rspi sulianti saroso

7/30/2019 RSPI Sulianti Saroso

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Hospital Preparedness plan for Avian

Influenza and Pandemic Influenza

Pontianak -Indonesia, 21 March 2013

National Infectious Disease Hospital Prof.dr. Sulianti

Saroso, Jakarta


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Avian Influenza

Pandemi Influenza


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Pandemic phase


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4

1918 SPANISH FLU

40 t0 50 million deaths

A (H1N1)

1957 Asian Flu

2 million deaths

A (H2N2)

1968 Hongkong Flu

1 million deaths

A (H3N2)

INFLUENZA PANDEMIC IN 20TH

CENTURY


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Pandemic Influenza( H1N1) 2009

Since Mei 2009 ~ Juni 2010

First Case Indonesia

hospitalized in Sulianti

Saroso - Hospital

Total case :

Suspect case : more

than 500

Confirm case : 291 (130ward, 161 outpatients)

Death : 5

CFR : 1 % Last pandemic????


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N=1055 cases

Cases H1N1 PandemiIndonesia, 2009

55

140

31

326

1

96

39

183

1037

3 11 734

4 3 126 16

1 8 1 220

0

50

100

150

200

250

300

350

Bali

Ban

tenDIY

DKIJak

arta

Ja

mbi

JawaB

arat

JawaTen

gah

JawaTimur

KalimantanB

arat

KalimantanSelatan

KalimantanTen

gah

KalimantanTimur

Kepulauan

Riau

Lamp

ung

NAD

NTB

NTT

Riau

SulawesiSelatan

SulawesiTen

gah

SulawesiUtara

SumateraB

arat

SumateraSelatan

SumateraU

tara


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Clinical manifestation influenza A H1N1 patients in USA

Percentage

MMWR, May 8 2009/vol. 58/no.17


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Age > 65 years Children < 5 years old Pregnant women Chronic medical conditions

(Asthma, Diabetes, Heart disease)

Immunosuppressed(e.g., taking immunosuppressive medications,

infected with HIV)

Higher risk of serious complications


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Avian Influenza


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Epidemiology


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Updates H5N1

WHO H5N1 cumulative case : 2003-2013

(12 March 2013)

INDONESIA : 160/192 ; CFR: 83,3 %

WORLDWIDE : 371/ 622 : CFR : 59,6 %

15 Province and 57 District (West

Kalimantan No case)

Last case:

West Java, child , 4 years old, 6 December 2012


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Distribution Avian Influenza 2005-2012


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Cluster Case AI 2005-2012


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AVIAN INFLUENZA ( H5N1) at

NIDH Sulianti Saroso

SINCE : 2005- 2011

TOTAL CASE :

SUSPECT CASE : MORE THAN 300 CONFIRM CASE : 36

DEATH : 30

CFR : 83,3 %


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Unit 5 - Clinical Management Slide 5-15

Suspected influenza A/H5 case

A person presenting with unexplained acute lower respiratory illness

with fever ( >38oC) and cough, shortness of breath or

difficult breathing

AND

One or more of the following exposures in the 7 days prior to symptom

onset:

A. Close contact (within 1 metre) with a person (e.g. caring for,

speaking with, or touching) who is a suspected, probable, or

confirmed H5N1 case;B. Exposure (e.g. handling, slaughtering, defeathering,

butchering, preparation for consumption) to poultry or wild

birds or their remains or to environments contaminated by

their faeces in an area where H5N1 infections in animals or

humans have been suspected or confirmed in the last month;

C. Consumption of raw or undercooked poultry products in an

area where H5N1 infections in animals or humans have been

suspected or confirmed in the last month;

D. Close contact with a confirmed H5N1 infected animal other

than poultry or wild birds (e.g. cat or pig);

E. Handling samples (animal or human) suspected ofcontaining H5N1 virus in a laboratory or other setting.

Probable influenza A/H5 case

i) A person meeting the criteria for a suspected case

AND

One or more of the following additional criteria:

A. Infiltrates or evidence of an acute pneumonia on chest radiograph plus

evidence of respiratory failure (hypoxemia, severe tachypnea)

B. . positive laboratory confirmation of influenza A infection but insufficient

laboratory evidence for H5N1 infection.

OR

ii) A person dying of an unexplained acute respiratory illness who isconsidered to be epidemiologically linked by time, place, and exposure to a

probable or confirmed H5N1 case.

Confirmed influenza A/H5 case

A person meeting the criteria for a suspected or probable case

AND

One of the following positive results conducted in a national, regional or

international influenza laboratory whose H5N1 test results are accepted by

WHO as confirmatory:

A. Isolation of an H5N1 virus;

B. Positive H5 PCR results from tests using two different PCR targets,

e.g. primers specific for influenza A and H5 HA;

C. A fourfold or greater rise in neutralization antibody titer for H5N1

based on testing of an acute serum specimen (collected 7 days or

less after symptom onset) and a convalescent serum specimen. The

convalescent neutralizing antibody titer must also be 1:80 or higher;

D. A microneurtralization antibody titer for H5N1 of 1:80 or greater in a

single serum specimen collected at day 14 or later after symptom

onset and a positive result using a different serological assay.

WHO Case Definition


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Diagnosis

1) People on investigation

2) Suspect AI3) Probable AI

4) Confirm AI


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Clinical Presentation

Fever

Respiratory symptoms:

- Influenza like illness/URTI

- cough, breathlessness

- severe, rapidly progressive pneumonia

- Acute Respiratory Distress Syndrome

Gastrointestinal : diarhea

Unusual : conjunctivitis, encephalitis, renal failure,hepatic impairment,


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Common Admission Laboratory Characteristics Leukopenia, especially lymphopenia Thombocytopenia (mild to moderate)

Elevated Aminotransferase (moderate)

Complications Renal failure

Cardiovascular collapse

Ventillator-associated pneumonia Pancytopenia

Sepsis (without documented bacteremia)

Rapid respiratory failure (ARDS)

Clinical Manifestations


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Clinical and laboratory features on admissionsKandun et al,The Lancet Aug 2008


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Multifocal or patchyinfiltration

Diffuse uni/bilateralinfiltrate

Intertitial, groundglassappearance

Segmental, lobarconsolidation

ARDS manifestations. Pleural effusions

2005

Radiology

Rapid progresif to ARDS


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Management


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Case Management Protocol

Hospitalized in individualisolation room/ICU

Infection controlstrict barrier nursing

Respiratory/supportivecare

Antiviraltherapy/prophylaxis

Antibiotics

Supportive care

Nutrition enteral optimal Prepare nosocomial

infection

Prepare deep vein

thrombosis (DVT)

Monitoring fluid adequate

(vena central)

Respiratory monitoring: Oxygen therapy (canula and

masker,O2>90%)

Ventilatory support

Prevent barotraumas


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Treatment

Treatment should begin as soon aspossible after symptoms start

DRUG OF CHOICE the antiviralmedication OSELTAMIVIR (TAMIFLU)may make the disease less severe ifyou start taking the medicine within48 hours after your symptomsstart.

Zanamivir : shows promise in the lab

but has not been widely used inhuman cases of bird flu

Human Avian Influenza RESISTEN tothe antiviral medicines AMANTADINEand RIMANTADINE

24

Therapeutic dose : 2 X 75 mgfor 5 days, may up to 10 days

Prophylactic dose: 1 X 75 mg for 7

days


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PRE HOSPITAL

Pre-hospital care is predominantly supportive: Supplemental oxygenation to manage respiratory symptoms or

objective hypoxia may be needed

Tamiflu and symptomatic drugs

Ventilatory support with a bag-valve-mask device and/or with field

intubation may be required if the patient is in respiratory failure.

Intravenous access should be obtained, and a bolus of a crystalloid

can be administered to support hemodynamic stability.

Attention should be given to the appropriate use of personal

protective equipment (PPE) by the pre-hospital providers and

advance notification should be given to the hospital regarding the

potential need for patient respiratory isolation.

General guidelines in low-risk areas are that patients with

fever and respiratory complaints should wear a standard

mask, if tolerated, to decrease airborne and droplets


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Facilities


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Ward

In Patient : 137 186 Beds Intensive Care Unit :

Infectious : 7 Beds (renovation)

Non infectious : 3 Beds Isolation Ward :

( HEPA filter , close ventilation ) 11 Beds : 1 for HCU, 10 beds for airborne isolation

MDR TB Ward: (HEPA filter) 2 beds


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Anticipating the Avian Influenza case

and Preparedness Pandemi Influenza

Set up a team

Develop a Standard Operation Procedure

Logistics (PPE, Medicines, disposables, etc)

Center of activity response out break(Internet, Faximile)

Hotline Phone : (021) 6506559 ext 1710, (021)6401412

Socialization , Refreshing & Simulation Networks :

CDC office, NIHRD

Provincial Health Offices Surveillance, etc


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Policies

Follow MoH guidelines for case definition,

management, etc

Follow WHO guidelines for case definition,

management, etc

Case management depends on clinical

manifestation and hospital resources

Upgrade standard procedure


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Flow patient AI to Hospitalized


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Scenario 1

Referral from

RS/fasyankes

security

Isolation

ward Mawar


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Skenario 2

Referral RS/fasyankes with

Mechanical ventilation to RSPI

Security

ICU Isolation


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Scenario 3

Patient at IGD RSPI

with suspect AI

Suspect AI

Isolation ward

Mawar

Observation atTriage Complete :

Lab and Radiology


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Air borne isolation ward

Enter patient

Enter HCW

Patient Out

Nurse Station


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Isolation Wards

Established since 2003 (after

SARS outbreak)

11 beds capacity Isolation

( expand 3 wards 35 beds) Equipped with:

- Single room with bathroom

- Negative pressure

- HEPA filter- Close ventilation system

- Anteroom

- CCTV Enter patient


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Isolation Room Nurse Station


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Reporting

Faximile

Personal computer Printer

Internet

Phone direct andinternal


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Ambulance

2 Ambulance with portable

mechanical ventilation

2 Ambulance Trauma

1 Ambulance for death

bodies


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Field Hospital

4 units mobile

Capasity 24 beds kohorting

per unit


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Simulation Manage Avian

Influenza and Pandemi Influenza


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Simulation


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Monitoring and protection for HCW

All HCWs in contact with suspect/confirmed

cases are ordered to self record their own

health daily, if fever and other symptoms

appears

Blood samples were collected but time of

sampling were vary. The result was negative in

all HCWs blood samples Should any symptom appear, nasal and

pharyngeal swab be taken for PCR test


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Summary

Develop, simulation, Refreshing team

Avian Influenza : Poultry to Human

Diagnosis : PCR and serology

DOC : Oseltamivir

Personal hygiene and PPE

No pandemic Influenza again


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I HOPE BIRDS FLU GO FROM INDONESIA,

AND BUSINESS COUNTINUITY

bij k l i


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Kebijakan Penanggulangan Episenter

Pandemi Influenza

1. Komando dan Koordinasi

2. Surveilans Epidemiologi

3. Respon Medik

4. Intervensi farmasi

5. Intervensi non farmasi

6. Komunikasi risiko

7. Mobilisasi Sumber Daya

8. Pengawasan perimeter

9. Pengawasan Kekarantinaan di pintu masuk(Bandara, Pelabuhan dan PLBD)


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10 STRATEGI NASIONAL

1. Pengendalian penyakit pada hewan sumbernya

2. Penatalaksanaan Kasus pada Manusia

3. Perlindungan Kelompok Risiko Tinggi

4. Surveilans Epidemiologi pada Hewan & Manusia

5. Restrukturisasi Sistem Industri Perunggasan

6. Komunikasi Informasi dan Edukasi

7. Penguatan Dukungan Peraturan

8. Peningkatan Kapasitas PILLAR 3: RAPIDRESPONS & RAPID CONTAINMENT

9. Penelitian Kaji Tindak

10. Monitoring & Evaluasi

rspi sulianti saroso

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