Avian Influenza Pandemic Influenza Update April 2006

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Avian Influenza / Pandemic Influenza
UpdateApril 2006
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H5N1 Poultry outbreaks in 2005
H5N1 Poultry outbreaks in 2005
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Current Situation in Viet Nam
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Confirmed Human Cases of A/H5N1 December 2003
26 April 2006
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Case fatality ratio differences in Viet Nam
December 2004 June 2005
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H5N1 Cases by Age group as of 4th May 2005
3rd wave (Dec04 4 May 05) Cambodia n4
Viet Nam n32 excluded 12 cases with no
information about age
1st wave (Dec03 Mar 04) Thailand n12
Viet Nam n23
2nd wave (Jul04 Oct 04) Thailand n5
Viet Nam n4
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Current 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 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
• and
• Incidence of ILI in humans remains high
• Virus is believed to be still circulating in
  poultry/migratory birds
• but
• 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?

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Government 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

• 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 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 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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Challenges

• 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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Weaknesses

• 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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Summary

• 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 Response Planning in
Viet Nam
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WHO Pandemic Phases
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Planning Scenarios

• The scenarios being planned for are
• Ongoing H5N1 outbreaks in birds (MOA-DAH)
• Sporadic human cases of avian A/H5N1 (MOH/MOA)
• Local emergence of pandemic form of human A/HxNy
  influenza (MOH) - containment
• 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 Timeline
Current situation
An outbreak caused by a low pathogenic virus that
does not cause significant illness in humans may
not be recognised until it is quite extensive
Days ? months?
Outbreak
2 weeks?
Containment or not?
Failure of intervention Successive countries
affected
Weeks?
Global pandemic
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Pandemic 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

• 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 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 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

• 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 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

• 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 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
  care
• and
• capacity to screen 3,000 people per day
• with
• 30 less staff

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Implications 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?

• 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?
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Best 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 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 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 Tools
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National Preparedness and Response Planning

• The purpose of national planning is to
• provide guidance to local authorities in
  preparing their own plans for (both AI and PI)
• preparedness
• response
• recovery
• mobilise resources in support of local plans
• coordinate cross sectoral management,
  information, logistics and communication systems

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Increased morbidity and mortality (traditional
high risk groups lt2, gt60, immuno-compromised) Epi
demic period of 100 days, 2 waves of case numbers
surge 30 of population become ill 2.0 of
population develop pneumonia 1.5 of population
need hospital care 0.5 of population die (90
from the high risk groups)
Health Sector Response Case definitions Case
confirmation criteria Case management
protocols Referral system (clinical and
laboratory) Admission/discharge
criteria Isolation criteria Guidelines
for Vaccination Tamiflu PPE Preparing provincial
and municipality hospital plans Temporary
treatment centres Triage of patients Infection
control Staffing plans/role of volunteers (vnrc,
Womens Union) Procurement plans Stockpiles of
supplies and equipment Distribution, transport
and communications plans Mortuary
services Psychosocial care Staff
benefits/conditions Surveillance
systems Reporting and data management
systems Quarantine procedures Border
services/controls Travel/public places
advice Home care advice Advice to schools and
workplaces Media management Rumour control Public
information and education Professional
information and education Maintain essential
services Research and documentation Legislation/or
ders
Increased risk to health sector staff 30 staff
sick with influenza Overloaded services Increased
working hours Absenteeism (fear, family member
ill)
Increased demand for health care/services Hospita
ls, laboratories (clinical and public
health) Private clinics Pharmacies over 100
days 300/100,000 population additional
consultations/day 20 new cases pneumonia/100,000
population/day 15 admissions/100,000
population/day for 5 day admission, need 75
beds/100,000 population during surge periods,
these numbers may double use to calculate
staffing/equipment needs (clinical and lab)
Confirmed cases of general human to human
transmission in the community
Increased demand for prophylaxis Role of
Tamiflu Role of vaccination seasonal, HxNy,
pneumococcal
Lack of resources/disruption of all health care
services and programmes Acute medical and
surgical care Emergencies - obstetrics,
trauma Special units (intensive care, burns,
coronary care) Hospital care for potentially
unstable chronic illnesses asthma, diabetes,
renal failure Programmes that use schedules
dots, epi etc Unstable water and electricity
supply General lack of supplies due to high
global and local demand, reduced transportation,
lack of opportunity to import and reduced local
production
Shortage of medical supplies and equipment Needs
for 100 days x sets of PPE/day x doses of
antibiotics (30 IV, 20 pædiatric)/day x doses
of paracetamol/day IV fluids, oxygen, steroids,
salbutamol, disinfectant, laboratory reagents,
vaccines, electricity/water supply systems
Slowdown in economic and commercial activity For
100 days Closure of public places (cinemas,
schools etc) Cancelled conferences, meetings,
travel and tourism Cancelled air, land and sea
transport Closed markets, factories, businesses,
distribution systems, leading to unstable food,
water and electricity supply Reduced agricultural
output
Public concern High levels of media interest High
demand for information and advice on services
available, home care, prevention and
treatment Increased demand for funeral/welfare
services Rumours and misinformation Fear and
public safety concerns, role of the police
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Thank you for your attention
Please visit http//www.un.org.vn/who/avian/