INFLUENZA PANDEMIC RESPONSE PLAN:

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INFLUENZA PANDEMIC RESPONSE PLAN PRIMARYCARE
RESPONSE FRAMEWORK
LIM KOK PENG Deputy Dir Ops Control ORC Div, MOH
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SCOPE

• Overview of the National Pandemic Response Plan
• Primary Care Response Framework
• Conclusion

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Human cases of Influenza A (H5N1)

• Cumulative total of 369 cases and 234 deaths (63
  case fatality) as at 28 Feb 2008.
• 2003 4 cases (4 deaths) 100
• 2004 46 cases (32) 70
• 2005 98 cases (43) 44
• 2006 115 cases (79) 69
• 2007 86 cases (59) 69
• 2008 20 cases (17) 85

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Pandemic Planning Assumptions

• Two or more waves in same year or in successive
  flu seasons
• Second wave may occur 3-9 mths later may be more
  serious than first (seen in 1918)
• Each wave lasts about 6 weeks

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Estimates of Local Pandemic Cases(US CDC Flu Aid)

• Attack rate of 25
• 450,000 do not need care
• 550,000 outpatients (ave abt 13,000 per day)
• 11,000 hospitalised
• 1,900 deaths

NB Use of anti-virals can reduce the
hospitalised popn by about 50.
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Strategy

• Surveillance for early
• detection
• Ring fence early cases
• Rapid response to mitigate
• consequences of 1st wave
• Vaccinate population as
• vaccine becomes available

Newsweek 31Oct 2005 Issue
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Surveillance

• Detect importation, occurrence, as early as
  possible
• External surveillance
• International Health Orgns (WHO, CDC, FAO etc)
• Country Health Authorities
• Internal surveillance
• Focus on hospitals
• Atypical pneumonias
• Unexplained deaths respiratory illness
• Laboratory
• Samples from sentinel clinics, TTSH, SGH, NUH,
  KKH
• Community Surveillance
• Polyclinics
• All GP Clinics (Dec 05)
• Veterinary Surveillance - AVA

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Response Impact Mitigation

• Minimise illness, deaths and overall
  socio-economic impact
• Treatment
• Contain spread
• Infection control measures
• Social distancing measures
• Maintain essential services
• Anti-viral prophylaxis

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Vaccination

• Obtain vaccines as soon as possible.
• Vaccinate entire population.

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Influenza Pandemic Response

• Colour-coded Risk Management approach
• Green Largely animal disease occasionally
  infects humans (WHO Phase 1, 2, 3)
• Yellow - inefficient human-to-human transmission
  requiring close, sustained contact (WHO Phase 4)
• Orange more efficient H to H transmission, but
  still limited in certain settings (WHO Phase 5)
• Red pandemic widespread infection (WHO Phase
  6)
• Black - high mortality, morbidity (WHO Phase 6)
• Past pandemics have moved from Green to Red
  without transiting Yellow/Orange or just briefly

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Pre-Pandemic Response

• Green/Yellow/Orange Containment, Prevent Spread
• Effective surveillance to detect the importation
  of cases with a novel influenza virus
• Border control measures (e.g. temp screening)
• Containment through isolation of cases and
  quarantine of contacts Tamiflu.
• Outpatient clinic early detection of suspect
  case, isolation, notification of MOH and tpt to
  RH for confirmation treatment

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Pandemic Response

• Pandemic Red/Black Mitigate impact of 1st
  wave
• Whole of Govt
• Maintain essential services Tamiflu
  prophylaxis.
• Social distancing may have to be considered
  depending on severity. e.g. close schools, child
  care centres, ban public gatherings (e.g.
  cinemas, concerts)
• Strong public communications.

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Pandemic Response - Healthcare

• Pandemic Red/Black Mitigate impact of 1st
  wave
• Organize healthcare system to deliver care
  effectively
• Outpatient management Primary Care Framework
• Provide as many treatment facilities as possible
• Treat all with flu-like symptoms
• Separate system for non-flu patients
• Involve polyclinics and private primary care
  clinics
• Inpatient management (all hospitals)
• For severe cases only
• Manage flu and non-flu cases
• Prepare system for mass vaccination- vaccinate
  when vaccines available

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• Threat of a Global Pandemic Continues to Loom!!

Do you intend to stay open? Continue to treat
your patients? Do you have a contingency plan?
Are you prepared?
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Primary Care Response Framework
Helping private clinics continue treating the
ill in the community
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Primary Care FrameworkWhy involve Private
Clinics ?

• Retain normal community services as much
  possible
• - Care remains in the heartlands and easily
  accessible
• Reduce surge on Polyclinic System
• - waiting time
• - overcrowding will facilitate spread
• Reduce need for ill to travel for medical care
  thus limiting the spread of infection in
  community
• Family physician for every Singaporean
• - Partner the private family physicians who
  handle some 80 of normal primary care visits
• Primary outpatient care is a key strategy in
  pandemic case mgt

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Primary Care FrameworkConcept

• Activated at Pandemic - DORSCON RED
• Maintain normalcy and accessibility of primary
  care
• Support the private clinics to enable them to
  continue to manage the ill including pandemic flu
• Cluster the clinics around Polyclinics for
  coordination

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Maintain NormalcyEngaging the Private Clinics

• All on Board About 1400 private primary care
  clinics (with about 2000 doctors)
• Letters of Invitation sent to clinics (2006,
  2007,2008)
• Outreach Briefings carried out
• 2 Sessions (2006)
• Tie-up with large GP Groups
• Primary Care Workshops 2007
• 3 weekends July, Aug
• 2 weekends Feb, Mar 08
• Polyclinic dialogues/training FY 08 onwards
• About 60 on board, including the large GP
  Practices
• Inform the Public to identify closest clinic
• Continued effort to get participation from all
  private clinics by MOH, SMA CFPS

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Support the Clinics

• Staff protection identical to public HCWs
• PPE (3 N95 masks, 4 gowns, 10 prs gloves)
• Anti-viral prophylaxis (40 caps/staff/6 wks)
• Surgical masks for patients (50/day)
• Anti-viral drugs for treatment of flu cases (abt
  100/clinic/wk)

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Support the ClinicsLogistics Supply System

• Clinics encouraged to keep at least 1 week supply
  PPE
• DORSCON RED, clinics receive
• Staff PPE for 6 weeks
• Staff Anti-viral prophylaxis for 6 weeks
• Anti-viral treatment for 1 week
• Routine weekly resupply of anti-virals for
  treatment
• Feedback needed for
• N95 Mask Fit (Dr, 4 Staff)

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Support the Clinics

• Clustering around the Polyclinics for synergy and
  coordination
• Crowd Management and Security
• Public Communications MICA, MOH
• National Pandemic Readiness Response Plan
  (www.moh.gov.sg)
• Health Check System reporting case information
• Guide to Organising a Primary Care Clinic during
  an Influenza Pandemic

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Support the ClinicsClustering Framework

• 18 Polyclinic as focal point Clusters based on
  geographical location
• Sub-clustering and appointing leaders for better
  coordination
• Large Group Practices form own cluster

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SUPPORT THE CLINICS CLUSTERING FRAMEWORK
MOH
SMA
CFPS
Large GP Practice Cluster
Polyclinic-GP Cluster HQ AMK Headed by Head
Polyclinic Dy Head Clinic Group 1 IC
x 18
Coord Section (only during pandemic) Co-staffed
by Polyclinic staff Clinic staff
3- tier
Clinic Group 1 Headed by 1x Group IC 1x Group
2IC
Clinic Group 1 Headed by 1x Group IC 1x Group
2IC
AMK Polyclinic Headed by Hd Polyclinic
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Clustering FrameworkRole of Polyclinic/Cluster
Heads

• Coordination and liaison
• Information dissemination in normalcy and in
  crisis
• Assist to reallocate manpower and other resources
  within clusters/groups when required

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Support the ClinicsCrowd Management Security

• Expect larger than normal crowd at some clinics
• Likely to remain orderly policy of treatment to
  all patients suggestive of flu
• Clinics need to manage the larger numbers
  efficiently and smoothly
• SPF foot patrols around clusters

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Support the ClinicsPublic Communications

• Managed nationally by MICA and MOH
• Transparent and timely communication
• Educate raise awareness of disease, vigilance,
  good hygiene, socially responsible behaviour
• Build confidence, calm
• Support national response reduce load at
  hospital EDs, rush for treatment, community-wide
  measures

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Conclusion

• HPAI infections continue and number of human
  cases growing Singapore cannot relax vigilance
• Threat of a pandemic remains
• No one can predict when or how bad the next
  pandemic is going to be
• Basic National Plan is in place
• Public health system cannot cope with the
  expected numbers of ill on its own
• Need the entire healthcare system to work
  together and function as a well oiled team

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Thank You
www.flu.gov.sg www.moh.gov.sg www.sma.org.sg
www.cfps.org.sg