The Challenges of Communicable Diseases
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Transcript of The Challenges of Communicable Diseases
The Challenges of The Challenges of Communicable Communicable
Diseases Diseases
Dr Christopher KC LeeDr Christopher KC LeeInfectious Diseases UnitInfectious Diseases UnitDepartment of MedicineDepartment of MedicineSungai Buloh HospitalSungai Buloh Hospital
MalaysiaMalaysia
Global Leading causes of Death Global Leading causes of Death 20022002
WHO 2004
Dr Margaret ChanDr Margaret ChanDirector-General, WHODirector-General, WHO33rdrd. April 2007. April 2007
““The forces of globalization have changed the The forces of globalization have changed the epidemiology of emerging and epidemic-prone epidemiology of emerging and epidemic-prone diseases. From 1973 through 2003, when diseases. From 1973 through 2003, when SARS appeared, 39 pathogenic agents capable SARS appeared, 39 pathogenic agents capable of causing human disease were newly of causing human disease were newly identified.identified.
You will recognize the names of some: Ebola, You will recognize the names of some: Ebola, HIV/AIDS, and the organisms responsible for HIV/AIDS, and the organisms responsible for toxic shock syndrome and legionnaire’s toxic shock syndrome and legionnaire’s disease. Others include new forms of epidemic disease. Others include new forms of epidemic cholera and meningitis, Hanta virus, Hendra cholera and meningitis, Hanta virus, Hendra virus, Nipah virus, H5N1 avian influenza and, virus, Nipah virus, H5N1 avian influenza and, of course, SARS. All of this within 30 years.”of course, SARS. All of this within 30 years.”
Emerging PathogensEmerging Pathogens
Healthcare associated:Healthcare associated: MRSAMRSA MRSEMRSE VREVRE VISAVISA ESBL producing ESBL producing
Gm-ve organismsGm-ve organisms Multidrug resistantMultidrug resistant
AcinetobacterAcinetobacter MDR-TBMDR-TB
Community:Community: HIVHIV Pandemic / Avian FluPandemic / Avian Flu SARSSARS Foodborne diseasesFoodborne diseases Vector borne [malaria, Vector borne [malaria,
dengue, West Nile]dengue, West Nile] Hepatitis B & CHepatitis B & C Legionnaire’s diseaseLegionnaire’s disease Pathogens of Pathogens of
bioterrorismbioterrorismCenter of Disease Control, USACenter of Disease Control, USA
S. aureus
Penicillin
[1950s]
Penicillin-resistant
S. aureus
Evolution of Drug Resistance in Evolution of Drug Resistance in S. S. aureusaureus
Methicillin
[1970s]
Methicillin-resistant S. aureus (MRSA)
Vancomycin-resistant
enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
intermediate-resistantS. aureus (VISA)
[ 2002 ]VancomycinVancomycin
--
resistantresistantS. aureusS. aureus
Bacterial Resistance: Bacterial Resistance: An increasing threat to the successful An increasing threat to the successful
treatment of nosocomial infectionstreatment of nosocomial infections
•VRSAVRSA
•Carbapenem resistant Carbapenem resistant Enterobacter/KlebsiellaEnterobacter/Klebsiella
•MDR Pseudomonas/AcinetobacterMDR Pseudomonas/Acinetobacter
• ESBL’s resistant to quionolones, ESBL’s resistant to quionolones, aminoglycosides & aminoglycosides & piperacillin/tazobactampiperacillin/tazobactam
•Options for treatment are diminishingOptions for treatment are diminishing
Antibiotic Resistance: Antibiotic Resistance: The Global PerspectiveThe Global Perspective
Enterococcus faeciumvancomycin resistance
France 1988
Shigella dysenteriaemultiresistanceBurundi 1992
Vibrio choleraemultiresistanceEcuador 1993
Streptococcus pneumoniaemultiresistance
South Africa 1977
Salmonella typhimultiresistance
India 1990
Neisseria gonorrhoeaepenicillin resistance
The Philippines 1976
Streptococcus pneumoniaepenicillin resistance
Australia 1967
Klebsiella pneumoniaecefotaxime resistance
Germany 1983
Neisseria meningitidispenicillin resistance
Spain 1988
Enterococcus faeciumoxazolidinone
resistanceUSA 2001
Vancomycin intermediate Vancomycin intermediate Staphylococcus aureusStaphylococcus aureus
(VISA) Japan 1996(VISA) Japan 1996
Staphylococcus aureusStaphylococcus aureusvancomycin resistancevancomycin resistance
(VRSA) USA 2002(VRSA) USA 2002
0
5
10
15
20
25
30
35
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Non-ICU
ICU
Fridkin SK et al. Fridkin SK et al. Clin Chest Med.Clin Chest Med. 1999;20:303-316. 1999;20:303-316.
Res
ista
nce
(%
)R
esis
tan
ce (
%)
YearYear
Vancomycin-Resistant Vancomycin-Resistant EnterococciEnterococci
0
5
10
15
20
25
30
35
40
45
50
1996 1997 1998 1999 2000 2001 2002 2003
Coagulase-negative staphylococci S. aureus
Gram-negative organisms Candida spp.
Re-emergence of Gram-negative Re-emergence of Gram-negative Organisms in Nosocomial Bacteraemia Organisms in Nosocomial Bacteraemia
(US data)(US data)
**
*p<0.001 (from 1999 to 2003)*p<0.001 (from 1999 to 2003)Albretch, et al. Arch Intern Med 2006;166:1289–1294Albretch, et al. Arch Intern Med 2006;166:1289–1294
% o
rgan
ism
s am
ong
tota
l iso
late
s%
org
anis
ms
amon
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tal i
sola
tes
What is driving increasing What is driving increasing prevalence prevalence
of antibiotic resistant of antibiotic resistant pathogens?pathogens?•The selection of resistant mutants by The selection of resistant mutants by
antibiotic exposureantibiotic exposure
•The transfer of genetic determinants The transfer of genetic determinants of resistance between bacterial of resistance between bacterial strainsstrains
•The clonal spread of resistant The clonal spread of resistant bacteria among hospitalised patients bacteria among hospitalised patients within and between institutions and within and between institutions and community (poor infection control)community (poor infection control)
•Collateral damageCollateral damage
Chloramphenicol
Streptogramins
Quinolones
Sulphonamides
Tetracyclines
Penicillins
Aminoglycosides
Macrolides
Glycopeptides
1930´s 1940´s 1950´s 1960´s 1970’s 1980´s 1990´s 2000´s
Oxazolidinones e.g linezolid
Introduction of New Antibiotic ClassesIntroduction of New Antibiotic Classes
Lipopeptides e.g Daptomycin
BAD BUGS – FEW NEW BAD BUGS – FEW NEW DRUGSDRUGS
Cephalosporins
Carbapenems
Monobactams, fosfomycin
Key StrategiesKey Strategies
Prevent infectionPrevent infection
Diagnose and treat Diagnose and treat
infection effectivelyinfection effectively
Use antimicrobials wiselyUse antimicrobials wisely
Prevent transmissionPrevent transmission
Clinicians hold Clinicians hold the solution!the solution! CDC, CDC,
USAUSA
12 Steps in Addressing 12 Steps in Addressing
Nosocomial InfectionsNosocomial Infections::
Contain your contagionContain your contagion Prevent Prevent TransmissionTransmissionIsolate the pathogenIsolate the pathogen
Stop treatment when curedStop treatment when cured
Use Use Antimicrobials Antimicrobials WiselyWisely
Know when to say “no” to Know when to say “no” to vancovanco
Treat infection, not colonizationTreat infection, not colonization
Treat infection, not Treat infection, not contaminationcontamination
Access the expertsAccess the experts
Use local dataUse local dataPractice antimicrobial controlPractice antimicrobial control Diagnose & Diagnose &
Treat Treat EffectivelyEffectively
Target the pathogenTarget the pathogen
Get the catheters outGet the catheters out Prevent Prevent InfectionsInfectionsVaccinateVaccinate
Communicable Diseases Communicable Diseases Outbreaks: Outbreaks: Lessons learnt & Lessons learnt & Preparing for …Preparing for …
Major Social implications:Major Social implications: HIV, SARS HIV, SARS
High Mortality:High Mortality: Nipah Encephalitis Nipah Encephalitis
Endemic (recurrent):Endemic (recurrent): Dengue, Typhoid Dengue, Typhoid
Endemic (new manifestations):Endemic (new manifestations):
Leptospirosis Leptospirosis
Global Implications: Global Implications:
Avian Flu Avian Flu Pandemic Influenza: Pandemic Influenza:
Are we prepared?Are we prepared?
Estimated number of people living with HIV globally, 1986–2006
Number of people living with HIV
1986 1992 1996 2006
Year
0
10
20
30
40
50
Mill
ion
1988 1990 1994 20021998 2000 2004
HIV prevalence in adults in Asia, 1990−2005
Adults & children estimated to be living with HIV, 2006
Total: 39.5 (34.1 – 47.1) millionTotal: 39.5 (34.1 – 47.1) million
Western & Central Europe
740 000[580 000 – 970 000]
Middle East & North Africa
460 000[270 000 – 760 000]
Sub-Saharan Africa24.7 million
[21.8 – 27.7 million]
Eastern Europe & Central Asia
1.7 million [1.2 – 2.6 million]
South & South-East Asia
7.8 million[5.2 – 12.0 million]
Oceania81 000
[50 000 – 170 000]
North America
1.4 million[880 000 – 2.2 million]
Caribbean
250 000[190 000 – 320 000]
Latin America1.7 million
[1.3 – 2.5 million]
East Asia750 000
[460 000 – 1.2 million]
Estimated number of adults and children newly infected with HIV, 2006
Total: 4.3 (3.6 – 6.6) millionTotal: 4.3 (3.6 – 6.6) million
Western & Central Europe
22 000[18 000 – 33 000]
Middle East & North Africa68 000
[41 000 – 220 000]Sub-Saharan Africa
2.8 million[2.4 – 3.2 million]
Eastern Europe & Central Asia
270 000 [170 000– 820 000]
South & South-East Asia860 000[550 000 – 2.3 million]
Oceania7100
[3400 – 54 000]
North America43 000
[34 000 – 65 000]
Caribbean27 000
[20 000 – 41 000]
Latin America140 000
[100 000 – 410 000]
East Asia100 000
[56 000 – 300 000]
Estimated adult and child deaths from AIDS, 2006
Total: 2.9 (2.5 – 3.5) millionTotal: 2.9 (2.5 – 3.5) million
Western & Central Europe
12 000[<15 000]
Middle East & North Africa36 000
[20 000 – 60 000]
Sub-Saharan Africa2.1 million
[1.8 – 2.4 million]
Eastern Europe & Central Asia
84 000 [58 000 – 120 000]
South & South-East Asia590 000[390 000 – 850 000]
Oceania4000
[2300 – 6600]
North America18 000
[11 000 – 26 000]
Caribbean19 000
[14 000 – 25 000]
Latin America65 000
[51 000 – 84 000]
East Asia43 000
[26 000 – 64 000]
Over 11 000 new HIV infections a day in 2006
• More than 95% are in low and middle income More than 95% are in low and middle income countriescountries
• About 1500 are in children under 15 years of ageAbout 1500 are in children under 15 years of age
• About 10 000 are in adults aged 15 years and About 10 000 are in adults aged 15 years and older older
of whom:of whom:— almost 50% are among womenalmost 50% are among women— about 40% are among young people (15-24)about 40% are among young people (15-24)
Cummulative HIV infectionsCummulative HIV infectionsMalaysia 1993-2006Malaysia 1993-2006
780511198
1539619993
2391728541
3323338340
4427851256
5801264439
7055973427
0
10000
20000
30000
40000
50000
60000
70000
80000 1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Jun-06YearMalaysia
30/6//06
National Strategic National Strategic Plan 2006Plan 2006
Endorsed by the Cabinet Endorsed by the Cabinet
in April 2006in April 2006
Main Objectives in NSPMain Objectives in NSPStrengthening Leadership & Strengthening Leadership & AdvocacyAdvocacyTraining & Building Human CapitalTraining & Building Human CapitalReducing Vulnerability of Drug usersReducing Vulnerability of Drug usersReducing Vulnerability of Women & Reducing Vulnerability of Women & ChildrenChildrenReducing Vulnerability of other High Reducing Vulnerability of other High Risk groups eg. CSW, MSM.Risk groups eg. CSW, MSM.Increasing Access to Treatment, Care Increasing Access to Treatment, Care & Support& Support
In support of the UNGASS (AIDS) declarationIn support of the UNGASS (AIDS) declaration
Strengthening Strengthening Leadership & Leadership & AdvocacyAdvocacy
3 tiered policy making structure within 3 tiered policy making structure within
governmentgovernment
Cabinet Committee on AIDSCabinet Committee on AIDS chaired by the chaired by the
Deputy Prime MinisterDeputy Prime Minister
National Advisory Committee on AIDSNational Advisory Committee on AIDS chaired chaired
by the Minister of Healthby the Minister of Health
Technical Committee on AIDSTechnical Committee on AIDS chaired by the chaired by the
DG of HealthDG of Health
Broad platform of engagementBroad platform of engagement
Multisectoral esp. non-health sector Multisectoral esp. non-health sector
Nipah virus; Zoonotic infection: first isolated in 1999, Nipah virus; Zoonotic infection: first isolated in 1999, named after location it was first detected in Malaysia. named after location it was first detected in Malaysia.
Caused disease in animals, & in humans through Caused disease in animals, & in humans through contact with infected animals. contact with infected animals.
Outbreak of encephalitis in Malaysia, (initially in Ipoh Outbreak of encephalitis in Malaysia, (initially in Ipoh then Bukit Pelanduk) from Sept 98-April 99. A total of then Bukit Pelanduk) from Sept 98-April 99. A total of 265 people infected, of whom 105 died, & 93% of 265 people infected, of whom 105 died, & 93% of cases had a history of occupational exposure to pigs. cases had a history of occupational exposure to pigs.
An associated outbreak among abattoir workers in An associated outbreak among abattoir workers in S’pore in March 99: 11 cases, with 1 death. These S’pore in March 99: 11 cases, with 1 death. These workers had been handling pigs imported from workers had been handling pigs imported from outbreak areas in Malaysia.outbreak areas in Malaysia.
Nipah EncephalitisNipah EncephalitisMalaysian origin
Although both Nipah and Hendra, a closely Although both Nipah and Hendra, a closely
related zoonotic virus isolated in Australia related zoonotic virus isolated in Australia
(1994), have caused only a few focal (1994), have caused only a few focal
outbreaks, their outbreaks, their biologic property to infect a biologic property to infect a
wide range of hostswide range of hosts and to produce a and to produce a
disease causing significant mortality in disease causing significant mortality in
humans has made this emerging viral humans has made this emerging viral
infection a public heath concern. infection a public heath concern. Both Nipah & Hendra: members of the virus family Both Nipah & Hendra: members of the virus family Paramyxoviridae.Paramyxoviridae.
Nipah: a public health concernNipah: a public health concern
Nipah virusNipah virusNatural HostNatural HostCertain species of fruit bats are natural Certain species of fruit bats are natural
hosts of both Nipah & Hendra viruses. hosts of both Nipah & Hendra viruses. Distributed across an area encompassing Distributed across an area encompassing
northern, eastern & south-eastern areas northern, eastern & south-eastern areas of Australia, Indonesia, Malaysia, the of Australia, Indonesia, Malaysia, the Philippines & some Pacific Islands. Philippines & some Pacific Islands.
Bats appear to be susceptible to infection Bats appear to be susceptible to infection with these viruses, but do not themselves with these viruses, but do not themselves become ill. It is not exactly known how become ill. It is not exactly known how the virus is transmitted from bats to the virus is transmitted from bats to animals.animals.
Transmission: Nipah virusTransmission: Nipah virus
Mode of transmission from animal - animal, & from Mode of transmission from animal - animal, & from
animal to human is uncertain. Appears to require animal to human is uncertain. Appears to require
close contact with tissue or body fluids from infected close contact with tissue or body fluids from infected
animals. animals.
Nipah Ab have been detected in pigs, other domestic & Nipah Ab have been detected in pigs, other domestic &
wild animals. Role of other species in transmitting wild animals. Role of other species in transmitting
infection to other animals not yet determined. infection to other animals not yet determined.
Nipah not easily transmitted to man. Despite frequent Nipah not easily transmitted to man. Despite frequent
contact between fruit bats & humans; no serological contact between fruit bats & humans; no serological
evidence of human infection among bat carers. evidence of human infection among bat carers.
Pigs: apparent source of infection among human cases Pigs: apparent source of infection among human cases
in M’sia. Human-to-human transmission of Nipah in M’sia. Human-to-human transmission of Nipah
virus has not been reported.virus has not been reported.
Clinical features: Nipah encephalitisClinical features: Nipah encephalitis Incubation period: between 4 - 18 days.
Many cases mild or inapparent (sub-clinical).
In symptomatic cases, onset usually with
"influenza-like" symptoms, with high fever &
muscle pains (myalgia).
Disease may progress to encephalitis; with
drowsiness, disorientation, convulsions & coma.
50%percent of clinically apparent cases die.
Learning Points:Learning Points: Early & accurate surveillance crucial Early & accurate surveillance crucial
Early identification of pathogen Early identification of pathogen
would have resulted in earlier would have resulted in earlier
control of outbreakcontrol of outbreak ‘giving a name for my ‘giving a name for my
pain”pain”
Multisectoral cooperation important Multisectoral cooperation important
in dealing with large outbreaksin dealing with large outbreaks ‘ ‘
’ ’working together’working together’
Risk communication esp.with Risk communication esp.with
regards to media.regards to media. ‘control the panic’‘control the panic’
Preparedness of hospitals to deal Preparedness of hospitals to deal
with patient burden:with patient burden: ‘‘’’no learning curve’no learning curve’
Severe Acute Respiratory Syndrome (SARS)
WHO Disease OutbreakWHO Disease Outbreak (11/7/2003)(11/7/2003)
SARS first recognised on 26/2/03 in Hanoi, Vietnam SARS first recognised on 26/2/03 in Hanoi, Vietnam
Causative agent identified as novel type of coronavirus. Main Causative agent identified as novel type of coronavirus. Main
symptoms /signs include high fever (>38 °C), cough, SOB or symptoms /signs include high fever (>38 °C), cough, SOB or
breathing difficulties. A proportion of patients with SARS develop breathing difficulties. A proportion of patients with SARS develop
severe pneumonia; some of whom needed ventilator support. severe pneumonia; some of whom needed ventilator support.
As of 11/7/2003, total of 8437 cases with 813 deaths reported As of 11/7/2003, total of 8437 cases with 813 deaths reported
from 30 countries. from 30 countries.
SARS in SingaporeSARS in Singapore
Rapid spread: 200 cases in 6 weeks
SARS in Hong KongSARS in Hong Kong Deaths: 299 Probables: 1755Deaths: 299 Probables: 1755
(22/7/2003)(22/7/2003)
Nature Total Admission
Health care workers of Hospitals/Clinics and medical students
386
Patients, family members & visitors
1369
Total admission 1755
(Up till 22/7/2003)
Infection ControlInfection Control….. ….. our lifesaverour lifesaver
Learning Points:Learning Points:Malaysia’s report card: 5 casesMalaysia’s report card: 5 cases No local transmissionNo local transmission External infective source External infective source ‘learning from others’‘learning from others’
Triage at nation’s entry pointsTriage at nation’s entry points Designated hospitals Designated hospitals ‘controlling interface’‘controlling interface’
Protection of HCWs: most vulnerableProtection of HCWs: most vulnerable possible reservoirpossible reservoir surveillancesurveillance Isolation facilities: grossly inadequateIsolation facilities: grossly inadequate improvisationimprovisation Effective media relations Effective media relations ‘structured access’‘structured access’
LeptospiresLeptospires
Tightly Tightly coiled coiled spirochetesspirochetes
Requires Requires special special media to media to growgrow
Very slow Very slow growergrower
EpidemiologyEpidemiology Source of infectionSource of infection
– From direct or indirect contact of urine of an From direct or indirect contact of urine of an infected animalinfected animal
– Maintenance hosts (reservoirs)Maintenance hosts (reservoirs) Infection is endemicInfection is endemic Transferred from animal to animal by direct contactTransferred from animal to animal by direct contact Chronic infection of the renal tubules of infected Chronic infection of the renal tubules of infected
animals with intermittent renal excretionanimals with intermittent renal excretion Different species can be reservoirs for different Different species can be reservoirs for different
serovarsserovars
– Accidental / Incidental hostsAccidental / Incidental hosts
Risk factors for InfectionRisk factors for Infection– OccupationalOccupational
Direct contact – livestock farmers, Direct contact – livestock farmers, veterinariansveterinarians
Indirect contact – sewer workers, Indirect contact – sewer workers, soldiers, miners, rice field workerssoldiers, miners, rice field workers
– RecreationalRecreational Water sports Water sports
– Activities of daily careActivities of daily care Walking bare foot in damp conditionsWalking bare foot in damp conditions Gardening with bare handsGardening with bare hands Dogs, ratsDogs, rats
Leptospirosis: clinical Leptospirosis: clinical pyramidpyramid
Icteric Icteric LeptospirosisLeptospirosis
Febrile illness of sudden onsetFebrile illness of sudden onsetChills, headache, myalgia, Chills, headache, myalgia,
abdominal pain, abdominal pain, conjunctival suffusionconjunctival suffusion
Sub clinical or of very mild severity. Sub clinical or of very mild severity. No medical attention soughtNo medical attention sought
Old Foe – new presentationOld Foe – new presentation 19 yr old Malay male admitted on 17/5/05 in Melaka GH, with 1 19 yr old Malay male admitted on 17/5/05 in Melaka GH, with 1
week - fever & sore throat. Cough initially with whitish sputum, week - fever & sore throat. Cough initially with whitish sputum,
became blood stained 3 days before admission. Had dyspnoea became blood stained 3 days before admission. Had dyspnoea
pleuritic chest pain 1 day prior to admission. pleuritic chest pain 1 day prior to admission.
H/O going to Air Terjun Lata Kijang in Perak a week before onset. H/O going to Air Terjun Lata Kijang in Perak a week before onset.
On admission, Temp 39On admission, Temp 39ooC, No jaundice. Required ventilation on C, No jaundice. Required ventilation on
the same day of admission for severe pulm hemorrhage. the same day of admission for severe pulm hemorrhage.
CXR: diffuse alveolar shadows relatively sparing apices. Hb CXR: diffuse alveolar shadows relatively sparing apices. Hb
10g/dl, TWC 8.5x109/L, Platelet 128x109/l, Creat 113mmol/l, ALT 10g/dl, TWC 8.5x109/L, Platelet 128x109/l, Creat 113mmol/l, ALT
32U/L, APTT ratio 0.99, INR 1.03. 32U/L, APTT ratio 0.99, INR 1.03.
Treated initially as severe CAP - Clarithromycin & Ceftriaxone. Treated initially as severe CAP - Clarithromycin & Ceftriaxone.
Dengue IgM, SARS antibody test, Mycoplasma & HIV serology -ve. Dengue IgM, SARS antibody test, Mycoplasma & HIV serology -ve.
However his Leptospiral serology was positive, 1:840. However his Leptospiral serology was positive, 1:840.
Commenced C. pencillin. Improved & was extubated on 2.06.05Commenced C. pencillin. Improved & was extubated on 2.06.05
Pulmonary hemorrhagePulmonary hemorrhage Several reports of leptospirosis presenting Several reports of leptospirosis presenting
as pulmonary hemorrhage from Taiwan, UK, as pulmonary hemorrhage from Taiwan, UK, USA, India, Brazil and tropical areas of USA, India, Brazil and tropical areas of AustraliaAustralia
In Peru, 7 patients with histories of only In Peru, 7 patients with histories of only urban exposure to leptospirosis had severe urban exposure to leptospirosis had severe pulmonary manifestationspulmonary manifestations
– Clin Infect Dis, 2005. Clin Infect Dis, 2005. 4040(3): p. 343-51.(3): p. 343-51.
In Seychelles (Indian Ocean), 19% of the In Seychelles (Indian Ocean), 19% of the
patients had pulmonary hemorrhagepatients had pulmonary hemorrhage – Am J Trop Med Hyg, 1998. Am J Trop Med Hyg, 1998. 5959(6): p. 933-40. (6): p. 933-40.
Avian Influenza: Toll 2003-Avian Influenza: Toll 2003-0707
CountriesCountries Cases Cases [confirmed[confirmed
]]
DeathsDeaths
VietnamVietnam 9595 4242
IndonesiaIndonesia 102102 8181
ThailandThailand 2525 1717
IraqIraq 33 22
TurkeyTurkey 1212 44
AzerbaijanAzerbaijan 88 55
CambodiaCambodia 77 77
EgyptEgypt 3838 1515
ChinaChina 2525 16162525thth. July 2007. July 2007
Cumulative cases:Cumulative cases:
• 319 cases319 cases
• 192 deaths192 deaths
Mortality: 60%Mortality: 60%
Objectives of strategic actionsObjectives of strategic actions
Preparation: Preparation: Guidelines (MOH – Guidelines (MOH – NIPPP)NIPPP)
Use of antiviral drugs during pandemicUse of antiviral drugs during pandemic Recommendation of priority population groups for Recommendation of priority population groups for
vaccination during Influenza Pandemicvaccination during Influenza Pandemic Guidelines for Entry Point Screening of travelers Guidelines for Entry Point Screening of travelers
from / exiting Influenza affected countries or areasfrom / exiting Influenza affected countries or areas Health Declaration Card for travelers exiting Health Declaration Card for travelers exiting
Influenza affected countries or areas.Influenza affected countries or areas. Guidelines on isolation, home surveillance & Guidelines on isolation, home surveillance &
quarantine of contacts during flu pandemic.quarantine of contacts during flu pandemic. Guidelines for self-monitoring & reporting if ill of Guidelines for self-monitoring & reporting if ill of
influenza during pandemic.influenza during pandemic. Plus many others …..Plus many others …..
Facilities & EquipmentFacilities & Equipment Minimum standards laid down in Minimum standards laid down in
NIPPP must be complied to.NIPPP must be complied to.
When resources allow; the best When resources allow; the best
standards achievable should be standards achievable should be
goal eg. Isolation facilitiesgoal eg. Isolation facilities
Any lack of critical facilities & Any lack of critical facilities &
equipment should be addressed equipment should be addressed
and corrected in descending and corrected in descending
prioritypriority
Safety of patients and staff should Safety of patients and staff should
be paramount in all medical be paramount in all medical
decision making (evidence based) decision making (evidence based)
MedicationsMedications Antivirals & pandemic influenza Antivirals & pandemic influenza
vaccine will be centrally vaccine will be centrally controlled & distributedcontrolled & distributed
Stock pile of antivirals to be Stock pile of antivirals to be kept at regional centers kept at regional centers allowing for rapid deployment allowing for rapid deployment when neededwhen needed
Due to limited supply, usage Due to limited supply, usage must comply with indications must comply with indications listed in NIPPP listed in NIPPP
Usage of antivirals must be Usage of antivirals must be closely monitoredclosely monitored
Testing Our SystemsTesting Our Systems Simulation Exercise:Simulation Exercise:
- tabletop- tabletop
- ‘real-life’ / actual- ‘real-life’ / actual Check our surge capacity …Check our surge capacity …
- testing our limit- testing our limit Prepare for worse case Prepare for worse case
scenariosscenarios Keep preparation plans Keep preparation plans
realistic and keep scenarios realistic and keep scenarios plausibleplausible
‘‘Think out of the box’Think out of the box’
Dr Margaret ChanDr Margaret ChanDirector-General, WHODirector-General, WHOWorld Health Day 2World Health Day 2ndnd. April 2007. April 2007
““The best defence against The best defence against emerging and epidemic-prone emerging and epidemic-prone diseases is not passive diseases is not passive barriers at borders, airports barriers at borders, airports and seaports. It is proactive and seaports. It is proactive risk management that seeks risk management that seeks to detect an outbreak early to detect an outbreak early and stop it at source – before and stop it at source – before it has a chance to become an it has a chance to become an international threat. We are international threat. We are now in a good position to act now in a good position to act in this pre-emptive way.”in this pre-emptive way.”