Preparedness of Pandemic Novel Influenza in Taiwan:

from strategy to operation

Yen , Muh-Yong

Taipei City Hospital, TaiwanInfection Control Society of Taiwan

Introduction

• The SARS epidemic of Taiwan in 2003

• 347 casualties.

• 70 % are nosocomial related.

• 30% are health care workers.

Traffic control bundle

• An integrated infection control strategic bundle which includes

– triage of patients into hospital – zones of risks– installation of alcohol dispensers at checkpoint

for glove-on hand rubbing.

- Yen MY, et al. JHI ,2006.2,62:2:195 -

Factors Protecting HCW from SARS nosocomial infection

• 31 H w/o & 19 H w/c HCW SARS

– Leadership (p<0.01)

– Fever screening stations (p<0.01)

– checkpoint alcohol dispensers

for glove-on hand rubbing

between zones of risk (p<0.001)

- Yen MY, et al. 8th IFIC, Budapest, 2007 -

HCWs elevator or stairways

Nurse StationHallways to patient rooms

Patient rooms

HCW entering patient room (follow the arrow)

HCWs wear N95 and enter nurse’s station

Checkpoint: hand washing

HCWs wear PPE and enter hallway

HCWs elevator or stairways

Nurse StationHallways to patient rooms

Patient rooms

HCW leaving the patient room (follow the arrow)

HCWs decon* before entering nurse’s station

* decon: decontamination using 0.5% bleach solutionClean zone

Intermediatezone

Contaminationzone

patient

ProcessesProcesses

control

MMMME

control control control

MMMME

Process＃ 1

Process＃ 2

Process＃ 3

LastProcess

Process＃ 4

MMMME

MMMME

structu

re

ou

tpu

t

Conceptual framework of Six Sigma

Nothing is particularly hard if you divide it into small jobs.  

- Henry Ford -

Six-Sigma, as the knowledge base of traffic control bundle.

process management in diffluent manner (time and space)

６

5

4

１

２

２

6

1

3

2

KEELUNG

TAIPEI

TAOYUAN

HSIN CHU

TAICHUNG

CHUNG HWA

TAINAN

KAOHSIUNG

PINTONG

CHIAYI

Nationwide educational and supporting

network for infection control

Communicable Disease Control Medical Network

Infection Control Network

• Compilation of infection control guidelines.

• Inspection of hospital infection control

• Educational and supporting system for quality improvement (outbreak).

• Surveillance of nosocomial infection (TNIS)

• Promotion of Hand Hygiene.

　 2005 2006 2007

Initial Inspection 　 　 　 No. of Hospitals Inspected 522 524 507

No. of Hospitals Failed 89 25 20

Passing Rate 82.95%95.23

%96.06%

Year-End Inspection

　 　 　

No. of Hospitals Inspected 535 521 507

No. of Hospitals Failed 39 7 3

Passing Rate 92.71%98.66

%99.41%

Inspection and audit for hospital infection control, Taiwan CDC

Communicable Disease Control Medical Network

• Combine medical and public health systems• 6 sub-network nationwide • Experts from Hospital, public health, infection control,

local health department, CDC• 25 responding hospitals as special isolation hospitals.• Medical director to streamline the commanding and

information flow with efficient communications.• Coordination for inter-city surge capacity, education

program and drill/exercise.

Process Management (time axis)

• Levels of alertness

• 0 preparedness

• A surveillance

• B containment

• C impact reduction

Process Management (time axis)

• 0 preparedness- surveillance- surge capacity- exercise/drills

• A surveillance• B containment• C impact reduction

正門中華路二段

廣州街

發燒篩檢站

Transforming schools into pre-designed ACS as part of

preparedness plan for pandemic H5N1 influenza. -Yen MY, J Formos Med Assoc,2008;107(9):673-676.-

AccessibilityAvailability

SafetyExpandability

Figure 1. blueprint of school transformed into alternative care site with traffic control bundle.

1. 2.

3. 4.

Screen station from community

Special Isolation Hospital

School as shelter

Task force of special isolation hospital groups

Surge capacity of staff

Mobilization and education/training of human resources

• Prompt response epidemiological team• Obligatory military services for decomtamination. • Volunteer Taxi Driver to support EMS

• Medical personnel

• Linking nurse

Process Management (time axis)

• Levels of alertness: WHO phase 4

• 0 preparedness

• A surveillance

• B containment

• C impact reduction

The Front-line checkpoint for surveillance

• Airport fever screening station

• Community surveillance ( GP, Rx, ER )TOCC– Travel history– Occupational/Contact history– Cluster

Strategy of Responsiveness in level A & B

• First case finding through active surveillance

• Containment

– Epi. Investigation & Contact tracing– quarantine, isolation and containment

Process Management : algorithm

• Levels of alertness

• 0 preparedness

• A surveillance

• B containment

• C harm reduction

HCW, HotelT

airport

CCO

Level B response

• Layered Containment of the affected area, – Hot zone– Warm zone– Prophylaxis with antiviral agent

• Increase social distance in cold zone– Schools and offices and subway off for 3-7 days– Cold zone: traffic control into 68 subdivisions

Updated: 2009/06/23

Identified so H1N1 influenza A

陽性 陰性 檢驗中 陽性 陰性 檢驗中701 13 688 0

661 48 613 0 89 0 88 1

臺大醫院 227 13 214 0 1 0 1 0

三軍總醫院 77 7 70 0 5 0 5 0

林口長庚醫院 197 22 175 0 8 0 8 0

中國醫藥學院 26 0 26 0 0 0 0 0

台中榮總 43 0 43 0 8 0 8 0

彰化基督教醫院 25 3 22 0 23 0 22 1

成大合約實驗室 26 1 25 0 4 0 4 0

高雄榮總 24 2 22 0 12 0 12 0

高雄醫學大學附設醫院 12 0 12 0 12 0 12 0

慈濟實驗室 4 0 4 0 16 0 16 0

尚未輸入 0 0 0 0 0 0 0 0

1362 61 1301 0 89 0 88 1總計

檢驗結果累計檢驗單位 累計 檢驗結果病毒監測(定點社區調查)

合約實驗室疾管局

H1N1新型流感調查病例Investigated Sentinel surveillance

(+) (-) (+) (-) (?)

The futility in close border

this futility, the economic consequences of at- tempts to close borders are therefore

likely to be of a very short duration

Lesson learnt in 2009

• Action plans against Influenza A H1N1 in early 2009 had also provided a platform to access and improve our current system in mitigation for future pandemic influenza.

Epidemic Command Center(central government)

Strategy, SOP

Sub-division of Communicable Disease Control Medical Network Branch office of CDC

Local Epidemic Command Center

Execution/ channel

Video conference, Telephone conference inter-city/ inter sub-network coordination

Chain of command & Risk communications

６5

4

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6

1

32

Hotel sealed off ?

the Ripple Effect

Risk analysis and stratification

• High risk– Close contactor with index case 2 M ， 1 h

• Middle risk– Exposure to flu s/s– w/o alc. hand disinfection

• Low risk– others

Mass gathering events

• Computex Taipei, Jun 2-6, 2009 • Deaflympics Taipei, Sep. 5-15, 2009

• Hotels and Institutes as checkpoint– Letters to the guest– Respiratory hygiene & cough etiquette – HH after cough/sneeze/ surfaces– Reporting and surveillance

Welcome to Grand Hyatt Taipei! It is a great pleasure to have you as our guest. We trust that your stay will be a comfortable and enjoyable one.

In view of the current H1N1 Influenza situation in some countries around the world, we would like to take this opportunity to bring you up-to-date on the following measures that we at Grand Hyatt Taipei have put in place:

Grand Hyatt Taipei has developed a preparedness plan for a possible H1N1 influenza pandemic and the relevant employees have received H1N1 training.

We are increasing the frequency of cleaning our public areas, including the washrooms, elevators, door handles, and other points of contact in high frequency areas.

We are in close communication with the Center for Disease Control in Taiwan and will implement further actions as per their recommendations and as required.

The well-being of our guests and employees is always of paramount concern to us. In order to protect your health and to avoid the possible spread of any viruses, we would also like to remind you of the following:

Face masks are available for your use. Please contact the Concierge at ext 1.Various alcohol-based cleanser dispensers have been placed at the hotel's entrances, the

elevator lift landings on each guest floor, the gymnasium and our restaurants. Please use the dispensers to clean and sanitise your hands before and after using the elevators or when you arrive and depart from the hotel, the gymnasium and the restaurants.

Should you feel ill and/or carry any flu symptoms i.e. fever, coughing, sore throat, runny nose, headache, muscle aches, diarrhea, etc, please contact our Assistant Manager on duty on ext. 0 or visit our clinic on level 5. Our team members will be able to assist you and make the necessary arrangements.

Your cooperation in this matter is highly appreciated. If there is anything else we can do to further enhance the comfort of your stay, please contact any one of us at your convenience.

Hotel Management Grand Hyatt Taipei July 2009

- Hotels as channels of surveillance and communications -

• Dear Deaflympics athletes and guests:

• Welcome to Taiwan for participating the 21st Summer Deaflympics Taipei 2009. • We would like to congratulate for the excellent performance in the days to come. • Regarding the global novel H1N1 influenza pandemic, we have taken the measures of

disease prevention for protecting your health:• Taipei City Government has been developed a preparedness plan for a possible novel

H1N1influenza pandemic. All relevant employees and staffs have received training for against H1N1 influenza and others communicable diseases.

• All of the Deaflympics venues and accommodations are increasing the frequency of cleaning and sanitizing public areas. Alcohol-based hand sanitizers are placed at all public area.

• The well-being of all athletes and guests is our highest concern. In order to protect your health, we would also like to ask for your full cooperation as following:

• If you experience flu-like symptoms such as fever, coughing, sore throat, runny nose, headache, muscle aches, diarrhea etc., please put on a gauze mask and contact with staff members immediately. Subsequently medical arrangements will be assisted.

• During the period of Deaflympics, facial masks are available upon request from our volunteers and staff members at the first aid of sporting venues and accommodations.

• When entering sporting venues, hotel lobbies, restaurant, café and other public areas or touching door handles etc., please be sure to use alcohol-based hand sanitizer for hand disinfection. Also please cover your nose and mouth when you cough or sneeze.

• We thank you for your cooperation with great earnestness.

SHEA June/10/2009

• NO

• NPIR

• N95

• Respiratory hygiene & cough etiquette (manner)

• HH after cough/sneeze/surfaces

Da-An sub-division population ： 42,978 Middle ages ： 70%

100 %80 %60 %40 %

接觸率 (Contact Rate)

說明：模擬疫情傳播至台北市，「大安區敦化次分區」實施檢疫隔離與減少聚集活動，模擬該分區的人群接觸率從 100% 減少至 40% 的疫情趨勢。

Class I notifiable disease down grade to Class IV

• Crisis Management

• Prediction / Mitigation

• Preparedness

• Response

• Recovery

Process Management : algorithm

• Levels of alertness

• 0 preparedness

• A surveillance

• B containment

• C Impact reduction

Medical surge - Impact Reduction

• maintaining social order and integrity of the healthcare system

• The concept of traffic control bundle has now been implemented in our design of medical surge for pandemic influenza preparedness.

• Triage patient into hospital:– outdoor screening station.

• Zone of risk – Clean Hospitals: traffic control– Contamination zones: special isolation hospital groups.

• Alcohol dispensers for hand disinfection at checkpoint

39

醫療體系之準備• 規劃病人分流轉診

– 提升藥物普及性引導輕症病患於地區醫療院接受診治– 整合傳染病防治醫療網、緊急醫療網及醫療院所診治重症病患

• 結合消防單位緊急救護量能• 運用分級檢傷及電腦資訊，掌握及調度加護病床

– 規劃隔離病房治療感染抗藥性病毒株病患• 強化臨床治療量能

– 公布臨床治療指引– 辦理醫療相關人員之教育訓練

• 基層開業醫師 ( 健保局、地方衛生局、醫師公會 )

• 消防人員 ( 地方衛生局 )

• 具一定規模之醫院自行辦理

16,000

Task force of special isolation hospital groups

General Hospitals / Medical Centers to preserve fundamental social security

6000

o eo rl ta m

expandable surge capacity

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北投區

士林區

內湖區

松山區

南港區

文山區

中正區萬華區

大同區

中山區

關渡醫院關渡國中 逸仙國小關渡國小 北投國中桃源國中

振興醫院士東國小 明德國中天母國小 文林國小明德國小

市立醫院 -陽明院區雨聲國小 芝山國小雨農國小 蘭雅國中福林國小

泰安醫院中山國中 中山國小五常國中 五常中學新興國小

台北市立聯合醫院和平院區龍山國中 忠義國小南門國中 建國中學老松國小

西園醫院華江高中 雙園國中雙園國小 萬華國中大理國小

國立台灣大學醫學院附設醫院（公館院區）和平高中 公館國小芳和國中 大安國小民族國中

象山院區松山家商 永春高中吳興國小 留公國中興雅國中

臺北市立萬芳醫院萬芳高中 景興國小興華國小 興福國中興隆國小

信義區

市立聯合醫院 -忠孝院區忠孝國中 松山國小福星國小 永吉國小日新國小

國軍松山醫院介壽國中 民生國小健康國小 民族國小西松國小

康寧醫院明湖國中 明湖國小東湖國中 東湖國小南湖國小

:醫院

:學校

大安區

Task forces of special isolation hospital

groups

Infection Control against H1N1 for General Hospitals

• In addition to strict infection control programs.

• Outdoor screening station– Cough, flu, fever, ILI, diarrhea, DOA

• Traffic control, wearing mask

• Detention ward, fever ward

• Checkpoint hand washing

•Latent Period (latency) – The time from initial infection until the start of infectiousness. •Incubation Period – The time from the initial infection until the onset of clinical symptoms. •Period of communicability – The period during which an individual is infectious and can spread to other hosts.

Detention, quarantine

HCWs elevator or stairways

Nurse StationHallways to patient rooms

Patient rooms

HCW entering patient room (follow the arrow)

HCWs wear N95 and enter nurse’s station

Checkpoint: hand washing

HCWs wear PPE and enter hallway

HCWs elevator or stairways

Nurse StationHallways to patient rooms

Patient rooms

HCW leaving the patient room (follow the arrow)

HCWs decon* before entering nurse’s station

* decon: decontamination using 0.5% bleach solutionClean zone

Intermediatezone

Contaminationzone

patient

Detention Ward

A moderate pandemic phase 6

• WHO considers the overall severity of the influenza pandemic to be moderate ?

• Mild - moderate - severe

• Moderate - aggressive – severe ?

0

30

60

90

120

'08/31 39 47 3 11 19 27 35 43 51 7 15 23

0

10

20

30

40B AH1 AH3 Novel H1N1 A untype Flu positive rate

Iso

late

s

Week received

Flu

Po

sit

ive

ra

te

46

Updated: 2009/08/05

Taiwan laboratory weekly reoprt on influenza virus activities

The latest 3 weeks:Flu Positive rate= 13% (11,16)Novel H1N1 ratio = 90% (80,96)

47

Updated: 2009/08/05

國內流感疫情監測 -- 輕症

• 急診與門診類流感就診率皆呈上升趨勢• 估算台灣一週 H1N1病例數約 4340例 - 等比級數

0

1

2

3

4

5

6

7

26 29 32 35 38 41 44 47 50 1 4 7 10 13 16 19 22 25

Consultation Week

0

6

12

18

24

30

36

422008/2009-OPD 2009/2010-OPD2008/2009-ER 2009/2010-ER

OP

D-C

on

sult

atio

n R

ate

(%)

10.07

0.96

ER

-Co

nsu

ltat

ion

Rat

e (%

)

48

Updated: 2009/08/05Number of complicated influenza reports by month of onset

7/1/2008 to present國內流感疫情監測 --重症

• 流感併發重症通報數自 7月起大幅上升

0

10

20

30

40

50

60

70

80

200808 9 10 11 12 200901 2 3 4 5 6 7 200908 9 10 11 12 201001 2 3 4 5 6 7

Onset month

Ca

se

nu

mb

er

confirmed case pendind caseexcluded case expected value for reported case expected value for confirmed case

Pandemic (H1N1) 2009 clusters

• Cumulative number since July 1, 2009 was 30.

• schools 17 (57%) • workshops 5 (17%) • military camps 3 (10%) • workplaces 1 ( 3%) • hospitals 1 ( 3%) • long-term care facilities 2 ( 7%) • imported 1 ( 3%)

防治策略

圍堵

減災延緩散播提早治療減少傷亡

境外阻絕

邊境管制

個人與家庭防護

社區防疫

醫療體系保全

•手部衛生•咳嗽禮節•生病在家•停班停課•大型集會

•感染控制•持續營運•轉診調度

•疫苗接種

51

風險溝通之準備• 針對 13 項目標族群，規劃溝通策略，開發衛教宣導品

一般民眾

醫事團體

基層村里長

各級學校

運動會外籍選

手立法委員

各部會

外國使節

外籍人士

媒體

企業

新移民

防疫人員

• 整備與擴充 24小時 1922 民眾諮詢專線• 適時民意調查，了解民眾需求• 定期發布新聞，加強媒體溝通• 必要時再次徵用媒體時段

52

Surge capacity, anti-viral agents

• Stockpile: 17% (4,183,000 people)• Tamiflu 2,214,000

• Relenza 969,000

• Raw material 八角酸 1,000,000

• Consumption 1500

• Supplied by national insurance 0815

– ILI + RAT

53

surge capacity, so H1N1 vaccination

• Adimmune Corporation, Kuo Kwang Biotechnology Company. Funding from DOH to build up a state-of-the-art cGMP level manufacturing plant for vaccine production and plasmid DNA contract manufacturing business.

• 11th country capable of manufacturing H1N1 vaccine– 10,000,000 doses

• Priority 規劃優先接種順序– 醫護人員為第一優先對象，懷孕婦女、 6 個月以上慢性病

患及各年齡層之健康人口納入。

學校 325

社區篩檢中心CIC

Community influenza (screening) center

Infection control of H1N1 in GP

• Hand hygiene, hand hygiene, hand hygiene. With 75 % alcohol.

• Surgical mask

• RAT screen ?

• Disinfection.

• Ventilation.

• Traffic control

Hoping for the best

Prepare for the worst

Thanks for Your Attentions