Emerging and Re-emerging Infectious Disease Program (EREID)

In the recent past, the Philippines has seen many outbreaks of emerging infectious diseases and it
continues to be susceptible to the threat of re-emerging infections such as SARS, Ebola, Avian Influenza,
etc. The current situation emphasizes the risks and highlights the need to improve preparedness at local,
national and international levels for against future pandemics. New pathogens will continue to emerge
and spread across regions and will challenge public health as never before signifying grim repercussions
and health burden. These may cause countless morbidities and mortalities, disrupting trade and
negatively affect the economy.

There are several social determinants contributing to the emergence of novel infectious diseases
and resurgence of controlled or eradicated infectious diseases in our country. These contributing factors
are namely:
(1) Demographic factors like the population distribution and density
(2) International travel/ tourism and increased OFWs
(3) Socio-economic factors and
(4) Environmental factors

Emerging and Re-emerging Infectious Diseases are unpredictable and create a gap between
planning and concrete action. To address this gap, there is a need to come up with proactive systems that
would ensure preparedness and response in anticipation to negative consequences that may result in
pandemic proportions of diseases. Proactive and multi- disciplinary preparedness must be in place to
reduce the impact of the public the health threats.

Severity Assessment
Virological factor (Properties of the virus) – Self-limiting infections in majority of infected individuals – Can
cause very severe form of infections among the high risk group
Population vulnerability – Relatively high in the Philippines
Capacity to respond – Established outbreak response mechanism at national & regional levels

Prevention of Emerging Infectious Diseases Will Require Action in Each of These Areas
 Surveillance and Response
 Applied Research
 Infrastructure and Training
  Prevention and Control

Vision
A health system that is resilient, capable to prevent, detect and respond to the public health
threats caused by emerging and re-emerging infectious diseases

Mission
Provide and strengthen an integrated, responsive, and collaborative health system on emerging
and re-emerging infectious diseases towards a healthy and bio-secure country.

Goal
Prevention and control of emerging and re-emerging infectious disease from becoming public
health problems, as indicated by EREID case fatality rate of less than one percent.

Target Population/ Client: All ages; Citizen of the Philippines

Area of Coverage: Philippines and it’s international borders

Partner Institutions
DOH Central and Regional Bureau’s/Offices, Other Government and Non-Government Offices, Medical
Societies, Academe, Developmental Partners (World Health Organization, FAO-OIE, CDC, GPP-Canada)

Policies and Laws

 Executive Order No. 168 - Creating the Inter-Agency Task Force for the Management of Emerging
Infectious Diseases in the Philippines

 Administrative Order No. 10 s. 2011 - Creating the Philippine Inter-Agency Committee on

Zoonosis, Defining Its Powers, Functions, Responsibilities, Other Related Matters and Providing
Funds Thereof

Strategies, Actions Points

To achieve this goal within the medium term, with a benchmark of less than one percent EREID
case fatality rate, the EREID Program Strategic Investment Plan highlights the seven Strategic Priorities,
each with the following goals:
1. Policy Development
Establish updated, relevant, and implementable policies on EREID providing the overall
direction in implementing the different Program components for all the network of health
providers and facilities.

2. Resource Management and Mobilization

Effectively manage and mobilize available resources from the DOH and partners both
local and international needed in EREID detection, preparedness, and response.

3. Coordinated Networks of Facilities

Organize adequate and efficient systems of coordination among network of facilities both
public and private needed in EREID detection, preparedness, and response within the context of
integrated health service delivery system at national and sub-national levels.

4. Building Health Human Resource Capacity

 Health care professionals skilled, competent and motivated in detection, prevention and
management of EREID cases, with provision of supervised psychosocial support and risk
communication at the national and sub-national levels.

5. Establishment of Logistics Management System

Manage the systems of procurement and distribution of logistics for EREID detection,
preparedness and response under each mode of disease transmission.

6. Managing Information to Enhance Disease Surveillance

Improve case detection and surveillance of EREID to prevent and or minimize its entry
and spread and to mitigate the possible impact of widespread community and national
transmission.

7. Improving Risk Communication and Advocacy

Institute a risk communication and advocacy system that is factual, timely and context
relevant implemented at the national and sub-national levels.

Policy Development and Review

 Zika Guidelines finalized and approved ; Avian Influenza Guidelines updated

 Formation of the EREID Technical Working Group ; Experts Panel and EREID Management Group
 Development of the Situational Analysis of EREID in the Philippines
 Development of the EREID Manual of Operations for Preparedness and Response
 Development of the EREID 5- Year Strategic/ Investment Plan
 Active Participation in the finalization of the IRR of PhilCZ (AO No. 10)
 Community Simulation Exercise –CALABARZON (Oct 2017)
 Initial drafts of the Regional Preparedness and Response Plans (18) ; Initial drafts of the provincial
Preparedness and Response plans (5) -CALABARZON

Resource Management and Mobilization

 Program Implementation Review (PIR) (February 2017)
 Strategic Plan / Risk Communication Workshop (May 2017)
 Health Promotion / M&E Tool Workshop (Sept 2017)
 Participation in the Marawi Intervention
 Co-handling / assistance to BAI on the Avian Influenza (H5N6) outbreak
 Funding/ Sub- allotments to all regional offices ; RITM and 5 SNLs
 Strengthened collaboration with DOH bureaus, government agencies, medical societies,
academe, civil organizations and societies

Network of Facilities and Stakeholders

 CBCP, Schools, AFP and LGU; 7 TWG meetings conducted
 Medical societies as active (PIDSP, PISMD and PAFP)
 Academe collaboration started with UP Manila and NIH
 Philhealth, FAO and OIE, UP Manila, PGH as partners
 Regional EREID Forums: Region V, Region VI, Region IV A
 Field Visit: Region VI (RO, Hospital, RHU and LGU)
 Logistic Management System:
  Procurement of PPE (Personal Protective Equipment); Doxycycline; Oseltamivir;
 Pre-positioning EREID supplies to all regional offices (18); RITM and Sub National Laboratories
(SNLs)

Risk Communication and Advocacy

 Risk Communication Guidelines (per mode of transmission) –May 2017
 IEC, media placements, FB, advisories on Zika, Leptospirosis, Avian Influenza and JE
 Health Promotion Plan – Oct 2017

WAYS FORWARD – 2018

 Consolidation of all Regional preparedness plans and assistance to advocate to their Regional
Directors and LCEs
 Strengthening of the Rapid Response Team (RRT) – Regional, Provincial and LGU levels
 Strengthened collaboration with HEMB, HPCS, EB, RITM and other partner DOH bureaus and
private institutions
 Institutionalize the ONE HEALTH Paradigm (animal, human and environmental health) in the
EREID operational framework and activities
 Integration of strategies addressing the emerging infectious diseases and the public health
emergencies as in APSED III 2017 proposal
 IHR Joint External Evaluation Tool (JEE)
 Development of EREID National Policy and Program Monitoring Tool
 MOP dissemination thru Training Modules / Capacity Enhancement (18 ROs)
 One Health Strategy Workshops
 Interim Clinical Guidelines/ Policies - Review and Updating
 Field Support Visits / Annual Partners’ / Stakeholders’ Forum

INFLUENZA

Influenza is recognized both as an emerging and re-emerging viral infection and is described as an
unvarying disease caused by a varying virus. The virus mutates but its burden on health, lives, and
manpower is consistently overwhelming.
Flu is the commonly used name of influenza. It is a contagious viral infection caused by influenza
A and B virus.
The flu virus infects the upper and lower respiratory tract such as the nose, throat and sometimes
the lungs.

DOH Guidelines:
It is recommended in the Philippines to get flu shots before the rainy season which also marks the
start of the flu season.
It is given every year because the strain of the influenza virus continually changes and varies
every year. So the vaccine manufactured every year is dependent on the influenza virus strain. Immunity
provided by the vaccine does not last. It is therefore important that people at risk get vaccinated every
year.
Targeted Groups for vaccination
 Persons at increased risk for Complications
o Persons age 50 years old and above
o Children from six to 23 months old
o Adults and children with chronic cardiovascular disease, chronic lung disease, chronic
metabolic disease, chronic renal dysfunction and hemoglobinopathies.
o Immunosuppressed
o Children and adolescents who are receiving long term aspirin therapy and therefore
might be at risk for experiencing Reye’s syndrome after influenza infection.
o Residents of nursing homes and other chronic facilities
o Pregnant women on their 2nd or 3rd trimester who have not received their flu vaccine
within the last 12 months.
 Persons who can transmit influenza to those at high risk
o Health care workers
o Household contacts and caregivers of person at high risk
 The following groups of healthy population are encouraged to receive the vaccine depending on
its availability.
o Persons who provide essential and emergency community services
o Students and other persons in institutional settings
o Any person who desires to reduce the likelihood of becoming ill with influenza.

Persons who should not be vaccinated with inactivated influenza vaccine

 Persons who have anaphylactic hypersensitivity to the vaccine
 Persons with acute febrile illness should not be vaccinated until their symptoms have abated.

Prevention of Influenza in Health Care Settings

1. Patients with suspected or confirmed or influenza like illness (ILI) should be placed together in a
ward designated for influenza cases.
2. Ensure all health workers are completely fit and healthy and pose no medical threat to patients.
3. Limit the movement of staff between wards.
4. Prevent visitors and people with ILI from entering the ward for influenza cases.
5. Practice droplet precautions to prevent person-to person spread of the virus.
 wear masks when within 1 meter of the patient
 wear gowns if clothing likely to be soiled by body fluids
 practice hand hygiene before and after patient contact
6. As much as possible, limit the movement of patients between rooms to essential purposes only. If
transport or movement is necessary, provide the patient with a mask to minimize dispersal of
droplets.

AVIAN INFLUENZA

On August 2017, DOH was able to identify 34 suspect cases (30 from Pampanga and 4 from
Nueva Ecija). They were promptly placed in isolation as part of precautionary measures to avert any
possible human to human transmission of infection. As of 24 August 2017, all were negative for Influenza
A H5N6.
Under the Interim Guidelines, Standards and other Instructions in the Implementation of Enhanced
Human Avian Flu Surveillance Management, and Infection Control in the Health Setting:
 Ensure that poultry products are safe for consumption.
 DOH epidemiologic surveillance and response system is active and in place. Trained disease
surveillance officers and health workers have been alerted to investigate and report suspected
human cases within 24 to 48 hours.
 Pre-emptive positioning of necessary commodities to protect against bird flu transmission to
humans such as Personal Protective Equipment (PPE) and anti-viral medicines
 As a precautionary measure for those who had direct contact with infected poultry and had
developed any flu symptoms, we urge you and the public to report to the Regional Epidemiology
and Surveillance Units (RESUs) of the DOH Regional Offices and seek immediate consultation at
the nearest DOH Medical Hospital and Centers

SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

Since 2004, there have not been any known cases of SARS reported anywhere in the world.

Severe acute respiratory syndrome (SARS) is a newly identified acute viral respiratory syndrome
caused by a novel coronavirus, the SARS coronavirus (SARS-CoV) which is believed to have crossed the
species barrier recently from animals to humans. The first case was retrospectively recognized as having
occurred in Guangdong Province, China, in November 2002. By July 2003, the international spread of
SARS-CoV resulted in 8098 SARS cases in 26 countries, with 774 deaths. The epidemic caused significant
social and economic disruption in areas with sustained transmission of SARS, and on the travel industry
internationally, in addition to the impact on health services directly.
In the Philippines a local transmission outbreak was noted in the month of April 2003. As of May
of 2003 the Philippines was removed by the WHO from the lists of areas with recent local infection of
SARS. A total of 92 cases, mostly suspect SARS cases that were eventually diagnosed to have other
infections or underlying conditions, were admitted in RITM, San Lazaro Hospital or the regional hospitals
in the provinces. DOH reported 14 probable cases to WHO, 5 cases were imported. One of the imported
cases, who carried the disease is from Toronto, infected 7 others in the only chain of secondary
transmission that has occurred in the Philippines. Of the 7 secondary cases, all have been identified as
either family members of the index case or health workers who treated the index or the father both of
whom died. The four imported cases from SARS affected areas- Hong Kong, Singapore and Taiwan.

CONTROL MEASURES
International response
 CDC and WHO lead global response
 Global Alert and Response Network field teams assisting local authorities to investigate and
control the outbreaks
 Private sector
 Testing drugs and vaccines

Asian response
 International meetings
 Special ASEAN + 3 Ministers of Health Meeting on SARS held in Kuala Lumpur, Malaysia last 26
April 2003
  Set up an ASEAN center of excellence for disease control;
 Use of website to support the exchange of information among the ASEAN and the +3 countries;
 Strengthen capacity building for epidemiological surveillance; and
 Implement the ASEAN project on Strengthening Laboratory Capacity and Quality Assurance for
Disease Surveillance.
 Special ASEAN Leaders Meeting on SARS held in Bangkok, Thailand last 29 April 2003
 Exchange information on the latest developments of SARS based on unified rules, standards and
methods;
 Appoint a focal / contact point to facilitate communication in an emergency;
 Carry out cooperative research and training on SARS;
 Jointly sponsor organized high-level international symposium on SARS control and treatment in
China as soon as possible;
 Sponsor a special symposium to assess the political, security, economic and other possible impact
of SARS on this region and come up with regional counter-measures to address the impacts; and
 Work to make rigorous measures for immigration and customs control to prevent the out-spread
of SARS.

Philippine response
National response
 DOH-coordinated action with partners
 National Consultation with LGUs on local response, included other government agencies and the
private sector (May 3, 2003)
 Programs
- Mass media campaign, quarantine
 Legislations
-House Bills: HB 5937 on Quarantine
 Executive Order No. 201
Defines the powers, functions, and responsibilities of government agencies in response
to SARS

The DOH Secretary was appointed as Crisis Managers

Government Agencies involved:
 Department of Interior and Local Government
 Department of Foreign Affairs
 Department of Transportation and Communication
 Department of Labor and Employment
 Department of Tourism
 Department of Trade and Industry
 Department of Social Welfare and Development
 Bureau of Immigration
 Air Transportation Office
 Manila International Airport Authority and other air and port authorities
 National Security Council
 Office of the Press Secretary

Memorandum Order No. 98

National Anti-SARS Consciousness and Clean-Up Week (May 5 to 9, 2003)
Joint Program of the Department of Health and Department of Interior and Local Government
Activities
 Information dissemination
 Disinfection of public places
 Mobilizing public in proper disposal of garbage
 Enacting and/or enforcing ordinance on health, sanitation, and cleanliness

What is the local government units doing to prevent the spread of SARS?
Memorandum Circular 2003-97
Designates all Provincial Governors, City Mayors, Municipal Mayors, and Punong Barangays as
Anti-SARS Information Manager, Local Crisis Manager, and Environmental Health Manager

Barangay Health Emergency Response Team (BHERT)

 To address the containment, prevention, and control of SARS at the barangay level
 One should be created for every 5,000 population in the barangay
 Headed by an Executive Officer, appointed by the Punong Barangay
 Members: two Barangay Health Workers (one preferably a nurse or midwife)

What is the PhilHealth’s response to the SARS crisis?

 Expansion of hospitalization coverage
 Private or public health workers: PhP 100,000.00
 Other members and dependents: PhP 50,000.00

What is the response of the Occupational Safety and Health Center to address the SARS crisis in the
workplace?
 Information dissemination
 Radio, website, press releases, TV talk shows, documentation film integrating SARS in all training
and information programs
 Training for information officers, unions, health and safety officers, non-government offices
 Technical assistance for policies and programs on SARS
 Coordination of SARS prevention programs in the workplace

What should you do in workplace?

 Strict hygiene
 Protect yourself from workplace hazards like dusts, chemicals
 Protect yourself from secondary infection
 Always use appropriate PPEs for these hazards
 Know the hotlines of Department of Health, and OSHC for information

MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-CoV)

 Middle East respiratory syndrome (MERS) is a viral respiratory disease caused by a novel
coronavirus (Middle East respiratory syndrome coronavirus, or MERS‐CoV) that was first
identified in Saudi Arabia in 2012.
  Coronaviruses are a large family of viruses that can cause diseases ranging from the common cold
to Severe Acute Respiratory Syndrome (SARS).
Prevalence (Update)
 According to the World Health Organization, 1,179 cases of MERS have been confirmed in 25
different countries. Currently, South Korea has had the largest outbreak of MERS outside of Saudi
Arabia (where the virus was first discovered). As of June 9, 2015, there are 7 reported deaths, 87
confirmed cases of MERS and more than 2,500 people quarantined at home or in health facilities
in Korea
 Based on the 2018 WHO Global Summary and Assessment risk for MERS-COV the epidemiology
of pattern of MERS-CoV remains the same and that the Philippines still have 2 reported case of
MERS-CoV infection.

DOH Response
 Due to high concern over the potential spread for sustained person-to-person transmission and
spread, and reports of increasing cases and fatalities in the Middle East, the DOH issues the
following guidelines and standard procedures namely.
 Interim Guidelines on the Enhanced Surveillance on Middle East Respiratory Syndrome Virus
(MERS-CoV)
 Interim Guidelines on the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Contact
Tracing
 Interim Guidelines on the Enhanced Surveillance on Middle East Respiratory Syndrome Virus
(MERS-CoV)

Guidelines include:
Case investigation
 A person with sudden onset of fever, cough or sore throat or diarrhea in the absence of other
diagnoses and
 A person with history of travel from the Arabian Peninsula or neighboring countries within 14days
or
 A person who visited any health care facility with a known MERS-CoV or
 Any health worker with signs and symptoms of severe acute respiratory illness
 Case reporting

Interim Guidelines on the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Contact Tracing

 Contact tracing is the identification and diagnosis of persons who may have come into contact
with an infected person. Contact tracing plays an important role in containing the outbreaks of
infectious diseases. The main purpose of contact tracing is to: (1) confirm diagnosis, (2)
determine the extent of secondary transmission and (3) identify appropriate control measures for
the specific disease.
 Contact Identification persons who have had exposure (lived with, worked with, or cared for)
exposure to a confirmed case
 The World Health Organization (WHO) does not recommend the imposition of any travel, trade,
or screening restrictions related to MERSCoV. The virus does not appear to pass easily from
person-to-person, unless there is close contact with an infected person or provided unprotected
care to an infected person. Transmission of the virus has occurred mostly in healthcare facilities.
ABCs of preventing MERSCoV transmission
Ask about history of travel to Middle East
Be safe by using personal protective equipment both for health care workers and patients
Call DOH for advice at (02) 711-1001or (02) 711-1002

EBOLA VIRUS DISEASE (EVD) UPDATES

As of November 4, 2014, a total of 13,268 cases of Ebola Virus Disease, including 4,960 deaths,
have been reported in seven affected countries

With widespread & intense transmission:

 Guinea
 Liberia
 Sierra Leone
 With initial case/s or with localized transmission:
 Nigeria
- declared Ebola-free on Oct. 20
 Senegal
- declared Ebola-free on Oct. 17
 Spain
 United States of America
 Mali

DOH Interim Guidelines

 Inter-Agency Coordination on Prevention or Minimization of Entry/Spread of Ebola
 Procedures for Isolation, Case Management and Infection Control for Ebola
 Ebola Virus Disease Surveillance and Reporting
 Ensuring Health Security of OFWs in Guinea, Liberia, Sierra Leone Against Ebola
 Ensuring Health Security of Filipino UN Peacekeepers in Liberia Against Ebola
 Risk Assessment for Ebola Virus Disease in the Deployment of Overseas Filipino Workers in West
Africa

Inter-Agency Coordination
 DOH has worked with different agencies in facilitating the development of guidelines to address
the situation in Guinea, Liberia and Sierra Leone:
 repatriation of OFW
 repatriation of Filipino UN Peacekeepers

National Summit on Ebola Virus Disease

(Oct. 10, 2014)
National Plan of Action presented
Pledge of commitment from Government Agencies, Medical Community and Private Sector
#ebolafreeph

Monitoring of OFWs and UN Peacekeepers arriving from Guinea, Liberia & Sierra Leone
In coordination with DOLE-POEA and DFA, the Philippines has already repatriated 126 OFWs from Sierra
Leone as of Oct. 15, 2014; monitored by the DOH
UN Peacekeepers will undergo a 21-day quarantine period in a designated military facility upon arrival in
the Philippines

Next Steps
 Conduct of capacity building for identified dedicated hospital staff to attend to possible Ebola
cases with resource persons contributed by the WHO from the Johns Hopkins University, the
Doctors Without Borders and Australia
– October 28-30 (DOH Referral Hospitals, UP-PGH, AFP Medical Center and PNP General
Hospital) (DONE)
– November 4-6 (Selected Private Hospitals) (DONE)
– November 11-13 (Selected LGU Hospitals) (ONGOING)
 Procurement of additional Personal Protective Equipment
 Strengthening of RITM Laboratory
 Mobile field hospital set-up in Lung Center of the Philippines

ZIKA VIRUS

Zika virus is an emerging pathogen that is transmitted among nonhuman primates and humans
by Aedes mosquitoes. This is most likely misdiagnosed as dengue or influenza. Zika virus infected person
may manifest influenza-like clinical signs, such as fever, headaches, and malaise. Maculopapular rash,
conjunctivitis, myalgia, and arthralgia may follow these symptoms. The illness is usually mild and self-
limiting with symptoms lasting for 2-7 days.

Transmission

 Zika virus is transmitted to people through the bite of an infected mosquito from the Aedes genus,
mainly Aedes aegypti in urban areas and Aedes albopictus in rural areas.
o Aedes bite aggressively during the day.
o This is the same mosquito that transmits Dengue and Chikungunya.
 This virus can be transmitted through blood transfusion.
 A pregnant woman can pass Zika virus to her fetus during pregnancy.
 Zika virus can also be transmitted through sex carrying Zika virus unprotected.
o Zika virus has been detected in blood, urine, amniotic fluids, semen, saliva as well as body
fluids found in the brain and spinal cord.

Complication
• Guillain-Barre’ syndrome which is the sudden weakening of muscles.
• Neonatal malformation: Microcephaly is a condition where a baby’s head is smaller than those of
other babies of the same age and sex.

Situation
• Seventy-six countries and territories have reported evidence of mosquito borne Zika virus
transmission since 2007 (70 with reports from 2015 onwards), of which:
– Fifty-nine countries had reported outbreak from 2015 onwards
 – Seven of which has possible endemic transmission or evidence of local mosquito borne
Zika infections in 2016 or 2017
– Thirteen countries have reported evidence of person-to-person transmission of Zika virus
• Twenty-nine countries or territories have reported microcephaly and other CNS malformations
potentially associated with Zika virus infection, or suggestive of congenital
• In November 2016, World Health Organization (WHO) declared on that the Zika virus no longer
constitutes an international emergency, but it stressed a need for a long-term effort to address
Zika, which has been linked to birth defects and neurological complications.
• The WHO's Emergency Committee, which declared a public health emergency of international
concern (PHEIC), said the virus is still a long-term problem.

Statistics in Philippines

As of February 2017, there were 57 reported Zika cases in the Philippines. There were 38 (67%)
females and 19 (33%) males. Their ages ranged from 7 years to 59 years old. There were no deaths.
Cases were recorded in the following areas: National National Capital Region with 20 cases (35%);
CALABARZON with 18 cases (32%); Western Visayas with 15 cases (26%); Central Luzon with 2 cases (4%);
and Central Visayas - 2 cases (4%).
Of these cases, 7 were pregnant with ages ranged from 16 to 50 years old. Three came from the
National Capital Region, and 2 each from CALABARZON and Central Visayas. One case, a 16-year-old from
Las Pinas, already gave birth to a baby boy at full term without microcephaly. Another case, a 32-year-old
from Central Visayas, had spontaneous abortion at 9 weeks of pregnancy.

Health Advisories Against Zika Virus

Department of Health (DOH) issued a Department Memorandum No. 2016-0116 on February 22,
2016 which provides technical guidelines, standards, and other Instructions for Reference in the
Implementation of ZIKV Disease Surveillance which was amended on July 11, 2016 as Department
Memorandum 0116-A.
Also, DOH has been working on its advocacy to strengthen the 4S strategy against further Zika virus
transmission in the country and in establishing clinical management guidelines.

The 4S means
 Search & destroy mosquito breeding places,
 Use Self-protection measures,
 Seek early consultation for fever lasting more than 2 days,
 Say yes to fogging ONLY when there is an impending outbreak

The Research Institute for Tropical Medicine (RITM) also collaborated with the Disease Prevention
and Control Bureau (DPCB), Epidemiology Bureau (EB), Health Promotion and Communication Services
(HPCS) in conducting a National Summit on Zika Virus Disease (ZIKV) with the theme “One Philippines
Against Zika”, on October 28, 2016.