines
  Vicente Sotto Memorial Medical Center
  Davao Medical Center

  C. National Referral Hospital
  Research Institute for Tropical Medicine
             Influenza Pandemics in 20th Century




Credit: US National Museum of Health and
Medicine

   1918: “Spanish Flu”                     1957: “Asian Flu”   1968: “Hong Kong Flu”
                                               1-4 million          1-4 million
     20-40 million deaths,                   deaths, infants          deaths
          20-50 y/o,                          and children
           A(H1N1)                             A(H2N2)               A(H3N2)
         Cytokine storm                                         Recombination of human
         Avian source                                          and avian influenza viruses
STAGE 4: Human-to-human Transmission of
     Influenza (pandemic influenza)
    WHO announcement of pandemic
    influenza from other countries, clusters or increased
    number of sick passengers:

 • SARS-Influenza Alert System for Airports and Seaport
 • Detection of symptomatic cases in airports and
   seaports- thermal screening, health declaration
 • Quarantine of arrivals for 7 days from affected
   countries in communities
 • Isolation of cases

 •Of limited use because of the contagiousness of the
  patient during the symptom-free stage
Coping with increased demand for health
             services and goods
 Primary care

    • manpower augmentation
    • antipyretics, analgesics, liniments and
      antibiotics

   Secondary care

    •   Shortage of beds, equipment and supplies
    •   Only serious and urgent cases will be admitted
    •   Back-up / buddy system
    •   Supplies of relevant drugs (e.g. antibiotics) and
        equipment (e.g. Ventilator)
    Maintaining essential services
In an explosive spread, efforts and
resources will be shifted to maintenance
 of essential services
  Persons providing
  • Emergency and disaster response
  • Maintenance of peace and order
  • Transportation, including air traffic controllers
  • Utilities – water, electricity

• Arrange ahead places of duties and schedule to
  cover the required duties during the pandemic
• Back up
                       Oseltamivir
  For avian influenza
• Procured through WHO : Oseltamivir (Tamiflu) – P1.7 M
  700 bottles suspension - PhP 0.7M &10,000 capsules for 1000 cases
  PhP 1 M

   For pandemic influenza
   For Procurement ( Funds to be sourced out)
   • 100,000 capsules for 10,000 treatment courses = PhP 10 million
   • for treatment of patients in areas with initial outbreaks of pandemic
     influenza, to contain the infection/prevent spread

   Estimated cost requirement of Oseltamivir:
   2% of population (2% attack rate) – 1.7 Million cases x 10
   capsules/case
   17 Million capsules will be needed x P100/ capsule - PhP 1.7 Billion

   • efficacy is uncertain, in short supply,
   • decision on who should be given priority

   Possible sources of antiviral agents:
   1. International stockpile – yet to be established
   2. Business sector to buy antiviral agents for their own employees,
    Slowing the spread of infection
Personal hygiene – cough etiquette, handwashing
Social Distancing
•   Quarantine of persons/ areas
•   Reduction of unnecessary travel
•   Staying at home when sick
•   Isolation at home (separate room)
•   Closure of schools
•   Suspension of public events
•   Closure or limitation of people in public places or
    establishments
          Challenges in an Influenza Pandemic:
           Management of public panic
•   Pre-pandemic prepared IEC materials
      • Communication links at both national and
      local level
        - telephone lines, internet
      • Public advisories, IEC materials, press
      briefing,
        hotlines, designated spokesperson,
      • Regular information to doctors at all levels -
      Speakers’ Bureau
      health
        updates
       •Linkages with the media at the national and
                          local level
                  Accomplishments
               January 2005– 17 October 2005
Organization
•   Creation of a Management Committee on Prevention and
    Control of Emerging and Re-emerging Infectious Diseases
    (DOHMC– PCEREID)
•   National AI Task Force for Avian Influenza Protection
    Program (NATF-AIPP)
•   Formulated structure for Regional and Local TF-AIPP

Planning and Policy/ Technical Guidelines Development
•   Preparedness and Response Plan for    Avian and Pandemic
    Influenza

Orientation on Avian Influenza and Pandemic Influenza
  Preparedness
•   Regional Directors and Chiefs of Hospitals in the National
    Staff Meeting
•   Regional Coordinators and Epidemiology and Surveillance
    Units
•   Rural Health Midwives -600 RHMs in Olongapo City
Training
•   NCR Hospitals (Infection Control c/o NCHFD)
•   Planning with UP-CPH for Training on Risk Communication
                   Accomplishments
               January 2005– 17 October 2005
Advocacy
Legislators -Committee on Health, Lower House, Senator Pia Cayetano
Cabinet meeting, National Anti-Poverty Commission ,
National Disaster Coordinating Council
Medical specialty organizations
      - PPS, PSMID, PIDSP
Diplomatic Corps
American Chamber of Commerce
Asian Development Bank


Public information
Regional Summits (Joint DOH-DA activity)–6 regions –Regions 3, 4, 9,
10, 11 and Palawan
Development of IEC Materials – Target audience-based, Cough etiquette,
proper handwashing
Quadri-media including DOH website for bird flu
Lectures
DFA, Management Association of the Philippines,

Resource Mobilization
Request to PCSO
Request to PS-DBM for PPE (P8.5M)
Procurement through WHO: 700 bottles of suspension, 10,000 capsules
of Oseltamivir
                       Next Steps
Organization
• Planning Sessions/ Mobilization of DOH-Management
  Committee for PCEREID
• Monitor Organization of Regional and Local TF-AIPP
• Identification of Team Leaders for each critical area

Planning and Policy/ Technical Guidelines Development

•   Assist LGUs and other sectors in Preparedness and Response
    Planning for Avian and Pandemic Influenza
     - LGUs, Hospitals, DepEd and other agencies, Business sector

•   More Guidelines
    - Hospital Operations, Field Operations

Orientation/ Training on Avian Influenza and Pandemic Influenza
   Preparedness
• Speakers’ Bureau
• Technical training -Provincial, City and Municipal Health/
   Veterinary Officers and Private practitioners
• Joint Agriculture-Health Officers Training with the Poultry
   industry
                   Next steps
Training
•   Infection Control (NCHFD)- Other regions – Hospital Staff
    (Luzon, Visayas and Mindanao (need for P600,000)
•   Training on Risk Communication (1st training- December,
    ‘05)
•   Orientation of the Health Emergency Management Staff
    (December ‘05)

Advocacy
•   Updating of NDCC, Cabinet
•   Medical Specialties

Information Dissemination
•   Local Summits – November 2005, with DA, DILG, poultry
    industry
•   Reproduction of IEC Materials – Target audience,
       Cough etiquette, proper handwashing
•   Improvement of DOH website for bird flu (ADB Consultant
    for 1 month)
•   Lectures - Other specialties
             Next steps

Resource Mobilization
• Follow up request to PCSO (?)
• Follow up request to PS-DBM for PPE (P8.5M)
• Procurement of additional 100,000 capsules of
  Oseltamivir for 10,000 treatments (to source
  out P8.5M)
• Partnerships
  - for Health Promotion – Infomercials
  - Oseltamivir Stockpiling
  - PPE Stockpiling
  - Training
The SARS experience and the influenza
             pandemic
•SARS: "The relatively high case-fatality rate, the
identification of super-spreaders, the newness of the
disease, the speed of its global spread, and public
uncertainty about the ability to control its spread may
have contributed to the public's alarm. This alarm, in
turn, may have led to the behavior that exacerbated
the economic blows to the travel and tourism
industries of the countries with the highest number of
cases.“
•Economic impact of the six-month SARS
epidemic:
    Asia-Pacific region at about $40 billion.
    Canadian tourism- $419 million.
    Ontario health-care system -$763 million,
    Flights in the Asia-Pacific area decreased by 45 %
from
    the year before, the number of flights between
Hong Kong
How should the business sector prepare?
 • Schedule of duties with back-up
 • Buddy system
 • Raw materials – alternate sources, stockpile
 • Infection control in the workplace- cough
   manners, hand washing, provide facilities
 • Guidelines on reporting to work – staying at
   home when sick
          How can the business sector be
            of help to the government?
Pre-pandemic:
• Support for information dissemination
• Identify/ share resources – tents, diagnostics
  supplies and equipment
• Support for surveillance – diagnostics, reporting
  network, communication
Pandemic period:
• Augment resources – manpower, drugs and other
  supplies
• Communications

• AND MORE…..

				
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