Friday, April 22, 2016

NOROVIRUS OUTBREAK IN ZAMBOANGA CITY @ 2016

April 22, 2016.

This morning, I heard on the radio that City Health Officer, Dr. Rodelin Agbulos declared the Norovirus outbreak in Zamboanga City presenting as Acute Gastroenteritis (or LOOSE BOWEL MOVEMENT) with 777 in-patients in this city for part of April 2016 alone.

We sometimes go on duty at the Emergency Room and last March, we recognized the surge on the number of patients coming in for Acute Gastroenteritis or usually called AGE or LBM and even with a higher spike this April. The most common symptoms were: diarrhea, vomiting, nausea and abdominal pain.

These are representative data from one private hospital and one government hospital for AGE admissions. However, there are five other private and public hospitals in Zamboanga City who have similar data plus data from other smaller hospitals. The data also does not include out-patients, who visit doctors' clinics or the Emergency Room.


Most of the patients are children



City Health Office Files: Zamboanga City Medical Center data
Most of the admitted patients are young belonging to the 0-18 age group, although, most of these are the infants and toddlers (less than 5 years old) who usually come dehydrated and who refuse to drink since this triggers vomiting. Needless to say, parents are at a loss on how to rehydrate when kids vomit after each intake!

Adults have better chance of being treated as out-patient since they can understand the option of Oral Rehydration and they themselves felt the need for pain relief but also preferred to go home.

Everyone was wondering what the source of the AGE or LBM was since they could not pinpoint specific areas or communities affected. Initially, there were talks of contaminated water from refilling stations but then again could not explain the number of patients.

Authorities did inspect water refilling stations and dealt with them accordingly, although, was not directly the source of the Norovirus infection. The source of infection was not yet identified.

Interestingly, Zamboanga City is strongly experiencing the El Niño phenomenon and lots of barangays have water shortage! This indeed may be contributory to the new illness.

Eventually, news had spread that all hospitals are full and in fact, there is a lack of rooms due to the outbreak and many patients remain in the ER until they have recovered from dehydration. 

With the initiative of Dr. Rosemarie Arciaga, a Pediatric Infectious Disease specialist, representative cases from each hospital were sent to the Research Institute for Tropical Medicine to identify the virus and NOROVIRUS was named! 

Fourteen of the seventeen representative specimens were POSITIVE for NOROVIRUS! Three of the specimens were still pending for identification. 

An emergency forum with DOH IX and CHO and the different hospitals to discuss about the present status of the Gastrointestinal outbreak in Zamboanga City, the disease, its prevention and treatment was convened at the Zamboanga Peninsula Medical Center last April 20, 2016. 

The City Health Office and physicians especially pediatricians concur that this is indeed A NEW VIRUS in Zamboanga City, thus, the rapid spread! 

We are wondering if other places in the Philippines also has a concurrent outbreak like this, as Norovirus is not a known cause of LBM in the Philippines.

But, in the United States and the United Kingdom, NOROVIRUS is a very common stomach bug and even called the "winter bug".

We used to identify fecal-oral route as the usual mode of transmission, therefore, not necessarily contagious. We have heard of Cholera or Staphylococcal Food Poisoning and it is easy to identify the source of the infection. But, NOROVIRUS is different!

So, how is the NOROVIRUS Infection spread?

Norovirus is highly contagious with several modes of transmission. The virus may shed in stool (feces) and vomitus and is depicted in this infographic, wherein Norovirus spreads when a person gets poop or vomit from an infected person in their mouth. 


Therefore, to STOP NOROVIRUS, cleanliness is of utmost importance, especially proper HAND WASHING!
Note, even if a person is well, it is suggested that you continue to stay at home for two more days after your symptoms stopped. This is a reminder for Human Resource personnel for your staff who have called in sick. Again, the workforce can come back to work two days after their symptoms have stopped!

So from the Center for Disease Control, here are infographics which summarize what we should know about NOROVIRUS and how to prevent it from spreading.



Note: Antibiotics will not help with Norovirus illness.
Prevention from dehydration is the primary goal.

What do we do? 
Hand Hygiene is one of the best ways for prevention.
What is is Right Way to Wash Your Hands?
The healthcare institutions, then, have to be aggressive on the dissemination of information regarding NOROVIRUS

Ciudad Medical Zamboanga, through the Infection Control Nurse, Ms. Kamille Alcala, then disseminated to and discussed with the Infection Control links, especially the clinical areas including the Human Resource and Administrative departments such as Dietary, Linen and Laundry and the Janitorial service about the NOROVIRUS: The Disease, Symptoms, Transmission, Prevention, Treatment and most of all, Infection Control Recommendations.
CMZ Infection Control Nurse, Ms. Kamille Alcala shares to the Infection Control committee links on the results of the meeting the night prior.
with CEO,  Medical Director, Assistant Nursing Director for Training, Infection Control Nurse and Pediatric Ward nurses 

Infection Control Links: clinical areas, ancillary units, administrative and human resource departments

Pediatric Department Head, Dr. Mary Ann To, who also attended the meeting shares more about the Norovirus infection as part of the dissemination campaign.
from ER, wards and ancillary services

CEO, Administrative Officer, Infection Control Nurse and Assistant Nursing Director-Service 

from Dietary, Janitorial, Medical Records and with Human Resource Manager also intently listen on their role during this Outbreak

Let us all understand about the NOROVIRUS and optimize CLEANLINESS through proper hygiene, hand hygiene, environmental cleaning and for Healthcare Personnel, use of Personal Preventive Equipment (PPE) such as gloves and gowns and for understanding patient cohorting.

For the COMMUNITY, here are more infographics to help prevent further illness:
HOW DO WE HELP PREVENT THE SPREAD OF NOROVIRUS, if Norovirus is affecting your community?
HOW DO WE CLEAN UP AND DISINFECT FOR NOROVIRUS if someone had a vomiting and diarrhea accident?
***anything that has been in contact with vomit and diarrhea should be thrown away or disinfected!
Routine cleaning and disinfection on frequently touched surfaces with sodium hypochlorite 1:10 for those who use the metric system.

During this El Niño season, this is such a great challenge since how can we do hand washing, if we do not even have water in the first place! Somehow, we need strong government support and prioritization for water services and transport to improve the water supply to the different barangays in Zamboanga City! This WATER SHORTAGE must be the triggering factor!

Another challenge that the hospitals face is the lack of rooms. One contributing factor is the updated 2016 PhilHealth regulation that Acute Gastroenteritis (AGE) can only be compensated (paid) by PhilHealth if the patient stays for 72 hours or 3 days! We would want PhilHealth to be more flexible in times of outbreaks but I guess this needs further discussion with them!

Everyone needs to do extra effort for understanding the disease to help stop further spread! We do hope that very soon, this ACUTE GASTROENTERITIS (AGE)  outbreak will be controlled!!!

Since this diarrhea problem cropped up in Zamboanga City, we would like to ask again if other places in the Philippines also experienced an Acute Gastroenteritis (AGE) Outbreak, too?
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P.S. UPDATES
1) April 25, 2016
Mayor Isabel Climaco declared a Gastrointestinal outbreak in Zamboanga City through Executive Order No. BC 174-2016 signed April 25, 2016.
Executive Order signed by the City Mayor: 813 Gastrointestinal patients with three Pediatric deaths (March 28-April 18, 2016)


City Health Office files
City Health Office files
2) April 23, 2016
A multi-center collaborative study among Zamboanga City hospitals spearheaded by Dr. Rosemarie Arciaga, Pediatric Infectious Disease specialist (Zamboanga Peninsula Medical Center)  will conduct a medical research to delve more deeply into the Gastrointestinal Outbreak in Zamboanga City. 

For Ciudad Medical Zamboanga, Dr. Mary Ann To (CMZ Pediatrics Department Head), Dr. Bernadette Chua-Macrohon, ICN Kamille Alcala and Pedia Ward Head Nurse, Kris Encarnacion are among the participants in this research.

3) We also have epidemiologists from DOH looking into the problem since there seems to be a "cocktail" of viruses as cause of the AGE such as Rotavirus, Adenovirus and even the bacteria, Escherichia Coli. Could this be because the Zamboanga City water problem is more complicated than it looks? 

Let us bid them well in this research and their other studies for the better understanding of the ongoing Gastrointestinal outbreak --- especially on the disease, its presentation, course and pattern, modes of spread and most of all, the underlying environmental and social factors to better foster its prevention and treatment.

51 comments:

  1. Marie Sol: Yeah, it's very rampant here in UK...thanks for sharing Doc ������

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  2. Arlene Cavan: We call it Winter bug here in the UK.

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    1. My friends from the United Kingdom are the ones who know many things about the Norovirus infection! Thank you for the knowledge that you are sharing...

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  3. Arlene Cavan: Fluid replacement, hand washing and PPE jud ang kinahanglan.

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  4. Arlene Cavan: I know especially in the remote areas. Problem is this bug spreads really fast. Patient needs to be isolated

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  5. From Facebook: Rowena Catipay-Buyan from UK: We do hand washing before and after we see our patients Pinay; we place them in isolation when they are admitted.

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  6. From Facebook: Myla Lakibul: How it will be transmitted dra?

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    1. Marie Kamille Pamaran Aranal-Alcala: Primarily direct contact madam.. still handwashing is the basic preventive measure.

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  7. From Facebook: Tony Rome Victor: Glad to say wala dito sa davao city.

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  8. Very informative post. It is really a must to wash hands or bring hand sanitizer especially if you are out and going to use public restroom. Just imagine the doorknob of the restroom, ang dami humahawak niyan.

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    1. Thank you. Many times we take things like hand washing for granted.

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  9. Virus outbreaks are always alarming. Thank you for providing info on how to avoid it and how to know when you've contracted the norovirus. That's definitely going to help a lot of people.

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    1. We have to be vigilant because we do not want the outbreak to reach neighboring communities! At least, it is still in Zamboanga City at this time.

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  10. Let us follow the precaution to stop the spreadout of virus---cbolo

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    1. We need to share with our friends to help prevent spread.

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  11. Hello Doc! Is Novovirus same with stomach flu? If I remember it right, February nun bigla na lang nagsusuka anak ko with low grade fever. Hindi na nay kinaya pumasok sa school the next day which is Friday. But thank God naging okay naman sya the next day. I thought it was just the weather but I surprised when the school called for an emergency meeting because there were 6 other students on my son's class who suffered from vomiting and LBM. The parents were alarmed.

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  12. It is sometimes called stomach flu... Although, not caused by InFLUenza. Some other viruses may present the same. Maybe because of better hygiene in your place that is why it did not spread to others. Now I am thinking the present water supply problem in Zamboanga City may be the triggering factor for the Outbreak because as simple as hand washing would be difficult in the affected barangays!

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  13. Angelina Salazar (FB) Thank you for sharing this information Dr. Filipinas Rojo. Our Pedia ward is already overloaded and a lot of our healthcare workers got infected with this too.

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    1. Yes, all hospitals are full plus those staying in the ER... found out in FB that some of our friends got the infection too so I decided to share it in their timeline already for awareness and hopefully prevention.

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  14. Agnes Acorin (FB) Thanks Dra. Inday...correct as of now parang 1000 na daw ang patients sa hosp

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    1. yes, in just a few days, naging more than 1000 na...

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  15. Flai Pajarillo (FB) I highly appreciate this Doc Filipinas Rojo...we really have to be advocates...by information dissemination we are doing our roles as health providers...

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    1. Indeed Flai. Another of our Corporate Social Responsibility!

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  16. Anonymous (AR) @ (FB) Unfortunately, 3 of my family members had it.. And now my mom and sister. Tsk!

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    1. Ohhhh! Sometimes I hesitate to post it on other's walls but for this disease, I am doing so! Just a bit late for your family, though.... hope they are better.

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    2. Anonymous (AR) @ FB Been reading your blogs though... Unfortunately, naunahan ako ng norovirus.. Haha.. I wouldnt thínk they'll be affected of it.. Kasi OC ang parents ko lalo na sa food preparation and hygiene.

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    3. Yes, but very active infection talaga ang Norovirus ngayon.

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    4. Anonymous (AR) @ FB Good thing self limiting lang naman ata... As long as well hydrated and well maintained ang electrolytes sa katawan... Thanks for details doc...

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  17. Thanks that none in the family is infected. We need to continue to keep our surroundings clean. Since we work in the hospital, we also have to follow guidelines to prevent infection from spreading.---J. Canizares

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    1. Yes, let us follow Infection Control guidelines!

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  18. This is good information dissemination. Not a lot of people know about Norovirus because it rarely gets reported on big media networks. I hope info dissemination (on public health, not limited to norovirus) would be initiated on the barangay level to reach more people.

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    1. I believe the City Health Office is now seriously disseminating on how to prevent further spread of the LBM.

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  19. Thanks doc, I've never heard of Norovirus before, thanks for this post. This is for people like me to get more educated. :)

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    1. We are serious in dissemination since the outbreak is still ongoing and for me, it is really sad if our own family and friends are infected. Somehow, we feel we need to do more in teaching about prevention.

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    2. I hope maayos na and that the outbreak lalong lalo ay ma stop na. Good luck on the program you guys are planning for the prevention. :)

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  20. I've heard about this virus. It is certainly important to protect proper hygiene practice to keep yourself protected.

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    1. Let us give importance to proper hygiene and clean surroundings!

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  21. This one is very helpful. Madali din ako sakitan ng tyan, which is why always careful ako sa tubig na iniinom and laging naghuhugas ng kamay.

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    1. It is good to be very careful with food and drinks. Abdominal pain can really make a patient suffer and that was the reason why most adults sought consult in the Emergency Room and not necessarily for the LBM.

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  22. This is very informative.. I will note all the precautions to avoid the virus.

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    1. We hope the virus doesn't spread out of Zamboanga City.

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  23. Sharing this one so more people would be informed. This are all very informative. Thanks

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    1. Thank you. Yes, we intend to share for better understanding!

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  24. Thank you for this great post. Its nice to know the symptoms para maagapan agad and prevent it from spreading.
    www.sweetcuisinera.com

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    1. Yes. Understanding is the best way to lead to prevention.

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  25. Yes I heard this also sa news sa tv. Nagulat ako na pa increase yung numbers ng affected nito, hopefully ma solusyonan na to kasi kawawa lang sila lalo na ang mga bata.

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    1. All involved government agencies are now doing extra effort for this while the private sector also are doing their part.

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  26. THis is such a helpful and informative post. I didn't know about the Novovirus

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    1. Something new for us too even if we are in the healthcare industry.

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