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and do no necessarily reflect the views or policies of the Asian Development Bank
(ADB), or its Board of Governors, or the governments they represent. ADB does not
guarantee the accuracy of the data included in this paper/presentation and accepts no
responsibility for any consequence of their use. Terminology used may not necessarily
be consistent with ADB official terms.

Department of Health

Research Institute for Tropical Medicine

Socorro P. Lupisan, MD, MSc


Director IV
Public
Health
Research

RITM
Clinical
Trials

Tertiary
Training Healthcare for
Courses Infectious
Diseases

Executive Order 674, 1981


The Beginnings of Research Institute for Tropical Medicine
• More than a decade from concept to
construction
• In 1964, studies by research scientists of
the Philippine-Japan Joint Commission on
Cholera Research led to a better
understanding of epidemiology and
control of El Tor Cholera…need for basic
laboratory support…concept of a
research institute was born.
• In 1979, bilateral agreement between the
governments of Japan and the
Philippines was signed.
• EO 674 signed on March 28, 1981,
formally established the Research
Institute for Tropical Medicine.

• RITM was inaugurated on April 23,


1981 as a grant-in-aid from Japan.
Experimental Animal Laboratory
1 JICA Technical Cooperation

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8
5
1 9 8 9

Center for Training in Tropical Infectious Diseases


1989 Grant-in-aid from the Government of japan
Third Country Training Programs
*Acute Respiratory Infections

*Diarrheal Diseases

*HIV and Opportunistic


Infections

*TB
1 9 8 9

Residence Hall
Grant-in-aid from the Government of japan
2
0
0
2
Public
Health
Research
Biologicals
RITM Production

Clinical
Trials
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Training Tertiary National
Courses Reference
Healthcare Laboratories

Merging of RITM and BPS (1998) and


Establishment of RITM National Reference Laboratories (2000)
Research Institute for Tropical Medicine
Philippine Department of Health
• Responsibilities
– Main research arm of DOH for infectious and tropical
diseases (1981)
– National Reference Laboratories for infectious
disease (2000)
– Designated Referral Hospital for Emerging and
Reemerging Infections (2003)
– Biologicals production, storage and distribution of
EPI vaccines in the country (1998)
– Regional Training Center for Good Research
Practices- WPRO-WHO
Key Achievements
• Translation of research output to public
health policies
• Over 500 publications in peer-reviewed
international journals
• Rapid laboratory response to outbreaks
and pandemic threats
• Clinical expertise in management of
infectious and tropical diseases
• Established and expanded formal
linkages with local and international
institutions
RESEARCH MANDATE
Main research arm of the Department of Health for prevention and control of infectious and
tropical diseases.
• Acute Respiratory Infections • ARI Case Management/ Pnc and Hib vaccine studies/
• Dengue, JE evolving epidemiology and etiology
• Diarrhea • Dengue epidemiology/Dengue vaccine
• Filovirus • Breastfeeding/ Rotavirus epidemiology
• Hepatitis • Hepatitis epidemiology for vaccine recommendation
• HIV/AIDS • Largest cohort of HIV patients on ARV
• Influenza • Influenza surveillance infrastructure for flu and possible
• Leprosy emerging respiratory pathogens
• Malaria • Leprosy management recommendations
• Rabies • Malaria treatment guidelines
• Schistosomiasis • Cost-effective management of dogbites
• Tuberculosis (TB) • Schistosomiaisis epidemiology/diagnostics and R and D
• RITM-Tohoku University • MDR TB surveillance and new diagnostics
Research Collaborating Center • Novel respiratory pathogens, molecular epidemiology
for Emerging and Reemerging of rabies, burden of childhood pneumonia and burden
Infections of influenza
• Medical Research – other
infectious diseases
Research Institute for Tropical Medicine
Philippine Department of Health
• Responsibilities
– Main research arm of DOH for infectious and tropical
diseases (1981)
– National Reference Laboratories for infectious
disease (2000)
– Designated Referral Hospital for Emerging and
Reemerging Infections (2003)
– Biologicals production, storage and distribution of
EPI vaccines in the country (1998)
– Regional Training Center for Good Research
Practices- WPRO-WHO
National Reference Laboratories
Department Order 393-E, November 2001 designating RITM as NRLs
Laboratory Programs
Dengue Sentinel surveillance 2014
Measles and other exanthems Eradication program
Enteroviruses (Polio and other enteroviruses) AFP surveillance
Influenza Philippine National
Influenza Center 2014
Bacterial enteric diseases Outbreak response
Antimicrobial resistance Sentinel surveillance
Mycology Medical/dermatology
Tuberculosis and other mycobacteriology MDR TB surveys
Malaria and other parasites Therapeutic Efficacy Studies
Emerging diseases (Viruses, Bacterial pathogens, Local oubreaks/ PHEIC
Zoonoses)
Confirmatory testing for blood donors and blood units NVBSP support
Vaccine preventable Invasive Bacterial Diseases (VP-IBD) Sentinel surveillance 2014
2015 MERS CoV, Ebola Reston, Bioterrorism attack?

▼ ▼ ▼ ▼ ▼ ▼ ▼
2014 Measles, MERS CoV, Henipah, Ebola?
2013 Pertussis, Measles
2012 Leptospirosis No H5N1, H7N9, Ebola
2011 Chikungunya
2010 Dengue
2009 Pandemic A H1N1
2008 Ebola Reston in pigs and humans/ Leptospirosis/ Salmonella typhi

2007 Resistant Shigella flexneri 2a in Cavite, Bohol and Cotabato


2006
2005
2004 Meningococcemia outbreak in CAR

2003 SARS Outbreak


2002 West Nile Virus Pseudo outbreak (RITM as Referral Laboratory)


2001 Bioterrorism threat using Bacillus anthracis as biological weapon


1998 Serological Surveillance ABLV


▼ ▼

1996 Ebola Reston in monkeys (US)

1992 Ebola Reston in monkeys (Sienna, Italy)


▼ ▼

1989 Ebola Reston in monkeys (Reston, Virginia)


The National Reference Laboratory for Emerging and

Emerging Infections in the Philippines Reemerging Viral Zoonoses


RITM
HOSPITAL FACILITIES
▪Tertiary hospital with 50 bed capacity
• 8 negative pressure isolation rooms (including 2
Intensive Care Units) for cases and suspects
with highly communicable diseases, e.g. SARS,
H1N1, MERSCoV, H7N9, Ebola
• 40 beds (single rooms and ward including 2 rooms
for RITM employees needing hospitalization)
▪ Outpatient services
• General Infectious Disease OPD
• Dermatology Clinic
• Animal bite Clinic
• HIV/AIDS Clinic
• TB-DOTS Clinic
• Sexually Transmitted Infections (STI) Clinic
• Clinical Trials
▪ Emergency Room/Admitting Section
2nd FLOOR RITM SARS FACILITY, 2004

NORTH WING
NEGATIVE PRESURE
ISOLATION ROOMS

Exhaust System for the Air Handling Unit of the Negative Pressure Isolation Rooms
LABORATORY EAST WING
RESEARCH DIV

Negative Pressure Isolation Rooms

Hallway Control Panel for Negative Pressure


ICU
EBOLA 2014

BIGGEST CHALLENGE

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FACILITY DESIGN

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General Principles Objectives

• Stop the spread of Ebola in the community


• Provide a safe environment for staff and
patients
• Provide supportive care to patients

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HOW?
• Controlled and limited access to patients and contaminated
area ETU physically separate from outside and divided into
different risk zones with plastic mesh fences to let people
see through
• Controlled movement of staff Clearly defined gates for
entry and exit between risk zones and with outside with
unidirectional flow
• Access only to authorised and trained persons through
well-defined gates while using well-defined protocols
(disinfection, dressing)
• Disinfection facilities for people leaving contaminated area
(staff, visitors, and patients)
• Safe disposal of waste and corpse

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6 things to worry about
1. New patients/suspect cases
2. Probable/confirmed cases
3. Waste (of all kinds)
4. Staff
5. Materials
6. Dead bodies

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Risk Zones in ETUs
• LOW-RISK ZONE:
– Supportive activities such as chlorine preparation,
medical staff meetings, laundry of resuable materials,
pharmacy and stores
• HIGH-RISK ZONE
– Where patients are cared for, contaminated waste is
being treated, and corpse is being handled Subdivided
into suspects, probable, confirmed, waste
management Highly contaminated
• Between High and Low Risk Disinfection facilities
• There is no « no-risk » zone
• Between Low and High Risk Screening Area

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Flow
• Always move from the least to the most
contaminated zone, then to disinfection
facility Low risk suspect ward probable ward
confirmed ward morgue/waste management
disinfection  low risk

• Separate entrance to low-risk zone for staff, family


member, visitors
• Separate entrance for patients walking suspects
screening area  move to suspect ward
– patients arriving by ambulance  move to suspect ward
– patients already confirmed  move to confirmed ward

• Deceased patients leave the treatment Unit through the


morgue exit  ambulance

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Examples of transferring material
• Buckets, bed covers, blankets, sheets, etc.
– All belong to high-risk area
• Food and food containers
– Disposable containers or use ‘tipping’
• Personal items
– Only items that can be reliably disinfected
• PPEs
– Heavy rubber gloves, boots, goggles, etc. can be
disinfected with 0.5% chlorine solution

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ETU Personal and groups
• Medical staff (doctors, nurses, psychologists,
social support staff)
• IPC support staff (cleaners,laundry staff etc. )
• Patients
• Family Members
• Logistic staff
• Coordination staff
• Epidemiologists
• Lab team
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High-Risk Zone

• NO emergency
• NO running
• Buddy system
• Limited amount of time inside
• Clear idea of what you will be doing
before entering
• All material ready before dressing
• What goes in DOESN’T get out

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Thank You
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Entrance to Ebola Treatment Unit, East Ward, 2014

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Ebola Treatment Unit, East Ward

Doctors and Nurses’ Entrance

Doctors and Nurses’ Doffing Room


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Activity

Where is high-risk and low-risk zone?


Where will staff enter?
Where will patients enter?
Where will staff put on and put off PPE?
Where will staff leave?
Where will waste leave?
Where will human remains leave?
Where will high-risk items have to travel before
disposal?

April 16, 2018


Example layout

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Entering and exiting

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Growing a facility over time

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Activity

What will your isolation area and


patient flow look like?

April 16, 2018


April 16, 2018
Activity

Where is high-risk and low-risk zone?


Where will staff enter?
Where will patients enter?
Where will staff put on and put off PPE?
Where will staff leave?
Where will waste leave?
Where will human remains leave?
Where will high-risk items have to travel before
disposal?

April 16, 2018


Answers:

Laundry Waste Disposal

Morgue

Human Remains Exit Waste Linen Exit

water Confirmed Take off PPE


patient room

Supplies (clinical
and PPE), put on
PPE

after PPE
removed
Clean: Staff area,
medical records, break
room etc.
Suspected patient
room

Staff Exit
Staff Entry
Patient Entry

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Resources
• WHO 2014 Interim Infection Prevention and Control Guidance for Care of
Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in
Health-Care Settings, with Focus on Ebola
http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.
4_eng.pdf?ua=1&ua=1

• CDC 2014. Review of Human-to-Human Transmission of Ebola Virus.


http://www.cdc.gov/vhf/ebola/transmission/human-transmission.html

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