National Center for Disease Prevention and Control

LUNINGNING E. VILLA, MD, MPH, DTM

Medical Specialist IVProgram for Emerging Infectious Diseases

Influenza: Seasonal, HPAI, Pandemic

 

Seasonal Influenza

Highly Pathogenic

Pandemic Influenza

   Avian

Influenza  

Etiology Influenza A (H3N2, H1N1)

Pathogenic to humans: A new subtype

  Influenza B H5N1, H7N7 mutated H5N1 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 Influenza

Highly Pathogenic

Pandemic Influenza

   Avian

Influenza  

Exposurefrom persons infected infected birds

from persons infected

 with the usual circulating  

with a new virus subtype

 subtype, strains may vary  

       

Clinical

fever, respiratory signs

sustained fever >380C

fever, respiratory signs,

Manifestations

and symptoms that may

shortness of breath

severity to be determined

  or may not progress

dry, non-productive  

   cough, severe illness  

 

Seasonal Influenza

Highly Pathogenic

Pandemic Influenza

    Avian Influenza  

Who are at risk

young children, 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  

Influenza: Seasonal, HPAI, Pandemic

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

0-1 days high fever (above 38 °C), cough and shortness ofBreath

1-7 daysearly dyspnea crackles rapid progress to respiratorydistress - respiratory failure

Incubation Period

Prodromal Stage

Lower Respiratory Stage

Recovery in 30% of cases

Mostcases have died in spite of ventilatory support after about 10 days

Exposure

Clinical Stages of AI in humans

3 days, range 2-4 days

The signs are alarmingA. 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

• Import ban

• Border control

• Wildlife Act

• Early recognition/ reporting

• Mass culling,

• Quarantine of affected area

• Management of public panic

• Early recognition/ reporting • Proper handling of birds• Protective gear• Management of public panic

• Use of antiviral agents• Infection control• Quarantine of contacts

• Passenger entry-exit management • Border control• Quarantine of contacts• Isolation• Management of cases• Social distancing• Personal hygiene• Management of public panic

Strategic Approaches

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 HospitalLung Center of the Philippines Vicente Sotto Memorial Medical CenterDavao Medical Center

C. National Referral HospitalResearch Institute for Tropical

Medicine

Influenza Pandemics in 20Influenza Pandemics in 20thth Century Century

1968: “Hong Kong Flu”

A(H1N1) A(H2N2) A(H3N2)

1918: “Spanish Flu” 1957: “Asian Flu”

20-40 million deaths, 20-50 y/o,

1-4 million deaths, infants

and children

1-4 million deaths

Credit: US National Museum of Health and Medicine

Recombination of human and avian influenza virusesAvian source

Cytokine storm

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

• manpower augmentation • antipyretics, analgesics, liniments and

antibiotics

• 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)

Secondary care

Primary care

Maintaining essential services

Persons providing • Emergency and disaster response• Maintenance of peace and order• Transportation, including air traffic controllers• Utilities – water, electricity

In an explosive spread, efforts and resources will be shifted to maintenance of essential services

• 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 influenzaFor 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, may organize themselves for bulk procurement

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

• Regular information to doctors at all levels -health updates

•Linkages with the media at the national and local level

• Public advisories, IEC materials, press briefing, hotlines, designated spokesperson, Speakers’ Bureau

AccomplishmentsJanuary 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 CityTraining• NCR Hospitals (Infection Control c/o NCHFD) • Planning with UP-CPH for Training on Risk Communication

AccomplishmentsJanuary 2005– 17 October 2005

Advocacy Legislators -Committee on Health, Lower House, Senator Pia CayetanoCabinet meeting, National Anti-Poverty Commission , National Disaster Coordinating CouncilMedical specialty organizations - PPS, PSMID, PIDSP Diplomatic Corps American Chamber of Commerce Asian Development Bank

Public informationRegional 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 MobilizationRequest to PCSORequest to PS-DBM for PPE (P8.5M)Procurement through WHO: 700 bottles of suspension, 10,000 capsules of Oseltamivir

Next StepsOrganization• 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, communicationPandemic period:• Augment resources – manpower, drugs and other

supplies • Communications

• AND MORE…..