ABCs in EIDs: Preparing for Emerging Infectious Diseases

Your Step by Step Guide in Preparing
for Emerging Infectious Diseases
Arthur Dessi E. Roman MD MTM FPCP FPSMID
PHICS 21st Annual Convention
Crowne Plaza Galleria Manila, 28 May 2015
EIDs
@gonnabedess #WhatNow
@PHICS2015 @gonnabedess
‘s in
by AD Roman presented during the 21st PHICS
Annual Convention, 27-28 May 2015

2RESEARCH INSTITUTE FOR TROPICAL MEDICINE
Why is PH concerned about the
threat of EIDs?
According to NSO, as
of April 2014:
•
worldwide
• ~53.3 % in Middle
East (majority are
in KSA)
• China is nearby
by AD Roman presented duringthe 21st PHICS AnnualConvention, 27-28May 2015

With emerging diseases at
the forefront, should travel
history be placed in the
general data?

Objectives
• To discuss general guidelines in preparing for EIDs
in your institution
• To elaborate on the roles of hospitals/frontliners in
case detection, reporting, and controlling the
spread of EIDs

EIDs are evolving
Interim guidelines change as new
information becomes available.
Keep yourself
updated!

www.ritm.gov.ph

Patient care Safety of HCW

Definitions
“Emerging" infectious diseases
Infectious diseases whose incidence in humans has
increased in the past 2 decades or threatens to
increase in the near future which respect no
national boundaries
http://wwwnc.cdc.gov/eid/page/background-goals

Definitions
Re-emerging Infectious Diseases
Old infections re-emerging as a result of antimicrobial
resistance in known agents or breakdowns in public
health measures/ infrastructures, e.g. diphtheria,
pertussis, measles, Chikungunya

European Centre for Disease Prevention and Control. Communicable disease threats report, Week 21, 17-23 May 2015. Accessed on 23 May
2015 from http://www.ecdc.europa.eu/en/publications/Publications/ communicable-disease-threats-report-23-may-2015.pdf
MERS-CoV Case Count
as of 23 May 2015
• Total no. of confirmed cases: 1,152
• Total no. of deaths: 471 deaths
• Crude case fatality rate: 40.9%

Where did MERS-CoV come from?
• MERS CoV found in camels from
Egypt, Qatar, and Saudi Arabia
• Camels from Jordan, Oman, Qatar,
Saudi Arabia and the UAE (even
from Egypt, Kenya, Nigeria and
other African araes) have shown
high rates of antibodies against
MERS-CoV
Evidence for Camel-to-Human Transmission of MERS
Coronavirus. New England Journal of Medicine, 2014. 371(14):
p. 1359-1360.
Alagaili,A.N., et al., MiddleEast respiratory syndromecoronavirusinfectionin
dromedarycamelsinSaudi Arabia. mBio, 2014. 5(2):p. e00884-14.

Where did MERS-CoV come from?
• Many similar coronaviruses have been isolated in bats
• In MERS case, an identical MERS-CoV strain have been isolated
from a bat captured near the patient’s house
Taphozous
perforatus

How did it transfer from camels to humans?
• Still not clear.
• Droplet contact?
– high viral loads in nasal swab
samples from camels
– Fecal samples
– conjunctival swabs

• A recent study published by
Azhar EI et al. reported the
isolation of the virus in an
air sample collected in a
camel barn involved in a
possible camel-to-human
outbreak, warranting
further investigations for
the possible airborne
transmission of MERS-CoV

Camel urine:
A traditional medicine
Camel milk:
suggests a potential food-borne
transmission of the virus by
consuming raw milk, a traditional
behaviour in Arabic culture
Evidence for Camel-to-Human Transmission of MERS Coronavirus. New
England Journal of Medicine, 2014. 371(14): p. 1359-1360.

How infectious is
MERS?

Reproduction Number

MERS: Reproduction number
MERS R0 = 0.60 to 0.69
suggests that MERS-CoV does not yet have
pandemic potential
No ongoing spreading of MERS-CoV in the community
Romulus Breban, Julien Riou, Arnaud Fontanet: Interhuman transmissibility of Middle East respiratory syndrome
coronavirus:estimation of pandemicrisk. TheLancet, 05July 2013

MERS: Transmission
• human-to-human transmission occurs via, close
contact
– caring for or living with an infected person
– healthcare workers taking care of MERS patients
• All reported cases have been linked to countries in
and near the Arabian Peninsula.

MERS-CoV
• It is not always possible to identify patients with
MERS-CoV early because some have mild or unusual
symptoms
– It is important that health-care workers apply standard
precautions consistently with all patients regardless of
their diagnosis in all work practices all the time

MERS-CoV
• Droplet precautions should be added to the
standard precautions when providing care to all
patients with symptoms of acute respiratory
infection
• Contact precautions and eye protection should be
added when caring for probable or confirmed cases
of MERS-CoV infection
• Airborne precautions should be applied when
performing aerosol generating procedures

Personal Protective Equipment (PPE)
• Goggles or face shield
• N95 mask (or P100)
• Gown
• Gloves
• Shoecover
• Additional: cap

Spot Quiz
What is the is the single most
important action to stop
spreading infection and disease?
A. Wearing a mask
B. Taking daily Vitamin C
C. Handwashing
D. Taking antibiotics

General Guidelines in the Preparation
and Management of EIDs
1. Operationalize your response.
2. Designate a team in charge of EIDs.
3. Designate areas in your institution for:
– Screening and triage
– Isolation of suspect cases
4. Apply standard precautions for all patients.
5. Understand the basics of transmission-based
precautions.
6. Decide on the extent of your patient
involvement and prepare accordingly.

precautions.
• Align with national preparednessplan.
• Determineresponse based on current situation.
oNo reportedcase locally, one reportedcases, all
referralhospital full, overflowof cases in the
community
• Determinehow the regular hospital operationswill
be affectedby admittingEID cases.

precautions.
• Assess your capacityas a hospital in terms of:
o Manpowerand skills
o Space, equipment, facility
o Hospital operation
o Need of the community
o Availabilityand proximityof other institutions
who will admitEIDs

precautions.
• Formulate and train your ICC
• Attend trainings
• Seek the help of experts(IDS, ICN Nurses, PHICS)

precautions.

Screening and Triage
Screening
To quickly identify people with a travel history to
affected countries
Triage
To determine if these persons have significant contact
and if they have symptoms
Goal
To promptly isolate suspects if symptomatic or provide
home advice as necessary

Screening and Triage
A stepwise process of screening based on travel history
followed by triage is more manageable in most
institutions than a combined screening and triage
process.

Isolation/Holding Area
• This is the area where patients wait while
transfer to the referral hospital is being
coordinated.
• Provide surgical masks to the patients and as
much as possible minimize contact with them
unless deemed necessary

Isolation/Holding Area
• The holding area should be:
– Near triage area for quick transfer
– Distant from other crowded areas1
– Well ventilated / adequate ventilation and room
air exchange (negative pressure or
independent air-conditioning unit and exhaust
or open windows)1,2
– Own sink and toilet facilities2
– Have adequate sunlight1
– Known to everyone in the facility1
1Clinical Management of Patients with Viral Haemorrhagic Fever: A pocket Guide for the Front-line Health Worker
13 April 2014. . World Health Organization 2014
2Interim Clinical Guidelines on Severe Acute Respiratory Syndrome (SARS) for Health Facilities in the Philippines
Department of Health. Technical Working Group on SARS Clinical Guidelines, July 25, 2003

What if we don’t have a
negative pressure room?
• Properly labeled and identified,easily recognizableby
visitors and hospital personnel
• Good ventilation
• Entering HCWsshould wearappropriatePPE
by AD Roman presented duringthe

Air Changes
Room conditions ACH
Completely open window + open door 29.3–93.2
Completely open window + closed door 15.1–31.4
Half-open window + closed door 10.5–24
Closed window + open door 8.8
World Health Organization, Infection prevention and control of epidemic- and pandemic-prone
acute respiratory infections in health care. 2007.

Air Changes
Exhaust
fan is:
The door connecting the
room to the corridor is:
The door and windows
connecting room to the
balcony and outside air is:
ACH
OFF Closed Closed 0.71
OFF Closed Open 14.0
OFF Open Open 8.8–18.5
ON Closed Closed 12.6
ON Closed Open 14.6
ON Open Open 29.2
World Health Organization, Infection prevention and control of epidemic- and pandemic-prone
acute respiratory infections in health care. 2007.
Caveat: Air exhaustshould not be directed in an area with high human traffic.

precautions.

Airborne precautions for...
by AD Roman presented duringthe

CHECKLIST FOR THE ACUTE MANAGEMENT
AND/OR TRANSPORT OF SUSPECTED OR
CONFIRMED CASES OF MERS
ACTIVITY DONE
NOT
APPLICABLE
1. Screen and triage patients to identify suspects by inquiring about history
of travel to affected countries or contact with confirmed or probable
case and the presence of compatible symptoms
2. Institute standard precaution and the necessary transmission-based
precaution (contact, airborne, respiratory)
3. Isolate suspected patients in a room with adequate ventilation (negative
pressure room if available)
4. Ensure isolation room has the following:
Toilet or commode
Hand hygiene facility
Waste bin
Puncture-resistant sharps container
Telephone or other method of communication in the isolation room to
enable patients, family members or visitors and healthcare workers to
communicate with one another

ACTIVITY DONE
NOT
APPLICABLE
5. Dedicate non-critical patient-care equipment (e.g.
stethoscope, thermometer, blood pressure cuff and
sphygmomanometer) to the patient, if possible.
6. Post appropriate signage (discretely) alerting healthcare
personnel to isolation status, PPE required, proper hygiene, and
handling/management of infected patients and contaminated
supplies.
7. Encourage respiratory hygiene (i.e. Provide and advise patient
to wear a regular facemask whenever possible, use of tissues
when coughing or sneezing followed by hand hygiene)
8. Limit visitation.
9. Wear the appropriate PPE (N95 mask, face shield or goggles,
gown, shoe cover, cap if preferred) for healthcare workers who
will be involved in the care of the patient identified.

ACTIVITY DONE
NOT
APPLICABLE
10. Assign healthcare workers who have been adequately trained to
attend to the index patients. Entry of healthcare workers should be
limited only to those essential for patient care and support.
11. Keep track and monitor healthcare workers who took care of
suspect cases.
12. Environmental cleaning and decontamination of patient care area,
supplies and equipment based on standard hospital procedures.
13. Management of waste, laundry and linen based on standard hospital
procedures.
14. Perform screening and triage of contacts. Provide necessary advice.
15. Inform the Infection control office and other designated hospital
personnel/administrator.
16. Inform the DOH, NEC or your respective Epidemiology and
Surveillance Units.
17. Hand hygiene as frequently as recommended.by AD Roman presented during the 21st PHICS

FOR HOSPITALS WHO WILL ADMIT AND MANAGE
PATIENTS
1. Manage patients based on the Management Guidelines for the
Treatment of Severe Acute Respiratory Illness associated with
MERS-CoV.
2. Develop contingency plans for staffing, logistics, procurement,
security, and treatment. This includes sick leave policies and work
restrictions (for personnel who will have unprotected exposure).
3. Ensure adequate supply of PPEs are available at any time.
4. Coordinate with RITM regarding collection, preparation, and
transport of specimens and releasing of result.
5. Collection of samples wearing appropriate PPE and practicing
the necessary transmission-based precautions.

FOR HOSPITALS WHO WILL ADMIT AND
MANAGE PATIENTS
6. Perform aerosol generating procedures with extreme
caution, preferably inside a negative pressure room.
7. Adequate preparation and coordination when
transporting patient between units within the hospital.
8. Maintain constant communication and coordination
with the Department of Health/NEC
9. Proper risk communication

FOR HOSPITALS WHO WILL TRANSFER PATIENTS
1. Coordinate with DOH, NEC or your respective Epidemiology and
Surveillance Units regarding transfer.
2. Inform receiving unit of plans for transfer to allow ample time for
preparation.
3. Perform aerosol generating procedures only when necessary.
4. Develop staffing plan, sick leave policies and work restrictions
(for personnel who will have unprotected exposure).
5. Conduct a detailed inventory of available supply of PPE. Replace
used stocks to ensure availability.
6. Call the receiving institution prior to actual transport of patient
7. Decontamination of transport vehicle based on standard hospital
procedures.

Transport
• Use portable devices (e.g. portable x-ray,
ultrasound) as much as possible.
• Decontaminate infected surfaces afterwards.
• Transport and move patients only when necessary.
• Ask patients to wear surgical masks (if they can
tolerate) when going out of the isolation room to
contain secretions.

Transport
• Ensure that health-care workers who are
transporting patients wear appropriate PPE and
perform hand hygiene afterwards.
• Prior to transport and arrival, notify the receiving
unit of the patient's diagnosis and precautions that
will be required.

Transport: Ebola

Contact numbers
• NEC 711-1001/711-1002
• RITM Hotline 664-6568 (24 hrs)
• RITM Surveillance Unit 994-1887 (24 hrs)

EIDs are here and they are here to stay.
Efficient screening and triage is important:
To prevent entry and spread in the country
For prompt isolation and management
In the management of EIDs, balance
between patient care & healthcare worker
safety should be achieved
Summary

Infection control strategies play a major role in
the control of EIDs. This will depend on
transmission-based precautions and application
of standard precautions on all patients.
Institution should be ready to handle specific
issues that may arise in the course of
management in EIDs via a multidisciplinary
approach.
Do not be caught off guard.
Summary

ありがとう (JP) Thank you (En)
Arigatou

ABCs in EIDs: Preparing for Emerging Infectious Diseases

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