Sorasak Lochindarat, M.D.Sorasak Lochindarat, M.D.

Experiences of Services Response to Experiences of Services Response to Avian Flu in ThailandAvian Flu in Thailand

Poultry outbreaks and human cases Poultry outbreaks and human cases of AI (H5N1) in Thailand, 2004-2005of AI (H5N1) in Thailand, 2004-2005

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dead

survive

2004 2005

Country Situation Country Situation

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Three waves of poultry outbreaks since early Jan 2004

Each wave accompanied with human cases, total 22 cases with 14 deaths

Characters of cases:

• Male : Female = 13 : 9

• Case fatality by age:

under 5 years 1 / 3 (33%)

5-14 years 8 / 9 (88%)

15 yr & over 5 / 10 (50%)

• Risk factors: Contact with sick/dead birds 12 casesLiving in village having sick/dead

birds 8 casesClose contact with cases 2 cases

(Diagrammatic)First wave

Thirdwave

Second wave

Source: BOE, MOPH

Spot maps of human cases and poultry outbreaks in Thailand

Confirmed case

Suspect caseArea of outbreak in poultry

First round(Jan-May 2004)

Second round

(Jun-Oct 2004)

Third round

(Oct05-Jan06)

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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

A(H5N1)

B

A(H3N2)

A(H1N1)

Monthly Influenza Isolates : 2004-2005Monthly Influenza Isolates : 2004-2005

Pranee Thawatsupha, National Institute of Health, Department of Medical SciencesPranee Thawatsupha, National Institute of Health, Department of Medical Sciences

Reservoir SourcesReservoir Sources

• Backyard farm Backyard farm • Free – range duck Free – range duck • Fighting cock Fighting cock

Clinical Description of Influenza(H5N1) in Thailand (31 Oct 04)

(1)

Number 17 case (9 children, 8 adult)Number 17 case (9 children, 8 adult)

Age :- median 14 y. (2-58 y.)Age :- median 14 y. (2-58 y.) M : F = 9 : 8M : F = 9 : 8

Confirmed diagnosis by culture or PCR for H5Confirmed diagnosis by culture or PCR for H5

and / or virus isolation and / or virus isolation

Fatality rate Fatality rate

Children (Children (<< 14 y.) 89% 14 y.) 89%

Adult (> 14 y.) 50%Adult (> 14 y.) 50%

Presentation at hospitalPresentation at hospital

Fever, cough and dyspneaFever, cough and dyspnea 100%100%

Sore throatSore throat 71% 71%

MyalgiaMyalgia 53% 53%

DiarrheaDiarrhea 41% 41%

RhinorrheaRhinorrhea 53% 53%

VomitingVomiting 24% 24%

Abdominal painAbdominal pain 24% 24%

Clinical Description of Influenza(H5N1) in Thailand (31 Oct 04)

(2)

Result of Confirmatory Diagnosis of

17 H5N1 Patients in Thailand

Positive RT-PCR for H5Positive RT-PCR for H5 17/17 (100%) 17/17 (100%)

Virus isolation for H5N1Virus isolation for H5N1 11/16 (69%) 11/16 (69%)

IFAIFA 11/16 (69%) 11/16 (69%)

Positive Rapid test for Flu A 4/11 (36%) Positive Rapid test for Flu A 4/11 (36%)

Rapid Test For “Flu A” in Confirmed H5N1 Patients

Total H5N1 patients tested 11 casesTotal H5N1 patients tested 11 cases

Rapid test use :- Quick Vue, Directigen A, Rapid test use :- Quick Vue, Directigen A, BianaxBianax

Results of 11 casesResults of 11 cases :- positive 4/11 (36%), median 13 d. (6-18 d.):- positive 4/11 (36%), median 13 d. (6-18 d.) :- negative 7/11 (64%), median 7 d. (4-18 d.):- negative 7/11 (64%), median 7 d. (4-18 d.) :- notdone 6/17:- notdone 6/17

Mostly Directigen AMostly Directigen A®®

Viral Isolation of 16 H5N1 Patients in Thailand (2)

viral cultureviral culture NN No. of Day No. of Day** P P

range medianrange median

• PositivePositive 1111 3-12 3-12 7 7 0.2110.211

• NegativeNegative 5 5 6-16 6-16 1010

* Number of day from onset of illness to culture

Laboratory finding Survived Died p-value (n = 5) (n = 12)

WBC – median WBC – median ((//cumm)cumm) 5,4005,400 2,450 0.008 2,450 0.008

Lymphocyte – median Lymphocyte – median ((//cumm)cumm) 2,4292,429 663.5 0.096 663.5 0.096

Platlet count – median Platlet count – median ((//cumm)cumm) 203,000 137,500 0.496203,000 137,500 0.496

Laboratory Results of 17-H5N1 Patients,Thailand, 2004 (1)

Laboratory findingLaboratory finding Survived Survived Died Died p-value p-value (n = 5) (n = 12) (n = 5) (n = 12)

No. TestedNo. Tested 44 10 10 - -

SGOT – median SGOT – median (IU)(IU) 101.5101.5 202.5 0.282 202.5 0.282

SGPT – median SGPT – median (IU)(IU) 4949 51 0.325 51 0.325

Laboratory Results of 17-H5N1 Patients,Thailand, 2004 (2)

Radiologic Findings of 17-H5N1 Patients,

Thailand, 2004 Radiologic Radiologic Survived Survived Died Died P P findings findings (N=5) (N=12) (N=5) (N=12)

CXR (early)CXR (early) - interstitial- interstitial 11 1 1 0.51 0.51 - lobar, patchy- lobar, patchy 44 11 11

CXR (late)CXR (late) - ARDS - ARDS (diffuse bilateral)(diffuse bilateral) 11 12 0.02 12 0.02 - No ARDS- No ARDS 44 0 0

D 4 of Illness D 8 of Illness

CXR Finding of Patient 8 YOCXR Finding of Patient 8 YO

Antibiotics Therapy in 17 H5N1 Patients 2004, Thailand

Antibiotics use 2 - 5 kindsAntibiotics use 2 - 5 kinds(65% of cases use 3-4 kinds)(65% of cases use 3-4 kinds)

33rdrd gen. cephalosporin gen. cephalosporin 11/1711/17 (65%)(65%)

MacrolidesMacrolides 10/1710/17 (59%)(59%)

AminoglycosidesAminoglycosides 8/17 8/17 (47%)(47%)

CarbapenemCarbapenem 7/17 7/17 (41%)(41%)

DoxycylineDoxycyline 3/17 3/17 (18%)(18%)Other :- Co-trimoxazole, piperacillin, quinolonesOther :- Co-trimoxazole, piperacillin, quinolones

Corticosteriod Therapy in 17 H5N1 Patients 2004, Thailand

Corticosteriod therapy in 8/17 (47%)

methyl prednisolone 5/8

hydrocortisone 2/8

dexamethasone 1/8

Number of day from onset of illness to start corticosteroid medium 7.5 d.(Range 4-13 d.)

Oseltamivir Treatment of 10 Oseltamivir Treatment of 10 H5N1 Patients Thailand, 2004H5N1 Patients Thailand, 2004

RxRx

N mean duration mean durationN mean duration mean duration from onset to Rx of Rxfrom onset to Rx of Rx

SurvivedSurvived 5 5 3 3 5.3 d. 5.3 d. 6.7 d. 6.7 d. (4-7 d.) (5-10 d.)(4-7 d.) (5-10 d.)

DiedDied 12 7 10.9 d. 3.5 d. 12 7 10.9 d. 3.5 d. (5-22 d.) (1-5 d.)(5-22 d.) (1-5 d.)

Total 17 10 - -Total 17 10 - -

N

Outcome of 17 – H5N1 Patients,Outcome of 17 – H5N1 Patients,

Thailand, 2004Thailand, 2004

• • Total number (as of October 2004) Total number (as of October 2004) 17 cases17 cases

•• Respiratory failureRespiratory failure 13 (76%)13 (76%)

•• Cardiac failureCardiac failure 7 (41%)7 (41%)

•• Renal failureRenal failure 5 (29%)5 (29%)

•• Liver failureLiver failure 3 (18%)3 (18%)

•• Bone marrow failureBone marrow failure 1 (6%)1 (6%)

•• DeadDead 12 (71%)12 (71%)

National Avian Influenza

Committee

CABINET

National Operation

Center

DLD Operation

Center

MOPH Operation

Center

Dept. of Livestock

Development MOPH

Private Sectors

Other Agencies

Multi-sectoral coordination Multi-sectoral coordination for avian influenza controlfor avian influenza control

27 Jan 05

1. New influenza virus in animals

low risk for human

2. High risk

for human

3. Human infections, no or only inefficient

man-to-man Tx

Phases in development of Phases in development of influenza pandemicinfluenza pandemic

(WHO 2005)(WHO 2005)

11 Aug 05

4. Increased man-to-man Tx,

limited outbreak

5. Significant increase in man-to-man Tx,

extended outbreak

6. Pandemic6. Pandemic

A new pandemic A new pandemic is certain and imminent, is certain and imminent, only the matter of when!only the matter of when!

Prevent

Prevent

Contain

Contain

Respond

Respond

Estimated impact of new Estimated impact of new influenza pandemic in influenza pandemic in

ThailandThailand

Cases 6,500,000

Cases rate 10% CFR 1 %

Cases 26,000,000

Case rate 40% CFR 1%

Deaths 260,000

deaths65,000

Extensive Extensive social and economic social and economic

impactsimpacts

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National National CommitteCommittee on Avian e on Avian Influenza Influenza Response Response

The The CabineCabine

tt

27 Jan 05

Cabinet Cabinet approved 25 approved 25 January 2005January 2005

Strategic plans on Strategic plans on Avian Influenza and Avian Influenza and Influenza Pandemic Influenza Pandemic PreparednessPreparedness

Thailand is prepared for the

prevention of and response to

influenza pandemic

Objectives of Pandemic Flu PreparenessObjectives of Pandemic Flu Prepareness

- prevention and surveillance of pandemic flu- prevention and surveillance of pandemic flu

- reduce morbidity / mortality- reduce morbidity / mortality

- appropriate management- appropriate management

- set up commanding network of health care systems- set up commanding network of health care systems

- reduce economic and bio-psycho-social effects - reduce economic and bio-psycho-social effects

Aims of Pandemic Flu PreparenessAims of Pandemic Flu Prepareness

- Appropriate organization in the situation of- Appropriate organization in the situation of

pandemic flupandemic flu

- Conduct lab tests- Conduct lab tests

- NIH, University lab at Bangkok : viral study- NIH, University lab at Bangkok : viral study

- 13 regional lab centers : RT-PCR- 13 regional lab centers : RT-PCR

- Stockpile : Oseltamivir for ≥ 325,000 cases- Stockpile : Oseltamivir for ≥ 325,000 cases

(0.5% of population)(0.5% of population)

- Hospital capacity for severe flu : ≥ 10,000 beds- Hospital capacity for severe flu : ≥ 10,000 beds

and field hospital ≥ 5,000 bedsand field hospital ≥ 5,000 beds

- Mechanical ventilator : ≥ 2 for each district hospital- Mechanical ventilator : ≥ 2 for each district hospital

: High frequency oscillator in: High frequency oscillator in

25 regional hospitals25 regional hospitals

Strategies of Pandemic Flu PreparenessStrategies of Pandemic Flu Prepareness

- Prevention and control of epidemic in human and- Prevention and control of epidemic in human and

animalanimal

- Prepareness of rapid test, stock pile, PPE, ventilator,- Prepareness of rapid test, stock pile, PPE, ventilator,

respiratory isolation room and vaccinerespiratory isolation room and vaccine

- Prepareness for pandemic threat in- Prepareness for pandemic threat in

- health care system- health care system

- community- community

- Mass communication : for community awareness- Mass communication : for community awareness

- Organization neworks in health care system - Organization neworks in health care system

Village Health Volunteers & Community Leaders

SRRT : Surveillance and Rapid Response TeamSRRT : Surveillance and Rapid Response Team

• SurveillanceSurveillance• Outbreak investigation Outbreak investigation & control& control• Information &Information & knowledge exchangeknowledge exchange

District SRRTs

Provincial SRRTs

Central & Regional

SRRTs

Sub-district Health Centers

Over 1000 SRRTs have been established 3 Mar 06

CaseCase Management & Hospital Infection Control Management & Hospital Infection Control

Case managementCase management

- CPG- CPG

- training course for HCW- training course for HCWSS

- triage system- triage system

- rational use of rapid test & oseltamivir- rational use of rapid test & oseltamivir

- prepared ventilator, pulse oximeter- prepared ventilator, pulse oximeter

Infection control in hospitalInfection control in hospital

- PPE- PPE

- airborne infection isolation room (regional/- airborne infection isolation room (regional/

university hospital), respiratory isolation roomuniversity hospital), respiratory isolation room

(provincial/district hospital)(provincial/district hospital)

Risk communicationRisk communication Dissemination of risk communication messages Dissemination of risk communication messages

through various media, including call centersthrough various media, including call centers Centralized media releases with daily update of Centralized media releases with daily update of

situation and public advices situation and public advices

3 Mar 06

Stockpiling and logisticsStockpiling and logistics

•VaccineVaccine•Antiviral drugAntiviral drug

•Diagnostic test kitsDiagnostic test kits•RespiratorsRespirators

•PPE PPE

3 Mar 06

Administration of viral study & supphyAdministration of viral study & supphy

19 Regional CDC centers19 Regional CDC centers

- Organized & supply- Organized & supply - Seasonal flu vaccine for HCW- Seasonal flu vaccine for HCWSS, Culler,, Culler,

surveillance team, lab personnelsurveillance team, lab personnel - Rapid test- Rapid test - Oseltamivir- Oseltamivir - PPE- PPE

13 Regional Lab centers13 Regional Lab centers- RT-PCR- RT-PCR- send specimens to NIH (WHO National- send specimens to NIH (WHO National Influenza Center) in BangkokInfluenza Center) in Bangkok

Draft CPG for avian flu/pandemic flu

Pilot : table-top exercisePilot : table-top exercise DrillsDrills ScenariosScenarios

Modification of CPGModification of CPG

CPG implementationCPG implementation

EvaluationEvaluation

Guideline for avian flu/pandemic flu preparenessGuideline for avian flu/pandemic flu prepareness

Patients with suspecious of avian flu/pandemic fluPatients with suspecious of avian flu/pandemic flu

Group 1Group 1

Group 2Group 2

Group 3Group 3

Moderate to severe ARI* andModerate to severe ARI* and- Hx contact with sicked/dead poultry- Hx contact with sicked/dead poultry- Hx contact with unexplained pneumonia patient- Hx contact with unexplained pneumonia patient- Travel to/residence in area affected by avian flu- Travel to/residence in area affected by avian flu outbreakoutbreak

Unexplained severe pneumoniaUnexplained severe pneumoniaCluster of pneumoniaCluster of pneumoniaPneumonia in HCWPneumonia in HCWSS

Cluster of ILICluster of ILI****

* ARI : acute respiratory illness* ARI : acute respiratory illness** ILI : influenza like illness** ILI : influenza like illness

Group 1 : Algorithm for avian fluGroup 1 : Algorithm for avian flu

Persons with unexplained mod to severe ARI andPersons with unexplained mod to severe ARI and - Hx contact with sicked/dead poultry- Hx contact with sicked/dead poultry - Hx contact with unexplained pneumonia patient- Hx contact with unexplained pneumonia patient - Travel to/residence in area affected by avian flu- Travel to/residence in area affected by avian flu outbreak outbreak

CXRCXRRapid test (for Flu A&B)Rapid test (for Flu A&B)Viral study Viral study

Rapid test : negRapid test : negCXR : normal CXR : normal

Rapid test : negRapid test : negCXR : pneumonia CXR : pneumonia

Rapid test Flu A+Rapid test Flu A+CXR : normal/CXR : normal/ pneumonia pneumonia

Rapid test Flu B+Rapid test Flu B+CXR : normal/CXR : normal/ pneumonia pneumonia

Group 1 : Algorithm for avian flu Group 1 : Algorithm for avian flu (Cont’)(Cont’)

Rapid test Flu A+Rapid test Flu A+

CXR : normal/pneumonia CXR : normal/pneumonia

Rapid test : negRapid test : neg

CXR : pneumonia CXR : pneumonia

Rapid test : negRapid test : neg

CXR : normalCXR : normal

Rapid test Flu B+Rapid test Flu B+

CXR : normal/pneumonia CXR : normal/pneumonia

- Isolation room, PPE- Isolation room, PPE- Oseltamivir- Oseltamivir- waiting for RT-PCR- waiting for RT-PCR

Severe : RSevere : Rxx as above as above

Mod : supportive RxMod : supportive Rx waiting for RT-PCRwaiting for RT-PCR

- OPD case/F.U. in 48 hr- OPD case/F.U. in 48 hr- Viral study- Viral study

- Isolation room- Isolation room- Oseltamivir- Oseltamivir- waiting for RT-PCR- waiting for RT-PCR

Group 2 : Algorithm for pandemic flu preparenessGroup 2 : Algorithm for pandemic flu prepareness

- persons with unexplained severe pneumonia- persons with unexplained severe pneumonia

- Cluster of pneumonia- Cluster of pneumonia

- Pneumonia in HCW- Pneumonia in HCWSS

Rapid test for Flu A&BRapid test for Flu A&BViral studyViral study

Rapid test : negRapid test : neg- Supportive R- Supportive RXX

- Waiting for RT-PCR - Waiting for RT-PCR

Rapid test Flu A+Rapid test Flu A+- Isolation room, PPE- Isolation room, PPE- Oseltamivir- Oseltamivir- Waiting for RT-PCR - Waiting for RT-PCR

Rapid test Flu B+Rapid test Flu B+- Isolation room- Isolation room- Oseltamivir- Oseltamivir- Waiting for RT-PCR - Waiting for RT-PCR

Group 3 : Algorithm for surveillance ofGroup 3 : Algorithm for surveillance ofpandemic flupandemic flu

Cluster of ILI in communityCluster of ILI in community

Surveillance and rapid response teamSurveillance and rapid response team

Randomized viral studyRandomized viral studyClosed observation for pandemic fluClosed observation for pandemic flu

Lab investigationLab investigationLabLab Frequency of checkingFrequency of checking RemarkRemark

1. CBC1. CBC

2. UA2. UA

3. Hemo C/S, BUN,3. Hemo C/S, BUN, Cr, LFT, BSCr, LFT, BS

4. Quantitative PCR4. Quantitative PCR for H5 in bloodfor H5 in blood

5. Freeze serum5. Freeze serum

Baseline then as needBaseline then as need

Baseline then as needBaseline then as need

Baseline then as needBaseline then as need

Day 0, day 1- 4Day 0, day 1- 4then as needthen as need

Day 0, day 1, 3, 5, 7Day 0, day 1, 3, 5, 7then as needthen as need

For viral loadFor viral load

For cytokine studyFor cytokine study

Lab investigation Lab investigation (cont’)(cont’)

LabLab Frequency of checkingFrequency of checking RemarkRemark

6. Nasal swab,6. Nasal swab, throat swabthroat swab Tracheal suctionTracheal suction for viral studyfor viral study

7. Rectal swab : esp.7. Rectal swab : esp. diarrhea for viral diarrhea for viral studystudy

8. Urine for viral study8. Urine for viral study

9. CSF for viral study9. CSF for viral study

10. CXR10. CXR

OD until dischargeOD until discharge

OD for 5 daysOD for 5 days

D 0D 0

Baseline then as needBaseline then as need

Baseline then as needBaseline then as need

PCR, IFAPCR, IFA

PCR, IFAPCR, IFA

Case neuroCase neuroinvolvementinvolvement

Severity of avian flu and referral systemSeverity of avian flu and referral system

Severity of AISeverity of AI Level of hospitalLevel of hospital

No pneumoniaNo pneumonia

Mild pneumoniaMild pneumonia

Severe pneumoniaSevere pneumonia

ARDS, sepsis/septic shockARDS, sepsis/septic shockMulti-organ failures Multi-organ failures

District hospitalDistrict hospital

Provincial hospitalProvincial hospital

Provincial hospitalProvincial hospital

Regional hospitalRegional hospitalUniversity hospital University hospital

True numbers remain elusive in bird flu True numbers remain elusive in bird flu outbreak outbreak

• Mostly seriously ill patients get tested for H5N1Mostly seriously ill patients get tested for H5N1• Milder cases are likely to slip through the cracksMilder cases are likely to slip through the cracks• Ducks can carry H5N1 without symptoms Ducks can carry H5N1 without symptoms • H5N1 can present with diarrhea and brain H5N1 can present with diarrhea and brain

inflammationinflammation• Family clusters of H5N1 in Vietnam and Family clusters of H5N1 in Vietnam and

Thailand : human–to–human transmission Thailand : human–to–human transmission • Seriously ill patients from the process of Seriously ill patients from the process of

cytokines or drug resistant or delay treatmentcytokines or drug resistant or delay treatment

Oseltamivir stockpiling initiativeOseltamivir stockpiling initiative

• Purchase from RochePurchase from Roche– 100,000 treatment courses in 2005100,000 treatment courses in 2005– to secure 100,000 treatment courses in 2006to secure 100,000 treatment courses in 2006

• Effort for local production by GPOEffort for local production by GPO– pilot production (from imported API) underway, bio-pilot production (from imported API) underway, bio-

equivalent test pending, expecting to acquire FDA in equivalent test pending, expecting to acquire FDA in 20062006

– Proposal for government support to establish a Proposal for government support to establish a production plant submitted in “Mega-project” package, production plant submitted in “Mega-project” package, approved in principal by the Cabinetapproved in principal by the Cabinet

• Advocacy for establishment of regional stockpiles Advocacy for establishment of regional stockpiles

3 Mar 06

Exposure of 17 H5N1 Patients, 2004Exposure of 17 H5N1 Patients, 2004

Living in village with dead poultry• 15 (backyard chickens /fighting cocks) • 1 (Duck)

Not living in villageWith dead poultry

17 case (half are children under 15)

Male : Female = 1:1

Direct contact with ill/dead chicken(n=9)

No direct contact (7)

Provide bedside careOf a probable case

( Dr. K Ungchusak, BOE, MoPH)

Strengthening Strengthening Laboratory Laboratory

Capacity & NetworkingCapacity & Networking

Establish Lab Network : NIH, NAIH, Establish Lab Network : NIH, NAIH, University, Military, etc.University, Military, etc.

Equip and train 13 regional labs nationwide Equip and train 13 regional labs nationwide for molecular technique testingfor molecular technique testing

Enhance laboratory biosafety and biosecurityEnhance laboratory biosafety and biosecurity3 Mar 06

National Strategic Plan on Avian Influenza Control, 2005-2007Approved by the Cabinet,

25 January 2005

• Strengthening disease surveillance & control (animal health, public health, wildlife)

• Improving animal husbandry • Empowering the community for active roles in

disease prevention and control• Supporting R&D/ knowledge management • Promoting integrated management of disaster• Strengthening organization and manpower capacity

16

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5

7 Nov 05

Progress of the implementation of

pandemic preparedness plan

Surveillance–in man & animals Surveillance–in man & animals

Stockpiling and logistics Stockpiling and logistics

Emergency responsesEmergency responses Public healthPublic health CommunityCommunity

Public communication Public communication

Coordination and commandCoordination and command

• Influenza surveillance Strengthened

• laboratories improved • SRRTs established in

all districts

• National antiviral stockpile initiated

• Logistic system under improvement

• Clinical trials of pandemic vaccine to be initiated

• Case management guidelines revised

• Training & supervision underway

• Isolation rooms under improvement/construction

• Master operation plan prepared

• Pandemic preparedness plan to be integrated in national disaster preparedness plan

• To initiate table-top exercise on PPP at provincial level

National Committee on Avian Influenza Response

The Cabine

t

27 Jan 05

Cabinet approved 25 January 2005

Strategic plans on Strategic plans on Avian Influenza and Avian Influenza and Influenza Pandemic Influenza Pandemic PreparednessPreparedness

Thailand is prepared for the

prevention of and response to

influenza pandemic

Strategic plans on Avian Influenza and Influenza Pandemic Preparedness

(2005-2007)

25 July 05

Operation Plan of the Ministry

of Public Health

Operation Plan of the Ministry of

Agriculture & Cooperatives

Operation Plans of other Ministries and Agencies

Pandemic Influenza Preparedness Pandemic Influenza Preparedness

Strategies Strategies Surveillance – in man & animals Surveillance – in man & animals Stockpiling and logistics Stockpiling and logistics Emergency responsesEmergency responses

Public healthPublic health CommunityCommunity

Public communication Public communication

Coordination and commandCoordination and command

1 A

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05

Avian Influenza Control Measure,Thailand 2004

Influenza VaccineInfluenza Vaccine :- Culler :- Culler :- HCW’s esp. assigned medical :- HCW’s esp. assigned medicaland nursing teamand nursing team :- Laboratory personnels:- Laboratory personnels :- Surveillance team :- Surveillance team (medical, livestock)(medical, livestock)

Antiviral prophylaxisAntiviral prophylaxis :- Household contact :- Household contact

(oseltamivir)(oseltamivir) :- Culler:- Culler (in case of improper PPE)(in case of improper PPE)

:- HCW’s:- HCW’s (in case of improper PPE) (in case of improper PPE)

Histologic Examination in H5N1 Histologic Examination in H5N1 Patients Thailand, 2004Patients Thailand, 2004

Full postmortem autopsy was done on Full postmortem autopsy was done on 2 patients 2 patients

one childone childone adult (formalined)one adult (formalined)

Necropsy was done on 3 patientsNecropsy was done on 3 patientslung, liver, spleenlung, liver, spleen

If pandemic flu happened in ThailandIf pandemic flu happened in Thailand

CasesCases6,500,0006,500,000

DeathDeath65,00065,000

CasesCases26,000,00026,000,000

DeathDeath260,000260,000

Sick 10% of population (65 million)Sick 10% of population (65 million)Mortality 1%Mortality 1%

Minimum expectation Minimum expectation

Sick 40% of populationSick 40% of populationMortality 1%Mortality 1%

MMaxaximum expectationimum expectation

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JanFebMarAprMayJun Jul Aug SepOct NovDec JanFebMarAprMayJun Jul Aug

A/Fujian/411/2002(H3N2) A/Wellington/1/2004 (H3N2)A/California/7/2004 (H3N2) A/New Caledonia/20/99 (H1N1)B/Shanghai/361/2002 B/Hong Kong/330/2001B/Sichuan/379/99 B/Malaysia/2506/2004

Flu strain analysis 2004-2005Flu strain analysis 2004-2005

Pranee Thawatsupha, National Institute of Health, Department of Medical Sciences