RP A(H1N1) fatality rate at 0.06%

Although the health department has listed more than 1,800 cases of Influenza A(H1N1), only one has died so far. The fatality rate for the Philippines stands at 0.06%, Health Secretary Francisco Duque III said in a congressional hearing on A(H1N1) last Monday, July 5.
Still, World Health Organizations (WHO) statistics say there were young, healthy people WITH NO UNDERLYING MEDICAL CONDITION who died of Influenza A(H1N1). It’s still not clear how and why, but the WHO said that in those cases, the progression of the disease was rapid and by the time they were brought for treatment they were already in a serious condition.
My notes on the congressional hearing last Monday.

**who: young healthy people die, rapid progression. By the time brought for treatment already serious (in other words untreated cases). Seasonal flu strikes old people, with underlying medical condition.

RP fatality rate: 0.06%

Duque: morbidity rate doesn’t mean deaths on account of seasonal influenza….rate of affected individuals, with mortality rate.

Vaccines available for seasonal flu. Pandemic influenza, vaccines would not be available in early stages of pandemic. Vaccines to be developed only enough for about 5% of population. Among population priority group would be groups that provide essential services, at high risk of death, general population.

Our projected budgetary requirements for ah1n1…2% of population to be admitted as severe cases, PhP3.6b for medicines. 16b for priority group. PPEs – P22m…CHD support – 150m. Total: 19.839b.

Why do we need to provide up to date and rapid info: allow health care profs and public health authorities to adjust…reduce impact of inaccurate rumors…

Epidemic curve: establishment stage…cases in certain areas, being sustained…expect more cases to come in, exhausting all possible susceptible…

Once virus introduced in area, report sporadic cases…among outbreaks, there would be some cases…until report regression of cases in which case number of cases go down…medical response, non medical intervention and social economic system to keep society functioning.

Anti-viral drugs, vaccines…personal hygiene, quarantine, etc….non-medical…will keep society functioning…once socio economic system stable, will keep interventions going on. They complement each other, not stand alone thing.

Doing mitigation response, maintaining containment process in certain areas. Containment prevents and delays entry in area…stops transmission. Mitigation…adequate care to increasing number of cases…

Worldwide mortality rate: .42%.

450,000

Biazon: study on rate of spread

Duque: dr. oe nyunt-u: be careful in using those stats…in us, dir of cdc Atlanta…stas in us just tip of iceberg of this epidemic…us not exactly know complete situation of h1n1 epidemic…when we interpret stats we have to be careful…more cases than confirmed by lab tests…us and mexico started few months ahead of rp…current stats evolving…at beginning of epidemic in rp and us at the end…waiting for the end so see complete evolution…rp is consistently low…may not know total no. of h1n1 cases but pick up severe cases…in terms of mortality…our death figure may not increase but our morbidity figure may increase…who caution all member states not to neglect this mild pandemic…so far evidence shows moderately severe. Not seen complete evolution of this pandemic…we do not want everyone to be complacent.

Biazon: sec said mild but who gave caution, moderately severe. Conflict bet those two statements…in coming up with strategies to counteract problem, nothing to rely on but stats that’s why we’re looking at stats.

Duque: the mild definition that we adopt in phils on basis of clinical manifestation. From who perspective moderate in terms of geographic spread and no. of people affected.

Biazon: so the phils is describing ah1n1 as mild based on exhibited symptoms…and who moderately severe in terms of spread. Clarify because public listening to statements of these officials would sound conflicting…necessary for us to arrive at standard in terms of how to describe h1n1. My next question is…should we categorize as same level as seasonal flu, has been with us for a long time and we don’t pay attention to us. If it’s really that mild, about time for us to downgrade it?

Duque: premature for us to do so at this point. We haven’t really seen enough of this virus and how it continues to evolve. The mild clinical manifestations in affected persons…these are what we have commonly observed but also a word of caution is that the virus may lead to severe complications in patients with pre existing medical conditions. That clarification deserves to be highlighted.

Biazon: people have impression, when you say mild, nothing to worry about.

Duque: have to admit…struggling with coming up with effective risk communication. We would like to inform the public as often as we can about risks associated, but want to make sure we don’t create panic…we cannot underestimate the potential of this virus to undergo mutation and become more virulent and create complacency in mind of public…have to balance all time, symptoms mild but not want to be complacent…probably we’re not even halfway into the evolution of this virus. Remember seasonal flu in rp has begun, april may june. June july are the peak months of seasonal flu, see this trend going all way and waning until dec. not sure if ah1n1 will follow same trend of seasonal influenza.

Biazon: how relevant are stats for doh in coming up with policy?

Duque: stats extremely important..something that provides us with additional guideposts in reviewing and amending guidelines…all interim. Have to be nimble, to change as virus continues to evolve.

Biazon: another conflict that I see. My experience…brought them to doctor…doh guideline is not to test anymore. How do we know rate of infection in phils? That figures are accurate…if we did not have them tested, my nephew wouldn’t have been part of stat now, no clear picture of spread of ah1n1. Stats important but down the line the guideline is not to test anymore. Let people get better. How do we know the rate of infection?

Dr. so: the point I have mentioned about moderate severity. The who mandate is over global characterization of pandemic….within that context…as we have seen in all countries, majority of cases are mild, so mild that in most countries, no policy for country to test all suspected case, even in us…not trying to test all possible suspects. In that sense see that no country in this world trying to expend resources to test all h1n1 case to get stats…bear in mind that what this ah1n1 pandemic…although manifestations mild, no country can say adequately prepared to deal with is, even with mild manifestation and spread manageable. We are dealing with unknown, pandemic still evolving. But one thing is sure: pandemic is established. We will deal with this in the next couple of years.

Biazon: budgetary requirement….just for ah1n1 or other viruses? Back when we had sars…looking at preparing for the next infection that will come around soon.
Facilities…what lab facilities…would like to see other testing sites all over the country…even private hospitals sending samples to ritm.

Duque: specific to ah1n1. Pandemic preparedness plan that covers whole slew of other pandemics…given limited budget, we have decided to just make it specific to ah1n1. This week Vicente sotto starts testing of ah1n1…san lazaro opens testing capability for ah1n1…training for additional testing, labs in northern Luzon, underway. Part of budget is to capacitate further the testing capabilities of not just the hospitals per se but also for the new testing centers that will have to be supported as need for more testing arises.

Biazon: wise to throw in 16m for vaccines that may become irrelevant as virus mutates? Or put in upgrading capabilities?

Duque: in touch with thai min of health and thai is about to begin manufacturing their ah1n1 vaccine. 40 times cheaper than what other multinational companies…are developing which is heat inactivated virus. (yung isa light attenuated). You need two units of this. Might be good to look into what thai is doing…if cheaper, might consider accessing this.
Ritm, olveda: for past 5 years monitoring influenza all over…sentinel sites in different regions in country…first five years monitoring using culture…isolate and culture, 2-3 weeks after taking samples…results to monitor how many cases are due to influenza and whether there are unusual increases in different sites. Last 8 mos rtvcr in detection of influenza a virus…expensive and high technology…requires level 3 labs….have to protect samples from contamination and the individual from being infected…able to shift immediately from influenza a to h1n1…at beginning capacity was 120 samples a day. When first few cases picked up, increased to 250 samples a day…june 15, number of samples that ritm was receiving was more than our capacity. Went beyond capacity to 300, 400 samples but just too many samples coming in, unable to process them in time. At beginning reporting real time…considering also transport time…there was a time when samples were too many and we were running out of reagents, reagents from cdc were not coming on time because there was global shortage of reagents. Number of staff maximum, people working 12 hour rotation…layers of responsibility of managing these…want to make sure…in case of ili should be managed whether negative or positive, same process, same ili should stay at home whether results positive or negativve. To protect themselves and also others. When cases too many result not relevant anymore in management of cases. Now on real time in reporting…plus we have opened new testing sites in Vicente sotto, 120 a day, san lazaro, 120 a day and lung center and baguio gen and Davao medical center. Strategy on when to reduce number to be tested important because that’s the only way we can cope with number of people to be tested….ritm responsible for appearance of new strain, indicated by number of samples that cannot be typed. Indication that there is new strain coming in. monitor devt of resistance to virus. Also quality assure all labs that are testing the samples. …even if you are negative, there is no assurance that you are not positive.

Lagman: how much does gov’t spend on per capita basis for testing a patient?

Duque: about P3,200 but if you were to input labor costs easily about P4,000 as ceiling of cost.

Lagman: this is not passed on patients in gov’t hospitals.

Duque: true.

Lagman: P4,000 approximates what private hospitals are charging their patients.

Duque: heard some charging as much as P6,000.

Lagman: also give a kit…which they charge at P1,500…some have taken advantage of situation..which I think should call for another investigation. Talking with a parent who had child tested in a private hospital…P6,000 for the test. How does h1n1 compare to Spanish flu? Which killed about 50-100m people in one or two years?

Duque: Spanish pandemic of 1918…40-50m worldwide. Many reports say there was a first wave, and the first was relatively mild and the second came with a vengeance, causing millions of deaths. To compare the 2009 situation with 1918, very difficult to fathom. In 1918 world just beginning to recover from world war I and public health systems too few and far between….largely underdeveloped, most not ready to give care to those affected with pandemic flu. Think it’s a good thing to learn, the pandemic flu in terms of preparedness that we have put together to respond to the continuing threat…if you look at case fatality rate…relatively low. Sars and avian influenza…50-60% fatality rate…trouble with ah1n1 we don’t know how this virus will turn out. At stage where we have to keep our guard up.

Lagman: Spanish flu had avian influenza strain.

Duque: not the same…

Lagman: avian influenza strain. Spanish flu not indigenous to spain…but Spanish media had the courage to announce they had the flu compared to other countries.

Duque: didn’t want to announce it because they were concluding a war…

Golez: if there is a difference in opinion…which should prevail?

Duque: the doh.

Golez: who is just a resource agency? As un affiliate body?

Soe nyunt-u: we provide technical support to member states but decisions….to executive arm of country who makes decision. Doh of every country that makes decisions. We provide technical support; we don’t have decision making authority. Advisory support, globally, regionally…we don’t have serious disagreement, whenever there is an issue…resolve those by bringing in technical expert committees involving member states raising those issues and try to resolve in most consultative manner…this pandemic as we know is evolving we don’t have all signs in our hand…we can’t say we have all evidence to give strong advice. Learning to deal with pandemic, gathering evidence across all countries including phils.

Lagman: how much appropriation for ritm?

Olveda: when we started screening, emergency funds of p4m, new pcr, P5m. Regular budget being used for regular operation, sec appropriated additional amount…budget now is about P65m. Covers everything.

Lagman: I think ritm needs much more and we will consider that during the next budget season.

Maglunsod: no. of affected victims of virus. 1,709. Lahat na ba ito, kasama na mga victims from far flung barangays, victims from communities in work areas?

Duque: ito po lahat ang confirmed cases na nagpakita ng simptomas ng ILI. Katulad ng usa, uk, Canada, ang bilis ng pag test ng specimen ay hindi kasing bilis ng pag spread ng virus. Baka may kaso sa labas na hindi nakukuha sa pamamagitan ng testing.

Maglunsod: mekanismo ng doh para ma-monitor ang victims sa malayong lugar. Sa work places, vulnerable sila…ano ang gagawin ng gobyerno sa ganitong situation, lalo na sa manggagawa. Reports mula sa work places ang mga manggagawa, may viruses hindi confirmed…but sort of viruses at kailangan mabigyan ng karampatang pagtugon…pwedeng ma-avail ang phil health, what about workers na hindi regular. Community na walang ganoon. In connection to that…two weeks ago, pagkatapos ng free vaccination dito sa congress, hindi kasama ang non-plantilla staff..nag file ako ng resolution..expressing sense of congress na magkaroon ng vaccination along the vicinity of batasan.

Duque: pamamaraan kung paano matukoy…bahagi ng serbisyo, libre ang test. Sinuman ang may kinakailangan na indikasyon na masuri…binibigyan ng testing na libre, ang gamot binibigay din n alibre…nakasalalay sa surveillance systems, sentinel sites, events based surveillance na nangyayari, contact tracing para malaman natin kung sino sino ang mga apektadong manggagawa…iniuulat sa mg astride…lahat nakikipagugnayan pagdating ng mga ulat o reports of influenza like illness, ito po’y pinupuntahan natin.

Maglunsod: socio economic systems.

Duque: bahagi ng…economic and social sytems na kinakailangan ay masiguro ng pamamaraan na ang basic services ay nandyan, pagkain, kuryente, gasoline, tubig, sanitasyon, food production and distribution, financing, security…kailangan gumaganang lahat bago magawa ang medical at non medical intervention..upang masiguro na tunay na gumagana…kailangan ang medical at non medical intervention.

Maglunsod: batay sa 2009 budget, pinakamalaki foreign debt. 60% of budget of 2009. Given situation sa doh, P22b ang budget ng health sa 2009.

Duque: doh proper…P23b, isasama lahat, mga P33b. Tumaas na…ng 30% more ng dalawang beses.

Maglunsod: relatively sa ibang priorities, mas mallit pa rin ang pagtaas…aabot lang ng P249 bawat Pilipino ang budget natin para sa kalusugan…medyo interesante ako sa food production and distribution…may relasyon sa priority ng ating gobyerno…

Labor: dole issued dept advisory no.4, guidelines on ah1n1 prevention and control at workplace…gives essentials of prevention…imp’t may tubig, sabon…mga dapat nilang gawin kung sa mga info ng h1n1…kung may sakit na at karamdaman ang isang worker, hindi dapat pumasok, sa bahay na lang at magpasuri sa health care provider…paano ihandle ang manggagawang may ILI. To stay healthy so that they will not be affected by virus. Task force to monitor. All work places should submit reports illnesses to dole. Strengthen naming ulit ang monitoring system to be given to dole. Hindi lang h1n1…illnesses and accidents dapat nire-report sa regional offices.

Maglunsod: hindi pumapayag ang management na bayaran ang manggagawa habang may virus…hindi naman kasalanan na magkasakit sila..itong mga concern natin na karamihan ng Managua na hindi regular at walang economic benefits.

Labor: nasa guidelines din how to treat leave entitlements…however sinasabi din namin by mutual agreement…agree on leave of absence…look at other forms of leave sa mga workers na magkaroon ng h1n1.

Maglunsod: walang problema sa manggagawa…karamihan wala ng mga unyon…hanjin mismo malaking contractor hindi tumutupad…

Labor: nag-coordinate na kami sa regional officers…

Maglunsod: kung may violators, hindi pwedeng ma-criminalize ang management na lumalabag.

Labor: tignan po namin…may guidance po, may labor code tayong sinusunod…