1. Situation of Avian Influenza A(H5N1) in VIETNAM and role of National Institute of hygiene and epidemiology, hanoi, vietnam Dr. Nguyen thi Hong hanh nihe,hanoi,vietnam

2. Contents  Situation of Avian Influenza A(H5N1).  Role of National Institute of Hygiene and epidemiology in Vietnam.

3. Situation of Avian Influenza A(H5N1)

4. General Information about vietnam  Area:332,600 km2  Provinces:64  Districts:668  Communes/wards: 10,732  Population: 82 millions

5. THE GROWTH OF POUTRY RAISING IN VIETNAM million Total Chicken Duck Total Chicken Duck

6. POULTRY RAISING STRUCTURE  Poultry raising at small scale: back-yards and small farms: 65%.  Poultry raising at semi-industry: 20%.  Poultry raising at industry: 15%.  Annual growth rate: 6,5%.

7. AVIAN INFLUENZA SITUATION IN VIETNAM, DEC 2003 – january 2006  3 epidemic waves of avian influenza A/H5N1.  61 provinces reported outbreaks in poultry; 44.5 million poultry killed among more than 250 millions poultry population.  32 provinces have human cases; Total 93 cases, 42 deaths (CFR: 45,2%).

9. map of avian flu in vietnam

11. present time  until now:  - Last case A(H5N1) 13 november 2005.  - From 14/11/2005 untill 13/01/2006, not any case is confirmed  From 8 january 2006 until now in the Vietnam free of Avian Influenza

12. MAGNITUDE OF THE EPIDEMIC 1 st epidemic 2 nd epidemic 3 rd epidemic

13. 1 ST AI EPIDEMIC: AFFECTED COMMUNES AND RIVER NETWORK rivers outbreaks

14. Nam §inh (1/1)* Dec 2003 Timeline and Geographic distribution of h5n1 cases in Vietnam Bac Ninh (2/1) Jan 2004 Bac Giang (1/0) Jan 2004 Thai Binh (2/2)* Jan 2004 Ha Tay (1/1) Jan 2004 HCM City (3/1) Jan 2004 Tay Ninh (2/2) Jan 2004 Soc Trang (1/1) Jan 2004 Dong Nai (2/1) Jan 2004 Lam Dong (4/3) Jan 2004 Binh Phuoc (1/1) Jan 2004 Thanh Hoa (1/0) Feb 2004 Ha Nam(2/2) Dec 2003  57 provinces had poultry outbreaks; 43.9 million poultry killed.  13 provinces have human outbreaks; 23 cases, 16 deaths; CFR: 69.6%. wave 1: from dec 2003 to mar 2004

15.  17 provinces reported poultry outbreaks; 84,000 poultry killed).  3 provinces had human outbreaks; 4 cases, 4 deaths; CFR: 100%. Hau Giang (1/1) Aug 2004 Timeline and Geographic distribution of h5n1 cases in Vietnam wave 2: from July 2004 to aug 2004 Ha Noi (1/1) Aug 2004 Ha Tay (2/2) Jul 2004

16. Timeline and geographic distribution of h5n1 cases, in Vietnam ThaiBinh (8/2) Dec 2004 Tay Ninh (3/3) Dec 2004 Dong Thap (3/3) Dec 2004 Tra Vinh (2/2) Dec 2004 Hau Giang (2/2) Dec 2004 Tien Giang (1/1) Jan 2005 Long An (1/1) Jan 2005 Bac Lieu (1/1) Jan 2005 Nam §inh (1/1) Mar 2005 Ha Tay (2/1) Mar 2005 Quang Binh (5/0) Mar 2005 Ha Tinh (1/0) Mar 2005 Hai Phong (7/0) Mar 2005 Quang Tri (2/0) Mar 2005 Quang Ninh (1/1)Mar 2005  36 provinces have poultry outbreaks; 470,000 poultry killed.  25 provinces have human outbreaks; 66 cases, 22 deaths; CFR: 33.3%). wave 3: from dec 2004 until now Ha Noi (8/2) Jan 2005 Hung Yen (2/0) Jan 2005 Phu Tho (1/1) Jan 2005 Yen Bai (1/ 0) Apr 2005

17. NUMBER OF AVIAN INFLUENZA CASES AND DEATHS BY MONTH

18. DISTRIBUTION OF CASES AND DEATHS BY AGE GROUP distribution of death by age group

19. number of avian influenza cases and deaths by gender

20. family-clusters of h5n1 cases in some northern provinces, Wave 1 (2003-2004) Em g¸i Thai Binh Ha Nam Nam Dinh Hai Phong Hai Duong Ninh Binh Hung Yen 20 Dec 2003 Nghia Loi, Nghia Hung 1. D. T. H (patient-unconfirmed) 2. D.V. T (brother) 26 Dec 2003 Thanh Ha, Thanh Liem 1. P.T.V (patient) 2. P. T. B (mother) 6 Jan 2004, De Tham, Thai Binh city 1. N.L. H (patient-unconfirmed) 2. N.L. H (sister) 3. N.L H (sister)

21. FAMILY-CLUSTERS OF H5N1 CASES IN THAI BINH PROVINCE, WAVE 3 (2004-2005) 26 Dec 2004 Nam Cao, Kien Xuong 1. N. H. V (patient) 2. N.H. H (brother) 3. N. H. H (brother-carrier) 14 Feb 2005 Thuy Luong, Thai Thuy 1. N. S. T (patient) 2. N. T. N (sister) 3. N. H. K (grandfather- carrier) 4. N. D. T (HCW) 19 Feb 2005 Quyet Tien, Kien Xuong 1. P.K.T (patient) 2. L.T. Them (wife-carrier)

22. Thai Binh Hai Phong Hai Duong 21 Mar 2005 Hung Dao, Kien Thuy 1. V. V. S (patient) 2. N. T. L (wife) 3. V. T. N (daughter) 4. V. T. T (daughter) 5. V. T. D (daughter) Family-cluster of H5N1 cases in hai phong city, Wave 3 (2004-2005)

23. REMARKS ON EPIDEMIC SITUATION 1. Epidemics among poultry –Linked with two main river systems (Red and Mekong delta) – high density of ducks –2 nd and 3 rd epidemics: only small farm affected., more ducks infected than chickens. 2. H5N1 viruses seem to be more infectious for people: – Human cases occured sporadically in more provinces. – Human cases occured in all age groups, with the increasing mean age. 3. Majority of human cases have exposured history to infected poultry.

24. REMARKS ON EPIDEMIC SITUATION 4. Disease patterns is changing: Clinical symptoms become milder, more asymptomatic cases; case-fatality rate is decreased. 5. Genetic factors may play very important role in susceptibility to the virus.

25. REMARKS ON EPIDEMIC SITUATION 6. No clear evidence of human to human transmission is available, but it’s possibility should be considered :  Number of human cases increased, including number of healthy carriers.  Number of infected family cluster is increasing  Number of infected individuals in each family cluster is increasing.  Some cases without clear exposure history to sick poultry.

26. REMARKS ON EPIDEMIC SITUATION 7.Virus may have slightly changed it‘s antigenicity and pathogenicity:  HA gene homogeneity reduced from 99.1% in 2004 to 98.2% in 2005.  One amino acid deletion occurred in the multi-basic amino acid cluster (cleavage site), which may be associated with reduced pathogenicity.

27. RESPONSES 1.National and Provincial Steering Committee for AI epidemic prevention and control (as SARS Committee) –The leadership of the Communist Party, and Government. –Meeting every two weeks, especially every day during intensive epidemic. 2. Set up the system for the identification, investigation, diagnosis and treatment of AI –Enhancing the community-based surveillance system by providing financial incentives for AHWs –Cooperation closely with Public Health authorities.

28. STRUCTURE OF THE NATIONAL STEERING COMMITTEE FOR SARS CONTROL national steering committee 1. Chairperson: Minister of Health. 2. Member: Ministry of Foreign Affaires, Culture and Information, Social Security, Defense, Finance, Communication and Transport, General Department of Tourism, Office of the Government Sub-committee for logistic 1. Chair: Director, Dept. of planning and Finance 2. Members: Office of MOH, Dept. of Personnel & Organization, Dept. Medical Equipment & Health Programes, Dept. of Drug Administration, Dept. of International Cooperation Sub-committee for Therapy 1. Chair: Director Dept. of Therapy - MOH 2. Members: B¹ch Mai Hospital Institute for Clinical- Research in Tropical- Medicine. Dept. of Science and Training sub-committee for surveillance and control 1. Chairperson: Director, General Department for Preventive Medicine and HIV/AIDS Control 2. Members: NIHE, Dept.of Military Health, Military IHE Dept. of Immigration, Detention Service, Border Defense command, Communication & Transport, General Dept of Tourism Sub-committee for education 1.Chair: Director, Dept. of – Legislation - MOH 2. Members: - Dept. of International Cooperation Center for Health Communication and Education, Ministry of Foreign Affairs, Ministry of Culture and Information, Vietnam News Agency, People’s Newspaper, Vietnam Voice

29. RESPONSES  Strengthening of disease surveillance. –Upgrading diagnostic capability. –Improving disease reporting system. 3. Extensive IEC on 4 measures for AI prevention and control: mass media (newspaper, TV, internet....), distribution of pamphlets, booklets. 3.1 Early detection of poultry epidemic and inform the local authorities. –Culling of all birds in flocks if found sero- positive with H5N1 virus or virus isolated. Compensation for farmers.

30. CONSTRAINTS/CHALLENGES  A/H5N1 avian influenza is a new and emerging disease: lack of full knowledge about transmission mechanism, clinical spectrum, treatment and prevention.  Capacity and resources for surveillance, research and responses are still limited.  Some studies data show that virus maintain among ducks as asymptomatic hosts with very high prevalence, from 70%-80%.  There are still lack of animal health laws on transportation, quarantine, slaughtering of poultry

31. CONSTRAINTS/CHALLENGES  Most households raise ducks and chickens at backyard, for income and food. Outbreaks may escape detection, are difficult to control, and increase the likelihood of human exposures, which may occur when children play in areas shared by poultry or when families slaughter or prepare birds for consumption.  Awareness of people about the risks of infection with H5N1 avian influenza is still low.  More effective collaboration between human and animal health sectors is needed.  The national preparedness plan for influenza pandemic prevention and control should be completed as soon as possible.

32. STRATEGIC PLAN FOR INFLUENZA PANDEMIC PREVENTION AND CONTROL IN VIETNAM

33. OVERARCHING GOAL To ensure rapid characterization of the new virus subtype and early detection, notification and rapid response to additional cases. To ensure rapid characterization of the new virus subtype and early detection, notification and rapid response to additional cases.

34. OVERARCHING GOAL early detection Confirmativ e diagnosis rapid, effective intervention measures surveylan ce, investigate quaranty, surveylan ce, investigate quaranty, determine the most reliable diagnostic procedure To early prevent com bina tion

35. nihe Hightland Ihe Pasteur institute of Nha Trang Pasteur institue of Hå ChÝ minh city

38. Role of National Institute of Hygiene and epidemiology in Vietnam.

40.  Founded in 1926: Pasteur Institute of Hanoi  1945 – 1961: Institute of Microbiology  1962 – 1996: Hanoi Institute of Hygiene and Epidemilogy  1997- Until now: National Institute of Hygiene and Epidemiology Development History

41. Board of directors Admin. and logistic departmentsTechnicaldepartments Epidemiology Dept. Microbiology Dept. Virology Dept. Molecular Bio. and Immuno. Dept. Training and Research Man.Dept. Administration Dept. Personnel Dept. Material and Medical Equipment Dept. Network Coordinating Dept. Planning Dept. National Health Program Offices Center of Experimental Animals Company for Vaccines and Biological Production No.1 Scientific Committee Finance & Accounting Dept.

42.  Total: 472 –Professor: 7 –Assistant Professor: 13 –PhD: 40 –Master: 26 Staff

43. Functions A leading research institution responsible for scientific and technical issues related to transmissible diseases control as well as vaccine research and development nationwide. A leading research institution responsible for scientific and technical issues related to transmissible diseases control as well as vaccine research and development nationwide. Technical consultant for the government of Vietnam for national policies of preventive medicine and vaccination strategies. Technical consultant for the government of Vietnam for national policies of preventive medicine and vaccination strategies.

44. Functions  Act as leading part to direct the provincial and district level (preventive medicine centers, epidemic preventive hygiene groups and units);  organize and mobilize the population as well as other associated authorities and sectors in effectively penetrated infectious diseases prevention and eradication.

45. Functions  Upgrade and perfect the system of preventive medicine throughout Vietnam, ensure the training in technical skills, equipment supply… for junior levels with priority given to mountain and island remote areas and to ethnic minorities.

46. Functions  Participate in international scientific co- operation in order to be conversant with the latest progress of preventive medical technology, including monitoring of emerging and re-emerging infectious diseases, developing vaccines and biological, training professional staff.

47. Role of National Institute of Hygiene and epidemiology  NIHE has made considerable contribution to health sector in general and public health in particular.  NIHE cooperated with other related ministries and agencies to establish the preventive medicine system for the whole country which has helped Vietnam obtain a remarkable success in improvement of people health especially in the field of preventive health

48. Role of National Institute of Hygiene and epidemiology  Mortality and morbidity rates due to communicable diseases which are NIHE’s responsibilities have been reducing annually. Epidemics are combated relatively efficiently  Suffering from SARS epidemic as many other territories and countries of the world, Vietnam was the first country retaining the SARS outbreak. Despite of lacking necessary tools and equipments, NIHE’s staff has detected SARS virus. This has clearly contributed to the success of Vietnam in containing the epidemic.

49. Role of National Institute of Hygiene and epidemiology  As assigned by the MOH, NIHE has been responsible for implementing studies on virology, bacteriology and immunology, epidemiology and so on to prevent and control infectious diseases comprising circulating diseases, eliminated ones which tend to come back and also other emerging ones

50. Problem and barrier  the facilities are still poor; some of them are outdated because of non- synchronized and inappropriate investment, unable to meet the working demands.  Some modern molecular biological techniques cannot be implemented yet in Vietnam because of lacking necessary equipments.

51. Problem and barrier  incapable of conducting profound studies on the viral nature and pathogenic mechanism as the biosafety place with accompanying essential facilities is not available  At the moment, NIHE still does not have a laboratory of standard biosafety (BSL 3) in order to work peacefully with hazardous microorganisms (group 4) such as anthrax, SARS avian influenza viruses, or another...

52. Problems and barrier  due to the financial shortage, the training for NIHE staff appears to be spontaneous and part-time  To quickly master advanced technology in the field of medical biology, better meet the professional demand/ requirement such as providing timely reliable diagnostic tests  it is extremely important to train and enhance the research ability of the staff in developed countries with highly advanced science and technology

53. Proposals for activities  Reorganize and strengthen network for early detection, confirmative diagnosis and rapid intervention. Set up a National Reference and High Tech Center at NIHE in order to improve and reassure the quality of confirmative diagnosis.

54. Proposals for activities  Confirmative diagnosis Confirmative diagnosis known as the re- confirmation of early detection is performed by the combination of epidemiological investigations, clinical consultation and higher-level laboratory test.

55. Proposals for possible collaborations  Being a country leading organization in the field of preventive medicine and public health, the National Institute of Hygiene and Epidemiology (NIHE) has been also responsible for providing graduate studies in public health, epidemiology, virology and bacteriology.

56. Proposals for possible collaborations  Currently NIHE would like to cooperate with 4 Medical Universities, who has responsibility providing medical personals for Northern Region in order to enhance its training quality

57. possible collaborations  1. Undergraduate study to improve education quality by co organizing training programs, workshops, providing books and journals, educational materials, exchanging students and faculties in all specialties including bacteriology, virology, epidemiology and public health for undergraduate students, faculties at medical schools and health professionals as well.

58. possible collaborations 2 Graduate study In order to meet the need for health professionals in the fields of public health and preventive medicine for the national preventive medicine network as an assigned duty of NIHE, graduate study at NIHE in cooperation with medical schools will be enhanced by improving training quality for Ph.D. program and launching Master program.

59. possible collaborations  3. Research Enhancing close collaboration amongst NIHE, medical schools and Preventive Medicine Centers to carry out scientific researches, apply new techniques in field trials.

60. Surveillance system for communicable disease in Vietnam Ministry of health General dept. of preventive medicine National institute of hygiene and epidemiology General clinics, children clinics, infectious clinics Central hospitals Regional Surveillance Unit Regional IHE/Pasteur Institutes Pediatrics, infectious wards Central hospitals General clinics, children clinics, infectious clinics Provincial hospitals Surveillance Unit Provincial Preventive Medicine Centers Pediatrics, infectious wards Provincial hospitals General clinics, children clinics, infectious clinics District hospitals Private clinics Surveillance Unit District surveillance teams Commune medical station

61. THANK YOU FOR YOUR ATTENTION