Hospital Preparedness plan for Avian Influenza and Pandemic Influenza

National Infectious Disease Hospital Prof.dr. Sulianti Saroso, Jakarta

Pontianak -Indonesia, 21 March 2013

Avian Influenza

Pandemi Influenza

Pandemic phase

INFLUENZA PANDEMIC IN 20TH CENTURY

1918 SPANISH FLU 40 t0 50 million deaths A (H1N1)

1957 Asian Flu 2 million deaths A (H2N2)

1968 Hongkong Flu 1 million deaths A (H3N2)

4

Pandemic Influenza( H1N1) 2009

Since Mei 2009 ~ Juni 2010 First Case Indonesia hospitalized in Sulianti Saroso - Hospital Total case : Suspect case : more than 500 Confirm case : 291 (130 ward, 161 outpatients) Death : 5 CFR : 1 %

Last pandemic????

50

100

150

200

250

300

350

55

Bali

140

Banten

31

N=1055 cases
DIY 326 DKI Jakarta 1 96 39 183 10 37 Jambi Jawa Barat Jawa Tengah Jawa Timur Kalimantan Barat Kalimantan Selatan Kalimantan Tengah Kalimantan Timur Kepulauan Riau Lampung 4 NAD NTB NTT Riau Sulawesi Selatan Sulawesi Tengah Sulawesi Utara Sumatera Barat Sumatera Selatan Sumatera Utara

Cases H1N1 Pandemi Indonesia, 2009

3 11 7
34

3
1 26 16 1 8 1 2 20

Clinical manifestation influenza A H1N1 patients in USA

Percentage

MMWR, May 8 2009/vol. 58/no.17

Higher risk of serious complications

Age > 65 years

Children < 5 years old

Pregnant women
Chronic medical conditions (Asthma, Diabetes, Heart disease) Immunosuppressed (e.g., taking immunosuppressive medications, infected with HIV)

Avian Influenza

Epidemiology

Updates H5N1
WHO H5N1 cumulative case : 2003-2013 (12 March 2013)
INDONESIA : 160/192 ; CFR: 83,3 % WORLDWIDE : 371/ 622 : CFR : 59,6 %

15 Province and 57 District (West Kalimantan No case)

Last case:
West Java, child , 4 years old, 6 December 2012

Distribution Avian Influenza 2005-2012

Cluster Case AI 2005-2012

AVIAN INFLUENZA ( H5N1) at NIDH Sulianti Saroso

SINCE : 2005- 2011 TOTAL CASE : SUSPECT CASE : MORE THAN 300 CONFIRM CASE : 36 DEATH : 30 CFR : 83,3 %

WHO Case Definition

Suspected influenza A/H5 case
A person presenting with unexplained acute lower respiratory illness with fever ( >38oC) and cough, shortness of breath or difficult breathing AND One or more of the following exposures in the 7 days prior to symptom onset: A. Close contact (within 1 metre) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable, or confirmed H5N1 case; B. Exposure (e.g. handling, slaughtering, defeathering, butchering, preparation for consumption) to poultry or wild birds or their remains or to environments contaminated by their faeces in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last month; C. Consumption of raw or undercooked poultry products in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last month; D. Close contact with a confirmed H5N1 infected animal other than poultry or wild birds (e.g. cat or pig); E. Handling samples (animal or human) suspected of containing H5N1 virus in a laboratory or other setting.

Probable influenza A/H5 case

i) A person meeting the criteria for a suspected case AND One or more of the following additional criteria: A. Infiltrates or evidence of an acute pneumonia on chest radiograph plus evidence of respiratory failure (hypoxemia, severe tachypnea) B. . positive laboratory confirmation of influenza A infection but insufficient laboratory evidence for H5N1 infection. OR ii) A person dying of an unexplained acute respiratory illness who is considered to be epidemiologically linked by time, place, and exposure to a probable or confirmed H5N1 case.

Confirmed influenza A/H5 case

A person meeting the criteria for a suspected or probable case AND One of the following positive results conducted in a national, regional or international influenza laboratory whose H5N1 test results are accepted by WHO as confirmatory: A. Isolation of an H5N1 virus; B. Positive H5 PCR results from tests using two different PCR targets, e.g. primers specific for influenza A and H5 HA; C. A fourfold or greater rise in neutralization antibody titer for H5N1 based on testing of an acute serum specimen (collected 7 days or less after symptom onset) and a convalescent serum specimen. The convalescent neutralizing antibody titer must also be 1:80 or higher; D. A microneurtralization antibody titer for H5N1 of 1:80 or greater in a single serum specimen collected at day 14 or later after symptom onset and a positive result using a different serological assay.

Unit 5 - Clinical Management

Slide 5-15

Diagnosis
1) 2) 3) 4) People on investigation Suspect AI Probable AI Confirm AI

Clinical Presentation
Fever Respiratory symptoms: - Influenza like illness/URTI - cough, breathlessness - severe, rapidly progressive pneumonia - Acute Respiratory Distress Syndrome Gastrointestinal : diarhea Unusual : conjunctivitis, encephalitis, renal failure, hepatic impairment,

Clinical Manifestations Common Admission Laboratory Characteristics

Leukopenia, especially lymphopenia Thombocytopenia (mild to moderate) Elevated Aminotransferase (moderate)

Complications
Renal failure Cardiovascular collapse Ventillator-associated pneumonia Pancytopenia Sepsis (without documented bacteremia) Rapid respiratory failure (ARDS)

Clinical and laboratory features on admissions

Kandun et al,The Lancet Aug 2008

Radiology
2005

Multifocal or patchy infiltration Diffuse uni/bilateral infiltrate Intertitial, groundglass appearance Segmental, lobar consolidation ARDS manifestations. Pleural effusions

Rapid progresif to ARDS

Management

Case Management Protocol

Hospitalized in individual isolation room/ICU Infection control strict barrier nursing Respiratory/supportive care Antiviral therapy/prophylaxis Antibiotics Supportive care
Nutrition enteral optimal Prepare nosocomial infection Prepare deep vein thrombosis (DVT) Monitoring fluid adequate (vena central) Respiratory monitoring:
Oxygen therapy (canula and masker,O2>90%) Ventilatory support Prevent barotraumas

Treatment
Treatment should begin as soon as possible after symptoms start DRUG OF CHOICE the antiviral medication OSELTAMIVIR (TAMIFLU) may make the disease less severe if you start taking the medicine within 48 hours after your symptoms start. Zanamivir : shows promise in the lab but has not been widely used in human cases of bird flu Human Avian Influenza RESISTEN to the antiviral medicines AMANTADINE and RIMANTADINE
24

Therapeutic dose : 2 X 75 mg for 5 days, may up to 10 days Prophylactic dose: 1 X 75 mg for 7 days

PRE HOSPITAL
Pre-hospital care is predominantly supportive:
Supplemental oxygenation to manage respiratory symptoms or objective hypoxia may be needed Tamiflu and symptomatic drugs Ventilatory support with a bag-valve-mask device and/or with field intubation may be required if the patient is in respiratory failure. Intravenous access should be obtained, and a bolus of a crystalloid can be administered to support hemodynamic stability. Attention should be given to the appropriate use of personal protective equipment (PPE) by the pre-hospital providers and advance notification should be given to the hospital regarding the potential need for patient respiratory isolation.

General guidelines in low-risk areas are that patients with fever and respiratory complaints should wear a standard mask, if tolerated, to decrease airborne and droplets

VACCINATION
A vaccine has been developed protect humans against the H5N1 bird flu virus. There is some concern that the inactivated viral vaccine preparation (killed H5N1 viruses) may not be as effective as predicted if the virus continues to mutate. The standard flu vaccine developed each year does not protect against this strain.

Facilities

Ward

In Patient : 137 186 Beds Intensive Care Unit :

Infectious : 7 Beds (renovation) Non infectious : 3 Beds

Isolation Ward : ( HEPA filter , close ventilation )

11 Beds : 1 for HCU, 10 beds for airborne isolation 2 beds

MDR TB Ward: (HEPA filter)

Anticipating the Avian Influenza case and Preparedness Pandemi Influenza

Set up a team Develop a Standard Operation Procedure Logistics (PPE, Medicines, disposables, etc) Center of activity response out break (Internet, Faximile) Hotline Phone : (021) 6506559 ext 1710, (021) 6401412 Socialization , Refreshing & Simulation Networks :
CDC office, NIHRD

Provincial Health Offices Surveillance, etc

Policies
Follow MoH guidelines for case definition, management, etc Follow WHO guidelines for case definition, management, etc Case management depends on clinical manifestation and hospital resources Upgrade standard procedure

Flow patient AI to Hospitalized

Scenario 1
Referral from RS/fasyankes

security
Isolation ward Mawar

Skenario 2
Referral RS/fasyankes with Mechanical ventilation to RSPI

Security
ICU Isolation

Scenario 3
Patient at IGD RSPI with suspect AI
Observation at Triage Complete : Lab and Radiology

Suspect AI

Isolation ward Mawar

Air borne isolation ward

Patient Out

Nurse Station
Enter patient

Enter HCW

Isolation Wards
Established since 2003 (after SARS outbreak) 11 beds capacity Isolation ( expand 3 wards 35 beds) Equipped with: - Single room with bathroom - Negative pressure - HEPA filter - Close ventilation system - Anteroom - CCTV

Enter patient

Isolation Room

Nurse Station

Reporting
Faximile Personal computer Printer Internet Phone direct and internal

Ambulance
2 Ambulance with portable mechanical ventilation 2 Ambulance Trauma 1 Ambulance for death bodies

Field Hospital

4 units mobile

Capasity 24 beds kohorting per unit

Simulation Manage Avian Influenza and Pandemi Influenza

Simulation

Monitoring and protection for HCW

All HCWs in contact with suspect/confirmed cases are ordered to self record their own health daily, if fever and other symptoms appears Blood samples were collected but time of sampling were vary. The result was negative in all HCWs blood samples Should any symptom appear, nasal and pharyngeal swab be taken for PCR test

Summary
Develop, simulation, Refreshing team Avian Influenza : Poultry to Human Diagnosis : PCR and serology DOC : Oseltamivir Personal hygiene and PPE No pandemic Influenza again

I HOPE BIRDS FLU GO FROM INDONESIA, AND BUSINESS COUNTINUITY

Kebijakan Penanggulangan Episenter Pandemi Influenza

1. 2. 3. 4. 5. 6. 7. 8. 9. Komando dan Koordinasi Surveilans Epidemiologi Respon Medik Intervensi farmasi Intervensi non farmasi Komunikasi risiko Mobilisasi Sumber Daya Pengawasan perimeter Pengawasan Kekarantinaan di pintu masuk (Bandara, Pelabuhan dan PLBD)

10 STRATEGI NASIONAL
1. 2. 3. 4. 5. 6. 7. 8.
Pengendalian penyakit pada hewan sumbernya Penatalaksanaan Kasus pada Manusia Perlindungan Kelompok Risiko Tinggi Surveilans Epidemiologi pada Hewan & Manusia Restrukturisasi Sistem Industri Perunggasan Komunikasi Informasi dan Edukasi Penguatan Dukungan Peraturan Peningkatan Kapasitas PILLAR 3: RAPID RESPONS & RAPID CONTAINMENT 9. Penelitian Kaji Tindak 10. Monitoring & Evaluasi