MOH Malaysia’s Preparedness In Dealing With … of Health Malaysia MOH Malaysia’s Preparedness...

Ministry of Health Malaysia

MOH MalaysiaMOH Malaysia’’s s Preparedness In Dealing Preparedness In Dealing

With PHEIC In Compliance With PHEIC In Compliance to IHR 2005to IHR 2005

Dr Devan KurupDr Devan KurupOutbreak & Disaster Management SectorOutbreak & Disaster Management Sector

Disease Control DivisionDisease Control DivisionMINISTRY OF HEALTH MALAYSIAMINISTRY OF HEALTH MALAYSIA

Presentation LayoutPresentation Layout

Introduction: IHR & PHEIC in briefIntroduction: IHR & PHEIC in brief

IHR Core Capacity Monitoring FrameworkIHR Core Capacity Monitoring Framework

MOH MalaysiaMOH Malaysia’’s Compliance to IHRs Compliance to IHR

Public Health Surveillance, Preparedness & Public Health Surveillance, Preparedness & ResponseResponse

Selected Health Threats Encountered & Selected Health Threats Encountered & Responded by MOH MalaysiaResponded by MOH Malaysia

Way ForwardWay Forward

International Health Regulations (IHR) 2005International Health Regulations (IHR) 2005

The International Health Regulations (2005) (hereinafter "the The International Health Regulations (2005) (hereinafter "the IHR" or IHR" or ““the Regulationsthe Regulations””) is an international agreement that ) is an international agreement that is legally binding on 194 countries (States Parties). is legally binding on 194 countries (States Parties). The IHR define their "purpose and scope" as: "to prevent, The IHR define their "purpose and scope" as: "to prevent, protect against, control and provide a public health response protect against, control and provide a public health response to the international spread of disease in ways that are to the international spread of disease in ways that are commensurate with and restricted to public health risks, and commensurate with and restricted to public health risks, and which avoid unnecessary interference with international which avoid unnecessary interference with international traffic and trade". traffic and trade". Since their entry into force on 15 June 2007, the IHR directs Since their entry into force on 15 June 2007, the IHR directs and governs particular WHO and States Parties activities and governs particular WHO and States Parties activities aiming that protect the global community from public health aiming that protect the global community from public health risks and emergencies that cross international borders.risks and emergencies that cross international borders.

INTERNATIONAL HEALTH REGULATIONS 2005

Adopted at the 58th World Health Assembly in Geneva in May 2005, the IHR (2005) entered into force on 15 June 2007 and becomes legally binding in all WHO Member states.

The International Health Regulations 2005 (IHR 2005) is an International legally binding regulations to protect global public health threats of infectious diseases and other PH emergencies. Any public health emergency of international concern, be it biological, chemical or radiological.

3 TOP PRIORITIES –

ENTRY INTO FORCE

Assess & Strengthen National Capacities:

Annex 1A & 1B

National IHR Focal Point

WHOAssess & Notify PHEIC:Annex 2

DEPUTY DIRECTOR GENERAL OF HEALTH (PUBLIC HEALTH), MOH M’SIA

What is a Public Health Emergency of What is a Public Health Emergency of International Concern (PHEIC)?International Concern (PHEIC)?

An Extraordinary Public Health EventAn Extraordinary Public Health Event

that constitutes a public health risk to other that constitutes a public health risk to other countries through its international spreadcountries through its international spread

That may require a coordinated international That may require a coordinated international responseresponse

The IHR 2005 requires notification to WHO The IHR 2005 requires notification to WHO of any event that may constitute a PHEICof any event that may constitute a PHEIC

IHR (2005) : Annex 2 Assess public health events by using the decision instrument and

notify within 24 hours, of all events that may constitute a public health emergency of international concern

Events that may constitute a PHEICEvents that may constitute a PHEIC--11

A case of the following A case of the following shallshall be notified:be notified:--

SmallpoxSmallpox

Poliomyelitis due to wild type Poliomyelitis due to wild type poliomyelitispoliomyelitis

Human influenza caused by a new Human influenza caused by a new subtypesubtype

Severe Acute Respiratory Syndrome Severe Acute Respiratory Syndrome (SARS)(SARS)

Events that may constitute a PHEICEvents that may constitute a PHEIC--22An event involving the following need to assessed An event involving the following need to assessed due to their ability to cause serious public health due to their ability to cause serious public health impact & to spread rapidly internationally & needs impact & to spread rapidly internationally & needs the use of PHEIC decision instrument for the use of PHEIC decision instrument for assessment and possible notification.assessment and possible notification.

CholeraCholera

Pneumonic plaguePneumonic plague

Yellow FeverYellow Fever

Viral Haemorrhagic Fevers (Ebola, Lassa, Marburg)Viral Haemorrhagic Fevers (Ebola, Lassa, Marburg)

West Nile FeverWest Nile Fever

Other diseases of special national or regional concernOther diseases of special national or regional concern

Events that may constitute a PHEICEvents that may constitute a PHEIC--33

An event of potential international public An event of potential international public health concern, including those of causes or health concern, including those of causes or sources and those involving other events or sources and those involving other events or diseases than those listed in Slides PHEICdiseases than those listed in Slides PHEIC--1 1 and PHEICand PHEIC--2. 2.

This needs the use of the PHEIC decision This needs the use of the PHEIC decision instrument for assessment and possible instrument for assessment and possible notification.notification.

MEMBER STATES KEY OBLIGATIONS

Designate or establish a National IHR Focal Point;

Strengthen and maintain the capacity to detect, report and respond rapidly to public health risks & PHEIC (Public Health Emergency of International Concern);

Respond to requests for verification of information regarding potential PHEIC;

Collaborate with other States Parties and with WHO concerning IHR(2005) implementation;

MEMBER STATES KEY OBLIGATIONS…..Cont.

Assess public health events by using the decision instrument and notify within 24 hours, of all events that may constitute a public health emergency of international concern.

Provide routine inspection and control activities at designated international airports, ports and ground crossings to prevent the international spread of disease

Make every effort to implement WHO-recommended measures

IHR Core Capacity Monitoring FrameworkIHR Core Capacity Monitoring Framework28 Page Questionnaire for Monitoring Progress in the 28 Page Questionnaire for Monitoring Progress in the Implementation of IHR Core Capacities in the States Parties Implementation of IHR Core Capacities in the States Parties (Core Capacity(Core Capacity--ComponentComponent--Indicator)Indicator)

The IHR Sec required to provide an annual report to the WHAThe IHR Sec required to provide an annual report to the WHA

WHO & States Parties Progress on IHR ImplementationWHO & States Parties Progress on IHR Implementation

Core Capacities include National Legislation (5Q), Core Capacities include National Legislation (5Q), Coordination & NFP Communication (18Q), Surveillance Coordination & NFP Communication (18Q), Surveillance (18Q), Response (27Q), Preparedness (21Q), Risk (18Q), Response (27Q), Preparedness (21Q), Risk Communication (10), Human Resource Capacity (7Q), Lab Communication (10), Human Resource Capacity (7Q), Lab (22Q), POEs (35Q), Zoonotic Events (13Q), Food Safety (24Q), (22Q), POEs (35Q), Zoonotic Events (13Q), Food Safety (24Q), Chemical Events (18Q), & Radiation Emergencies (17Q)Chemical Events (18Q), & Radiation Emergencies (17Q)

Requires multiagency involvement and commitmentRequires multiagency involvement and commitment

Use of this format by States Parties is entirely voluntaryUse of this format by States Parties is entirely voluntary


MOH MALAYSIAMOH MALAYSIA’’S S COMPLIANCE TO COMPLIANCE TO

IHRIHR

The Proven Value of Crisis ManagementThe Proven Value of Crisis ManagementReduces

the total impact

and speeds

recovery from all kinds of health crises.

Reduces

the total impact

and speeds

recovery from all kinds of health crises.

Without Crisis Readiness

Without Crisis Readiness

Damage toFinancial Results, Reputation and Key Relationships

Damage toFinancial Results, Reputation and Key Relationships

Lost Time/ProductivityLost Time/Productivity

CrisisEventCrisisEvent

With Crisis Readiness

With Crisis Readiness

IMPACTIMPACT

TIME

CRISIS

READINESS

Warning Indicators(Flash Points)

WARNING PHASE

Months / Weeks / Hours

EMERGENCYPHASE

Days / Weeks

MitigationPreparedness

Search & RescueEmergency Relief

Rehabilitation

Reconstruction

Ongoing Development

Rapid / Detailed Assessment

SuddenImpact

Rehabilitation / Recovery

Many Months

TIME

AC

TIVITY

12

34 5

Emergency Response and RecoveryEmergency Response and Recovery

Selected Global Frameworks

International Health Regulations (2005)Biological & Toxin Weapons Convention (BTWC)Chemical Weapons Convention (CWC)Hyogo Framework for Action 2005-2015UN Framework Conventions on Climate ChangeAsia Pacific Strategy for Emerging Diseases (APSED) 2010Codex AlimentariusOther frameworks for specific hazards (chemical safety, radiation etc)WHA and Regional Committee resolutions

WHA, resolution 64.10 (2011)

18

OUTBREAKRESPONSE

RegionalCollaboration& cooperation

WHY

HealthEconomicPublic confidence

Infectious Diseases

Mass population movementTransportation of live animal & produceExpanding air travelEncroached territories

Public Health

Medical

Laboratory

Administration

b) Provide PH assessment & care for affected travellers, animals, goods by establishing arrangements with medical, veterinary facilities for isolation, treatment & other services

c)

Provide space, separate from other travellers in in order to interview suspect or affected persons

d) Provide for assessment, quarantine of suspected or affected travellers

e) To apply recommended measures, disinsect, disinfect, decontaminate, cargo, containers, conveyances, goods, etc.

f) To apply entry/exit control for departing & arriving passengers

g) Provide access to required equipment, personnel with protection gear for transfer of travellers with infection/ contamination

POE - Capacity requirements for responding to PHEIC

Point Of Entry - Capacity requirements for responding to PHEIC

a) Emergency response plan, coordinator, contact points for relevant PoE, PH & other agencies

20

PH response PH response ––surveillance systems surveillance systems

A functional INFECTIOUS DISEASE A functional INFECTIOUS DISEASE SURVEILLANCE SYSTEM in place SURVEILLANCE SYSTEM in place

Estimate disease burden Estimate disease burden Determine disease trends Determine disease trends Prediction of outbreaks Prediction of outbreaks

KES HFMD YANG DILAPORKAN DI MALAYSIA

0

50

100

150

200

250

300

350

400

2006 15 29 69 118 123 206 240 336 204 240 177 83 105 50

2005 25 16 70 39 141 67 75 204 239 298 184 178 138 133 106 124 146 247 223 209 192 179 100 154 102 177 85 107 144 130 128 109 115 140 62 81 45 146 97 47 130 110 39 29 40 59 49 32 45 77 24 13

2004 18 5 2 4 13 11 22 12 18 30 25 17 1 1 26 29 9 4 19 16 8 4 11 3 9 16 18 12 12 14 8 14 9 8 17 24 21 38 26 53 61 62 58 41 27 29 72 20 24 29 38 54

2003 9 9 14 11 14 23 31 40 29 53 55 118 102 68 61 52 44 45 36 31 29 24 24 25 19 17 17 18 21 20 27 20 18 17 10 7 10 18 14 7 12 5 6 2 9 5 2 2 5 2 1 2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

21

PUBLIC HEALTH SURVEILLANCE

collection

analysis

interpretationplanning

implementation

evaluation

ACTION


Surveillance Structure

Community / HealthCare Facilities

District

State / Province

National Programme

Global Network

Regional / Sub-regional Network

Information Feedback & Response

Capacity Building

Health Centres, GPs,

Hospitals

District Health Office

State Health Department

Laboratory-

Based

MicrobiologyLaboratories

Clinical based

Sentinel sites,A&E, Wards, OPD,HC

Community / Media /

International/ website

Mandatory notification

Event -

based

Disease Control

Division, MoH

Voluntary –

based

DVS,FOMEMA

IMR / PHL

Surveillance Systems in Malaysia Surveillance Systems in Malaysia --

MOHMOH

24

PreparednessPreparedness

Is the KEY to substantially reducing the health, social Is the KEY to substantially reducing the health, social and economic impact of infectious disease outbreaksand economic impact of infectious disease outbreaksPrudent preparation can limit spread and lessen effectPrudent preparation can limit spread and lessen effectReadiness = capabilityReadiness = capability

ResourcesResourcesSkillSkillKnowledgeKnowledge

Good surveillance mechanismGood surveillance mechanism

Simulation exercise - PanFlu

25

HEART HEART –– HHealth ealth EEmergency mergency AAnd nd

RResponse esponse TTeameam

Comprises ofComprises ofRAPID ASSESSMENT TEAM (RAT)RAPID ASSESSMENT TEAM (RAT)RAPID RESPONSE TEAM (RRT)RAPID RESPONSE TEAM (RRT)

Rapid Assessment And Rapid Assessment And Response TeamResponse TeamOutbreak/Crisis /

Disaster CRISIS PREPAREDNESS AND RESPONSE CENTRE

(CPRC)

CRISIS PREPAREDNESS AND RESPONSE CENTRE

(CPRC)

Public Health Laboratory

Public Health Laboratory

Hospitals & LaboratoriesHospitals & Laboratories

RRT (N)

RRT (N)

RRT(S)

RRT(S)

RRT(D)

RRT(D)

Rapid Assessment Team (RAT)

Rapid Assessment Team (RAT)

PUBLIC HEALTH RESPONSE


RAPID ASSESSMENT TEAMRAPID ASSESSMENT TEAM (RAT)(RAT)

Main function is at district levelMain function is at district levelVerify the occurrence of health Verify the occurrence of health crisiscrisisUndertake risk analysis and needs Undertake risk analysis and needs assessmentassessmentAssess the severityAssess the severityAction depends on the complexity Action depends on the complexity / extend of the outbreak / extend of the outbreak /situation./situation.Members: Members:

MOHMOHDistrict EpidemiologistDistrict EpidemiologistHealth Environmental OfficerHealth Environmental Officer


28

RAT RAT –– must have a sense of urgencymust have a sense of urgency

What the stakeholder wants to know– Situation

What happenWhere it happenWho is affectedHow did it happen

– Send information via SMS / call

RESPONSE RESPONSE MECHANISM MECHANISM

OutbreakOutbreakDistrict Health OfficeDistrict Health Office

Rapid Assessment Team (RAT)Rapid Assessment Team (RAT)

State Heath Office State Heath Office

Ministry of HealthMinistry of Health

RapidResponse Team (RRT)

RapidResponse Team (RRT)


RAPID RESPONSE TEAM RAPID RESPONSE TEAM (RRT) (RRT)

A preA pre--determined team based on determined team based on individual expertise and experience individual expertise and experience matched to meet the unique demands of matched to meet the unique demands of the incidentthe incident

Team approach with the MOH / Epid Officer Team approach with the MOH / Epid Officer being the Maestro being the Maestro

Function from district, state or national Function from district, state or national level depending on extend and level depending on extend and complexity of the outbreak /situationcomplexity of the outbreak /situation


RAPID RESPONSE TEAM RAPID RESPONSE TEAM (ROLES & FUNCTIONS) (ROLES & FUNCTIONS)

to analyse and act on surveillance informationto analyse and act on surveillance informationto plan control and response strategiesto plan control and response strategiesto identify additional resources needed for to identify additional resources needed for

rapid response.rapid response.to investigate and manage the outbreakto investigate and manage the outbreakto collaborate and coordinate with other to collaborate and coordinate with other

relevant agencies relevant agencies to evaluate the effectiveness of the response to evaluate the effectiveness of the response

and intervention measuresand intervention measuresto produce a detailed reportto produce a detailed reportto predict and plan for the management of to predict and plan for the management of

future outbreaksfuture outbreaks


FIRST 12FIRST 12--24 HOURS 24 HOURS

Verify the situationVerify the situationRAT, RRTRAT, RRT

Conduct notificationsConduct notificationsAssess the level of crisisAssess the level of crisis

TrackingTracking-- lab, cases, contactslab, cases, contacts

Organize & delegate assignmentsOrganize & delegate assignmentsPrepare reports Prepare reports Disseminate reports Disseminate reports


Ultimate Goal

Assessment

Management

RISK

Identification

Quantification

Decision

Control / Intervention Reduction

Prevention

HEALTY

POPULATION

RISK

Communication

PH

Response

34

Rapid Containment

Actions & measures taken prior to & during the outbreak will determines the desired outcome

35

Flow chart Outbreak

Physician / pediatrician Lab –District / State

Dpty. Director(Medical)

Dpty. Director (PH)/Epid Officer

MOH Incident Command Centre (CPRC)

(Surveillance Section)

Dpty. DG (PH) / Director Disease Control

Hospital Director

District MOH

State Health Director

Director General of Health

YB Minister /Sec-General

WHO / Others

IMR /NPHL

NATIONAL COMMAND CENTRE ORGANIZATION CHART

Inter‐ministry Crisis‐Disaster Committee(Chairman: Minister of Health)

Ministry of Health Crisis‐Disaster Technical Committee

(Chairman: Director General of Health)

National Command Centre(Chairman: DDG (PH) /Director Disease Control)

Logistic

Secretariat Supplies and

Procurement Health Information

and Promotion Guideline

Surveillance and

Epidemiology

Independent Expert Team

NATIONAL COMMAND CENTRE ORGANIZATION CHART

Director

:

Director of Disease Control Responsible to

:

Ministry of Health Outbreak Technical Committee Chairperson (DG/DDG (PH))

Members

:

All chairpersons of the Units/teams Secretariat UnitSurveillance and Epidemiology UnitSupplies and Procurement UnitHealth Promotion and Information UnitGuidelines UnitLogistic Unit

Task

:

Issuing directive and commands Chair National Operations Room meetingOversees overall outbreak response

STATE COMMAND CENTRE ORGANIZATION CHART

State Crisis‐Disaster Committee(Chairman: State Health EXCO/State Secretary )

State Health Department Crisis‐Disaster Technical Committee(Chairman: State Health Director)

State Command Centre(Chairman: State Operation Room Director)

Secretariat Technical

Information Unit Health

Information UnitSupport Unit


STATE COMMAND CENTRE ORGANIZATION CHART

DISTRICT COMMAND CENTRE ORGANIZATION CHART

District Crisis‐Disaster Committee(Chairman: District Officer)

District Health Department Crisis‐Disaster Technical Committee

(District Health Officer)

District Command Centre(Chairman: District Operation Room Director)

Secretariat EnforcementInvestigation

TeamControl Unit


Support Team

DISTRICT COMMAND CENTRE ORGANIZATION CHART

Chairperson

:

Medical Officer of Health

Members

:

Heads of all UnitsSecretariat UnitSupport UnitInvestigation Unitcontrol UnitEnforcement

Task

:

Issuing directives and commands Oversees overall outbreak response Epidemiological analysis of outbreakReport writingFinal report

42

Risk communicationRisk communicationProviding a customised regular & updated information Providing a customised regular & updated information package targetted at:package targetted at:

StakeholdersStakeholdersMediaMediaPublicPublic

MethodsMethodsUsing health channels Using health channels

Web site. FAQs, pamphlets Web site. FAQs, pamphlets Avenues for publicAvenues for public

HotlinesHotlinesMass mediaMass media

43

Speed of Information FlowDISTRICT

STATE

MOH INCIDENT COMMAND CENTRE (CPRC)(DIRECTOR OF DISEASE CONTROL)

YB MINISTER

DG

DDGs

OTHER AGENCIES

Between 4.00 -

6.00pm

You need to set the time appropriately

By 8.00 am next day

By 12.00 noon


Health Threats Encountered By Health Threats Encountered By the the

Ministry of HealthMinistry of Health


Real Risk of importationReal Risk of importationMalaysia and region at risk of importation of exotic Malaysia and region at risk of importation of exotic and novel biological agents:and novel biological agents:--

Wild poliovirus infection in 1992Wild poliovirus infection in 1992Visceral Leishmaniasis (Kala Azar) in 1993Visceral Leishmaniasis (Kala Azar) in 1993Chikungunya viral infection in 1998Chikungunya viral infection in 1998Nipah viral encephalitis in 1998/99Nipah viral encephalitis in 1998/99Menangle/Tioman Virus in 2000Menangle/Tioman Virus in 2000Cholera 0139 in 2002Cholera 0139 in 2002SARS in 2003 (SEARO & WPRO)SARS in 2003 (SEARO & WPRO)Avian influenza (H5N1) in 2004 (SEARO & WPRO)Avian influenza (H5N1) in 2004 (SEARO & WPRO)Pandemic H1N1 2009Pandemic H1N1 2009??? future importations (H7N9??? future importations (H7N9--WPRO) (MERS WPRO) (MERS CoVCoV--EMRO) (?select biological agents)EMRO) (?select biological agents)

THE CHALLENGES

ComplexityExpenditure

Anthrax scares

Dioxin contamination-Economic Loss

TimeEV71-Sarawak-131 Deaths

Nipah (N.Sembilan)-107deaths

SARS-Economic Loss 1% GDP

Pandemic H1N1(2009)-Economic Loss

Tsunami , 2005

Disaster Crisis

Tsunami-GEJE

Highland Towers-48 deaths

Mud Flood(Perak)-44 deaths

Tropical Storm-

(Sabah)-238 deaths

Malaysia

..countries affected

…death…morbid

% global GDP

Unpredictable - time, place, method, target, collateral damage

Likely to severely test organizationalEmergency Risk management capabilities

..countries affected

…death…morbid

% global GDP

Unpredictable - time, place, method, target, collateral damage

Likely to severely test organizationalEmergency Risk management capabilities

Human Loss, Economic Losses, & ProductivityHuman Loss, Economic Losses, & Productivity

September 11, 2001

Coronavirus, H7N9, MERS CoV…..

Sulu gunmen Incident, April –

May 2013

Bus plunging into ravine-

Genting Highlands-37 deaths

48

Main Aim during infectious disease outbreaks

Saves lives, minimize illness

Contain outbreak

Prevent spread

Minimize impact to the other services

Allay public fear/panic

Maintain public trust /order

49

Challenges Challenges ––emergence of emergence of infectious disease outbreaks infectious disease outbreaks

Over the past 40 years, 39 new infectious diseases have been disOver the past 40 years, 39 new infectious diseases have been discovered, 20 covered, 20 diseases are now drugdiseases are now drug--resistant, and old diseases have reappeared. About resistant, and old diseases have reappeared. About 75% of emerging pathogens are zoonotic. 75% of emerging pathogens are zoonotic. New diseases with old infectious agentsNew diseases with old infectious agents

Food poisoning (E.coli 0157:H7)Food poisoning (E.coli 0157:H7)Antibiotic resistant organism (NDMAntibiotic resistant organism (NDM--1,MDR/XDR)1,MDR/XDR)

New diseases with new infectious agentsNew diseases with new infectious agentsNipah, SARS, Ebola, HPAI, Pandemic (H1N1) 2009Nipah, SARS, Ebola, HPAI, Pandemic (H1N1) 2009

Old disease in new locationsOld disease in new locationsWest Nile Virus, Rift Valley Fever, Chikungungya, Kala AzarWest Nile Virus, Rift Valley Fever, Chikungungya, Kala Azar

50

Major ID outbreaks Major ID outbreaks –– Economic impact Economic impact

In MalaysiaIn Malaysia-- Pandemic H1N1 2009Pandemic H1N1 2009 ≋≋ nnot costed yetot costed yet

Avian Influenza (2004Avian Influenza (2004--6) 6) ≋≋ RM 2 millionRM 2 millionSARS (2003) SARS (2003) ≋≋ USD 1.5 billion (approx)USD 1.5 billion (approx)Nipah encephalitis (1998/99) Nipah encephalitis (1998/99) ≋≋ RM 6 millionRM 6 millionHFMD in Sarawak (1997) HFMD in Sarawak (1997) ≋≋ RM 4 millionRM 4 million

0 1 2 3 4 5 6 7

Philippines

Malaysia

Thailand

Indonesia

Singapore

Korea

Taiwan

China, mainland

Hong Kong

Reduction of GDP (USD billion) Source: ADB –Economic impact due to SARS

PANDEMIC H1N1 2009 PANDEMIC H1N1 2009

Pandemic H1N1 2009 Pandemic H1N1 2009 -- TimelineTimeline

April 12: an outbreak of influenza-like illness in Veracruz, Mexico reported to WHO

April 15-17: two cases of the new A(H1N1) virus infection identified in two southern California counties, USA

April 23: novel influenza A (H1N1) virus infection confirmed in several patients in Mexico

April 24: WHO declares a public health event of international concern (PHEIC)

April 27: WHO declares pandemic Phase 4 -

sustained community transmission in Mexico

In 9 weeks, all WHO regions reporting confirmed cases of pandemic (H1N1) 2009

April 29: WHO declares pandemic phase 5 (2 countries affected) June 11: WHO declares pandemic

Phase 6 (virus has spread to 2 WHO regions)

Malaysia: Pandemic ScenarioMalaysia: Pandemic Scenario--20092009

Population

Death 5,546

20%

2% 9%

499,140110,920

27,730

27,730,000 (2008)

5,546,000 8,319,000

8,319

748,710166,380

41,595

0.1% 0.5%

30%

2% 9%

0.1% 0.5%

Hospitalisation

Sick

Penularan Global

“ …… At this point, further spread of the pandemic, within affected countries and to new countries, is considered inevitable.

This assumption is fully backed by experience. The 2009 influenza pandemic has spread internationally with unprecedented speed. In past pandemics, influenza viruses have needed more than six months to spread as widely as the new H1N1 virus has spread in less than six weeks. ….”

WHO, Geneva, 16July 2009

Global spread

http://images.google.com.my/imgres?imgurl=http://www.thewashingtonnote.com/archives/globe.jpg&imgrefurl=http://www.thewashingtonnote.com/archives/2007/12/&usg=__ab_xNPpirlPNHlzpkO9uqmqCGnY=&h=360&w=360&sz=23&hl=en&start=10&tbnid=zmD4ClHYVzUxhM:&tbnh=121&tbnw=121&prev=/images%3Fq%3Dglobe%26gbv%3D2%26hl%3Den%26sa%3DG

Shift from Containment to Mitigation Shift from Containment to Mitigation

Sporadic Cases Clustering (limited community-

level transmission)

Community level outbreak

(sustained transmission)

Pandemic level spread

(extensive transmission)

CONTAINMENTCONTAINMENT

MITIGATIONMITIGATION

To stop or delay the spread of the virus by detecting cases and taking vigorous actions, such as contact tracing, treatment and/or quarantine

of contacts

To slow the spread of the virus in the community and minimize transmission to vulnerable populations

To ensure healthcare for those who need it most

To minimise social disruption and other

negative consequences

Control Measures Implemented by MOH Control Measures Implemented by MOH MalaysiaMalaysia

ACTIVITY CONTAINMENT PHASE

MITIGATION PHASE

ORGANISATIONAL RESPONSENational Pandemic Influenza Inter Agency Committee

√ √

National Pandemic Influenza Technical Committee

√ √

National Pandemic Influenza Command Centre (National,State & District Levels)

√ √

PUBLIC HEALTH RESPONSESurveillance System √ √

Screening at Entry Point √ √

Home Quarantine √ −

Case Detection and Investigation √ −

Contact Tracing √ −

Home isolation & Self Monitoring − √



MITIGATION PHASE

PUBLIC HEALTH RESPONSE (contd.)Academic Institution Closure √ −

(commenced on 12/08/2009)

Influenza-like illness (ILI) case Cluster Management

− √

Risk Communication –

Website, Press Statement, Print & Electronic media

√ √

MEDICAL RESPONSEClinical Case Management √

(28 hospitals)√

(Hospital & Clinic)

Antiviral Stockpiling √(10% of population)

√(20% of

population)

Influenza A(H1N1) case notification √ √

Infection Control √ √



MITIGATION PHASE

LABORATORY RESPONSE

Clinical Sample Management √(IMR & NPHLab)

√(IMR,

NPHLab,+UMMC = HSB + UKM)

Viral sequencing analysis & resistance study − √

Laboratory-based Surveillance √ √

PH response PH response ––Prevention & Control measuresPrevention & Control measures

Activities Activities Case definition Case definition –– field basedfield basedACD & Contact tracingACD & Contact tracingHome surveillance Home surveillance Infection Control & Triaging Infection Control & Triaging Case isolation / QuarantineCase isolation / QuarantineFood premises inspection & closureFood premises inspection & closureCulling & depopulateCulling & depopulate

PH response PH response ––Prevention & Control Prevention & Control MeasuresMeasures

Activities Activities Stockpiling Stockpiling ––drugs/vaccine/PPEsdrugs/vaccine/PPEs

Risk communicationRisk communication

Health educationHealth education

Advisories Advisories

SOPs/ GuidelinesSOPs/ Guidelines

PH response PH response ––Prevention & Control Prevention & Control MeasuresMeasures

Engineering & Environmental controlEngineering & Environmental controlWater supplyWater supply

Waste disposalWaste disposal

Sewage disposalSewage disposal

Home & work place environmentHome & work place environment

PH response PH response –– Cooperation & Cooperation & Coordination Coordination

Safe work place Safe work place Public order & securityPublic order & securityCommunity mobilizationCommunity mobilizationEntry points in to the country Entry points in to the country Inter & intra agency involvementInter & intra agency involvementInternational relationsInternational relations

International Health Regulations 2005International Health Regulations 2005

64

PH response PH response –– Human resource Human resource

Healthcare personnel needs and protection Healthcare personnel needs and protection Vaccination Vaccination PPEsPPEsHealth screening Health screening SOPs & GuidelinesSOPs & GuidelinesHealth talksHealth talksTrainingTrainingWork safety (Biorisk Mx)Work safety (Biorisk Mx)

HospitalHospitalLaboratoryLaboratoryFieldField

Medical responseMedical response

Notification & reporting Notification & reporting Triaging and isolationTriaging and isolation

Fever clinics Fever clinics

Clinical managementClinical managementEarly diagnosis & confirmationEarly diagnosis & confirmationTimely isolation & appropriate treatmentTimely isolation & appropriate treatmentDecontamination facilities Decontamination facilities Designated hospitals with specialized ID servicesDesignated hospitals with specialized ID services

Laboratory responseLaboratory response

Pathogen surveillance Pathogen surveillance LabLab--based surveillancebased surveillance

Sample collection, handling & transportationSample collection, handling & transportationExpanded repertoire of diagnostic tests at reference Expanded repertoire of diagnostic tests at reference labslabs

IMR, PHLsIMR, PHLsBSL3 BSL3

Stockpiling of essential requirementsStockpiling of essential requirements

Response from material support Response from material support

Supplies & procurement Supplies & procurement Vaccines, essential items, etc Vaccines, essential items, etc

FinanceFinanceContingency fundContingency fund

Logistics Logistics TransportTransportIT, computers,etc.IT, computers,etc.

A document which serves as a time bound guide A document which serves as a time bound guide for preparedness and response plan for influenza for preparedness and response plan for influenza pandemicpandemicContain specific advice and actions to be taken by Contain specific advice and actions to be taken by MOH and other relevant agencies & NGOsMOH and other relevant agencies & NGOsEnsure resources are mobilized and used most Ensure resources are mobilized and used most efficientlyefficientlyUndergoing revision and updating to meet Undergoing revision and updating to meet current/future needscurrent/future needs

National Influenza Preparedness Pandemic National Influenza Preparedness Pandemic Plan (NIPPP)Plan (NIPPP)–– an example of collective an example of collective

preparedness & responsepreparedness & response

National Influenza Pandemic Preparedness Plan (NIPPP)

Preparation started in 2003

Prepared by National Influenza Pandemic Planning Committee –multidisciplinary, inter-agencies/departmental and experts.

Launched on 9 Jan 2006 by Minister of Health

Documents available on website

NIPPP – Strategies

Organizational Response –3 main committees

Public Health Response

Medical Response

Laboratory Response

Risk Communication

Social Response

National Influenza Preparedness National Influenza Preparedness Pandemic PlanPandemic Plan

Public Health Response Public Health Response Surveillance of ILISurveillance of ILIPrevention & Control measuresPrevention & Control measuresCoordination with relevant agencies Coordination with relevant agencies Travel advisories Travel advisories SelfSelf––health monitoring health monitoring Training & simulation exercisesTraining & simulation exercisesInformation dissemination &Information dissemination &Risk communicationRisk communication


Medical ResponseMedical ResponseClinical case definition & admission criteria Clinical case definition & admission criteria

Stockpiling of essential drugs / vaccines / Stockpiling of essential drugs / vaccines / PPEsPPEs

Isolation & deIsolation & de--contamination facilities contamination facilities

Training & simulation exercisesTraining & simulation exercises

Notification & reporting Notification & reporting


Laboratory ResponseLaboratory ResponseInfluenza virus surveillance Influenza virus surveillance

Reference lab & BSL3 Reference lab & BSL3

Training & simulation exercise Training & simulation exercise

International collaborationInternational collaboration

VIRALVIRAL ENCEPHALITISENCEPHALITIS

(JE+Nipah)(JE+Nipah)

OUTBREAKOUTBREAK (period Sept 1998 (period Sept 1998 -- May 1999)May 1999)

Gaps identified & Lessons LearntGaps identified & Lessons Learnt

Key Facts For Action……. ♦Relationship between domestic

animals and human Nipah Virus infection

♦Reasons for high prevalence in certain ethnic groups

♦Steps in controlling spread of Nipah Virus in Malaysia

♦Preventing re introduction and spread of Nipah virus

KEDAHP. Langkawi

SELANGOR

N. SEMBILAN

MELAKA

KELANTAN TERENGGANU

PAHANG

Pulau Tioman

JOHOR

THAILAND

PERAK

P .PINANG

Manjung

P.D ickson

B .Pahat

Pont ian

Kinta

PERLIS

K.LangatKe

A .Gajah

Sepang Seremban

Figure 1 : LOCATION of NIPAH VIRUS OUTBREAK in PENINSULAR MALAYSIA

S P U

S P S

>

> >

>

>

>

>

>

>

>

>

Bkt. Minyak

SikamatBkt Pelanduk Site A & Site B

Ampang

>

Kg. Selam at

Damar Laut / Segari

Paya Mengkuang

Pekan Nenas

ValdorBt. Maung

Sepang Tumbok

>Arau

Tumpat >

T U M P A T

>

>

K.KangsarK.Kangsar

C.HighlandC.Highland

GurunK.M uda

M.Tengah Mersing

M ersing

Kuantan >Kuantan

>K.KraiK .K R A I

>

>

>

Pig farm ing areas

Nipah virus outbreak areas

The Nipah Virus Landscape

No of VE Cases According to date of onset from No of VE Cases According to date of onset from epid week 39, epid week 39, 19981998 to week 23 year to week 23 year 19991999

0

10

20

30

40

50

60

39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 230

50000

100000

150000

200000

250000

300000

No of cases No of pigs culled

Okt98 Nov98 Dis98 Jan99 Feb99 Mac99 Apr99 May99 June99

Outbreak in Perak

Outbreak in Kinta, PerakAnd Sikamat, Negeri Sembilan

Outbreak in Sg. Nipah,Bkt Pelanduk,

Negeri Sembilan

Outbreak in Sg. Buloh,Negeri Sembilan

10 0 0

5

12

17

48

45

1 0 0 1 0

4

1 12 1 0 0

5

10

0 1 13

12

4

15

28

48

0

10

20

30

40

50

60

39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 190

50000

100000

150000

200000

250000

300000

BIL. KHINZIR DIMUSNAHKAN BIL. KES

Okt,98 Nov,98 Dis,98 Jan,99 Feb,99

BIL KES

MINGGU

No. of Nipah cases according to Date Onset from Epid Week 39 1998 to Week 19 Year 1999No. of cases

EPID WEEK

Mac,99 Apr. 99

Mei 99

Source: MOH

Outbreak in Kinta locality, Perak State

Outbreak in Kinta, Perak & Sikamat, Negeri Sembilan

Outbreak in Sg Nipah, Bkt Pelanduk, Negeri Sembilan

ContentsContents……..EpidemiologyEpidemiologyInvestigationInvestigationPrevention Prevention and Controland ControlFurther Further researchresearchLessons Lessons LearntLearnt

EpidemiologyEpidemiology……

Cases Cases : : 283 VE cases 283 VE cases admittedadmittedDeaths :Deaths : 110 deaths (VE)110 deaths (VE)Case Fatality rateCase Fatality rate: : 39%39%Occupational history/Occupational history/Exposure history:Exposure history: 80% pig 80% pig farmers and proprietors.farmers and proprietors.

EpidemiologyEpidemiology……Age Age : : Mean age 38 Mean age 38 yrs (2yrs (2--75yrs)75yrs)Age distribution:Age distribution: 52%52%((3030--49yrs),49yrs), 22%22%((above 50 yrs,above 50 yrs, 18%18%(20(20--29yrs)29yrs)Gender distributionGender distribution : : 83% males83% males

Frequency Frequency of Clinical of Clinical SymptomsSymptoms……

Fever : 100%Fever : 100%Drowsiness: 88%Drowsiness: 88%Headache : 82%Headache : 82%Disorientation/confusion : Disorientation/confusion : 76%76%Giddiness : 6%Giddiness : 6%Myalgia : 54% Myalgia : 54% Cough /Respiratory symptoms Cough /Respiratory symptoms : 40%: 40%Seizure : 28%Seizure : 28%Vomiting : 19 %Vomiting : 19 %

Frequency Frequency of Clinical of Clinical SymptomsSymptoms……

Reduced consciousness: Reduced consciousness: 88%88%Segmental myoclonus : Segmental myoclonus : 60%60%Hyporeflexia /Areflexia : Hyporeflexia /Areflexia : 60%60%Seizure : 40%Seizure : 40%Cranial nerve palsy : 29%Cranial nerve palsy : 29%Pyrimidal signs :21%Pyrimidal signs :21%Nystagmus /cerebellar Nystagmus /cerebellar signs :17%signs :17%Meningism :10%Meningism :10%Dysphasia : 6%Dysphasia : 6%

Paramyxovirus Paramyxovirus groupgroup……

Similar toSimilar to Hendra Hendra virusvirus ((Australia , Australia , 1994)1994)EnvelopedEnveloped RNA virusRNA virus21% difference21% difference in the in the nucleotide sequences nucleotide sequences && 11% differences11% differences in in the amino acid the amino acid sequence compared sequence compared to Hendra virusto Hendra virus

Paramyxovirus Paramyxovirus groupgroup……

Transmitted to Transmitted to humans through humans through close contact ofclose contact of body body secretionssecretions of the pigof the pigSusceptible toSusceptible to soapsoap& common & common householdhouseholddetergentsdetergentsLocally namedLocally namedNipah Nipah virusvirus

ImpactImpact……High morbidity & mortalityHigh morbidity & mortality among human among human & animals& animalsMovement (eviction)Movement (eviction) of peopleof peopleDamage to pig farming industryDamage to pig farming industryChange in direction ofChange in direction of futurefuture of pig of pig industryindustrySubstantial Substantial economic losseconomic loss

Prevention & Prevention & ControlControl

InteragencyInteragencyCollaborationCollaboration

National Task forceNational Task forceMinistries of Health, Ministries of Health, Agriculture,Education, Agriculture,Education, Social welfare, Public Social welfare, Public works, Finance, Armed works, Finance, Armed forces, Police ,etc.forces, Police ,etc.

Interagency Interagency CollaborationCollaboration

Rapid Action TeamRapid Action TeamDeploymentDeployment of staffof staffLocalLocal collaboration:collaboration:

Research InstitutesResearch InstitutesUniversitiesUniversitiesArmy, veterinary, Army, veterinary, police & otherspolice & others

International International collaboration:collaboration:

CDC Atlanta,USACDC Atlanta,USAAustralia Animal Australia Animal Research Research Lab,Geelong,AustraliaLab,Geelong,AustraliaWHO ,WPRO/ WHO ,WPRO/ Geneva,OIEGeneva,OIE..

Prevention & Prevention & ControlControlStrengthen Strengthen NotificationNotification

Health education of Health education of the publicthe public

Strengthen Strengthen SurveillanceSurveillance of of humanshumans (farm (farm workers,army workers,army personnel, MOH,DPH personnel, MOH,DPH staff through testing staff through testing using serologyusing serology

Prevention & Prevention & ControlControl

Sentinel Sentinel animal animal surveillancesurveillance

Pigs inPigs in farmfarm ttested ested usingusing serologyserologyPigs atPigs at abattoirs abattoirs selectively selectively screenedscreenedPigs at farms Pigs at farms tested usingtested usingserology and SNTserology and SNT

Protective Protective GearGear

ToTo betterbetter understand understand thethedisease disease To further clarifyTo further clarify modes modes of transmissionof transmissionTo ascertainTo ascertain natural natural history of diseasehistory of disease

Is thereIs there delayed delayed manifestation ?manifestation ?Is thereIs there relapse ?relapse ?Is thereIs there late onset ?late onset ?IsIs reinfectionreinfection possible?possible?

To establishTo establish illness to illness to infection ratioinfection ratio

ResearchResearch……

Research..Research..To know theTo know the natural natural history of the virushistory of the viruswildlife reservoirwildlife reservoirMechanisms & factors Mechanisms & factors associated with associated with transmission oftransmission of Nipah Nipah VirusVirus from animal to from animal to animal, animal to animal, animal to human, & potential human, & potential routes of human to routes of human to human spread.human spread.

lessons lessons Learnt..Learnt..No capacityNo capacity to cope with such to cope with such emerging infectious disease :emerging infectious disease :

Lacking in rapid response Lacking in rapid response Infectious Disease CentreInfectious Disease Centre..

No biosafety labsNo biosafety labs in the in the country to handle an organism country to handle an organism whichwhich CDC classified asCDC classified as a a P4 P4 agent.agent.

Upgraded 2 MOH labs to P3.Upgraded 2 MOH labs to P3.Smart working partnershipSmart working partnershipwith international agencies.with international agencies.

lessons lessons Learnt..Learnt..Poor inPoor in risk communication.risk communication.

Need toNeed to relayrelay the right messagesthe right messages at at the right time , by the right person the right time , by the right person to the right target population .to the right target population .Handling the media.Handling the media.

Disease reporting byDisease reporting by““SyndromicSyndromic”” approach.approach.To beTo be everever--vigilantvigilant fforor zoonotic zoonotic diseasesdiseases

Pigs may transmit bacterial Pigs may transmit bacterial diseases like anthrax, brucellosisdiseases like anthrax, brucellosisHong Kong Avian influenza. (H5N1)Hong Kong Avian influenza. (H5N1)

The OpportunityAn An allall--hazardshazards, , multisectoral health multisectoral health emergency risk emergency risk management management approach:approach:

Better health outcomes for Better health outcomes for people at risk of people at risk of emergenciesemergencies

Increased capacity to Increased capacity to manage health risks from all manage health risks from all hazardshazards

Effective prevention, Effective prevention, preparedness, response, preparedness, response, recoveryrecovery

Resilience of communities Resilience of communities and health systemsand health systems

WAY FORWARDWAY FORWARD…………..Efficient response depends on:Efficient response depends on:

Moving away from a disease based strategy to a Moving away from a disease based strategy to a multi hazard approachmulti hazard approachPreparedness which include innovative Preparedness which include innovative infrastructure, appropriately trained personnel and infrastructure, appropriately trained personnel and adequate fundingadequate fundingAn efficient integrated IT enabled surveillance An efficient integrated IT enabled surveillance system, early alert mechanism & data management system, early alert mechanism & data management CoCo--ordination of various parties involved with well ordination of various parties involved with well defined responsibilities and functionsdefined responsibilities and functionsA clear line of communication and chain of commandA clear line of communication and chain of commandCustomised preventive and control measures Customised preventive and control measures Targeted Risk communication Targeted Risk communication


WAY FORWARDWAY FORWARD…………contd.contd.Efficient response depends on:Efficient response depends on:

Regional collaborative approach through Regional collaborative approach through established bilateral/multilateral platforms established bilateral/multilateral platforms Strengthening of the Strengthening of the ‘‘One HealthOne Health’’ agendaagendaSmart integrative compliance to existing Smart integrative compliance to existing international conventions and agreementsinternational conventions and agreementsApplication of select lessons learnt during Application of select lessons learnt during previous incident experienceprevious incident experiencePreparing for that element of surprise and Preparing for that element of surprise and anticipating a worst case scenarioanticipating a worst case scenario

Acknowledgement and Acknowledgement and AppreciationAppreciation

DirectorDirector--General of Health MalaysiaGeneral of Health Malaysia

Deputy DirectorDeputy Director--General (Public Health) and General (Public Health) and Director of Disease Control, MOH MalaysiaDirector of Disease Control, MOH Malaysia

Ministry of Foreign Affairs MalaysiaMinistry of Foreign Affairs Malaysia

Assistance of related Agencies in MalaysiaAssistance of related Agencies in Malaysia

UNODA, EU and the Implementation Support Unit UNODA, EU and the Implementation Support Unit of the BTWCof the BTWC

To various persons for use of content in selected To various persons for use of content in selected slides in this presentationslides in this presentation

Organisers & Secretariat of this Regional Workshop Organisers & Secretariat of this Regional Workshop

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