Aicp 065-66-narm

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Avian Influenza Control ProjectDepartment of Health Services

Dr. Jeetendra Man ShresthaDeputy Coordinator

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Risk of Avian Influenza

• Path of major migratory birds flyways

• 3 in every 5 households have poultry

• Mixed farming – poultry mixed with pigs/wild birds

• Poultry free-ranging – contamination of surfaces

• Children as poultry care-taker

• Slaughtering – no protection to butcher or buyer

• Live chicken and unprotected meat

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GOALS

Nepal Avian Influenza Control Project -HUMAN HEALTH COMPONENT-

To reduce the risk of infection to humans

To mitigate the health and socio-economic impact of an influenza pandemic

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Avian Influenza Control Project

COMPONENTS & SUB-COMPONENTS Animal Animal HealthHealth

Strengthening Disease Surveillance

Strengthening Quarantine Services

Upgrading Laboratory Capacity

Field Veterinary Services

Compensation Fund

Social Mobilization and Behavior Change Communication

Project Management

Strengthening Disease Surveillance and Laboratory Capacity

Prevention and Containment Measures

Health Care Delivery System Preparedness and Response

Project Management

Human HealthHuman Health

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COORDINATION MECHANISMSCOORDINATION MECHANISMSNepal Avian Influenza Control Project

National Disaster Relief Central Coordination Committee

Technical Subcommittee on Avian Influenza Jointly chaired by MOAC+MOHP Secretaries

TSCAI secretariat at AHD

MOAC Program

MOHP Program

DOLS Animal Health Component

DOHS Human Health Component

Communication

Working Group

Surveillance Working Group

AI Coordination Committee

Activities to be

implemented by MOLD

Activities to be

implemented by MOHA

Compensation Working

Group

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Surveillance: Objectives Strengthening the existing disease surveillance

capacity at the national, regional and district level

Building an influenza surveillance system on existing

structures

SARI (Pneumonia) Surveillance (IPD-ACD)

Suspected Outbreak Investigation (ACD)

- PDSR - Participatory Disease Surveillance & Response

Implementers: DPHO/DHOs, RHDs, EDCD, WHO/IPD

Supported by: WHO-CSR, WHO/VPD

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Laboratory: Objectives To ensure the necessary laboratory network

to the national influenza surveillance system

Molecular Diagnosis at NPHL

Orientation to field laboratory technicians on

sample collection, storage and dispatch

To upgrade the NPHL to reach BSLIII Implementers: PHCs, DPHO/DHOs, District Hospitals labs, Regional

Referral Hospitals and National Referral Hospitals, NPHL

Supported by: WHO, other partners like WARUN

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Prevention and Containment: Objectives

To prevent avian and seasonal influenza transmission

in high risk groups

To develop a modern quarantine system in the ports

of entry

To develop a legal and regulatory framework for

public health interventions during epidemics.

Identification of high risk groups

Stockpiling of PPE, AVs and Vaccine

Implementers: DPHO/DHO, RHDs, EDCD, AICP

Supported by: USAID, WHO

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Health Care Delivery System Preparedness and

Response: Objectives

To develop and implement acute respiratory disease

triage and referral system.

To prepare and implement contingency plans at the

primary care system

Develop Triage and Referral System

Management of the cases

Implement Infection Control

Implementers: PHCs, District, Regional & National Referral Hospitals

Supported by: Curative Division, MOHP; Management Division, DHS

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Program Management:Monitoring and Evaluation

Monitoring

Build on existing recording and reporting system.

Specific separate indicators at each level

Each Line Ministry report to AITSC

Feed back by AITSC ensures two way flow of

information and accountability

Evaluation Midterm (2yrs) and final at the end of the project

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Common Communication Strategy• Advocacy:

To gain political and social commitment to address AI

• Social Mobilization:To build inter-sectoral alliances and participation in the delivery of BCC messages at the household level

• Behavior Change Communication (BCC):To design and deliver targeted communication and training materials to initiate behavior change to each of the defined target groups

Implementer: National focal Point: NHEICC for NAICC (AH and HH)UNICEF on cross cutting issues

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Achievement during FY 2065/66

Policy Updates

• Preparedness mode switched to Emergency mode after the introduction of HPAI & PI into the country.

• Zonal Hospitals in the border district and the Poultry hub - primary isolation facility and do primary case management.

• New site in the existing NPHL’s building for the establishment of BSL-III facility

• The technical specification for proposed BSL-III laboratory facility is prepared by WHO Consultant and Experts.

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Surveillance and Laboratory

• The medical team (HRRT) mobilization during AI outbreaks in Jhapa

• The PCR diagnosis from the suspected human case/s of Avian influenza will be carried out by NPHL in collobration with WARUN. For A(H1N1) through CDC and WHO

• House to House Surveillance in the epicenter (ward No. 10, Mechi NP) and Saranamati VDC; passive surveillance around the affected area.

Prevention and Containment

• Provision of 5000 doses of trivalent seasonal

vaccines to the health workers

• 16000 tablets of Tamiflu and 100 bottles of Tamiflu

suspension for the culling team and suspected

human case/s of AI

• Antimicrobial, antipyretic, Antitussive, disinfectant,

pumps and PPE


• An isolation room with 2 sets of ventilator and pulse oxymeter at BPKIHS.

• An isolation room with a set of ventilator, mobile x-ray machine and pulse oxymeter at Mechi, Seti and Bheri Zonal Hospital.

• 2 sets of ventilator, pulse oxymeter, IBP+NIBP monitors, a mobile x-ray machine, portable dialysis machine, syringe pump, suction pump, four ICU beds and 10 Fowler beds, small equipment and consumables at TUTH

• An Isolation Room at Amda Hospital

• 5 Isolation rooms at STIDH

Others

• Partnership with CDC, Atlanta in order to strengthen surveillance of ILI in collaboration with Patan Academy of Health Sciences including other public and private hospitals

• Partnership with H2P Project - CARE, NRCS, SCF and AED (AI.COMM) with the objective of Pandemic Preparedness (Non-pharmaceutical intervention) at the district and community level.

• Integrated HH+AH Outbreak Preparedness and Response Centre at the regional level

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Communication

• HE Messages from National Daily newspapers.

• HE Messages production and aired through TV and radio.

• Regular briefing to the Media personnel

• Awareness in affected area through miking.

• Different types of HE Messages (During low/high risk and after introduction of disease) prepared disseminated jointly by HH, AH and UNICEF.

• A joint press release by DOHS and WHO.

• A joint press release by MOHP and MOAC.

Pandemic Influenza A(H1N1)2009

Chronology of Events

• 25 April - EC decided situation constitutes Public Health

Emergency of International Concern

• 28 May - EC recommended Director General to declare Phase 4

• 29 May - EC recommended DG (WHO) to raise to Phase 5

• 11 June - EC recommended DG (WHO) to raise to Phase 6

• Surveillance- Case definitions adapted and shared

– Suspected/probable/confirmed

– Reporting frequency and channel

• Monitoring - daily video/teleconferences- HQ/ROs

Situation of A (H1N1)2009 in Nepal

• Popularly known as “Swine Flu”• Introduction of Disease to the country was

declared on 15 Ashad 2066• Total number of confirmed cases: 63• Nepalese Citizen: 29 (Residing/working abroad)

• Foreigner: 2 • Close Contact Transmission: 5• Community Transmission: 27 (15 Oct onwards)

Surveillance

• Case definition 75 RRTs, 40 Sentinel Hospitals, 80 WHO/VPD sites

• Laboratory diagnosis: RT-PCR (NPHL)

• Coordination with WHO Collaborating Center

• 11 points of entry – 1 TIA, 10 land crossings

• Health care facilities: All zonal + Amda – Primary referral facilities.

BPKIHS, NSRH, LZH, BHZH and SEZH – Secondary

Central- STIDH, TUTH, PAHS – Tertiary

CRITERIA FOR SAMPLE TESTING

• Any person matching the case definition +– develop shortness of breath or – required hospital admission.

• In case of community outbreak or cluster of cases, samples are collected by random sampling.

• Confirming infection in new geographical areas or communities

Criteria for Hospitalization

• Signs of severe illness– Shortness of breath, difficulty breathing,

weakness/unable to stand, unconsciousness, convulsions, inability to drink fluids and dehydration, high fever.

– If you are pregnant (especially in the 2nd and 3rd trimester) and become ill with fever, cough and/or sore throat, visit the health facility.

Criteria for administrating antiviral

• Seriously ill • Fever goes away; comes back after 2-3 days • Underlying condition such as

– asthma, COPD, cardiac disease, diabetes mellitus; chronic renal diseases; immunosuppressant (cancers, HIV/AIDS infection, drugs)

• Should visit health facility for advice on antiviral medications:– Above 60 years of age

– has an ill child under 5 years old

• Antivirals – 36,000 courses

• 200 courses at each Referral/zonal hospitals and above

• Antibiotics and other medical supplies – 35,000 courses

• Disposable masks – 100,000

• Surgical gloves – 20,000

• N95 Respirators - 3000

• Disinfectants

• Soaps

Stock-piling

1. Cover Coughs and Sneezes (with elbow/tissue/cloth/mask)

2. Wash Your Hands (frequently, in the recommended manner)

3. Keep Your Distance (stay at least 1 meter away from others who are coughing or sneezing)

4. Separate Sick People (keep them away from others)

5. Avoid crowds

6. No trade and travel restriction

Communication

Dos and Don’ts

Communication

TV spots Radio Spots FM radio spots Leaflets Posters Flex Chart Pamphlets Banner (under preparation) Hoarding Board (under

preparation) NPI training guide for trainer NPI handbook for HCW NPI handbook for volunteer

Last 3 Years’ Performance/Indicators

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Programme Name FY 2006-07 FY 2007-08 FY 2008-09

Surveillance and Laboratory Strengthening

AICP was launched on 5

May 2007, so the FY 2007-08 is

regarded as the first year of the

programme

50% of sentinel sites submit reports timely

>80% of sentinel sites submit reports on time

- QC tests couldn’t be done at NPHL.


4500 sets of PPE,1000 antiviral(30% of the targeted high risk)

6000 sets of PPE, 5000 seasonal Flu vaccine, 38,000 course antiviral(>100% of the targeted high risk)

- Quarantine check posts (Health Desk) at TIA and 10 land crossing points

During 2006-07, the approved programme was there but no transfer of funds, only remaining balance NRs.799,000 in the special account (ADB) was spent


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Health Care Delivery System Preparedness and Response AICP was

launched on 5 May 2007, so

the FY 2007-08 is regarded as the first year

of the programme

30% of HCWs (RRTs) at public HCF have adequate knowledge on HPAI

50% of HCWs (RRTs) at public HCF have adequate knowledge on HPAI

- 1 primary, 5 Regional and 1 National referral hospitals are equipped

Program Management Timely Conduct of Planned activities (50%)

Timely conduct of planned activities (achieved 50% instead of 70%)


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Communication Comprehensive Communication program launched

Comprehensive Communication program launched

High level (50%) awareness of Program message

High level (70%) awareness of Program message

This Years’ Performance/Indicators

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Sub-Components Output Indicators

Targeted FY 2065/66 (2008/2009)

Annual Output

Cumulative Output

1Surveillance and Laboratory Strengthening

Reporting by sentinel surveillance sites (Immediate, Weekly, Monthly)

80% 86%

Consistency of laboratory results to WHO Reference laboratory

90% 100%

2Prevention and Containment

Seasonal Influenza vaccine for high risk occupational groups

90% 90%

PPE and antiviral for high risk occupational groups

100% 100%

Quarantine facilites functional at TIA and border entry points

1/51/10

(Temporary)

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Overall Physical Progress: 84% Overall Financial Progress: 82%

Sub-Components Output Indicators

Targeted FY 2065/66 (2008/2009)

Annual OutputCumulative

Output

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Health Care Delivery System

Preparedness and Response

Adequate knowledge of HAI among public health care workers

50% 50%

District PHOs have Influenza epidemic prepaedness and reponse plan

50% 0%

Establishment of a national referral hospital

feasibility study at STIDH

0%

4Program

Management

Timely implementation of procurement (% not beyond 1 month)

80% 30%

Submission of project reports every four month to TSCAI

100% 66%

5Communication

Component (Human Health)

Comprehensive Communication Program launched

yes yes

Target group population showing high level of awareness (survey)

60% 70%

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NRs. NRs. NRs.

Surveillance and Laboratory Strengthening

Budget

AICP was launched on 5 May 2007, so the FY 2007-

08 is regarded as the first year of the programme

155,403 84,560

Exp. 50,108 75,476

Exp. % 32% 89%


Budget 32,696 34,036

Exp. 229 20,410

Exp. % 1% 60%


Budget 56,764 53,661

Exp. 20,547 49,100

Exp. % 36% 91%

Amount in ‘000Last 3 Years’ Budget and Expenditure

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NRs. NRs. NRs.

Program Management Budget

AICP was launched on 5 May 2007, so the FY 2007-08 is regarded as

the first year of the programme

11,804 25,298

Exp. 7,338 11,884

Exp. % 62% 47%

Communication Budget 22,503 13,063

Exp. 17,174 14,802

Exp. % 76% 113%

Overall Exp% 35% 82%

Amount in ‘000Last 3 Years’ Budget and Expenditure

* Direct Payment to WHO and Custom and duties of the vehicles are included

** Annual Budget was reduced by NRs. 50 M to NRs. 210.618 M by the decision of MoF

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Problems/Issues/Challenges

• No leadership at the Project since Ashad 2066

• BSL-III laboratory establishment – WB cancelled funding

• Hospitals – Not admitting the patients if suspected H1N1

• Lab. Diagnosis – demanded

• Health care absorption capacity is low– 16,000 non-obstetric beds in 84 Public hospitals– 4015 peripheral health facilities with HA or AHWs

• Advocacy for Political Commitment

• Coordination Among different Stakeholders

• Establishment of timely and effective coordination and communication mechanism

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• Contingency Plan – being prepared

• Case Management Module at Community

• Quarantine check points – possibility?

• Risk Assessment on the introduction of AI

• Development of Risk Communication Strategy based on local situation

• Mobilization of social workers/Volunteers

• Social Research


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IssuesReset Target

Original Target

Surveillance Core Capacities at all levels 2011 IHR-2012

Establishment of BSL-III Laboratory 2011 2010

Establishment of Border Health Check Posts 2009 2009

Regional Referral Hospital Strengthening (Initial facility upgrading has been accomplished)

2009 2009

Additional referral hospital at the Poultry Hub (Bharatpur Hospital, Kanti Children etc.)

2009 2009

Assessment and cost estimation for the strengthening of Central Referral Hospital (Sukraraj Infectious and Tropical Disease Hospital)

2009 2009

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Health & Medicine

Aicp 065-66-narm