AVIAN INFLUENZA IN VIETNAM: SITUATION AND LESSONS LEARNED

NIHE AVIAN INFLUENZA IN VIETNAM: SITUATION AND LESSONS LEARNED Assoc. Prof. Nguyen Tran Hien, MD, MPH, PhD. Director, National Institute of Hygiene and Epidemiology (NIHE) Hanoi, Vietnam OVERVIEW OF AVIAN INFLUENZA SITUATION IN VIETNAM, DEC 2003 UNTIL NOW From Dec. 2003 March 2008 5 epidemic waves of avian influenza A/H5N1 Almost all provinces have reported outbreaks in poultry; ~ 50 million poultry culled 36/63 provinces have human cases; Total 106 cases, 52 deaths (CFR: 49.0%) No new outbreaks in humans have been reported since March 4, 2008. 1

GEOGRAPHIC DISTRIBUTION OF H5N1 CASES IN VIETNAM WAVE 1: FROM DEC 2003 TO MAR 2004 57/64 provinces reported poultry outbreaks; 43.9 million poultry culled. 13/64 provinces reported human outbreaks: 23 cases, 16 deaths; CFR: 69.6%. GEOGRAPHIC DISTRIBUTION OF H5N1 CASES IN VIETNAM WAVE 2: FROM JUL 2004 TO AUG 2004 17/64 provinces reported poultry outbreaks; 84,000 poultry culled) 3/64 provinces reported human outbreaks: 4 cases, 4 deaths; CFR: 100%. 2

GEOGRAPHIC DISTRIBUTION OF H5N1 CASES, IN VIETNAM WAVE 3: FROM DEC 2004 UNTIL NOV.2005 36/64 provinces have poultry outbreaks; 470,000 poultry killed 25/64 provinces had human outbreaks; 66 cases, 22 deaths; CFR:33.3%) GEOGRAPHIC DISTRIBUTION OF H5N1 CASES IN VIETNAM WAVE 4: FROM MAY 2007 TO DECEM 2007 18/64 provinces reported poultry outbreaks; 176.407 poultry culled (data source of Department of Aminal Health) 6/64 provinces reported human outbreaks: 8 cases, 6 deaths; CFR: 75%. 3

GEOGRAPHIC DISTRIBUTION OF H5N1 CASES IN VIETNAM WAVE 5: FROM JAN 2008 TO MAR 2008 5/64 provinces reported human outbreaks: 5 cases, 5 deaths; CFR: 100%. Number 20 18 16 14 12 10 8 6 4 2 number of human avian influenza cases Case death and deaths by month 0 12/ 03 3/ 04 6/ 04 9/ 04 12/ 04 3/ 05 6/ 05 9/ 05 12/ 05 3/ 06 6/ 06 9/ 06 12/ 06 3/ 07 6/ 07 9/ 07 12/ 07 3/ 08 4

50 45 40 35 30 25 20 15 10 5 0 % 18 19 DISTRIBUTION OF CASES AND DEATHS BY AGE GROUPS 24 33 24 21 17 19 8 6 5 case death 3 3 0 2 0-9 10-19 20-29 30-39 40-49 50-59 60-69 >70 0 age DISTRIBUTION of avian influenza cases and deaths by gender Case by gender Death by gender 46.2% 53.8% 48% 52% Male Female 5

Age (Year) 50 45 40 35 30 25 20 15 10 5 0 15.816.0 Mean age of cases and deaths by epidemic waves Mean age of cases Mean age of deaths 5.5 5.5 30.6 26.3 25.6 26.6 26.6 24.0 20.8 Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Average 19.6 CORRELATION BETWEEN RIVER NETWORK AND LOCATIONS WITH HPAI OUTBREAKS rivers outbreaks 6

SURVEILLANCE OF AVIAN INFLUENZA IN VIETNAM COMMUNICABLE DISEASE SURVEILLANCE SYSTEM MOH NIHE Central Hospitals Regional Pasteur Institutes Central and Regional Hospitals Provincial centre for Preventive Medicine Provincial Hospitals District centre for Preventive Medicine District Hospitals Commune health Centre 7

Severe Viral Pneumonia (SVP) Surveillance 1. Case definition: Sudden onset of fever > 38 o C, AND Difficulty in breathing, AND Chest radiograph findings compatible with viral pneumonia, AND No alternative diagnosis, such as bacterial pneumonia 2. Method Hospital based in all provinces Immediate reporting required Investigation of cases by public health authorities within 48 hours of report RT-PCR testing for influenza viruses by regional public health laboratories within 48 hours of notification 54 of 64 provinces reported SVP cases Jan.2006-April 2008 (N=418) 0 1-3 4-8 9-15 16-41 42-70 8

Influenza virus causes of SVP Type/Subtype Number cases Percent Positive A/H5 13 3.1 A/H3 6 1.4 A/H1 6 1.4 B 3 0.7 Total positive 28 6.7 N=418 MOH/CDC/WHO/NIHE LANG SON National Influenza Sentinel Surveillance 2006-2007 HOA BINH BA TRIEU THANH XUAN NIHE NIITD NPH THAI BINH Organizational network of 4 regional public health laboratories and 15 sentinel sites DAK LAK TAY NGUYEN DONG NAI NHATRANG THUA THIEN-HUE DA NANG KHANH HOA HCMc TDH HCMC TIEN GIANG HCMC PH #1 9

RISK FACTORS FOR INFECTION A case-control study in Vietnam 2004 have shown the risk factors for H5N1 infection: Direct contact to ill/dead poultry 7 days prior to onset (OR=31.0, 95%CI: 3.4-1050). Having ill/dead poultry in household 7 days prior to onset (OR=7.4; 95%CI: 2.7 59.0) Lack of an indoor water source (matched OR 6.46, 95% CI 1.20 34.81, p = 0.03). Factors not significantly associated with infection: raising healthy poultry, preparing healthy poultry for consumption, exposure to persons with an acute respiratory illness. Epidemiological Characteristics of H5N1 cases in 2007-2008 (n=13) Gender : Male: 76.9% Female: 23.1% Age: Max: 40 Min: 4 Mean: 23,2 (+/-2.6) Occupation Children: 7,6% (1/13) Student: 15,3% (2/13) Farmer: 61,5% (8/13) Civil servant: 15,3% (2/13) 10

Epidemiological Characteristics of H5N1 cases in 2007-2008 (n=13) Occupational exposure Cleaning cage/farm, slaughtering poultry: 3/13 Working at A/H5 influenza labs: 0/13 Working at health facilities: 0/13 Epidemiological Characteristics of H5N1 cases in 2007-2008 (n=13) Animal exposures Slaughtering, direct contact: 53% (7/13), in which: 3/7: Healthy poultry 3/7: sick/dead poultry 1/7: unknown Involved in culling poultry: 0 Eating poultry and its products: 69% (9/13) 3/7: Healthy poultry 4/7: sick/dead poultry 2/7: unknown No evidences that patients ate raw poultry blood or half-done products 11

Epidemiological Characteristics of H5N1 cases in 2007-2008 (n=13) Animal exposures Raising poultry near house: 9/13 4/9: Healthy poultry 5/9: Sick or dead poultry Raising pigs/exposure to pig within 1m 3/13: yes 10/13: no Visiting poultry cages within 6 weeks before onset: 1/13: yes 10/13: no 2/13: unknown Average Timelines Average time (days) from onset to: CHC: 2,6 (Std:0,9) District hospital: 3,5 (Std:0,5) Provincial hospital: 4,5 (Std:0,5) Central hospital: 5,6 (Std:0,3) Date of testing for H5: 7,6 (Std: 0,7) Test result releasing: 9,6 (Std:0,7) 12

Practices Project of Community based active surveillance model on AI implemented by Care International in Vietnam Percentage of doing at least 3 behaviours to protect family from AI 60 40 54 29 Intervention Control *p<0.05 20 0 Doing at least 3 behaviours to protect family from AI Practices Project of Community based active surveillance model on AI implemented by Care International in Vietnam Percentage of households reporting of sudden death of poultry 80 60 40 72 Intervention Control *p<0.001 20 0 Reporting to Volunteer or village authority 9 13

Percentage of seeking help for people in family catching a flu over the past 2 years Project of Community based active surveillance model on AI implemented by Care International in Vietnam Taking to district/provincial hospital Taking to commune health centre 5 31 32 Intervention 45 Control *p-value<0.05 Self-treating at home 41 63 0 20 40 60 80 EVOLUTION OF H5N1 VIRUSES IN VIETNAM In 2007-2008, H5N1 clade 2.3.4 viruses replaced clade 1 viruses in northern Vietnam and human isolates have high homology to contemporary poultry isolates. Mutations on NA protein have been recognized at position117v (clade 2.3.4 viruses, 2007-2008), which is associated with reduced susceptibility to oseltamivir and is unrelated to treatment. The new mutation (I117V) was also found in poultry isolates, No mutations in the M2 gene were found conferring amantadine resistance. 14

A/Cambodia/JP52/2005 A/chicken/VietNam/1/2004 98 A/VietNam/JP14/2005 A/VietNam/JP4207/2005 A/VietNam/JP178/2004 A/VietNam/JPHN/30321/2005 A/VietNam/HN1194/2004 A/VietNam/HN1203/2004 A/Thailand/SP83/2004 Clade 1 89 99 A/duck/Vietnam/568/2005 A/goose/Guangxi/3017/2005 Clade 2.3.2 A/duck/China/E319.2/03 A/chicken/Hunan/999/2005 Clade 2.3.1 97 A/VietNam/HN3062/2004 A/VietNam/HN30408/2005 A/VietNam/HN30212/2004 100 A/chicken/Guangxi/12/2004 A/duck/Guangxi/13/2004 Clade 2.4 99 A/chicken/Guiyang/3570/2005 A/goose/Guiyang/3422/2005 96 A/Anhui/1/2005 Clade 2.3.3 A/chicken/Yunnan/493/2005 88 A/chicken/Indonesia/11/2003 A/chicken/Indonesia/7/2003 63 A/VietNam/HN31203/2007 A/chicken/HongKong/YU324/2003 Clade 2.1 A/duck/Laos/3295/2006 64 A/Japanese white-eye/hongkong/1038/2006 A/VietNam/HN30850/2005 100 A/chicken/Korea/2003 Clade 2.5 A/chicken/Yamaguchi/7/2004 90 A/barheaded goose/qinghai/12/2005 64 A/chicken/India/NIV33487/2006 99 A/Egypt/2321NAMRU3/2007 Clade 2.2 97 99 95 A/VietNam/HN31432/2008 A/Vietnam/HN31312/2007 A/VietNam/HN31461/2008 89 95 A/turkey/Turkey/1/2005 99 A/duck/Vietnam/568/2005 A/goose/Guangxi/3017/2005 Clade 2.3.2 A/duck/China/E319.2/03 A/chicken/Hunan/999/2005 Clade 2.3.1 80 A/VietNam/HN31323/2007 95 A/chicken/NCVD74/2007 A/duck/NCVD75/2007 99 A/chicken/Guiyang/3570/2005 Clade 2.3.3 A/goose/Guiyang/3422/2005 96 A/Anhui/1/2005 A/duck/Laos/3295/2006 64 A/Japanese white-eye/hongkong/1038/2006 A/VietNam/HN30850/2005 95 A/VietNam/HN31432/2008 A/VietNam/HN31461/2008 97 99 A/Vietnam/HN31312/2007 A/VietNam/HN31323/2007 A/duck/NCVD79/2007 A/VietNam/HN31239/2007 A/VietNam/HN31394/2008 A/duck/NCVD92/2007 A/muscovy duck/ncvd85/2007 A/muscovy duck/ncvd87/2007 Clade 2.3.4 80 95 A/chicken/NCVD74/2007 A/duck/NCVD75/2007 A/duck/NCVD79/2007 A/VietNam/HN31239/2007 A/VietNam/HN31394/2008 A/duck/NCVD92/2007 A/muscovy duck/ncvd85/2007 A/muscovy duck/ncvd87/2007 A/chicken/NCVD84/2007 A/VietNam/HN31388/2007 Clade 2.3.4 A/chicken/NCVD84/2007 A/VietNam/HN31388/2007 A/chicken/NCVD89/2007 A/duck/NCVD91/2007 A/duck/NCVD86/2007 A/VietNam/HN31413/2008 A/chicken/NCVD89/2007 A/duck/NCVD91/2007 A/duck/NCVD86/2007 A/VietNam/HN31413/2008 A/duck/NCVD76/2007 A/duck/NCVD76/2007 A/VietNam/HN31412/2008 A/VietNam/HN31242/2007 A/VietNam/HN31412/2008 A/VietNam/HN31242/2007 81 A/VietNam/HN31244/2007 81 A/VietNam/HN31244/2007 0.005 0.005 SUMMARY 1. Cases were reported sporadically and in scattered provinces 2. Majority of human cases have exposure history to infected poultry. 2. Epidemics occured mainly in wet and cold seasons (winter and spring) 3. Genetic factors may play a very important role in susceptibility to the virus among family-clusters. 4. Clade 1 viruses are currently being replaced by clade 2.3 viruses in poultry and humans. 5. No evidence of human to human transmission is available. 15

LESSONS LEARNED IN HPAI PREVENTION AND CONTROL IN VIETNAM LESSONS LEARNED 1. Highest political commitment: Strong leadership of the Government. 2. Establishment of multi-sectoral Steering Committees for control and prevention of avian and human influenza at all levels, from central to communal level. 3. Good collaboration between MARD, MOH, other ministries and mass organizations to develop and implement Integrated Operational Program for Avian and Human Influenza (OPI) Role of Poultry Vaccination: contributing in reducing epidemics among poultry and H5N1 human cases 16

LESSONS LEARNED 4. The well developed health care system including curative care and preventive medicine system from central to local level, which implemented prevention activities, surveillance and early detection, care and treatment 5. Timely sharing information and mobilizing support from international organizations and other Governments CHALLENGES 1. New and emerging disease: lack of knowledge about viral behaviors, pathogenicity, transmission mechanism, treatment 2. Virus maintain among ducks as asymptomatic hosts 3. Poultry raising system is not appropriate: back-yards in household, small farms 4. Poor recognition and reporting of suspected HPAI in poultry. Human case identifications mostly occurred before reports of disease in poultry. 5. Low awareness and high risk behaviors of handling and eating sick poultry/their products 6. Collaboration between human and animal health sectors not yet strong enough, especially at local level 7. Lack of capacity and resources for active surveillance and research 17

RECOMMENDATIONS 1. Avian Influenza should be considered as a combined agricultural, major public health, economic and social threat. 2. Strengthen epidemiological, virological and clinical surveillance and researches for better assessment of AI situation with the more concrete collaboration mechanism between animal and human health sectors, at all levels. 3. Increase capability to study pathogenicity, transmissibility, and antiviral susceptibility of HPAI virus. 4. Develop and implement integrated operational program for avian and human influenza 5. Develop regional and global multi-sectoral collaboration on surveillance, researches and responses Thank you for your attention 18