Regional Clinical Network on Emerging Infectious Diseases
1 0 - 12 November 2009 Manila, Philippines
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-f . 1 ~ World Health
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Western Pacific Region
REPORT
~TINGOFTHE
REGIONl£"CLINICAL NETWORK ON EMERGING INFECTIOUS DISEASES
10- 12 November 2009 Manila, Philippines
Convened by:
WORLD HEALTH ORGANIZATION
WHO/WPRO Lll3RARY
MANILA, PHILIPPINES
~7 MAR 20 ·\~
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The views expressed in this report are those of the participants of the Meeting of the Regional Clinical Network on Emerging Infectious Diseases and do not necessarily reflect the policies of the Organization .
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Meeting of the Regional Clinical Network on Emerging Infectious Diseases, held in Manila, Philippines on
10-12November2009. · ::• ''':
1. INTRODUCTION . . . .. . .. .. . .. . .. .. .. . .. . .. . .... ... 1
1.1 Objectives... 1
1. 2 Opening Remarks .. .. . . .. .. .. .. . . .. . . .. . . .. . . .. . . .. . . .. .. .. . . .. .. . .. . . .. . .. . 1
2. PROCEEDINGS . . .. . .. . .. . . .. . . .. . . .. . . .. . . .. . . .. . . .. . . .. .. . . .. . . .. . .. 2
2.1 Plenary 1: Regional clinical network on Emerging Infectious Disease (BID) . . . .... 2
2.1.1 Role of clinicians and WHO in response to outbreaks ... 2
2.1.2 Forming the Regional Clinical Network on BID ... 2
2.1.3 Global Outbreak Alert and Response Network (GOARN) . . . .. 2
2.1.4 Field experiences of the clinical network . . . 3
2.2 Plenary 2: Pandemic influenza A(H1N1) 2009- clinical management and country response and preparedness . . . 3
2.2.1 Regional update of pandemic A(H1N1) 2009 ... 3
2.2.2 Update of clinical management of pandemic A(H 1N1) 2009 . . . 3
2.2.3 Intensive care for pandemic influenza A(HlNl) 2009 .. .. . .. . . ... . . ... ... . . .. . . 4
2.2.4 Clinical management in resource poor settings (1) . . . ... 4
2.2.5 Clinical management in resource poor settings (2) .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 5
2.2.6 Country Experience- China... 5
2.2.7 Country Experience- Japan ... 5
2.2.8 H1N1 management in the intensive care unit- Malaysia . . . 5
2.2.9 Country Experince- Lao People's Democratic Republic . . . 6
2.3 Plenary 3: Current situation ofH5N1 infection ... 6
2.3.1 Overview of WHO guidelines on H5Nl clinical management ... 6
2.3.2 Country experience on clinical management ofH5N1 infection- China ... 7
2.3.3 Country experience on clinical management ofH5Nl infection- VietNam ... 7
2.3.4 Indonesia's experience on managing avian influenza patients . . . .. . . .. 7
2.4.1 Regional update on HFMD . . . .. 8
2.4.2 Overview of "Forum on Hand, Foot and Mouth Disease in Asia-Pacific Region" in Singapore 2009 .... ~ ... ~ . r,'' 1 t ' ' ' • '1 ' • ' ' ' '' I ' ' ' I ' ' t ' I ' ' ' t' ' ' I ' ' I ' I I ' ' I I I ' 1 ' ' I ' I I . I • I • • I t t • I • • I • I • • I R 2.4.3 Overview of "International Symposium on Hand, Foot and Mouth Disease" in Beijing, China 2009 . . . .. 9
2.4.4 Country experience on clinical management of hand, foot and mouth disease: China... 9
2.4.5 Country experience on clinical management of hand, foot and mouth disease: Malaysia.... 9
2.4.6 Country experience on clinical management of hand, foot and mouth disease: Singapore ... 10
2.4.7 Country experience on clinical management of hand, foot and mouth disease: VietNam ... 10
3. GROUP DISCUSSION ... 11
3.1 Group discussion 1: Clinical management ofH5N1 and pandemic (H1N1) 2009 infections ... 11
3.1.1 Needs ... 11
3.1.2 Issues/Challenges clinicians and health care facilities are currently facing ... 12
3.1.3 Approaches clinicians and health care facilities are currently taking in pandemic response and preparedness for H1N1 and H5N1 infection ... 12
3.1.4 Actions for the regional clinical network ... 12
3.2 Clinical management of severe HFMD- the way forward ... 12
3.2.1 Needs ... 12
3.2.2 Issues/Challenges clinicians and health care facilities are currently facing ... 13
3.2.3 Approaches clinicians and health care facilities are currently taking to improve the clinical management of severe cases ... 13
3.2.4 Actions for the regional clinical network ... 13
4. CONCLUSIONS ... 13
4.1 General ... 13
4.1.1 Next steps for pandemic response ... 14
4.1.2 Next steps for HFMD ... 14
ANNEX 1: LIST OF PARTICIPANTS AND SECRETARIAT ... 15 ANNEX 2: PROGRAMME OF ACTIVITIES . . . ... :LJ ANNEX 3: GROUP DISCUSSION QUESTIONS . . . 27 ANNEX 4: GROUP DISCUSSION MEMBERS ... 29
Keywords
Communicable diseases, Emerging diseases therapy I Disease management I Influenza A virus, H1N1 subtype I Influenza A virus, H5Nl subtype I Hand, foot and mouth disease
The first meeting of the Regional Clinical Network on Emerging Infectious Diseases was held in Manila, Philippines, from 10 to 12 November 2009. The workshop was convened by the
\V entem Pacific Regional Offloo in oon3ultation with the membership of the Regional Clinical Network on Emerging Infectious Diseases.
The objectives of the meeting were:
(1) formally establish the Regional Clinical Network in accordance with the objectives, terms of references, operational procedures and membership created during the regional consultation in December 2008;
(2) share experiences and formulate clinical management options or guidelines on the emerging and re-emerging infectious diseases of concern in the Region, particularly human infections with the pandemic influenza A (H1Nl) 2009, avian influenza HSNI and EV-71 viruses; and
(3) discuss the areas for strengthening and the way forward in pandemic preparedness and response in health care facilities.
The meeting affirmed that early diagnosis and early treatment were key factors to
improving clinical outcomes for patients infected with pandemic (HI Nl) 2009, H5N1 and EV -71 hand, foot and mouth disease. It was recognized that the sharing of clinical experiences is very important to the process of establishing guidelines and consensus on best practises. The Regional Clinical Network was appreciated by participants as an effective way to share clinical experiences, lessons learned and to access expertise.
1. INTRODUCTION
The first meeting of the Regional Clinical Network on Emerging Infectious Diseases was held in Manila, Philippine~. from 10 to 1?. Novr.mhr.r ?.009 Thr. work~ hop Wi'lS r.nnvf':nf':rl hy thf':
Western Pacific Regional Office in consultation with the membership of the Regional Clinical Network on Emerging Infectious Diseases. Attending the workshop were clinicians from
countries in the Western Pacific Region and WHO staff from the Western Pacific Regional Office and WHO Headquarters. (the list of participants and programme of activities are shown in
Annexes 1 and 2).
1.1 Objectives
(1) Formally establish the Regional Clinical Network in accordance with the objectives, terms of references, operational procedures, and membership created during the regional consultation in December 2008;
(2) Share experiences and formulate clinical management options or guidelines on the emerging and re-emerging infectious diseases of concern in the Region, particularly human infections with the pandemic influenza A (HlNl) 2009, avian influenza H5Nl and EV-71 viruses.
(3) Discuss the areas for strengthening and the way forward in pandemic preparedness and response in health care facilities.
1.2 Opening remarks
Dr Shin Y oung-soo, Regional Director, Western Pacific Regional Office, welcomed all meeting participants and observers and thanked the audience for their attendance at the first official meeting of the Regional Clinical Network on Emerging Infectious Diseases. Dr Shin emphasized the continued vulnerability of the Region to infectious diseases and the need to work together to address these diseases. The response to severe acute respiratory syndrome (SARS) remains a textbook example of how international cooperation among clinicians, laboratory experts, epidemiologists and public health officials effectively can control an outbreak. It also illustrated the important role appropriate clinical management plays in minimizing morbidity and mortality during such outbreaks.
Dr Shin also highlighted the Asia Pacific Strategy for Emerging Diseases (APSED), which has provided a strategic framework for Member States to continue to strengthen their capacity to confront emerging infectious diseases. He noted that the establishment of the Regional Clinical Network presented an opportunity to further strengthen clinical capacity within the Region.
Dr W eigong Zhou, Epidemiologist, Influenza Division, Centre for Disease Control and Prevention, presented an overview of the meeting objectives, expected outcomes and agenda that focused on three diseases impacting the Region: pandemic influeiiza A (HlNl) 2009, avian influenza and hand, foot and mouth disease. He noted that the Regional Clinical Network presents a valuable opportunity for clinicians to pool their knowledge to strengthen the response to
emerging infectious diseases.
2. PROCEEDINGS
2.1 Plenary 1: Regional Clinical Network on Emerging Infectious Diseases
In the first plenary session, presentations were delivered outlining the role of clinicians, WHO and regional networks in addressing emerging infectious diseases in the Region. Emerging diseases continue to pose a threat and clinical capacity is a critical component of the response.
The Regional Clinical Network for Emerging Infectious Diseases provides a platform for improving clinical management in the Region through the sharing of experiences, expertise and evidence-based best practise in addition to building consensus on best practise when evidence is not yet available.
2.1.1 Role of clinicians and WHO in response to outbreaks
Dr Takeshi Kasai, Regional Adviser, Communicable Disease Surveillance and Response, Western Pacific Regional Office, outlined the role of clinicians and WHO in responding to emerging diseases that continue to pose a threat to the Region, with about 206 events reported between July 2008 and June 2009. WHO's role includes mobilizing partners and formulating policies that will prevent and control infectious diseases. One partnership is the Global Outbreak and Response Network (GOARN), which provides international support to countries during outbreak responses and has assisted in over 100 events since 2000.
The International Health Regulations (IHR) 2005 also have been established to provide a global legal framework for public health security. In addition, APSED is being implemented by countries with support from WHO to strengthen core capacities to enable countries to meet their IHR obligations. In recognition that clinical management is vital in outbreak control and response, WHO is working more closely with clinicians to establish systems to control and respond to emerging infectious diseases.
2.1.2 Forming the Regional Clinical Network on Emerging Infectious Diseases
Dr Weigong Zhou, Epidemiologist, Influenza Division, Centre for Disease Control and Prevention, outlined the formation of the Regional Clinical Network for Emerging Infectious Diseases of the Western Pacific Region. This network was established in recognition that clinical capacity is a critical component in controlling and responding to disease outbreaks. The network was established in December 2008 during consultative meetings with experts from 10 countries in Manila, Philippines, to determine the network's objectives, terms of reference, operational
procedures and membership. The network seeks to improve clinical management of critically ill patients during outbreaks through sharing of lessons learned and evidence-based best practise and to facilitate consensus among experts when evidence is not yet available.
2.1.3 Global Outbreak Alert and Response Network (GOARN)
Amy Cawthorne, Epidemiologist, Communicable Disease Surveillance and Response, Western Pacific Regional Office, introduced the Global Outbreak Alert and Response Network (GOARN), which can be called upon by Member States to assist with responding to outbreaks of infectious disease.
GOARN was born out of the recognition that there is an occasional need for international support for responses to outbreak events and that no single institution has all of the specific capacities required. GOARN team members can be drawn from the GOARN network to meet all
technical needs of a response, including case management, surveillance and risk communication.
Several GOARN missions were outlined in countries, including Papua New Guinea, the
Democratic Republic of Congo, Sri Lanka and, most recently, providing support to the Philippines in its response to a leptospirosis outbreak following Typhoons Ketsana and Parma in late 2009.
Clinicians can play an extremely important role in GOARN missions by providing in-country technical support and advice based on observation and case review and via teleconference.
2.1.4 Field experiences of the clinical network
Dr Dale Fisher, Department of Medicine, National University of Singapore, shared his experience participating in a GOARN mission to Malaysia in August 2009. The objective of the mission was to assist the government in assessing the true situation of the pandemic HlNl virus in the country and to identify ways in which the response could be improved.
By requesting assistance, Malaysia demonstrated a willingness to open itself to scrutiny.
The GOARN team included a clinician to ensure that clinical issues were well understood and that evidence-based outcomes were concluded. The involvement of a clinician also facilitated
productive communication with clinicians in-country. The mission involved hard work, flexibility and the ability to communicate well and with cultural and political sensitivity.
2.2 Plenary 2: Pandemic influenza A(B1Nl) 2009- clinical management and country response and preparedness
In the second plenary discussion, participants heard how the pandemic (HlNl) 2009 virus spread at an unprecedented rate in the Region and worldwide. While most cases are mild, severe cases and deaths have been reported in many countries in the Region. The virus is still
unpredictable and vigilance is required. The importance of the early identification of high-risk patients and early treatment in improving clinical outcomes was emphasized in addition to the need to learn more about effective treatments and clinical management strategies through sharing experiences and the current practise of clinical treatment of pandemic influenza (Hl Nl) patients.
The significant challenges to clinical management in resource-poor settings also were recognized and discussed. The revised publication of WHO guidelines for clinical management of pandemic influenza (HlNl) also was highlighted.
2.2.1 Regional update of pandemic influenza A (HlNl) 2009
Dr Satoko Otsu, Medical Officer, Pandemic Preparedness and Response, Communicable Disease Surveillance and Response, Western Pacific Regional Office, provided an update on the pandemic (HlNl) 2009 situation in the Region. As ofNovember 2009, more than 6000 deaths globally had been reported to WHO. In the Western Pacific Region, 483 deaths have been reported, of which 84% have been identified as having an underlying medical condition. At the time of reporting, the northern hemisphere was showing an increase in influenza-like illness (ILD.
ILl activity in the southern hemisphere generally was low while ILl activity in the tropics generally was declining, with a number of exceptions.
The pandemic (HlNl) virus has spread at an unprecedented rate, largely due to increased population mobility. While it is difficult to predict how the pandemic will progress, it is plausible to assume extensive community transmission during the northern hemisphere's winter. While the majority of cases have been mild, the virus is unpredictable and it is important to remain vigilant.
There have been fatal cases in age groups not usually seen with seasonal influenza.
2.2.2 Update of clinical management of pandemic influenza A (HlNl) 2009 Dr Charles Penn, Global Influenza Programme, WHO, Geneva, summarized the Washington consultation on the clinical management of pandemic (HlNl) 2009 held in
October 2009. The consultation brought together experts from across the world in virology, pathology, public health and clinical management. The purpose of the meeting was to draw on worldwide knowledge and experience in managing cases of pandemic (HlNl) 2009 and to revise the WHO Initial Guidance for Clinical Management. New guidelines were published in the week beginning 9 November 2009.
The consultations identified groups at higher risk of developing severe influenza illness or complications. However, about one third of the patients who experienced very severe illness were previously healthy persons. The consultations also provided guidelines for infection control, diagnosis and treatment. Diagnosis should be based on clinical presentations only when influenza is known to be circulating and practitioners should be alert to coinfections or infections with similar presentations. The importance of prompt or immediate antiviral treatment for severe cases or for patients at higher risk was emphasized
2.2.3 Intensive care for pandemic influenza A (HlNl) 2009
Dr Colin McArthur, Clinical Director, Department of Critical Care Medicine, Auckland City Hospital, New Zealand, delivered a presentation on New Zealand's experience with
pandemic (HlNl) 2009 from April2009 to August 2009. During the peak ofthe epidemic in New Zealand, HlNl cases were responsible for 230 per million hospitalizations, while intensive care unit (ICU) admissions were 27 per million, or 12% of hospitalizations. Fully 65% ofiCU cases required mechanical ventilation for a median duration of eight days.
The percentage ofiCU beds occupied by HlNl confirmed cases in Australia and New Zealand ranged from 8.9% to 26.9%. Cases occurred over a relatively brief period and many patients required an extended stay, creating additional strain on ICUs. Of the HlNl cases, about one third of the patients previously were fit and well, about one third had severe comorbidity and the remaining one third had other risk factors such as pregnancy, obesity or asthma without severe comorbidity.
Australia and New Zealand found higher rates of hospitalization for Maori, Pacific islanders and people of aboriginal background. It was not possible to determine whether this was related to genetics, socioeconomic variables or other factors such as obesity. Critical syndromes observed in the New Zealand experience included airflow limitation (such as croup in infants or exacerbation of asthma), viral pneumonitis/adult respiratory distress syndrome (ARDS), secondary bacterial pneumonia, critical oxygenation and hyperthermia.
2.2.4 Clinical management in resource-poor settings (1)
Dr Edward Zuroweste, WHO Headquarters, outlined the recent formulation of draft guidelines to guide hospitals in resource-limited settings in managing patients with severe respiratory distress and septic shock. The guidelines include extracts from the Integrated Management of Adolescent and Adult Illness (IMAI) District Clinical Manual, including quick check and initial emerging treatments and treatment instructions. These tools have been written on the assumption that they will be applied in settings where resources, including human resources, and the availability of drugs and equipment, are limited.
These guidelines present a unified approach to the treatment of septic shock or severe respiratory distress without shock. The importance of early treatment and early response was emphasized. The guidelines also present best-practise responses in stabilizing the physiology of a presenting case, treating the infection and patient monitoring.
2.2.5 Clinical management in resource-poor settings (2)
Dr Christian Winter, Clinical Assistant Officer, WHO, the Lao People's Democratic Republic, reviewed the response to pandemic (HlNl) 2009 in the Lao People's Democratic Republic. Factors that facilitated an effective response included a clear hierarchical structure in the health system, a high level of political support, effective cooperation and coordination, the length of time between the WHO announcement of pandemic alert phase 4 and the detection of the first r.~sf: in thf: r.mmtry (seven weeks) and the existence of a Clinicians Working Group. The group was able to respond rapidly to the pandemic, formulating a suspect case definition along with guidelines and training on case management and infection control.
Challenges in the pandemic response included the delay of case management decisions by pending positive laboratory results and the testing of patients who did not fulfil the suspect case definition in the initial stages of the response. Communicating changes to the laboratory testing strategy during the course of the pandemic also posed a challenge, as did constraints posed by limited laboratory capacity, hospital equipment and facilities and the storage and availability of Tamiflu.
2.2.6 Country experience - China
Dr Cao Bin, Director, Department of Infectious Diseases and Clinical Microbiology, Beijing Chaoyang Hospital, Capital Medical University, China, spoke on behalf of the Chinese National Influenza A Pandemic (HlNl) 2009 Clinical Investigation Group. The role of the group was to assist in the pandemic response in China by formulating guidelines, providing clinical expertise, training clinicians and analysing clinical data. In the initial stages of the pandemic, patients were hospitalized to facilitate isolation, providing an opportunity to track their demographic and clinical features.
Dr Bin also reported the results of a study carried out to evaluate the efficacy and safety of treatment using Chinese traditional medicine and oseltamivir. Cases were allocated to one of four groups: a control group; treatment with oseltamivir; treatment with Chinese traditional medicine;
and treatment with both oseltamivir and Chinese traditional medicine. There was no significant difference in time to resolution of fevers among treatment groups although the difference between control and treatment groups was statistically significant. The history and treatment of two
patients who had received influenza A (HlNl) vaccine also was presented. One patient became ill a day after vaccination while the other suffered chronic renal failure. Both cases did not improve with empiric antibiotic therapy, but fever subsided once oseltamivir was administered.
2.2.7 Country experience- Japan
Dr Akihiko Kawana, Professor of Infectious Diseases, Department of Internal Medicine, National Defence Medical College, Saitama, Japan, reported that the number of influenza cases in Japan was increasing- between epidemiological weeks 36 and 44, the estimated number of patients visiting hospitals rose tenfold. The rise in the number of cases occurred several months before the normal influenza season. The greatest number of hospitalizations was among children 5 years to 9 years old while the highest mortality rate occurred among adults 60 years to 79 years old. The majority of older patients had some kind of comorbidity. In the younger generation, the most common comorbidity was chronic asthma.
2.2.8 HlNl management in the intensive care unit- Malaysia
Dr Tai Li Ling, Consultant Intensivist, Department of Anaesthesia and Intensive Care, Hospital Kuala Lumpur, Malaysia, shared the experience of Hospital Kuala Lumpur's intensive care unit (ICU) in responding to pandemic (HlNl) 2009. The hospital has 20 ICU beds and only treats patients older than 12 years old. The ICU's usual bed occupancy rate is 112%, presenting a
significant capacity constraint before the onset of the pandemic. Between confirmation of the first case ofH1N1 on 26 July and 30 September, a total of 112 ILl cases presented to the hospital, with 39 cases confirmed as pandemic (H1N1) 2009. To cope with the surge of cases, additional beds were opened within the bums unit, staff were deployed to the lCU and all elective surgery was deferred. The hospital followed the infection control measures introduced by the Ministry of Health and used by all public hospitals.
The age, gender and risk factor profiles of preEenting cae;ee; were comparable with thooe of other countries. Of the lCU cases, mechanical ventilation was used in 89% of them. Dr Ling spoke about the application of invasive and noninvasive ventilation and emphasized the effect of ventilatory strategies on patient outcomes. All patients (except the first case) were treated with antivirals. Vasoactive drugs were used in 42% of cases and steroids were used only for those patients suffering from septic shock or as treatment for chronic pulmonary disease. The median length of stay in the ICU unit was five days, with four patients requiring stays of longer than 50 days.
2.2.9 Country experience- Lao People's Democratic Republic
Dr Snong Thongsna, Head oflsolation Unit, Mittaphab Hospital, Ministry of Health, the Lao People's Democratic Republic, reviewed the management of pandemic (H1Nl) 2009 cases in the Lao People's Democratic Republic. Initial measures in the country focused on the protection of borders, with hospitals quarantining all visitors with fever.
The first HlNl confirmed case was an Australian citizen who had travelled to numerous countries. The first death case was an obese young man with chronic asthma. His case was diagnosed late and he was admitted to a provincial hospital only after visiting three clinics. This case was followed by 37 further infections, which caused significant panic, with many health care workers taking leave. The second death case exhibited ILl symptoms for more than 10 days but did not receive antivirals. Although close contacts of this case also exhibited ILl symptoms, all recovered without antivirals. Dr Thongsna also outlined the current case definition being applied in the Lao People's Democratic Republic, the guidelines for specimen collection priorities and treatment guidelines.
2.3 Plenarv 3: Current situation ofH5Nl infection
In the third plenary session, the current situation ofH5N1 infection was discussed. While the virus is not yet easily transmitted among humans, its endemic presence in birds continues to pose a significant threat to the Region. In 2009, three countries in the Region reported human infections ofH5Nl. The human case fatality rate from the virus is high and proper infection control remains a crucial element in health care practise as well as early treatment with antivirals.
2.3.1 Overview of WHO guidelines on avian influenza A (H5Nl) clinical management Dr Charles Penn, Global Influenza Programme, WHO, outlined the current WHO guidelines on H5Nl. The virus has a natural reservoir in wild birds and frequently causes outbreaks in domestic poultry. The high case fatality rate of patients (56% based on data from December 2003 to April2006) is a cause for concern. While H5Nl is less easily transmissible among humans than H1N1, it is more pathogenic and severe; a prolonged illness should be expected. Guidelines on the clinical management of human infection with avian influenza A (H5Nl) were published in 2007, with revised guidelines released in November 2009. For both H5Nl and HlNl infections, prompt medical intervention is the key to preventing deaths.
2.3.2 Country experience on clinical management ofH5N1 infection- China
Dr David S.C. Hui, Professor, Department of Medicine and Therapeutics Head·ofDivision of Respiratory Medicine, Deputy Director, Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong (China), Prince of Wales Hospital, presented the
experience ofH5N1 in Hong Kong (China). The first case of human infection ofH5N1 occurred in early 1997 and resulted in the death of the infected child. However, the disease received limited attention until November 2007, \Vith a major outbreak of 17 cma:m and five deatho. The ouoc fatality rate was higher for patients over 12 years old, perhaps because younger children were more likely to be taken to a hospital.
Dr Hui also discussed the relationship between clinical features and the prognosis ofH5N1 infection in cases in mainland China, where from October 2005 to May 2008 there were 28 cases and 10 deaths. It was concluded that lactic acid dehydrogenase (LDH) levels of more than eight times the normal value on admission suggested a poor prognosis. Patients with acute respiratory distress syndrome (ARDS) or acute renal injury had a higher risk of death. The time taken to initiate treatment with oseltamivir had a statistically significant impact on survival rates, while there was no statistical difference in survival rates between patients that did or did not receive corticosteroid treatment.
2.3.3 Country experience on clinical management ofH5N1 infection- VietNam Dr Nguyen Van Kinh, Director, National Institute of Infectious and Tropical Disease, HaNoi, VietNam, reviewed the avian influenza situation in VietNam between December 2003 and March 2009. Three epidemic waves occurred in birds during that period, with 111 cases and 56 deaths in humans. The National Institute of Infectious and Tropical Disease has treated a total of 44 patients, 1 0 of whom died.
Almost all patients were farmers, with only one health care worker having been infected.
Household clustering tendencies were sporadic, with four households having at least two patients.
Cases were classified as mild, moderate, severe or asymptomatic based on dyspnea, degree of hypoxemia and extent of chest X-ray (CXR) lesions. Oseltamivir was administered to the majority of patients, but in some cases treatment was delayed. Respiratory support was based on case classification, with invasive ventilation used in the majority of severe cases. Antibiotics also were given to all patients, with the type of antibiotics varying depending on the case classification.
Severe cases also were treated with corticosteroids.
2.3.4 Indonesia's experience on managing avian influenza patients
Dr Za Hussain Reed, Assistant Director for Clinical Research, Regional Emerging Diseases Intervention (REDI) Centre, Singapore, presented Indonesia's experience with avian influenza.
Animal cases have been reported in 31 of 33 provinces, with human cases in 12 of these
provmces. In total, there have been 141 cases of human infection with 115 deaths- the highest in the world.
Fully 100 hospitals have been designated as AI referral hospitals, with isolation rooms and essential medical equipment. Case management guidelines for avian influenza were formulated by medical specialists in 2006, and regional training workshops for these guidelines have been conducted. Early identification and early treatment with antivirals are key to an effective clinical response. To facilitate this, there has been a focus on training primary health care staff (including in private clinics) on case management and referral pathways, oseltamivir has been distributed to primary health care providers and patients are offered reimbursement for treatment. A critical care improvement initiative also has been implemented involving the training of trainers in hospitals.
The initiative has targeted clinical and nursing leadership to maximize the potential to advocate for improved clinical care management practises and the establishment of standard approaches.
2.4 Plenary 4: Hand, Foot and Mouth Disease CHFMD): Clinical management and response In the fourth plenary session, the clinical management and response to outbreaks of hand, foot and mouth disease (HFMD) was discussed. In the 2008 consultation meeting to establish the Regional Clinical Network, it was agreed that HFMD would be discussed at the first network meeting. HFMD is commonly considered to be a child's disease with mild symptoms. However it can spread rapidly and in some cases can be severe. In the Asia Pacific Region, it has had
significant impact, both on public health and alGo on public concern. Surveillance ofHFI\ID has not been established in all countries in the Region and in some countries more clinical training is needed for early detection, diagnoses and treatment of severe cases.
2.4.1 Regional update ofHFMD
Dr Wakaba Fukushima, Assistant Professor, Department of Public Health, Faculty of Medicine, Osaka City University, Japan, presented a regional update ofHFMD to the meeting.
HFMD is caused chiefly by the EV -71 virus and is a common acute viral illness primarily
affecting infants and young children, with children under 4 years old particularly susceptible to the most severe forms of the disease.
The symptoms ofthe disease typically are fever, oral ulcers and skin rashes (on hands, feet and buttocks). Possible complications of HFMD caused by EV -71 include aseptic meningitis, brain stem/cerebral encephalitis, acute flaccid paralysis, pulmonary edema/hemorrhage and myocarditis. Outbreaks of HFMD associated with EV -71 have occurred since 1972 in the Region, affecting Japan, Australia and, more recently, Brunei Darussalam, China, Taiwan, China,
Malaysia, Singapore and VietNam. A major outbreak occurred in China in 2008 with 488 955 cases and 126 deaths, highlighting the significant impact of this poorly understood disease.
2.4.2 Overview of the "Forum on Hand, Foot and Mouth Disease in Asia-Pacific Region" in Singapore 2009
Dr Zarifah Hussain Reed, Assistant Director for Clinical Research, Regional Emerging Diseases Intervention (REDI) Centre, Singapore, presented an overview on clinical issues raised in the recent Forum on Hand, Foot and Mouth Disease in Asia-Pacific Region, held in Singapore in 2009. The key activities of the forum were to review the epidemiological distribution of HFMD, compare regional public health experiences and to review the clinical, diagnostic and treatment experience.
The etiological agent ofHFMD is of the enterovirus genus and first was isolated from a child who died of encephalitis in California in 1969. The virus is excreted in the feces and is also found in pharyngeal secretions, with viral shedding found to be from six to eight weeks in the stool and up to two weeks in the throat. There is no rapid diagnostic test. Rather, specimens from the throat, stool, vestical fluid or cerebrospinal fluid (CSF) are tested using reverse transcription polymerase chain reaction (RT-PCR) and serology.
In the 1990s, an increase in the size, frequency and severity of outbreaks and emergence of serious and fatal complications was noted in Japan, Taiwan, China, and Malaysia. This may have been caused by differences in behaviour of novel subtypes, pre-existing immunity of the
population, host genetic susceptibility or coinfection with other viruses. Key clinical management questions that arose from these outbreaks included how to detect high-risk children that should be hospitalized, what are likely indicators of severe cases and clinical deterioration, what are the best management strategies and how decisions on therapeutic interventions can be made. The forum concluded that clinical management ofHFMD could be optimized through networking and collaboration to share experiences, treatment and management practises and to collect and document clinical data.
2.4.3 Overview of the "International Symposium on Hand, Foot and Mouth Disease" in Beijing, China 2009
Dr Weigong Zhou, Epidemiologist, Influenza Division, Centre for Disease Control and Prevention), presented an overview of the International Symposium on Hand Foot and Mouth Disease, held in Beijing from 13 to 14 January 2009. The symposium was organized by the China CDC, cosponsored by WHO and United States of America Centres for Disease Control and involved 160 public health profcssionala and clinicians. Topics of discussion included IIPMD epidemiology; virology, laboratory testing and networking; surveillance and outbreak response;
clinical care of serious patients; and research and development.
The symposium made several recommendations on prevention and control ofHFMD, including establishment or improvement of surveillance systems, investigation and response strategies, formulation of a standardized case definition and definition of clinical indicators for severe infection and establishment of a regional Enterovirus Laboratory Surveillance Network.
The symposium also recommended that more research be carried out, specifically on the pathogen epidemiology, transmission routes and risk factors, the effect of school closure on transmission of the disease, pathogenesis and clinical treatment of severe and complicated cases as well as vaccine development.
2.4.4 Country experience on clinical management of hand, foot and mouth disease- China Dr Gao Zifen, Professor, Department of Pathology, Peking University, Health Science Centre, offered a pathological overview of death cases ofHFMD from China in 2008. In that year, China experienced 489 000 cases, of which 0.24% were severe and 0.026% resulted in death (126 death cases). Children under 5 years old accounted for 91.27% of the total. Neuropathologic autopsy findings included parenchymal lesions in the brain, with neuronophagia, glial nodules, widespread pericvascular cuffing and encephalomyelitis. Pulmonary results revealed serious pulmonary dysfunction, including congestion, edema, haemorrhage, focal hyaline membranes, hyperaeration and no exudate. The major pathological fmdings to be highlighted from these results were encephalitis (spinal cord gray matter, cerebrum, motor cortex), cerebral edema, pulmonary congestion, haemorrhage and lymphadenopathy.
2.4.5 Country experience on clinical management of hand, foot and mouth disease- Malaysia Dr Revathy Nallusamy, Consultant Paediatrician and Head of Department, Department of Paediatrics, Penang Hospital, Malaysia, gave a presentation on the experience ofHFMD in Malaysia. In 1997, nationwide clusters of encephalitis and cardiac failure occurred in children, mostly under 5 years old. The outbreak resulted in 42 deaths, with patients experiencing brief febrile illness and subtle neurological signs but which progressed dramatically to acute refractory cardiac dysfunction and culminant pulmonary oedema.
In 1998, surveillance ofHFMD was changed from an outbreak strategy to a sentinel surveillance strategy. HFMD became a notifiable disease beginning in 2007. Currently, yearly seasonal outbreaks of HFMD with three yearly cycles of EV -71 activity occur and continue to cause severe disease and death. Early clinical predictors for severe disease may be able to be used for early admission, monitoring and effective therapy. Sampling for virologic diagnosis should be optimized. Challenges also exist in surveillance, home monitoring, effective early therapy and access to timely laboratory diagnostics.
2.4.6 Country experience on clinical management of hand, foot and mouth disease- Singapore Associate Professor Y ee-Sin Leo, Clinical Director, Communicable Disease Centre and Head, Department of Infectious Disease, Tan Tock Seng Hospital, presented an overview of HFMD in Singapore. In April 1998, after outbreaks in the Region, Singapore implemented surveillance ofHFMD based on notification from child care centres. Mandatory reporting to the Ministry of Health has been required since October 2008. An epidemic ofHFMD occurred in 2000 with 3790 euses reported, including four deaths. Another three deaths were recorded in 2001. EV-71 was isolated in all death cases, and also from 71% of all isolates in 2000 and 44.3%
of isolates in 2001. Comparison of fatal and nonfatal cases from 2000 and 2001 showed that risk factors for death may include vomiting, absence of mouth ulcers, atypical presentation and raised white blood cells (WBC). Fatalities occurred from interstitial pneumonitis alone or with
myocarditis or encephalitis. In 2008 and 2009, multiple serotypes ofHFMD were isolated in Singapore, with no predominate type.
2.4.7 Nam
Country experience on clinical management of hand, foot and mouth disease - Viet
Dr Lam Yen Minh, Vice-Director, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam, gave an overview ofHFMD as experienced at his hospital. The hospital has 550 beds and is a tertiary referral centre for infectious diseases for southern VietNam. The hospital treated 328 cases ofHFMD in 2008 and 255 cases in 2009. Patients generally recovered well ifno
complications occurred. Cause of death mainly was from pulmonary edema, shock due to autonomic disorder or cardiomyositis, or apnea.
Challenges include incorrect diagnosis because symptoms can be mistaken for common diseases such as measles, pneumonia, croup and viral infection. Late diagnosis is also an issue, with subtle early warning signs that easily are missed, including sleep disorder, agitation, irritability and myoclonic jerk. Antiviral treatment or vaccination does not exist, and available treatments are only supportive. Intravenous immunoglobulin (IVIG) can be a very successful treatment, but is expensive and time-consuming to apply thoroughly. During epidemics, accessing advanced medical equipment and shortages of trained ICU and other medical staff are significant challenges.
3. GROUP DISCUSSION
Participants discussed issues of clinical management regarding avian influenza H5N1, pandemic (H1N1) 2009 and HFMD in two group discussion sessions. Participants were divided into four groups to discuss each topic. Group discussion questions and members are shown in
Annexes
3and 4.
3.1 Group discussion 1: Clinical management ofH5Nl and pandemic (HlNl) 2009 infections - the pandemic response and preparedness of clinicians and health care facilities
3.1.1 Needs
Overall, countries were able to adapt WHO guidelines for local or national application following the principles of the WHO guidelines with local flexibility (e.g. use of antivirals ).
However, a need was identified for more efforts to plan for other issues such as referral and triage, hospital surge capacity, ICU surge capacity, critical care guidance and building capacity to
implement plans, particularly in low-resource settings. Following the release of WHO- revised clinical management guidelines in November 2009, the need to review existing national and local guidelines also was discussed.
The sharing of clinical experiences among countries with similar circumstances, and disseminating information to smaller countries was regarded as particularly important. More accessible information was commonly identified as a need because some countries could not easily access existing regional teleconference arrangements or other information-sharing because of time differences or a lack of technology or resources.
3.1.2 Issues/Challenges clinicians and health care facilities are currently facing
Appropriate, consistent and timely risk communication was a common issue discussed by participants. Problems that arose included media sensationalization of information and
inconsistent messages sent by different spokespeople and politicians in the same country.
Confusing information also was sent to clinicians. A need was identified for more data and evidence in order to formulate clearer recommendations to general practitioners (GPs) about risks and treatment.
Lack of surge capacity and planning for surge capacity were identified as significant issues.
Surge capacity planning also would need to be accompanied by capacity to practically implement the plan and should also involve the whole organization, not just speciality units. Surge capacity planning also should be supported by supply chain planning (drugs, personal protective equipment (PPE), finance, staff) and needs to involve all of hospital management.
The focus on HlN1 could lead to reduced attention on other diseases with pandemic potential such as HSN1. The coexistence of other diseases with pandemic influenza also could result in misdiagnosis. Some participants said some parts of the WHO guidelines were not feasible for implementation in resource-poor settings, which also had very limited capacity and facilities for critical care in addition to limited or no access to antivirals and vaccine.
3 .1. 3 Approaches clinicians and health care facilities are current! y taking in pandemic response and preparedness for H1N1 and H5N1 infection
All countries had established national guidelines or were adapting WHO guidelines to their local or national settings. WHO was field-testing a clinician's manual and training package for low-resource settings in acknowledgement of the constraints faced by many countries.
Mn!';t r.mmtn~!'; Ft l<:n w~r~ wnrk-ing tnwFtnl<: pr~p<1nng ft1r.iliti~<:, <:11r.h <1<: idt:"ntifying isolation rooms and cohort isolation. Active networking through teleconference and Internet
communication was being conducted, although this was not able to be accessed by all.
Some countries were able to proactively engage the media, such as New Zealand's approach of including a communications officer in the incident management team. A strategy used in Hong Kong (China) was to work with academics to ensure consistent messages and credibility.
3 .1.4 Actions for the regional clinical network
Information-sharing and dissemination methods could be improved, particularly for smaller, isolated or low-resources countries. In particular, sharing clinical experiences would be very valuable for countries with similar circumstances. Alternative or complementary information- sharing forums also were suggested, such as a website, blog or an internal telephone hotline to enable field clinicians to get emergency technical advice.
Further review of existing guidelines also could be undertaken to ensure they are in line with updated WHO clinical management guidelines published in November 2009. H1N1 guidelines also should be consistent with other existing guidelines and should be updated as evidence becomes available. Again, guidelines should be adapted appropriately to local contexts, particularly for low-resource settings. Overlooked areas such as surge capacity and business continuity planning for health care facilities also should be addressed.
Laboratory capacity shortages in the Region also could be assisted by supporting intercountry laboratory collaboration and flows of specimens from countries with limited laboratory capacity to countries that have available resources to perform laboratory tests.
Continued surveillance and reporting also should be encouraged, particularly for antiviral
resistance. Training of front-line and primary health care workers also should be emphasized and referral systems strengthened.
3.2 Clinical management of severe HFMD -the way forward 3.2.1 Needs
Participants expressed a need to improve laboratory diagnostic capability to confirm HFMD cases, which was not always possible in some countries that suspected cases ofHFMD. Better communication between paediatricians and infectious disease specialists is also needed as well as information on infection control and general public education about the disease.
Regional standardization also was needed, in particular for laboratory procedures,
surveillance, clinical management of severe cases and case definition. However, more data is also needed to work out case definitions as well as predictors of severity. In general, more research about the disease (including vaccine development) is needed.
3.2.2 Issues/Challenges clinicians and health care facilities are currently facing
Surveillance was a significant issue raised. by participants. Not all countries have a formal surveillance system for HFMD, and notification policies differ among countries. In addition, there is limited understanding of common early clinical indicators of severe disease, and not all
countries have national clinical management guidelines for HFMD.
Laboratory issues also were raised. In countries where HFMD is not a notifiable disease, laboratory capacity was not being advanced. It also was noted that laboratory diagnoses is more important for surveillance than for treatment and that the cost of laboratory testing can be prohibitive.
In a resource-poor context, there are significant challenges in the areas of ICU management ofHFMD, laboratory support and training for clinicians and health care workers. In countries with more resources, risk communication to the public and mass media information about HFMD is an issue. Public health interventions such as school and kindergarten closure are commonly used to control outbreaks, but more research should be conducted to validate their effectiveness against their social cost.
3.2.3 Approaches clinicians and health care facilities are currently taking to improve the clinical management of severe cases
Some countries are training clinicians to recognize early predictors and symptoms,
particularly in patients presenting with atypical symptoms. Clinical diagnosis ofHFMD is critical, especially since laboratory confirmation (particularly in low-resource settings) can take much time. In some severe cases, IVIG treatment is being successfully given. However the most effective timing of giving this treatment is not clear.
3.2.4 Actions for the regional clinical network
Participants identified the need to raise awareness of the disease and to facilitate training for health care workers. The importance of recognizing early indicators of severe illness and
diagnosing cases with limited symptoms also was discussed.
4. CONCLUSIONS
4.1 General
The meeting affirmed that early diagnosis and early treatment were key factors to
improving clinical outcomes for patients infected with pandemic (HlNl) 2009, H5Nl and EV-71 (HFMD). It was recognized that the sharing of clinical experiences is very important to the process of establishing guidelines and consensus on best practises. The Regional Clinical Network was appreciated by participants as an effective way to share clinical experiences, lessons learned and to access expertise.
In conclusion, the following steps were identified:
( 1) Maintain momentum generated by the establishment of the Regional Clinical Network.
(2) Facilitate GOARN training for clinicians.
(3) Coordinate with other organizations to address the needs in the region.
4.1.1 Next steps for pandemic response:
(1) Facilitate a review of existing national clinical guidelines to ensure consistency with updated WHO clinical management guidelines (November, 2009).
(2) Facilitate experience- and information-sharing and access to expertise.
(a) Establish Internet-based information sharing mechanisms; and
(b) Organize conference calls, video conferences or urgent meetings to address common concerns.
(3) Advocate for continued support for surveillance and reporting.
( 4) Facilitate field testing of a training package for resource-poor settings.
4.1.2 Next steps for HFMD:
(1) Facilitate a comprehensive review of the disease situation and clinical management strategies and dissemination of this information.
(2) Formulate guidelines on clinical management of severe cases, standard case definitions and improve awareness of clinicians.
(3) Provide a mechanism for sharing experiences and best practises in clinical management.
List of Participants and Secretariat
1. PARTICIPANTS
CAMBODIA
Dr CHEU Sivuthy
Chief of Hospital Services and Biomedical Engineering Office
Department of Hospital Services Ministry of Health
#151-153 KampucheaKrom Phnom Penh
Tel no. : (855) 12 914686/
Fax no.: (855) 23 882 317 E-mail : cheusivuthy@gmail.com
Professor CHHUOY Meng
Head of Intensive Care Unit and Vice Technical Bureau
Calmette Hospital
#3 Monivong Boulevard Phnom Penh
Tel. No. : (855) 12 886781 Fax No : (855) 23 426948
E-mail : calmette.tox@online.com.kh
Dr TAING Sovanna Reanimation Specialist Calmette Hospital
#3 Monivong Boulevard Phnom Penh
Tel no. : (855) 12 660565 Fax no. : (855) 23 426948 E-mail : taingsovanna@yahoo.fr
Dr UNG Sophal
Chief of Reanimation Department National Pediatric Hospital
#1 00 Russian Federation Boulevard Phnom Penh
Tel no. : (855) 12 857082 Fax no. : (855) 23 881<)03 E-mail : phalnph@yahoo.com
CHINA
Dr DUBin
Director and Professor of Critical Care Medicine Peking Union~edical 'College Hospital
1 Shuai Fu Yuan Beijing
Tel no. : (8610) 65295036 Fax no.: (8610) 65294036 E-mail : dubin98@gm.ail.com
DrGAOZifen Professor
Department of Pathology
Peking University Health Science Center No. 38 Xuaxuan Road, Haidan District Beijing 100083
Tel no. : (8610) 82802623 Fax no.: (8610) 82802623 E-mail : marvgaoz@vina.com
Dr LI Xingwang Director
Infectious Disease Center of Beijing Ditan Hospital No. Jiangshun dongjie Chaoyang District Beijing 100083
Tel no. : (8610) 084322585 Fax no.: (8610) 084322585 E-mail : ditangixw@yahoo.com.cn
DrCAOBin Director
Department of Infectious Diseases and Clinical Microbiology Beijing Chaoyang Hospital Capital Medical University Beijing
Tel no. : (8610) 8523 11167 Fax no. : (8610) 8523 1513 E-mail : caobin1999@gmail.com
Dr LAI Kang Yiu Consultant
Intensive Care Unit Queen Elizabeth Hospital 30 Gascoigne Road Hong Kong
Tel no. : (852) 2958 6363 Fax no : (852) 2388 1231 E-mail : laiky@ha.org.hk
Dr LO Y ee Chi, Janice
Consultant Medical Microbiologist Public Health Laboratory Centre 5/F 382 Nam Cheong Street Shek Kip Mei, Kowloon Hong Kong
Tel no. : (852) 2319 8254 Fax no : (852) 2776 5758 E-mail : janicelo@dh.gov.hk
Dr LAI Sik To, Thomas Consultant
Department ofMedicine and Geriatrics Princess Margaret Hospital
Lai Chi Kok, Kowloon Hong Kong
Tel no. : (852) 2990 3452 Fax no : (852) 2990 3333 E-mail : laist@ha.org.hk
DrYUWai Cho Consultant Physician
Department ofMedicine and Geriatrics 2-1 0, Princess Margaret Hospital Lai Chi Kok, Kowloon
Hong Kong
Tel no. : (852) 2990 33737 Fax no : (852) 2990 3333 E-mail : yuwc@ha.org.hk
Dr Yasuyuki KATO Chief Physician
Division of Information and Logistics Disease Control and Prevention Center International Center of Japan
1-21-1 Toyama, Shinjuk:u-ku Tokyo
Tel no. : (81 3) 3202 7181 Fax no : (81 3) 3207 1038 E-mail : ykato@,incj.hosp.go.jp
Dr Yoshitsugu MIYAZAKI Director
Department of Chemotherapy and Mycoses National Institute of Infectious Diseases Toyoma 1-23-1, Shinjuku-ku
Tokyo
Tel no. : (81 3) 6427 5622 Fax no : (81 3) 6427 5622 E-mail : ym46@nih.go.jp
LAOPDR
Dr Bounleua OUDAVONG Deputy Director
Mother and Child Hospital Ministry of Health
Phontong Cl}ommony Chanthabouh District Vientiane
Tel. no.: (856) 21 216410, 252622 Fax no. : (856) 21 216410
E-mail : oudavong@gmail.com
DrKhampePHONGSAVATH Deputy Director
Setthathirath Hospital Ministry of Health Vientiane
Tel no. : (856) 21 351151 Mobile : (856) 20 2226100 Fax no. : (856) 21 3511600 E-mail : khampe@hotmail.com
Mahosot Hospital Ministry of Health Vientiane
Tel no. : (856) 21 214018 Fax no. : (856) 21 214020 E-mail : hounkongs@yahoo._\:.om
Dr Snong THONGSNA Head of Isolation Unit Mittaphab Hospital Ministry of Health Phonetong Road Vientiane
Tel no. : (856) 21 710006 Mobile : (856) 20 2210589 Faxno.: (856)21710005 E-mail : thongsna@vahoo.com
MALAYSIA
Dr Suresh KUMAR Consultant
Infectious Diseases Physician Hospital Sungai Buloh Department of Medicine
Hospital Sungai Buloh, Jalan Hospital Sungai Buloh
Tel no. : (603) 123091690 Fax no. : (603) 61544222
E-mail : chikku-suresh(a)gmail.com
Dr Revathy NALLUSAMY
Consultant Paediatrician and Head of Department Department of Paediatrics
Penang Hospital, Residency Road Penang 10450
Tel no. : (604) 222 5303 Fax no. : (604) 228 1737
Dr Zainah SAAT
Clinical Virologist, Virology Unit,
Institute for Medical Research, Jalan Pahang Kuala Lumpur 50588
Tel no. : (603) 2636 2671 Fax no. : (603) 2693 8094 E-mail : zainah@irnr.gov.mv
Department of Anaesthesiaand Intensive Care Hospital Kuala Lumpur, Jalan Pahang
50586 Wilayah Persekutuan Kuala Lumpur
Tel no. : (601) 222 57128 Fax no. : (602) 2o1 :'i:'il o7 E-mail : taililing(a),yahoo.com
MONGOLIA
Dr JADAMBA Lkhagvasuren Deputy Director
Khovsgol Aigmag Health Department Khovsgol Aimag
Murun City
Tel no. : (976) 99388049 Fax no. : (976) 0138223334 E-mail : 2"erlushka@yahoo.com
Dr BAT-ERDENE Ariungerel Physician and Epidemiologist
Department for Research and Surveillance of Infectious Diseases
Bayanzurkh Khothon 6-21 8th Khoroo, Bayanzurkh District Ulaanbaatar
Tel no. : (976) 911 97733
E-mail : 2"erlee bilguun@yahoo.com
Dr GARMAA Gereltmaa
Non-Communicable Disease Programme Coordinator
Arkhangai Health Department General Hospital
Arkhangaf aimag
Tel no. : (976) 9906 7230 Fax no. : (976) 01332 21189 E-mail : giimaa 69{a{yahoo.com
Dr SHONKHUUZ Enkhtur Medical Director
Children's Internal Clinical Hospital Maternal and Child Health Research enter Bayangol District
Ulaanbaatar
Tel no. : (976) 99059825
E-mail : enkhtur mgl@yahoo.com
Dr John David HOLMES Medical Officer of Health
(Otago/Southland) and Clinical Senior Lecturer, University of Otago
Public Health South
P () Rox 'i144, Mmily Plilr.f':
Dunedin 9058
Tel no. : (64 3) 476 9800 Fax no. : (64 3) 476 9858
E-mail : john.holmes@phsouth.co.nz
Dr Colin James MCARTHUR Clinical Director
Department of Critical Care Medicine Auckland City Hospital
Private Bag 92024 Auckland
Tel no. : +64 21 722 781 Fax no. : +64 9 307 4927 E-mail : colinm@adhb.govt.nz
Dr Sally Ann ROBERTS
Acting Clinical Director of Pathology and Clinical Head of Microbiology
Auckland District Health Board Private Bag 92924
Auckland
Tel no. : (64) 09 379 7440 Fax no. : (64) 09 307 4939 E-mail : sallvrob@adhb.govt.nz
Dr Margaret WILSHER Respiratory Physician CMO Medical Director
Auckland District Health Board Private Bag 92024
Auckland
Tel no. : (64) 21!32636
E-mail : mwilsher@adhb.govt.llZ
Dr Edna EDRADA Medical' Specialist II San Lazaro Hospital Quiricada Street, Sta. Cruz Manila
Tel no. : (632) 364 0095
E-mail : emedrada@yahoo.com
Dr Nimfa PUTONG Medical Specialist II San Lazaro Hospital Quiricada Street, Sta. Cruz Manila
Tel no. : (632) 732 3777
E-mail : nmputongmd@yahoo.com.ph
Dr Marice! RIBO Medical Officer IV San Lazaro Hospital Quiricada Street, Sta. Cruz Manila
Tel no. : (632) 931 6117
E-mail : mruicelreginoo-ribo74@yahoo.com
Dr Ruel TEANO
Medical Specialist IISan Lazaro Hospital Quiricada Street, Sta. Cruz
Manila
Tel no. : (632) 882 2142 E-mail : rotmd65@yahoo.com
Dr KIM Joon-Hyung
Epidemic Intelligence Services Officer Division of Epidemic Intelligence Service
Korea Centres for Disease Control and Prevention 194, Tongil-ro, Eunpyung-gu
Seoul122-701
Tel no. : (822) 380 1474 Fax no. : (822) 354 2723 E-mail : jhkim531 @cdc.go.kr
Dr SONG Jin-su
Epidemic Intelligence Services Officer Division of Epidemic Intelligence Service
Korea Centres for Disease Control and Prevention 194, Tongil-ro, Eunpyung-gu
Seoul122-701
Tel no. : (822) 380 2679 Fax no. : (822) 354 2723 E-mail : dicaful@hanmail.net
SINGAPORE
Associate Professor Y ee-Sin LEO
Clinical Director, Communicable Disease Centre Head, Department ofinfectious Disease
Tan Tack Seng Hospital Ministry of Health
College of Medicine Building 16 College Road
Singapore 169854
Tel no. : (65) 6357 791117916 Fax no. : (65) 62524056
E-mail : yee_sin_leo@ttsh.com.sg
VIETNAM
Dr LAM Yen Minh Vice-Director
Hospital for Tropical Diseases 190 Ham Tu, District 05 Ho Chi Minh City
Tel no. : (848) 3825 3704 Fax no. : (848) 3923 6943
E-mail : yenlam848@yahoo.com
Expert of Therapy Department Ministry of Health
138a Giang Vo HaNoi
Tel no. : (844) 356 55361 Fax no. : (844) 6273 2289
R-m<~il : c'llH-:ttiF:nhyt@gmail.com
Dr NGUYEN Thi Bich goc
Doctor of Infectious Diseases Ward National Institute of Tuberculosis and Lung Diseases
63 Hoang Hoa Tham HaNoi
Tel no. : (844) 3832 6249 Fax no. : (844) 3832 6249 E-mail : ngocn4@hotmail.com
Dr TRAN Phuong Thuy Chief of Outpatient Department National Institute of Infectious and Tropical Diseases
Giai Phong Street, Dong da District HaNoi
Tel no. : (844) 6278 2033 Fax no. : (844) 3576 4305
E-mail : tranphuong thuy2005@yahoo.com
2. TEMPORARY ADVISERS
Dr CHHOR Nareth Chief, Emergency Room Calmette Hospital
# 3, Monivong Blvd.
Phnom Penh, Cambodia Tel no. : (855) 12 990 229 Fax no. : (855) 23 724 892
E-mail : chhornareth@yahoo.com
Dr Christopher K.C. LEE
Head and Senior Consultant Physician Department of Medicine
Hospital Sungai Buloh, Selangor, Malaysia
Tel no. : (603) 6145 4333 ext. 2204 Fax no. : (603) 6145 4222
E-mail : chrislee@hkl.gov.my
Communicable Diseases Control Ministry of Health
Government Building VIII Olympic Street-2
Sukhbaatar District Ulaanbaatar, Mongolia Tel no : (976) 1 9916 4451 Fax no.: (632) 11 263631 E-mail : naraa61us@yahoo.com
Dr Dale FISHER
National University of Singapore Department of Medicine
National University Hospital 5 Lower Kent Ridge Rd Singapore 11907 4 Tel no. : (656) 772 4373 Fax no. : (656 779 4112 E-mail : mdcfda@nus.edu.sg
Dr David S.C. HUI
Professor, Department ofMedicine and Therapeutics
Head of Division of Respiratory Medicine
Deputy Director, Stanley Ho Center for Emerging Infectious Diseases,
The Chinese University of Hong Kong Prince of Wales Hospital
Shatin, NT, Hong Kong Tel no. : (852) 2632 3128 Fax no. : (852) 2648 9957 E-mail : dschui@cuhk.edu.bk
Dr Akihiko KA W ANA
Professor of Infectious Diseases Department of Internal Medicine National Defense Medical College 3-2 Namiki, Tokorozawa
Saitama '
359-8513 Japan
Tel no. : (814) 2995 1221 ext. 2577 Fax : (814) 2996 5201
E-mail : kawana59@ndmc.ac.jp
Philippine Council for Health Research and Development
General Santos A venue Bicutan, Taguig City Philippines
Tel no. : (632) 837 2942 Fax no. : (632) 837 2924
E-mail : mnty jm~yahoo.com
Dr NGUYEN Van Kinh Director
National Institute oflnfectious and Tropical Disease
7 8 Giai Phong Road HaNoi
VietNam
Tel no. : (844) 3576 4656 Fax no. : (844) 3576 3491 E-mail : kinhvaac@yahoo.com
Dr Myoung-don OH
Chief, Division of Infectious Diseases Seoul National University Hospital Professor, Department of Internal Medicine
Seoul National University College of Medicine
101 Daehangno, Jongno-gu, Seoul110-744
Republic ofKorea Tel no. : (822) 2072 2945 Fax no. : (822) 762 9662 E-mail : mdohmd@snu.ac.kr
Dr Weigong ZHOU
Epidemiologist, Influenza Divisison Centers for Disease Control and Prevention 1600 Clifton Road MS G-16
Atlanta, GA 3_0333 United States of America Tel no. : (1 404) 639 2555 Fax no. : (1 404) 639 3866 E-mail : waz6@cdc.gov
Regional Emerging Diseases Intervention (RED!) Centre 10 Biopolis Road
#02-0 1 Chromos · Singapore 138670 Republic of Singapore Tel no. (65) 6874 7033 Fax no. : (65) 6874 7031 E-mail zareed@redi.org.sg
Dr Wakaba FUKUSHIMA Assistant Professor
Department of Public Health
Osaka City University, Faculty of Medicine 1-4-3, Asahi-machi, Abeno-ku
Osaka 545 8585 Japan
Tel no. (81 6) 6645 3756 Fax no. : (81 6) 6645 3737
E-mail wakaba@med.osaka-cu.ac.jp
3. OBSERVERS/REPRESENTATIVES
Dr BOUAKHANH Phakhounthong Head of Central Provincial Hospital Department of Curative Medicine Ministry of Health
Vientiane
Lao People's Democratic Republic Tel no. : (856) 20 2204685
E-mail bphakhounthong@yahoo.com
4. SECRETARIAT
Dr Takeshi KASAl (Responsible Officer) Regional Adviser
Communicable Disease Surveillance and Response World Health Organization Western .Pacific Regional Office P.O. Box 2932
1000 Manila Philippines
Tel no. : (632) 528 9730 Fax no. : (632) 521 1036 E-mail : kasait@wpro.who.int
Pandemic Preparedness and Response Communicable Disease
Surveillance and Response World Health Orgimization Western Pacific Regional" Office P.O. Box 2932
1000 Manila Philippines
Tel No.: (632) 528 9949 Fax No.: (632) 521 1036 E-mail : otsus@wpro.who.int
Dr Ailan LI
Medical OfficerMedical Officer Communicable Disease
Surveillance and Response World Health Organization Western Pacific Regional Office P.O. Box 2932
1
ooo
ManilaPhilippines
Tel. No. : (632) 528 9732784 Fax No.: (632) 521 1036 E-mail : lia@wpro.who.int
Ms Amy CAWTHORNE Epidemiologist
Communicable Disease Surveillance and Response World Health Organization Western Pacific Regional Office P.O. Box 2932
1000 Manila Philippines Tel. No.
Fax No.
(632) 528 9732917 (632) 521 1036
cawthornea@wpro.who.int
Ms Rhiannon COOK Communicable Disease Surveillance and Response World Health Organization Western Pacific Regional Office P.O. Box 2932
1000 Manila Philippines
Tel No. : (632) 528 9920 Fax No.: (632) 5211036 E-mail : cookr@wpro.who.int
Communicable Disease Surveillance and Response World Health Organization Western Pacific Regional Office P.O. Box 2932 1
1000 Manila
Philippin~s
Tel No.: (632) 528 9920 Fax No.: (632) 521 1036 E-mail : khutq@wpro.who.int
Dr Christian Henrk WINTER Clinical Assistant Officer World Health Organization 125 Saphanthong Road, Unit 5
Ban Saphangthongta, Sisattanak District Vientiane
Lao People's Democratic Republic Tel. No. : (856) 21 353902 Fax No.: (856) 21 353905
E-mail : WintersC@wpro.who.int
Dr Ariuntuya OCHIRPUREV Communicable Disease Surveillance and Response World Health Organization Ministry ofHe~lth,
Government Building 8 Ulaanbatar 13
Mongolia
Tel. No. : (976) 73211 32 7870 Fax No. : (976) 11 32 4683 E-mail: ochirpureva@wpro. who.int
Dr Charles R. PENN
Global Influenza Programme World Health Organization 20, A venue Appia ' CH-1211 Geneva 27 Switzerland
Tel no. : (4122) 79 15567 E-mail: pennc@who.int
Johns Hopkins School of Medicine Chief Medical Officer
Migrant Clinicians Network 878 North Allen Street State College, P A 16803 United States of America!
Tel no. : (1-814) 238-6566 Mobile : (1-814) 571-7395
E-mail : kugelzur@migrantclinician.org zurowestee@who.int
Programme of Activites
Day 1- Tuesday, 10 November 2009
08:00-08:30 08:30-09:30
09:30-10:00 10:00- 12:00 10:00- 10:20
10:20- 10:40
10:40- 10:50 10:50-11:15
11:15-11:40
11:40 - 12:00 12:00- 13:00
Registration Opening session Opening remarks Self introduction
Overview of objectives and agenda -Dr Zhou Weigong
Administrative announcements - Dr Satoko Otsu
Group photo Coffee break
Plenary 1: Regional clinical network on emerging infectious disease Role of clinician and WHO activity in response to outbreaks
-Dr Takes hi Kasai
Regional clinical network on EID - Dr Zhou Weigong
Q&A and Discussion
Global Outbreak Alert & Response Network (GOARN) -Amy Cawthorne
Experiences of clinical network in the field - Dr Dale Fisher
Q&A and Discussion Lunch break
13:00- 13:15
13:15-13:40 the
(H1N1) 2009
13:40- 14:10
14:10-14:30
14:30- 14:50
14:50- 15:00 15:00- 15:30 15:30- 17:00
16:30- 17:00 18:00
Regional update of pandemic (H1N1) 2009 - Dr Satoko Otsu
Update of clinical management of pandemic (H1 N1) 2009 -Summary of Washington consultation on the clinical aspects of pandemic -Dr Charles Penn
Q&A and Discussion
Intensive care for pandemic influenza (H1N1) 2009 - Dr Colin McArthur
Questions and clarifications
Clinical management in resource poor setting - Dr Ed Zuroweste
Questions and clarifications
Clinical management in resource poor setting Dr Christian Henrk Winter
Q&A and Discussion Coffee break
Country experience on clinical management of pandemic (H1N1) 2009 (each country makes 15 minutes presentation)
Country experience - China -Dr CaoBin
Country experience- Japan - Dr Akihiko Kawana
H1N1 Management in the Intensive Care Unit setting: The Malaysian experience
-Dr Tai Li Ling
Country experience -Lao's People Democratic Republic - Dr Sanong Thongsna
Q&A and Discussion Reception
