Preparedness of Pandemic Novel Influenza in Taiwan: from strategy to operation

1
Preparedness of Pandemic Novel Influenza in
Taiwanfrom strategy to operation

• Yen , Muh-Yong
• Taipei City Hospital, Taiwan
• Infection Control Society of Taiwan

2
Introduction

• The SARS epidemic of Taiwan in 2003
• 347 casualties.
• 70 are nosocomial related.
• 30 are health care workers.

3
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 ,2006.2,622195 -
4
Factors Protecting HCW from SARS nosocomial
infection

• 31 H w/o 19 H w/c HCW SARS
• Leadership (plt0.01)
• Fever screening stations (plt0.01)
• checkpoint alcohol dispensers
• for glove-on hand rubbing
• between zones of risk (plt0.001)
• 
  
• 
  

- Yen MY, et al. 8th IFIC, Budapest, 2007 -
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Conceptual framework of Six Sigma
structure
output
Process2
Process1
Process3
Last Process
Process4
control
control
control
control
Processes
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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)
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Nationwide educational and supporting
network for infection control
Communicable Disease Control Medical Network
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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.

10
Inspection and audit for hospital infection
control, Taiwan CDC
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
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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.

12
Process Management (time axis)

• Levels of alertness
• 0 preparedness
• A surveillance
• B containment
• C impact reduction

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Process Management (time axis)

• 0 preparedness
• - surveillance
• - surge capacity
• - exercise/drills
• A surveillance
• B containment
• C impact reduction

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Transforming schools into pre-designed ACS as
part of preparedness plan for pandemic H5N1
influenza. -Yen MY, J Formos Med
Assoc,2008107(9)673-676.-

• Accessibility
• Availability
• Safety
• Expandability

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1.
2.
3.
4.
Figure 1. blueprint of school transformed into
alternative care site with traffic control
bundle.
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Task force of special isolation hospital groups
Special Isolation Hospital
School as shelter
Screen station from community
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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

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Process Management (time axis)

• Levels of alertness WHO phase 4
• 0 preparedness
• A surveillance
• B containment
• C impact reduction

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The Front-line checkpoint for surveillance

• Airport fever screening station
• Community surveillance ( GP, Rx, ER )
• TOCC
• Travel history
• Occupational/Contact history
• Cluster

21
Strategy of Responsiveness in level A
B

• First case finding through active surveillance
• Containment
• Epi. Investigation Contact tracing
• quarantine, isolation and containment

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Process Management algorithm

• Levels of alertness
• 0 preparedness
• A surveillance
• B containment
• C harm reduction

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HCW, Hotel
T
C
C
O
airport
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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

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Updated 2009/06/23
Identified so H1N1 influenza A
Investigated
Sentinel surveillance
() (-)
() (-) (?)
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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

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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.

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Epidemic Command Center(central
government)Strategy, SOP
Chain of command Risk communications
Video conference, Telephone conference
inter-city/ inter sub-network coordination

• Sub-division of Communicable Disease Control
  Medical Network
• Branch office of CDC
• Local Epidemic Command Center
• Execution/ channel

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Hotel sealed off ?
the Ripple Effect
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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

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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

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• 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 -
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• 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.

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SHEA June/10/2009

• NO
• NPIR
• N95
• Respiratory hygiene cough etiquette (manner)
• HH after cough/sneeze/surfaces

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Da-An sub-division population42,978 Middle
ages70
????????????,???????????????????????, ???????????
?100???40??????
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Class I notifiable disease down grade to Class
IV

• Crisis Management
• Prediction / Mitigation
• Preparedness
• Response
• Recovery

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Process Management algorithm

• Levels of alertness
• 0 preparedness
• A surveillance
• B containment
• C Impact reduction

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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

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General Hospitals / Medical Centers to preserve
fundamental social security
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expandable surge capacity
Task force of special isolation hospital groups
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Task forces of special isolation hospital groups
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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

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Detention, quarantine

• 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.

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Detention Ward
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A moderate pandemic phase 6

• WHO considers the overall severity of the
  influenza pandemic to be moderate ?
• Mild - moderate - severe
• Moderate - aggressive severe ?

46
Taiwan laboratory weekly reoprt on influenza
virus activities
Updated 2009/08/05
The latest 3 weeks Flu Positive rate 13
(11,16) Novel H1N1 ratio 90 (80,96)
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Updated 2009/08/05
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Updated 2009/08/05
Number of complicated influenza reports by month
of onset 7/1/2008 to present????????--??

• ??????????7??????

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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)

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Surge capacity, anti-viral agents

• Stockpile 17 (4,183,000 people)
• Tamiflu 2,214,000
• Relenza 969,000
• Raw material ??? 1,000,000
• Consumption 1500
• Supplied by national insurance 0815
• ILI RAT

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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 ????????
• ???????????,?????6?????????????????????

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?? 325

• ??????
• CIC
• Community influenza (screening) center

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Infection control of H1N1 in GP

• Hand hygiene, hand hygiene, hand hygiene. With 75
  alcohol.
• Surgical mask
• RAT screen ?
• Disinfection.
• Ventilation.
• Traffic control

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Hoping for the best

• Prepare for the worst
• Thanks for Your Attentions