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Research Institute for Tropical Medicine

Department of Health

Socorro P. Lupisan, MD, MSc

Director IV

Preparedness and Response to a Pandemic or Emerging Infectious Disease Outbreak

Socorro P. Lupisan, MD, MScResearch Institute for Tropical Medicine

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Topics

• Emerging and reemerging infections in the

Philippines

• Control Program Preparedness and Response

• Capabilities for the rapid detection, identification

and monitoring of bioagents

• Issues, Concerns and Gaps

EMERGING AND REEMERGING

INFECTIOUS DISEASE OUTBREAKS IN

THE PHILIPPINES

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EMERGING

INFECTIONS

The National Reference Laboratory for Emerging and Reemerging Viral Zoonoses

RITM

Ebola Reston in monkeys (Reston, Virginia)

2006

▼

1998

▼▼

2002

▼2003

2005

▼

Serological Surveillance ABLV

West Nile Virus Pseudo outbreak (RITM as Referral Laboratory)

SARS Outbreak

Pandemic A H1N1

1989

▼

Bioterrorism threat using Bacillus anthracis as biological weapon

▼

Meningococcemia outbreak in CAR2004

2001

2008

2009

▼ Ebola Reston in pigs and humans/ Leptospirosis/ Salmonella typhi

2007

▼ Resistant Shigella flexneri 2a in Cavite, Bohol and Cotabato

2010

▼ Dengue2011

▼ Chikungunya2012 Leptospirosis▼

No H5N1, H7N9, Ebola2013 Pertussis, Measles▼2014

▼ Measles, MERS CoV, Henipah, Ebola?

▼

1992

▼

1996

Ebola Reston in monkeys (Sienna, Italy)

Ebola Reston in monkeys (US)

2015

▼

MERS CoV

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The threat is real!

• The occurrence of an infectious disease threat becoming a pandemic, due to a novel

pathogen is unpredictable, imminent and possibly inevitable.

• The pandemic will most likely be a respiratory infection…

Emergence of SARS-CoV in 2003,

The highly pathogenic Avian Influenza in 2004,

The pandemic influenza A (H1N1) of 2009, and

The very recent MERS-CoV (2013)

• Microbes do not respect borders putting global health and the international

community at risk. Pathogens may be imported or exported out of the country to

cause outbreaks.

• 4.3 million foreign tourists annually from 2011-2013

• 12 million Filipinos live overseas, and an annual average of 1-1.5 million are

deployed abroad as overseas workers. Most of these overseas workers return to the

Philippines for vacation or during contract breaks.

• Participation in the annual Hajj pilgrimage, where millions of pilgrims from all over

the world converge to visit holy sites in western Saudi Arabia.

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MERS CoV Threat…

Suspected cases of MERS-CoV infections have been referred and tested at RITM since 2013 when WHO declared MERS-CoV as a “threat to the entire world.”

April 2014

An overseas Filipino healthcare worker who was reported to be positive for MERS-CoV came home from UAE.

386 out of 414 passengers on the same flight were tested at RITM following the “No Regrets Policy” of the Philippine Government. All tested negative including the reported +case.

February 2015

A Filipino nurse supervisor from Saudi, who claimed no patient exposure, was the first RITM NRL confirmed MERS case. She was first admitted to a private hospital.

Lab findings confirmed by HK Reference Lab. Patient sent home after 2 negative tests.

All contacts were quarantined, screened. After testing negative 2x, all were sent home quarantine for 14 days.

July 2015

A foreign national travelling from the Middle East consulted at a private hospital for a skin rash. Assessed as a PUI, samples were collected and sent to RITM. Tested positive according to WHO criteria, he was admitted to RITM. All contacts traced and tested.

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Food and Waterborne Outbreaks

Jan-Jun 2015

• Food poisoning

• Regions 1, 2, 3, 4A, 4B, 5, 6, 10, 11,

12,CARAGA, NCR

• Pathogens –

– Aeromonas

– E coli

– Samonella

– Staph aureus

– Vibrio

– Shigella

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National preparedness

• Program response by the country, as a responsibility and commitment to the International Health Regulations and Global Health Security

Strong system of detection and identification, surveillance, reporting and information sharing

Rapid identification and characterization, especially for severe cases of unknown or suspected novel origin, will be the key to implement effective prevention, containment and control measures.

Laboratory capacity, technical expertise and surveillance network system not only for Influenza but also for other emerging infectious disease threats

A strong and efficient network of functional laboratories to provide timely and accurate laboratory services for surveillance and response.

DOH CONTROL PROGRAM

PREPAREDNESS AND RESPONSE

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2009 Pandemic A H1N1 outbreak

What facilitated program response

• Philippine pandemic preparedness plan for avian and pandemic influenza

was put in place in 2005.

• The Department of Health Emerging Infections Control Program was quick

in coming up with local interim guidelines (DM 2009-0133) as the

pandemic progressed, providing guidance at all levels of health service

delivery.

• On going CDC supported National Influenza Surveillance then, by the

Philipine National Influenza Center (PNIC) and the DOH Epidemiology

Bureau (EB) tracked the spread of the outbreak in the country.

• Vigilant monitoring of the entry of avian and swine influenza at the

various airports and seaports was being done.

• Coordination between the various concerned agencies was present.

Organizational Chart

Coordination Mechanism for Stakeholders

Disease Prevention & Control Bureau

Infectious Disease Office – Emerging & Re-emerging

Disease Program

Research Institute for Tropical

Medicine NRL

Surveillance

Training

Epidemiology Bureau

Quality

assuranceFurther

testing

RESU and Sentinel

Surveillance Sites

Subnational

Laboratory Network

Support lines Specimen referral linesReporting Line

Laboratory

training

Surveillance Monitoring

and Evaluation

WHO Regional Reference

LaboratoryWHO

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DIAGNOSTIC CAPABILITY FOR

RAPID DETECTION

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RITM NRL FOR EMERGING

INFECTIONS

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RITM National Reference Laboratory for

Emerging Infections Preparedness at a glance

2007

2005

2009

2003

2013

SARS was wake up call that a new deadly disease can emerge.

SARS diagnostics in place with WHO and CDC assistance.

Lab preparedness for H5N1 influenza when Avian flu appeared in many neighboring countries

Capability to detect circulating human subtypes H1 and H3 and avian subtypes H5, H7 and H9 using real-time PCR technology

Response system for Pandemic A H1N1 was tested; subnational labs set up

Lab preparedness for MERS CoV and H7N9

RITM NRL preparednessThe RITM NRL for Emerging Infections has

established rapid and direct detectiontechniques for the followingpathogens:

Ebola viruses including the Restonstrain

Australian Bat Lyssavirus (ABLV),

Coronavirus - causing Severe AcuteRespiratory Syndrome (SARS)

Nipah and Hendra viruses

West Nile virus

Human-Avian Influenza A virussubtypes (H5N1, H7N9)

Influenza A (H1N1) pandemic

Bacterial emerging infections including anthrax, meningococcemia, leptospirosis, diphtheria, pertussis

MERS CoV

BSL2 laboratory work during SARS - NO BSL3 for Emerging Pathogens. Government of Japan is donating a modular BSL3 to RITM and may be available last quarter of 2016.

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Specimen collection guide

• WHO supported RITM initiative

– Guidelines for Specimen Collection, Transport and Referral during Infectious Disease Outbreak

SUBNATIONAL

LABORATORIES

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Subnational Laboratories for EREID

• DPO 2009-2441 -establishmentof 5 Subnational Laboratories (SNLs) for realtime PCR for Flu A (H1N1) with NCHFD (as surge capacity response during the 2009 Flu A (H1N1) outbreak)

• AO 2015 recognizes the SNLs and responsibilities of the SNLs and of other DOH offices have been assigned to ensure sustainability of operations.

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Quality Assurance Activities for SNLs

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2009 -2015• OJT of Lab Staff 2009

• Proficiency Testing* 2009-2014

• RITM-based Training 2010, 2013

• Site Assessments* 2013, 2015

• SNL-based Training as need

arises

* Currently all SNLs have proficient laboratory staff. Facility and

equipment need to be working during the interpandemic period.

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CASE MANAGEMENT OF

EREID

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2nd FLOOR RITM SARS FACILITY, 2004

EAST WING

NEGATIVE PRESURE

ISOLATION ROOMSNO

RT

H W

ING

LABORATORY

RESEARCH DIV

Exhaust System for the Air Handling Unit of the Negative Pressure Isolation

Rooms

Control Panel for Negative PressureHallway

Negative Pressure Isolation Rooms

ICU

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Entrance to Ebola Treatment Unit, East Ward, 2014

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Ebola Treatment Unit, East Ward

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Doctors and Nurses’ Entrance

Doctors and Nurses’ Doffing Room

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Hospitals for EREID Admission

RITM

• MERS CoV

San Lazaro Hospital

• MERS CoV/ Ebola

Lung Center of the Philippines

• MERS CoV

Other hospitals

• Training in Hospital Management of Ebola Virus Disease-

744 health workers from 102 hospitals: 37 private, 33 DOH, 23 LGU, 4 military, 4 industrial, PGH

• WHO Critical Care Training Short Course: Clinical Management Of Patients With Severe Forms Of Influenza Infection, RITM 20-23 April 2015

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Issues and concerns

• Local outbreaks and Public health emergencies of international concern

• Natural or man-made? What is the cause of food and waterborne outbreaks?

• If man-made, source of biological materials for bioterrorism? National inventory of pathogens?

• Students requesting for Risk Group 2 (sometimes Risk Group 3) isolates for research as a school requirement– Policies and guidelines?

– Biosafety concerns- where will the experiment be performed and do they have training? Do the teachers/faculty have training?

– Contribution to science?

• Zoonoses – animal pathogens jumping to humans

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Issues and Challenges

Facilities/equipment • BSL2 laboratory for the NRL for Emerging Infections• Subnational Reference Laboratories proficiency and sustainability• Public health functions for Government Hospital Laboratories

Developing Business Continuity Plans for essential sectors (energy, transportation, banking, communication, food)

Role of other government agencies in the National Biopreparedness and Response Plan

• Military? National Defense (national security issue, bioterrorism)

• Who is in charge?

• Source of funds?

• Policies?

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MARAMING SALAMAT

THANK YOU