Republic of the Philippines Department of Health OFFICE OF THE SECRETARY June 20, 2013 DEPARTMENT MEMORANDUM NO. 2013 - 0206 FOR : DOH BUREAUS, CENTER _FOR HEALTH DEVELOPMENT, HOSPITALS AND ATTACHED AGENCIES, UNITS AND TEAMS DESIGNATED TO WORK FOR THE PREVENTION, CONTAINMENT, ‘AND CONTROL OF AVIAN INFLUENZA A(H7N9) INFECTION FROM : ENRIQUE A. T) MD, PHSAE, FPSMID, CESO III Head, Support to Service Delivery Technical Cluster I! SUBJECT: ‘Technical Guidelines Standards, and Other Instructions for Reference in the Surveillance on Avian Influenza A(H7N9) Infection Whereas, Republic Act 3573 entitled “Law of Reporting of Communicable Diseases” requires all individuals and health facilities to report notifiable diseases to local and national health authorities. Whereas, Resolution WHAS8.3 (2005) formally adopted the revised International Health Regulations that further urged Member States to carry out surveillance at all levels to diseases or events that may constitute a public health emergency of intemational concern and contribute fully to international health security. Whereas, the Department of Health issued Administrative Order 2007-0036 establishing the Philippine Integrated Disease Surveillance and Response (PIDSR) Framework for Reporting of Notifiable Diseases and other Health Events through the National Epidemiology Center (NEC), also the National Focal Point for IHR 2005 Due to the high concern over the potential spread for sustained person-to-person transmission and spread, the DOH issues the following guidelines and standard procedures namely: 1. Interim Guidelines on the Surveillance Avian Influenza A(H7N9) Infection 2. Interim Guidelines on the Communication Flow During Special Situations for Avian Influenza A(H7N9) Infection For compliance.Republic of the Philippines Department of Health OFFICE OF THE SECRETARY Interim Guidelines No. 1 On the Surveillance of Avian Influenza A(H7N9) This set of guidelines is issued as reference for all participating health agencies (DOH Central Offices, Regional Centers for Health Development, referral hospitals, etc.) and their local counterparts to enable the public appreciate, cooperate and participate with regards to public health surveillance requirements for Avian Influenza A(H7N8). Implementing Offices of the Central Department of Health The national authorities of China have notified WHO on 31 March 2013 of A(H7N9) avian flu infections in humans. Prior to this event, the DOH National Epidemiology Center (NEC) has included Influenza-like-illness (ILI) as one of the 27 diseases, syndromes and conditions under surveillance through the Philippine Integrated Disease Surveillance and Response (PIDSR) system. In addition, the DOH also sets an event-base surveillance system to monitors events that are deemed threats to public health, such as Avian Influenza A(H7N9) infection. The Research Institute for Tropical Medicine (RITM) has maintained laboratory-based IL! surveillance in selected region of the country. The Bureau of Quarantine (BOQ), on the other hand, performs mandatory screening procedures for diseases and conditions have public health significance as prescribed by the International Health Regulations. General Principles 1. The aim of disease surveillance in the early part of a disease outbreak is to provide early indications of the extent and speed of transmission of the disease among geographic regions or countries 2. Surveillance of diseases requires capability for laboratory confirmation of the disease causative agent. 3. As more information is gathered, analyzed and situations changed, surveillance activities are shifted towards long term monitoring of the disease. Objectives 1. To describe early epidemiological, virological and clinical characteristics of Avian Influenza A(H7N9). 2. To establish mechanism for coordination among existing surveillance system in terms of case detection, confirmation, validation, investigation, reporting and feedback. 3. To provide recommendations for preventive and control measures.Implementing Guidelines PIDSR and Laboratory Surveillance of Influenza-like-ilIness 1. The surveillance of Influenza-lke-illness under the regular PIDSR will continue be implemented with the supervision of the NEC. However, in order to enhance the sensitivity of the system to detect early cases of Avian Influenza A(H7N9) infection or signs of human to human transmission, the following activities should be simultaneously performed: a. Daily analysis of PIDSR Data to determine clustering of ILI and changes in the epidemiology and mortality associated with the occurrence of ILI in a particular geographic area, and reporting when these occur. b. Reporting of unexplained acute respiratory illness in one or more health workers who provide care for patients with respiratory diseases. c. Reporting of changes noted in response to treatment or in the treatment outcome of those with severe lower respiratory illness. 2. The laboratory-based ILI surveillance maintained by RITM in selected regions shall be utilized to facilitate the collection, storage and transport to RITM of nasopharyngeal and oropharyngeal swab specimens from suspected cases of Avian Influenza A(H7N9) admitted to hospitals only. The designated IL! surveillance officer in coordination with the RESU (regional epidemiology and surveillance unit) shall develop a mechanism to do this. 3. In regions without laboratory based ILI surveillance, the RESU staff shall be responsible in facilitating the collection, storage and transport to RITM of nasopharyngeal and oropharyngeal swab specimens from suspected cases of Avian Influenza A(H7N9) admitted to hospitals only. Actual collection of specimens shall be done only by trained disease surveillance coordinators. 4. RITM shall designate a point person who will be responsible for reporting laboratory results and other relevant information on cases of Avian Influenza A(H7N9). 5. All reports and rumors of Avian Influenza A(H7NS) infection must be reported to DOH NEC Event Based Surveillance and Response (ESR) 651-7800 loc 2929 for verification. If the rumor is on poultry, the Bureau of Animal Industry should be informed at hotline: (032) 925- 9999. Surveillance by the Bureau of Quarantine 1, The BOQ shall be responsible for entry screening and preliminary investigation of all suspected Human Avian Influenza cases identified in all ports of entry. These cases should be reported within 24 hours to the corresponding RESU and NEC. 2, BOQ shall provide RESU the passenger manifest and other relevant information in situations where contact tracing is necessary.Role of Hospitals and Other Health Facilities (Clinics, infirmaries, etc) in Surveillance 4 Orient or re-orient hospital/health facility staff regarding mandatory disease reporting requirements, such as those for influenza-like-illness. Designate disease surveillance coordinators who will be responsible for preliminary investigation of suspected cases seen at the hospital, as prescribed by the PIDSR guidelines, Prepare communication system, such as directory of referral hospitals and NEC-ESR, for reporting and referral of suspected Avian Influenza A(H7N9) infection cases. Case Investigation 1 ¢. Suspected Human Avian Influenz: The case definitions for used surveillance of Avian Influenza A(H7N9) are the following and shall be followed: a. Suspected Influenza like-ilness case: A person with sudden onset of fever of 238°C and cough or sore throat in the absence of other diagnoses. Note: The onset of fever should be within three days of presentation and fever should be measured at the time of presentation. b. Severe Acute Respiratory Infection: Meets ILI case definition and shortness of breath or difficulty breathing and requires hospital admission, ‘A suspect ILI or SARI case with exposure to sudden bird deaths (sudden bird deaths in two or more households in a barangay or death of at least 3% of commercial flock increasing twice daily for 2-3 consecutive days) OR confirmed human avian influenza case. d. Suspected A(H7N9) Case: A Suspected Human Avian Influenza case AND meets either of the following exposure criteria and for whom laboratory confirmation is not known or pending, or for whom test results do not provide a sufficient level of detail to confirm novel influenza A virus infection. A patient who has had recent contact (within 10 days of illness onset) with a confirmed or probable case of infection with novel influenza A (H7N9) virus. OR A patient who has had recent travel (within 10 days of iliness onset) to a country where human cases of novel influenza A (H7N9) virus have recently been detected’ or where novel influenza A (H7N9) viruses are known to be circulating in animals. e. Probable A(H7N9) Case: A patient with illness compatible with influenza for whom laboratory diagnostic testing is positive for influenza A, negative for H1, negative for Hipdm09, and negative for H3 by real-time reverse transcriptase polymerase chain reaction (RT-PCR), and therefore unsubtypeable. f. Confirmed A(H7N9) Case: A patient with novel influenza A (H7N9) virus infection that is confirmed by certified public health laboratory.2. The disease surveillance officers of the BOQ at all points of entry shall be responsible for the preliminary assessment of suspected cases. Designated disease surveillance officers in hospitals and other facilities shall be responsible for doing the preliminary assessment of suspected cases in their respective health care facility. 3. The Case Investigation Form (Annex C) shall be used for all investigations of suspected cases of Avian Influenza A(H7NQ) infection. All other forms in laboratory-based ILI surveillance (RITM), syndromic ILI surveillance (PIDSR) and screening forms of the BOQ shall continue to be used. Case Reporting 1, The notification and reporting of immediately notifiable diseases, syndromes and events shall follow the described in Annex A.1. 2. Weekly reporting of ILI cases under the PIDSR shall be pursued. All epidemiology and surveillance units are required to provide weekly zero reports to the next higher ESU even if no cases are seen during the week. (Annex A.2) 3. Reporting of cases of Avian Influenza A(H7N9) shall follow the flow described in Annex B.World Heatth Organization National Epidemiology ‘Center —_.— Regional pidemiology and Surveillance Units (RESU) Epidemiology and Survelance Units (@ESU) Rural Health Unit/ City Health Office Barangay Health ‘Station (BHS) cases from hospital, clinics, ports, airports and laboratories Legend: ——> Immediate notification (within 24 hours) > ReportingAnnex A.2 soa FLOW OF WEEKLY REPORTING OF NOTIFIABLE DISEASES cates from referral hospitals National laboratories Epidemiology Center ports, airports ‘cases from aaa level’ and earl retained Eve hospital, ports, ‘Surveillance Units en. (RESU) Cases from provincial and district hospitals, ports, airports ‘Ghy Epidemiology cases from ‘and Survellance local hospitals, Units (CESU) in lines, ports, chartered cities aiports ‘ural Mealth Units and city Health Offcesin non-chartered cites ‘cases from local hospitals, nics, ports, ‘airports Cases from the ‘community‘mo]y esuodsey pue uopeUUosU| @ xouuyAnnex C Avian Influenza A(H7N9) Case Investigation Form ‘Asia fata A(ET7N9Y TT ha coment) ‘Sensation Nate Ea eda Ba acAvian Influenza A(H7N9) Case Investigation Form ae vestigation Fem Asian fttaenta AtHEND) cee r a ea ower | ve | pce hide Durcitecns [HAMM rentntiney | anrrtont | Resi = =z — { vm. Feat caassimecxTioN pe ae Oe IC nerd iran tee Peters AaKNoY YS) pet [a sexe wae Resp Bison Ghats ote 80) | ea seca Hae Ase a 1 tien ssa ess HH) 1 OUTCOME) Ae Diet) tan ied Te ie inion Suypeci nfs tees cases A pee reno af th ‘Severe ete Restor Enc: Met. se éfion el stories of eu sey retin empiri anion Sexpected Homes Aries Ife: se Ll ce SARI cine with eepame shir hs one Sea ee Roun tana ov dh rat ean yk tang ict half 2 Scones dep OR cnn ban aan mace Sipeunt ATH Case 1 Sigel Hua Assi lias case ANT mete ebro he flowing egw ct min a a a cet confit =H ayo Re wh ed eal asi ith oe ana ATR) sha ow A tet ws sca cat ve hn ag lana fo ome a wraeua ET aucun edly Dundee whee me ile THT, vines ae oro icuting anima, ‘rabble HFT) Cane Aso Ac HIN wih ess comabe winery for wham oer di lieing jive ac pte or HL negli al sate ox By ea ‘ie erate weep pease Sse ace (RT-PCR). ane teens wanteypei, Compe AKAN Caves A ae wus tanea® ENS) sir infction ta cee ete 0 eh boy Annex CRepublic of the Philippines Department of Health OFFICE OF THE SECRETARY Interim Guidelines No. 2 On the Communication Flow During Special Situations for Avian Influenza A(H7N9) This set of guidelines is issued as reference for all participating health agencies (DOH Central Offices, Regional Centers for Health Development, referral hospitals, etc.) and their local counterparts to appreciate, cooperate and participate with regards to the communication flow during special situations for Avian Influenza A(H7N9). Implementing Offices of the Central Department of Health The national authorities of China have notified WHO on 31 March 2013 of A(H7NS) avian flu infections in humans. Prior to this event, the DOH National Epidemiology Center (NEC) has included Influenza-like-illness (ILI) as one of the 27 diseases, syndromes and conditions under surveillance through the Philippine Integrated Disease Surveillance and Response (PIDSR) system. In addition, the DOH also sets an event-base surveillance system (ESR) to monitor events that are deemed threats to public health, such as Avian Influenza A(H7N9) infection. The event-based surveillance is linked with the DOH-Operations Center's Health Emergency Alert Response System (HEARS) based at the Health Emergency Management Staff. Both ESR and HEARS generate daily reports concerning public health threats. The Research Institute for Tropical Medicine (RITM) has maintained laboratory-based ILI surveillance in selected region of the country. The Bureau of Quarantine (BOQ), on the other hand, performs international health surveillance through mandatory screening procedures for diseases and conditions that have public health significance as prescribed by the International. Health Regulations. General Principles 1. The aim of communication flow during special situations is to ensure that the public shall receive timely and accurate information concerning special situations of Avian Influenza A(H7NQ). 2. Routine reporting and feedback flow specific for existing DOH sureillance and alert systems shall be maintained. 3. Synchronicity of timely and accurate information is of the utmost concer of the DOH during special situations of Avian Influenza A (H7N9). Objective 1. To establish mechanism for communication flow during special situations for Avian Influenza A (H7NS).Implementing Guidelines Routine Reporting and Feedback through PIDSR, Lab-Based ILI, ESR and HEARS 1. The surveillance of Influenza-like-iliness under the regular PIDSR will continue be implemented with the supervision of the NEC through the RESUs. Information obtained from such system shall follow its usual reporting and feedback mechanisms. 2. The laboratory-based ILI surveillance system maintained by RITM shall follow its usual reporting and feedback mechanisms. 3. The Event-based Surveillance and Health Emergency Alert and Response systems shall maintain its usual reporting and feedback mechanisms 4, The BOQ shall maintain its usual reporting and feedback mechanisms for international health surveillance. 5. The above five systems shall maintain its usual links concerning reporting and feedback mechanisms. 6. Interim Guideline No. 1 on the Surveillance of Avian Influenza A (H7NS) shall be the reference concerning public health surveillance requirements for Avian Influenza A (H7N9) Communication Flow during Special Situations for Avian Influenza A(H7N9) 1. Special situations for Avian Influenza A (H7N9) shall be defined as the first confirmed case, the first fatality of a confirmed case and the first confirmed outbreak of Avian Influenza A(H7N9) in the country. 2. BOQ, RITM, NEC and HEMS, together with its networks through its surveillance and alert systems, shall report any of the above three situations immediately to Director Il of Health Emergency Management Staff, Dr. Carmencita A. Banatin. 3. Director Banatin shall then inform USec Teodoro J. Herbosa and ASec Enrique A. Tayag of the DOH Execom who would consequently inform the Secretary of Health Dr. Enrique T. Ona 4. The Secretary of Health shall inform the President of the Republic of the Philippines of the reported special situation for Avian Influenza A (H7N9). 5. Information on the reported special situation for Avian Influenza A (H7N9 shall then be released to the public.Figure 1. Communication Flow during Special Situations for Avian Influenza A(H7N9) “suspect Special Situation [Suspect Case, Death oF Outbreak of A (H7NS)) “Suspect Specat ‘Stuation Confiemes? ‘Stuation Monitored sing Usval Survellance and Alert Systems Public informed of the Special suation yes HEM Oiector CAB informs €xECOM {usec TH, asec ean) Usee THM and ASce EAT laforms SOH £10 'SOH ETO informs the President ofthe special situationInterim Guidelines No. 2 On the Communication Flow During Special Situations for Avian Influenza A(H7N9) This set of guidelines is issued as reference for all participating health agencies (DOH Central Offices, Regional Centers for Health Development, referral hospitals, etc.) and their local counterparts to appreciate, cooperate and participate with regards to the communication flow during special situations for Avian Influenza A(H7N9). Implementing Offices of the Central Department of Health The national authorities of China have notified WHO on 31 March 2013 of A(H7N9) avian flu infections in humans. Prior to this event, the DOH National Epidemiology Center (NEC) has included Influenza-like-illness (ILI) as one of the 27 diseases, syndromes and conditions under surveillance through the Philippine Integrated Disease Surveillance and Response (PIDSR) system. In addition, the DOH also sets an event-base surveillance system (ESR) to monitor events that are deemed threats to public health, such as Avian Influenza A(H7N9) infection. The event-based surveillance is linked with the DOH-Operations Center's Health Emergency Alert Response System (HEARS) based at the Health Emergency Management Staff. Both ESR and HEARS generate daily reports concerning public health threats. The Research Institute for Tropical Medicine (RITM) has maintained laboratory-based ILI surveillance in selected region of the country. The Bureau of Quarantine (BOQ), on the other hand, performs international health surveillance through mandatory screening procedures for diseases and conditions that have public health significance as prescribed by the International Health Regulations. 1. The aim of communication flow during special situations is to ensure that the public shall receive timely and accurate information concerning special situations of Avian Influenza A(HTN9). 2. Routine reporting and feedback flow specific for existing DOH surveillance and alert systems shall be maintained. 3. Synchronicity of timely and accurate information is of the utmost concern of the DOH during special situations of Avian Influenza A (H7NS).. Objective 1. To establish mechanism for communication flow during special situations for Avian Influenza A (H7N9),Implementing Guidelines Routine Reporting and Feedback through PIDSR, Lab-Based ILI, ESR and HEARS 1. The surveillance of Influenza-lke-illness under the regular PIDSR will continue be implemented with the supervision of the NEC through the RESUs. Information obtained from such system shall follow its usual reporting and feedback mechanisms. 2. The laboratory-based ILI surveillance system maintained by RITM shall follow its usual reporting and feedback mechanisms. 3. The Event-based Surveillance and Health Emergency Alert and Response systems shall maintain its usual reporting and feedback mechanisms. 4. The BOQ shall maintain its usual reporting and feedback mechanisms for international health surveillance. 5. The above five systems shall maintain its usual links concerning reporting and feedback mechanisms. 6. Interim Guideline No. 1 on the Surveillance of Avian Influenza A (H7N9) shall be the reference concerning public health surveillance requirements for Avian Influenza A (H7N9) Communication Flow during Special Situations for Avian Influenza A(H7N9) 1. Special situations for Avian Influenza A (H7N9) shall be defined as the first confirmed case, the first fatality of a confirmed case and the first confirmed outbreak of Avian Influenza ‘A(H7NQ) in the country. 2. BOQ, RITM, NEC and HEMS, together with its networks through its surveillance and alert systems, shall report any of the above three situations immediately to Director Ill of Health Emergency Management Staff, Dr. Carmencita A. Banatin. 3. Director Banatin shall then inform USec Teodoro J. Herbosa and ASec Enrique A. Tayag of the DOH Execom who would consequently inform the Secretary of Health Dr. Enrique T. Ona 4, The Secretary of Health shall inform the President of the Republic of the Philippines of the reported special situation for Avian Influenza A (H7N9) 5, Information on the reported special situation for Avian Influenza A (H7N9 shall then be released to the public.Figure 1. Communication Flow during Special Situations for Avian Influenza A(H7N9) Suspect Special Situation (Suspect Suspect Spc! ves Case, Death or uation Confirme (Outbreak of A (H7NS)) ‘Stuation Monitored using Usual Surveitance and Alert Systems Public nformed of the Special Situation HEMS Director CAB Informs EXECOM (usec TH, asec Ear sec THH and ASec EAT informs SOH ero SO} ETO informs the Prsident ofthe special situation