Download - 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
World Health Organisation Viet Nam
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)
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H5N1 Poultry outbreaks in 2005
H5N1 Poultry outbreaks in 2005
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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
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Current Situation in Viet NamCurrent Situation in Viet Nam
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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
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World Health Organisation Viet Nam
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
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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
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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
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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?
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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
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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
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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)
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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
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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
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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)
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SummarySummary
• Much exists on paper and there is lot of activity at national level
But
• Many gaps in implementation at local level
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Pandemic Preparedness and Pandemic Preparedness and Response Planning in Viet NamResponse Planning in Viet Nam
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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
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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
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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?
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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?
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How severe would a pandemic be?How severe would a pandemic be?
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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
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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
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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
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Planning ToolsPlanning Tools
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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
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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
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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
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Thank you for your attentionThank you for your attention
Please visit: http://www.un.org.vn/who/avian/