Enclosure 2. List of the Priorities for the Immunization by Mono-Valence Vaccine, Chemo

Enclosure 1.

PROPOSAL

of the network of managing, activities and regulations in implementation of the Activities Plan and of the needs of the Republic of Montenegro before and in the course of the potential occurrence and pandemic of avian influenza.

Managing

/ Coordination / Activities / Regulations
Republican Coordination Headquarters – Vice-President presiding. Members: Ministers of Health, Agriculture, Interior, Traffic, Economy, Finance / Authorized competent Ministries, based on the needs / Adopts the amendments and changes to the Plan and proposes to the Government the introduction of the following phases of the Plan; Proposes to the Government the introduction and dismissal of the state of the emergency at the proposal of the Ministry of Health; Proposes to the Government the activation of the budgetary reserves and requests from the Government additional resources; Proposes to the Government the requests for international assistance. / The Law on the Protection of the Citizens from the Influential Diseases (Official Gazette of the Republic of Montenegro, no. 32/2005); the Law on Veterinary (Official Gazette of the Republic of Montenegro, no. 11/2004); the Constitution of the Republic of Montenegro (Official Gazette of the Republic of Montenegro, no. 48/92).
Coordination body for the issues of veterinary and health – Managed by the Ministers of Agriculture and Health / Ministry of Health; Ministry of Agriculture, Forestry and Water Industry; Republican Commission for the Protection of Citizens from the Infective Diseases; Veterinary Administration; Institute for Public Health; Clinical center of the republic of Montenegro; Specialized Hospital for Lungs Diseases; Specialized Veterinary Laboratory; Montefarm; Red Cross of Montenegro; Doctors Chamber of Montenegro; World Health Organization representative in Podgorica / Monitors the epizootic and epidemiologic situation on domestic and international level; Proposes the Plan and changes to the Plan; Continuously estimates the risk from the avian influenza and pandemic influenza occurrence; Evaluates the effectiveness of the proposed measures; Performs the control over the implementation of the plan through the inspection services as well as availability of medicines, vaccines; Performs the control over the reference health institutions; Exchanges information with the OEI and WHO. / The Law on the Protection of the Citizens from the Influential Diseases (Official Gazette of the Republic of Montenegro, no. 32/2005); the Law on Veterinary (Official Gazette of the Republic of Montenegro, no. 11/2004);
Municipal Coordination Headquarters – Managed by the President of the Municipality (Mayor) / Health Centers; General Hospitals; Veterinary ambulances; Municipal utility services; Ministry of interior; Firefighting services; Local grocery suppliers etc. / Proposes and enacts Plans for the territories of its competency; Performs the control over the application of the municipal plan; Estimates the efficiency of the measures applied and reports on it to the Republican Coordination Headquarters and coordination headquarters in charge for the issues of health and veterinary. / The Law on Local Self-Governments (Official Gazette of the Republic of Montenegro, no. 42/2003 and no. 28/2004)

Enclosure 2. List of the priorities for the immunization by mono-valence vaccine, chemo profilax by anti-virus medicines

Bearing in mind the general sensitivity of the population at the new influenza virus sub-type, ideal prevention would be the vaccination of the whole population. Vaccinating I and II groups of priorities provides the medical treatment of diseased and functioning of the vital functions of the state, and expending the list for the III and IV group of priorities decreases the number of heavy complications and dying. Vaccination is performed with the 2 doses of the vaccine. Chemo profilax with anti-virus medicines is performed in the later phases of the Plan, at the confirmed exposure to the new influenza virus sub-type and under condition that vaccination has not been undertaken. Therapy with the anti-virus medicines is efficient only within the first 36-48 hours from the beginning of the disease. The WHO recommendszanamivir and oseltamivir (Tamiflu).

Groups of Priorities / Targeted population / Number of doses (two doses per person)* / Chemo profilax and medical tratament with anti-virus medicines** / Number of doses for short-term/long-term profilax***
Group 1.
Health and veterinary workers exposed to risk / Health and veterinary workers and staff involved in medical checkups and treatments of diseased and services (priority: Infective Diseases Ward; Health Centers; Retirement Homes; HES; Micro-Biological and other Terrain Services; Veterinary Ambulances; Sanitary, Health and veterinary Inspectors). / 10 000 x 2 / Pre-exposed profilax of professional risk / 500 – 10 000
doses
Group 2.
Persons engaged in general functions of the state / Staff engaged in distribution and production of medicines, food, water, electrical energy, members of the operational police services, fire-departments, public transportation, telecommunication, utility services, customs, members of judiciary, teams on duty for electronic and printed media, members of the Parliament and Government and of foreign consular missions. / 36 500 x 2 / Post-expositional profilax of exposed to animal virus of avian influenza / 100 – 2000 doses
Group 3.
Persons in permanent collective lodgings / Retirement homes, homes for pupils and students, social institutions or children and youth at the permanent custody, collective centers. / 6 500 x 2 / Post-expositional profilax / 100 – 500
doses
Group 4.
Persons with chronically diseases / Heavy disturbances of respiratory functions, chronically cardio-vascular diseases, chronically kidney diseases, patients on chemo-dialyze, diabetic disease, immune-deficiency. / 20 000 x 2 / Post-expositional profilax of the exposed chronically patients / 500- 2 000 doses
Group 5.
Persons older than the age of 65. / 75 000 x 2 / Post-expositional profilax of the exposed persons / 1 000- 5 000 doses
Group 6. Kindergarten age of children (6 months of age to 6 years). / 60 000 x 2 / Post-expositional profilax of the exposed persons / 1 000- 5 000 doses
Group 7. Schooling age children (7 to 14 years of age) / 72 000 x 2 / Post-expositional profilax of the exposed persons / 1 000- 5 000 doses
Total for all / 280 000 x 2 / 4 200- 29 500
doses

*in the event that the vaccine is not available at all or that it doesn’t come on time, in order to provide for enough time to receive two doses of the vaccine

**for the needs of vaccination it is necessary to provide approximately 600 000 sterile needles and syringes for single use, 300 l of alcohol and 500 kg of absorbent cotton, 300 ampoules of adrenaline and 300 ampoules of metileprednisolon

*** putting an effort in trying to provide larger quantities of vaccine for the following influenza season of 2006/2007 (requesting as soon as possible since its production capacities world vide are very limited)

Enclosure 3.

Plan of the available health workers and beds fund

Health service / Health institution / Number of doctors / Number of technicians medium + higher / Beds fund
Treatment of the non-hospital patients and vaccination / Health centers / 515 / 1 650 / 80
Supervision and suppression of the disease and vaccination / Institute for Public Health / 23 / 36 / -
Isolation of the first cases and serious cases / Wards for infective diseases and particularly isolated parts of units of intensive care (with monitoring and mechanical ventilation provided) / 14 + 20 / 35 + 40 / 59 + 23
Hospital treatment of the influenza complications / Internal wards of all the general hospitals and of the Clinical Center of the Republic of Montenegro / 75 / 180 / 414
Hospital treatment for complications of influenza / Part of the beds fund of the Specialized hospital for lungs diseases in Brezovik / 18 (7) ** / 51 (20) ** / 141 (60) **
Hospital treatment for complications of influenza with children / Pediatric wards of all the general hospitals and of the Clinical Center of the Republic of Montenegro (institute for the diseases of children) / 56 ** / 150 ** / 296
Hospital treatment for complications of influenza – extended list / Dermatologic-veneorology and certain chirurgical wards in accordance with the needs / 3 / 10 / 19
Total / 713 / 2 121 / 951

*In the event of the need for increased number of health workers, for the works of triage, treatment of easier cases and vaccination, additional staff would be engaged. If the number of the diseased would increase in a short period of time, the number of health workers could be increased alternatively with the retired doctors, final exams students and students of the final year of medicine, as well as with students of the final schooling years of the secondary and high medical schools. Bed funds could be increased with hotel capacities, beds in the students homes and boarding schools.

**Only available beds fund may be used

Estimated staff resources and hospital capacities would be revised after drafting the municipal plans

***In the event of need tourist facilities capacities would be used

Enclosure 4.

Plan of medicines and equipment needs for the period of pandemic

Based on the latest estimation of the WHO, projected for the population of the Republic of Montenegro, in the event of non-available vaccines, the spreading of the disease is projected to be 5% and 35% of the total population of the Republic of Montenegro, that is from 33 000 to 228 000 persons. Out of this number, it is estimated that the non-hospital health protection would be used by 5 000 to 21 800 diseased, while hospital treatment would be used by 500 – 3 000 persons with heavy complications.

MEDICINE

/ SHAPE OF MEDICINE
Syrup (children up to 6 years of age) original package about 65 000 children / Tablets/capsules (adults) 580 000 persons / Injections (ampoules)
erythromycin / 5 000 – 10 000 / 20 000 - 58 000 / -
benzyl penicillin / - / - / 10 000
cephalosporin III generation / - / - / 59 000
aminoglycozides / 55 000
chloramphenincol / 7 000
methronidazoe / 10 000 / 24 000
imipenem / 1 800
merepenem / 450
vancomicine / 500
clindamicine / 300
ciprofloxacin / 800 / 2 500
cortimoxazol / 400 / 100
oseltamivir (TAMIFLU)* / 5 000 – 16 500 * / 25 000 -145 000 * / -
flukonazol / - / 5 000 / 4 000
nesteroi anti-rheumatics / 5 000 – 20 000 / 25 000 – 115 000 / 20 000
diuretics / 10 000 / 20 000

*quantities of oseltamivir depend on whether the mono-valence vaccine would be available and on whether there would be enough time to apply two doses of it

Beside medicines it is estimated that there would be needed 6 000 bottles of infusion solution, 310 000 of syringes and needles for single use, 500 l of alcohol, 500 kg of gauze, 200 kg of chloral remedies for disinfection.

For the treatment of the most seriously diseased patients in the wards for isolation 10 fixed and 20 mobile respirators are needed, 30 monitors for vital functions monitoring, 30 aspirators, 2 mobile RTG devices, 1 device for ultrasound diagnosis, 20 EKG devices, 20 devices for acid-base status, 20 devices for fast determination of glycolic, 100 devices for blood pressure measuring, 10 autoclaves

Enclosure 5.

Needs estimates in resources and equipment for personal protection of health workers in the pandemic influenza

If we accept the estimates that the first couple of waves would last a few months (in average 5 months), for different levels of exposures of the health workers, without the capacities extension in temporary facilities, there should be acquired the following:

Medical activity / Number of usual multi-layer masks for single use – chirurgical (pieces) / Number of specialized masks N-95 and N-100 for health workers and particularly exposed (pieces) / Special protective suits (2 models –standard and PAPR) / Number of protective glasses (pieces) / Number of usual gloves for single use (pairs) / Number of chirurgical gloves (pairs) for single use. / Number of rubber boots (pairs) / Number of paper coats (pieces)
Citizens / 5 000 000 * / - / - / - / 100 000 * / - / - / -
Farmers / 10 000 * / 1 000 * / ? / 1 000 * / 5 000 * / - / 400 * / 1000 *
Health centers, HES, inspection services of local community, Institutes for public health / 320 000 / 35 000 / 250 / 3 000 / 330 000 / 2 000 / 800 / 60 000
Microbiological and biochemical laboratories / - / 2 000 / 100 / 200 / 30 000 / 500 / 50 / 8 000
Hospital wards for adults / 800 000 / 25 000 / 350 / 2 700 / 500 000 / 5 000 / 300 / 54 000
Children hospital wards / 300 000 / 10 000 / 150 / 800 / 200 000 / 3 000 / 200 / 16 000

Total

/ 6 430 00 / 73 000 / 850 / 7 700 / 1 165 000 / 11 100 / 1 750 / 139 200

*quantities available for citizens in free sails (pharmacies)

** includes the needs for patients who need to wear mask in the scope of preventing the spreading of disease in the hospital

***protective caps (chirurgical) – 1 430 000 pieces (for health workers)

Estimated quantities are subject to revision based on further experiences

Enclosure 6.

Estimates of needs in resources for biochemical, microbiological laboratory equipment and reagents and radiological service

Based on the estimated number of the hospitalized cases and the price of the analysis of basic biochemical parameters, estimated expenses amount from 12 500 to 90 000 €.

Based on the estimated number of hospitalized cases and the price of the analysis of general microbiological parameters, estimated expenses amount from 12 500 to 90 000 + 3 laminar chambers for bio-safety of levels 2/3 20 000 – 40 000

Based on the estimated number of the hospitalized cases and the price of radiological services (RTG of lungs) estimated expenses amount from 50 000 to 100 000 €

Total : ...... 95 000 – 320 000 eura

ESTIMATION OF THE ADDITIONAL NEEDS OF BUDGETARY RESOURCES

FOR THE NEEDS OF THE PREVENTION AND SUPRESSION OF PANDEMIC INFLUENZA

(IN THE EVENT OF VIRUS TRANSMISSION FROM ONE HUMAN TO ANOTHER)

I Vaccines, anti-microb medicines and nesteroid anti-rheumatics

Mono-valence vaccine A (H5N1) – 560 000 doses
Oseltamivir capsules a 75 mg (original package of 10 capsules) – 25 000 to 145 000
Oseltamivir syrup a 12 mg/5 ml (original package of 120 ml) – 5 000 – 16 500
Erythromycin syrup 5 000 – 10 000
Erythromycin tablets a 500 mg – 20 000 – 58 000
Benzyl penicillin ampoules a 1 000 000 – 10 000
Cephalosporin III generation Ceftriaxon, ampoules 59 000 (10 ampoules)
Aminoglykozid (amikacin), ampoules a 500 mg – 25 000 (10 ampoules)
Aminoglykozid (gentamicin), ampoules a 80 mg – 30 000 (10 ampoules)
Chloramphenincol, ampoules – a 1 g – 7 000
Metronidazol, tablets a 250 mg (original package 20 tablets) – 10 000
Metronidazol, ampoules a 500 mg/100 ml – 24 000
Imipenem, ampoules a 500 mg – 1 800 (5 bottles)
Meropenem, ampoules a 1 g – 450 (10 ampoules)
Vancomicin, ampoules a 500 mh
Clindamicine, ampoules a 300 mg – 300 (10 ampoules)
Cyprofloksacin, capsules a 250 mg – 800
Cyprofloksacin, ampoules a 100 mg – 2 500
Kotrimokasazol, tablets a 480 mg – 400
Kotrimoksazol, ampoules a 5 ml – 100 (50 ampoules)
Fluconazol, tablets a 50 mg – 5 000
Fluconazol, sol. A – 4 000
Nesteroid anti-rheumatics, ibuprofen, tablets a 400 mg – 5 000 to 20 000
Nesteroid anti-rheumatics, paracetamol, syrup – 5 000 to 20 000
Nesteroid anti-rheumatics, paracetamol, tablets – 20 000 to 95 000
Nesteroid anti-rheumatics, diclophen, ampoules a 3 ml – 20 000 (5 ampoules)
Diuretics (Lasix, Yurinex, Lometazid), tablets – 10 000
Diuretics (Lasix, Yurinex), ampoules – 20 000 (ampoules)
Infusion solution, bottles 500 ml – 6 000
TOTAL ………………………………………………………………………………………………………………. 6 798 706 – 10 253 636 €

II Personal protection equipment

Basic multi-layer masks for single use – chirurgical - 6 430 pieces

Special masks N-95 or N -100 for health workers and other particularly exposed staff – 73 000 pieces

Special protective suits – standard model – 700 sets

Special protective suits – PAPR model – 150 sets

Protective glasses – 7 700 pieces

Usual gloves non-sterile for single use – 11 650 pairs (50 pieces)

Chirurgical gloves sterile for single use – 11 100 pairs

Protective rubber boots – 1 750 pairs

Protective coat – 139 000 pieces

Protective caps – chirurgical – 11 430 000 pieces

TOTAL ...... 521 920 eura +

...... 455 150 US $ x 0,83..... 377 774 €

*5 000 000 of basic masks for citizens who would be buying them in free sails, but the resources for their acquisition need to be acquired

250 000 €

III Means for disinfection

Sodium dychlorizocijanurat a 1 kg – 200 kg
Manual pumps for sprinkling a 10 l, 50 pieces
Motor pumps for sprinkling 3 pieces
Formal dechide 100 l

TOTAL:...... 15 200 €

IV Disposable means

Syringes plastic sterile for single use – 910 000 pieces
Needles sterile for single use – 910 000 pieces
Alcohol 70% or 96% a 1 l – 800 l
Absorbent cotton – 1 000 kg

TOTAL ...... 32 840 €

V Equipment

Fixed respirator – 10 pieces
Mobile respirator with concentrator of oxygen – 20 pieces
Monitor for vital functions tracking – 30 pieces
Aspirator – 30 pieces
Mobile RTG device – 2 pieces
Device for ultrasound diagnosis – 1 piece
EKG device – 20 pieces
Device for acid-base status – 20 pieces
Device for quick determination of glikemia – 20 pieces
Blood preasure measuring device – 100 pieces
Autoclave – 10 pieces

TOTAL ...... 625 000 €

VI Overtime and terrain work of the health workers and inspectors

Terrain work for 60 sanitary – health inspectors MZ x 60 days
Mobile teams work – 5 teams (1 team – 10 people) – 50x60 days
Overtime work of health workers in Health centers, Hospitals, laboratories – 5 000 persons x 60 days

TOTAL ...... 4 599 000 €

TOTAL ...... 13 064 444 - 16 744 374 €+ 250 000 € for citizens masks – Montefarm and private pharamacies + 105 000 doses of three valence vaccine against influenza 336 000 €

Resources needed for urgent acquisition of required medicines and equipment for the initial response with occurrence of avian influenza and/or pandemic influenza

Oseltamivir capsules a 75 mg (original package of 10 capsules) – 10 000
Oseltamivir syrup a 12 mg/5 ml (original package of 120 ml) – 2 000
Basic multi-layer masks for single use – chirurgical - 10 000 pieces
Special masks N-95 or N -100 for health workers and other particularly exposed staff – 20 000 pieces
Special protective suits – standard model – 100 sets
Special protective suits – PAPR model – 50 sets
Protective glasses – 500 pieces
Usual gloves non-sterile for single use – 100 000 pairs (50 pieces)
Chirurgical gloves sterile for single use – 2 000 pairs
Protective rubber boots –200 pairs
Protective coat – paper -10 000 pieces
Protective caps – chirurgical – 10 000 pieces
Sodium dychlorizocijanurat a 1 kg – 50 kg
Manual pumps for sprinkling a 10 l, 10 pieces
Motor pumps for sprinkling 2 pieces
Formal dechide 20 l
Fixed respirator – 3 pieces
Mobile respirator with concentrator of oxygen – 5 pieces
Monitor for vital functions tracking – 8 pieces
Aspirator – 8 pieces
Mobile RTG device – 2 pieces
Device for ultrasound diagnosis – 1 piece
EKG device – 10 pieces
Device for acid-base status – 5 pieces
Device for quick determination of glikemia – 5 pieces
Autoclave – 10 pieces
Re-agents for biochemical analysis
Re-agents for microbiological analysis
Laminar chambers bio-safety 2 – 2 pieces
Re-agents and films for radiological services (RTG of lungs etc.)

TOTAL : ...... 727 887 €