Preparedness of Pandemic Novel Influenza in Taiwan: from strategy to operation

1. Preparedness of Pandemic Novel Influenza in Taiwan:from strategy to operation Yen , Muh-Yong Taipei City Hospital, Taiwan Infection Control Society of Taiwan

2. Introduction • The SARS epidemic of Taiwan in 2003 • 347 casualties. • 70 % are nosocomial related. • 30% are health care workers.

3. Traffic control bundle • An integrated infection control strategic bundle which includes • triage of patients into hospital • zones of risks • installation of alcohol dispensers at checkpoint for glove-on hand rubbing. - Yen MY, et al. JHI,2006.2,62:2:195 -

4. Factors Protecting HCW from SARS nosocomial infection • 31 H w/o & 19 H w/c HCW SARS • Leadership (p<0.01) • Fever screening stations (p<0.01) • checkpoint alcohol dispensers for glove-on hand rubbing between zones of risk (p<0.001) - Yen MY, et al. 8th IFIC, Budapest, 2007 -

6. M M M M M M M M M M M M M M M M E E E E Conceptual framework of Six Sigma structure output Process＃2 Process＃1 Process＃3 Process＃4 Last Process control control control control Processes

7. Nothing is particularly hard if you divide it into small jobs.   - Henry Ford - Six-Sigma, as the knowledge base of traffic control bundle. process management in diffluent manner (time and space)

8. KEELUNG TAIPEI １ 1 TAOYUAN HSIN CHU ２ 2 TAICHUNG 3 ２ CHUNG HWA CHIAYI 4 ６ 6 TAINAN 5 KAOHSIUNG PINTONG Nationwide educational and supporting network for infection control Communicable Disease Control Medical Network

9. Infection Control Network • Compilation of infection control guidelines. • Inspection of hospital infection control • Educational and supporting system for quality improvement (outbreak). • Surveillance of nosocomial infection (TNIS) • Promotion of Hand Hygiene.

10. Inspection and audit for hospital infection control, Taiwan CDC

11. Communicable Disease Control Medical Network • Combine medical and public health systems • 6 sub-network nationwide • Experts from Hospital, public health, infection control, local health department, CDC • 25 responding hospitals as special isolation hospitals. • Medical director to streamline the commanding and information flow with efficient communications. • Coordination for inter-city surge capacity, education program and drill/exercise.

12. Process Management (time axis) • Levels of alertness • 0 preparedness • A surveillance • B containment • C impact reduction

13. Process Management (time axis) • 0 preparedness - surveillance - surge capacity - exercise/drills • A surveillance • B containment • C impact reduction

15. Transforming schools into pre-designed ACS as part of preparedness plan for pandemic H5N1 influenza.-Yen MY, J Formos Med Assoc,2008;107(9):673-676.- Accessibility Availability Safety Expandability

16. 1. 2. 3. 4. Figure 1. blueprint of school transformed into alternative care site with traffic control bundle.

17. Task force of special isolation hospital groups Special Isolation Hospital School as shelter Screen station from community

18. Surge capacity of staff Mobilization and education/training of human resources • Prompt response epidemiological team • Obligatory military services for decomtamination. • Volunteer Taxi Driver to support EMS • Medical personnel • Linking nurse

19. Process Management (time axis) • Levels of alertness: WHO phase 4 • 0 preparedness • A surveillance • B containment • C impact reduction

20. The Front-line checkpoint for surveillance • Airport fever screening station • Community surveillance ( GP, Rx, ER ) TOCC • Travel history • Occupational/Contact history • Cluster

21. Strategy of Responsiveness in level A & B • First case finding through active surveillance • Containment • Epi. Investigation & Contact tracing • quarantine, isolation and containment

22. Process Management : algorithm • Levels of alertness • 0 preparedness • A surveillance • B containment • C harm reduction

23. T C C HCW, Hotel O airport

24. Level B response • Layered Containment of the affected area, • Hot zone • Warm zone • Prophylaxis with antiviral agent • Increase social distance in cold zone • Schools and offices and subway off for 3-7 days • Cold zone: traffic control into 68 subdivisions

25. Updated: 2009/06/23 Identified so H1N1 influenza A Investigated Sentinel surveillance (+) (-) (+) (-) (?)

26. The futility in close border this futility, the economic consequences of at- tempts to close borders are therefore likely to be of a very short duration

27. Lesson learnt in 2009 • Action plans against Influenza A H1N1 in early 2009 had also provided a platform to access and improve our current system in mitigation for future pandemic influenza.

28. １ 1 ２ 2 ２ 3 4 ６ 6 5 Chain of command & Risk communications Epidemic Command Center(central government)Strategy, SOP Video conference, Telephone conference inter-city/ inter sub-network coordination Sub-division of Communicable Disease Control Medical Network Branch office of CDC Local Epidemic Command Center Execution/ channel

29. Hotel sealed off ? the Ripple Effect

30. Risk analysis and stratification • High risk • Close contactor with index case 2 M，1 h • Middle risk • Exposure to flu s/s • w/o alc. hand disinfection • Low risk • others

31. Mass gathering events • Computex Taipei, Jun 2-6, 2009 • Deaflympics Taipei, Sep. 5-15, 2009 • Hotels and Institutes as checkpoint • Letters to the guest • Respiratory hygiene & cough etiquette • HH after cough/sneeze/ surfaces • Reporting and surveillance

32. Welcome to Grand Hyatt Taipei! It is a great pleasure to have you as our guest. We trust that your stay will be a comfortable and enjoyable one. In view of the current H1N1 Influenza situation in some countries around the world, we would like to take this opportunity to bring you up-to-date on the following measures that we at Grand Hyatt Taipei have put in place: Grand Hyatt Taipei has developed a preparedness plan for a possible H1N1 influenza pandemic and the relevant employees have received H1N1 training. We are increasing the frequency of cleaningour public areas, including the washrooms, elevators, door handles, and other points of contact in high frequency areas. We are in close communication with the Center for Disease Control in Taiwan and will implement further actions as per their recommendations and as required. The well-being of our guests and employees is always of paramount concern to us. In order to protect your health and to avoid the possible spread of any viruses, we would also like to remind you of the following: Face masks are available for your use. Please contact the Concierge at ext 1. Various alcohol-based cleanser dispensers have been placed at the hotel's entrances, the elevator lift landings on each guest floor, the gymnasium and our restaurants. Please use the dispensers to clean and sanitise your hands before and after using the elevators or when you arrive and depart from the hotel, the gymnasium and the restaurants. Should you feel ill and/or carry any flu symptoms i.e. fever, coughing, sore throat, runny nose, headache, muscle aches, diarrhea, etc, please contact our Assistant Manager on duty on ext. 0 or visit our clinic on level 5. Our team members will be able to assist you and make the necessary arrangements. Your cooperation in this matter is highly appreciated. If there is anything else we can do to further enhance the comfort of your stay, please contact any one of us at your convenience. Hotel Management Grand Hyatt Taipei July 2009 - Hotels as channels of surveillance and communications -

33. Dear Deaflympics athletes and guests: • Welcome to Taiwan for participating the 21st Summer Deaflympics Taipei 2009. • We would like to congratulate for the excellent performance in the days to come. • Regarding the global novel H1N1 influenza pandemic, we have taken the measures of disease prevention for protecting your health: • Taipei City Government has been developed a preparedness plan for a possible novel H1N1influenza pandemic. All relevant employees and staffs have received training for against H1N1 influenza and others communicable diseases. • All of the Deaflympics venues and accommodations are increasing the frequency of cleaning and sanitizing public areas. Alcohol-based hand sanitizers are placed at all public area. • The well-being of all athletes and guests is our highest concern. In order to protect your health, we would also like to ask for your full cooperation as following: • If you experience flu-like symptoms such as fever, coughing, sore throat, runny nose, headache, muscle aches, diarrhea etc., please put on a gauze mask and contact with staff members immediately. Subsequently medical arrangements will be assisted. • During the period of Deaflympics, facial masks are available upon request from our volunteers and staff members at the first aid of sporting venues and accommodations. • When entering sporting venues, hotel lobbies, restaurant, café and other public areas or touching door handles etc., please be sure to use alcohol-based hand sanitizer for hand disinfection. Also please cover your nose and mouth when you cough or sneeze. • We thank you for your cooperation with great earnestness.

34. SHEA June/10/2009 • NO • NPIR • N95 • Respiratory hygiene & cough etiquette (manner) • HH after cough/sneeze/surfaces

35. 接觸率 (Contact Rate) 100 % 80 % 60 % 40 % Da-An sub-division population：42,978 Middle ages：70% 說明：模擬疫情傳播至台北市，「大安區敦化次分區」實施檢疫隔離與減少聚集活動， 模擬該分區的人群接觸率從100%減少至40%的疫情趨勢。

36. Class I notifiable disease down grade to Class IV • Crisis Management • Prediction / Mitigation • Preparedness • Response • Recovery

37. Process Management : algorithm • Levels of alertness • 0 preparedness • A surveillance • B containment • C Impact reduction

38. Medical surge - Impact Reduction • maintaining social order and integrity of the healthcare system • The concept of traffic control bundle has now been implemented in our design of medical surge for pandemic influenza preparedness. • Triage patient into hospital: • outdoor screening station. • Zone of risk • Clean Hospitals: traffic control • Contamination zones: special isolation hospital groups. • Alcohol dispensers for hand disinfection at checkpoint

39. 醫療體系之準備 規劃病人分流轉診 提升藥物普及性引導輕症病患於地區醫療院接受診治 整合傳染病防治醫療網、緊急醫療網及醫療院所診治重症病患 結合消防單位緊急救護量能 運用分級檢傷及電腦資訊，掌握及調度加護病床 規劃隔離病房治療感染抗藥性病毒株病患 強化臨床治療量能 公布臨床治療指引 辦理醫療相關人員之教育訓練 基層開業醫師 (健保局、地方衛生局、醫師公會) 消防人員 (地方衛生局) 具一定規模之醫院自行辦理 39

40. 16,000 General Hospitals / Medical Centers to preserve fundamental social security 6000 a l o t e m o r expandable surge capacity Task force of special isolation hospital groups

41. Task forces of special isolation hospital groups 關渡醫院 關渡國中 逸仙國小 關渡國小 北投國中 桃源國中 振興醫院 士東國小 明德國中 天母國小 文林國小 明德國小 :醫院 :學校 市立醫院-陽明院區 雨聲國小 芝山國小 雨農國小 蘭雅國中 福林國小 北投區 士林區 康寧醫院 明湖國中 明湖國小 東湖國中 東湖國小 南湖國小 泰安醫院 中山國中 中山國小 五常國中 五常中學 新興國小 內湖區 國軍松山醫院 介壽國中 民生國小 健康國小 民族國小 西松國小 中山區 台北市立聯合醫院和平院區 龍山國中 忠義國小 南門國中 建國中學 老松國小 大同區 松山區 市立聯合醫院-忠孝院區 忠孝國中 松山國小 福星國小 永吉國小 日新國小 南港區 中正區 信義區 萬華區 大安區 西園醫院 華江高中 雙園國中 雙園國小 萬華國中 大理國小 象山院區 松山家商 永春高中 吳興國小 留公國中 興雅國中 文山區 國立台灣大學醫學院附設醫院（公館院區） 和平高中 公館國小 芳和國中 大安國小 民族國中 臺北市立萬芳醫院 萬芳高中 景興國小 興華國小 興福國中 興隆國小

42. Infection Control against H1N1 for General Hospitals • In addition to strict infection control programs. • Outdoor screening station • Cough, flu, fever, ILI, diarrhea, DOA • Traffic control, wearing mask • Detention ward, fever ward • Checkpoint hand washing

43. Detention, quarantine • Latent Period (latency)– The time from initial infection until the start of infectiousness. • Incubation Period– The time from the initial infection until the onset of clinical symptoms. • Period of communicability–The period during which an individual is infectious and can spread to other hosts.

44. Detention Ward

45. A moderate pandemic phase 6 • WHO considers the overall severity of the influenza pandemic to be moderate ? • Mild - moderate - severe • Moderate - aggressive – severe ?

46. Taiwan laboratory weekly reoprt on influenza virus activities Updated: 2009/08/05 The latest 3 weeks: Flu Positive rate= 13% (11,16) Novel H1N1 ratio = 90% (80,96) 46

47. Updated: 2009/08/05 國內流感疫情監測--輕症 • 急診與門診類流感就診率皆呈上升趨勢 • 估算台灣一週H1N1病例數約4340例- 等比級數 47

48. Updated: 2009/08/05 Number of complicated influenza reports by month of onset 7/1/2008 to present國內流感疫情監測--重症 • 流感併發重症通報數自7月起大幅上升 48

49. Pandemic (H1N1) 2009 clusters • Cumulative number since July 1, 2009 was 30. • schools 17 (57%) • workshops 5 (17%) • military camps 3 (10%) • workplaces 1 ( 3%) • hospitals 1 ( 3%) • long-term care facilities 2 ( 7%) • imported 1 ( 3%)

50. 防治策略 境外阻絕 圍堵 邊境管制 • 手部衛生 個人與家庭防護 • 咳嗽禮節 • 生病在家 減災 延緩散播 提早治療 減少傷亡 • 停班停課 社區防疫 • 大型集會 • 疫苗接種 • 感染控制 醫療體系保全 • 持續營運 • 轉診調度