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

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Title: 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 -
5
(No Transcript)
6
Conceptual framework of Six Sigma
structure
output
Process2
Process1
Process3
Last Process
Process4
control
control
control
control
Processes
7
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)
8
Nationwide educational and supporting
network for infection control
Communicable Disease Control Medical Network
9
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
11
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

13
Process Management (time axis)
  • 0 preparedness
  • - surveillance
  • - surge capacity
  • - exercise/drills
  • A surveillance
  • B containment
  • C impact reduction

14
(No Transcript)
15
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

16
1.
2.
3.
4.
Figure 1. blueprint of school transformed into
alternative care site with traffic control
bundle.
17
Task force of special isolation hospital groups
Special Isolation Hospital
School as shelter
Screen station from community
18
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

19
Process Management (time axis)
  • Levels of alertness WHO phase 4
  • 0 preparedness
  • A surveillance
  • B containment
  • C impact reduction

20
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

22
Process Management algorithm
  • Levels of alertness
  • 0 preparedness
  • A surveillance
  • B containment
  • C harm reduction

23

HCW, Hotel
T
C
C
O
airport
24
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

25
Updated 2009/06/23
Identified so H1N1 influenza A
Investigated
Sentinel surveillance
() (-)
() (-) (?)
26
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

27
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.

28
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

29
Hotel sealed off ?
the Ripple Effect
30
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

31
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

32
  • 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 -
33
  • 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.

34
SHEA June/10/2009
  • NO
  • NPIR
  • N95
  • Respiratory hygiene cough etiquette (manner)
  • HH after cough/sneeze/surfaces

35
Da-An sub-division population42,978 Middle
ages70
????????????,???????????????????????, ???????????
?100???40??????
36
Class I notifiable disease down grade to Class
IV
  • Crisis Management
  • Prediction / Mitigation
  • Preparedness
  • Response
  • Recovery

37
Process Management algorithm
  • Levels of alertness
  • 0 preparedness
  • A surveillance
  • B containment
  • C Impact reduction

38
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
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39
40
General Hospitals / Medical Centers to preserve
fundamental social security
6000
o
e
l
t
a
o
r
m
expandable surge capacity
Task force of special isolation hospital groups
41
Task forces of special isolation hospital groups
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42
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

43
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.

44
Detention Ward
45
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)
46
47
Updated 2009/08/05
????????--??
  • ?????????????????
  • ??????H1N1????4340?- ????

47
48
Updated 2009/08/05
Number of complicated influenza reports by month
of onset 7/1/2008 to present????????--??
  • ??????????7??????

48
49
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)

50
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51
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  • ??13?????,??????,???????

???? ???? ????? ???? ??????? ???? ??? ???? ???? ?? ?? ??? ????
  • ?????24??1922 ??????
  • ??????,??????
  • ??????,??????
  • ???????????

51
52
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

52
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 ????????
  • ???????????,?????6?????????????????????

53
54
?? 325
  • ??????
  • CIC
  • Community influenza (screening) center

55
Infection control of H1N1 in GP
  • Hand hygiene, hand hygiene, hand hygiene. With 75
    alcohol.
  • Surgical mask
  • RAT screen ?
  • Disinfection.
  • Ventilation.
  • Traffic control

56
Hoping for the best
  • Prepare for the worst
  • Thanks for Your Attentions
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