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.

 Most countries have warned travel advisory avoidance to

the affected countries and implemented entry screening.

 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”.

 Some countries culled pigs for the propose of disease

prevention.

 Activated national Influenza Pandemic Preparedness plan.

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

• 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.

• 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

• 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

• 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 DESCRIPTION
PHASE 1 No animal influenza virus has caused infection in
humans
PHASE 2 An animal influenza virus has caused infection in
humans
PHASE 3 Influenza reassortant virus has caused sporadic case or
small cluster of disease in people
PHASE 4 Human to human transmission and sustain
community-level outbreaks
 WHO Pandemic Phase, 2009
PHASE DESCRIPTION
PHASE 5 Sustained community level outbreaks in two or more
countries in one WHO region
PHASE 6 Sustained community level outbreaks in at least one
other country in another WHO region
POST PEAK Levels of pandemic influenza dropped below peak
PERIOD levels
POST Returned to the levels seen for seasonal influenza
PANDEMIC
PERIOD
 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
• Take prescribed medicinefollows
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.

• 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. Alcohol-
based 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
Sub-reg.
WPRO 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
Cases implications
6,500,000

Cases rate 10% Case rate 40%

16 Apr 05
CFR 1 % CFR 1%
Avian influenza

Safe animal husbandry

Surveillance in animals
and man
2nd Strategic plan on
Multi-sector & international Avian Influenza and
cooperation Influenza Pandemic
Preparedness
Pandemic influenza (2008-2010)
preparedness

Pandemic influenza
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 Private
sector sector

Essential service sector

Energy, water supply, transportation,
communication/IT, banking/financing,
security, etc
30 Nov 07
Pandemic Antiviral drug
preparedness PPE, Medical care
strategies facilities,
vaccine
Medical /
Pharmaceutical Risk communication
Personal hygiene
Travel restriction
Simulation non-pharmaceutical
Non-medical / Social distancing
Quarantine
exercises of
AI
response & Security and rule of law
Socio-economic, Food and water supply
pandemicsecurity 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 Risk com.
response and public
Education
Emergency
Surveillance response:
and control Non-medical,
Pandemic medical
influenza
preparedness
strategies Multi-sector
Essential
services/ business & international
continuity cooperation
planning
Stockpiling
and logistics Initiate and
30 Nov 07
escalate
Stockpiling and logistics
Personal Seasonal
influenza
Protective vaccine
Equipment 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
ared d
ness emic
Long term plan

 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 Antiviral drug
preparedness PPE, Medical care
strategies facilities,
vaccine
Medical /
Pharmaceutical

 Pandemic influenza vaccine

Non-medical / Pandemic
a most non-pharmaceutical
important tool for vaccine
health protection
 National access to pandemic vaccine
is preferably secured by establishing
capacitySocio-economic,
for local production of
security
influenza and governence
vaccine
(to keep society running)
 Increased use of flu vaccine to
provide market for locally produced
seasonal flu vaccine in inter-
pandemic period
27 Mar 08 Modified from: David Nabarro at APEC-HMM, Sydney 8 June 2007
 Drive toward secure access to
pandemic
• 2007: MOPH was
granted government
influenza vaccine
support for
establishing capacity
for flu vaccine
production
• 2007: GPO/ MOPH Pandemic
vaccine
received WHO’s GAP
support for flu vaccine
capacity development
• 2007-2008: GPO made
progress on GAP
• Build research, regulatory
and programmatic capacities
projects
• 2009: GPO to received •Increase use of seasonal flu vaccine
2nd year of WHO’s GAP
support • Establish flu vaccine production capacity
•Assess disease burden / justify flu investment
15 Aug 08
 Projected use of influenza vaccine in
Thailand, 2000–2015 : a favorable scenario
Pre-AI AI Pandemic Pande
period respons preparedn mic
e period ess period respon
se
12000000 Vaccine
production Scale up
10000000 project to produce
Increased pandemic
8000000 vaccine
use of flu
vaccine
6000000
Capacity Technology:
4000000 building Cell-culture
Adjuvant
2000000 LAIV
0
00

02

04

06

08

10

12

14

16

18

20
Year?
20

20

20

20

20

20

20

20

20

20

20
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 Seasonal influenza
vaccination in health vaccination in high-risk
care personnel population
12000000
Started 2003 2008: 120,000 persons > 65
Target 400,000 / yr
10000000 with health conditions
8000000 2009: 1.8 mill. People, all
ages with health conditions
6000000

4000000

2000000

0
00

02

04

06

08

10

12

14

16

18

20
COPD, asthma, heart disease,
20

20

20

20

20

20

20

20

20

20

20
cerebro-vascular dis., renal
failure, chemotherapy, DM
Calendar for Pending
TTx on National level
Influenza 8 Mar 07
Pandemic Ministerial level

Start
July 06
Departmental level

Start Mar 06
Now 76 provinces
Provincial level 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
Preparedness 2005 (chaired by PM)

National plan on National Committee

Civil Public on Civil Public Emergency
Emergency Preparedness (chaired by PM/DPM)
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
 Policy
From
National

Policy Strategic
Plan

National
Operational
Practice 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