Washington Global Health Alliance Discovery Series Supamit Chinsuttiwat May 22, 2008 'Response to Avian Influenza and Preparedness for Pandemic Influenza: Thailand's Experience'

1. Thailand’s Experience in Avian Influenza Response and Pandemic Influenza Preparedness Supamit Chunsuttiwat Ministry of Public Health, Thailand 22 May 2008

5. 2007 Total: 61 countries reporting infections in poultry and wild birds since 2003 28 countries in 2008 2004 2005 2006

6. Total human infections: 382 cases 241 deaths In 14 countries (30 April 08)

7. Reported human H5N1 infections 2003-2008 Source: WHO, as of 30 April 2008 241 382 24 31 59 88 79 115 43 98 32 46 4 4 Total 52 106 5 5 5 8 0 0 19 61 20 29 3 3 Vietnam 4 12 0 0 0 0 4 12 0 0 0 0 0 0 Turkey 17 25 0 0 0 0 3 3 2 5 12 17 0 0 Thailand 1 3 0 0 1 3 0 0 0 0 0 0 0 0 Pakistan 0 1 0 0 0 1 0 0 0 0 0 0 0 0 Myanmar 1 1 0 0 1 1 0 0 0 0 0 0 0 0 Nigeria 2 2 0 0 2 2 0 0 0 0 0 0 0 0 Laos 2 3 0 0 0 0 2 3 0 0 0 0 0 0 Iraq 108 133 13 16 37 42 45 55 13 20 0 0 0 0 Indonesia 22 50 3 7 9 25 10 18 0 0 0 0 0 0 Egypt 0 1 0 0 0 0 0 1 0 0 0 0 0 0 Djibouti 20 30 3 3 3 5 8 13 5 8 0 0 1 1 China 7 7 0 0 1 1 2 2 4 4 0 0 0 0 Cambodia 5 8 0 0 0 0 5 8 0 0 0 0 0 0 Azerbaijan D C D C D C D C D C D C D C Total 2008 2007 2006 2005 2004 2003 Country

8. Sources : UNSIC & World Bank

10. Migratory bird flyways East Atlantic flyway East Atlantic flyway

12. Sector 1: Industrial integrated system; high level biosecurity Sector 2; Semi-vertical integrated system ; moderate biosecurity Sector 3: Small commercial poultry production; low biosecurity Sector 4: Village or backyard poultry ; no biosecurity

13. Source: BOE, MOPH Confirmed case Suspect case Maps of poultry outbreaks and human cases in 2004 Area of outbreak in poultry First round (Jan-May 2004) Second round (Jun-Oct 2004) 13 Dec 04

15. Government DLD/ Min.of Agric. Ministry of Public Health Private sector Other ministries Multi-sector AI response coordination at national level 27 March 2008 National Committee on AI response & PI preparedness MOPH AI operation center DLD AI operation center Government AI operation center Strategy WG

16. National Committee on AI Response & Pandemic Influenza Preparedness The Government Anim. 27 Mar 08 1 st Strategic plan on Avian Influenza and Influenza Pandemic Preparedness (2005-2007) 2 nd Strategic plan on Avian Influenza and Influenza Pandemic Preparedness (2008-2010)

17. Immediate response to AI outbreak: Stamping out infected poultry DLD

19. Cleansing & disinfection campaign Targeting previously affected areas following “x-ray” campaign

23. Distribution of AI in poultry and human cases, 2004-2007 Fujian-like virus (clade 2) in Nakornpanom Province, while all the rest is Vietnam-like virus (clade 1) 22 May08 Total 27 cases/ 17 deaths during 2004-2007, Since Jan 2008: 2 confirmed poultry outbreaks, no human infection found. Jan-May 04 Jun-Oct 04 Jul-Nov 05 Jan-Nov 07 Jun-Aug 06 Confirmed case Suspect case Poultry outbreak

24. AI outbreaks in poultry 2004-2005 Continuous decline in outbreaks and losses during 2006 – 2007, minimal in 2008 27 Mar 08 0. 417 M 3 M 30 M Number culled 5/2 5/4 12/8 Human case ( cases/deaths) 76% 58% 63% Backyard poultry ~0.18 M ~ 5 M ~ 130 M Compensation cost (USD) 55 784 ~ 890 Sub-district s 11 51 42 Provinces 75 1,539 190 Cases (No. flocks) 3 rd round 2005 2 nd round 2004 1 st round 2004 Indicators

25. PM’s move to ease public concern on food safety in 2007

26. Protection of high-risk groups Case management and infection control Infected wild and migratory birds Infected poultry Risk communication for the public Man Disease Surveillance Surveillance on infection Outbreak control in poultry (under DLD supervision) AI control strategies in animals and humans 30 Nov 07

27. Routine disease surveillance Since 1970s Epidemiologic surveillance Laboratory investigations 60 reportable Diseases (by report 506) Influenza & pneumonia surveillance Opportunity for surveillance improvement SARS Surveillance 2003 Syndrome and history of contact Avian flu Surveillance since 2004 Syndrome (ILI), history of contact, lab.tests Report system strengthening

28. MOPH Routine disease reporting system 65% of influenza and 90% of pneumonia cases are reported from hospitals 76 Provincial Health Offices Report 506 Aggregated in e-files Report 506 > 100 General hospitals & medical centers Report 506 > 800 Community hospitals Through district health offices Report 506 > 9000 Health centers Report 506 Private clinics Private hospitals Feed back in weekly and annual reports in publication and on internet websites

30. Specimen collection Autopsy / necropsy Environment investigation Community investigation SRRT Investigation of avian influenza cases

34. Population-based prospective influenza surveillance Sakeo Nakorn-panom

37. Poultry husbandry practices of public health concern Fighting cocks fight! fight! my son. Fighting cocks Backyard Free-range ducks

40. Health volunteers & community leaders Coordination & support Missions Surveillance & control Diagnosis & treatment Hospital infection control Stockpiling and logistics Risk communication SRRTs 16 Nov 05 Organization of AI control and PIP at provincial level Local health Infra structure Mr Bird Flu

41. Health volunteers & community leaders SRRTs Mr Bird Flu Public health and animal health collaboration at provincial level 27 Mar 08 Livestock volunteers & community leaders District Livestock Officers & staff Prov. Livestock Officer Local health Infra structure Provincial committee Exchange & Cooperation Report Report Exchange & Cooperation

43. Public health – animal health collaboration in avian flu surveillance Public Health Case detection at health services with the support of health volunteers Animal Health Poultry outbreak detection and Control by veterinary staff and volunteers Daily Exchange of information 27 Mar 08 info. on suspected poultry infection info. on affected areas Disease prevention and control in poultry Updated information Disease prevention and control in man Updated information

46. 1. New influenza virus in animals low risk for human Path towards influenza pandemic… 10 Sep 06 2. High risk for human 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, extended outbreak 6. Pandemic

47. 1 Aug 07 Avian Flu Pandemic Influenza

48. Source: WHO Influenza Pandemics in 20th Century 1918 Spanish Flu A(H1N1) 20 - 40 mill.deaths 1957 Asian Flu A(H2N2) 1- 4 mill.deaths Credit: US National Museum of Health and Medicine 1968 Hong Kong Flu A(H3N2) 1 - 4 mill.deaths

49. Past Influenza Pandemics observed 10-40 year cycles Is a new pandemic due / overdue? 1900 1850 1950 2000 1847 1889 1918 1957 1968 42 yrs 29 yrs 39 yrs 11 yrs

50. 30 Nov 07 Global cooperation for pandemic influenza preparedness Other regions preparedness SEA region preparedness National preparedness National preparedness National preparedness Thailand’s preparedness

55. Estimated pandemic influenza impact in Thailand Deaths 260,000 deaths 65,000 Tremendous social and economic implications 16 Apr 05 Cases 6,500,000 Cases rate 10% CFR 1 % Cases 26,000,000 Case rate 40% CFR 1%

56. National Committee on AI Response & Pandemic Influenza Preparedness The Government Anim. 27 Mar 08 1 st Strategic plan on Avian Influenza and Influenza Pandemic Preparedness (2005-2007) 2nd Strategic plan on Avian Influenza and Influenza Pandemic Preparedness (2008-2010)

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

58. Private sector Public sector Essential service sector Energy, water supply, transportation, communication/IT, banking/financing, security, etc Health Multi-sectoral pandemic influenza preparedness 30 Nov 07

59. Pandemic preparedness strategies Modified from: David Nabarro at APEC-HMM, Sydney 8 June 2007 Risk communication Personal hygiene Travel restriction Social distancing Quarantine Security and rule of law Food and water supply Power supply Transportation Telecommunication Financial and banking Antivirals Vaccine, PPE Medical care 27 Mar 08 Non-medical / non-pharmaceutical Medical / Pharmaceutical Socio-economic, security and governence (to keep society running)

60. Risk com. and public Education Emergency response: Non-medical, medical Multi-sector & international cooperation Essential services/ business continuity planning Stockpiling and logistics Surveillance and control 30 Nov 07 Pandemic influenza preparedness strategies Expand on AI response Initiate and escalate

61. Stockpiling and logistics 3 Mar 06 Seasonal influenza vaccine For health personnel Personal ProtectionEquipment

65. Hypothetical scenario: (1) 30 Jan 06 Day 30

66. 30 Jan 06 Day 60 Hypothetical scenario: (2)

67. 30 Jan 06 Day 90 Hypothetical scenario: (3)

68. 30 Jan 06 Day 120 Hypothetical scenario: (4)

69. 30 Jan 06 Day 150 Hypothetical scenario: (5)

70. 30 Jan 06 Day 180 Hypothetical scenario: (6)

71. 30 Jan 06 Day 240 Hypothetical scenario: (7)

72. 30 Jan 06 Hypothetical scenario Epicurve of pandemic in Thailand

73. Pandemic build-up ; Early phase Ro = 2 Later stage Ro = 4 Narrow window of opportunity for containment 16 Nov 05

74. Exercises of pandemic influenza preparedness plans Central level Provincial level Service center level 7 Feb 05 Functional drills Table-top exercise

75. Hypothetical scenarios Hospitals overloaded Sick hospital staff Medical supply Shortage Sick students & teachers School closed Shortages of food and commodities Sick security forces Energy shortage Telecommunication interrupted Busses stopped

76. TTX in Nakorn-nayok

77. Tabletop exercises at provincial level

78. Tabletop exercises at MOPH Departments 27 Mar 08

79. Tabletop exercises at MOPH 27 Mar 08

80. Tabletop exercises on pandemic preparedness Started 2006 and to repeat annually 27 Mar 08 Started 2006 and to repeat annually Government To initiate ASAP Rachaburi province N.Nayok province Other provinces DMS DDC Other departments MOPH

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

83. Private sector preparedness

86. What….if an influenza pandemic does not come in recent years? A waste of time and resources, a non-productive investment? On the contrary, it’s a most cost-beneficial investment: building of national capacity for future public emergency responses.

87. Preparedness for response to PHEs Botulism outbreak in Nan Province of northern Thailand in 2006, total 163 cases, after consumption of canned bamboo shoot, no death. Medical support moved in from other provinces and antitoxin shipped in from several countries.

91. Thank You