RITM Prepares for Ebola Virus Disease

RITM Releases Outbreak Manual for Specimen Collection and Handling

With the Philippines’ vulnerability to the threat of Ebola Virus Disease (EVD),

the RITM, along with its head agency, the Department of Health (DOH), is in full preparation to properly manage the possible entry of EVD in the country and prevent its further spread.

As the country’s National Referral Center for Emerging and Re-emerging Infectious Diseases, RITM is geared with trained hospital and

laboratory staff, rapid detection methods and adequate facilities in responding to the threat of emerging and re-emerging diseases such as EVD.

RITM’s hospital facilities include six negative-pressure isolation rooms which prevent the spread of infectious agents from the suspected cases. RITM’s response plan also includes converting the other rooms in its 50-bed hospital capacity in the event of increase in number of cases.

The RITM published the first edition of the Guidelines for Specimen Collection,

Transport, and Referral during Infectious Disease Outbreak last August 2014. The Outbreak Manual aims to set standard laboratory practices during outbreak situations.

“As experienced by RITM with the previous outbreaks, confusion regarding specimen collection, referral and information flow resulted

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WHAT’S INSIDE >>

Currently, RITM has available detection methods to confirm an EVD case. These are the serological tests enzyme-linked immunosorbent assay (ELISA) and the Reverse Transcription Polymerase Chain Reaction (RT-PCR).

Upgrading of RITM Equipment and FacilitiesThe Department of Health also announced its planned upgrading of the biosafety level (BSL) of RITM laboratories handling special pathogens from current BSL 2 to BSL 3 or even BSL 4. “A BSL 3 facility has the capacity to contain severe and lethal pathogens and prevent its spread outside the facility while a BSL 4 facility can contain lethal and infectious diseases with which no treatment or vaccine is available at present,” DOH Secretary Enrique Ona explained in a press briefing.

RITM also has at least a three-month stockpile of Personal Protective Equipment (PPE) to protect RITM’s laboratory and healthcare workers.

Collaboration and Capacity BuildingTo spread awareness on EVD and to encourage

in failure of the laboratory to confirm the etiologic agent. Problems have also occurred due to non-compliance with proper specimen transport guidelines and poor coordination between the shipper and [RITM],” explained Dr. Socorro Lupisan, Director of RITM.

The publication of the Outbreak Manual was initiated by the RITM Department of Microbiology, in coordination with the

The outbreak of Ebola Virus Disease in West Africa prompted the World Health Organization to declare an international public health emergency. Above is the microscopic image of the Ebola virus. (Image from www.cdc.gov)

>> p3INFOGRAPHIC/Specimen Handling for Ebola

>> p4FEATURE/Escaping Rabies’Death Crawl

>> p6IN PICTURES/RITM RoundUp!Q3 2014

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>> p8STAFF UPDATES/

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RITM Prepares for Ebola... (from page 1)

RITM Releases Outbreak Manual... (from page 1)

Message participative action from different sectors in the country’s fight against the disease, the Department of Health tasked RITM for the organization of the National Ebola Virus Disease Summit on October 10.

RITM will also hold a training series for healthcare workers for the proper management

of possible cases of EVD, with support from WHO experts. The training will include guidelines on infection prevention and control, proper use of PPE, clinical management and isolation, and laboratory diagnosis. The training series is set for three batches in three consecutive weeks, and is scheduled on October 28-30, November 4-6, and November 11-13.

Department of Virology, Special Pathogens Laboratory, Department of Parasitology, Molecular Biology Laboratory, Surveillance Unit; and the National Epidemiology Center and National Center for Health Facility Development of the Department of Health.

The World Health Organization - Country Office and Western Pacific Regional Office supported the publication of the Outbreak Manual.

The Outbreak Manual was launched at the Field Epidemiology Training Programme (FETP)

Annual Conference in Montemar Beach Resort, Bagac, Bataan on August 28. The Outbreak Manual also comes with a quick guide - a handy, shortened version of the publication for use in the field.

As the National Reference Laboratory for Emerging and Re-emerging Infections, RITM advocates the importance of laboratory support during outbreaks for rapid detection, accurate identification of etiologic agents, and effective response, to control and contain the spread of diseases.

from the RITM Director

The increasing number of Ebola Virus Disease (EVD) cases in Western Africa highlighted our need to heighten our preparedness as the National Referral Center and National Reference Laboratory for Emerging and Re-emerging Infections.

Aside from ensuring our Institutional preparedness for EVD and the continuing threat of MERS-CoV, RITM has also been entrusted by the Department of Health with the organization of the National Ebola Virus Disease Summit and with the series of Training for Hospital Management of EVD. We aimed at carrying out these responsibilities with minimal disruption to our usual research and surveillance activities, routine hospital services, among other functions in our mandate.

I commend all RITM staff for the tireless commitment for public health, despite hectic seasons such as this third quarter.

The RITM management continues to provide utmost support to the RITM healthcare workers so that we remain informed, trained and equipped - and that we can effectively model preparedness and response to other responding institutions.

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Socorro P. Lupisan, MDDirector IV, RITM-DOH

Medical Technologists from Special Pathogens Laboratory (SPL) don the Personal Protective Equipment necessary for laboratory processing of samples from patients suspected with Ebola Virus Disease. RITM tests the samples through ELISA at the SPL and molecular detection by Reverse Transcription - Polymerase Chain Reaction at the Molecular Biology Laboratory.

(From left to right) Mr. Dominic Tomas and Ms. Melissa Jiao of the RITM Department of Virology; Ms. Theresa Kapawan and Ms. Daryl Joy Almonia of the RITM Department of Microbiology; Dr. Amado Tandoc, Head, RITM Department of Virology; Ms. Melissa Mondoy of the RITM Department of Microbiology; Ms. Weng Capistrano of the RITM Surveillance Unit; and Dr. Vito Roque of the National Epidemiology Center during the launch of the manual at Montemar Beach Resort, Bagac, Bataan.

3RITM UPDATE JULY - OCTOBER 2014

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Although extensive research has been done on rabies, scientists have not yet developed a cure once the virus reaches the human nervous system.

Rabies-free PH by 2020Rabies continues to be a prevalent public health threat in the Philippines. The Philippines ranks among the highest in the world in terms of rabies prevalence. The Department of Health accounts that around 200 to 300 Filipinos die of rabies every year.

The Philippine government aims to bring these figures down to zero. In 2007, the government passed the Anti-Rabies Act (RA 9482), a law that calls for the control and elimination of human and animal rabies. It mandated the creation of the National Rabies Prevention and Control Program (NRPCP), a multi-agency/multi-sector initiative that targets to eliminate human rabies by 2016, and declare a rabies-free Philippines by 2020.

The main component activities of this program are: (1) mass vaccination of dogs; (2) establishment of a central database system for registered and vaccinated dogs; (3) impounding field control and disposition of unregistered, stray and unvaccinated dogs; (4) information and education campaign on the prevention and control of rabies; (5) provision of pre-exposure treatment to high-risk personnel and Post Exposure Treatment to animal bite victims; (6) provision of free immunization or Pre-Exposure Prophylaxis of schoolchildren aged five to fourteen in areas where there is high incidence of rabies as well as the (7) encouragement of the practice of responsible pet ownership. The program also provides support services in the form of capacity-building.

Since the launch of the NRPCP, the number of deaths due to rabies has slowly dropped. From 257 deaths in 2010, it went down to 187 last year. The number of human rabies cases has also dropped by 27 percent from 2010 to 2013.

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Marco knows that this is the safest situation for his father to prevent him from harming himself and others around him. A few weeks earlier, Rolando was bitten by a dog. He did not seek treatment then, and a few days earlier, he started having fever, and his behavior changed.

The rabies virus already reached Rolando’s brain. The doctors told Marco that they are 100% sure that his father will die.

‘Deadliest disease on Earth’ Rabies claims a person’s life every 10 minutes, according to the United States Centers for Disease Control and Prevention (CDC). Most of these death incidents happen in Asia and Africa with children aged below 15 years old comprising more than half of the deaths.

Rabies is a viral disease that attacks the central nervous system. It is transmitted to a person through a bite of an infected animal. All warm-blooded mammals may carry the rabies virus,

but dogs account for the most number of reported rabies cases. Other animals such as cats also contribute to the virus transmission.

Once a person is bitten by a rabid animal and the victim was not vaccinated, the rabies virus will travel from the site of the bite to the victim’s brain. As it reaches the human nervous system, it becomes 100% fatal.

As the rabies virus goes on a death crawl to the brain, the victim will feel the initial symptoms such as a high temperature of 38ºC, chills, fatigue, irritability, anxiety, and vomiting. After two to 10 days, more severe symptoms will start to manifest including aggressive behavior such as biting, excessive salivation, hallucination, hydrophobia, aerophobia, and muscles spasm. When these symptoms start, death is fast approaching.

Rabies is tagged by the Global Alliance for Rabies Control as the ‘deadliest disease on Earth’.

Escaping Rabies’Death Crawl: PH’s combat against the deadly disease

Why am I tied down? Untie me. Before I die,” begs Rolando*.

Strapped to a steel hospital bed with his hands shaking, Rolando pleads as he forcefully tries to free himself from the thick white band tied around his waist.

He is confused. He doesn’t understand why he’s locked in a room behind bars, with his own son Marco* just watching him suffer.

On the other side of the bars, Marco holds back his tears. “I don’t know what to do with him anymore”, he silently utters.

*Not their real names. Rolando and Marco’s story is from the documentary, Families: The Human Cost of Rabies, produced by the Global Alliance for Rabies Control and Al Jazeera News Channel.

FEATURE

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100% Fatal:Although extensive research has been done on rabies, scientists have not yet developed a cure once the virus reaches the human nervous system

5RITM UPDATE JULY - OCTOBER 2014

RITM’s Role in Rabies Control and EliminationThe Research Institute for Tropical Medicine serves as a referral center for human rabies and animal bite management. Around 12,000 to 13,000 new animal bite patients are treated in the Institute annually, and it manages two to three severe human rabies cases every month.

Also, as the principal research arm of the Department of Health, RITM conducts research on rabies and provides results which can help improve NRPCP’s strategies for rabies control and elimination.

Laboratory confirmation of rabies is essential for a country desiring to eliminate rabies. It identifies current epidemiologic patterns of rabies and helps in the planning and monitoring of control programs. A study in RITM headed by Dr. Daria Manalo of RITM’s Veterinary Research Department, in partnership with the Japan National Institute of Infections Disease (NIID), aims to produce a local reagent for the Direct Rapid Immunohistochemical Test (DRIT), an alternative diagnostic test developed by the Center for Disease Control. The test is more rapid, simpler, and more cost-efficient than the direct fluorescent antibody test (dFAT), the gold standard and most frequently used diagnostic test for rabies.

According to Dr. Manalo, this alternative test is more applicable to developing countries like the Philippines.

“There are only 19 laboratories in the Philippines that are capable of conducting laboratory confirmation of rabies in animals. Most local laboratories are not financially capable in conducting dFAT. As a result, animal rabies is underdiagnosed and underestimated in the country,” added Manalo.

Another study by Manalo and NIID seeks to provide an alternative specimen for rabies diagnosis (i.e. salivary gland) in cases that the brain sample is autolyzed, or if invasive procedure of getting a brain sample is not

possible.

Meanwhile, another collaborative study by the the RITM-Tohoku University Research Center for Emerging and Re-emerging Infections aims to describe how rabies viruses circulate in the country through molecular epidemiology. Molecular epidemiology traces viral spread as documented in the viral genome; such study provides insights on the improvement of the mass dog vaccination strategies of NRPCP.

This molecular epidemiological study of rabies used samples from all over the Philippines to identify major clusters. The findings of the study suggests that a geographically targeted dog vaccination campaign may effectively control rabies in the country.

The Institute also conducts clinical researches that are directed towards evaluating new rabies biologicals and new vaccination regimens.

Ongoing clinical trials by Dr. Beatriz Quiambao, Dr. Rose Delos Reyes, Dr. Ma Cecilia Ama, and Dr. Cristina Ambas, in collaboration with different pharmaceutical institutions, aim to evaluate the safety, efficacy and immunogenicity of a new four-sites intradermal vaccine regimen for post-exposure prophylaxis (PEP) that can be completed within one week. PEP is required to ensure that an animal bite patient does not succumb to rabies. The currently used intradermal regimen for PEP takes a month to complete and requires four visits to the clinic.

RITM also provides laboratory diagnosis services. It is the only laboratory in the country that is capable of performing human rabies diagnosis and antibody analysis. It also assists in quality assurance of animal rabies diagnosis in Regional Animal Disease Diagnostic laboratory (RADDL).

Furthermore, RITM contributes to the capacity-building of the staff involved in rabies control and prevention. The Institute conducts

quarterly trainings on rabies and animal bite management. It also conducts training on laboratory diagnosis of rabies for RADDLs and other local rabies laboratories.

A Continuing CombatThe combat with rabies is still far from over. But with these combined efforts from the government, private institutions, and the community, there is still hope that one day rabies will be eliminated in the country - and that steel hospital bed that was once occupied by Rolando in the room behind bars, will be empty forever.

Animal rabies is underdiagnosed &

underestimated in the country.

RITM conducts quartery training of healthcare workers who intend to set-up Animal Bite Treatment Centers.

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RITM UPDATE >> July to September 2014

410,000 animal bite cases (2012)

187

70%

human rabies cases (2013)

animal rabies cases (2013)

1:10 dog:human population ratio (2013 estimate)

QuickFacts

563

Rabies in the Philippines

recommended dog vaccinationcoverage to control rabies (WHO, OIE)

6 RITM UPDATE APRIL-JUNE 2014

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7RITM UPDATE JULY - OCTOBER 2014

RITM Joins Nat’l Hospital Week Celebration

Dermatology Department Conducts 10th Postgrad Course

RITM Holds 2nd Infectious Disease Fellowship Graduation

RITM Communication and Engagement Office Launches the RITM Brand Manual

RITM Prepares for Shift to Centralized Information System

RITM Staff Participate in Training-Workshop on Gender Sensitivity and Gender Mainstreaming

RITM joined DOH hospitals nationwide in celebrating the National Hospital Week on August 4-12, with the theme: Pagamutang Dekalidad para sa Mamamayan.

In line with the celebration, RITM held various health-related activities such as free eye check-up, body massage, and distribution of free hand sanitation supplies.

The National Hospital week is an annual celebration in pursuance of Presidential Proclmation No. 181. The celebration aims to promote awareness on the health programs and social roles of hospitals, and collaboration of the community for a healthy citizenry.

The RITM Department of Dermatology conducted its 10th Postgraduate Course at the RITM Auditorium on August 28-29. With the theme Basic to Best Practices in Dermatology, the course aimed at discussing updates on dermatology research and practices. Topics included neglected skin diseases such as Hansen’s Disease and Psoriasis; natural ways to treat dermatologic diseases; minimally invasive technologies against aging; new tips to treat dermatologic diseases; and new and emerging dermatological infections.

The Postgraduate Course was attended by dermatologists and other physicians from all over the country. The Course will have its next installment on 2016.

The Medical Department of the Research Institute for Tropical Medicine held its Second Infectious Disease Fellowship Training Graduation Ceremony on April 25 at Crimson Hotel, Alabang. Dr. Manolito Chua, Overall Training Officer of the program, presented the lone graduate of this year’s fellowship, Dr. Mark Kristoffer Pasayan.

As part of its mandate to establish and safeguard the RITM brand identity, the Communication and Engagement Office (CE Office) launched the RITM Brand Manual through RITM Memorandum 069, dated September 18, 2014.

The RITM Brand Manual sets out the requirements in the representation of the Institution’s visual identity. It provides guidelines on the creation of communication collaterals to ensure that RITM will always be presented in a positive and consistent manner.

Aside from setting identity requirements, the CE Office also developed official RITM templates for communication collaterals such as stationery, brochures, certificates and posters.

In line with the Institute’s plan to strengthen its Gender and Development (GAD) Plan, the GAD Focal Point Committee of RITM conducted a Training-Workshop on Gender Sensitivity and Gender Mainstreaming on July 30-31, 2014.

The Training-Workshop was attended by 35 RITM key staff involved in GAD-related activities. It aimed to equip RITM staff with knowledge on gender sensitivity, gender analysis tools, and Gender Responsive Planning and Budgeting (GRPB), so they can create GAD programs and integrate GAD concerns into their existing programs and projects.

Dr. Beatriz Quiambao, head of the GAD Focal

The CE Office serves as the custodian of the official RITM brand and sets the strategic framework on the use of the brand in institutional marketing and communication.

From a manual system of recording of patient transactions, staff and customers of RITM will soon benefit from an automated and centralized system as the Institute starts the installation of its Hospital Information System (HIS) and Laboratory Information System (LIS).

The centralized information system will integrate all the records of transactions in the hospital and laboratory operations of the Institute, improving RITM’s efficiency in the management of patient records.

Abraham Sepulveda, Senior Science Specialist of the RITM Department of Epidemiology and Biological Statistics (DEBS) and coordinator of the HIS and LIS project, explained that the system will be of ease to the RITM staff as they no longer need to manually check and re-encode the transaction history of every

Point Committee, said that more training workshops on Gender Sensitivity will be organized as it is crucial to make all RITM staff knowledgeable on Gender Sensitivity. “The plan is to educate everybody, orient everybody, and eventually make GAD part of our thinking”, added Dr. Quiambao.

RITM organized a GAD Focal Point Committee in compliance to the Executive Order 273 of 1995 or Philippine Plan for Gender-Responsive Development (PPGD) 1995-2025 which mandates all agencies to incorporate and reflect GAD concerns in their agency performance commitment contracts, budget proposals, and work and financial plans.

patient.

“Our information system is already programmed to generate all the transaction-related data that the RITM staff need. This is very helpful especially when we have to submit reports required by DOH,” Abraham Sepulveda.

Currently, the installation of HIS is 80% complete while the LIS installation is under way. The two information systems will be linked to each other.

Sepulveda also stated that an information system will also be set-up for the administrative operations of the Institute such as accounting and timekeeping. His team targets to complete the installation of all the components of the information system before the year ends.

Trainings @ RITM

RITM UPDATE >> July to September 2014

8 RITM UPDATE APRIL-JUNE 2014

RITM Update is a quarterly newsletter published by the Research Institute for Tropical Medicine - Department of Health (RITM-DOH), through its Communication and Engagement Office.

Web: www.ritm.gov.ph Mail: 9002 Research Drive, Filinvest Corporate City Alabang, Muntinlupa City 1781 PhilippinesTel: (632) 809-7599 / 807-2628 to 32 Fax: (632) 842-2245

For your feedback, e-mail us at communication.ritmdoh@gmail.com.

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Head Jun Ryan C. Orbina

Communication and Engagement OfficersKaymart A. Gimutao

Leah Melita G. de Ocampo

Contributors Titus C. Tan - Infographic on Ebola

Iza Mae S. Chamen, RMT - TTI NRL Article

Childhood malnutrition and parasitic helminth interactions. Papier K, Williams GM, Luceres-Catubig R, Ahmed F, Olveda RM, McManus DP, Chy D, Chau TN, Gray DJ, Ross AG. Clin Infect Dis. 2014 Jul 15;59(2):234-43.

Can Mass Drug Administration Lead to the Sustainable Control of Schistosomiasis? Ross AG, Olveda RM, Chy D, Olveda DU, Li Y, Harn DA, Gray DJ, McManus DP, Tallo V, Chau TN, Williams GM. J Infect Dis. 2014 Jul 28. pii: jiu416.

Relative efficacy of AS03-adjuvanted pandemic influenza A(H1N1) vaccine in children: results of a controlled, randomized efficacy trial. Nolan T, Roy-Ghanta S, Montellano M, Weckx L, Ulloa-Gutierrez R, Lazcano-Ponce E, Kerdpanich A, Safadi MA, Cruz-Valdez A, Litao S, Lim FS, de Los Santos AM, Weber MA, Tinoco JC, Mezerville MH, Faingezicht I, Kosuwon P, Lopez P, Borja-Tabora C, Li P, Durviaux S, Fries L, Dubin G, Breuer T, Innis BL, Vaughn DW. J Infect Dis. 2014 Aug 15;210(4):545-57.

HIV multi-drug resistance at first-line antiretroviral failure and subsequent virological response in Asia. Jiamsakul A, Sungkanuparph S, Law M, Kantor R, Praparattanapan J, Li PC, Phanuphak P, Merati T, Ratanasuwan W, Lee CK, Ditangco R, Mustafa M, Singtoroj T, Kiertiburanakul S; TREAT Asia Studies to Evaluate Resistance – Monitoring Study (TASER-M). J Int AIDS Soc. 2014 Aug 19;17:19053.

Comparison of the safety and immunogenicity of an MF59®-adjuvanted with a non-adjuvanted seasonal influenza vaccine in elderly subjects. Frey SE, Reyes MR, Reynales H, Bermal NN, Nicolay U, Narasimhan V, Forleo-Neto E, Arora AK. Vaccine. 2014 Sep 3;32(39):5027-34.

Trends in first-line antiretroviral therapy in Asia: results from the TREAT Asia HIV observational database. Boettiger DC, Kerr S, Ditangco R, Merati TP, Pham TT, Chaiwarith R, Kiertiburanakul S, Li CK, Kumarasamy N, Vonthanak S, Lee C, Van Kinh N, Pujari S, Wong WW, Kamarulzaman A, Zhang F, Yunihastuti E, Choi JY, Oka S, Ng OT, Kantipong P, Mustafa M, Ratanasuwan W, Sohn A, Law M. PLoS One. 2014 Sep 3;9(9):e106525. doi: 10.1371/journal.pone.0106525. eCollection 2014.

Evaluation of banked urine samples for the detection of circulating anodic and cathodic antigens in Schistosoma mekongi and S. japonicum infections: A proof-of-concept study. van Dam GJ, Odermatt P, Acosta L, Bergquist R, de Dood CJ, Kornelis D, Muth S, Utzinger J, Corstjens PL. Acta Trop. 2014 Sep 16. pii: S0001-706X(14)00294-0.

The chronic enteropathogenic disease schistosomiasis. Olveda DU, Olveda RM, McManus DP, Cai P, Chau TN, Lam AK, Li Y, Harn DA, Vinluan ML, Ross AG. Int J Infect Dis. 2014 Sep 20. pii: S1201-9712(14)01594-X.

RECENT PUBLICATIONS/

TTI-NRL Staff Undergo EQAS Capacity Building Training

Technical staff of the Transfusion Transmissible Infections - National Reference Laboratory (TTI-NRL) underwent a training at the RITM Training Center on July 7-17 to improve TTI-NRL’s capability as External Quality Assessment Scheme (EQAS) Provider.

The training was facilitated by Ms. Sandy Walker of Australia’s National Serology Reference Laboratory, a World Health Organization Collaborating Centre for diagnostics and laboratory support for HIV and AIDS and other blood-borne infections.

In addition, the TTI-NRL staff were also trained by representatives of Canada’s One World Accuracy Systems (OASYS) on Oct. 20-24. on EQAS-related informatics and data analysis.

OASYS offers a state of the art informatics system that will allow TTI-NRL to manage their EQA program online, perform quality data analysis, reduce their workload and improve their turn around time for releasing of summary results.

Aileen D. Gianan, MD, FPCP of the RITM Medical Department received the First Place Award of the Philippine Coalition Against Tuberculosis’ (PhilCAT) First Young TB Researcher. Dr. Gianan is investigating the sensitivity and diagnostic accuracy of GeneXpert in detecting tuberculosis among people living with HIV. GeneXpert is a World Health Organization-recommended testing method.

Rema Joy G. Cejar, MD of the RITM Dermatology Department is the grand winner in the Poster Category of the Department of Health-organized Inter-hospital Research Contest. Dr. Cejar presented her research entitled Randomized, double blind, controlled study on the safety and efficacy of 10% bee propolis ointment vs 2% mupirocin ointment on superficial pyodermas caused by Staphylococcus aureus. Dr. Cejar’s study aimed to verify if the safety and effectivity of bee propolis as anti-bacterial agent.

Mark Christopher U. Pasayan, MD of the Medical Department placed second in the Philippine Society for Microbiology and Infectious Disease (PSMID) Specialty Board Exam. Dr. Pasayan is the second graduate of RITM’s Infectious Disease (ID) Fellowship Training Program.

July to September 2014as indexed in Pubmed