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, Speakers’ Bureau • Regular information to doctors at all levels -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 and the United States fell 69 % 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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