world health organisation viet nam avian influenza / pandemic influenza update april 2006

World Health Organisation Viet Nam

Avian Influenza / Avian Influenza / Pandemic Influenza Pandemic Influenza

UpdateUpdateApril 2006April 2006


The designations on this map do not imply the expression of any opinion on the part of the Regional Director concerning the legal status of any country or territory or the delimitationof its frontiers.

NOTE: Shaded areas are member states and areas of the WHO Region for the Western Pacific

World Health OrganizationWestern Pacific Region

Member: 28 States and 9 areasPopulation: 1,665.6 million (1999)Offices:

WHO Regional Office (1)WR Offices (10)CLO Offices (5)PTT Office (1)


H5N1 Poultry outbreaks in 2005

H5N1 Poultry outbreaks in 2005


2006200520042003

District with A(H5N1) Outbreak

Disclaimer: The presentation of material on the maps contained herein does not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or its authorities of its frontiers or boundaries

Turkey

2006 - 12

Iraq

2006 - 2

China

2006 – 8

2005 – 8

Thailand

2005 – 5

2004 – 17

Cambodia

2006 - 1

2005 - 4

Viet Nam

2005 – 61

2004 – 29

2003 – 3

Indonesia

2006 – 13

2005 – 17

Azerbaijan

2006 - 7

GEOGRAPHIC DISTRIBUTION OF HUMAN AVIAN INFLUENZA – 5 April 2006GEOGRAPHIC DISTRIBUTION OF HUMAN AVIAN INFLUENZA – 5 April 2006


Current Situation in Viet NamCurrent Situation in Viet Nam


Confirmed Human Cases of A/HConfirmed Human Cases of A/H55NN11 December 2003 – 26 April 2006December 2003 – 26 April 2006

Country

2003 2004 2005 2006 Total

cases deaths cases deaths cases deaths cases deaths cases deaths

Azerbaijan 0 0 0 0 0 0 7 5 7 5

Cambodia 0 0 0 0 4 4 2 2 6 6

China 0 0 0 0 8 5 8 6 16 11

Egypt 0 0 0 0 0 0 4 2 4 2

Indonesia 0 0 0 0 17 11 13 12 30 23

Iraq 0 0 0 0 0 0 2 2 2 2

Thailand 0 0 17 12 5 2 0 0 22 14

Turkey 0 0 0 0 0 0 12 4 12 4

Viet Nam 3 3 29 20 61 19 0 0 93 42

Total 3 3 46 32 95 41 48 33 192 109


Case fatality ratio differences in Viet Nam December 2004 – June 2005

31%

16%

100%

0%

50%

100%

South North Total

Region

Cas

e fa

tali

ty


HH55NN11 Cases by Age group as of 4 Cases by Age group as of 4 thth May 2005 May 2005

1st wave

(Dec’03 – Mar ’04)

Thailand n=12

Viet Nam n=23

2nd wave (Jul’04 – Oct ’04)

Thailand n=5

Viet Nam n=4

3rd wave (Dec’04 – 4 May ’05)

Cambodia n=4

Viet Nam n=32**excluded 12 cases with no information about age

0%

50%

100%

40+30-3920-2910-19 0- 9


Current SituationCurrent Situation

• Last outbreak of Influenza A/H5N1 in poultry was 15th December 2005

• Last confirmed human case of Influenza A/H5N1 was 14th November 2005


In 2006In 2006• Most legal instruments, technical guidelines and administrative

orders now in place (at least in interim form)• Tamiflu stocks in place for suspected cases of AI• Mass vaccination of poultry is ongoing

andand• Incidence of ILI in humans remains high• Virus is believed to be still circulating in poultry/migratory birds

butbut• Very few suspected cases reported (based on number of specimens

sent for confirmatory testing - only 3 in the south)• No confirmed human cases so far

Why?Why?


Government OrganisationGovernment Organisation

• National AI Coordination Committee chaired by Minister of Agriculture, MOH is vice-chair

• Similar committees at all provincial and municipal levels

• High levels of engagement of Committees with FAO, WHO, OIE, UNDP, World Bank, ASEAN and ADB


Government Activities Government Activities

• The “Red Book” – national AI preparedness and response plan (MOA)

• The “Green Book” – national PI preparedness and response plan (MOH)

• Comprehensive poultry vaccination campaign (MOA)• Animal workers/vaccinators/cullers health monitoring

system (MOA/MOH)• National campaign on “community hygiene for

prevention of AI spread” (MOA/MOH)• Public information campaign on radio. TV and

newspapers (MOA/MOH)• Web based information dissemination in Vietnamese

and English for halth and agriculture sectors


MOH activitiesMOH activities• Protocols for diagnosis, case management, case

confirmation and prevention of spread of influenza

• Networks for case notification, referral and treatment

• Networks for specimen collection, referral and case confirmation

• Guidelines for prevention and care in the community

• Translation of key documents and references into Vietnamese (including FluAid and FluSurge)


MOH activitiesMOH activities

• Construction of BSL3 labs in north and south (JICA and government funds)

• Strengthening capacity to develop a human PI vaccine

• WHO supported pilot project for surveillance of ILI at 4 sites – now being scaled up with US-CDC support

• Simulation exercises in major cities to test PI response plans (3 so far)

• Research on continuing efficacy and safety of Tamiflu


ChallengesChallenges

• Maintaining political will• Penetration to local level• Financial constraints (who pays in a user-fee based

health financing system?)• Administrative constraints• Weak surveillance system in general• General lack of clinical accountability/medical ethics

for diagnostic accuracy and patient outcomes• Lack of field investigative capacity (human and animal

epidemiology)• Lack of system to link all AI/PI related data


WeaknessesWeaknesses

• No guidelines or training for local government officers and managers on how to make a PI response plan

• No monitoring of existence and/or quality of local plans• No cross-checking of reporting – hospital vs.

community, epidemiology reports vs. lab reports• No programme of continuing professional education• No investment in building PI related nursing skills• Small investment in research (compared to the high

case load in VTN)


SummarySummary

• Much exists on paper and there is lot of activity at national level

But

• Many gaps in implementation at local level


Pandemic Preparedness and Pandemic Preparedness and Response Planning in Viet NamResponse Planning in Viet Nam


Phase Description

1 Birds are sick and dying but people are not affected.The virus that is circulating in animals cannot infect humans.

2 The animal virus has undergone some genetic changes which makes it possible to infect humans but not enough to make infection very likely

3 Individuals fall sick, and rarely someone who was in close contact with them also becomes sick.The virus has changed enough to make infection from animals to humans easier, but infection

from human to human still remains difficult.

4 Small groups of people start to fall sick but the outbreaks remain local and subside over time.The virus is still not well adapted to surviving for long periods in humans.

5 Larger groups of people start to fall ill, but these outbreaks generally remain confined to the area where they first occur and eventually subside.

The virus still has some difficulty to persist for long periods in humans

6 Infection is spreading generally in the populationThe virus is well adapted to surviving in humans

WHO Pandemic PhasesWHO Pandemic Phases


Planning ScenariosPlanning ScenariosThe scenarios being planned for are:

1. Ongoing H5N1 outbreaks in birds (MOA-DAH)2. Sporadic human cases of avian A/H5N1 (MOH/MOA)3. Local emergence of pandemic form of human A/HxNy

influenza (MOH) - containment4. Emergence of pandemic human HxNy influenza in

another country (MOH) - response

During a human pandemic,epidemics in birds will continue to occur


Response Planning TimelineResponse Planning Timeline

‘Outbreak’

Days months?

Global pandemic

Failure of intervention: Successive countries affected

2 weeks?

Weeks?

Current situationAn outbreak caused by a low pathogenic virus that does not cause significant illness in humans may not

be recognised until it is quite extensive

Containment or not?


Pandemic Risk AnalysisPandemic Risk Analysis

• Increased morbidity and mortality• Increased demand for health services• Shortage of staff, medical supplies and

equipment• Disruption of routine health programmes• Disruption of essential services• Slowdown in economic and commercial activity• Heightened public concern


Other Pandemic Risks …Other Pandemic Risks …

• Closure of public places (cinemas, schools etc)• Cancelled conferences, meetings, travel and

tourism• Cancelled air, land and sea transport• Closed markets, factories, businesses and

distribution systems (further affecting medical supplies)

• Unstable food, water and electricity supplies (due lack of transport and sick/absent staff)

• Reduced agricultural output


Other Pandemic RisksOther Pandemic Risks

• High levels of media interest• High demand for information and advice on

services available, home care, prevention and treatment

• Increased demand for social and welfare services

• High demand for funeral services• Rumours and misinformation• Fear and public safety concerns


Organisational ConcernsOrganisational Concerns

• Infective influenza cases need to be isolated from non influenza patients in hospitals

• Influenza patients will need special arrangements for access to services such as radiology

• Tamiflu will require secure storage and restricted access to prevent theft and misuse

• During a pandemic, there will continue to be cases of seasonal influenza A, influenza B, other ILI and bacterial/atypical pneumonia. These will complicate diagnosis, strain diagnostic services and consume critical resources

• During a pandemic, there will continue to be demand for non-influenza medical care e.g. traffic accidents


Planning Assumptions …Planning Assumptions …An epidemic period of 100 days, including 2

waves where case numbers surge: • 30% of population become ill• 2.0% of population develop pneumonia• 1.5% of population need hospital admission• 0.5% of population die (?? from the traditional

high risk groups - under 2, over 50, the immuno-compromised)


Planning AssumptionsPlanning Assumptions

• A mutation of the current avian strain (as occurred in 1918)

or• A new virus resulting from reassortment of avian and

human viruses (as occurred in 1968)so

• Tamiflu is not certain to be useful or effective• The virulence cannot be predicted• A vaccine cannot be developed until the pandemic

strain emerges• A vaccine will take 6 months to become available, with

rich countries getting it first


Implication of Assumptions …Implication of Assumptions …

• over a period of 100 days, for every 100,000 population there will be:– 30,000 people needing home care– 300 additional consultations/day– 20 new cases pneumonia/day– 15 admissions/day (average 5 days/admission)– 75 ventilated patients/day– 30%+ health sector staff sick or absent

• during surge periods, these numbers may double• for each patient admitted, 20 patients will need to

be screened


Implication of AssumptionsImplication of Assumptions

A city of 1,000,000 people would need:• 750 hospital beds/day for ventilated cases

and• capacity to support 3,000 people per day on

home careand

• capacity to screen 3,000 people per day with

• 30% less staff


Implications for BogotáImplications for Bogotá

In addition to meeting all other health needs, for PI alone, Bogotá DC (pop 8,350,000) would need:

• 6,250 hospital beds per day for ventilated cases• capacity to support 25,000 people per day in

home care• capacity to screen 25,000 people per day

with 30% less staff


What about your city?What about your city?

• How many ventilators needed?

• How many people to screen each day?

• How many people in home care?

• How many staff available each day?


How severe would a pandemic be?How severe would a pandemic be?


Best Case ScenarioBest Case Scenario

• Significant amount of illness, but mostly not severe and few deaths– Hospitals still function– Medical insurance provides cover (at increased

premium)– Sufficient Tamiflu to provide staff prophylaxis and

case treatment– Food and basic supplies continue to be available at

reasonable cost– Airlines keep flying, staff can move freely– Communications not disrupted– No security issues


Worst Case ScenarioWorst Case Scenario

• Huge numbers of ill people, many severe cases and many deaths– Severe illness in staff, with some deaths– Hospitals overwhelmed despite applying strict triage– Medical insurance not available except at prohibitive levels– Severe pressure on use of Tamiflu for treatment of cases and

contacts and for prophylaxis of staff– Severe and prolonged disruption to food, energy and water

supplies– Airlines not operational – essential travel only possible– Communications disrupted (telephones / internet)– Security and public safety issues


Nightmare ScenarioNightmare Scenario

• Highly pathogenic pandemic virus emerges during bad dengue or JE season, or during bad flood/typhoon or severe winter season

and / or• Tamiflu is no longer effective

As long as the virus is circulating in animals, it can mutate or reassort at any time and multiple

times


Planning ToolsPlanning Tools


National Preparedness and National Preparedness and Response PlanningResponse Planning

The purpose of national planning is to:• provide guidance to local authoritiesguidance to local authorities in

preparing their own plans for (both AI and PI):– preparedness– response– recovery

• mobilise resourcesmobilise resources in support of local plans• coordinatecoordinate cross sectoral management,

information, logistics and communication systems


National Policy

National AI Committee Sets the national goals and objectives

MOH, other agencies of Government

Prepare protocols, guidelines, procedures, administrative orders needed for local planning

Provincial, Municipal and Institutional Plans

Provincial Preparedness Plan

Provincial Response Plan Provincial Recovery Plan

Personnel needs: numbers, knowledge and skills

Resource needs (operational, organisational, financial and

material)

Public information needs

MOH Plan

Coordination of provincial, municipal and institutional preparedness, response and recovery actions Mobilisation of critical resources in support of local plans Consolidated reporting, public information and health promotion Monitoring and evaluation of the effectiveness and efficiency of the overall response and recovery Advocacy to political decision makers on health sector issues and needs Liaison with other agencies of government and the international community


Confirmed cases of general human

to human transmission in the community

Increased morbidity and mortality (traditional high risk groups: <2, >60, immuno-compromised)Epidemic period of 100 days, 2 waves of case numbers surge 30% of population become ill2.0% of population develop pneumonia1.5% of population need hospital care0.5% of population die (90% from the high risk groups)

Increased demand for health care/services:Hospitals, laboratories (clinical and public health)Private clinicsPharmaciesover 100 days:300/100,000 population additional consultations/day20 new cases pneumonia/100,000 population/day15 admissions/100,000 population/dayfor 5 day admission, need 75 beds/100,000 populationduring surge periods, these numbers may doubleuse to calculate staffing/equipment needs (clinical and lab)

Shortage of medical supplies and equipmentNeeds for 100 days:x sets of PPE/dayx doses of antibiotics (30% IV, 20% pædiatric)/dayx doses of paracetamol/dayIV fluids, oxygen, steroids, salbutamol, disinfectant, laboratory reagents, vaccines, electricity/water supply systems

Slowdown in economic and commercial activityFor 100 days:Closure of public places (cinemas, schools etc)Cancelled conferences, meetings, travel and tourismCancelled air, land and sea transportClosed markets, factories, businesses, distribution systems, leading to unstable food, water and electricity supplyReduced agricultural output

Public concernHigh levels of media interestHigh demand for information and advice on services available, home care, prevention and treatmentIncreased demand for funeral/welfare servicesRumours and misinformationFear and public safety concerns, role of the police

Increased risk to health sector staff+30% staff sick with influenzaOverloaded servicesIncreased working hoursAbsenteeism (fear, family member ill)

Increased demand for prophylaxisRole of Tamiflu

Role of vaccination – seasonal, HxNy,

pneumococcal

Lack of resources/disruption of all health care services and programmesAcute medical and surgical careEmergencies - obstetrics, traumaSpecial units (intensive care, burns, coronary care)Hospital care for potentially unstable chronic illnesses – asthma, diabetes, renal failureProgrammes that use schedules– dots, epi etcUnstable water and electricity supplyGeneral lack of supplies due to high global and local demand, reduced transportation, lack of opportunity to import and reduced local production

Health Sector ResponseCase definitionsCase confirmation criteriaCase management protocolsReferral system (clinical and

laboratory)Admission/discharge criteriaIsolation criteriaGuidelines forVaccinationTamifluPPEPreparing provincial and

municipality hospital plansTemporary treatment centresTriage of patientsInfection controlStaffing plans/role of

volunteers (vnrc, Women’s Union)

Procurement plansStockpiles of supplies and

equipmentDistribution, transport and

communications plansMortuary servicesPsychosocial careStaff benefits/conditionsSurveillance systemsReporting and data

management systemsQuarantine proceduresBorder services/controlsTravel/public places adviceHome care adviceAdvice to schools and

workplacesMedia managementRumour controlPublic information and

educationProfessional information and

educationMaintain essential servicesResearch and documentationLegislation/orders


Thank you for your attentionThank you for your attention

Please visit: http://www.un.org.vn/who/avian/

world health organisation viet nam avian influenza / pandemic influenza update april 2006

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