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?

~ * ~ ~ * ~ ~ * ~ ~ * ~

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.