Influenza A H1n1(english Version)

New Influenza A (H1N1) Real Pandemic??

Influenza A(H1N1) A novel influenza virus, is contagious and transmitted person to person. Outbreaks in human first occurred in Mexico and the United States in March 2009. The disease then spreads to other countries in many parts of the world through international traveling.

Mexico has reported high abnormal peak of flu and pneumonia since 18 Mar. 09

Late Apr.09 : 2 confirmed cases of swine flu in US. (2 States near the border, California and Texas)

Major Event Timeline of WHO • 25 Apr.09 --Declared “Flu outbreaks in Mexico & US” as “Public Health of International Concern ; PHEIC” • 27 Apr.09 – Raised level of pandemic alert from phase 3 to phase 4 -- not recommended travel restriction or border closure • 29 Apr.09 – Raised phase 4 to 5 -- Recommended Pandemic Preparedness Plan activation -- Renamed the novel virus “Swine flu” to “Influenza A (H1N1)”

แผนที่การกระจายของโรคไข้หวัดใหญ่สายพันธุ์ใหม่ ชนิดเอ เอช1เอ็น1

As of 8 June 09 Total 73 countries, 25,288 cases , 139 deaths

New flu A (H1N1) Situation in Thailand  Since 12 – 8 June 09 -- The Ministry of Public Health, Thailand has reported 10 Thai laboratory confirmed cases of Influenza A (H1N1).  9 cases Travel History from overseas to BKK, but 1 of these 10 cases has no travel history.  All are mild cases of URI with Antiviral drug (Oseltamivir) completion and now are being recovery.  The close contacts are given complete oseltamivir prophylaxis with close monitoring.

Global Response to New flu 

WHO is working aggressively and constantly to ensure access to affordable drugs and pandemic vaccine, should that be required.

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Most countries have warned travel advisory avoidance to the affected countries and implemented entry screening.

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Several countries have imposed trade restrictions on countries exporting animals or products of animal origin that have declared human cases related to the new influenza of the type known as “A/H1N1”.

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Some countries culled pigs for the propose of disease prevention.

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Activated national Influenza Pandemic Preparedness plan.

OIE RESPONSE •

The OIE advocates implementing international standards for human killing of animals for disease prevention purposes.

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The OIE advised its Members that the culling of pigs will not help to guard against public or animal health risks presented by this novel A/H1N1 influenza virus and that such action is not recommended.

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The first transmission of “A/H1N1” virus from human to pigs in a single herd was officially notified to the OIE by Canada on the 5 May 2009

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Pork and pork products, handled in accordance with good hygienic practices recommended by the WHO , Codex Alimentarius Commission and the OIE, will not be a source of infection

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Authorities and consumers should ensure that meat from sick pigs or pigs found dead are not processed or used for human consumption under any circumstances. Source : OIE

WHO Pandemic Phase, 2009 PHASE PHASE 1 PHASE 2 PHASE 3 PHASE 4

DESCRIPTION No animal influenza virus has caused infection in humans An animal influenza virus has caused infection in humans Influenza reassortant virus has caused sporadic case or small cluster of disease in people Human to human transmission and sustain community-level outbreaks

WHO Pandemic Phase, 2009 PHASE PHASE 5 PHASE 6 POST PEAK PERIOD POST PANDEMIC PERIOD

DESCRIPTION Sustained community level outbreaks in two or more countries in one WHO region Sustained community level outbreaks in at least one other country in another WHO region Levels of pandemic influenza dropped below peak levels Returned to the levels seen for seasonal influenza

Causative Agent The disease is caused by a novel influenza A(H1N1) virus. From current evidence, the virus is a result of re-assortment between human, swine and avian influenza viruses never before been found in human.

Transmission of Influenza Virus (1) Influenza A(H1N1) virus in a patient’s nose and throat excretion is passed to other persons directly through coughing and sneezing. Another person within 1 metre in distance can also be exposed to the virus by breathing in contaminated air.

Transmission of Influenza Virus (2) A person can be infected by touching contaminated hands, surfaces and utensils such as glasses, telephone and door knob etc. The virus infects a person while they touch their nose, eyes and mouth.

Transmission of Influenza Virus (3) A patient can even transmit the virus 1 day before symptom appears. The most contagious period is the first 3 days of illness. The longest contagious period normally does not exceed 7 days.

Signs and Symptoms (1) In a very rare case that incubation period approaches 7 days. After getting infected, a person will have fever greater than 37.5 Celsius. Symptoms of this new influenza A(H1N1) is quite similar to seasonal influenza starting with fever, headache, body aches, chills, fatigue, cough, sore throat, and in some cases, nausea, vomiting and diarrhea.

Signs and Symptoms (2) Most patients have only mild symptoms and do not require any hospitalization. A patient will gradually recover within 5 – 7 days. However some ill individuals might have severe complications such as pneumonia which can be observed through rapid and trouble breathing.

Treatment (1) Patients with severe illness should seek medical care at a nearby hospital immediately. Antiviral drug such as oseltamivir prescribed within 48 hours after onset on illness under care of a physician usually gives good treatment result.

Treatment (2) Patients with mild sickness i.e. low grade fever and appetite should seek care at a private clinic or consult a pharmacist for proper medicine and advice. Home care of a sick person are as follows • Take prescribed medicine for : relief of symptoms such as paracetamol etc. Wipe the patients’ skin gently and intermittently using towel soaked with clean water to help relief fever. • Drink plenty of clean water and fruit juice. Avoid drinking cold water.

Treatment (3) •

Eat soft nutritious food including eggs, vegetables and fruits. In case of low appetite, supplement vitamins will be helpful.

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As the disease is caused by a virus, there is no need to take any antibiotics. Only in case of bacterial complications, antibiotics will be prescribed and a patient must take all of the medicine to prevent drug resistance problem.

Prevention from Infection (1) • Avoid close contact with influenza ill persons. • if you have to care for an ill person, you should wear a mask. Wash your hands with soap and water thoroughly after each contact with the ill person. • Avoid sharing the same glasses, straw, spoon, handkerchief etc. with other persons especially influenza ill persons.

Prevention from Infection (2) • Use serving spoon when eating with other persons. • Wash hands with soap and water thoroughly and often especially after coughing and sneezing. Alcoholbased gel hand cleaners are also effective disinfectants. • take actions to stay healthy including nutritious food, proper and regular exercises, adequate safe water and sleep and avoidance of cigarettes and alcoholic drink.

Prevention of Virus Spreading (1) • Ill persons should stay at home or see k medical care for 3 - 7 days. This will prevent spreading of influenza. • Avoid close contact with others.

Prevention of Virus Spreading (2) Wear mask when happen to be with others or cover nose and mouth with tissues after coughing and sneezing. Throw used tissues in a trash can. Clean hands with soap a nd water right after.

High-Level Consultation for all Member States at the start of the 62nd World Health Assembly Geneva, 18 May 09 Current Epidemiological Situation • As at 18 May 09, 40 countries reported 8,829 confirmed cases of new flu A (H1N1) infection. 74 deaths. • The virus is transmitted easily from H-H to sustain in communities and to spread regionally. • Most are mild and self-limited. • Severe illness and deaths has occurred among young and healthy adults including adults with underlying disease.

Key Uncertainties • Nothing is certain. • How fast the virus will spread throughout the world. • Infectivity and virulence. • Southern hemisphere could have different and more severe effects than seen in the northern hemisphere. Source : High-level consultation, 18 May 09, Geneva

Lessons Learnt from new flu A (H1N1) • Being prepared has made a vital difference. • Success depends on a multi-stakeholder approach. • Effective communication is paramount. • Science-based approaches remain the bedrock of the response. • Health systems matter. Source : High-level consultation, 18 May 09, Geneva

Challenges on new flu A (H1N1) • Living proof of the value of international cooperation. • Seasonal and new influenza A (H1N1) vaccines. • From containment to mitigation. • Guarding against complacency. • Maintaining surge capacity and institutional coordination. • Sustaining solidarity. • Protecting lives, restoring livelihoods. Source : High-level consultation, 18 May 09, Geneva

International stockpiles of Oseltamivir EURO PAHO

EMRO WHO Geneva

AFRO

SEARO WPRO

Sub-reg. Stockpile

BKK

Mainly for rapid containment of pandemic at origin.  WHO-HQ, Geneva  WHO Regional Offices  ASEAN, Singapore 5 July 07

Estimated pandemic influenza impact in Thailand

Deaths 260,000

deaths 65,000

Tremendous Cases social and economic 26,000,000 implications Cases Cases rate 10% CFR 1 %

Case rate 40% CFR 1%

16 Apr 05

6,500,000

Avian influenza Safe animal husbandry Surveillance in animals and man Multi-sector & international cooperation Pandemic influenza preparedness

Pandemic influenza

2nd Strategic plan on Avian Influenza and Influenza Pandemic Preparedness (2008-2010)

Pandemic build-up

Narrow window of opportunity for containment

; Early phase Ro = 2 Later stage Ro = 4 16 Nov

Multi-sectoral pandemic influenza preparedness Health

Public sector

Private sector

Essential service sector Energy, water supply, transportation, communication/IT, banking/financing, security, etc 30 Nov 07

Pandemic preparedness strategies

Antiviral drug PPE, Medical care facilities, vaccine Medical / Pharmaceutical

Risk communication Personal hygiene Travel restriction Social distancing Quarantine

Non-medical / Simulation non-pharmaceutical exercises of AI Security and rule of law response & Food and water supply Socio-economic, pandemic security and governence Power supply influenza (to keep society running) Transportation Telecommunication preparedness: Financial and banking

 Tabletop exercise 27 Mar 08

Modified from: David Nabarro at APEC-HMM, Sydney 8 June 2007

Expand on AI response Surveillance and control

Essential services/ business continuity planning

Risk com. and public Education

Pandemic influenza preparedness strategies

Stockpiling and logistics 30 Nov 07

Emergency response: Non-medical, medical

Multi-sector & international cooperation

Initiate and escalate

Stockpiling and logistics Personal Protective Equipment

Seasonal influenza vaccine For health personnel

3 Mar 06

Strategies toward pandemic vaccine access Short term  Import  Resort to global stockpile (emerging opportunity)

Nati o prep nal pan d ared ness emic plan

Long term  Establish local capacity for development and manufacture of influenza vaccine, ready for pandemic vaccine production  Stepwise expansion of seasonal flu vaccination  Strengthen national capacity for vaccine regulatory, logistics and delivery, R&D

Pandemic preparedness strategies

Antiviral drug PPE, Medical care facilities, vaccine Medical / Pharmaceutical

 Pandemic influenza vaccine Pandemic Non-medical / a most non-pharmaceutical important tool for vaccine health protection  National access to pandemic vaccine is preferably secured by establishing Socio-economic, capacity for local production of security and governence influenza vaccine (to keep society running)  Increased use of flu vaccine to provide market for locally produced seasonal flu vaccine in interpandemic period 27 Mar 08

Modified from: David Nabarro at APEC-HMM, Sydney 8 June 2007

Drive toward secure access to • 2007: MOPH was pandemic influenza vaccine granted government support for establishing capacity for flu vaccine production Pandemic • 2007: GPO/ MOPH vaccine received WHO’s GAP support for flu vaccine capacity development • 2007-2008: GPO made Build research, regulatory • progress on GAP and programmatic capacities projects •Increase use of seasonal flu vaccine • 2009: GPO to received 2nd year of WHO’s GAP • Establish flu vaccine production capacity support

•Assess disease burden / justify flu investment 15 Aug 08

Projected use of influenza vaccine in Thailand, 2000–2015 : a favorable scenario Pre-AI period

AI respons e period

12000000

Pande mic respon se Scale up to produce pandemic vaccine

Pandemic preparedn ess period Vaccine production project

10000000

Increased use of flu vaccine

8000000 6000000

Technology: Cell-culture Adjuvant LAIV

Capacity building

4000000 2000000

20 20

20 18

20 16

20 14

20 12

20 10

20 08

20 06

20 04

20 02

20 00

0

Year?

Note: 2000-2003 figures -- from Simmerman et al. 2004 -2005 figures – initial projection

15 Aug 08

Increased use of influenza vaccine in Thailand, 2000–2015 : projected scenario Seasonal influenza vaccination in health care personnel 12000000 Started 2003 Target 400,000 / yr 10000000 8000000 6000000

Seasonal influenza vaccination in high-risk population 2008: 120,000 persons > 65 with health conditions 2009: 1.8 mill. People, all ages with health conditions

4000000 2000000

20 20

20 18

20 16

20 14

20 12

20 10

20 08

20 06

20 04

20 02

20 00

0

COPD, asthma, heart disease, cerebro-vascular dis., renal failure, chemotherapy, DM

Calendar for TTx on Influenza Pandemic

Pending National level

8 Mar 07 Ministerial level

Departmental level

Provincial level

Start July 06 Start Mar 06 Now 76 provinces completed

A Package of Guideline on Tabletop Exercise - Guideline for Tabletop Exercise on Influenza Pandemic Preparedness at the Provincial Level for Exercise Organizers and Facilitators, 2006 - Master Operation Plan for Influenza Pandemic Preparedness for Multi- sector Coordination 2006 - six compact discs containing different contents: CD1- tabletop exercise, CD2, 3, and 4- the video presentation of lectures, CD5- slide presentation, and CD6- document files.

TTX in Nakorn-nayok

Tabletop exercises at provinces

Tabletop exercises at MOPH Departments

27 Mar 08

Tabletop exercises at MOPH

27 Mar 08

AI control and pandemic influenza preparedness integrated in National Public Emergency Preparedness National policy National Public Emergency on Public Emergency Preparedness Committee (chaired by PM) Preparedness 2005 National plan on National Committee Civil Public on Civil Public Emergency Preparedness (chaired by PM/DPM) Emergency Preparedness National Strategic plan National Committee on Avian Influenza and on Avian Influenza Control and Pandemic Pandemic Influenza Influenza Preparedness Preparedness (chaired by Dep. PM) 27 Mar 08

From Policy Practice

Policy National Strategic Plan

National Operational Plan

Operational Plan / Guidelines / Protocols at all levels

Exercises at all levels

Business continuity planning

Getting prepared Businesses, industries, markets, department stores, hotels, travel & tourism, communications & IT, transportations, power plants, gas stations, water supply, banks, hospitals, etc.

•Safety of staff and owners •Continuation of business during pandemic •Cooperation with public sector in pandemic response • Rapid recovery after pandemic 27 Mar 08

Private sector preparedness

Business Continuity Plan

Business Continuity Plan for Influenza Pandemic Preparedness Package

Fact Sheet BCP for IPP Manual Poster (Hygiene, mask) CD (Power Point, Video Presentation)

Regional / International collaboration Bilateral  With neighbours: Laos, myanmar, Cambodia, Vietnam, Malaysia  With assistance providers: US, Japan, EU, Australia, etc. Regional  Through ASEAN, APEC, ACMECS, etc. International  Through WHO, OIE, FAO, UNICEF, etc.

Participation in regional exercises for pandemic preparedness  APEC Pandemic Response Exercise, 7-8 June 06  Mekhong Basin Countries Workshop on Pandemic Influenza Preparedness, Siemriep, Cambodia, 14-14 March 2007  Workshop on Pandemic Influenza Preparedness, Yangon, Myanmar, early 2007  Public Health Security Exercise

11-12 June 2008 29 May 08

ANTS’ PHILOSOPHY ANTS THINK WINTER ALL SUMMER • So ants are gathering their winter food in the middle of summer. • How much will an ant gather during the summer to prepare for the winter? • All that he possibly can. Do the most we can to maximize our preparedness and response to emerging diseases !

Conclusion  Thailand has been struggling to control and prevent H5N1 AI on animal health and public health fronts with continuous improvement. Infections in poultry are under control, no new human cases have been seen since August 2006.  In awareness of the risk of pandemic influenza, the country is joining global efforts in pandemic preparedness. National preparedness plan highlights national capacity for self-reliance and regional / international cooperation.  Effective AI response & pandemic preparedness rely on:  Government’s leadership and support  Strength of existing infrastructure and manpower  Extent and quality of multi-sector cooperation  Knowledge and understanding of partners & the public  Problems and limitations prevail and change with time, need to be continuously managed among partners, with perseverance, reconciliation and transparency. 22 May 08