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

g to

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



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]


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



12 000[<15 000]

Middle East & North Africa36 000

[20 000 – 60 000]

Sub-Saharan Africa2.1 million

[1.8 – 2.4 million]


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.”

The Challenges of Communicable Diseases

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