Transcript Experiences of Services Response to Avian Flu in Thailand Sorasak Lochindarat, M.D.

Experiences of Services Response to
Avian Flu in Thailand
Sorasak Lochindarat, M.D.
Country Situation
Poultry outbreaks
Poultry outbreaks and human cases
of AI (H5N1) in Thailand, 2004-2005
Each wave accompanied with human cases,
total 22 cases with 14 deaths
250
(Diagrammatic)
First
wave
200
Three waves of poultry outbreaks since early
Jan 2004
Characters of cases:
• Male : Female = 13 : 9
150
Second
wave
100
Third
wave
• Case fatality by age:
50
 under 5 years 1 / 3
(33%)
 5-14 years 8 / 9
(88%)
0
dead
survive
7
6
5
4
3
2
1
2004
2005
N
ov
Se
p
Ju
l
ay
M
ar
M
Ja
n
N
ov
Se
p
Ju
l
ay
M
M
ar
0
Ja
n
Human cases
8
 15 yr & over 5 / 10
(50%)
• Risk factors:
Contact with sick/dead birds 12 cases
Living in village having sick/dead
birds 8 cases
Close contact with cases 2 cases
Spot maps of human cases and
poultry outbreaks in Thailand
Confirmed case
Suspect case
Area of outbreak
in poultry
First round
(Jan-May 2004)
Second round
(Jun-Oct 2004)
Third round
(Oct05-Jan06)
Source: BOE, MOPH
Monthly Influenza Isolates : 2004-2005
300
A(H5N1)
B
250
A(H3N2)
A(H1N1)
200
150
100
50
0
Jan Feb Mar Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
Apr May Jun
Jul
Aug Sep Oct Nov Dec
Pranee Thawatsupha, National Institute of Health, Department of Medical Sciences
Reservoir Sources
• Backyard farm
• Free – range duck
• Fighting cock
Clinical Description of Influenza
(H5N1) in Thailand (31 Oct 04) (1)
Number 17 case (9 children, 8 adult)
Age :- median 14 y. (2-58 y.)
M:F
= 9:8
Confirmed diagnosis by culture or PCR for H5
and / or virus isolation
Fatality rate
Children (< 14 y.) 89%
Adult
(> 14 y.) 50%
Clinical Description of Influenza
(H5N1) in Thailand (31 Oct 04) (2)
Presentation at hospital
Fever, cough and dyspnea
Sore throat
Myalgia
Diarrhea
Rhinorrhea
Vomiting
Abdominal pain
100%
71%
53%
41%
53%
24%
24%
Result of Confirmatory Diagnosis of
17 H5N1 Patients in Thailand
Positive RT-PCR for H5
17/17 (100%)
Virus isolation for H5N1
11/16 (69%)
IFA
11/16 (69%)
Positive Rapid test for Flu A
4/11 (36%)
Rapid Test For “Flu A” in
Confirmed H5N1 Patients
Total H5N1 patients tested 11 cases
Rapid test use :- Quick Vue, Directigen A,
Bianax
Results of 11 cases
:- positive 4/11 (36%), median 13 d. (6-18 d.)
:- negative 7/11 (64%), median 7 d. (4-18 d.)
:- notdone 6/17
Mostly Directigen A®
Viral Isolation of 16 H5N1 Patients
in Thailand (2)
viral culture
N
No. of Day*
range
P
median
• Positive
11
3-12
7
• Negative
5
6-16
10
* Number of day from onset of illness to culture
0.211
Laboratory Results of 17-H5N1 Patients,
Thailand, 2004 (1)
Laboratory finding
WBC – median (/cumm)
Survived Died p-value
(n = 5) (n = 12)
5,400
2,450
0.008
Lymphocyte – median (/cumm) 2,429
663.5
0.096
137,500
0.496
Platlet count – median (/cumm) 203,000
Laboratory Results of 17-H5N1 Patients,
Thailand, 2004 (2)
Laboratory finding
No. Tested
Survived Died p-value
(n = 5) (n = 12)
4
10
-
SGOT – median (IU)
101.5
202.5
0.282
SGPT – median (IU)
49
51
0.325
Radiologic Findings of 17-H5N1 Patients,
Thailand, 2004
Radiologic
findings
Survived
(N=5)
CXR (early)
- interstitial
- lobar, patchy
Died
(N=12)
P
1
4
1
11
0.51
1
4
12
0
0.02
CXR (late)
- ARDS (diffuse bilateral)
- No ARDS
CXR Finding of Patient 8 YO
D 4 of Illness
D 8 of Illness
Antibiotics Therapy in 17 H5N1
Patients 2004, Thailand
Antibiotics use 2 - 5 kinds
(65% of cases use 3-4 kinds)
3rd gen. cephalosporin
Macrolides
Aminoglycosides
Carbapenem
Doxycyline
11/17
10/17
8/17
7/17
3/17
(65%)
(59%)
(47%)
(41%)
(18%)
Other :- Co-trimoxazole, piperacillin, quinolones
Corticosteriod Therapy in 17 H5N1
Patients 2004, Thailand
Corticosteriod therapy in
8/17 (47%)
methyl prednisolone
5/8
hydrocortisone
2/8
dexamethasone
1/8
Number of day from onset of illness to start corticosteroid medium 7.5 d.
(Range 4-13 d.)
Oseltamivir Treatment of 10 H5N1
Patients Thailand, 2004
N
Survived
Rx
N
mean duration mean duration
from onset to Rx
of Rx
5
3
5.3 d.
(4-7 d.)
6.7 d.
(5-10 d.)
Died
12
7
10.9 d.
(5-22 d.)
3.5 d.
(1-5 d.)
Total
17
10
-
-
Outcome of 17 – H5N1 Patients,
Thailand, 2004
• Total number (as of October 2004)
17 cases
• Respiratory failure
13 (76%)
• Cardiac failure
7 (41%)
• Renal failure
5 (29%)
• Liver failure
3 (18%)
• Bone marrow failure
1 (6%)
• Dead
12 (71%)
Multi-sectoral coordination for
avian influenza control
Private
Sectors
Dept. of
Livestock
Development
DLD
Operation
Center
CABINET
National Avian
Influenza
Committee
National
Operation
Center
Other
Agencies
MOPH
MOPH
Operation
Center
27 Jan 05
1. New influenza
virus in animals
low risk for human
2. High risk
for human
Phases in development of
influenza pandemic
(WHO 2005)
3. Human infections,
no or only inefficient
man-to-man Tx
4. Increased
man-to-man Tx,
limited outbreak
5. Significant increase
in man-to-man Tx,
A new pandemic
is certain and imminent,
only the matter of when!
11 Aug 05
extended outbreak
6. Pandemic
Estimated impact of new
influenza pandemic in
Thailand
Deaths
260,000
Extensive
deaths social and economic
65,000
impacts
Cases
Cases
26,000,000
Cases rate 10%
CFR 1 %
Case rate 40%
CFR 1%
16 Apr 05
6,500,000
The Cabinet
Cabinet approved
25 January 2005
Strategic plans on Avian
Influenza and Influenza
Pandemic Preparedness
National Committee
on Avian Influenza
Response
Thailand is prepared
for the prevention of
and response to
influenza pandemic
27 Jan 05
Objectives of Pandemic Flu Prepareness
- prevention and surveillance of pandemic flu
- reduce morbidity / mortality
- appropriate management
- set up commanding network of health care systems
- reduce economic and bio-psycho-social effects
Aims of Pandemic Flu Prepareness
- Appropriate organization in the situation of
pandemic flu
- Conduct lab tests
- NIH, University lab at Bangkok : viral study
- 13 regional lab centers : RT-PCR
- Stockpile : Oseltamivir for ≥ 325,000 cases
(0.5% of population)
- Hospital capacity for severe flu : ≥ 10,000 beds
and field hospital ≥ 5,000 beds
- Mechanical ventilator : ≥ 2 for each district hospital
: High frequency oscillator in
25 regional hospitals
Strategies of Pandemic Flu Prepareness
- Prevention and control of epidemic in human and
animal
- Prepareness of rapid test, stock pile, PPE, ventilator,
respiratory isolation room and vaccine
- Prepareness for pandemic threat in
- health care system
- community
- Mass communication : for community awareness
- Organization neworks in health care system
SRRT : Surveillance and Rapid Response Team
• Surveillance
• Outbreak investigation
& control
• Information &
knowledge exchange
Provincial
SRRTs
Central
& Regional
SRRTs
District
SRRTs
Sub-district
Health Centers
Village Health Volunteers
& Community Leaders
Over 1000 SRRTs have been established
3 Mar 06
Case Management & Hospital Infection Control
Case management
- CPG
- training course for HCWS
- triage system
- rational use of rapid test & oseltamivir
- prepared ventilator, pulse oximeter
Infection control in hospital
- PPE
- airborne infection isolation room (regional/
university hospital), respiratory isolation room
(provincial/district hospital)
Risk communication
 Dissemination of risk communication messages
through various media, including call centers
 Centralized media releases with daily update of
situation and public advices
3 Mar 06
Stockpiling and logistics
•Vaccine
•Antiviral drug
•Diagnostic test kits
•Respirators
•PPE
3 Mar 06
Administration of viral study & supphy
19 Regional CDC centers
- Organized & supply
- Seasonal flu vaccine for HCWS, Culler,
surveillance team, lab personnel
- Rapid test
- Oseltamivir
- PPE
13 Regional Lab centers
- RT-PCR
- send specimens to NIH (WHO National
Influenza Center) in Bangkok
Draft CPG for avian flu/pandemic flu
Pilot : table-top exercise
Drills
Scenarios
Modification of CPG
CPG implementation
Evaluation
Guideline for avian flu/pandemic flu prepareness
Patients with suspecious of avian flu/pandemic flu
Group 1
Moderate to severe ARI* and
- Hx contact with sicked/dead poultry
- Hx contact with unexplained pneumonia patient
- Travel to/residence in area affected by avian flu
outbreak
Group 2
Unexplained severe pneumonia
Cluster of pneumonia
Pneumonia in HCWS
Group 3
Cluster of ILI**
* ARI : acute respiratory illness
** ILI : influenza like illness
Group 1 : Algorithm for avian flu
Persons with unexplained mod to severe ARI and
- Hx contact with sicked/dead poultry
- Hx contact with unexplained pneumonia patient
- Travel to/residence in area affected by avian flu
outbreak
CXR
Rapid test (for Flu A&B)
Viral study
Rapid test : neg
CXR : normal
Rapid test : neg
CXR : pneumonia
Rapid test Flu A+
CXR : normal/
pneumonia
Rapid test Flu B+
CXR : normal/
pneumonia
Group 1 : Algorithm for avian flu (Cont’)
Rapid test Flu A+
CXR : normal/pneumonia
- Isolation room, PPE
- Oseltamivir
- waiting for RT-PCR
Rapid test : neg
CXR : pneumonia
Severe : Rx as above
Mod : supportive Rx
waiting for RT-PCR
Rapid test : neg
CXR : normal
- OPD case/F.U. in 48 hr
- Viral study
Rapid test Flu B+
CXR : normal/pneumonia
- Isolation room
- Oseltamivir
- waiting for RT-PCR
Group 2 : Algorithm for pandemic flu prepareness
- persons with unexplained severe pneumonia
- Cluster of pneumonia
- Pneumonia in HCWS
Rapid test for Flu A&B
Viral study
Rapid test : neg
- Supportive RX
- Waiting for RT-PCR
Rapid test Flu A+
- Isolation room, PPE
- Oseltamivir
- Waiting for RT-PCR
Rapid test Flu B+
- Isolation room
- Oseltamivir
- Waiting for RT-PCR
Group 3 : Algorithm for surveillance of
pandemic flu
Cluster of ILI in community
Surveillance and rapid response team
Randomized viral study
Closed observation for pandemic flu
Lab investigation
Lab
Frequency of checking
Remark
1. CBC
Baseline then as need
2. UA
Baseline then as need
3. Hemo C/S, BUN,
Cr, LFT, BS
Baseline then as need
4. Quantitative PCR
for H5 in blood
Day 0, day 1- 4
then as need
For viral load
5. Freeze serum
Day 0, day 1, 3, 5, 7
then as need
For cytokine study
Lab investigation (cont’)
Lab
Frequency of checking
Remark
6. Nasal swab,
throat swab
Tracheal suction
for viral study
OD until discharge
PCR, IFA
7. Rectal swab : esp.
diarrhea for viral
study
OD for 5 days
PCR, IFA
8. Urine for viral study
D0
9. CSF for viral study
Baseline then as need
10. CXR
Baseline then as need
Case neuro
involvement
Severity of avian flu and referral system
Severity of AI
Level of hospital
No pneumonia
District hospital
Mild pneumonia
Provincial hospital
Severe pneumonia
Provincial hospital
ARDS, sepsis/septic shock
Regional hospital
Multi-organ failures
University hospital
True numbers remain elusive in bird flu
outbreak
•
•
•
•
Mostly seriously ill patients get tested for H5N1
Milder cases are likely to slip through the cracks
Ducks can carry H5N1 without symptoms
H5N1 can present with diarrhea and brain
inflammation
• Family clusters of H5N1 in Vietnam and Thailand
: human–to–human transmission
• Seriously ill patients from the process of
cytokines or drug resistant or delay treatment
Oseltamivir stockpiling initiative
• Purchase from Roche
– 100,000 treatment courses in 2005
– to secure 100,000 treatment courses in 2006
• Effort for local production by GPO
– pilot production (from imported API) underway, bioequivalent test pending, expecting to acquire FDA in
2006
– Proposal for government support to establish a
production plant submitted in “Mega-project” package,
approved in principal by the Cabinet
• Advocacy for establishment of regional stockpiles
3 Mar 06
Exposure of 17 H5N1 Patients, 2004
Living in village with dead poultry
• 15 (backyard chickens
/fighting cocks)
• 1 (Duck)
Direct contact with
ill/dead chicken(n=9)
No direct contact (7)
17 case (half are children under 15)
Male : Female = 1:1
Not living in village
With dead poultry
( Dr. K Ungchusak, BOE, MoPH)
Provide bedside care
Of a probable case
Strengthening Laboratory
Capacity & Networking
 Establish Lab Network : NIH, NAIH,
University, Military, etc.
 Equip and train 13 regional labs nationwide
for molecular technique testing
 Enhance laboratory biosafety and biosecurity
3 Mar 06
National Strategic Plan on Avian
Influenza Control, 2005-2007
• Strengthening disease surveillance & control
(animal health, public health, wildlife)
• Improving animal husbandry
• Empowering the community for active roles in
disease prevention and control
• Supporting R&D/ knowledge management
• Promoting integrated management of disaster
• Strengthening organization and manpower capacity
16 Apr 05
Approved by the Cabinet,
25 January 2005
Progress of the implementation of
• Influenza surveillance
Strengthened
• •laboratories
improved
National antiviral
• SRRTs
established
stockpile
initiated in
districtssystem
•allLogistic
pandemic preparedness plan
under improvement
Surveillance–in man & animals
• Clinical trials of
pandemic vaccine to
• Case management
Stockpiling and logistics
be initiated
guidelines
revised
• Training & supervision
 Emergency responses
underway
• Isolation rooms under
 Public health
improvement/construction
 Community
• Master operation plan
prepared
Public communication
• Pandemic preparedness plan
Coordination and
to be integrated in national
command
disaster preparedness plan
• To initiate table-top exercise
on PPP at provincial level7 Nov 05
The Cabinet
Cabinet approved
25 January 2005
Strategic plans on Avian
Influenza and Influenza
Pandemic Preparedness
National Committee
on Avian Influenza
Response
Thailand is prepared
for the prevention of
and response to
influenza pandemic
27 Jan 05
Strategic plans on Avian
Influenza and Influenza
Pandemic Preparedness
(2005-2007)
Operation Plan
of the Ministry
of Agriculture
& Cooperatives
Operation Plan
of the Ministry
of Public
Health
Operation
Plans of other
Ministries
25 July 05
and Agencies
Pandemic Influenza Preparedness
Strategies
 Coordination and command
1 Aug 05
 Surveillance – in man & animals
 Stockpiling and logistics
 Emergency responses
 Public health
 Community
 Public communication
Avian Influenza Control Measure,
Thailand 2004
Influenza Vaccine
Antiviral prophylaxis
(oseltamivir)
:- Culler
:- HCW’s esp. assigned medical
and nursing team
:- Laboratory personnels
:- Surveillance team
(medical, livestock)
:- Household contact
:- Culler
(in case of improper PPE)
:- HCW’s
(in case of improper PPE)
Histologic Examination in H5N1
Patients Thailand, 2004
Full postmortem autopsy was done on
2 patients
one child
one adult (formalined)
Necropsy was done on 3 patients
lung, liver, spleen
If pandemic flu happened in Thailand
Death
260,000
Death
65,000
Cases
6,500,000
Sick 10% of population (65 million)
Mortality 1%
Minimum expectation
Cases
26,000,000
Sick 40% of population
Mortality 1%
Maximum expectation
250
Flu strain analysis 2004-2005
200
150
100
50
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
A/Fujian/411/2002(H3N2)
A/California/7/2004 (H3N2)
B/Shanghai/361/2002
B/Sichuan/379/99
A/Wellington/1/2004 (H3N2)
A/New Caledonia/20/99 (H1N1)
B/Hong Kong/330/2001
B/Malaysia/2506/2004
Pranee Thawatsupha, National Institute of Health, Department of Medical Sciences