Download Strategy Plan for Execution of Influenza Pandemic Response

Strategy Plan for Execution of Influenza
Pandemic Response
Department of Health, Executive Yuan
Republic of China (Taiwan)
January 2007
Table of Contents
Foreword
8
1. Background
11
1.1 Current Epidemic Situation
11
1.2 Administrative Mechanisms
15
1.2.1 Central Government Mechanisms
15
1.2.1.1 National Security Level
15
1.2.1.2 Executive Yuan Level
16
1.2.1.3 Department of Health Level
16
1.2.1.4 Emergency Mobilization Mechanisms
16
1.2.2 Local Government Mechanisms
17
1.2.3 Exercises
18
1.3 Outline of Strategies
19
1.3.1 Four Major Strategies
19
1.3.2 Five Lines of Defense
21
1.4 Classification of the Pandemic Situation
23
1.4.1 WHO Classification of Pandemic Phases
23
1.4.2 Taiwan Classification of Pandemic Phases
25
1.4.3 Comparison of Classification of Pandemic Phases between Our
26
Country and WHO
2. Surveillance
27
2.1 Rationale
27
2.2 Implementation Strategies
29
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2.2.1 Usage of Multiple Surveillance Systems
29
2.2.1.1 Current Surveillance Systems
29
2.2.1.2 Operation of Surveillance Systems
30
2.2.2 Laboratory Diagnosis
31
2.2.2.1 Techniques of Laboratory Diagnosis
31
2.2.2.2 Execution of Laboratory Diagnosis
32
2.2.3 Case Investigation
32
2.2.3.1 Execution of Case Investigation
33
2.2.3.2 Management of Close Contacts
33
3. Antivirals Strategy
35
3.1 Rationale
35
3.2 Implementation Strategies
36
3.2.1 Stockpile Quantity of Antivirals
36
3.2.2 Time of Administration
36
3.2.3 Administration Plan of Antivirals in the Future
37
3.2.4 Procedures of the Use of Tamiflu API
38
3.2.4.1 Activation Mechanism for Use
38
3.2.4.2 Packaging and Labeling
39
3.2.4.3 Medicine Prescription
39
3.2.4.4 Delivery
40
3.2.5 Information Management
40
3.2.6 Activation of Domestic Manufacture of Tamiflu
41
4. Vaccine Strategy
43
4.1 Rationale
43
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4.2 Implementation Strategies
45
4.2.1 Short-Term: Stockpile of “Pandemic-like”Vaccine
45
4.2.2 Medium-Term: Self-manufacturing of Emergency Vaccine
45
4.2.3 Long-Term: Plan for Domestic Vaccine Manufacture
48
4.2.4 Establishment of Capability in Virus Strain Selection
49
4.2.5 Administration of Pandemic Vaccine
49
5. Transmission Interruption Measures
50
5.1 Rationale
50
5.2 Implementation Strategies
52
5.2.1 Infection Control Strategies
53
5.2.2 Contact Restriction Strategies
55
5.2.2.1 Isolation
55
5.2.2.2 Quarantine
56
5.2.2.3 Community restriction
58
5.2.2.4 Sheltering
59
6. Preparedness of Personal Protective Materials
61
6.1 Rationale
61
6.2 Implementation Strategies
62
6.2.1 Estimation of PPE Demand
62
6.2.2 Determination of Safety Stockpile
62
6.2.3 Information Management and Monitoring
63
6.2.3.1 Real-time of Information
64
6.2.3.2 Stockpile Inspection and monitoring for Abnormality
64
Management
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6.2.4 Reallocation and Delivery
65
6.2.4.1 Reallocation
65
6.2.4.2 Delivery
65
6.2.5 Dealing with PPE Shortage
66
6.2.5.1 Reduce Expenditure
66
6.2.5.2 Speed up Supply
66
6.2.5.3 Stockpile and Release of Masks for Common Need
67
6.3 Emergency Handling of Abnormality
68
6.3.1 Back-Up Personnel of PPE Reallocation
68
6.3.2 Emergency Contact Points
68
7. Maintaining Health Services
70
7.1 Rationale
70
7.2 Implementation Strategies
71
7.2.1 Primary Care Settings
71
7.2.1.1 Home Treatment
73
7.2.2 Medical Network for Prevention and Control of Infectious
74
Diseases
7.2.3 Large Care Facilities
75
7.2.4 Handling of Off-Shore Patients
76
7.2.5 Deployment of Medical Staffs
77
7.2.6 Compensation for Personnel Deployment and Requisition
78
8. Response and Execution
79
8.1 Phase O+ phase3
79
8.2 Phase A1+ phase4
80
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8.3 Phase A1+ phase5
82
8.4 Phase A2+ phase3~5
84
8.5 Phase B+ phase5
86
8.6 Phase C+ phase6
89
9. Risk Communication
91
9.1 Correct Consumption of Poultry Products
91
9.1.1 Rationale
91
9.1.2 Implementation Strategies
91
9.2 Strengthening of Respiratory Hygiene/Cough Etiquette
93
9.2.1 Rationale
93
9.2.2 Implementation Strategies
93
9.3 Correct Usage of Respirators and Medical Masks
94
9.3.1 Rationale
94
9.3.2 Implementation Strategies
95
9.3.2.1 Usage of Medical Masks
95
9.3.2.2 Usage of N95 or Higher Level Masks
96
9.3.2.3 Selection of Masks
97
9.3.2.4 Clarification of Related Concepts
98
9.3.2.4.1 Transmission Routes of Influenza Virus
98
9.3.2.4.2 Medical Mask Is Not a Respiratory Protection Gear
100
9.3.2.4.3 Recommendations on Using Masks for Common People
101
9.3.2.4.4 Materials of Mask and Filtration Mechanisms of Airborne
105
Particles
9.4 Public Seeking Medical Help
106
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9.4.1 Rationale
106
9.4.2 Implementation Strategies
108
9.5 Business and Organization Continuity
117
9.5.1 Rationale
117
9.5.2 Implementation Strategies
117
10. Exercises
120
10.1 Rationale
121
10.1.1 Purpose of Exercise
121
10.1.2 Exercise Types
121
10.1.3 How to Plan An Exercise
123
10.1.4 Organizational Structure of Exercise
125
10.1.5 Affairs to be Managed After Exercise
127
10.2 Implementation Strategies
127
10.2.1 International Exercise
128
10.2.2 Central-Level Exercise
130
10.2.3 Local-Level Exercise
134
Appendix 1. Characteristics of Avian Influenza A (H5N1) virus
137
Appendix 2. Estimation on Health Impact of Influenza Pandemic
144
Appendix 3. Excerpt of Presidential Instructions to a High Level National
147
Security Meeting
Appendix 4. Enforcement Regulations Governing the Central Epidemics
156
Command Center
Appendix 5. Exercises in Response to Influenza Pandemic
170
Reference
173
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Table of Contents
Chart
Hierarchy of related plans in response to influenza pandemic
10
Chart 6.1 Safety Stockpile of PPE
63
Chart 9.1 Planned Procedures of Communication With Patients Seeking
112
Medical Help — Out-Patient visits/Hospitalization
Chart 9.2 2006 ” Medical Network for Prevention and Control of Infectious 114
Diseases” Flowchart of Activation of Infectious Disease
Prevention and Control Hospitals
Chart 9.3 “Medical Network for Prevention and Control of Infectious
115
Diseases” Procedure Flowchart for Transfer of Infected Patients
from Off-Shore Area to Main Island for Treatment
Chart 9.4
“Patient doesn’t move, physicians moves” Operation Procedures 116
for off-shore Area
Table 3.1 Time of Administration of Antivirals
42
Table 6.1 PPE Stockpile and Allocation
63
Table 9.1 Comparison of Product Specifications between Respirator and
101
Medical Mask
Table 9.2 Comparison of Functions of Respiratory protection Gear and
Masks
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104
Foreword
Influenza is the most potential pandemic disease. Since 2004, the World
Health Organization (WHO) has continued to announce cases of Influenza A
virus subtype H5N1 in human. Various global information show that influenza
pandemic is approaching. And all developed countries are preparing for its
coming.
Influenza pandemic affects not only our people’s life and health, it will also
lead to pressure and disorder both socially and economically. The national goals
of the influenza pandemic response are as follows:
1. Preclude occurrence – Preclude the domestic occurrence of any single
human H5N1 case before pandemic outbreak
2. Avoid transmission – Once H5N1 virus has been imported from abroad,
every effort will be implemented to prevent further domestic transmission
3. Reduce harm – If H5N1 virus becomes more contagious, aggressive
intervention of medical and public health means will be implemented to
reduce its impact to citizen’s health. Social functions and economic
activities will keep functioning.
4. Effective recovery – After the pandemic period, social psychological and
economic recovery plans will be launched.
In order to be prepared, the Executive Yuan has ratified “National
Influenza Pandemic Preparedness Plan” (“Preparedness Plan” in short) in
May 2005. All levels of government should proceed with preparedness
according to the plan, such as stocking medical and epidemic prevention
materials, establishment of mobilization structure, training of epidemic
prevention manpower, etc.
This
“Strategy
Plan
for
Execution
of
Influenza
Pandemic
Response”(“Strategy Plan” in short) is in response to the strategies and
guidelines that WHO announced in succession. Recent prevention concepts of
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other developed countries were also referred to. Possible epidemic prevention
measures by government during different epidemic phases were studied.
Rationale and principle of each measure are described logically. All government
organizations and people can get a complete picture of the strategy, and detailed
epidemic prevention plans can be pre-drafted by various authorities according to
their respective responsibilities.
Centers for Disease Control (CDC) of Department of Health of Executive
Yuan published the “Mobilization and Preparedness Plan for Influenza
Pandemic Prevention (Implementation Plan)” (“Battle Plan” in short) in
February, 2005. The Battle Plan is based on our country’s previous epidemic
control experience. Standard operation procedures and the division of
responsibilities among government authorities have been established in the areas
of epidemic surveillance, onsite health management of domestic poultry
outbreaks, medical care of patients, case management, and material usage and
control, so that related authorities can cooperate in execution of tasks. The Battle
Plan is based on the SOP defined in Strategy Plan, but it will be constantly
updated and announced according to the latest situation.
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Chart. Hierarchy of related plans in response to influenza pandemic
Corresponding WHO documents
Project Name

National Influenza
Avian influenza: assessing the pandemic
threat. Jan. 2005.

WHO global influenza preparedness plan.
----
Mar. 2005.
Pandemic
Preparedness Plan
Hierarchy illustration

The highest guiding principles
ratified by the Executive Yuan
----- 
Striving for budgets accordingly
for various preparedness tasks
(Preparedness Plan)
outlined
↓


----
WHO checklist for influenza pandemic
Influenza
Pandemic
-----

Outline of Principles for various
control measures

Response
preparedness planning. 2005.
Execution strategy set up
according to “Preparedness Plan”
Execution of
pandemic threat: Recommended strategic
actions. Sep. 2005.

Strategy Plan for
Responding to the avian influenza
(Strategy Plan)
Basis of every organization in
devising actual measures
↓

WHO guidelines for global surveillance
of influenza A/H5. Jan. 2004.

WHO pandemic influenza draft protocol
for rapid response and containment. May.
2006.

Avian influenza, including influenza A
(H5N1) in humans: WHO interim infection
control guideline for health care facilities.
Apr. 2006.

WHO rapid advice guidelines on
pharmacological management of humans
----
for Influenza
Pandemic
Prevention
(Battle Plan)
virus. May. 2006.
A Manual for improving bio-security in
the food supply Chain: Focus on live
animal markets. Apr. 2005.
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SOP established according to
“Strategy Plan”
Preparedness Plan
infected with avian influenza A(H5N1)


Mobilization and
-----

Details of execution of epidemic
prevention by each unit

Will be constantly updated
according to latest situation
1. Background
1.1. Current Epidemic Situation
A possible threat of influenza pandemic comes from the epidemic spread
within fowls caused by influenza A virus subtype H5N1 and the occurrence of
human cases. Since the middle of year 2003, highly pathogenic avian influenza
(HPAI) has ravaged poultry and animal farms in 8 Southeast Asia countries.
The pathogen was influenza A subtype H5N1 avian flu. This virus existed in
these countries since then, and is hard to eradicate. Again between July and the
end of year 2005, the geographic distribution of fowl infections by H5N1 virus
extended beyond Asia. Cases of wild and domestic birds infected by H5N1
virus were reported in Russia, Kazakhstan, Turkey, Romania and Ukraine. Wild
bird infections were reported in Croatia and Mongolia. The widespread was
even more extensive during February and April 2006. There were 32 countries
in Africa, Asia, Europe and Middle East reporting their first H5N1 infection
case in wild or domestic bird. Some of these affected areas are highly populated.
Some lack of surveillance and medical care system. Therefore the risk of human
infection increases.
According to research, the virus of avian flu spread from Russia to
Kazakhstan, Nigeria, Iraq, and Turkey and into Europe can be traced back to the
same source with the avian flu virus that infected wild birds in Qinghai Lake in
northwestern China in spring 2005.[1,2] Besides, a survey around Poyang Lake
in China showed that as much as 3.1% of wild duck excretion was H5N1
antibody positive, which shows that the virus is adaptive in certain wild fowls
and is able to spread along the migratory path of migrant birds. The researches
confirmed the important role of migratory birds in H5N1 virus spread and its
possibility to accelerate the global widespread of avian flu.
Other scholars suggested that, besides the migration of migratory birds,
human trading and smuggling conduct cannot be taken lightly. Even though
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several leading countries in poultry husbandry have prohibited the export of
related agricultural product after their HPAI outbreak, virus might have already
spread into import countries quietly before the prohibition. And smuggling will
be even more difficult to anticipate and prevent. Statistics show that among all
smuggled goods, the ranking of fowls and its related products is the third
highest in quantity, only next to narcotics and firearms. With import prohibition
announced by certain countries, the risk of smuggling fowls and its related
product becomes higher. And it will be harder to block the transmission and
spread of avian flu virus.
Because the existence scope of the virus expands, human exposure to the
virus is getting higher and the risk of infection increases. With every one case
of human H5N1 avian flu, the virus becomes more adaptive to human body, or
the risk of gene reassortment of human and fowl virus increases, hence forming
a new human influenza virus. Once this virus evolves and can easily spread
among humans, a majority of the world population will be infected within a
short period of time, because no one carries an antibody against the new virus.
This is the so-called “influenza pandemic”.
As for the human cases in H5N1, the first confirmed case of this epidemic
wave was found in Vietnam in December 2003. Until January 9, 2007, there
were 263 confirmed cases. Reporting countries include Azerbaijan, Cambodia,
China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey and Vietnam. H5N1
virus caused serious systemic disease in these patients. Among these patients,
157 have died. Most patients were children and young adults, with unknown
reasons.
WHO announced on 30 July, 2006 the epidemiologic information of the
205 human H5N1 cases collected until April, 2006. Analysis showed that about
50% of the cases are children or adolescent under 20 years old. The median of
the time between falling ill and hospitalization is 4 days. Mortality rate of all
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cases is 56%. Mortality rate in 10-19 year old cases is as high as 73%. Among
death cases, the median of the time between falling ill and death is 9 days.
However, the percentage of infection without symptom or with minor
symptoms is unknown, and further research is necessary. Even though cases
were reported all year, more cases were reported in colder seasons. If this
infection pattern persists, another peak of infection is expected to come from
the end of 2006 to the beginning of 2007[4].
According to recent evidence, the species barrier of H5N1 virus still exists.
In other words, this virus is still fowl adaptive, and it’s not easy to be
transmitted from fowl to human. After investigation of human cases, it is found
that they mostly inhabited in HAPI-affected areas and had engaged in risky
activities which involved close contact with ill or dead fowls, such as butchery,
defeathering or cooking.
There was one possible limited human-to-human transmission event in
Thailand in year 2004. Three patients were infected. The index patient’s last
contact with home-bred ill chicken was three to four days before falling ill. The
index patient’s mother came home from another city to take care of the patient
in hospital, and later died of pneumonia. The index patient’s aunt was also
infected. Neither of them had appropriate protection while taking care of the
index patient. In Indonesia, there was also a household cluster of human H5N1
cases in May 2006, which constituted another of the very few events of possible
limited human-to-human transmission. After WHO experts’ investigation, it
was found that virus didn’t spread within the community. No health care worker
was infected either. It showed that infection is only possible with very close
contact with H5N1 infected patients. Therefore the global pandemic alert phase
is still maintained at level 3. That is to say, even though there were occasional
human cases of H5N1 virus infection, no evidence supported that the virus can
be transmitted among people effectively and continuously.
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In the aspects of social and economic influences caused by influenza
pandemic, it is estimated that the possible number of death will be
approximately between 2 and 7.4 millions if pandemic occurs now, calculating
according to influenza pandemic pattern in year 1968. If the virulence of this
pandemic virus is as strong as the one in 1918, then the number of deaths will
be far more than this. Besides, in the economical aspect, tourism, mass
transportation, retail sale, food and beverage and manufacturing industry will
all be influenced. According to the experience of SARS period, the GDP of East
Asia countries dropped 2% in the 2nd quarter of 2003 while SARS ravaged the
region. The number of deaths at that time was 800 people. Ministry of
Economic Affairs estimates that Taiwan’s GDP will drop 2.85% if the next
pandemic lasts three months. Assuming GDP of all countries drops 2% and the
epidemic situation persists for one year, there will be a pecuniary loss of US$
800 billion.
For the characteristics of Avian Flu virus A subtype H5N1, please refer to
Appendix 1. For the health impact of influenza pandemic, please refer to
Appendix 2.
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1.2 Administrative Mechanisms
1.2.1 Central Government Mechanisms
The periodical Foreign Affairs, which always reports international politic
issues, published with huge capacity to comment on the possibility of the attack
of influenza pandemic[5]. In the same month, our country also defined the
possible pandemic caused by H5N1 virus to be a “non-traditional” threat to
national security.
In May 2005, APEC Ministerial Meeting on Avian and Influenza
Pandemics was held in Vietnam[6]. Influenza pandemic, tsunami, earthquake,
man-made disastrous event and space garbage were defined as principal events
of dealing with global emergency. Influenza pandemic was positioned in
preventive phase. Other events were positioned in preparatory phase, responsive
phase and recovery phase respectively.
Therefore the administration level of Influenza pandemic control has been
raised to National security level. A three-tier control and management hierarchy
has been established at the levels of Presidential Office (National Security level),
Executive Yuan and Department of Health (DOH).
1.2.1.1 National Security Level
The “National Security Meeting ” in response to avian and influenza
pandemic chaired by the President analyses national and international epidemic
situations, and based on its evaluation of the possible impact of a pandemic to
national security, strategically instructions are given to Executive Yuan and
related departments. There have been three meetings from August 2005 to
March 2006. Please refer to Appendix 3 for detailed instructions by the
President in the three National Security Meetings.
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1.2.1.2 Executive Yuan Level
Since 25 October 2005, Executive Yuan has held the “Executive Yuan
Coordination
Meeting
for
Avian
Influenza
Prevention
and
Control”
(“Coordination Meeting” in short) periodically. Premier of Executive Yuan has
assigned a convener. When the domestic epidemic situation level is O, Council
of Agricultural of Executive Yuan assists the convener. Once domestic fowls
have tested positive for H5 or H7 HPAI, Department of Health of Executive
Yuan (DOH) will assist. Every related department is assembled to discuss,
debate and make strategic decisions on each cross-sectoral or important issue
related to avian flu and pandemic flu. Up to December 2006, there have been 22
such meetings. In addition, in response to national and international epidemic
situations, unscheduled reporting will be given in Executive Yuan meetings.
1.2.1.3 Department of Health Level
Since September 2005, DOH has held the “Preparedness and Mobilization
Meeting for Influenza Pandemic Control” (“Preparedness Meeting” in Short).
This meeting discusses preparedness work for a possible epidemic and every
preventive measure currently underway is reviewed according to respective
WHO guidelines. Important issues to be brought up to the above mentioned
Coordination Meeting for discussion or affairs handed-down from Coordination
Meeting to be implemented and followed up will be covered in the agenda of the
Preparedness Meeting. Up to December 2006, there have been 49 such
meetings.
1.2.1.4 Emergency Mobilization Mechanisms
We are currently in phase 0. CDC analyzes international epidemic
situations to grasp their development, and reports to higher authorities at any
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time. The occurrence of influenza pandemic is bound to be an emergent and
serious event, and no single government organization is capable of complete
control. Therefore, once the situation worsens, Executive Yuan will establish a
Central Epidemic Command Center for Influenza Pandemic Level A1~C
according to “Communicable Disease Control Act” and “Enforcement
regulations Governing the Central Epidemics Command Center”. The center
will be run under the spirit and framework of Incidence Command System (ICS).
A single command system will facilitate efficient coordination of resources,
equipment and staffs. Regional Command Centers will be established according
to the administrative jurisdictions of CDC branches to facilitate regional joint
defense and smooth flow of orders and information. Please refer to Appendix 4
for Enforcement Regulations Governing the Central Epidemics Command
Center.
1.2.2 Local Government Mechanisms
Article 4 of the Communicable Disease Control Act defines the division of
responsibilities among central and local (special municipality, city and county)
government organizations in implementing infectious disease prevention and
control measures. It is also applicable to the control of influenza pandemic.
Central government devises policy and plans for prevention and control. Local
government should draft local response and implementation plans according to
local needs and put them into practice. Central organization should make regular
and irregular assessment of these plans.
To implement the preparedness and response measures for influenza
pandemic, local government should draft a local implementation plan and
prepare for the required budget according to the preparedness plan, strategy plan
and battle plan. Other than that, a cross-sectoral mechanism should be properly
established to manage and make use of the area’s medical resources, to store
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necessary epidemic preventive materials, and to examine hospital infection
control. Every type of non-governmental organizations and voluntary groups
that could be mobilized in the community should be duly noted to facilitate
future mobilization of related resources for epidemic control once an epidemic
command center is established based on Item 3 of Article 4 of the
Communicable Disease Control Act.
In the future, the Central Epidemics Command Center may decide to
implement strategies such as rapid containment (including measures such as
restriction of movement in and out of the area, ”ring” prophylaxis, restriction on
social contact, etc) and establishing large-scale care facilities. Local government
should plan in advance the operation mode, and mobilize various human and
material resources timely to prevent discontent of the people and effectively
control the epidemic situation.
When the Central Epidemics Command Center for Level A1 is established,
a local government can decided not to establish a county/city command center
after evaluating the extent of internationalization and risk of epidemic situation
in its jurisdiction. However, contact points must be assigned to enable smooth
flow of information and commends. When the epidemic level upgrades to A2,
all county/city governments should establish a local command center and active
the response mechanism whether infected cases are present in their jurisdictions
or not.
1.2.3 Exercises
Central government has conducted 13 exercises in total from July 2005 to
October 2006. Six of them were hosted by the DOH, including 3 tabletop
exercises simulating the operation of the Central Epidemics Commend Center,
and 4 drills for specific preventive strategies (incoming passengers at the airport,
prescription of antiviral agents, PPE emergency distribution, medical team’s
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deployment to off-shore islands).The Council of Agriculture also conducted
drills on culling work for HPAI.
Local governments held 40 drills in total from January to October, 2006
with all county/city governments having been involved. The modes included
tabletop exercises and drills, and the scenarios involved evacuation of hospitals,
requisition of non-infectious disease prevention hospitals, response actions of
market retailers and street vendors, patient managements and transfer disease
importation through mini-three link with China, ad-hoc diagnosis/treatment
centers, etc.
Appendix 5 contains a detailed list of all exercises and drills. For detailed
principles and strategies of exercises, please refer to Chapter 10 of this Strategy
Plan.
All exercises and drills concerning influenza pandemic are coded “Egret”
for identification after August 2006.
1.3 Outline of Strategies
In response to influenza pandemic, our country set up “4 major strategies
and 5 lines of defense” as the main framework for pandemic control, in order to
provide sufficient health protection to our countrymen.
1.3.1 Four Major Strategies
WHO had included surveillance for pandemic preparedness, public health
interventions, the use and availability of antivirals, and better access to better
vaccines as four major topics for discussion in “WHO consultation on priority
public health interventions before and during an influenza pandemic” held in
March 2004[7].
The 4 major strategies in response to influenza pandemic set up by our
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country also focus on early detection, interruption of transmission, anti-virals
and influenza vaccine.
Strategy I - Early detection
The important function of surveillance is to detect unusual cluster of cases
at an early stage or to discover abnormal clinical manifestations in cases and
then to understand virus characteristics through analysis. This will help us to
block the virus in time once its transmission ability enhances and will facilitate
the execution of epidemic control measures to prevent the epidemic situation
from worsening.
Strategy II – Interruption of transmission
Other than medical interventions such as anti-virals and vaccine, there are
non-medical public health interventions such as personal hygiene practices
(including washing hands frequently and wearing a mask when being ill),
isolation of patients, control of contacts, social distancing, etc. All of them are
important and economic preventive measures.
Strategy III - Antivirals
At present, the cure and preventive function of neuraminidase inhibitor
anti-viral has been confirmed in seasonal influenza. As a consequence, it is
expected to be effective in treatment and after exposure prophylaxis for avian
influenza and pandemic influenza, so as to block the virus transmission or to
reduce morbidity and mortality.
Strategy IV - Influenza vaccine
Annual influenza vaccination program has effectively decreased morbidity
and mortality of seasonal influenza. Similarly, it is expected that, during
influenza pandemic, sufficient amount of effective vaccine obtained through
purchase or domestic manufacture to maintain major social function, even to
safeguard the health of high-risk groups.
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1.3.2 Five Lines of Defense
In response to influenza pandemic, our country set up 5 lines of defense
including containment aboard, border quarantine, community epidemic control,
maintaining normal functioning of medical system, and individual and family
protection.
Line of Defense I - Containment aboard
At present stage, “Containment aboard” is the main objective. Only
containment of the spread of virus at the early phase of its adaptation to human
can we interrupt or delay the occurrence of influenza pandemic. Hence we can
strive for more time to proceed with other preparedness.
Therefore, it is essential in current stage that we actively participate in
global collaboration plan in prevention and treatment, reinforce exchange and
sharing of epidemic control information, and build up tight cooperation channels.
At the same time, we should keep changes in the international epidemic
situation under surveillance, and upgrade border control measures according to
situation to prevent epidemic spread into our country.
Line of Defense II - Border quarantine
The risk of influenza pandemic occurring overseas is higher than
domestically. Should the transmission ability of virus continues to increase,
reinforcement of quarantine inspection in airports and seaports is a major
method to protect our people’s health. Health monitoring and management of
incoming passengers will be upgraded gradually depending on the international
epidemic situation. Potential patients can be identified immediately and treated
promptly to prevent epidemic spread within our country.
Line of Defense III - Community epidemic control
In the future, if transmission ability of influenza virus becomes extremely
strong, and the virus is impossible to be blocked by containment aboard or
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border quarantine measures which enable its spread into communities in our
country, then community epidemic control will become the major method to
decrease its impact. Furthermore, during influenza pandemic, supply of vaccine
for pandemic virus strain may not be sufficient and timely and supply of
anti-virals may also be limited, and hence non-medical interventions are
absolutely indispensable. Although some of the non-medical interventions may
influence people’s behaviors and rights, according to the Communicable Disease
Control Act, the government is authorized to implement related epidemic control
measures when an infectious disease occurred.
However, to implement each public health intervention thoroughly,
enforcement by the government is not enough. The key to diminish the spread of
virus in community depends on whether people can understand the meaning of
each epidemic control measure and thereupon to obey and cooperate. In the
future, the government will combine forces with civil groups and volunteers to
provide people with correct protection information, and to strengthen the
public’s level of cooperation with community epidemic control measures. At
present, DOH has started to recruit and to train backup manpower to deal with
epidemic control requirements during influenza pandemic.
Line of Defense IV - Maintaining normal functioning of medical system
The attack rate of the 1918-1919 influenza pandemic was estimated to be
25%. Nowadays with frequent social interaction and convenient traffic, the
attack rate is bound to increase should another influenza pandemic occur. When
the time comes, a large number of influenza patients will definitely bring
enormous challenge to the medical system. In order to prevent patients of other
diseases from being deprived of medical resources during a pandemic, and to
provide more extensive care to a large number of patients affected by the
epidemic disease, CDC has established a National Medical Network for
Prevention and Control of Infectious Diseases. It will provide emergency
- 22 -
response to national epidemic control needs. Besides, local governments should
plan in advance the necessity of setting up large-scale care facilities should the
capacity of Medical Network for Prevention and Control of Infectious Diseases
was exceeded by patient number of pandemic influenza.
Line of Defense V - Individual and family protection
For prevention of most infectious diseases, it may be said that hygiene
habits are the most basic factor. Correct hygiene habits should be formed in
ordinary days and should maintained during pandemic period. In case there is
influenza pandemic, people should stay home as much as they can to reduce
unnecessary social interaction. In addition, people with mild disease may also
need to recuperate at home. At this time, the government will demand higher
levels of personal and household hygiene to be practiced but will strive to avoid
causing public panic.
1.4 Classification of the Pandemic Situation
1.4.1 WHO Classification of Pandemic Phases [8]
Warning status
Phase
Human risk situation
Phase 1
Low risk of human cases
Phase 2
High risk of human cases
Phase 3
No or very limited human-to-human
transmission
Phase 4
Evidence of increased
human-to-human transmission
Phase 5
Evidence of significant
human-to-human transmission
Phase 6
Efficient and sustained
human-to-human transmission
Inter-pandemic
Pandemic alert
Pandemic
Above table is the classification for warning of influenza pandemic alert in
- 23 -
the WHO Global Influenza Preparedness Plan announced in 2005. The purpose
of classification is to provide appropriate suggestions for epidemic control
preparation. In this WHO plan, different suggestions were also provided
according to whether an individual country is affected by the new virus.
Descriptions of each classification are as follow:
Phase 1. No new influenza virus subtypes have been detected in humans. Low
risk of human infection.
Phase 2. No new influenza virus subtypes have been detected in humans, but
an animal variant threatens human disease.
Phase 3. Human infection(s) with a new subtype but no human-to-human
spread, or only few cases of close contact spread.
Phase 4. Small cluster(s) with limited localized human-to-human transmission.
It is shown that virus is not complete adaptive to human bodies. In
this phase, it is still possible to block or delay the spread of virus.
Possible scenarios include:
˙ One or more clusters involving a small number of human cases, e.g.
a cluster of <25 cases lasting <2 weeks.
˙ Appearance of a small number of human cases in one or several
geographically linked areas without a clear history of a non-human
source of exposure.
Phase 5. Larger cluster(s) but human-to-human spread still localized. It shows
increased virus adaptation to human body, but lacking absolute
effective infection strength. At this phase, there may still be
possibility to carry out the last containment measure by means of
international cooperation. Possible scenarios include:
˙ Transmission within cluster(s) continues to occur. But total patient
number does not increase rapidly. For example, a cluster of 25~50
patients which only lasted for 2~4 weeks.
- 24 -
˙Transmission continue to occur, but patients are localized within
specific region (such as remote village, school, military camp,
off-shore island, etc).
˙ In a community with known cluster of event. Infection source of a
small number of patients cannot be identified.
Phase 6. Pandemic: increased and sustained transmission in general
population. At this phase all countries should strengthen surveillance
and responsive strategy.
1.4.2 Taiwan Classification of Pandemic Phases
WHO has set up the classification according to virus variation from a global
point of view. Different suggestions are provided to affected countries and
non-affected countries respectively starting from phase A2. Therefore,
preparedness and responsive measures should be different for foreign or
domestic epidemic situations. DOH announced Taiwan’s own Classification of
Pandemic Phases on 29 December 2004:
Classification
Activation time
Detection of avian influenza virus H5 or H7 domestically or
Phase O
confirmed human cases of avian flu aboard.
1. Lowly pathogenic avian flu occurred in poultry domestically
2. Highly pathogenic avian flu occurred in poultry domestically
Phase A1
Phase A2
Confirmed human-to-human cases aboard
Suspected domestic cases of fowl/animal-to-human transmission,
imported infection or lab infection
Phase B
Confirmed domestic human-to-human cases
Phase C
Large-scale domestic human-to-human transmission
- 25 -
1.4.3 Comparison of Classification of Pandemic Phases between Our
Country and WHO
Taiwan Classification
Phase 0
Detection of avian influenza
virus H5 or H7 domestically or
confirmed human cases of avian
flu aboard.
WHO Classification
Inter-pandemic
Phase 1
Low risk of human cases
Phase 2
High risk of human cases
Pandemic alert
Phase
A1
Phase
A2
Confirmed human-to-human
cases aboard
Suspected domestic cases of
fowl/animal-to-human
transmission, imported infection
or lab infection
Phase B Confirmed domestic
human-to-human cases
Phase C Large-scale domestic
human-to-human transmission
Phase 3
No or very limited human-to-human
transmission
Phase 4
Evidence of increased human-to-human
transmission
Phase 5
Evidence of significant
human-to-human transmission
Phase 3~ Phase 5 are all possible.
Phase 5
Evidence of significant
human-to-human transmission
Pandemic
Phase 6
- 26 -
Efficient
and
sustained
human-to-human transmission
2. Surveillance
2.1 Rationale
The objective of surveillance is to continuously collect, analyze and
announce information to control the epidemic. The Global Influenza
Surveillance Network of WHO provides information on international epidemic
situations. Domestically, CDC has established National Influenza Center (NIC)
and multiple surveillance systems to understand the prevalence and variation of
influenza virus at any time.
When the domestic classification of pandemic alert is phase 0 and
international classification is phase 3, information on epidemic situations
overseas can be obtained through WHO network, IHR focal point and other
established information exchange channels. Other than these, Bureau of Animal
and Plant Health Inspection and Quarantine of the Council of Agriculture has
established “SOP for the Surveillance, Alert and Reporting of Highly Pathogenic
Avian Influenza (HPAI)”. Monitoring of avian flu was performed on suspected
wild birds, farm poultry and excretion of migratory birds. Health authorities
have also conducted surveillance on severe influenza cases and influenza cluster
events. If abnormal condition is identified, investigation will be proceeded.
Examination will be done when necessary to clarify the aetiology and to
understand the trails of the new type of virus as early as possible. Criteria for
“Human H5N1 influenza” case reporting, specimen collection and laboratory
testing were set up according to information on H5N1 infection in humans
overseas, in order to understand whether there are domestic cases of H5N1
infection in humans. Furthermore, lab surveillance system analyzes the variation
of influenza virus to understand if the compositions of seasonal influenza
vaccine can effectively prevent influenza occurrence.
If domestic classification of pandemic is phase A1, international
classification is either phase4 or phase 5, then health surveillance of incoming
- 27 -
passengers will be the major task of epidemic surveillance, other than obtaining
information on the latest epidemic situations in affected countries through
various channels. In the meantime, every domestic surveillance system should
also increase alertness to monitor closely of any possible case in Taiwan.
If domestic classification of pandemic becomes phase A2 and phase B (i.e.
several H5N1 human cases or small clusters have occurred domestically), now
the priority of surveillance is to identify all possible patients and to complete lab
diagnosis promptly, so that epidemic control measures can be implemented
immediately to block the virus from spreading, and to evaluate the outcomes of
containment measures. During this phase, rapid test method is to be devised to
shorten examination time.
Should domestic classification upgrade to phase C and international
classification to phase 6, in the beginning, surveillance system will still proceed
with reporting and examination on a case-by-case basis. Characteristics of virus
strain should be understood to facilitate the establishment of a gene database of
the virus. Once it is found that most cases are human H5N1 infections, for which
case by case examination can no longer help much with epidemic surveillance,
but will instead increase infection risk for sampling staff, it may be possible that
case by case examination and investigation will not be carried out in a later stage.
At that time, existing surveillance system will be used to monitor the long-term
trend of pandemic situation. Samples will be collected from a small number of
patients for examination to understand variation of virus. Epidemiological
research will be carried out at the same time to describe related characteristics of
domestic influenza pandemic.
In order to detect epidemic situation of avian influenza and pandemic
influenza in time, so as to benefit from early alert, DOH has set up reporting
procedures and investigation methods according to Article 4 and 26 of the
Communicable Disease Control Act. Special municipality and county/city
- 28 -
governments should also implement measures for the surveillance, reporting,
investigation, and management of epidemic situation in their respective
jurisdiction according to Article 4 and 41 of the Communicable Disease Control
Act.
2.2 Implementation Strategy
2.2.1 Usage of Multiple Surveillance Systems
2.2.1.1 Current Surveillance Systems
Among multiple reporting channels set up by CDC, influenza related
sections are described as follow:
1. Notifiable Diseases Surveillance System: The disease under surveillance is
“Influenza with severe complications”. Reported cases will be examined by
clinical expert and sample collected for testing.
2. Syndromic Surveillance System: “Acute respiratory syndrome” and “Acute
neurological syndrome” reported by all hospitals above the regional level
and by all local teaching hospitals.
3. Symptom Surveillance System: Patients that meet the case definition of
“Person under investigation for Human H5N1 influenza” and cluster of
influenza-like illness are to be reported through this channel.
4. Contracted Virus Lab Surveillance System: There are approximately more
than 100 fixed sites for collection of samples. Two samples are selected
each week and are sent to the 12 contracted viral infection labs to be tested
for pathogen, in order to know the strain type of influenza virus. This
provides a reference for making disease prevention and vaccination policy.
5. Surveillance System for Population Institutions: Management and health
care providers of densely populated organizations should report within 24
hours of detecting any inhabitant or staff in the organization meeting any
- 29 -
criteria defined in “Standards for Immediate Reporting”.
6. Sentinel Surveillance System: There are in total around 700 sentinel
physicians. They will report influenza-like patient numbers by phone, fax,
email or mail, which enables understanding of the epidemiological trend of
influenza-like cases country-wide and the possibility of an outbreak.
7. School-based Surveillance System: Given that schools are major
transmission places of influenza, influenza-like cases will be reported each
week. At present, there are more than 400 schools included in this system,
with at least one public elementary school in each of the 25 counties/cities.
Schools at all levels should report when ever a cluster occurs.
In addition, DOH will compare influenza patients against a list of fowl and
animal traders and farm workers provided by the Council of Agriculture. Once a
trader in the list is identified as influenza-like illness, health authorities will be
notified for special care. Fever patients found by border quarantine will also be
reported and managed through Symptom Surveillance System.
2.2.1.2 Operation of Surveillance Systems
When domestic pandemic is in phase O, and international pandemic is in
phase 3, all surveillance systems maintain original operation in principle.
Reported cases will be examined and be collected of samples. If abnormal
clusters of patients occur, or epidemic situation worsens abnormally, further
investigation should take place. Samples should be collected to clarify the
pathogen. In this phase (phase O+phase 3), virus is not yet adaptive to human,
therefore most infectious cases have contact history with fowls. Doctors and
primary public health staffs should be reminded to ask patients in details about
contact history with fowls and animals and travel history.
If international pandemic enters phase 4 or phase 5, domestic pandemic will
- 30 -
be raised to phase A1. Border control will be the major measure. Incoming
passengers from affected foreign areas must practice health self-management.
Local health authorities must be aware of their health condition through system.
Influenza patients with travel history to affected areas should be investigated and
followed up with attention.
Once a domestic case occurs, the domestic pandemic alert will enter phase
A2 or higher. Reporting frequency of some surveillance systems will be
increased in view of epidemic control needs, in order to control the expansion of
epidemic situation timely, or to evaluate the effects of epidemic control
interventions.
DOH will revise reporting criteria immediately according to new
information on human cases of H5N1 aboard as announced by WHO. The virus
is not completely adaptive to human, hence future variation with different
manifestation is still possible. Therefore reporting or sample collection criteria
should be revised at any time according to information announced by WHO.
In order to effectively apply surveillance information to the evaluation of
control measures, integration of all epidemic information is necessary. Data in
current systems are connected. An integrated information platform will be built
up in the future.
2.2.2 Laboratory Diagnosis
2.2.2.1 Techniques of Laboratory Diagnosis
Current techniques and methods used for laboratory diagnosis are:
1. Real time RT-PCR: If result is A(+) then continue with H1 & H3 subtype
testing. If H1(+) or H3(+) then continue with sequence analysis. If H1(-)
and H3(-) then continue with H5, H7, H9 subtype testing.
2. Virus culture: If cell culture of virus is positive, then continue with HI
- 31 -
method for serotype and gene sequence analysis of the virus strain.
Influenza rapid test should still be confirmed by RT-PCR. Therefore it is not
suggested unless in off-shore islands or cluster events.
In current practice, patients who fulfill human H5N1 reporting criteria
should be collected of pharyngeal-laryngeal swab, blood serum of both acute
phase and recovery phase. According to US CDC Health Update (June 07, 2006),
lower respiratory samples among all H5N1 samples have higher density of virus
that is easier to be detected, including tracheal aspirates and bronchoalveolar
lavage. These two samples can be collected in addition.
2.2.2.2 Execution of Laboratory Diagnosis
At present, there are 12 contracted viral labs country-wide other than the
NIC of CDC to execute the testing. The mechanism for collection of specimens
and delivery to influenza testing labs has been set up and in running, and the
labs will continue to maintain their testing capacity and biological safety. Should
epidemic situation worsens in the future, the daily volume of samples handed
can be increased in view of epidemic control needs. Coordination plan for
deployment of back-up lab staff has also been devised in response to demand of
large quantity of testing at that time.
2.2.3 Case Investigation
The objective of case investigation is to learn about the infection
mechanism, clinical manifestation and transmission strength of virus. According
to information obtained from investigation, we can propose or revise
self-protection methods timely, and to decide appropriate objects of prophylaxis
and other containment measures.
- 32 -
2.2.3.1 Execution of Case Investigation
When in the stage of Phase 0 (domestic) and Phase 3 (international), local
health authorities proceed with brief investigation after receiving a case report of
human H5N1. If after testing, the case is found to be infected by Influenza A
virus, but not H1 or H3 subtypes, a comprehensive investigation form should be
completed within 24 hours. Investigation items in the form include: travel and
exposure history 10 days before falling ill, investigation of contacts, clinical
symptoms, medical history, etc. The “close contacts” identified will be included
in the health self-management information system, and their condition will be
managed and followed up everyday.
“Close contacts” regarding “human H5N1 influenza” may change according to
scientific knowledge. In principle, people who inhabit in the same house or have
meals with a suspected patient of human H5N1 influenza during the period of
communicability, office co-workers working within a radius of 3 meters,
classmates, care-givers, riders on the same long-route (longer than 1 hour)
public transport, etc., are recognized as “close contacts”, but the investigators
can make flexible determinations according to actual investigation results.
2.2.3.2 Management of Close Contacts
If the close contacts described in previous section had appropriate
protection during contact with suspected patient, daily activities can still be
maintained.
If close contacts didn’t have appropriate protection during contact period,
the possibility of being infected cannot be ruled out. Therefore arrangements
should be made to decrease the opportunity of pathogen spread. Close contacts
will be asked to perform health self-management for 7 days. During this period
until being removed from health self-management, one should stay home and
- 33 -
avoid going out, maintain good hygiene habits, monitor one’s own health
condition, and once a health problem develops, medical help should be sought
according to instructions from local health authorities.
If close contacts develop symptoms when being investigated, the possibility
of human H5N1 infection should be considered. They should be arranged to
seek medical help to clarify the cause of symptoms.
- 34 -
3. Antivirals Strategy
3.1 Rationale
There are 2 classes of antivirals specific for influenza: M2 inhibitors and
neuraminidase inhibitors. M2 inhibitors launched earlier and are cheaper. But
evidence shows higher incidence of resistance, and whether they’re safe to be
used by pregnant women is unknown. A major concern is that H5N1 virus has
been found to be resistant to M2 inhibitors. It is possible that H5N1 virus keeps
the resistance and becomes global pandemic. Neuraminidase inhibitors, such as
Oseltamivir and Zanamivir, are newly developed. Their safety profiles are
relatively higher and resistance is relatively low. However, they are expensive
and current supplies are very limited [9].
Antivirals are being used to treat and prevent seasonal influenza. In terms
of responding to a influenza pandemic at the early phase, when effective vaccine
is not yet available, the intervention of antivirals is extremely important. Most
human H5N1 influenza cases were treated with oseltamivir. WHO has also
stockpiled 3 millions doses of oseltamivir to contain the widespread of
human-to-human transmission. However, the experience of oseltamivir
treatment of H5N1 virus infection is not yet sufficient. There should be more
research regarding its dosage and duration of administration.
WHO suggests the following opportunities for using antivirals: (1) At
present situation, antivirals are being used to treat H5N1 infected patients, and
prophylaxis in patient’s close contacts such as health care workers and family
members; (2) At the beginning of efficient human-to-human transmission,
antiviral administration to the entire community where clusters are occurring
may stop the virus from further improving its transmissibility or delay the spread;
(3) If global influenza pandemic occurs, antivirals will be used as a medical
intervention for reducing morbidity and mortality[9]. The stockpile and
administration of anti-virals of DOH are planned according to above principles.
- 35 -
3.2 Implementation Strategies
3.2.1 Stockpile Quantity of Antivirals
Our country follows the principle of diversified stockpile. The medications
chosen are neuraminidase inhibitors recommended by WHO. One is Tamiflu
(Roche) with active ingredient oseltamivir, in both capsule form and API (active
pharmaceutical ingredient). The other is Relenza (GSK) with active ingredient
zanamivir, in spray dosage form. The total stockpile quantity is 2.37 million
doses up to June 2006, which can cover at least 10.44% of population. The
stockpile of these two medicines not only serves to avoid the occurrence of
resistance, but can also be used in patients with special indication.
Tamiflu API has the same active ingredient of Tamiflu capsule (oseltamivir
phosphate). Several characteristics of the API, such as small volume (1 gram of
powder is sufficient for 1 treatment dose), long shelf life (currently 5 years, can
be extended to 11 years at the longest with proper storage), and rapid and large
quantity prescription make it suitable to be used in treating large number of
patients and in mass prophylaxis for rapid containment. In addition, Tamiflu API
can be used in a wider range of age. All those who meet administration criteria
of being older than 1 year of age can use this medicine. In order for Tamiflu API
to be effective during influenza pandemic, DOH authorizes Taiwan Association
of Clinical Pharmacy to hold “Anti-virals Prescription Training and Delivery
Program”. Up to now, 105 prescription facilities have completed this training.
3.2.2 Time of Administration
At the stage of phase 0 (domestic) and phase 3 (international), a patient
who meets definition of human H5N1 influenza can be administered with
antiviral immediately according to the patient’s physiological condition after
being examined and sampled by a doctor and being reported to the health
- 36 -
authorities. Prophylaxis can only be provided to the workers involved in culling
animals of HPAI.
Upon entering phase B, C, Executive Yuan will establish a Central
Epidemic Command Center (“Command Center” in short). Once the command
center decides to use Tamiflu API, the logistics division of command center will
inform the director of Taiwan Association of Clinical Pharmacy to activate
prescription operation. The Logistics division will also inform Roche
Pharmaceuticals to follow its instruction in delivering Tamiflu API in batches to
GMP manufacturers contracted by DOH for packaging and labeling. GMP
manufacturers will then deliver Tamiflu API to prescription facilities authorized
by Taiwan Association of Clinical Pharmacy to proceed with liquid prescription.
At last, the local governments will deliver the liquid drug. Drug prescription,
delivery and use are controlled by the Material Information System (MIS,
http://mis.cdc.gov.tw).
3.2.3 Administration Plan of Antivirals in the Future
At the stage of phase A1/phase 4-5, when the virus is developing greater
ability of human-to-human transmission abroad but no cases have occurred
domestically, medicine recipients are still limited to patients who meet the
definition for case reporting. Tamiflu capsules will be administered by medical
organizations that perform testing and examination.
At the stage of phase A2/phase 3-5, when there are suspected cases of
fowl-to-human transmission, imported infection or lab-acquired infection
domestically, medical organizations that perform testing and examination will
provide Tamiflu capsules in a similar way to patients who meet the reporting
criteria. Close contacts of suspected patients will be given Tamiflu capsules as
prophylaxis.
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At the stage of phase B/phase 5, when localized outbreaks have occurred in
the country, Tamiflu capsules will continue to be supplied to patients who meet
the reporting criteria. In addition, packaging and prescription of Tamiflu API
will be performed according to the decision of the Command Center to facilitate
extensive administration of the drug prophylaxis to block the virus spread.
At the stage of phase C/phase 6, when the world has entered the pandemic
phase with widespread domestic outbreaks, antivirals will be used to treat
infected patients to prevent serious symptoms and to reduce fatality. All Tamiflu
API will be packaged and be distributed by direct municipality and county/city
governments to designated Infectoius Disease Prevention and Control Hospitals
and to large-scale medical care facilities in their respective jurisdictions.
The above-mentioned time of administration of Tamiflu is listed in Table
3.1.
Relenza is for administration to the respiratory tract by local inhalation. It
will be provided to health care workers of H5N1 influenza patients.
3.2.4 Procedures of the Use of Tamiflu API
3.2.4.1 Activation Mechanism for Use
When entering phase B, the logistics division of central epidemic command
center will propose to the commander about the activation mechanism of
Tamiflu API use (proposal includes time of activation, quantity of prescription,
demanded quantity of each county/city, and timeframe for completion). Once
commander orders the activation of the mechanism, the logistics division will
execute the following measures:
1. Inform Roche Pharmaceuticals by phone or email to deliver a specific
quantity of Tamiflu API along with a medicine delivery checklist to GMP
manufacturers designated by DOH within a specific period of time.
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2. Inform the GMP manufacturers by phone or email to await order to proceed
with packaging and labeling. Ask the manufacturers to check the quantity of
Tamiflu API. If no discrepancy is noted, fax the medicine delivery checklist
to the logistics division and confirm by phone.
3. Inform Taiwan Association of Clinical Pharmacy by phone or email about
this prescription order and contents. Ask them to report back when standby is
ready by phone or fax and to report regularly on the progress of prescription
in each area.
4. Inform each local government in writing about the activation of the Tamiflu
API mechanism. Also inform them about the estimated time to get Tamiflu
solution at prescription facilities in respective county/city.
3.2.4.2 Packaging and Labeling
1. The warehouse of Roche Pharmaceuticals will complete delivery of API to
contracted GMP manufacturers within a specific period after receiving
delivery notification from the logistics division.
2. GMP manufacturers will complete all API packaging and labeling within 72
hours, and deliver the medicine to contracted prescription hospitals.
3.2.4.3 Medicine Prescription
1. Prescription facilities receive small packages of Tamiflu API. After
confirming no discrepancy is noted, log into MIS and enter Tamiflu API into
the system.
2. Prescription facilities start prescription procedure according to indications of
Taiwan Association of Clinical Pharmacy. After the completion of
prescription, enter the quantity of Tamiflu solution into MIS to complete the
procedure.
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3. Taiwan Association of Clinical Pharmacy reports back regularly to Logistics
about the progress of prescription of each area by phone or fax.
4. Logistics and local responsive center obtain information on prescription
status in MIS.
5. Prescription facilities are responsible for proper storage of medicine stored in
their facilities.
3.2.4.4 Delivery
1. Tamiflu API is used according to command center’s indication or by local
command center’s decision in its governance based on epidemic situation.
2. The local governments should arrange vehicles and staffs to prescription
facilities to receive medicine after presenting a medicine requisition list with
authorization of Bureau of Health.
3. After receiving the medicine, store it under 25℃ and deliver it promptly to
places that demands the medicine (large-scale care facilities, infection
prevention hospitals, communities or other). Ask them to check and accept
the medicine and to provide an administrating list.
4. Bureau of Health will log data into the MIS according to the administrating
list.
5. If cross county/city administration and delivery of medicine are involved,
local branches of CDC will coordinate it.
3.2.5 Information Management
MIS is used as the operation interface for managing information flow on
anti-virals, and this applies to all three medicines stockpiled in our country
(Tamiflu capsule, Tamiflu API, Relenza). Recipient units of the drugs make
- 40 -
entries into MIS, and handouts are also registered into the MIS by the units
when medicine is sent out. The drugs are handed down units, which must
subsequently report back the basic information of drug recipients.
3.2.6 Activation of Domestic Manufacture of Tamiflu
The office of Intellectual Property of Ministry of Economic Affairs has
granted special permission to DOH to overlook the patent of Tamiflu under
certain conditions since November 2005. The type of Tamiflu manufactured in
our country is in API form. The administration procedure is the same as “3.2.4
Procedures of the Use of Tamiflu API”. The domestic manufacture mechanism is
activated by the decision of commander of the Command Center according to
epidemic situation and the storage quantity of anti-virals during influenza
pandemic period.
- 41 -
Table 3.1 Time of Administration of Antivirals
Source of Medicine
Phase
Recipient
Tamiflu capsule
Phase A1/ phase 4~5
1.Human-to-human
cases aboard
2.No domestic case
Phase A2/ phase 3~5*
Suspected domestic
cases of
fowl/animal-to-human
transmission, imported
infection, lab-acquired
infection
Phase B/phase 5
Localized domestic
outbreaks
Those who meet
definition of human
H5N1 influenza
Sentinels for H5N1
infection
1.Those who meet
definition of human
H5N1 influenza
2.Close contacts of
possible cases
1. Sentinels for H5N1
infection
2.Local Branches of CDC
1. Those who meet
definition of human
H5N1 influenza
Sentinels for H5N1
2.Large-scale
infection
administration of
preventive medication
aiming at regional
containment of virus
Phase C/phase 6
1. Large-scale
1.Global pandemic
administration of
2.Widespread domestic preventive medication
outbreaks
aiming at containment
of virus
2.Patients treated at
infection control
hospitals
3.Patients treated at large
care facilities
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Tamiflu API
Central Coordination
1.Central
Coordination
2.Central or local
government
coordination
3.Central or local
government
coordination
4. Vaccine Strategy
4.1 Rationale
Influenza vaccine is the most important means to control influenza
epidemic. Even though seasonal influenza vaccination cannot prevent future
influenza pandemic, the routine promotion of the annual influenza vaccination
program contributes to capacity-buidling in the manufacture, delivery and
administration of pandemic vaccine. Our country’s current vaccination program
aims at elders above 65 years of age, infants between 6 months and 2 years of
age, health care personnel, workers in industries related to poultry and animal
husbandry and animal influenza control workers. At present, all vaccines are
purchased from international manufacturers through agent. We are temporarily
unable to manufacture influenza vaccines.
Traditional manufacture of influenza vaccine uses egg-based technique,
which requires large quantity of eggs. Cell-based technique is more advanced,
with the advantage of more capability of manufacturing large quantity of
vaccine in response to epidemics. Cells to be used can be stored frozen in
advance, lest the decrease in egg quantity caused by avian flu will impact the
manufacture of vaccines. People with allergies to eggs can also be vaccinated.
The US Government announced an investment of $1 billion in May 2006 to
develop research of cell-based technique and vaccine manufacture.[10]
Based on current vaccine manufacturing technique, once influenza
pandemic occurs, mass production of pandemic flu vaccine will become
possible 6 months after acquisition of virus strain. WHO have invited related
experts and vaccine manufacturers to discuss relevant issues concerning vaccine
research/ development and supply, hoping to shorten the period of vaccine
manufacture and supply.
Even so, it is not easy for countries with no vaccine manufacture capacity
to obtain sufficient pandemic vaccine at the beginning. Influenza vaccine
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manufacturers are located in 9 countries: Australia, Japan, Canada, USA, France,
Germany, Italy, Netherlands and United Kingdom. In 2003, global vaccine
supply was approximately 292 million doses. 71% among them was provided to
Australia, Japan, Canada, USA and Western Europe countries. That is to say,
with only 12% of the world’s population, these vaccine manufacturing countries
used almost 2/3 of influenza vaccine. According to WHO estimation, 70% of
global influenza vaccine is manufactured by 5 major European manufacturers.
However, the most probable origin of influenza pandemic virus –Asia, is located
at the far end of vaccine supply. There are enormous differences between supply
and demand whether in total manufacturing capacity or region distribution.
Once pandemic occurs, countries without manufacturing capacity will be unable
to acquire sufficient vaccine.
Our country does not possess the manufacturing technique and capability of
influenza vaccine now. Facing an unknown future, if influenza pandemic occurs,
global demand for vaccine will increase substantially hence causing imbalance
of supply and demand. At that time, importation of sufficient vaccine cannot be
guaranteed and will have huge influence over every aspect of our country. In
view of that, it is essential and important for Taiwan to acquire manufacturing
techniques capacity for influenza vaccine. Taiwan should even develop
influenza vaccine related industries to improve national epidemic control and
response capabilities.
To effectively implement the “Influenza Vaccine Self-Manufacture Plan”
approved but Executive Yuan in November 2004, and to build up domestic
vaccine manufacture capability, CDC has launched a “BOO Project for
Domestic Manufacturing of Influenza Vaccine for CDC” according to the “Law
for Promotion of Private Participation in Public Infrastructure Project” (“Law
for Promotion of Participation” in short).
- 44 -
4.2 Implementation Strategies
4.2.1 Short-Term: Stockpile of “Pandemic-like” Vaccine
To provide sufficient vaccine during influenza pandemic period is one of
the major objectives of CDC. To be farsighted, the most fundamental solution is
to establish the capability of manufacturing influenza vaccine. However, the
timing of influenza pandemic onset cannot be estimated precisely. If it comes
within a short time, stockpiling foreign-made H5N1 vaccine which is under
clinical trial for emergency will be the way to respond. Therefore, with the CDC
striving for funds, Executive Yuan agreed in 2006 on a budget of USD $1.9
million to purchase and stockpile human influenza A/H5N1 vaccine.
Arrangements concerning purchase and public bidding are underway to acquire
doses to cover at least 95,000 people. The stockpile will be provided to first-line
health care workers and epidemic control staffs with priority when influenza
pandemic occurs.
4.2.2 Medium-Term: Self-manufacturing of Emergency Vaccine
In order to effectively deal with influenza pandemic, CDC has solicited and
elected publicly for research and development plans of influenza vaccine in our
country according to Government Purchase Law. And it will be executed by
public and private colleges and universities, public academic research
organizations, corporate academic research organizations, medical facilities with
ranking higher than regional hospital, and medical health related academic
organizations. Execution period is 2006-2008, with total funds of USD $18.8
million. Funds of 2006 Influenza vaccine research and development plan are
USD $4 million. It can be divided to 3 major frameworks and 20 plans. The
contents are:
1. Selection of vaccine strain and vaccine policy research
- 45 -
(1) To manufacture standardized antiserum and antigen for influenza virus
(2) Research on Taiwan influenza virus molecular evolution and the influence
of each gene on virus antigen manifestation
(3) Analysis of influenza virus HA and NA：Integration of Taiwan influenza
virus detection systems, in order to set up standard procedures and
methods for collection and analysis of influenza virus information
(4) Establish bioinformatics system of influenza virus
(5) Utilization of integrated infectious disease surveillance software to assist
the monitoring of influenza and to provide public health reference
(6) Use mathematical models to research Taiwan’s influenza vaccine policy
and other disease control policies.
(7) Establish the blood serum database of community public and monitor
antibody immunoreactions before and after influenza vaccination in
Taiwan children, adults and elders
(8) Influenza vaccine research and development plan— Epidemiology
sub-plan: Establish our country’s surveillance system on antibody to
influenza virus
(9) Establish our country’s surveillance and analysis system on antibody to
influenza virus— Evaluation of antibody reaction after vaccination and
analysis of immunity condition of people with poor antibody reaction
after vaccination
(10) Investigation of serum antibody to human influenza A virus and avian
flu virus of poultry/animal husbandry workers in Taiwan and Kinmen area
2. Establish Basic Vaccine Technique
(1) Influenza virus group study—Interaction of congenital immunity receptor
and virus, technical platform for immunity analysis, influence of virus
- 46 -
gene variation to immunity reaction of host, manufacturing of primitive
virus vaccine
(2) Identification of genomes of new influenza virus strain and manufacture
of new vaccine strain by reverse genetics
(3) Influenza virus group study—virology, immunopathology, technical
platform for immunity analysis, technical application of reverse gene
system
(4) Emergency plan of influenza vaccine manufacturing
(5) Manufacture of new influenza vaccine using serum-free micro carrier cell
culture
(6) Research and development of new influenza subunit vaccine and new
high-molecular vaccine slow release form
(7) Improve mammal cells and select virus replication accelerator to increase
the capacity of influenza virus (vaccine strain)
(8) Research and develop bi-valence vaccine combining human influenza and
avian flu using new type carbohydrate and lipid assisting agent.
3. Promote the development of this industry and the execution clinical trials
(1)Establish our country’s management mechanism of clinical studies of new
influenza vaccine
(2)Development plan for technical and managerial talents
The establishment of our country’s emergency manufacturing line of new
influenza vaccine is planned and executed by National Health Institute. This
plan is expected to start in the 3rd quarter of 2006, and will entail continuous
manufacturing and stockpiling of H5N1 influenza vaccine. 5000 doses of H5N1
vaccine to be used in clinical trials will be available in the 4 th quarter. IND
application of clinical trials will begin at the 2nd quarter of 2007. Clinical study
- 47 -
will start in the 3rd quarter of the same year. It is expected that emergency
manufacturing capacity can reach 100,000 doses per year in the 3 rd quarter of
2008.
4.2.3 Long-Term: Plan for Domestic Vaccine Manufacture
DOH
has
enthusiastically
raised
funds
to
conduct
domestic
manufacturing of influenza vaccines. The tender process for seeking influenza
qualified vaccine manufacturers has been completed. It is estimated that, at the
end of 2009, our country will have its first flu vaccine plant with an annual
manufacturing capacity of 16 million doses. In the future, this factory must have
an annual production of at lease 16 million doses of general tri-valence influenza
vaccine. When influenza pandemic occurs, it should be able to provide vaccines
that cover at least one fourth of Taiwan’s population within 3 months.
In view of the government’s obligation and responsibility to establish
epidemic prevention system, civilian participation is introduced to the execution
aspect of domestic manufacturing of influenza vaccine to improve the efficiency
and quality of public construction. Here the Law for Promotion of Participation
is used. A civilian organization invests and constructs the new facilities. The
organization has ownership, and can manage the business by itself or through a
third-party (Build-Own-Operate, BOO in short). In order to encourage active
participation of private manufacturers, long-term purchase agreement is planned
as a strategy to encourage investment other than methods defined in Law for
Promotion of Participation.
As for the timeframe, the contract is estimated to be signed in the 2 nd half of
2006. Factory construction will be completed 2 years within signing the contract.
Production will start within 3 years of signing the contract.
- 48 -
4.2.4 Establishment of Capability in Virus Strains Selection
Because of the frequent antigen draft of influenza virus, WHO give
suggestions to north and south hemispheres respectively every year on influenza
virus strains of vaccine to be administered. The virus strains chosen are based on
virus strain information and epidemiologic trends collected by WHO Global
Influenza Surveillance Network. The Network includes 116 national influenza
centers in 87 countries, and 4 WHO Collaborating Centers (US, United
Kingdom, Australia, and Japan). These participating centers process samples
from influenza-like patients for virus testing, and send representative isolated
strains to a WHO Collaborating Center to continue with gene and antigen
analysis. In order to establish our capability of vaccine manufacture, it is also
essential to establish the ability to identify and select virus strain, other than
research and development of techniques and factory construction plan. Besides
existing resources, cooperation with internal and international scholars is also
necessary.
4.2.5 Administration of Pandemic Vaccine
Some research institutes and vaccine manufacturers are working on
technique development of related vaccine. Some are in clinical trial stage. We
are still waiting for a breakthrough in aspects of increasing immunity and
development of evaluation tools. How to speed up procedures like registration
for examination when a pandemic takes hold is a major topic for both foreign
and domestic organizations.
As for the recipients of pandemic vaccination, medical staffs, personnel
who maintain essential social functions, high-risk population who tends to
develop serious symptoms or death, will be vaccinated with priority considering
available vaccine quantity at that time.
- 49 -
5. Transmission Interruption Measures
5.1 Rationale
Traditionally, people all think vaccination is most cost-effective way to
infectious disease control. However, as far as influenza pandemic is concerned,
the influenza virus strain that cause pandemic is not available. It is not possible
to manufacture effective and large quantity of vaccine timely to prevent
occurrence of pandemic. Though WHO recommends antiviral stockpile for
pandemic preparedness, the appropriate dose and administrative duration for
pandemic flu is unclear. The occurrence time and scope of pandemic is
unpredictable. As a consequence, the stockpile of medication is indeed
troublesome.
In addition to ”non-pharmaceutical public health interventions” described
in WHO Global Influenza Preparedness Plan, [8] in Emerging Infectious Disease
Journal, those interventions are categorized into 4 types: (1) Measures that limit
the international transmission of virus, such as screening of fever at border and
travel restriction; (2) Measures that reduce virus transmission, such as isolated
treatment of patient, health self-management of contact, quarantine, cancellation
of rallies and class suspension, etc; (3) Decrease personal risks, such as frequent
practice of hand-washing; (4) Communication of risks to the public
[11]
. In our
country, these prevention measures are generally called “ Transmission
Interruption Measures”.
In the “Implementation Plan for Pandemic Influenza” announced by the US
Department of Homeland Security in May 2006, some social distance measures
were mentioned, for example, keeping distance of at least 1 yard (3 inches) with
others, using teleconference tools in meetings at work, closing elementary
schools, canceling unimportant rallies, or restriction of traveling, etc. These
measures are more cost-benefit. Other measures include snow day restrictions,
namely that government force the public of staying home to limit social contacts
- 50 -
to reduce communicable diseases transmission. These measures cost more,
therefore can only be implemented for a limited duration. But they there should
be at least two incubation periods in order to reach maximum benefit. US CDC
announced in October 2006 that it will take months to develop effective vaccine.
Therefore “non-pharmaceutical interventions” could be the first line measures.
Except for hand-washing and cough etiquette, it is of high priority to select
appropriate prevention measures in community. These measures include “social
distance” (closing schools/work places or canceling rallies) and “ isolation &
quarantine”. Therefore once the pandemic occurs, low-cost and continuous
social distance measures should be implemented immediately. High-cost and
short-term measures can be hold back until there’s a need of containment.[12]
The Spanish influenza pandemic in 1918~1919 almost killed 50,000,000
lives globally, with around 675,000 Americans. It was estimated that among
American metropolis, the lowest mortality rate was 0.3% in St. Louis. The
highest was 0.8% in Pittsburgh, and next was 0.76% in San Francisco. Why a
lower mortality rate was in St. Louis? Public health scholars believed that it
should be attributed to Dr. Starkloff, the health official of St. Louis at that time.
He was alert that Spanish flu might invade along with troops. In early October
he asked the mayor to implement social distance measures such as closing
schools, theaters and churches, prohibition of rallies, balls at hotels and
restaurants, restriction of public visit the sick in the hospital, and restriction of
children going to playgrounds or libraries. After Dr. Starkloff died in 1942, the
City Hospital of St. Louis was named after him to remember his contributions.
When recalling past events, we should also learn from them to respond to
pandemic.
The scientific evidence of non-pharmaceutical interventions effectiveness
in influenza prevention is quite limited. In fact, the guidelines are mainly
obtained from observation of history and present day instead of control studies.
- 51 -
Recently mathematical simulation is added. Much information is from
estimation and calculation. Therefore, during pandemic, epidemiology, virology
and field investigation should be applied immediately to proceed with
cost-benefit analysis. With estimation of mathematical simulation, a more
objective and precise decision-making basis can be provided. There are 4
principles of using these measures: (1) Broaden the scope of crisis management;
(2) Limitation of social interaction; (3) Using the fewest and necessary
restriction measures; (4) Making community public into partners.
There are 3 elements of infectious disease development: pathogen,
susceptible host and transmission pathway. In a word, to prevent the spread of
pandemic, the susceptible host should be prevented of contact with pathogen.
Therefore, we can begin with eliminating or reducing infectious sources and
stopping or slowing down virus transmission among people . Strategies of
infection control and strategies of contact restriction are generally called
“Transmission Interruption Measures “ in this text.
According to Communicable Disease Control Act, central and local
governments have their own responsibilities and authorities to implement
prevention measures. All departments of government have started preparation
actively in response to the pandemic threat. Transmission interruption measures
constitute 1 of the 4 major strategies of pandemic prevention in our country. All
levels of government must make all the people to cooperate in order to eliminate
the occurrence, transmission and spread of infectious diseases.
5.2 Implementation Strategies
During pandemic alert period, control measures such as surveillance, case
investigation, patient isolation, contact tracing and prophylaxis with antivirals
are intended to delay the occurrence of pandemic,. But during pandemic period,
depending solely on the above measures will not necessarily prevent the
- 52 -
epidemic from spreading. Community-based concepts should be incorporated in
the thinking of prevention measure application, for example closing schools,
canceling public activities, constraints similar to snow day restrictions,
quarantine of close contacts or even enlarged community quarantine (such as
closing streets).
The decision making and time consideration of broadening social distance
measures should be evaluated according to epidemic situation of each individual
community. No single measure can be applied to all epidemic situations. For this
reason, the following measures can be implemented individually or in
combination.
All the infection control strategies and contact restriction strategies
described in this chapter may be applied during a pandemic. When the time
comes, national contact restriction strategies will be decided and ordered by
Central Epidemic Command Center according to virus characteristics,
prevention needs and feasibility at that time. Local governments, medical
facilities and community organizations can fully understand the rationale and
objectives of each measure through the content of this plan. The way of
implementation can be planned in advance to make use of them with flexibility.
5.2.1 Infection Control Strategies
Infection control is to employ physical measures to protect individuals from
entering into or contact with pathogen-polluted environment. It is divided into 4
types according to disease transmission pathways: (1)standard precautions;
(2)contact precautions; (3)droplet precautions; (4)airborne precautions. Details
can be found in the newest version of infection control guidelines drawn by
WHO, on subjects such as environmental cleaning and disinfection process,
hand hygiene, cough etiquette, personal protective equipment (PPE) and
operation procedure control, etc.[13]
- 53 -
Coughing, sneezing and speaking create droplets. Pathogens in mucous
membrane of respiratory tract, such as H5N1 influenza virus, will probably
adhere to the surface of droplets≧5 ㎛ in diameter and suspend in the air.
Droplets will fall gradually to the ground or surfaces of environment facilities
because of gravity over about a distance of 1 meter (3 inches). If one’s hand gets
in contact with contaminated surfaces and then touches the mouth, nose, or eye
without disinfection procedure, then virus will invade the mucous membrane
and infects that person. If moisture of the droplet vaporizes which makes its
diameter<5 ㎛, then the droplet core will float even farther under airflow
influence. Virus infection through this method is called airborne transmission
pathway, the extent of influence of which will be even greater. There is
sufficient evidence in several studies that influenza virus is usually transmitted
by tiny particles of respiratory tract rather than by larger ones as believed in the
past. Different from large particles or droplets that may be trapped in upper
respiratory tract, tiny particles are likely to invade the lungs. Much evidence
shows that current H5N1 influenza virus mainly invades lower respiratory tracts.
Human influenza virus can remain in smooth surfaces for about 24~48
hours. In the surfaces of clothes, paper or toilet paper (in the environment of
35~49% humidity and 28℃), it can remain for about 8~12 hours. For this reason,
cleaning and disinfection are effective ways to reduce pathogen during
pandemic. Cleaning should come before disinfection. In the infection control
guideline of WHO, the following ingredients are suggested to be used: phenols,
quadrivalence
ethanol(70%).
ammonium,
Refer
hydrogen
to
peroxide
solution,
following
chloride,
web
and
page:
www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf
In addition, for details of key points regarding hospitals’ work on infection
control in response to avian flu and pandemic flu, refer to following web page:
http://www.cdc.gov.tw/internet-cdc/疫情報導/files/第 22 卷/中文版 22-07.pdf
- 54 -
5.2.2 Contact Restriction Strategies
5.2.2.1 Isolation
Isolation is to separate and limit the movements of suspected, possible or
confirmed cases of infectious disease within a specific facility with medical
service provided, in order to reduce the possibility of pathogen spread.
Regarding the duration of isolation, basically, it is determined by remission of
clinical symptoms and virus characteristics, namely the duration in which a
patient continues to release the virus and whether immunity is developed in
patient. The planning of isolation during pandemic can be classified to:
1. Air isolation wards
The planning of this kind of wards can facilitate influenza pandemic
control. But practically the number of wards is limited after all, and cannot
satisfy the needs of a large scale epidemic. All levels of government should
establish and plan substitutes for isolation wards in community in advance.
2. Home isolation
When hospital capacity is overloaded, home isolation is one of the
options. Patient should be separated from family during home isolation
treatment period. It has 4 advantages: With less pressure, more comfortable,
more opportunities of family-provided care, and psychological benefit. There
are also 2 disadvantages: increased risk of family infection and decreased
accessibility of professional medical services. Therefore, if patient cannot
obtain proper and basic medical services, home isolation should not be an
option. Once home isolation is executed, necessary PPE and sufficient
information should be provided to family and care-givers. Related discards
produced by patients have to be handled properly.
3. Facility isolation
When air isolation wards are greatly insufficient, or home isolation
- 55 -
could not be fully supported by family, requisition of a designated hospital
could be the best option for facility isolation. When hospital requisition is not
possible, other facilities can be taken into consideration, for example hotels,
schools, gymnasiums, religious constructions, nursing homes, convention
centers, mobile tents, ambulant trailers, sailing ships, government
organizations, etc. Every operation procedure inside the facility should take
into consideration the possibility of direct or indirect infection of staffs other
than patients. If yes, the infection factor should be prevented or eliminated in
advance.
5.2.2.2 Quarantine
Those who are suspected of infection exposure but not yet falling ill will
be asked to wear masks correctly to be differentiated and to limit their
movements. They should keep a distance of at least 1 meter with others. The
objective of quarantine is to monitor their health condition and to know well
about possible patients as soon as possible. The quarantine duration is
uniformly 7 days for close contacts.
Quarantine cannot stop infectious disease transmission immediately, but
it’s one of the many methods to decrease new patients. Both isolation and
quarantine will restrict personal freedom. Most people can accept that when
symptoms occur one should be isolated. However, quarantine performed on
those under exposure but with no symptoms is difficult to implement, even
with the consideration of public interest over personal interest. Even so, local
governments should well communicate with people about what are the risks
and what are government’s strategies. In addition, daily activities and food
during quarantine should be pre-planned. According to characteristics and
scale of epidemic situation, the following types of quarantine can be adopted:
1. Home quarantine
- 56 -
The subject unit of home quarantine could be individual or family. But
only when most people in a building are at risks of exposure can we consider
including all people in the entire building into subjects of quarantine. People
who fall ill during quarantine period should be escorted to isolated treatment
immediately.
During the quarantine period, individuals under quarantine should wear
masks correctly. Their daily activities, ranging from sleeping and eating to
drinking and bathing, should be separated from others. Once a quarantined
individual falls ill, in addition to being sent to treatment immediately, the
patient’s family will become subjects of quarantine and their activities
restricted.
If home quarantine is regarded as necessary and appropriate, local
government should ensure that special requirements of susceptible groups are
met, including elders, infants, those with movement incapability, and those
with chronic diseases.
2. Facility quarantine
For those who will not or cannot sustain home quarantine, for example
people without relatives, tourists or those requiring special care, local
governments should set up quarantine facilities to take in these kinds of
quarantine subjects and limit their movements.
3. Work quarantine
Work quarantine may be implemented for health care workers. These
personnel are most possible to be exposed to pathogen, and they play
important roles in epidemic control. It will be troublesome to implement
home or facility quarantine for them. On the other hand, work quarantine will
allow staffs to continue to work, but PPE should be used. When not working,
home or facility quarantine can be implemented, meaning that they cannot
- 57 -
have contact with family or other colleagues, and have to perform strict
health self-management. Those who develop symptoms will be reported and
be sent for treatment.
4. Community quarantine
Community quarantine can be implemented in an area if, within this
area, there are a relatively high number of confirmed cases or extensive
exposure risks. All people in this area are to be restricted of their movements,
such as closing of streets and hospitals during SARS period.
5.2.2.3 Community restriction
Community restriction is the way to reduce public interaction in
community through limitation of public activities and closing of buildings, etc.
Community restriction may be implemented together with isolation and
quarantine, but they are different in ways of execution after all. Community
restriction measures not target individual cases or groups, neither will it target
patients, contacts or potential contacts directly. Basically, the subject of
implementation is one whole community. Social interaction within the
community will be restricted to reduce possibility of disease transmission. Due
to its great impact, it should be considered of how to execute to reach maximum
effects, and how to maintain functioning of other important infrastructures as
well. For example, if there are other transportation systems to substitute when
mass transit system is closed.
Below are 5 classes of restriction measures to be referred to when drafting
implementation practice:
1. Encouraging community-based infection control actions
For example: environment cleaning, practice of frequent hand-washing,
cough etiquette, bowing instead of hand-shaking, and discouraging kiss
- 58 -
salutation, etc.
2. Travel restrictions
Travel types include air, sea, railway and land route, etc. The extent of
restriction ranges from issuing travel warning to stopping people from getting
near high-risk regions to canceling trips.
3. Canceling public gatherings
For example, sports games, performances, concerts, political rallies,
festive activities, religious activities, weddings and funerals, etc. The
principle is cancellation; minimization of scale and postponement as
exceptions.
4. Closing public facilities
For example, schools, government offices, transportation stations,
libraries, and public swimming pools, etc. When thinking about closing
civilian properties such as mega selling stores, concert halls, skating rinks,
theaters and hotels, etc, there must be strong legal basis, such as an
emergency order.
Closing elementary schools will help reduce or prevent influenza
transmission among young school children. But the need for someone to
accompany the parents at home should also be considered when
implementing, because we do not want to see children being let loose and
gathering outside schools.
5. Reinforcement of screening capacity
5.2.2.4 Sheltering
Sheltering is a measure to restrict many people’s social activity in order to
protect their health. It is different from isolation and quarantine. It does not
target those who fall ill or contacts. It targets those who have never been
- 59 -
exposed to pathogen; and it is not compulsory. It can be considered in below
situations: (1) when the scale of community spread is as large that it’s
impossible to proceed with contacts investigation, and with social activities
continuing, the risk of infection will not be slowed down; (2) when isolation,
quarantine and community restriction measures still cannot properly prevent
pandemic flu from spreading; (3) when influenza virus is very contagious and is
greatly pathogenic, all active measures should be implemented, even though
some can only serve to limit the transmission of disease; (4) when the disease is
infectious even before symptoms appear.
In foreign countries, during the days of snowstorm attack, and in our
country when typhoon attacks, government will announce “no work or no
school” messages. The objective is to restrict people going out to ensure safety
by asking people to stay home. These actions are not compulsory and the
compliance is associated with the enhancement of people’s “self-sheltering”
behaviors. They are usually called ”snow day restriction” or ”sheltering”
or ”self-shielding” in literature.
This “self-shielding” concept was first developed to be applied to
management in response to biological terror events. Nowadays, this concept can
also be used during pandemic period. After each county/city government makes
such an announcement according to law, people should make voluntary
decisions to stay home and decrease going out for public gatherings. The
implementation period can be set initially as 2 weeks, after that, strategies can
be refined according to epidemiological information at that time. Nonetheless,
during pandemic, local governments should be cautious when making such
decisions as to maintain basic social infrastructures, such as communication and
transportation, water and electricity, etc.
- 60 -
6. Preparedness of Personal Protective Equipment
6.1 Rationale
In laboratories, out-patient consulting rooms, emergency rooms and
isolation wards, infection control installations and measures should be
considered in advance, and personal protective equipments (PPE) can be used to
supplement insufficiency of those fixtures and measures. PPE is also critical to
ensuring the safety of first-line workers who are involved in case investigation,
health education and culling work in avian flu affected farms. Therefore,
advance planning and implementation of PPE preparedness are urgently needed
in the face of pandemic threat.
Based on SARS control experience, the most important PPE is mask.
According to material, common masks sold in the market can be roughly
divided to: gauze masks, cotton masks, activate carbon masks and medical
masks. The filtration rate of the first 3 types of masks is less than 20% for
particles with diameters between 0.1 ㎛~1.0 ㎛. Medical masks can be divided
into 3 types according to CNS14774 and T5017 standards: “procedure mask”
(flat mask), “surgical mask” and “surgical D-2 dust-proof mask” (level of N95
or above mask). Their filtration rates are 70%, 80%, and above 95% respectively.
Whether protection can be achieved depends on wearing a mask correctly and
performing a fitness test whenever possible. P100 semi-face respirator and
powered air purifying respirator (PAPR) are used for aerosol-generating
procedures when having close contact with patients (within 1 meter of distance)
with high frequency, or when performing endotrachel intubations treatment.
DOH and all local governments are both asked to stockpile PPE
respectively according to Articles 4.1.1.1 and 4.1.2.2 of Communicable Disease
Control Act. Medical facilities also have to stockpile sufficient PPE by
themselves according to Article 20 of the same law.
- 61 -
6.2 Implementation Strategies
6.2.1 Estimation of PPE Demand
The main objective of estimation for the overall demand is to provide
reference for drafting inter-entity supply contracts of related items and for
estimation of related budgets. Estimation is done by using FluAid2.0 and
FluSurge1.0 software developed by USCDC to predict the curve of infections,
out-patient visits, hospitalizations, mild cases, serious cases and death numbers
under the scenario of influenza pandemic with an attack rate of 25% to 35%,
from which demands for various epidemic control materials can in turn be
derived. Among them, the demands of the Medical Network for Prevention and
Control of Infectious Disease in early phases are calculated according to
medium attack rate (25%). Demands of large care facilities in later phases with
the most serious epidemic situation are calculated according to high attack rate
(35%). Parameters of PPE rundown are determined by referring to related WHO
guidelines and the advice of infectious disease experts in our country.
6.2.2 Determination of Safety Stockpile
According to the above estimation and the PPE market conditions (both
manufactured and imported), once pandemic shifts to phase C, there will be
significant difference between supply and demand of all major types of PPE in
Taiwan. Chart 6.1 illustrates the integration of the difference, which is the safety
storage volume. In addition, based on the quantity of each PPE item consumed
by the central government, local governments and medical facilities in the recent
two and half years after SARS epidemic, safety stockpile volumes at these three
levels have been established. Central government’s stockpile is for epidemic
control and emergency dispatch. Local governments’ stockpiles provide for local
public health and epidemic control needs. Therefore, 25% of the total safety
stockpile comes from the central government, and local governments are
- 62 -
responsible for another 25%, with the remaining 50% of total safety stockpile
shared by medical facilities. Table 6.1 shows the estimations of safety storage
and distribution list.
Chart 6.1 Safe Stockpile of PPE
Table 6.1 PPE Stockpile and Allocation
Levels
Items
N95 equivalent or
higher-level masks
(pcs)
Surgical mask (pcs)
Flat mask (pcs)
Protection clothes (suit)
Central
Local
government governments
Medical
facilities
Total
500,000
500,000
1,000,000
2,000,000
1,750,000
1,750,000
3,500,000
7,000,000
75,000,000
0
200,000
200,000
0 75,000,000
400,000
800,000
6.2.3 Information Management and Monitoring
The goal of PPE management is not only to set up safety stockpiles, but
also to grasp real-time information about the dynamic changes in PPE stockpiles
to provide accurate parameters for the reference of decision makers. Stockpile
- 63 -
monitoring is used to manage abnormalities and to prevent gaps between
registered information and actual storage.
6.2.3.1 Real-time Information
1. In phase 0, each storage unit logs into Material Information System (MIS) at
least once every 2 weeks to upload updated information on use, replenish and
storage.
2. In phase A, each storage unit logs into MIS at least once a week to upload
updated information on use, replenish and storage.
3. In phase B and phase C, each storage unit logs into MIS everyday to upload
updated information on use, replenish and storage.
6.2.3.2 Stockpile Inspection and monitoring for Abnormality Management
1. Primary inspection: For those who did not log in within time limit or when a
shortage of storage is detected, the system will issue an automatic
notification email to the reserve manager on the first day. System
maintenance personnel will telephone to ask for improvement on the second
day.
2. Secondary inspection: For those who did not log in within time limit or when
a shortage of storage is detected, the local health bureau will intervene to
inspect from the third day to the ninth day.
3. Tertiary inspection: For those who have exceeded the log-in time limit or
have had a shortage of storage for over 10 days, the regional branch of CDC
will supervise the local health bureau in reinforcing inspection. Direct
intervention of inspection will be implemented when necessary.
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6.2.4 Reallocation and Delivery
6.2.4.1 Reallocation
1. Active dispatch: When central and local governments become aware of PPE
shortage in related units through MIS, active deployment will be arranged
after evaluating the reserve condition and confirming with the units with
shortage.
2. Application for dispatch: Those who have shortage in PPE reserve can apply
for dispatch from central and local governments. The application will be
either approved or rejected after evaluating the epidemic situation and
reserve condition. Hospitals can also apply for support materials from nearby
hospitals in similar way.
3. The payment for material deployment or the arrangement for free dispatch is
agreed between the supporting and the supported institutions unless
otherwise defined by law.
6.2.4.2 Delivery
1. Ordinary delivery: Ordinary delivery from central government to local
governments and hospitals is limited to 2 days after approval in main island
and 3 days for off-shore island. Nearby delivery from local governments to
medical facilities is in principle limited to 24 hours after approval. Ordinary
delivery timeline between hospitals is as agreed by both parties.
2. Emergency delivery: Emergency delivery from central government to local
governments and hospitals is limited to 24 hours after approval in main
island and 3 days for off-shore island. Nearby delivery from local
governments to medical facilities is in principle limited to 4 hours after
approval. Emergency delivery timeline between hospitals is as agreed by
both parties.
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3. The delivery can be carried out with civilian support. Requisition and
compensation can be processed when necessary according to “Epidemic
Control Materials Requisition Operation Procedures and Compensation
Method”announced on July 14, 2004.
6.2.5 Dealing with PPE Shortage
6.2.5.1 Reduce Expenditure
1. Suspension of PPE exportation: Taiwan has manufacturing capacity for N95
equivalent or higher level masks, surgical masks and isolation gowns. In
ordinary time, these products are mainly for exportation. Once there is
shortage of PPE, Ministry of Economic Affairs and Ministry of Finance can
enforce suspension of the exportation of related items.
2. Reuse: Although N95 equivalent or higher level masks, surgical masks or
isolation gowns are all disposable, and are in principle not to be reused, when
there’s a material shortage, they can be reused with limitation after cleaning
and decontamination and under safe situation. For example, before entering
isolation wards, wear a surgical mask over N95 mask and an isolation gown
over the protection clothes, and when leaving the ward, only the surgical
mask and isolation gown need to be replaced. In this way, consumption rate
of N95 mask and protection clothes can be slowed down.
6.2.5.2 Speed up Supply
1. Accelerate importation: Obtaining foreign resources with the help of
Taiwan’s representative offices aboard. Besides, Ministry of Finance and
Ministry of Economic Affairs will assist with rapid custom clearance.
2. Use of expired PPE: PPE stockpiled during the 2003 SARS outbreak
still be kept and used if they pass relevant examinations.
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can
3. Alternative: If surgical masks and procedure masks are not available, people
with low risk can wear cotton or gauze masks or active carbon masks,
because it can still block droplets spread from coughing.
4. Speed up manufacturing: The main restriction factor of mask manufacturing
is labor, and no complicated operation technique is required. If supply and
demand of mask is unbalanced, soldiers will be deployed to support the mask
manufacturing line.
5. Management and delivery of donated PPE: Central epidemic command
center will designate a responsible unit to manage donated PPE and their
delivery.
6.2.5.3 Stockpile and Release of Masks for Common Need
1. Central government will stockpile 34 million pcs of procedure masks in
advance to tackle panic buying.
2. Monitoring mask shortage:
(1) Vendor information--In the post-SARS period after 2003, CDC has
obtained market information of procedure masks from domestic
convenient stores every week.
(2) Supply information-- Since 2004, all manufacturers having signed a PPE
inter-entity supply contracts with CDC have provided international and
domestic market information.
(3) Information on needs-- MIS has a “Scheduled Receipts” monitoring
function. Once there are “Scheduled Receipts” to regional and higher
level hospitals or local health bureaus that have not been checked and
acknowledged within 1 month, an inspection and monitoring mechanism
will be implemented to understand the reason
(4) Market order-- When pandemic shifts to phase A1 or higher, Ministry of
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Economic Affairs and Fair Trade Commission will implement monitoring
on PPE market order and price fluctuation.
3. Release timing and price: When the Central Epidemic Command Center
decides to release its stockpiled procedure masks to regulate demand and
supply after evaluation, logistics and vendor spots in convenient stores set up
by Ministry of Economic Affairs will offer a channel for the public to acquire
qualified and reasonably priced procedure masks with convenience. The
release price and speed will be proposed by Ministry of Economic Affairs
and decided by Central Epidemic Command Center.
4. Delivery channels and time limits: Coordination center for mask deployment
to convenient stores planned by Ministry of Economic Affairs will send
vehicles directly to the central mask storage warehouse to get the masks. It is
estimated that within 24 hours after receiving the order of release, delivery
will be completed following existing delivery mechanism to more than 8000
convenient stores. Instruction of use is available on small-packaging masks.
Barcode is also available to facilitate selling in each retail convenience store.
6.3 Emergency Handling of Abnormality
6.3.1 Back-Up Personnel of PPE Reallocation
In response to high attack rate of influenza pandemic, should the current
material controllers be unable to carry out their duties, personnel familiar with
MIS system and PPW dispatch will be assigned to support . CDC planned to
complete simulation training and exercise on PPE dispatch for back-up
personnel before the end of October 2006.
6.3.2 Emergency Contact Points
Following units should set up emergency contact points to deal with
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emergency in PPE matters promptly. When Central Epidemic Command Center
was established and staffed, the contact points will be stationed at command
center or participate in dealing with emergency according to the operational
procedures of the mechanism and orders of the commander.
1. Fair Trade Commission, Executive Yuan
2. Industrial Development, MOEA
3. Department of Commerce, MOEA
4. Centers for Disease Control, DOH
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7. Maintaining Health Services
7.1 Rationale
During SARS period in 2003, there was no planning at the initial stage on
health-care facilities for infectious disease control responsible for receiving and
treating patients. Patients sought medical help everywhere, resulting in the
spread of SARS virus and nosocomial infection events. Some hospitals were
closed, which further caused the collapse of medical system, confusion of public
feeling and serious impact to social stability.
According to estimations, if the attack rate of influenza pandemic reaches
25%, 3,042,610 citizens in Taiwan will need out-patient service and the number
of hospitalization will reach 664,269. Assuming that the pandemic persists for
12 weeks, the demand for hospital bed will reach the peak in the 7th week after
onset of pandemic. 98%~124% of hospital beds of all hospitals in the whole
country may be occupied, which will greatly push out bed occupancy of other
diseases. Hospital beds of existing hospitalized patients cannot be cleared rashly
to be used by influenza patients. It will definitely result in collapse of medical
system.
To prevent the aggregations of large numbers of patients, which will result
in cross-infections and cause burden to medical facilities, all local governments
should plan in advance to bring the role and function of primary care settings
into full play. According to “Article 51 of the Communicable Disease Control
Act”, “community disease screening stations” will be set up when necessary.
Furthermore, the concepts of “stay home for self care” or “snow-day restriction”
can be introduced. Patients should be separated at the early stage of out-patient
visits according to pre-planned patient handling principle of human H5N1 or
influenza pandemic. According to “Articles 27 and 51 of the Communicable
Disease Control Act”, proper planning must be made for the use of hospitals in
Medical Network for Prevention and Control of Infectious Diseases, other
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hospitals and large care facilities, taking into consideration patients’ various
conditions and different medical resources in each area. Suspected (confirmed)
human H5N1 cases will be housed together and treated to prevent paralysis of
general medical systems.
A Chinese military aphorism goes: “To maintain an army for a thousand
days to use it for an hour.” This concept can be extended to manpower back-up
strategy for pandemic. A list of manpower back-up should be established, and
they should be provided with education, training and drill experience in
peacetime. It will be used to transfer and requisite personnel according to
“Article 51 of the Communicable Disease Control Act” and “Epidemic Control
Materials Requisition Operation Procedures and Compensation Method” at the
right time.
7.2 Implementation Strategies
There are 23 hospitals in Medical Network for Prevention and Control of
Infectious Diseases (around 9,000 beds, including 373 negative pressure
isolation beds and 158 general isolation beds). The capacity of the network can
only meet a small portion of hospitalization need, so health services for
pandemic require implementation of the following measures:
7.2.1 Primary Care Settings
In response to influenza pandemic, overall coordination within the medical
system should be taken into consideration to bring out maximum function of
epidemic control. When pandemic attacks, it should be avoided that a large
number of patients crowd into hospitals which results in nosocomial infection.
Patients with mild diseases should seek medical help from nearby clinics in
priority, so that the role and function of primary clinics can be brought out.
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Local governments should plan in advance the capacity, functions, responding
actions of medical facilities and clinics under their control. The role and function
of primary care settings should be brought into full play.
Primary clinics play the important role of 1st line epidemic control in the
entire medical system. Therefore these physicians should enhance their
understanding of the epidemic situation and control measures, including
reporting, sampling, delivery of samples and patient transfer procedures.
Medical staffs and all personnel should properly carry out self-safety protection
measures when examining patients. The public should be taught and requested
to comply with infection control instructions.
The “community disease screening stations” is another option to avoid
paralysis of health care system. Local governments should plan of related
arrangements of setting up community disease screening stations before Central
Epidemic Command Center elevates the pandemic situation to phase B. When
pandemic enters phase B, commander will decide whether community disease
screening stations will be set up according to epidemic situation at that time. If
yes, the set up should be completed within 1 week after announcement of
entering phase B and can be activated at anytime.
Local governments should plan in advance the responsible medical
facilities or large care facilities that can support with set up and transfer of
patients. Also medical manpower, medical information and logistic service
should be planned. For the reason of availability, it is suggested that places of
ordinary public activities be chosen. The number of stations to be set up is
decided according to geographical range, number of population and
characteristics. Inside the station it should be divided to observation area,
waiting area and examination area according to the concept of separation
management, so people can seek medical help with order to prevent cross
infection.
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7.2.1.1 Home Treatment
The planning for patients with mild diseases seeking medical help is centered
on the resources available in primary care settings. Primary physicians not only
play the role of medical care provider, but also the role of monitor. With the
introduction of the division concept, local health stations will assist the
integration of related clinics in the unit of neighborhood. Education to the public
will be reinforced to instruct them to go to neighborhood clinics when symptoms
occur.
It is suggested to separate outpatient visits to fixed visits and mobile visits.
For fixed visits, people go to clinics by themselves. First, a phone call is made
by the patient to the clinic to register for a visit. Nurses at the clinic will inform
the patient of the appointment to limit attending patients to a fixed number and
to maintain the space capacity in the clinic. Patients will be classified and
divided according to the patient definition formulated by Central Epidemic
Command Center. To proceed with patient division promptly, they can be
classified according to patient definition and their condition:
1. Non-influenza patients (treatment to be provided according to general
medical handling, but to be separated from flu patients)
2. Influenza patients with mild symptoms, subdivided into children, adults and
with or without other chronic diseases. Prescription sheets will be sorted by
different colors respectively to facilitate rapid prescription, so that patients
can go back home as soon as possible and adopt “stay home for self-care”
strategy.
During patient’s self-care at home, the local health station is responsible for
telephone interview. If necessary, the health station will notify local clinic
physicians and nurses form a home medical group to go to the patient’s home to
perform examination and diagnosis. Or clinic nurses can arrange a route of visit
to play the role of “gate-keeper of community health”. Besides, to prevent
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patients’ condition from worsening, clinic physicians must know clearly the
back-up hospital of the clinic and maintain smooth communication. A
comprehensive information platform is to be established for horizontal and
vertical patient transfer. Should patients’ condition worsen, they will be
transferred promptly for treatment.
7.2.2 Medical Network for Prevention and Control of Infectious Diseases
There are 23 hospitals in the network and 18 supporting hospitals
designated by the central government to be responsible for receiving, treating
and supporting human H5N1 influenza or pandemic influenza patients with
serious symptoms. All other medical facilities and community disease screening
stations will arrange transportation of patients fulfilling the pre-defined criteria
to the designated hospitals according to the “Principles for Transfer of Suspected
Cases of Pandemic Influenza”.
The 23 hospitals in the network and other hospitals that are selected for
requisition in the future should set up a hospital evacuation plan in response to
continuous increase of pandemic patients. Discussion should be made in
advance with the regional Command Center and Consulting Committee of the
Network for Prevention and Control of Infectious Diseases in the area where the
hospital is located. Evacuation plan should be drafted for evacuation of a certain
number of contracted beds (including both negative pressure isolation wards and
general isolation wards), evacuation by floor (area), and evacuation of the entire
hospital. Passage, back-up medical manpower, patient transfer and security
should also be considered as a whole.
According to Article 51 of the Communicable Disease Control Act, the loss
incurred by medical facilities or public places from being designated, dispatched
and requisitioned should be compensated properly, the administrative
procedures and compensation methods of which will be defined by the
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Department of Health (DOH). If there is loss of profit for hospital caused by
receiving patients designated by the regional commander of Medical Network
for Prevention and Control of Infectious Diseases, then DOH will subsidize the
loss within this period for the difference in profit from the same period last year
(excluding medicine and special material fees). In principle, the subsidy is
limited to 3 months, starting from the month of receiving patients until the time
of DOH announcement of no more epidemic situation. All related subsidy will
be paid by CDC.
7.2.3 Large Care Facilities
Large care facilities will be activated when the number of hospitalized
patients keeps increasing, causing shortage in isolation wards for severe cases
despite the execution of hospital requisition and evacuation strategies.
Considering the simple and crude equipment of such facilities in comparison to
hospitals, subjects received will mainly be hospitalized patients with milder
diseases.
Local governments should check and plan in advance the related measures
such as manpower, capacity, equipment and patient receiving route, etc. The
location better be somewhere far from urban areas, with good air ventilation and
spacious, with clean water source, compliant with related public health and fire
fighting regulations. Commanders of each region will activate large care
facilities according to epidemic needs and preparedness plans to receive
transferred patients from primary care settings, community disease screening
stations or out-patient service of general hospitals. If patients treated in a
hospital of the Medical Network for Prevention and Control of Infectious
Diseases are recovering, they can also be transferred to large care facilities for
subsequent treatment. Should the condition of cases in large care facilities
worsen from mild to serious, they will be transferred to a designated hospital
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immediately. Local governments should also complete measures such as facility
set-up and control mechanism in the surrounding areas as soon as possible. To
strengthen management of large care facilities, after activation decision,
responsible staff and organizations should be set up to maintain functioning and
related logistic supplies. They will also ensure smooth connection and
transportation between large care facilities, medical facilities and community
screening stations, so that the patient can receive treatment in the right facility
without delay.
Large care facilities should be divided and managed, such as administration
area (including nurse station) and receiving area. Receiving area should be
subdivided to area of pandemic patients and area of patients also having other
chronic diseases to be treated separately. For the planning of space and basic
equipments of large care facilities, refer to “Medical facilities set up standards”,
but negative pressure is not needed and there should be many windows which
can be opened for better ventilation.
7.2.4 Handling of Off-Shore Patients
When pandemic hits an off-shore island, commander ought to make
decisions on how the patients will be treated according to case condition,
epidemic situation, hospital capacity, risk of transfer and administration factor,
etc. Infected patients can be treated locally, be treated by medical group formed
under instruction of commander if necessary or be transferred to the Taiwan
main island. All measures in response must be planned in advance by the local
government in each off-shore island in view of epidemic development and local
capacity according to above mentioned principles, including agreement with
civilian airline companies for patient transfer, which is considered one of the
important response measures.
Drills and practices of all handling measures should be carried out and
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strengthened to familiarize relevant personnel with each response action, to
improve their ability to deal with emergency, and to enhance overall efficiency
in epidemic prevention.
7.2.5 Deployment of Medical Staffs
During pandemic, patients will increase rapidly in every setting, be it a
medical facility, large care facility or home treatment. Demand of medical
manpower will increase substantially. Local governments should plan in
advance the name list of medical manpower to support hospitals of Medical
Network for Prevention and Control of Infectious Diseases, large care facilities,
home medical treatment and community disease screening stations in response
to pandemic. They can be retired staffs of medical facilities, primary clinics and
health centers, trained nurse school students, other related manpower, or
patients’ relatives (for stay home self-care). They should be informed and be
trained before and during the event, and to be dispatched by commanders in
pandemic. If cross-regional medical manpower support is needed, commander
of the area in need can ask for dispatch from commander of another area after
obtaining approval from the Commander in Chief. Bureau of Medical Affairs of
DOH or Ministry of National Defense can be invited to form Medical
Manpower Deployment Committee when necessary to decide dispatch operation
directions. If medical capacity is exceeded, all heath care facilities will adjust
the ratio and shifts of medical care workers and adjust current medical operation
procedures to make full use of each material and human resource. Central and
local governments will encourage people not to seek medical help when not
necessary and to perform “stay home self-care”.
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7.2.6 Compensation for Personnel Deployment and Requisition
Local governments must draft preparedness plan in advance in terms of
designation or requisition of medical facilities or public venues to setup
temporary care facilities. Civilian medical staffs will also be dispatched to assist
in care work. Responsible organizations will be subsidized and compensated
afterwards according to “Set up and compensation methods of temporary
infection medical facilities” and “Epidemic Control Materials Requisition
Operation Procedures and Compensation Method”. The central government will
offer subsidies when necessary. If the hospitals in Medical Network for
Prevention and Control of Infectious Diseases are affected by receiving patients
designated by commander in response to epidemic activation, the shortfall in
NHI revenue will be subsidized according to “Infectious Disease Prevention and
Control Network cooperation contract”.
For more information on health services, refer to “Medical Network for
Prevention and Control of Infectious Diseases guidelines”(全球資訊網/專業人
仕/應變準備/「感染症防治醫療網」/95 年度第三期感染症防治醫療網/地方
版-95 年度感染症防治醫療網工作指引).
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8. Response and Execution
8.1 Phase 0 (domestic) and Phase 3 (international)
At this time, there’s no possible cases of human H5N1 in our country; there
are foreign cases but without efficient and sustained human-to-human
transmission. Global cooperation and routine border control will continue in an
effort to stop new virus from entering our country. Monitoring and preparedness
should be started in our country. New virus strain should be prevented from
occurring domestically at the same time. Key points of epidemic control are:
1. Protect the health of poultry and animal husbandry workers
(1) Monitoring of animal epidemic is performed to grasp the epidemic
situation at any time, in order to promptly prevent animal epidemic from
spreading.
(2) Strengthen self protection concept of poultry and animal husbandry
workers.
(3) Reinforcement of seizing smuggling of fowls.
(4) Implementation of protection, health
management
and
antiviral
prophylaxis to epidemic control staffs when animal epidemic occurs.
(5) Enhance hygiene management of wet markets to reduce risks from on-site
butchery and selling of live fowls.
2. Border control
(1) Educate people to avoid contact with fowls and their excretion when
traveling in HPAI-affected areas.
(2) Continue to monitor temperature of incoming passengers using infrared
thermal monitor. Evaluate infection risks of passengers with abnormal
temperature and handle properly.
(3) Educate passengers from countries with human H5N1 cases of the
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concept of self monitoring.
(4) Perform reporting and sampling according to the reporting criteria
announced by DOH.
3. Surveillance
(1) Perform reporting and sampling according to the reporting criteria
announced by DOH.
(2) Once
abnormal
influenza
cases
with
serious
symptoms
and
influenza-like illness clusters are reported, investigation should be
performed. Sampling and testing will be done to clarify the pathogen if
necessary.
4. Response of medical system
(1)Perform revision, education & training, and inspection of infection control
measures
(2)The hospitals of Medical Network for Prevention and Control of
Infectious Diseases conduct drills on patient management and evacuation.
(3)Local government designates large care facilities.
5. Central and local governments have to stockpile antivirals and PPE. Vaccine
strategies and stockpile are prepared by central government.
6. Communication: The core task is to strengthen public education of
government preparedness, respiratory hygiene and cough etiquette.
8.2 Phase A1 (domestic) and Phase 4 (international)
At this time, there are no possible cases of human H5N1 in our country.
There are small-scale, localized outbreaks of limited human-to-human
transmission aboard. The infection ability of virus increases, but it is not yet
easily adaptive to human. In addition to the establishment of central epidemic
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command center, the most important affair is to intensify quarantine measures.
Key points of epidemic control are:
1. Border control
(1) The initial soft-toned education will switch to compulsory implementation.
Passengers and air crew entering from countries in phase 4 will be
requested to perform health self-management and be followed up by the
local authorities.
(2) Passengers entering from affected countries and with suspected human
H5N1 influenza symptoms will sent to medical facilities for diagnosis,
examination and sampling.
(3) Enhance education of dealing with emergency to airport personnel.
(4) Preparation of facilities for centralized quarantine of incoming
passengers.
2. Surveillance
(1) Perform reporting, sampling and testing according to reporting criteria
and related regulations announced by DOH, with reinforcement of
protection education to staffs performing sampling.
(2) Closely
monitor
international
epidemic
situation,
and
enhance
communication with affected countries to grasp latest conditions.
(3) Strengthen understanding and willingness of case reporting on the part of
physicians and managers of surveillance institutions to enhance the
timeliness and correctness of every surveillance system.
3. Response of medical systems
(1) All health care facilities have to strengthen precaution measures. Local
health authorities set up supervision and inspection team to ensure
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infection control measures are carried out.
(2) The hospitals of Medical Network for Prevention and Control of
Infectious Diseases ensure preparation regarding patient management and
hospital evacuation are completed.
(3) Local government ensures large care facilities are truly usable.
4. Complete preparedness of antivirals, vaccines and PPE.
5. Communication: Communicate public health messages to overseas
Taiwanese living in affected areas, promote public awareness of border
quarantine, and educate people about health self-management.
8.3 Phase A1 (domestic) and Phase 5 (international)
At this time, there are no possible cases of human H5N1 in our country.
However there are large-scale foreign outbreaks of human-to-human
transmission. Although the epidemic is localized, virus adaptation to human
increases. The most important affair at this stage is to block the new virus from
entering into our country. Key points in response are:
1. Border quarantine
(1) Issue travel warnings to suggest our people delaying traveling to affected
countries if not necessary.
(2) Decide the time of activation of centralized quarantine measure on
incoming passengers. Passengers from countries with large-scale
human-to-human clusters will be arranged to undergo health observation
in designated isolation facilities. Should related symptoms occur during
observation period, examination and diagnosis will be performed
immediately to clarify pathogen and provide proper care.
(3) If passengers from affected areas already have fever or related symptoms
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when entering our country, they will be transferred to a hospital
immediately.
(4) Airline companies must implement health management on air crew from
affected areas.
(5) If capacity of centralized quarantine facilities for incoming passengers is
exceeded, alternatives will be implemented such as home quarantine.
(6) Whether flight restriction will be implemented for affected areas will be
evaluated of its feasibility and necessity according to epidemic situation
before any decision made.
2. Surveillance
(1) Perform reporting, sampling and testing according to reporting criteria
and related regulations announced by DOH. The latest information
regarding
clinical
symptoms
and
transmission
route
will
be
communicated to physicians and staffs performing sampling.
(2) Closely
monitor
international
epidemic
situation,
and
enhance
communication with affected countries to grasp the latest conditions.
(3) Strengthen understanding and willingness of case reporting on the part of
physicians and managers of surveillance institutions to enhance the
timeliness and correctness of every surveillance system.
3. Response of medical systems
(1)All health care facilities have to strengthen precaution measures. Local
health authorities set up supervision and inspection team to ensure
infection control measures are carried out.
(2)The hospitals of Medical Network for Prevention and Control of
Infectious Diseases ensure preparation regarding patient management and
hospital evacuation can be operated at ant time.
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(3)Local governments ensure that large care facilities can be operated at ant
time.
4. Distribution mechanism of antivirals, vaccines and PPE is ready and awaits
orders.
5. Communication: Announce policies of quarantine and isolation.
8.4 Phase A2 (domestic) and Phase 3~5 (international)
At this time, single or several possible cases of human H5N1 appear in our
country, which might be the result of importation, domestic fowl-to-human
transmission, or lab-acquired infection. Global pandemic alert may be at phase 3,
4, or 5. Each epidemic control measure will be the same with phase A1
(domestic) according to different international phase. In addition, the
transmission must be blocked to prevent domestic spread from a single case.
Key points in response are:
Response action in communities with possible H5N1 cases
1. Case investigation
(1) Interview with patients about contact history before falling ill to find out
possible source of infection.
(2) Interview with relatives and other contacts to know about their late travel
history and health condition, and to administer antiviral prophylaxis and
hygiene education.
(3) Reviewing medical records to obtain clinical information.
(4) Analyze investigated information to proceed with description of
demography, occupation, exposure history, incubation period and
transmission mode (to determine if it’s human-to-human transmission, if
they are infected by common source).
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2. Patient management: Treatment in air isolation wards.
3. Enforced hygiene education: Hygiene education will be reinforced aiming at
communities with reported patients to make community public understand
characteristics of virus, self-protection measures and the correct way to seek
medical help, and to avoid panic. Community volunteers will be mobilized to
assist when necessary.
4. Strengthened case finding: Search thoroughly within patient’s activity range
for suspected cases and perform sampling and testing. Intensifying
monitoring function of medical facilities within the affected community.
5. Contact tracing: Asymptomatic contacts will be administered with antiviral
prophylaxis. Home isolation must also be implemented and to monitor health
condition daily.
6. Strict infection control measures are implemented in community medical
facilities. Caregiver of patients wears PPE.
7. Environmental cleaning and disinfection of home
8. If the infectious source is animal, then all animals within a specified range of
the source must be culled and sterilized thoroughly.
National response action
1. Central Epidemic Command Center monitors epidemic situation daily. The
change in domestic pandemic alert level will be announced in appropriate
opportunity according to epidemic development.
2. Reinforce education of maintaining hand hygiene, respiratory hygiene and
cough etiquette.
3. Strengthen surveillance in the entire country.
4. Combine all monitoring information to evaluate the transmission ability of
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the virus.
5. Decide if further community control measures need to be implemented
according to epidemic situation.
6. Report related information to WHO.
8.5 Phase B (domestic) and Phase 5 (international)
At this time, small-scale human H5N1 influenza clusters have occurred
domestically, and the international pandemic alert may be at phase 5. The most
important affair of this period is to prevent small-scale clusters from spreading.
Rapid containment should be implemented.
Rapid containment
If sufficient antivirals are available and food, daily necessities, medical care
and emergency services can be normally provided for in the affected community,
Central Epidemic Command Center will decide to carry out rapid containment
measures. [14] Execution key points are:
1. First stage
(1) Active surveillance to monitor change of epidemic situation, collect
information on geographical spread, and evaluate necessity to revise
containment measures. Also collect recent travel information of patients
to evaluate the necessity of enforced surveillance in other areas.
(2) Identify the social network and travel history of confirmed patients and
their contacts. Contacts should be tracked for at least 7 days.
(3) Administer antiviral prophylaxis to contacts. Request them to comply
with public health measures at the same time of drug administration.
(4) Monitor contacts. Inform them of initial symptoms to pay attention to,
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teach them how to measure temperature and monitor their own health
conditions, ask them to report immediately when symptoms occur, and
visit or telephone daily to confirm the health condition of contacts.
(5) Medical facilities must comply with infection control measures suggested
by WHO and DOH.
(6) Communication: Reduce panic of people in containment areas, and ask
them to comply with government instructions.
2. Second stage
(1) People in containment areas implement home isolation to the utmost and
prevent unnecessary social contact.
(2) Consider compulsory home quarantine in the following situations and
provide food, means of communication, psychological support and
regular medicine (especially to those with chronic diseases):
①A group of people with previous exposure to virus, for exampl e at
home, work places or schools, or in a clearly identified public
gathering.
②Exposure occurred in a definite spot or inside a building (such as
hospitals or apartment buildings).
(3) Stop large gathering activities and consider restriction on public
transportation.
(4) Dispatch antivirals and administer mass prophylaxis to people within
containment range.
(5) Communication: Reduce panic of people in containment areas, and ask
them to comply with government instructions.
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National response
1. Border control
(1) Entry: Maintain “Border control” measures of phase A1 (domestic) and
phase 5 (international).
(2) Exit: Implement fever screening and health surveillance measures on
out-bound passengers. Those with abnormal temperature must hold a
diagnosis certificate excluding human H5N1 influenza issued by an
airport physician, regional (or higher-level) hospital or testing authority
for clearance to travel abroad.
2. Surveillance
(1) Set up reporting criteria according to WHO suggestions and communicate
related information to physicians immediately.
(2) Strengthen understanding and willingness of case reporting on the part of
physicians and managers of surveillance institutions to enhance the
timeliness and correctness of every surveillance system.
3. Response of medical system
(1)All health care facilities have to strengthen precaution measures. Local
health authorities set up supervision and inspection team to ensure
infection control measures are carried out.
(2)The hospitals of Medical Network for Prevention and Control of
Infectious Diseases start receiving H5N1 infection cases.
(3)Local governments ensure that large care facilities can be operated at ant
time.
4. Reinforce education of maintaining hand hygiene, respiratory hygiene and
cough etiquette.
5. Decide if further community control measures need to be implemented
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according to epidemic situation.
6. Communication: Reduce panic of all people.
8.6 Phase C (domestic) and Phase 6 (international)
Once WHO announce phase 6 of pandemic, phase C will be announced
domestically. At the initial stage of this period, if epidemic is still localized in a
portion of communities rather than the entire country, then it’s possible to
implement rapid containment described in the previous section. If virus spread
becomes uncontrollable and coverage expands to the entire country, then the
below national measures will be implemented.
1. Border control: Maintain fever screening measures on out-bound passengers
in airports.
2. Surveillance: Sampling and investigation of every case will be stopped
depending on the epidemic situation, but specimen collection will still be
performed for a small portion of patients with symptoms to understand the
activity and variation of the virus domestically.
3. Response of medical system
(1) All medical facilities thoroughly implement infection control measures.
(2) The hospitals of Medical Network for Prevention and Control of
Infectious Diseases receive H5N1 infection cases.
(3) Local governments have already completed the set up of large care
facilities and deployment of personnel, materials and equipments. Once
the capacity of hospitals in Medical Network for Prevention and Control
of Infectious Diseases in a city or county is exceeded, large care facilities
will be activated.
4. Reinforce education of maintaining hand hygiene, respiratory hygiene and
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cough etiquette.
5. Social distance measures will be implemented accordingly: such asschool
closure, flexible work, forbiddance of public gatherings and control of public
place capacity, etc.
6. Maintain essential services: Maintain supply of water, electricity, energy and
communication, etc. In principle, functioning of business will be maintained.
However, attention must be paid to infection control measures.
7. Council for Economic Planning and Development observes and evaluates the
impact of pandemic on internal and international economies, and draft
internal economy recovery plan accordingly.
8. Risk communication.
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9. Risk Communication
9.1 Correct Consumption of Poultry Products
9.1.1 Rationale
There has been no case infected by H5N1 virus through eating poultry or
poultry products so far. Human cases all lived in HPAI-affected countries, and
most of them had direct contact with ill fowls. However from the results of virus
research, safety management of food is still necessary to current affected areas.
Ordinary avian flu virus only appears in respiratory and digestive tracts of ill
fowls. But HPAI viruses, including H5N1, may probably appear in any part of ill
fowls (including meat), and they can still exit in low temperature. Research
shows that H5N1 virus in fowl excretion can exits 35 days in 4℃ and 6 days in
37℃. Therefore it cannot be excluded entirely that virus will spread with fowl
meat selling and transportation.[15]
Especially in some Asian countries, people in remote area are used to
breeding fowls and animals at their backyards. They kill, eat and sell fowls and
animals, but lack self-protection concepts. And communication of information is
not easy. They are regarded as the group with highest risk of H5N1 infection. In
industrialized production and marketing system, ill fowls will not leak into food
chain because of biological safety control measures. Therefore WHO and World
Organization of Animal Health (OIE) all suggest that biological safety control of
fowl-breeding industry and fowl goods production and marketing systems be
strengthened in countries with H5N1 epidemics.[16]
9.1.2 Implementation Strategies
Until now, there has not been a case of local fowl infected with H5N1 virus
in Taiwan. Therefore general public don’t have to be panic over consumption of
fowl products. General cooking procedure (heating over 70℃ of every part) is
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able to de-activate H5N1 virus. Suggestions of food safety by WHO are: Avoid
eating raw poultry meat and eggs, separated preparation of raw and cooked food
to prevent contamination, and wash hands frequently during food preparing
process, etc. The above suggestions are sufficient in the current stage when
traveling to affected areas.
Besides, in related symposiums of WHO and OIE, the selling of fowls in
wet markets is a higher risk situation being mentioned frequently. Many Asian
countries are used to consumption of un-frozen meat, and there are often
multiple types of live fowls sold in wet markets. It has been found that part of
water fowls (such as ducks) can excrete large quantity of virus but no symptoms
appeared. Therefore the risk of virus spread in wet markets cannot be taken
lightly. Organizations such WHO also suggest to reinforce hygiene management
in wet markets.[16]
To protect fowl-related industries in our country and health of the public,
we should prepare in advance to prevent future impact even though there is no
H5N1 virus invasion domestically. Executive Yuan established “Executive Yuan
Special Committee for Forbiddance of Live Fowls Selling and Butchery in Wet
Markets” in 2006 to study related measures. It was decided that butchery and
selling of live fowls will be forbidden starting in April 2008. After half year of
promotion, beginning from 1 October, 2008, those who cull live fowls in and
around wet markets and at stores/homes will be fined up to NT$500,000
according to Animal Husbandry Law. Bodies of killed fowls will be confiscated
and destroyed. In addition, DOH announced on 7 November 2006 that once the
HPAI virus subtype H5 or H7 has been detected in domestic poultry flocks,
poultry sale in and around wet markets and at stores/homes will be completely
banned.
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9.2 Strengthening of Respiratory Hygiene/Cough Etiquette
9.2.1 Rationale
Respiratory hygiene and cough etiquette can be applied to all patients with
respiratory symptoms. There is no systematic research of the effect of covering
while coughing and sneezing and cough/sneezing patients wearing masks on
control of pathogenic droplets and secretions of respiratory tract. But methods
that limit the spread of respiratory droplets should reduce transmission in theory.
Wearing masks may be difficult for some patients, therefore the key point should
be cough etiquette.[13]
9.2.2 Implementation Strategies
In the ”Avian influenza, including influenza A (H5N1), in humans: WHO
interim infection control guideline for health care facilities” revised by WHO in
24 April 2006, there are descriptions regarding respiratory hygiene/cough
etiquette for health care facilities. These were subsequently reviewed and agreed
to at the 9502nd Consulting Committee of Hospital Infection Control in Taiwan
on 6 June 2006. They are:
1. Educate all people about respiratory infection symptoms to:
(1) Cover nose and mouth with tissue paper when coughing, and then discard
the tissue paper into a rubbish can;
(2) Wear a mask if bearable;
(3) Wash hands after contact with respiratory secretions (using alcohol-based
hand rubs or soap and clear water);
(4) Keep a distance of at least 1 meter (3 inches) from other people.
2. Promote respiratory hygiene/cough etiquette in medical facilities:
(1) Educate all health care providers, patients, relatives, and visitors. Avoid
respiratory droplets to prevent spread of influenza virus or other
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respiratory tract virus;
(2) Post notices requesting patients and relatives to report respiratory tract
symptoms actively and comply with respiratory hygiene/cough etiquette;
(3) Post notices requesting people with respiratory tract symptoms to avoid
visiting the sick in medical facilities;
(4) Provide masks, tissue papers and alcohol-based hand rubs. Locations in
which patients gather, such as waiting room, should be provided with
priority;
(5) Provide hand-washing facilities and resources (such as alcohol-based
hand rubs and hand-washing equipment) in general areas. Locations in
which patients gather, such as waiting room, should be provided with
priority.
9.3 Correct Usage of Respirators and Medical Masks
9.3.1 Rationale
Prevention and control of respiratory diseases, such as influenza, should
consider the 3 factors of infectious diseases, which are pathogen, transmission
pathway and susceptible host. In general, the closer of prevention work to the
source of infection, the higher the efficiency and the lower the cost. Therefore
public health interventions such as isolation, quarantine, closing of schools and
restriction of gatherings should be considered with top priority. Next is
installation of local exhaust ventilation, separate patient transport route, and air
circulation, etc. When above measures are not entirely effective, measures such
as patients wearing masks, respiratory hygiene/cough etiquette or frequent
hand-washing may be helpful. Personal respiratory protection is the last line of
defense.
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The important modes of transmission of influenza are mainly “droplet
infection” and “contact infection”. Even though the probability of “airborne
transmission” is not clear, it does have some roles. There are two ways to
prevent influenza virus infection: (1) Using filtering materials to trap microbial
particles and let clean air pass through to reduce infection risk of wearer, for
example respiratory protection gear such as N95 or higher level masks; (2)
limit the spread of exhaled droplets to affect outer air, such as medical masks,
etc.
9.3.2 Implementation Strategies
9.3.2.1 Usage of Medical Masks
Medical masks are originally designed to protect patients in the operating
field from contaminants generated by healthcare staffs. It can also be worn by
patients in preventing spreading virus-containing droplets or mucus to the
environment by coughing, sneezing or talking, in order to reduce the probability
of infectious disease spread. Disposable masks can be generally divided to 3
layers: the outermost layer is the protective payer against body fluids, the
innermost layer is the supporting layer, the middle layer is the main filtering
layer. There are roughly 3 mechanisms of removing particles from the air stream:
larger particles are trapped because of inertial impaction, smaller particles are
trapped because of diffuse or electrostatic attraction. There exists a range at
which no mechanism is dominant. In this range, known as the Most Penetrating
Particle Size(MPPS), generally between 0.1～0.3 ㎛, the efficiency of the
filtration medium is at its minimum.
The diameter of influenza virus is small (0.08~0.12 ㎛). But it usually
adheres to cell fragments or droplets with larger diameters when spreading via
coughing, sneezing and talking, making it easier to be trapped by masks.
- 95 -
Most masks are designed with colored outer layer which is liquid-resistant.
The correct way to wear a mask is to let the colored layer facing out. If there is
a pliable mental nosepiece, wear the mask with nosepiece facing out and on top.
Adjust the sheet metal conforming to the shape of nose after wearing it to
ensure fit of the mask.
9.3.2.2 Usage of N95 or Higher Level Mask
N95 equivalent or higher level masks can block particles of any diameter to
the degree of greater than 95%. As for filtering efficiency, N95 equivalent or
higher level masks are better than medical masks, which are in turn better than
woven cloth masks. In terms of of shape, the entire filtering media of
“3-dimentional cup shape” can be utilized. As for “flat” ones, only surface near
nostrils can be utilized, not the part that sticks to the cheeks. As a whole, the
protection effects of “3-dimentional cup shape” N95 equivalent or higher level
masks are superior to “flat” medical masks. Therefore it is suggested that first
line medical staffs at high risks use N95 equivalent or higher level respirators.
To achieve the goal of protecting wearers, besides high filtering efficiency
of mask itself, the fit to the face is an important factor. Without proper fit, the
protective function cannot be brought out even with the best protection gear.
Therefore, “fit testing” is the first lesson of using respiratory protection gear.
From 2004 to 2005, Taiwan CDC cooperated with Institute of Occupational
Safety and Health under the Council of Labor Affairs to promote fit test for
medical staffs in medical facilities and to choose appropriate personal masks.
The fit test needs to be performed at least once a year. When a wearer
gains/losses more than 10% of weight, or if there’s significant change in the
shape of the face, the test will be performed again. Facing a huge number of
medical care providers in the whole country, the fundamental solution is that
the department responsible for labor safety and health in each medical facility
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is equipped with “quantitative respirator fit testers” and a complete respiratory
protection program to provide timely service. In addition, medical staffs should
perform “fit check” every time when wearing a mask to make sure the fit of
masks. Cover the mask with both hands and give a puff, and the air should not
leak from the cheek part in contact with the mask.
9.3.2.3 Selection of Masks
Medical staffs should be aware of risk concept and choose appropriate
respiratory protection gear according to extent of environment contamination
and exposure probability. N95 equivalent or higher level masks provide general
medical staff with sufficient protection. But for medical staffs taking care of
infectious patients and/or performing aerosol-generating therapies, such as
endotracheal intubation, suctioning, nebulizer treatment, bronchoscopy and
cleaning of discard, their risk of infection increases because patients may cough
or even throw up when their throat are stimulated. They should choose
protection gear of higher standards. Generally, higher level of filtering materials
can be used, such as N100 or P100. Half-face or whole-face type of gear which
is more fitted should also be considered. Even the more protective and
comfortable powered air-purifying particulate respirators (PAPR) can be
considered. It provides more complete protection for first line medical staffs and
decrease infection probability to the lowest.
Disposable masks are suggested not to be used repetitively. During SARS
period in Asia, surgical masks were worn over N95 or higher level masks when
quantity of masks was not sufficient. Surgical masks were discarded after each
use. N95 masks or higher level of respiratory gear were stored in clean and
ventilated environment to prolong its usage. A prerequisite is that N95 or
higher level masks are well fitted, otherwise flat masks worn outside will
increase breathing resistance and probability of leakage. Pay attention to the
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order of wearing and taking off to prevent touching the outer layer of masks
which might have already been contaminated. It is best to clean hands by
washing hands or sterilization before and after taking off masks.
Since the beginning of 2005, many health departments, companies or
consumers has started storing every type of epidemic prevention materials.
Mask manufacturers also speed up manufacturing to meet orders from
everywhere. Taiwan CDC urges medical facilities, public/private organizations
and the public everywhere to start storing an appropriate quantity of masks to
prepare for epidemic.
9.3.2.4 Clarification of Related Concepts
9.3.2.4.1 Transmission Routes of Influenza Virus
We must know the transmission pathway of the disease in order to develop
effective pandemic prevention/treatment plan. Even though the virus strain of
next pandemic has not appeared, but experts all agree that once pandemic occurs,
its transmission pathway should be the same with seasonal flu. There are 3
modes of transmission of seasonal flu:
1. Droplet transmission
The conjunctivae or mucous membrane of a susceptible person gets in
contact with droplets (usually with diameter >5 ㎛) from virus carrier or
infected people. These droplets vary in diameter. Their time of suspension in
the air also changes from diameter, sedimentation rate, relative humidity and
air currents. Usually particles with diameter >5 ㎛ will fall to the ground
within 1 meter (3 inches) after staying in the air for a short period of time.
Some researches show that droplet transmission is the major transmission
pathway, especially smaller particles. Therefore, measures like respiratory
hygiene/cough etiquette plus disposable tissue paper and frequent
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hand-washing of both infected and exposure people are important ways to
inhibit the transmission of flu virus. Air-conditioning and ventilation is not
important for the prevention of droplet transmission because larger droplets
will not float in the air for a long time.
2. Contact transmission
Direct (skin-to-skin) or indirect contact (contact with contaminated
objects) has been suggested as transmission factors in some studies. So
frequent hand-washing using soap and water or alcohol-based hand gel is an
important method to limit virus transmission through contact.
3. Aerosol transmission
It occurs by dissemination of either through airborne droplet nuclei or
small particles containing the infectious agents. Particles with diameter <5 ㎛
will form droplet nuclei after surface moisture vaporizes. The sedimentation
rate will slow down and can float with air current for a longer time. If
pathogen is still active, it will cause infection after inhalation by healthy
people.
Divided by 5 ㎛, infection caused by particles >5 ㎛ is called “droplet
infection”; infection caused by particles <5 ㎛
is called “airborne
transmission”. Although evidence of airborne transmission of flu virus is
limited, studies in animals and humans have raised significant concerns that
airborne transmission is a potentially important mode of transmission for
some infectious agents. Several therapeutic steps that produce aerosol (such
as intubations, suctioning, nebulizer treatment and bronchoscopy) could
increase the potential for transmission of droplet nuclei. This probability
makes consideration of aerosol protection an important part of infection
control planning.
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9.3.2.4.2 Medical Mask Is Not a Respiratory Protection Gear
According to CNS defined by Bureau of Standards, Metrology and
Inspection under the Ministry of Economic Affairs, the definition of respiratory
protection gear is: the general name of personal protection gear worn by
individual in harmful environmental air to prevent respiratory harm. Masks that
are well known to medical staffs and the public, such as medical masks, surgical
masks, procedure masks, active carbon masks and cotton masks, etc, are not the
same in protection effects and application range though they all possess
nose/mouth coverage.
Medical mask is not a kind of respiratory protection gear, and does not
require a fit test. Medical masks may be used as barriers against disease
transmission by fluids, especially blood, and some large droplets, and they are
designed to prevent release to the environment of large droplets generated by
the wearer. They are not designed or approved for the purpose of protecting
the wearer against entry of infectious aerosolized particles. Medical masks are
divided to 2 types: surgical masks or procedure masks.
1. Surgical masks: They are suitable to be used by medical staffs in surgery,
laser, isolation, dental department or other medical procedures. The main
purpose is to prevent dissemination of microbes, body fluids and biological
particles between patients and medical staffs. They can be divided to
flat-pleated, duck-billed shape, cone shape or other. The medical mask is
secured to the wearer’s head and face by drawstring, ear loop or head ties.
Masks with splash visors have an attached antifog-treated plastic shields.
There should not be an exhaust valve in medical masks. Surgical masks must
pass FDA testing, and are only available in adult sizes.
2. Procedure masks: Flat or duck-billed shape, fastened to the head with ear
loops. Splash-proof to some degree, but no testing required. Available in
children and adult sizes.
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9.3.2.4.3 Recommendations on Using Masks for Common People
If people develop cold or cough symptoms, a mask should be worn. The
microbe will transmit to the environment and to others through droplets of the
respiratory tracts. In addition, performing health self-management, resting at
home as much as possible, staying away from work or class, not going to public
places, washing hands frequently and establishing good respiratory hygiene and
cough etiquette are all self-loving and family-loving behaviors that also show
respect to others.
To avoid transmission through droplets to others, masks can be considered
(to prevent expiring droplets). It not only prevents transmission of droplet, it
also reduces probability of virus spread through unnecessary hand contact with
droplets.
Besides, people working in poultry farms better wear a mask to protect
themselves.
Table 9.1 Comparison of Product Specifications between Respirator and
Medical Mask
N95or higher level mask (N95
Filtering Facepiece Respirator)
Medical Mask
Intended use
Decrease inhalation of particles Prevent expired droplet
<100 ㎛ in the air by wearer
contamination by wearer to
protect patients undergo
surgeries and operating
personnel
Use limitations
Consideration includes
One time use
prediction of contamination,
breakage, deformation, filth,
odor, increase of breathing
resistance, etc. Can only be used
beyond 8 hours proving that
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filtering efficiency will not
decrease after prolonged use,
and filtering material load
<200mg
Certificate
requirements
Passing the most basic level of Reviewed by FDA.
qualified dust-proof mask using Marketed with approval
42CFR Part 84 method of
NIOSH
Filter elements
Not to be replaced
Not to be replaced
Filtering
efficiency
Protection efficiency of
sub-micrometer particles more
than 95%
Filtering efficiency more
than 95% for bacteria
Testing aerosol Sodium chloride particles with
and particle size Mass Median Aerodynamic
Diameter (MMAD) of about 0.3
㎛
Polystyrene latex sphere test
aerosol around 0.1 ㎛ and
Staphylococcus aureus
filtration test, per America
Society for Testing and
Materials(ASTM) standard
Airflow rate
85 L/min (liters per minute)
28.3 L/min
Respiratory flow speed of
general middle-intensity worker
is around 30 L/min.
Therefore 85 L/min is the
respiratory flow of high
intensity.
Test aerosol
Must undergo charge
Unneutralized test aerosol
neutralized test aerosol to
achieve Boltzmann balance to
prevent particles be attracted to
electrostatic filtering material,
causing testing error
Preconditioning N series of filtering materials
must be placed in environment
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No preconditioning
of 38℃ and 85% relative
humidity for 24 hours before
testing, to know the influence of
high temperature and humidity
environment to filtering
materials.
Fit test
Performed at the first selection None
annual fit test required
Fit check
Required with each use
Size
Some brands available in 3 sizes Only 1 size generally
available. Smaller masks
tend to leak more.
None
Note:
1. N95 mask is the most basic level of qualified dust-proof mask passing 42CFR Part 84 test
of NIOSH. Not only trapping efficiency of mask is tested, it also ensures the procedures
and quality to a fixed extent. Therefore N95 certification cannot be marked only with
same trapping efficiency. The most important is to be certified by US NIOSH (or other
certification system).
2. N95 is the most basic level of US dust-proof masks testing standard (42CFR Part 84). In
other words, from the protection view, masks if the same or higher levels can also be used.
WHO listed all levels N95, N99, N100, R95, R99, R100, P95, P99, P100 within 42CFR
Part 84 (dividing dust-proof masks into N, R, P types, with 3 levels of 95%, 99% and
>99.7% respectively) and FFP2, FFP3 within EN 149:2001 standard of EU standard as
masks of choice in “Guidelines of Infection Control in Response to SARS Hospital
Infection”. In addition, qualified masks certified by other countries of the same standards
described above are also accepted (N/R/P 95/99/100 or FFP 2/3 or an equivalent national
manufacturing standard).
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Table 9.2 Comparison of Functions of Respiratory protection Gear and
Masks
Masks available in the market Function
Respiratory protection gear (all 
those N95 or higher level
masks certified by NIOSH or
higher
level
respiratory
protection gear)
Block inhalation of particles<100 ㎛
Surgical D2 dust-proof mask  Block inhalation of particles<100 ㎛
(surgical N95)*
 Prevent expired droplet spread to others
 Prevent blood and possible contagious
substance from contaminating the skin,
mouth and mucous membrane of the wearer
 Prevent inhalation of droplets or larger
particles. Trap particles of 5 ㎛ or larger in
the air to prevent them from entering into
mouth/nose
Medical mask
 Prevent expired droplet spread to others
 Prevent blood and possible contagious
substance from contaminating the skin,
mouth and mucous membrane of the wearer
 Prevent inhalation of droplets or larger
particles. Trap particles of 5 ㎛ or larger in
the air to prevent them from entering into
mouth/nose
Cotton (or other gauze mask)  Prevent expired droplet spread to others
and self-made mask
*It possesses both characteristics of surgical mask and respiratory protection
gear. It can avoid inhalation of particles and prevent expiration of droplets and
liquid permeance. It also conforms to regulations of NIOSH and FDA. The full
name is Medical mask/N95 filtering facepiece respirators, surgical N95 for
short. It is called surgical D2 dust-proof mask in CNS.
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9.3.2.4.4 Materials of Mask and Filtration Mechanisms of Airborne
Particles
Respirator and medical mask filters are typically composed of mats of
non-woven fibrous materials, such as wool felt, fiberglass paper, or
polypropylene. These filtering materials produce circuitous path, using different
mechanisms to trap particles to fibers without blocking the open space, so that
air can flow through the filter freely.
Media used for the filtration of airborne particles do not work by the same
principles as those used for the filtration of liquids. Airborne particles cannot
block the space between fibers after being trapped to filtering fibers, or it will
influence the breathing of wearer.
There are 3 major mechanisms to remove particles from the air stream:
inertial impaction, diffusion, and electrostatic attraction. Trapping mechanisms
are different for large and smaller particles.
Larger-diameter particles (>=1 ㎛) will be trapped by inertial impaction.
Such particles cannot easily flow around the respirator fibers as air stream
because of inertial effect. Particles deviate from the air streamlines and collide
with the fibers and may stick to or to be caught in them. Small particles (<0.1 ㎛)
are effectively trapped by diffusion. Brownian movement-the process in which
the constant motion of oxygen and nitrogen molecules causes collisions between
particles-results in an irregular movement or jumping. The complex path
followed by the small particles increases the chance that they will collide with
the filter fiber and remain there.
Another efficient method of capturing both large and small particles from
the air-stream is electrostatic attraction. Electrically charged fibers or granules
are embedded in the filter to attract particles carrying opposite electric charge.
With the same weight, the smaller the particle result in the larger the surface
area. The larger the surface area the more easily it is to produce static. Smaller
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particles are more easily trapped and more difficult to remove because of static
charge on surfaces. In past times, resin is added to natural wool fibers to retain
an electrostatic charge. This addition enhanced the efficiency many times over
the basic wool material. However, the efficiency of resin electrostatic filters is
degraded when they are exposed to airborne oil mists and other materials that
shield the electrostatic charge. Nowadays synthetic fibers are mostly used, such
as polypropylene, to effectively resist shielding effect caused by oil mist.
Once particles are trapped, they cannot come off easily because of Van der
Waals bonding and other reactions. When particles adsorbed the fiber there will
be more trapping points and hence trapping efficiency will increase. But when
particles are too many block the space, the respiratory resistance will increase.
Too many particles will also cause trapped particles to detach from fibers.
Hospital wards are in general quite clean, and there is restriction on usage time
of respiratory protection gear, so it will not be a problem. Limitation of load will
not be a problem for clean wards either.
9.4 Public Seeking Medical Help
9.4.1 Rationale
Future pandemic will definitely cause national panic with continuous
reports of the media. Even thought the government has stockpiled antivirals and
vaccines, the psychological aspect of public should be taken into account. In
order to make the public understand every epidemic prevention strategy, there
should be education and promotion about how to seek medical help and to
prevent infection through all related channels in response to the pandemic threat.
The goal is to make people understand how to seek medical help to prevent
infection when facing a pandemic. Close communication between the
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government and the public will lead to the satisfactory results that people are
confident in, supportive of and cooperative with the authorities, reducing the
panic of epidemic outbreak to the lowest extent. The cost to society will thus be
relatively low.
The key to successful implementation of communication that informs the
public about the potential risk of seeking medical care is through effective
multi-channel health education and promotion. Government policy is to be
delivered and explained in a concise way so that people can obtain correct
information timely and make use of it and to cooperate with the authorities. It
will prevent social turbulence, block epidemic spread effectively, ensure
people’s health and increase government efficiency. Principles guiding the
planning of communication strategies that inform the public about the potential
risk of seeking medical help are as follows:
1. Early and expertise: Understand the need of the public beforehand, and
provide what they need via communication plan.
2. Correct information: Overall planning for delivery of related information to
increase public understanding of and cooperation with pandemic control, and
to instill in people the correct procedures of seeking medical help to achieve
maximum benefit.
3. Message Delivery: Set up a mechanism for promoting and marketing
government policy on pandemic control to the public and implement this
mechanism effectively.
4. Honest and Opening. Directly explain government strategies through mutual
communication with the public to gain trust and to establish professional
image of the government.
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9.4.2 Implementation Strategies
1. Activation Timing
At phase B or C (domestic) or phase 6 (international).
2. Work Division
Central government:
Health promotion in national mass media, cross-departmental coordination
and education, provision of correct and timely information.
Local governments:
Planning of proper execution methods for health promotion and education,
and production of local advertisement flyers. Mobilization of systematic
promotion channels, like neighborhood heads, police officers and health centers,
and of other local promotion channels (information sessions, propaganda
vehicles).
3. Core of Execution
(1) Procedures and information related to people attending out-patient or
in-patient services in hospitals, including community disease screening
stations and large care facilities.
(2) Contents about the operation of the Medical Network for Prevention and
Control of Infectious Diseases and the procedures and principles of
seeking medical help.
(3) Patients in off-shore island seeking medical help are handled by two
possible strategies: “patient doesn’t move and physician moves: local
treatment” and “patients transferred to main island for treatment”.
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4. Execution Principle
(1) Plan and communicate in advance. Correct and uniform information
(2) Step by step communication to reinforce impression
(3) Propaganda channels for mass population, small population groups,
specific population segments and individuals
(4) Propaganda of information to specific groups
(5) Timely evaluation, review and adjustment
(6) Ample use of health promotion materials
5. Execution methods and tools
(1) Electric media: television, radio, internet
(2) Print media: newspapers, posters, LED advertisement, bus advertisement
(MRT , coach)
(3) PR activities and survey can evaluate people’s needs and thoughts in a
quantitative way
(4) Dedicated telephone lines for consultation, including CDC’s 1922 hotline,
activation of the 177 fever hotline according to situation, and other
hotlines
(5) Volunteer groups go deep into every level of community or target at
important members in the family and group leaders for health education
(6) Epidemic control staffs walk out of the office and face the public directly
to communicate government strategies
(7) Hold national epidemic communication symposiums and seminars aiming
at different groups
(8) Hold press conferences, information sessions or symposiums routinely to
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release information on related national and international epidemic
situations and prevention strategies to let people obtain correct
information
(9) Personnel of primary administrative organizations and health centers are
the main players in conducting health education and promotion. Village
heads and neighborhood heads will assist to expand education and
propaganda, walking into the public to spread the words.
(10) Make national advertising pamphlets and establish communication
channels
(11) Plan
proper
locations
for
out-patient
visits,
treatment
and
hospitalization. Make nationally unified identification signs and labels to
clearly mark these places
(12) At phase C, the news media regulatory authority should handle news,
make announcements, conduct media requisition and promote government
orders according to Article 5 of Communicable Disease Control Act.
(13) Local governments can make use of current message delivery channels,
such as “community public health groups”, etc.
6. Execution Contents
(1) Correct procedures for seeking out-patient and in-patient services at
hospitals, locations of community disease screening stations and large
care facilities planned by each local government.
(2) The subjects to be received and treated by Infectious Disease Prevention
and Control Network and the activation timing of the network according
to directions from regional command center, and procedures and
principles of patient seeking medical help
(3) The principle of medical handling of off-shore island patients is either
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“patient doesn’t move and physician moves” for local treatment or
“patients transferred to main island for treatment”. The regional
commander activate medical handling according to related factors such as
patient condition and off-shore island medical resources
Details of above contents are listed in Chart 9.1~9.4
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Chart 9.1 Planned Procedures of Communication With Patients Seeking Medical Help—Out-Patient visits/Hospitalization
Procedures of Plan
Central Epidemic Command
Center announces phase B
Evaluation of setting up community
disease screening stations or large
care facilities
Contents of Propaganda
1. Knowledge of influenza pandemic and the
characteristics of the virus
2.Infection control measures that can prevent
individuals from getting infected
3.Governments’ policy for pandemic control,
especially the planned procedures for seeking
medical attention
WHO 5 Major Principles
Understand
the public’s
thoughts
Decides to set up
Set up must be completed within
1 week
Information on community disease screening stations
and large care facilities, including functions,
locations, activation date, how to seek medical care,
required IDs and other matters to pay attention to
when entering facilities
Plan in
advance
Announce
Symptoms appear
Seek medical care in
community disease screening
station or large care facility
Health
self-management
N
Y
Confirmed as H5N1 or
pandemic flu case
Treatment and housing arrangement
decided by regional commander
ASAP
Matters pertaining to community disease screening
stations and large care facilities:
1.Infection control measures
2.Control of passage, notification of area division
3.Procedures to enter screening station for visit
Information
transparency
Methods
1.Television, radio, internet
2.Symposiums and seminars
3.Poster and advertisement brochures
4.Mass media, bus/subway advertisement,
radio, newspaper
1.Propaganda through administers of
neighborhood, police, health centers and
schools
2.Regional advertisement brochures, posters,
booklets ( Indicate detail locations of
community screening stations and large care
facilities)
3.Community bulletin board, radio, TV or
propaganda vehicle
1.Reinforce
propaganda
and explanation on the
4..Hotlines of
health authorities
scene by administers of neighborhood,
administrative staff, control staff, medical staff,
medical facility personnel and volunteers.
2.Explanation of passage control and area
division
3.Poster and pamphlet distribution
Establish/
Maintain/
Y:1.Patient transfer matters
2.Psychological support to patient and relatives
3.Satisfaction evaluation after recovers
N: Health self-management and satisfaction
evaluation
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Reconstruct
people’s trust
1.Explanation, psychological support &
pacification
2.Assistance of transfer by health care workers
3.Distribution of leaflets
Chart 9.2
2006 ” Medical Network for Prevention and Control of Infectious Diseases”
Flowchart of Activation of Infectious Disease Prevention and Control Hospitals
"National Infectious Disease Prevention
and Control Hospital" Activation
authority: CDC
Centers for Disease Control
Department of Health
“Infectious Disease Prevention and Control Hospital”(23 hospitals) activation authority: CDC
Taipei Command Center
Northern Command
Commander:
Center
Chang ShangChuan
Commander:
Commander:
Commander:
Commander:
Commander:
CDC 1st branch
Lin TsoYan
Wang JenHsien
Lee JenChi
Chuan YinChing
Liu YungChing
CDC 2nd branch
CDC 3rd branch
CDC 6th branch
CDC 4th branch
CDC 5th branch
Center
General KeeLung Hospital, DOH
General TaoYuan Hospital, DOH
Taipei Joint Hospital HoPing Region
Center
Southern Command
Center
General HuaLien Hospital DOH
General MiaoLi Hospital, DOH
General NanTao Hospital, DOH
General TaiTung Hospital
YunLin Region
DOH
General ChiaYi Hospital,
General HsinChu Hospital, DOH
General FunYuan Hospital, DOH
Region
National Taiwan
Command Center
Kaohsiung City MingShen Hospital
General PingTung Hospital, DOH
General ShinYin
General ChuDon Hospital, DOH
Hospital, DOH
General KinMen Hospital, DOH
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General ChiShan Hospital, DOH
DOH
General Changhua Hospital, DOH
LianChiang County Hospital
Kao-hsiung/PingTung
University Hospital
Region
General YiLan Hospital, DOH
Eastern Command
General TaiChung Hospital, DOH
HsinWu Region,
Taipei County Hospital SanChung
Middle Command
General PengHu Hospital, DOH
Chart 9.3 “Medical Network for Prevention and Control of Infectious Diseases” Procedure
Flowchart for Transfer of Infected Patients from Off-Shore Area to Main Island for
Treatment
Off-shore hospital reports patient
Report
1. Command
centers in related
areas evaluate then
confirm transfer
2. Fax and send
approval to Bureau
of Health
Off-shore Bureau of Health
1. Initial evaluation of case condition
2. Contact with all organizations for related
matters such as patient transfer,
receiving and transportation
Forward
message
after
receiving
response
Bureau of Health
衛生局通知
inform 2 2
Inform 1
Response
Vice Director
Shih Wen-Yi
Report
Division Director
Chiu Jen-Hsiang
Inform 3
 DOH Center for air transfer evaluation
Hsin-Hang
Tel:886-2-8195-9119 or 886-2-8911-4119 CEO Tsai
 Ministry of the Interior Air Service Command Center
Tel: 886-2-8911-1100
 Executive Yuan National Search and Rescue Command Center
Tel: 886-2-8196-6119
 Dedicated Fax: 886-2-8196-6740 or 886-2-8196-6741
Response
Receiver end
Bureau of Health
Order announced
Response
Support 2
Executive Yuan
Coast Guard Administration
Priority
Support 1
Airline company that
signed emergency medical
transfer contract
Departure from main island port
Ministry of the Interior
Air Service Head Team
Departure from main island airport
Arrival at off-shore island port
Arrival at off-shore island airport
Ambulance
Sender end Fire
Bureau
Departure from off-shore island
port
Departure from off-shore island
airport
Arrival at receive
end port
Arrival at receive
end airport
Receiver end
Fire Bureau
Ambulance
Dispatch vehicle
Response
Arrival at receiver end infectious disease prevention and control hospital
Note: 1.Off-shore areas include Peng-hu county, King-men county, Lian-chiang county, Ping-tung county (Hsiao liu chiu),
Tai-nan county Landau village & Green Island village
2. Priority of patient transfer: 1st – Airline company that signed emergency medical transfer contract; 2nd – Air Service
Head Team; 3rd – Coast Guard Administration
3. Solid line represents major procedures, dotted line represents response action
Chart 9.4 “Patient doesn’t move, physician moves” Operation
Procedures for Off-shore Area
Suspected or
confirmed novel
influenza case
Coordination and contact
Off-shore
health bureau
Report local epidemic situation,
material and human resources
and demand evaluation
Off-shore infectious hospital
or Health station
Request
manpower
support
Request manpower support
Infectious Disease Prevention Network Command Center
Decision of Commander
Video diagnosis or
local treatment
Deployment of
medical group
No
CDC Central Infectious Disease
Surveillance System
Yes
CDC branch director reports to headquarters to confirm
off-shore back-up manpower name list.
Meet up location/time at main island
Assist in buying flight/boat ticket
Support in dispatching epidemic materials
Inform
Support hospital
Informs back-up manpower
Back-up manpower arrive at meeting spot and go to area in need by plane (boat)
Off-shore area Bureau of Health assists in stationing
of medical group, coordinating traffic, food and
accommodation, as well as continuous epidemic
evaluation and reporting back
Report back on
epidemic handling
Stationing in
Regional Command Center
evaluates the need for
continuous support
No
Medical
group
否 - 116
withdraw -
否
Off-shore infectious hospital
prepares epidemic control
materials and back-up work
items
Briefing on scale of epidemic
and personnel arrangements
Yes
9.5 Business and Organization Continuity
9.5.1 Rationale
Influenza pandemic will spread cross borders and continents. Not
only individual live and health were influenced, economy and society
were also impacted to a certain degree. Many employees may not be able
to work because of being sick or quarantined. Some ancillary support,
such as raw material supply, contractors, logistic supply, transportation
and energy resources, may all be influenced.
Government’s expectation of business, besides being responsible for
protecting employee’s health, is that each business keeps operating during
pandemic. Therefore it is suggested that business should perform overall
risk evaluation according to individual operation characteristics.
Strategies of response should be drafted in advance and conduct drills
assuming different scenarios [19].
9.5.2 Implementation Strategies
Feasible preparation suggested to business and organizations at
current stage includes:
1. Establish platform for information communication
Receive timely and correct pandemic information and make
known to employees by network, bulletin board and telephone hotline,
etc. Reinforce employees’ recognition and precaution of avian flu in
peacetime. During pandemic it can be used as the channel of external
communication, to send out messages and to clarify rumor.
2. Build up healthy working environment
Sufficient and convenient infection control measures are to be
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provided in work places, such as hand-washing liquid, tissue paper
and garbage can. Pay attention to ventilation according to individual
environment. During epidemic period, perform cleaning and
disinfection of public equipment in the office according to CDC or
WHO suggestions.
3. Set up emergency response team
A member of high-level management will serve as convener, who
combines the company’s environmental safety department, medical
personnel, general administrative department, human resources
department and public relations department to proceed with planning
of matters such as infection control, seeking medical help,
environment maintaining and communication, etc.
4. Drafting emergency response plan
Each business should not only make use of existing emergency
response mechanism but also incorporate 2 major objectives into this
mechanism: infection control measures and sustainable operation. The
contents of the plan should be made known to internal and external
personnel of the business. The plan is suggested to include:
(1) Risk assessment of domestic and international epidemic situations
and analysis results of financial impact
(2) Organizational structure of emergency response
(3) Infection control measures:
① Measures that reduce face to face contact, such as
teleconference or video conference, working in shifts and
flexible working hour system, working at home (consider data
backup and information security), reducing shared working
space and visitor restriction, etc.
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②Emergency response measures such as reporting procedures,
handling of staff falling ill, channels for seeking medical help,
case occurrence in office and cooperation with case
investigation.
(4) Business continuity program: Identify critical work that must be
done during pandemic and evaluate essential material and human
resources to maintain the work, train and confirm back-up
manpower and goods, establish working procedures of that
situation, and backup of system data.
(5) Human resources management: Set up guidelines on employee
salary, compensation, sick leave and return to work of recovered
staffs who are no longer infectious.
(6) Communication plan: establish a system for obtaining timely and
reliable avian flu or pandemic flu information and proper
connection.
Decide
internal
and
external
emergency
communication methods and contact channels during pandemic.
Review and revise it routinely.
(7) Recovery plan
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10. Exercises
For the preparation of pandemic, WHO not only urges all countries
to draft national level preparedness plans but also continues to elaborate
on the importance and necessity of exercises to pandemic control.
“Exercise Development Guide for Validating Influenza Pandemic
Preparedness Plans”[20] was also published in February 2006 to provide
reference to all countries.
Over recent years in our country, the concept of military exercise has
been reinforced and applied to disease control mobilization, for it was a
relatively weak link in the overall chain of disease mobilization in the
past. We expect that, through various types of of exercises, all
preparedness measures can be connected effectively, even with bonus
effects.
In view of the establishment of disease control systems, Articles 14
to 17 of Communicable Disease Control Act stipulate that central and
local governments could activate disease control systems. As for
infectious disease prevention, Articles 19 to 27 also bestow all relevant
government agencies with the legal authority and responsibility of
stockpiling medicines for infectious disease control, early detection of
epidemic situations, establishment of medical network and strengthening
of health education and promotion, etc. Articles 29 to 31 bestow medical
facilities with the legal authority and responsibility of conducting
thorough medical consultation and evaluation, taking proper care of
patients and practicing proper health management in highly-populated
institutions. To thoroughly implement all infectious disease control
strategies according to law, strategies, standard procedures and
communication platforms should be set up in advance. In view that
pandemic attack is unpredictable, exercises should be performed to
- 120 -
evaluate each preparedness measure.
According to Article 18 of Communicable Disease Control Act,
should there be a serious infectious disease epidemic or an epidemic
caused by biological pathogenic attack in our country, each level of
competent authorities should mobilize the entire population for
systematic defense and preparedness to implement related disease control
measures.
10.1 Rationale
10.1.1 Purpose of Exercise
WHO believes that the main purpose of exercise is to practice
existing preparedness/battle plan, or to use it to form a project.
The comprehensive and broad purposes of exercise defined in our
country are:
1. Help the first line personnel, command center or the public to be
familiar with existing SOP and each response procedure;
2. Reinforce vertical (between central and local) and horizontal (between
central departments) communication channels and negotiate a
cooperation mechanism/unspoken consensus;
3. Review possible gaps in every link, to detect problems and to propose
resolutions for active improvement.
10.1.2 Exercise Types
Exercise is a specialized field. Different types of exercise should be
selected based on purpose, budget and requirement of exercise. WHO[20]
and the US Federal Emergency Management Agency (FEMA)
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[21]
categorize exercises into the following 5 types:
1. Orientation
An orientation is the simplest and least costly among the five
types of exercises. It takes the form of informal discussion designed to
familiarize participants with the structure, role designation and
procedures of the preparedness plan, with a focus on issues pertaining
to coordination and assignment of responsibilities.
2. Drill
A relatively smaller-scale exercise, which aims to develop and
maintain skills in a single response procedure. Drills are limited in
scope and related procedures should be set up in advance.
3. Table-top
Table-top exercise is a process in which officials and/or key staff
with emergency management responsibilities are gathered together
informally, without tight time constraints, to examine and discuss
simulated emergency situations and attempt to resolve problems based
on their emergency plans. It can be conducted over a time period from
a few hours to a few days. Sometimes “Desk-top” will be misused.
4. Functional
The completeness is only second to Full-scale (see next item for
description), and is more challenging than Table-top. Participants react
in accordance with a series of simulated events according to the
individual roles they play. The emphasis is on understanding the
interaction between important strategies during an emergency event. It
is different from a table-top exercise in three ways: first, it is
interactive between roles; second, it is conducted under time
constraints that would be similar to, or often more challenging than a
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real event; third, it is usually conducted in a facility designated for
coordination and management of a real event, so the available tools
and technologies can be used and evaluated.
A single or multiple emergency situations can be exercised, in
order to implement strategies, role, mobilization and division of work,
response ability and emergency response procedures. Many resources
are required to ensure maximum benefit of functional exercise.
There are three ways to perform functional exercise, including
planned ruling, free ruling or half free (half planned) ruling[22]. In
general, a “reference document” is to be prepared, which is the
solution to the exercise situation.
5. Full-scale
A full-scale exercise is the most complete and usually the largest
type of exercise. It resembles actual emergency, including actual
deployment of the resources required to demonstrate coordination and
response capabilities in as realistic a setting as possible without
putting the safety of the public and staff at risk. A full-scale exercise
focuses on the operational ability in emergency events.
10.1.3 How to Plan An Exercise
Following above purpose and types of exercise, WHO suggested[30]
that in the early stage of planning, following 4 prerequisites should be
thought over:
1. Is there a policy-level committee to organize and (or) participate in the
exercise?
“Policy-level” usually refers to administrators, whose role is to
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lead and provides direction. In central government, it is usually
director of a department or a high-level executive official in
administrative
organizations.
In
local
or
non-governmental
organizations, it is usually a high-level official or president of board of
committee (board of directors/board of committee).
2. What are the intended scope and objectives of the exercise?
Scope and objectives are linked. “Scope” is decided by the range
of the plan and participation number of organizations. The larger the
scope, the more objectives can be included, but realistic limits should
be established.
3. Who will coordinate the exercise?
One organization or individual must be responsible for
coordinating the exercise. In the case of either an orientation or drill,
the coordinating agency usually will be the principal author/owner of
the plan. In all other types of exercises, the coordinator may be from
outside the agency that prepared the plan. In “full-scale exercise”, it
is common to have a coordination team with members drawn from
all of the significant participating agencies.
4. Who should participate in the exercise?
All plan-related organizations should participate in the exercise.
In the case of table-top exercise, it is common to allow a number of
observers who have a professional, operational or policy interest in
the outcome, but care should be taken to ensure that the presence of
too many observers does not interfere with the conduct of the
exercise.
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Source of funds (or sponsor) should also be considered. Commander
of the exercise should form “design team” to perform exercise planning.
The 4 major elements of exercise planning, namely scenario, control plan,
exercise plan and evaluation plan, should be developed. They are
described briefly as follows:
1. Scenario: It should be close to actual situation based on a series of
hypotheses and participants are to respond to the scenario according to
decided actions and strategies
2. Control plan (or called general plan): describes how exercise will be
carried out
3. Exercise plan (or called guiding plan): provides a higher-level
blueprint for the overall structure of the exercise
4. Evaluation plan (or judgment plan): describes how exercise will be
evaluated and what are the evaluation tools
10.1.4 Organizational Structure of Exercise
The organizational structure of exercise is approximately as below
chart [22]:
Exercise Development Team
Exercise Director
Assistant Exercise Director
Exercise Control
Team
Participant Support Team
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Exercise
Evaluation Team
Exercise Force
Related roles and assignments are described below:
1.Exercise Development Team: “Exercise Director” is assigned to serve
as the highest commander in the exercise. Assistant Exercise Director is
assigned to assist, to act as deputy and to supervise ruling work. In
small-scale exercises, Exercise Director can serve concurrently as
director of judgment, who is responsible for planning, guiding,
controlling and reviewing.
(1) Planning: Exercise conducted and led by a single (top-tier)
authority, such as Executive Yuan, DOH, CDC, county/city Bureau
of Health or a hospital, etc, must include control plan (general
plan), exercise plan (guiding plan), evaluation plan (judgment plan).
Exercise conducted and led by a second-tier authority, such as
Bureau of Pharmaceutical Affairs under DOH, the Fourth Division
of CDC, Section of Disease Control at a County/City Health
Bureau or infection control team at a hospital, can be presented in
the manner of teaching plan, including a teaching outline, exercise
composition chart and guiding plan chart.
(2) Guiding and controlling: including announcing exercise orders,
assigning judgment officer and guiding the proceeding of
exercise,etc.
(3) Reviewing:
Review
of
performance
of
participants,
and
suggestions on reward and punishment will be sent to human
resources unit to be processed accordingly.
2.Exercise Plan Control Team: Draft all plans of the exercise and draw
up/control all proceeding of the exercise
3.Participant Support Team: Provide service/business matters during the
course of the exercise
4.Exercise Evaluation Team: Perform the role of guiding and judgment;
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draft and compose ruling plan according to objectives, type, mode, and
extent of control; and assign evaluators according to professional
specialty. It should be avoided to assign evaluators from participating
units in the exercise. In “drill exercise”, the evaluation method of
divisional supervision can be adopted. On-the-scene evaluators can be
assigned at the spot according to professional specialty. In “functional
exercise”, centralized supervision can be adopted.
5. Exercise Corps: All participants.
10.1.5 Affairs to be Managed After Exercise[20,22]
1. If the exercise is more than 1 day, “On-the-day review meeting”
should be held daily. Participants report what they have learned and
review successes and shortcomings.
2. “Evaluation meeting” should be held within 2 weeks after exercise
completion
3. Every question at the review meeting should be noted and answered to
in a report, which will be divided and submitted to related
organizations to process accordingly. The processing outcomes should
be reported.
4. After exercise completion, exercise records should be cataloged as a
source of history, including scenario, all plans, judgment (review)
report and other documents which are sufficient to record actual
events.
10.2 Implementation Strategies
As mentioned in the 1st chapter of this plan, pandemic is considered
“non-traditional” security threat by APEC, Journal of US Foreign Affairs
- 127 -
and our country. On the basis of expansion of national security concept,
DOH has given more weight to and deepened the scope of “exercise”
with regard to “influenza pandemic”, including participation in
international exercises, conduct central-level vertical/horizontal exercises
and supervise local governments in conducting different types of
exercises.
In order to conduct more specialized and systematic exercises, DOH
asked National Defense University to provide guidance with their
specialty on military exercise. “Seminar on Military Exercise
Application –Taking influenza pandemic as an example” was held in
July 2006, with the planning of courses focusing on “managerial
positions” and “staff positions”, in order to establish mutual language
and a unified direction with regards to exercise type, exercise planning,
scenario composition and review method, etc.
10.2.1 International Exercise
The APEC “Pandemic Response Exercise” was organized and held
in Australia on 8 June 2006. Our country participated in this exercise
simultaneously with other countries. The exercise started at 9am Taipei
time. Eight member bodies participated as primary players, including our
country, Japan, China, Indonesia, Malaysia, Chile, Korea and Vietnam.
Twelve other member bodies, including the US and Canada, acted as
secondary players. WHO, OIE and UN Food and Agriculture
Organization acted as observers. The exercise response group of our
country was formed by related organizations such as DOH, CDC
Ministry of Foreign Affairs, Bureau of Animal and Plant Health
Inspection and Quarantine under Council of Agriculture, Disaster
Prevention and Rescue Committee. Chen Zai-Ching, Vice-Minister of
- 128 -
DOH, acted as exercise commander of our country, and relevant
personnel were stationed at “National Health Command Center” on the
7th floor of CDC headquarters after exercise started.
During this exercise, information was delivered between member
bodies via telephone, fax or email. The main objective is to test whether
the communication network and information sharing channels were
smooth, ability of member bodies to deal with emergency and regional
coordination/cooperation mechanism.
During the exercise, our country received 6 scenarios brought up by
exercise coordination center:
1. WHO pandemic alert upgraded to phase 5;
2. Destruction of PPE stockpile due for delivery to Taiwan in an overseas
factory by fire;
3. Types of assistance Taiwan could offer to affected countries;
4. Request from the Canadian government to check on the wellbeing of
their back-packers;
5. Taiwan’s inclination to participate in the upcoming APEC Youth
Football Tournament held in Danang, Vietnam;
6. Request for medical support from a cruise ship with suspected
pandemic flu cases on board.
After receiving these scenarios, all related units immediately
proposed strategies and solutions in response to these scenarios. The
strategies and solutions were reported to the Commander. After approval
by Commander, our reply was reported back to the Exercise Coordination
Center within designated time. The exercise terminated at 3pm.
In the future, our country will continue to strive for participation in
related international exercises.
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10.2.2 Central-Level Exercise
The central-level exercises already held or will be held by DOH for
influenza pandemic are as follows:
1. 7 July 2005: Functional exercise for pandemic phase A1~A2; Exercise
items are:
(1) Organizational operation in pandemic phase A1;
(2) Organizational operation in pandemic phase A2;
(3) Procedures for delivery of samples collected from in-bound
passengers from infected areas;
(4) Investigation of novel influenza patients being picked out for
epidemic investigation;
(5) Transfer procedures for suspected novel influenza patients;
(6) Handling operation when poultry/animal husbandry workers
develop suspected symptoms;
2. 27 Dec 2005: Functional exercise of novel influenza in phase B/C;
Exercise items are:
(1) Quarantine and centralized quarantine measures on incoming
passengers at CKS airport;
(2) Preparation aiming at suspension of international flights and
mini-three link traffic with China;
(3) Preparation measures of all departments under Executive Yuan in
response to pandemic phase B;
(4) Actions of all competent authorities in response to novel influenza
cluster events;
(5) Preparation measures of all departments under Executive Yuan in
- 130 -
response to phase C pandemic.
3. 6 April 2006: Drill on airport management of incoming passengers
during pandemic; Exercise items are:
(1) Central activation of domestic phase A1 epidemic. It is announced
that centralized quarantine measure will be implemented for
incoming passengers from affected areas. A press conference is be
held to inform the public;
(2) All related units of CKS airport convene a meeting on centralized
quarantine measure in response to pandemic phase A1. Units
related to entry promptly arrange and set up special places to
perform entry customs clearance. Once flight arrives, ground staffs
will be ready to activate special entry clearance services.
(3) During check-in an boarding, staffs of airline companies stationed
aboard inform passengers of Taiwan’s centralized quarantine
measure on in-bound travelers;
(4) One hour before the landing of a plane, the captain reports to
control tower that there are 2 passengers with fever on board. After
landing, the flight purser announces special cautions related to
centralized quarantine before passengers disembark;
(5) Immediate handling and following management of passengers
detected to have abnormal temperature by infrared thermal
scanners at the airport (including recheck of temperature and
diagnosis by an epidemic control physician);
(6) Issuing “centralized quarantine notice” to passengers with normal
temperature;
(7) Handling non-compliance of passengers to get on the ambulance;
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(8) When there are insufficient ambulances at the airport, contact is
made to request dispatch of other ambulances. When the capacity
of the designated hospital for patient transfer from the airport is
exceeded, patients will be sent to other hospitals;
(9) Passengers go through ID check and luggage check at the customs;
(10) Joint handling of smuggled birds by quarantine staffs from the
airport customs office, Bureau of Animal and Plant Health
Inspection and Quarantine under the COA and CDC;
(11) After completing all custom procedures, passengers are sent to
centralized quarantine facilities by a vehicle. ;
(12) Personnel take off their gear and clean the scene.
4. At next stage, exercises will be held to test the medical system’s
response capabilities; Exercise items are:
(1) A hospital reports one inpatient with pneumonia of unknown cause.
Bureau of Health performs case investigation. Sampling of the case
confirms H5N1 influenza infection;
(2) In response to the first confirmed domestic case of H5N1 influenza,
the “Central Epidemic Command Center” is launched;
(3) H5N1 influenza cases are reported in succession in central Taiwan
and first wave of epidemic begins;
(4) Suspected H5N1 influenza cases are reported in succession
everywhere in Taiwan;
(5) Due to rapid increase in reported cases, commander announces
suspension of sampling and case investigation in order to control
the response capacity and to adjust the control emphasis.
Sections 1, 2 and 4 pertain to functional exercise, while section 3
pertains to drill exercise. Central-level exercises are centered on
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information collection (information flow), policy-making (strategy
decision) and procedures of passing down orders (chain of command)
by Central Epidemic Command Center during a pandemic. Therefore,
they are mainly in the form of orientation exercises, table-top exercises
and functional exercises are usually used. In section 3 “Exercise for
airport management of in-bound passengers during pandemic,” a drill
exercise was used. Because in national epidemic control strategies,
border control is an important and universal measure. Therefore it is not
appropriate to change the location of the procedures.
As for exercise on disease control, there has not yet been a
full-scale exercise domestically or internationally. Full-scale exercise
is similar to the occasional air defense exercise or wan-an exercise,
which is conducted in actual and open territory. Once people appear in
the exercise scene, they must cooperate with the exercise, and are
regarded as participants. The appropriateness and execution methods
of full-scale exercise in disease prevention/treatment are to be
evaluated.
During exercise, evaluators are assigned. In drill exercises,
additional “on-the-scene evaluators” will be assigned. The invitation of
evaluators should be based on their professional specialties, and
complete exercise data and evaluation criteria should be provided in
advance. On the day of exercise, evaluators/on-the-scene evaluators will
comment and review, and record according to the facts. All participating
units, evaluators and on-the-scene evaluators will be invited on another
day after the exercise to hold a joint “evaluation meeting”. All reviewed
matters will be forwarded to related units to proceed with correction.
That way, the actual effect of exercises can be achieved.
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10.2.3 Local-level Exercise
Local governments should perform orientation, table-top or
functional exercises following the example of central government
according to needs. The exercise should focus on information collection
(information flow), policy-making process (decision flow) and order
receive/announce procedures (chain of command) by “local response
center” during pandemic.
All offices and sections of local government are at the first line of
epidemic control, therefore control procedures of all diseases and the
single measure “drill exercises” should be strengthened. The main
objective is to familiarize 1st line personnel with all SOP and execution
methods so that they are able to response swiftly once an epidemic occurs.
Each local government differs in geographical environment, population,
extent of urbanization, climate, culture, funds and organizational structure,
and even central strategies still need to be adjusted accordingly. Therefore,
a local government should establish its own exclusive “SOP” and
“checklist” according to relevant laws, regulations and strategies to be
followed by the first line personnel and to serve as the basis of “exercise
plan” and “evaluation plan”.
Drills that local governments should execute in response to the
pandemic threat can be generalized in 10 categories. Other special drills
should be proceeded actively by local governments:
1. Response center: Information flow, policy-making process and chain
of command;
2. Case management: Reporting, surveillance, delivery and testing of
samples and case investigation procedures (including monitoring of
information system);
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3. Resource
management:
Local
epidemic
prevention
resources
(including: human resources, logistic service goods), stockpiles,
reserves, delivery and management (including monitoring of
information system), etc;
4. Infection control: Management of Designated Infectious Disease
Prevention and Control Hospitals in terms of coordination of hospital
beds, (including monitoring of information system), nosocomial
infection control management, human resources and institutional
capacity;
5. Patient delivery mechanism: Procedures of case transfer and related
protection and disinfection;
6. Communication plan: vertical (with central authorities), horizontal
(across all bureaus and departments, cross county/city governments)
and communication with public. Proper health education and media
interaction;
7. Management of large number of cases: Centralized quarantine of
passengers
returning
to
Taiwan
from
affected
areas
and
software/hardware planning for large care facilities;
8. Community restriction: Various community restriction measures and
society stabilizing strategies;
9. Handling of remains: handling procedures of the dead cases and
capacity management;
10.Recovery of society: Reconstruction in the recovery phase of the
pandemic.
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Appendix
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Appendix 1. Characteristics of Avian Influenza A(H5N1) Virus
1. Virology
Influenza virus is an RNA virus belongs to the Orthomyxoviridae
family. It has sheath and is sensitive to ether. In the sheath there are 2
types of glycoprotein: hemagglutinin(HA) and neuraminidase(NA). HA
enters cells of host by binding to sallic acid receptor in cell surface of
host. It is the most important virulent factor of virus’ invasion into cells.
It is also the most important antigen in virus antibody neutralization test,
and can be used to produce vaccine. NA is the 2nd most important antigen
in flu virus neutralization test. Its action is to break sallic acid connecting
virus and host cells, which helps virus granule enter host cells. It is an
important target protein for anti-virals. The 3rd glycoprotein in virus
surface is M2 protein, which is only present in the surface of a few
influenza A virus. It is mainly ion channel protein used to control the ph
value of virus. It also affects the initial phase of virus replication,
therefore it is also the target protein of some anti-virals.
Gene hereditary substance is a reverse RNA. It is divided into 8
segments. Important virus genes of each segment are listed below:
Segment
Gene
Gene function
1
PBa
RNA transcriptase
2
PB1, PB2 RNA transcriptase
3
PA
RNA transcriptase
4
HA
Hemagglutinin (bind to sallic acid)
5
NP
Constructional protein
6
NA
Neuraminidase (cut sallic acid)
7
M1
Matrix protein (help virus recombination)
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8
M2
Non-structure protein (ion channel in virus surface)
NS1
Non-constructional protein
NS2
Non-constructional protein
Influenza is divided to type A, B, C according to N, P and M protein.
Up to now, all avian flu is caused by type A influenza virus. Virus A is
subdivided by HA and NA. There are currently 16 types of HA (H1~H16),
and 9 types of NA (N1~N9). The late outbreak of avian flu is confirmed
to be caused by H5N1 type.
2. Pandemic Caused by Avian Flu Virus
HA gene of avian influenza A derived antigen has never caused
epidemic in human. Therefore, human immune system lacks immune
function to virus with this kind of antigen. Once virus can transmit within
human, there will definitely be a rapid spreading and will cause global
pandemic. There were 3 similar influenza pandemics in the 20 th century,
in 1918, 1957 and 1968 respectively, which killed millions of people
globally.
The pandemic in 1957 and 1968 were originated from south Asia. Its
genotype is between avian flu virus and human flu virus. The virus strain
serotype of avian flu pandemic in 1957 was virus H2N2. It is the hybrid
of avian flu virus in wild ducks and human H1N1 flu virus. “Hong Kong
influenza virus” pandemic in 1968 was caused by new H3N2 virus from
hybridation of H and PB1 gene in duck flu and H2N2 human flu virus. It
resulted in human-to-human pandemic. As for the “Spanish flu” outbreak
in 1918, human didn’t have immunity against its H1N1 virus and resulted
in global pandemic. It is estimated that 1 million people died because of
this flu. According to research, the reason for 1918 flu outbreak may be
the same with outbreaks in 1957 and 1968.
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3. History of Human Infection by H5N1
In recent years, highly pathogenic avian flu virus is gradually able to
infect human, and cause serious or even deadly symptoms. H5N1avian
flu virus has attacked many Asian countries. According to previous
human infection cases, H5N1 virus is limited to bird-to-human. But in
southern Asia, living space of human and domestic animals (such as pigs)
are very close. These kinds of animals are probable media for avian flu
mutation of human adaptivity. According to an essay that H5N1 virus
has been found in pigs. Low-pathogenic avian flu antibody is also
detected in many pigs. These conditions are similar to those of 1957 and
1968 avian flu pandemic outbreaks, which should be paid attension to.
4. Clinical Symptoms of Human Infected with H5N1 Flu Virus
According to analysis of available case data, latent period of human
infected with H5N1 virus is mostly 2 to 4 days. In some rare cases, it
can be as long as 8 days. Infection characteristics are serious flu
symptoms. Its clinical manifestation includes fever, cough, short breath
and
pneumonia observed
radioactive imaging. Especially that
pulmonary damage can still be observed through radioactive imaging
several months after H5N1 infection. In addition to respiratory
symptoms, a large portion of people presents digestive system
symptoms. These symptoms are similar to symptoms of some children
infected with influenza, such as vomit, diarrhea and abdominal pain, etc.
H5N1 symptoms are not localized to acute respiratory tract syndrome,
some cases also present renal failure, multi organ failure, coma and
death. H5N1 virus can be separated from throat swab, feces, blood and
cerebrospinal fluid. Therefore it can be concluded that H5N1 infects
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organs of the whole body extensively. Until now, it is still rare for H5N1
to invade central nervous system. Host genetic expression plays a very
important role in symptom manifestation of disease.
In addition, patients infected with H5N1 virus will present a special
immuno-phenomenon. Large quantity of chemokines and cytokines will
be present inside patient’s body. These hormones will attract large
quantity of white cells to lungs, causing self-immune cells to aggregate
in lungs. Phagocytosis and cytotoxic of lung cells infected with virus
will cause cell lung necrosis and function loss. This autoimmune
reaction is not localized to lung; others include fibrosis of small intestine
tissue, necrosis of liver cell and some blood diseases. It is suggested that
some local ill tissues be tested of virus RNA.
5. H5N1 Flu Virus Laboratory Diagnosis
5.1. Culture of virus
Avian flu virus can be cultured by egg-based technique or by cell
strain infection. Cells used are kidney cells of rhesus and Madin Darby
dogs. The difference from normal cold virus is that highly pathogenic
avian flu virus cell culture does not require addition of pancreatin to
facilitate virus replication. Labs of highly pathogenic virus culture should
better be biological grade 3 or higher. Samples better be collected by
throat swab and respiratory tract gargle. H5N1 virus can be separated
from other samples, including serum, cerebrospinal fluid and large
intestine smear.
5.2. Detection of antigen
Current influenza virus A detection methods are direct fluorescent
immunoassay and immunochromatography. However the sensitivity of
- 140 -
these test are low. Antigenic tests to H5N1 virus are still under research.
5.3. Reverse transcriptase polymerase chain reaction (RT-PCR)
It is currently the method with more H5N1 specificity and sensitivity.
The gene of H5N1 is a reverse RNA, therefore reverse transcription is
used to transcript RNA reversely to cDNA. Polymerase chain reaction
will magnify specific segments of H5N1 as screening.
5.4. Serological detection
When there is an avian flu outbreak, detection of H5N1-specific
antibody becomes very important. Blood aggregation test is the standard
testing method to detect influenza antibody. However this test still cannot
be used in detection of H5N1 antibody in serum. A possible reason is that
H5N1 virus is not able to induce large fluid immuno reaction, causing
insufficient H5N1-specific antibodies in mammals and low sensitivity in
blood aggregation test. Sensitivity is higher when using ELISA to detect
neutralized antibodies in serum directly, also with sufficient specificity.
Therefore it is a good choice to detect neutralized antibodies directly.
6. Treatment and Prevention
6.1. Antiviral treatment
At present, there are 2 types of anti-virals: M2 inhibitors and
neuraminidase inhibitors. M2 inhibitors are launched earlier and are
cheaper. But resistance is more frequent according to using experience. In
addition, it is not known whether it’s safe to pregnant women. Another
major point is that H5N1 has been found to be resistant to M2 inhibitors.
Other type of new medicine is neuraminidase inhibitors, such as
Oseltamivir and Zanamivir. This type of medicine is safer, and with less
- 141 -
concern of resistance. However it is more expensive and its capacity is
limited. Oseltamivir is only effectively when used at early stages of
symptom occurrence. Zanamivir is a spray, and is only effective in
respiratory tract infection part. Therefore, it is suggested that these 2
neuraminidase inhibitors be used within 48 hours to achieve better
therapeutic effect.
6.2 Infection control and prevention
When fowls are infected with avian flu, large amount of virus will
appear in their excrement and secretions. These contaminants will spread
extensively within the environment, such as water, dust, soil, bird cages
and some utensils. Avian flu virus can exist in soil and water from weeks
to months. The lower the temperature, the longer it survives. Flu virus
can be found in most tissues and organs of the bird infected by highly
pathogenic avian flu, even in the egg it laid. Therefore, it is highly
probable that highly pathogenic avian flu virus be transmitted to human
through bird-to-human mode by direct/indirect contact with or consuming
of these bird excrement or products.
To prevent avian flu from evolving to human adaptive, isolation
measure should be implemented to patients infected by avian flu. Their
excretion and secretion should also be collected and be sterilized. In
addition, try not to get into contact with wild birds as much as possible.
Wear a surgical mask to prevent infection if necessary. Nueraminidase
inhibitors can be administered to close contacts with avian flu patients
and medical staffs as preventive medication to prevent its spread in
hospitals or densely populated areas.
- 142 -
6.3. Vaccine
The human influenza vaccine is produced by culturing highly
pathogenic avian flu virus in eggs. This procedure is suggested to be
operated in labs with biological safety grade 3 or higher. The H5 antigen
is presented in large quantity by genetic engineering, or by using DNA
vaccine to make H5 gene a target gene. However DNA vaccine is not
effective to some heterogeneous H5N1 in mice study.
7. The Use of Disinfectant
In the guidelines for H5N1 infection control in medical facilities
announced by WHO in 24 April 2006, ethanol and bleaching agents
(sodium hypochlorite) were suggested to use. Ethanol effectively inhibits
activity of flu virus. Ethanol of 70% concentration is an effective and
extensive disinfectant, which is often used to sterilize a small range of
surface. Bleaching agent is a very potent and effective disinfectant. Its
active ingredient, sodium hypochlorite, kills bacteria, mold and viruses,
including influenza virus. Diluted home bleaching solution is effective in
different contact time (10minutes~60minutes).
- 143 -
Appendix 2. Estimation on Health Impact of Influenza Pandemic
Senario 1
Influenza Pandemic Impact
Hospital Admission
/
Weeks
1
Weekly admission
4,489
2
3
ICU Capacity
5
6
7
8
9
10
7,482 11,223 14,215 14,215 11,223 7,482 4,489
Peak admission/day
Hospital Capacity
4
2,215 2,215
# of flu patients in hospital
4,489
% of hospital capacity used
6%
10%
# of flu patients in ICU
673
1,428 2,193 2,897 3,135 3,050 2,423 1,673
% of ICU capacity used
10%
22%
34%
37%
26%
ventilators
337
714
1,096 1,448 1,567 1,525 1,212
837
% usage of ventilator
3%
7%
11%
14%
8%
# of deaths from flu
838
1,396 2,095 2,653 2,653 2,095 1,396
# of flu deaths in hospital
586
7,482 11,223 14,215 14,935 13,749 10,640 7,015
15%
19%
44%
20%
48%
18%
47%
14%
9%
# of flu patients on
Ventilator Capacity
Deaths
- 144 -
977
16%
15%
12%
1,466 1,857 1,857 1,466
977
838
586
Senario 2
Influenza Pandemic Impact /
Weeks
1
2
3
4
5
6
7
8
9
10
11
12
13 14
Hospital
Weekly admission
Admission
Peak admission/day
Hospital
# of flu patients in hospital
748
Capacity
% of hospital capacity used
1%
4%
7%
10%
13%
15%
15%
14%
ICU
# of flu patients in ICU
112
500
989
1,479
1,968 2,346
2,475
2,428 2,080 1,631 1,153
675
Capacity
% of ICU capacity used
2%
8%
15%
23%
30%
36%
38%
37%
32%
25%
18%
10%
Ventilator # of flu patients on ventilators
56
250
495
739
984
1,173
1,237
1,214 1,040
816
576
337
Capacity
1%
2%
5%
7%
10%
12%
12%
12%
8%
6%
3%
# of deaths from flu
140
559
977
1,396
1,815
2,095 2,095 1,815 1,396
977
559 140
# of flu deaths in hospital
98
391
684
977
1,271
1,466 1,466 1,271
684
391 98
Deaths
% usage of ventilator
748
2,993 5,237 7,482
9,726 11,223 11,223
1,749
2,993 5,237 7,482
- 145 -
9,726 7,482 5,237 2,993
748
1,749
9,726 11,223 11,791 10,989 9,376 7,132 4,887 2,643
12%
10%
9%
6%
977
3%
The above estimation was simulated under 25% attack rate by FluSurge.
Variables
Age Group
Values
References
0-17 yrs
5,338,586
Stastics from Ministry of
18-64 yrs
15,199,201 the Interior in January,
+ 65 yrs
2,158,562
2005
Total staffed beds
76,074
2003 Health Statistics
Staffed ICU beds
6,526
2003 Health Statistics
Total number of
10,000
Estimated
ventilators
Duration
Senario 1: 8 weeks
Senario 2: 12 weeks
- 146 -
Estimated
Appendix 3. Excerpt of Presidential Instructions to High-level
National Security Meetings
First High-level National Security Meeting on ”Response Strategies to
Possible Invasion of Avian Flu”
19 August 2005
Even though avian flu is not the same as SARS, we should bear in mind
the lessons learned from our previous mistakes. Below is a summary of
some major deficiencies that should not have occurred during course of
fighting SARS for everyone’s reference. They will be further reviewed to
see if previous lessons have indeed been learned to assist relevant
preparations in response to the pandemic threat.
1. Lacking a communication mechanism between central and local
governments, which led to inconsistencies in the pace of fighting
SARS and in government announcements, and sometimes even to
hostility between relevant authorities due to unprofessional factors.
2. Incomplete patient reporting and control system. Individual patients
moved from one medical facility to another to seek care, causing rapid
spread of the epidemic. In addition, patients tended to seek medical
help in emergency rooms in teaching hospitals or medical facilities of
equivalent status.
If nosocomial infections occurred in these
hospitals, the worse case scenario would force hospital closure and
result in paralysis of the whole medical system.
3. Screening of confirmed cases took too much time. The number of
suspected patients was always high. Related isolation and control
measures were difficult to implement, and resulted in unnecessary
panic.
4. Insufficient training to frontline medical staffs in self protection and
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lack of strict compliance with related SOP, which resulted in injuries
and deaths of medical staffs.
5. Severe insufficiency of epidemic prevention equipment and materials
resulted in worries and dissatisfaction of medical staffs and the public.
Under provocation and manipulation by special interest groups, there
were distrust and severe criticisms of the government.
6. Relevant epidemic prevention and medical information was not
delivered timely and explained properly. Matters that required public
cooperation and health self-management were not communicated
concisely.
7. Insufficient horizontal and vertical communication within the
government.
Organizations
of
police
administration,
social
administration, population and household administration, health
management and environment conservation were not able to cooperate
with one another smoothly. Thorough implementation of epidemic
prevention and control measures could not be achieved across all
levels of government, and a seamless safety net for disease control
could not be established to link together central, county/city and
village authorities.
Based on the miserable experience and lessons of fighting SARS in the
past, and combining the reports and opinions of related organizations in
attendance today, the following instructions are given:
1. The above mentioned deficiencies will be reviewed one by one by
administrative departments to make sure the same mistakes won’t
happen again. SARS fighting was our first experience. However, if
we repeat the same mistakes in the future, we will not be forgiven by
the public. So please perform all preparation tasks with the most
- 148 -
careful attitude. Premier Hsieh must strictly supervise the
implementation of all the instructions given to make sure that they
are properly carried out.
2. The
fundamental
solution
to
avian
flu
epidemic
is
the
research/development and stockpiling of anti-virals and vaccines.
Related departments and committees should draft concrete schedules
to manage the work progress of building a stockpile that meets the
safety storage volume. The process should be speeded up to reach a
stockpile volume sufficient for 10% of the population. In addition,
related plans of priority in vaccine distribution and administration
should be drafted based on different stockpile levels.
3. Human-to-human avian flu is a novel type of influenza. The health
authorities should proceed with conducting relevant briefings and
training for medical and public health staffs to reduce mis-diagnosis
and to actively strengthen the reporting and control capabilities of the
frontline epidemic prevention network.
4. Epidemic prevention is regarded as a battle. Preparation and
exercises in peacetime should be given priority. Each government
authority should complete related epidemic prevention battle plans
and SOP within a specified timeframe, and arrange drills and onsite
practices according to various scenarios as soon as possible.
5. Strengthen cooperation with nearby countries and international health
organizations to actively collect information on the latest epidemic
situations and on epidemic prevention strategies. Strengthen border
control and quarantine of people from pandemic areas, strictly block
smuggling of related fowls and animals, and provide complete health
management service to poultry husbandry workers and people who
may be in close contact with migratory birds or who live in areas
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where migratory birds rest.
6. There are similarities and differences between avian flu and SARS
epidemics. We must remember the experiences and lessons from the
SARS epidemic, which taught us the importance of correct
knowledge and comprehensive preparedness and response strategies.
However, we should not overreact. Responsible departments should
make clear policy announcements to all people.
7. All valuable opinions of today’s attendees should be incorporated
into the existing “Response strategies to Possible Invasion of Avian
Flu” of each responsible department to provide a basis for
implementation.
Second High-level National Security Meeting
31 October 2005
President Chen Shui-bian received briefings given by the
Department of Health and Council of Agriculture, Executive Yuan, and
joined discussions with participants. The president made a nine-point
conclusion following the meeting.
1. Although the highly pathogenic avian influenza runs the risk of
becoming an epidemic worldwide, the Executive Yuan has worked
with all related authorities in formulating pre-emptive measures
regarding prevention and quarantine of the disease and helped Taiwan
to remain as a non-affected area. Taiwan also ranks No. 3 following
Japan and Australia in ratings made by international risk assessment
companies. I hereby express my highest affirmation to the disease
prevention team of the Cabinet.
2. The Chinese government has on the one hand suppressed Taiwan from
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entering international health organizations, making it difficult for us to
join the worldwide effort of disease prevention. On the other hand,
they have a tendency of covering up this epidemic, given their
concerns on economic development, social stability and the 2008
Olympic Games. The possible lack of transparency of the disease in
China will put Taiwan at the risk of extreme danger. We hereby urge
the international community to join efforts and monitor the spread of
the bird flu in China and to ensure that they have a well-established,
fast and transparent report system, so China will not become a
loophole in the world disease prevention.
3. It is fortunate that the Coast Guard Administration has seized some
1,000 smuggled birds on their way to Taiwan from China on October
14. This prevented us from facing a potential invasion of the deadly
disease. We never know, however, whether birds carrying virus H5N1
have already been brought into Taiwan. We all understand that
combating a disease is like waging a war. And there should be no
loophole in our disease prevention network. And we are concerned
that China might set off the epidemic of avian flu in Asia as it boasts
to have the world's largest bird and poultry population. We must be on
guard and never rule out the possibility that the bird flu might have
already entered into this island, and we must do everything we could
to break every possible link to the disease. We should also revise
immediately related laws and regulations, intensifying the punishment
of bird smuggling so as to stop the crime.
4. The making and stockpiling of antiviral drugs and vaccines have
become the utmost important work regarding the disease. Whether we
purchase it from abroad or make it by ourselves, we must have a
satisfiable amount of drugs and vaccines that meet the safety standard
- 151 -
of the World Health Organization (WHO). Already in our stockpile is
the Tamiflu, the internationally test-proven and most effective solution
to the disease. It is meanwhile our only weapon combating the
epidemic, though doubts have arisen in respect to its effectiveness. It
is the responsibility of the government to teach our general public and
help them understand the usefulness of the drugs. On the issue of the
authority of drug production, I hope that Premier Frank Hsieh would
pay more attention to the matter and solve the problem as soon as
possible.
5. The paranoid about the avian influenza in Italy has caused its poultry
farmers to go on strikes. But we must know that it doesn't do us good
either if we overestimate or underestimate the situation. And we
should re-evaluate the appropriateness of the measure announced by
the Ministry of Education that students are advised from now on to
take their temperature. What we should do for the time being is to
educate and to equip people with the correct knowledge about the
disease. Also, we must keep the international community with the
correct information. Whenever wrong stories about the disease were
reported in the international society, we should ask that it be corrected
immediately.
6. The outbreak of avian flu in Taiwan will become not only a disaster for
national health and for Taiwan's birds and poultry business, but a great
threat to social stability and national security. Internationally, we
should fight for the right to join efforts with the world in disease
prevention. Domestically, everyone from central to local governments
should work together to prevent the disease, gather useful resources,
maintain enough manpower, engage in inspections and quarantines of
the disease, combat bird smuggling, monitor route of migratory birds,
- 152 -
keep good management of domestic animals, and increase the ability
to manage crises.
7. Up to 18 countries have found cases of the highly pathogenic avian
influenza, with China, Vietnam and Thailand being listed as high-risk
areas by the WHO. Our government should take on the responsibility
and teach our nationals who plan to travel to these countries on how to
save themselves from contracting the epidemic. And we also urge
travelers arriving from the above-mentioned nations to exercise health
self-management.
8. The strike of SARS two years ago wrecked havoc in the stock market
as well as our economy. Western economists have agreed that the
impact of avian flu on world economy could run beyond imagination
if not handled with care. We therefore ask Vice Premier Wu Rong-yi
and Minister without Portfolio Lee Ying-yuan to complete the risk
assessment of countermeasures and help the government deal with
emergencies.
9. Related authorities please incorporate opinions and suggestions by all
participants regarding the issue of avian flu, making them as
references for the government's policy-making.
Third High-level National Security Meeting
9 March 2006
President Chen directed the adoptation of the following 10 points:
1. China has become a black hole of the global avian flu prevention
network. Taiwan should watch more closely on China's avian flu
updates, strengthen surveillance, and, more importantly, ask the
international community to urge Chine to keep China's disease status
- 153 -
and information transparent before it's too late to control the
outbreaks.
2. Highly pathogenic avian flu H5N1 is transmittable from migrant birds
to domestic birds and vice versa. As Taiwan is located amid the
migration routes, it should continue to keep track on this matter. Also,
avian flu prevention policies should be persistent and regularized.
3. According to other countries' experiences, some important strategies
against avian flu pandemics include: effective isolation of wild birds
from domestic ones; culling H5N1-infected birds as soon as there is an
outbreak; and preventive vaccination. If any outbreak of this sort
happens in Taiwan, the central government and the local governments
must work in synergy, all the orders must be fully carried out, and no
negligence and procrastination are allowed to happen in any link of
the chain of command.
4. We should be more stringent on inbound and outbound traffic
quarantine, particularly in preventing illegal bird imports from China,
blocking China's fishing boats from entering our territory, cracking
down on human trafficking, and strengthening the quarantine work in
the "Mini Three Links" in Kinmen and Matsu.
5. Storage and development of antivirus drugs and vaccination are most
effective to fight against avian flu pandemics. Our antivirus drug
storage must reach the required safety level, and the research and
development capacity of vaccines must be built up in accordance with
Dr. Lee Yuan-tseh's initiation proposed in 2004 APEC Leaders'
Meeting.
6. Traditional markets are the blind spots in avian flu prevention. The
government should work on the possibility of prohibiting butchering
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poultry in traditional markets and follow the stipulations according to
the Law of Animal Husbandry and thus conduct centralized butchering
with machinery.
7. After examining the disease spreads in Hong Kong, Guangzhou, Hanoi,
and Ho Chi Minh City, the Urbani Foundation has brought back useful
information on avian flu prevention. The government should guide
and assist the foundation to communicate with China in regard to
disease prevention and control.
8. The key to successful disease prevention and control lies in setting
correct strategies and transforming these strategies into standardized
operation procedures according to which practices and examinations
can be applied. Educating the public is another key area that should
not be overlooked. According to the conference conclusions, the
Executive Yuan is held responsible to arrange an on-the-site operation
and schedule for the president to inspect.
9. In order to establish a reference tank, the Executive Yuan should,
according to the conference conclusions, pre-assess any possible
impact resulted from avian flu outbreaks on national defense, economy,
social
stability,
cross-strait
exchange,
transnational
marriage,
introduction of foreign labors, etc.
10. All the related ministries and departments should adapt and adhere to
the opinions presented in the conference and its conclusions, and thus
incorporate the above mentioned measures into their respective
counterpart strategies.
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Appendix 4. Enforcement Regulations Governing the Central
Epidemics Command Center
Formulated and announced in 37 articles by the Department of Health, the Executive
Yuan, on December 20, 2004, under Shu-Shou-Chi order No. 0930001221
Chapter 1 General Principles
Article 1
This set of Regulations is formulated in accordance with
regulations of Paragraph 2, Article 17 of the Communicable
Disease Control Act (hereafter referred to as the Act).
Article 2 If the central competent authority, in judging the severity of
the epidemic situations in the country in accordance with
regulations of Paragraph 1, Article 17 of the Act, decides that
there are needs to consolidate resources, facilities, and to
integrate personnel of organizations (institutions) concerned,
may make concrete recommendations on mobilization for
disease control, and reports to the Executive Yuan for approval
for the establishment of a central epidemics command center
(hereafter referred to as the Center), and appoints a
commanding officer to meet the epidemic situations.
The severity of epidemic situations mentioned in the
preceding Paragraph refers to the epidemics of major
communicable diseases, attacks of biological pathogenic agents,
or conditions judged by the central competent authority
requiring mobilization to meet emergencies.
Article 3 The functions of the Center are as follows:
1. To evaluate the information of disease surveillance, to formulate
and promote emergency policies for disease control;
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2. To consolidate and integrate resources, facilities, and personnel
of organizations (institutions) concerned needed for meeting
emergencies of disease control;
3. To conduct matters concerning news releases, information and
education, use of mass media with priority, control of entry and
exit of country (border), house quarantine, liaison and
cooperation with international organizations, control of airports
and harbors, requisition of transportation means, cleaning and
disinfection of public environment, labor security and hygiene,
control of communicable diseases common to humans and
animals, and other necessary control measures against major
communicable diseases.
Article 4 The commanding officer of the Center has complete authority
over, supervises, and coordinates government organizations at
various levels, public enterprises, reserved servicemen’s
organizations, nongovernmental organizations, to implement
disease control matters; when necessary, support of the army
may be coordinated.
The commanding officer may assign one to three deputy
commanding officers to assist in executing the functions of the
Center.
Article 5 The commanding officer may, in accordance with regulations
of Article 50 through Article 54 of the Act, instruct government
organizations at various levels to requisition, appropriate, and
integrate resources, facilities or manpower of organizations
(institutions) concerned.
Chapter 2 Organization and Assistance
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Article 6 The Center may establish a secretariat, department of execution,
department of planning, department of logistics, and department
of finance; each department may establish several task force
sections.
In each department mentioned in the preceding Paragraph, there
shall be one director appointed by the commanding officer.
The commanding officer may, upon needs for meeting the
emergencies of disease control, flexibly adjust the task force
sections of each department, their size of staff, and their timing
of establishment. Organizations concerned may be requested
to assist, when necessary, the functions of each department.
Article 7 The Department of Health, the Executive Yuan, shall be
responsible for the Secretariat. The functions are as follows:
1. Overall control of the emergency operations and management
of situations, coordination, and consolidation of resources;
2. Conduct of training and exercises on emergency operations for
personnel to be involved;
3. Follow-up and assessment;
4. Other matters concerning overall control.
Article 8 The Executive Department may establish the following sections:
1. Disease investigation section;
2. Medical affairs section;
3. Immigration control section;
4. Foreign affairs section;
5. Information section;
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6. Control section;
7. Service section;
8. Emergency management section.
Article 9 The Department of Health, the Executive Yuan, shall be
responsible for the Disease Investigation Section of the
Executive Department. The functions and division of support
are as follows:
1. Epidemiological investigations and surveillance of community
health, patients, sources of infection, or vectors;
2. Surveillance of animals, to be supported by the Council of
Agriculture, the Executive Yuan;
3. Surveillance of environment, to be supported by the
Environmental Protection Administration, the Executive Yuan;
4. Investigation and control of crimes, to be supported by the
Ministry of the Interior;
5. Information on bio-terrorism attack, to be supported by the
National Security Council and Ministry of Justice;
6. Other
matters
concerning
disease
investigations
and
surveillances.
Article 10 The Department of Health, the Executive Yuan, shall be
responsible for the Medical Affairs Section of the Executive
Department. The functions and division of support are as
follows:
1. Emergency care before arrival to hospital, resource control on
scene, and when necessary, military medical support and care,
to be supported by the Ministry of the Interior and Ministry of
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National Defense;
2. Medical care, follow-up care, evacuation, liaison, reporting, to
be supported by the Ministry of the Interior, Ministry of
National Defense, and Ministry of Education;
3. Measures concerning medical safety and infection control;
4. Other matters concerning medical care and infection control.
Article 11 The Ministry of the Interior shall be responsible for the
Immigration Control Section of the Executive Department.
The functions and division of support are as follows:
1. Control of entry and exit of the country (border), to be
supported by the Mainland Affairs Council, the Executive
Yuan;
2. Quarantine at borders, to be supported by the Department of
Health, the Executive Yuan;
3. Disease control, to be supported by the Department of Health,
the Executive Yuan, Mainland Affairs Council, the Executive
Yuan, and Coast Guard Administration, the Executive Yuan;
4. Establishment of registration and reporting systems for
passengers entering or exiting the country (border);
5. Other matters concerning immigration control.
Article 12 The Ministry of Foreign Affairs shall be responsible for the
Foreign Affairs Section of the Executive Department. The
functions are as follows:
1. International cooperation in disease control, relief, liaison, and
provision of information;
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2. Assistance to and management of aliens at risk;
3. Visa control of aliens;
4. Other matters concerning international cooperation in disease
control and liaison.
Article 13 The Department of Health, the Executive Yuan, and the
Government Information Office, the Executive Yuan, shall be
jointly responsible for the Information Section of the Executive
Department. The functions are as follows:
1. Release of news concerning disease control;
2. Report of international and domestic news on disease control,
and coordination of management;
3. Negotiation on the use on priority basis of mass media and
communications facilities;
4. Consolidation and dissemination of information for disease
control education;
5. Other matters concerning disease control information and
education.
Article 14 The Department of Health, the Executive Yuan, shall be
responsible for the Control Section of the Executive Department.
The functions and division of support are as follows:
1. Public health control measures such as immunization, house
quarantine, and self health management, to be supported by
the Ministry of the Interior;
2. Vector surveys and control;
3. Control and disinfection of environment, safety of water
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supply, elimination of vectors and sources of breeding, to be
supported by the Environmental Protection Administration,
the Executive Yuan;
4. Quarantine and control of host animals of communicable
diseases common to humans and animals, to be supported by
the Council of Agriculture, the Executive Yuan;
5. Other matters concerning disease control.
Article 15 The Department of Health, the Executive Yuan, shall be
responsible for the Service Section of the Executive Department.
The functions and division of support are as follows:
1. Mental health services to the public, patients, and families;
2. Handling, examination of remains which have died of
communicable diseases, professional counseling or technical
support, to be supported by the Ministry of the Interior and
Ministry of Justice;
3. Matters concerning condolences to families of victims of
communicable diseases, to be supported by the Ministry of the
Interior;
4. Other matters concerning services to peatients.
Article 16 The Ministry of the Interior shall be responsible for the
Emergency Management Section of the Executive Department.
The functions are as follows:
1. Matters concerning emergency management such as fire
control of the scene of incident, search and rescue, control of
order, and management of hazardous articles;
2. Maintenance of public works;
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3. Other matters concerning emergency management.
Article 17 The Department of Planning may establish Information
Section and Evaluation Section, to be under the responsibility of
the Department of Health, the Executive Yuan. The functions
are as follows:
1. Surveillance of disease epidemics and collection, compilation
and analysis of real-time information for the advance warning
systems;
2. Designing of information systems, negotiation, maintenance,
and management of information exchanges;
3. Amendment of emergency measures and standard operational
procedures and evaluation of achievements;
4. Epidemiological investigations, and formulation of emergency
management, restoration, or mid-, long-term, alternative plans,
and evaluation of their achievements;
5. Support to the briefing of epidemic situations and incidents;
6. Other matters concerning data processing, program planning,
and evaluation of achievements.
Article 18 The Department of Logistics may establish the following
sections:
1. Technical section;
2. Transportation section;
3. Supply section;
4. Manpower section;
5. National defense resource section.
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Article 19 The Department of Health, the Executive Yuan, shall be
responsible for the Technical Section of the Department of
Logistics. The functions are as follows:
1. Quality control of laboratory testing and technical support;
2. Control of communications, and maintenance of the soft and
hardware of information and visual-information systems, and
technical support;
3. Assessment
of
techniques
for
disaster
management,
maintenance of special facilities;
4. Other matters concerning disease control technology.
Article 20 The Ministry of Communications shall be responsible for the
Transportation Section of the Department of Logistics. The
functions are as follows:
1. Requisition of sea, land, air transportation means and support
to their communications technology;
2. Management of the transportation of manpower, disease
control supplies and facilities;
3. Emergency transportation of specimens;
4. Other matters concerning transportation.
Article 21 The Department of Health, the Executive Yuan, shall be
responsible for the Supply Section of the Department of
Logistics.
The functions and division of support are as
follows:
1. Sufficient supply and storage control of materials for disease
control and medical care, to be supported by the Ministry of
Economic Affairs;
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2. Supervision and control of the fair trade of materials for
disease control and medical care, to be supported by the Fair
Trade Commission, the Executive Yuan;
3. Appropriation of special materials and facilities for disease
control and medical care, to be supported by the Ministry of
Economic Affairs;
4. Other matters concerning the control of materials for disease
control.
Article 22 The Department of Health, the Executive Yuan, shall be
responsible for the Manpower Section of the Department of
Logistics. The functions are as follows:
1. Requisition and training of medical manpower;
2. Life support, medical care of employees, and assistance to
their families;
3. Other matters concerning manpower support.
Article 23 The Ministry of National Defense shall be responsible for the
National Defense Resource Section of the Department of
Logistics. The functions are as follows:
1. Provision of information on relevant hazards collected by the
military information systems;
2. Monitoring and control of disease epidemics in army, and their
reporting;
3. Support of isolation sites, devices, or manpower for disease
control and medical care;
4. Other matters concerning support needed for disease control.
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Article 24 The Department of Finance may establish the following
sections:
1. Administration section;
2. Industry section;
3. Relief section;
4. Reconstruction section.
Article 25 The Department of Health, the Executive Yuan, shall be
responsible for the Administration Section of the Department of
Finance. The functions are as follows:
1. Administrative support to biddings for procurement, financial
reports, and management of the registration of properties;
2. Review, approval, and supervision of monetary awards for
personnel, compensations and their procedures;
3. Security control of the Center, and installation and
maintenance of business machines;
4. Other matters concerning administrative support.
Article 26 The Council for Economic Planning and Development, the
Executive Yuan, shall be responsible for the Industry Section of
the Department of Finance. The functions are as follows:
1. Stable development of domestic economics and finance;
2. Assistance to industries to meet impacts of disease epidemics;
3. Supervision of stable commodity prices and fair trade;
4. Other matters concerning stability of industries.
Article 27 The Ministry of the Interior and the Ministry of Finance shall
be jointly responsible for the Relief Section of the Department
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of Finance. The functions are as follows:
1. Education on policies of post-disaster reconstruction and
restoration, and assessment of the costs;
2. Assistance to the relief of industries under impact;
3. Approval of documents for relief and sympathy money;
4. Abatement, exemption, or delayed payment of taxes,
assistance to matters such as the settlement of disaster
insurance claims or low-interest loans, to be supported by the
Finance Supervision and Management Commission, the
Executive Yuan;
5. Other matters concerning relief.
Article 28 The Department of Health, the Executive Yuan, shall be
responsible for the Reconstruction Section of the Department of
Finance. When necessary, support of relevant organizations may
be requested. The functions are as follows:
1. Attribution of responsibilities and explanation of public health
laws and regulations;
2. Risk-management of medical care (medical) institutions, and
coordination;
3. Managements of use licenses for pharmaceuticals, medical
devices, and special facilities;
4. Reconstruction after disaster of medical care (medical)
institutions, management of restoration, and compensations to
losses of emergency appropriation;
5. Other matters concerning the reconstruction and restoration of
medical care (medical) institutions.
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Chapter 3 Training
Article 29 As needed for meeting emergencies of disease situations, the
Center may, in coordination with the emergency plans of the
central competent authority, conduct special lectures and
training for relevant personnel.
Chapter 4 Operational Procedures
Article 30 The commanding officer may, pending upon the epidemic
situations, notify ministries and departments concerned to
dispatch personnel to the Center by the designated time.
Each organization or department concerned shall arrange a duty
shift schedule for personnel to be assigned, and prepare a name
list for emergency contact, and send them together to the Center.
Article 31 The departments and sections of the Center shall at all times be
kept aware of all new information of the situations; and upon
receipt of the information, shall process it in the following
ways:
1. The processing of information and recommendations for
management shall be reported to the Secretariat, and notify
departments concerned.
2. When cross-departmental coordination or reporting is
necessary, the relevant department with authority and
responsibility shall be informed immediately for prompt
action; and shall, at the same time, report to the Secretariat.
3. Reporting of information with attributable responsibility,
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recommendations for management, orders, supervision, and
telephone calls, shall be recorded in writing, and submitted
to senior officers with authority and responsibility.
4. A daily record shall be kept, and submitted to the senior
officers with authority and responsibility.
Article 32 The Center may send official communication to other
organizations under the name of either the Center or the
commanding officer.
Article 33 The commanding officer may, depending upon the epidemic
situations and their management, request the Executive Yuan to
dissolve the Center.
Article 34 Upon dissolution of the Center, the organizations which have
joined the Center shall submit all records made during the
existence of the Center to the central competent authority for
collection
and
reporting;
the
various
restoration
and
reconstruction measures shall be continued by the organization
with authority and responsibility.
Chapter 5 Supplementary Provisions
Article 35 The administrative expenses of the Center shall be paid from
the budget prepared by the central competent authority.
Article 36 When local competent authorities establish, in order to meet
epidemic situations, local epidemics commanding centers, the
relevant regulations of this set of Regulations may also apply.
Article 37 This set of Regulations shall be implemented on the day of
announcement.
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Appendix 5. Exercises in Response to Influenza Pandemic
Central Government (July 2005~October 2006):
1. 7 July 2005: Functional exercise of novel influenza for pandemic
phase A1~A2 (held by CDC)
2. 19 October 2005: 2005 Joint epidemic prevention exercise of highly
pathogenic influenza (held by Council of Agriculture)
3. 27 December 2005: Functional exercise of novel influenza for
pandemic phase B~C (held by CDC)
4. 21-22 March 2006: 2006 national defense No. 29 WanAn exercise –
Suspected novel influenza (human avian flu) induced “Joint exercise
of administration and army” (held by Command Department of
National Reserve Force in southern area)
5. 6 April 2006: Drill on control measures for incoming passangers in the
airport (held by Ministry of Transportation and Communication,
Ministry of the Interior and DOH)
6. 20 April 2006: 2006 national defense No. 29 WanAn exercise –
Exercise of large care facilities in novel influenza pandemic phase C
(held by Ministry of National Defense and Pingtung county
government)
7. 11 August 2006: Drill of anti-virals prescription (held by Bureau of
Pharmaceutical Affairs of DOH)
8. 17 August 2006: Egret No.1 – Off-shore infectious disease patients
exercise without prior notice – Exercise of Taipei area Infectious
Disease Prevention and Control Medical Network on handling
infectious disease patients in off-shore islands – “Patient doesn’t move,
medical group stationing” (held by CDC)
9. 22 August 2006: Egret No. 7 – Operation of Central Epidemic
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Command Center in pandemic phase A1 (held by CDC)
10. 14 October 2006: Egret NO.2 – Exercise on emergency dispatch of
epidemic prevention materials (held by CDC)
11. 19 October 2006: Egret No.1 (2nd exercise) – Off-shore infectious
disease patients exercise without prior notice – Exercise of Infectious
Disease Prevention and Control Medical Network on handling
infectious disease patients in off-shore islands – “Patient doesn’t move,
medical group deployed” (held by CDC)
Local Government (January~October 2006):
1. 16 January 2006: Exercise on procedures of hospital evacuation
during novel influenza pandemic (held by Changhua county)
2. 8 January 2006: “Exercies on handling procedures and transfer of
novel influenza patients” without prior notice (held by Hualien
county)
3. 21 February 2006: 2006 Exercise on retail market and street vendor
aggregated areas in response to avian flu prevention in Tainan (held by
Tainan city)
4. 24 March 2006: Exercise on transportation and treatment of novel
influenza cases imported through mini-three links with China (held by
Kinmen General Hospital of DOH)
5. 31 March 2006: Table-top exercise of Incident Command System
(ICS): Dealing with novel influenza (held by Taipei city)
6. 9 June 2006: Exercise of large care facilities in Changhua county
during influenza pandemic (held by Changhua county)
7. 26 July 2006: Table-top exercise on epidemic prevention of novel
influenza (avian flu) in phase A and C (held by Taipei city)
8. 26 July 2006: 2006 Exercise of large care facility mobilization during
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influenza pandemic (held by Miaoli county)
9. 27 July 2006: 2006 Exercise of large care facility in influenza
pandemic phase B and C (held by Hualien county)
10. 31 July 2006: 2006 Functional exercise on epidemic prevention of
highly pathogenic avian flu (held by Hualien county)
11. 13 August 2006: Receiving, treatment and transfer of novel influenza
patients from primary clinics (held by Taipei county Bureau of Health)
12. 27 October 2006: Exercise of pandemic large care facilities in Tainan
county during pandemic (held by Tainan county)
13. 4 October 2006: Exercise of establishment of large care facilities in
response to pandemic in Yilan county (held by Yilan)
14. September~October 2006: Table-top exercise of evacuation plan of
Infectious Disease Prevention and Control Hospital. Twenty-three
exercises in total (held by county/city governments)
15. September~October 2006: Table-top exercise on evacuation of
non-infectious disease prevention and control hospitals enlisted for
help by government in response to novel influenza pandemic. Six
exercises in total (held by county/city governments)
- 172 -
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