Responses of the National Center for
Global Health and Medicine as a
Designated Medical Institution forSpecified Infectious Diseases
Norio Omagari
Disease Control and Prevention Center
National Center for Global Health and Medicine

Since 1871

Since 2004

Responses to suspected cases of infectious
diseases that may be international menaces in theNational Center for Global Health and Medicine

Ebola hemorrhagic fever
Date of occurrence

Travel destination

Diagnosis

October 27, 2014

Liberia

Undisclosed

November 7, 2014

Liberia

Acute pharyngitis (GAS)

December 29, 2014

Sierra Leone

Acute paranasal sinusitis

January 18, 2015

Sierra LeoneInfluenza B

Date of occurrence

Travel destination

Diagnosis

June 16, 2015

Korea

Acute bronchitis* Direct consultation with our Hospital

January 3, 2016

UAEInfluenza B* Direct consultation with our Hospital

January 5, 2016

Dubai

S. pyogenes pneumonia, bacteremia

February 4, 2016

Qatar

Acute upper respiratory tract inflammation

MERS

Request for the reception of transfer ofa suspected case of Ebola virus

disease from the Tokyo Airport
Quarantine Branch Office of Tokyo

Quarantine Station

 A vehicle for picking up samples was confused with thevehicle for patient transportation, and misinformation ofpatient’s arrival was given (unexpected)
 Communication at distance of 10 km from the hospital
before arrival → It takes 15-20 minutes to arrive Waiting for arrival with PPE on, but physical strength was being lostwith time“When wearing full PPE, active time should be limited to 30
minutes ...”
“Narrow view, sealing, heat, sweat, fogged glasses ...”

 As the suspected case wore full PPE, it was difficult todistinguish accompanying quarantine officer from thepatient (unexpected)
 As the hospitalization had not been explained to patient,but only transportation just for examination, it turned into
an argument (unexpected)
 Brief history taking about travel history, activities at thesite, contact history with patients with Ebola hemorrhagic
fever, preventive medication of Malaria
 Managed to reach an agreement to be hospitalized in
the New Infectious Disease Ward
 “Already drenched in sweat, fog on glasses gets thicker”(unexpected)

 After about 1 hour of active time, once left thepatient’s room “The effective field view is just a size of 1 yen coin,lower left corner of glasses ...” (unexpected)
 Threat of infection for work to remove PPE for whichlevel of difficulty is more than that in training due tosweat during activity (unexpected)

 Passed over the specimen for Ebola PCR to the person
in charge of transfer
 As there was no means of access between the testinglaboratory and other rooms, put on PPE again to get theresults of biochemical examination and visuallymemorized them• Patient is a man of 40 years of age• He has a history of staying in West Africa and arrived atHaneda Airport this afternoon• After arrival, he showed a symptom of fever, and wastransferred to the National Center for Global Health andMedicine and now is under examination• The result of examination will be announced when it isdetermined• The result will be determined in the early hours of tomorrow* Age, nationality, profession, travel history details, return
flight, and other personal information were revealed without
the person’s intent

 After confirming the decline of fever in 2 days,
conducted the second PCR test  negative What the person said at the time of discharge

Basic Idea for Transfer
Extract from MHLW/HSB Tuberculosis and Infectious Diseases Control Division
Notification No. 0331001 issued on March 31, 2004 “Guideline for the Transfer
on Patients with Infectious Diseases”

Key points:• Prevent the spread of infection based on thecharacteristics of pathogens• Consideration of human rights• Transfer by appropriate materials andequipment• Ensuring the security of those who areengaged in transfer
10Reality of Transfer by Disease - Hemorrhagic Fever• Longer travel distance than provided by common fireand ambulance services• Diagnose whether the patient can be transferred or not• Drains other than endotracheal intubation tube should
be closed circuit• When the patient is incontinent, insert urethral balloon
catheter and use disposable diapers for fecal
incontinence / melena• It is desirable to pay attention to the use of a watershedding disposable gown, because it may lead to
unexpected contamination due to the outflow of bloodand body fluid
11

Reality of Transfer by Disease - Hemorrhagic Fever• Regarding the vehicle for transferring the patient, it is desirable thatthe vehicle has a structure that can ensure measures to prevent thespread of infection.
• Cover equipment and wall surfaces with sheets and placehygroscopic sheets or non-woven material over an vinyl sheet on thefloor so as not to expand the contaminated area due to hemoptysis or
hematemesis, and dispose of whole set of these materials including
vinyl sheet as contaminated waste after the transfer.

• When it is certain that there is contamination around the patient withhemoptysis, hematemesis, or incontinence, create a space for thepatient with transparent vinyl to prevent the exposure of theaccompanying transfer staff to the patient’s space for a long time.
• Regarding wall and floor surfaces of the patient space in the vehicle,
wipe clean with gauze or other cloth initially, wipe again using
hypochlorite disinfectant, and then wipe off with water.
12Reality of Transfer by Disease – Hemorrhagic Fever• As there is no preventive / therapeutic drug forhemorrhagic fevers other than Lassa fever, full attention
should be given to infection.
(Note: An preventive medication of favipiravir is available
for Ebola fever, and ribavirin is used for Lassa fever.)• For those who had close contact with the patient, it isdesirable to monitor health conditions for 3 weeks. It isnecessary to prevent secondary infection due to sexualintercourse or other behavior during this period.

13

[Reference] Super ambulance
In addition that a capsule-style stretcher for the transfer of an infected patient(isolator) can be mounted using a hydraulic elevator (lift) from its rear door, thedriving compartment is completely separated from the sick and wounded person’scompartment by a bulkhead as a measure of infection control (extract from the14website of Tokyo Fire Department)Example: A model not being used now Hard type built-in stretcher capsule Reusable Difficult for medical practice Heavy and poor mobility
 Unstable and easy to fall down
 Hard to find a place to store thecover Many parts with projection cause arisk to destroy gloves
 Stretcher capsules of this type were purchased in various locations in the SARS epidemic
during 2012-2013; however, a lot of medical institutions stopped use of and disposed ofthem because turnover accidents, injuries, back pain, and other occupational injury andillness in staff happened during training in the Ebola epidemic in 2014.

Example: Type adopted in Tokyo
Metropolitan and Quarantine Office
 Soft type
 With handle parts, it is carried byseveral persons / A transport bag
used even for a patient on astretcher Disposable / reusable Rescue action from the outside of
the bag is impossible
 There is a type with a control unit ofnegative / positive pressure Low price modelStandard type

Custom-order type

DIF Trans-bag

CaseA man of 45 years of age
without any special history[Major complaints] Fever, cough, respiratory discomfort[Current medical history]
X-8 day

Transient fever

X-3 day

Visited the office of previous doctor with anawareness of cough, hoarseness, sore throat,and diarrhea

Diagnosis of gastroenteritis
X-2 day

Returned to clinic due to protracted
symptoms, fever of 39℃, Lowered SpO2.

Diagnosis of pneumonia, hospitalized andstarted to receive CFPM, SBT/ABPC18

Case[Medical history]

No special description[History of allergy] No[Life history]

Occasional drinking, never a smoker, livingwith his wife

[Sick contact]

No clear history of contact (except that hiswife had a cold)[ROS](+) Dry cough, hoarseness, sore throat, nasal discharge,
diarrhea(-) Abdominal pain, nausea, and vomiting

19

Case
[Current medical condition]

BT 39.6 BP 124/80 PR 102
SpO2 98 (Cannula 4L) RR 24[Physical findings]• Head and neck area: Redness of the pharynx, mildly swollen• Breast: Lung – A crackle was heard in left anterior chest to theback , wheeze (+), stridor (-)
No labored breathing

20

Case
[Blood test]<Blood counts><Biological examination>

WBC7600

CRP

37.4 H

Neut94.0Na137Lym3.0K

3.5

Hb

14.6

Cl100

Ht

43.8

BUN

13.6

Plt

15.2

Cre0.87

T-Bil

0.5

AST24

<Blood gasses> (O2 4L)
pH

7.449

ALT19

pCO2

35.7

LDH402 H

pO2

162.9

Glu119 H

SaO2

99.1

21

[Imaging test]

Case• Chest Xp (left: X-1 day, previous doctor; right: X+1 day)
R Standing Position22

- Chest CT (X-1 day, previous doctor)

気管周囲に多小葉性に浸潤影を認め

23

Case
[Major complaints]

A man of 45 years of age
without any special history

Fever, cough, respiratory discomfort[Current medical history]X-15 day
X-8 day
X-3 day

X-2 day

Xday

Travel to Dubai, Morocco, contact with a one-hump camel
Transient fever
Visited the office of previous doctor with an awareness ofcough, hoarseness, sore throat, and diarrhea
Diagnosis of gastroenteritis
Returned to clinic due to protracted symptoms, fever of39℃, Lowered SpO2, raised inflammatory response.
Diagnosis of pneumonia, hospitalized, and started toreceive CFPM, SBT/ABPCTransfer to our Hospital with suspected MERS
24

Center Hospital of the National Center for Global Health and Medicine

Hospital Infection Risk Management TeamLeader: Hospital Director

Members: Chairperson, General Administrative Director, Manager ofGeneral Affairs, Research Medical Practice Manager, Director of Nursing,Director of the Disease Control and Prevention Center (also the Chief ofMedical Practice Team)

Center Hospital of the National Center for Global Health and Medicine

Infection Risk Management MedicalPractice Team
Ver1.0: as of October 16, 2016

Standard response in hospital management section

Time from thefirst report for theHospital Director(hours)(an indication)0

Ministry ofHealth, Labourand WelfareQuarantine
OfficeLocalGovernmentReport to our HospitalInformation sharing among the administrator of the Hospital (Hospital Director),
person in charge of the medical front (Director of DCC Center), Research Medical
Practice Manager (administrative section)

Judgment of the opening of theNew Infectious Diseases Ward

Information sharing among therelevant parties in the Center2In-hospital response meeting

Sharing of actual situations
Confirmation of the shifts of in-hospital staff
Liaison and coordination with Ministry of Health, Labour and Welfare (confirmation ofnecessity of liaison dispatch, etc.)
Confirmation of the response to mass media
Confirmation of the response to other patients, etc.

Arrival of the person in charge of specimen transfer (Quarantine Office or Public
Health Center)4

Arrival of the patient

5

Start of transfer by the person in charge of specimen transfer

5In-hospital response meeting
Sharing of actual conditions (health condition of the patient, etc.)
Confirmation of the press release from the Ministry of Health, Labour and Welfare

16

Sharing the PCR result among the members of in-hospital response meeting* When the PCR result is positive, hold an in-hospital response meeting as soon aspossible

Instruction / Communication System within theNew Infectious Disease Ward(from opening the Ward to reception of the patient)* The posts in the yellow column are
established only for a few hours from theopening of the ward until when a patiententers and the condition becomes stable

Floor Leader
ICN

Nurses incharge ofPatients’Room

Chief of medical practice(Director of DCC)

Doctors TeamLeader

PublicRelations
Public health center /Quarantine Office / Local
Government

Circulating nurse(Only at the opening of ward /Request for Department ofNursing)

Doctors(DCC infectiousdiseaseprofessionals)

Person incharge for
1st Floor
Outpatient
Liaison(DCC doctor)* To prevent confusion, those who are not on the figure above should comply
with the following items:
1. Don’t join the medical practice without having the permission of the Chief of medical practice.
2. Don’t talk to or ask for the members of medical practice team or hinder the activities of medicalpractice.
3. Don’t give instructions to the members of medical practice team without permission of the Chief ofmedical practice.

Work Shifts for New Infectious Diseases Ward
Proposal on October 27, 2014
New Infectious Diseases Ward – Shift Sheet
Monday,October 27

Tuesday,
October 28

Wednesday,
October 29

Thursday,
October 30

Friday,October 31

0:00-8:00

Kutsuna /Shinohara

Kutsuna /Shinohara

Kutsuna /Shinohara

Kutsuna /Matono8:00-16:00

Takeshita /Muto

Takeshita /Muto

Takeshita /FujiyaTakeshita /Shinohara

Kato /
MatonoKato /
MatonoKato / Muto

Kato / Fujiya

16:00-24:00

Kato /
MatonoWork Shifts for New Infectious Diseases Ward
Proposal on January 18, 2015
- Based on a 12-hour shift January 18

New Infectious
Diseases Ward 1New Infectious
Diseases Ward 2

January 19

January 20

13:00-22:00

22:00-10:00

10:00-22:00

22:00-10:00

10:00-22:00

Hayakawa

Takeshita

KutsunaHayakawa

Takeshita

FujiyaIntegratedInfectious
Diseases
Residents

MatonoFujiyaMatonoWard /
Consultation

Yamamoto / Furukawa / Fukui

Outpatient

Kanagawa / Mawatari / Takeuchi

On call

Furukawa

Furukawa

Response to Emergency Situations of Infectious Diseases - Operation Checklist for the On-Site Director
Name of emergency situation:
Person in charge:
Item No.
12345678910
Initial responses
1112131415
16
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20
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25
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27
28
29
Preparation of the30
Ward
31
32
33
34
35
36
37
38
39
40
External
41
communication
42
43
44
45
46
47
Instructions to the48
Ward staff
49
50
51
52
53
Media
54
countermeasures
55
56
57
58
Measures for
59
discharge
60
61
62
Measures for63
restoring to the64
status quo
65

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Start to make a note sequentially for the response. Surely write down the date and time.
Ask Quarantine Office and Public Health Center for further information.
Report the information from Quarantine Office and Public Health Center to the Director of Hospital as a first report.
Decide the opening of the New Infectious Diseases Ward.
Notify the Director of Hospital of the opening of the Ward.
Print out the system of instruction and communication in the New Infectious Diseases Ward.
Print out the protocol of Abigan.
Print out the list of contact of executives (posted on the website).
Prepare a time sheet for temporal record.
Ask Quarantine Office and Public Health Center for further information.
Report the information from Quarantine Office and Public Health Center to the Director of Hospital as a first report.
Ask for the establishment of the Crisis Management Headquarters.
Confirm with the Crisis Management Headquarters that all information should be submitted by the Ministry of Health, Labour and Welfare.
Notify the MHLW of the centralization of information management.
Get in touch with Research Medical Practice Manager (if absent, with Director of Planning and Management).
Get in touch with the duty person of Testing Department.
Get in touch with the duty person of Imaging Diagnosis Department.
Get in touch with the Director of Pharmaceuticals.
Get in touch with the Director of Nursing.
Get in touch with the General Administrative Director.
Prepare an organizational chart for the operation of the New Infectious Diseases Ward.
Prepare a doctors’ shift sheet.
Ask Nursing Department to prepare a shift sheet.
Call out necessary number of operation staff for the New Infectious Diseases Ward.
Ask those who don’t join the operation of the New Infectious Diseases Ward to get out of the New Infectious Diseases Ward.
Ask ACC and Respiratory Medicine Department for the division of work on consultation.
Prepare the medical chart.
Ask Information Department to lock the medical chart.
Send Information Department the list of persons who can access the electronic health record.
Issue a gag order to medical practice staff.
Don’t write down the contents of explanation, perspective of examination, perspective of discharge on the medical chart (write down only the contents of medical practice).
Instruct that relevant documents should be stored in a single place.
Instruct to prepare a journal of the Ward.
Instruct medical practice staff on health management during duty.
Shut down the door connecting travel clinic and the New Infectious Diseases Ward.
Confirm with the Ward about the time required to open the Ward.
Confirm the procedure of clinical trial of Abigan.
Confirm with the Pharmaceutical Department about the stock of Abigan.
Request the MHLW liaison staff to remain on duty at all times and exchange contact addresses (mobile phones).
Request quarantine liaison staff to remain on duty at all times.
Confirm with Quarantine Office or Shinjuku Public Health Center about the way to hand over the specimen.
Coordinate with Quarantine Office or Shinjuku Public Health Center about the arrival time at our Hospital to take over the specimen.
Notify Quarantine Office or Public Health Center of the preparation completion of the acceptance when three-fourths of preparation for thawing is completed.
Ask Quarantine Office or Public Health Center about the time of departure on site.
Conduct body temperature checks twice a day during the period of health management for staff.
Notify imaging diagnosis staff of the unnecessity of examination.
Ask whether staff members know the “procedure for writing down the medical chart when implementing medical practice for suspected case of Class I infectious diseases.”
Prepare the address list of employees on duty.
When a patient is transferred from the Quarantine Office, understand the behavior in the airplane.
Understand the health observation and contents of behavior in the Public Health Center.
Hold Ward conferences at 13:00 every day.
Ask Financial Department for in-hospital administrative affairs.
The result of examination should be notified to the patient first, then released to the press.
Confirm the first report of press release from MHLW (then, get in touch with external medical institutions).
Prepare explanatory document to the patient, family, and visitors, then post it.
Prepare a notification of in-hospital newsletter.
Confirm the discharge route of the patient.
Set the time of discharge.
Confirm the in-hospital discharge route.
Confirm that no mass communication occurs at the exit of discharge.
Confirm the time of discharge.
Ask MHLW to submit a press release of discharge after the patient arrives at home.
Confirm the time of patient’s arrival at home.
Confirm that a press release of discharge is submitted from MHLW.
Instruct the normalization of medical practice system (by email, etc.)

Challenges in the Future
1. Medical Practice System
1. Securing of manpower and resources in medical
institutions: System enabling an intensive treatment
for 3-4 weeks
2. Medical practice fees commensurate with cost
3. Is response possible with the staff of a single
medical institution? : How about the division of labor
among medical institutions or dispatch of relief staff
within Japan
4. Establishment of the means / methods of transfer

Challenges in the Future
1. Continuous discussion on the infection control measures for
medical professionals
1. Appropriate use of PPE
2. Health management / Prevention after exposure
2. Treatment
1. Establishment of standard treatment
2. How to introduce new drugs, including unapproveddrugs
3. How to do to safely provide an invasive treatment
3. Preparation of temporary response to imported infectious
diseases in general medical institutions
4. Considerations of patients’ human rights, personalinformation

References
1. IASR 36(6), 2015 [Special topic] Ebola hemorrhagic fever in West Africa, as ofMay 2015. http://www.nih.go.jp/niid/ja/ebola/1096-idsc/iasr-topic/5716-tpc424j.html

2. Narumi Hori, Norio Omagari “Infection Control Measures for Ebola Virus
Diseases (EVD) in Medical Institutions” Medical Asahi (0919-7818) vol. 44-1;
page. 28-29 (2015.01)
3. Shiho Takaoka “Public Health Administration Key Words: Responses in
Administration Division in Hospital for Suspected Case of Ebola Hemorrhagic
Fever (commentary)” Public Health (0368-5187) Vol. 79-7; Pages 478-480(2015.07)

4. Norio Omagari “Actuality of Medical Practice for Infectious Diseases: World
Trends of Infectious Diseases” Journal of the Japan Medical Association (00214493) Vol. 143 Special version 2; Page S30 (2014.10)