93 JOURNAL OF SCIENCE, Hue University, N 0 61, 2010 AN ASSESSMENT OF THE TREAMENT RESPONSE FOR THE EPIDEMIC OF INFLUENZA A (H1N1) IN THUA THIEN HUE PROVINCE IN 2009 Nguyen Dung, Hoang Huu Nam, Duong Quang Minh Nguyen Mau Duyen, Nguyen Khoa Nguyen Thua Thien Hue Provincial Health Department Nguyen Dinh Son, Nguyen Thai Hoa Thua Thien Hue Provincial Preventive Health Center SUMMARY The epidemic of Influenza A (H1N1) broke into Vietnam with the first case identified at Ho Chi Minh City Tropical Hospital on 31 st May, 2009. It quickly spread nationwide, with a pattern of infection involving clusters of cases at schools, enterprises, and factories which affected community activities and social security.The epidemic hit the Province at the end of June, 2009 with the two peaks, one in September and mid-October and one in November. It then gradually reduced at the end of 2009. The first patient, a Vietnamese Australian coming from Australia, was hospitalized on the 24 th June, 2009. After that, all of the District/City Health Centers (DHC) organized an area to receive patients, and set up emergency groups for treatment of influenza A (H1N1). Through an assessment of clinical progress of influenza A (H1N1) cases, the provincial health network devised a strategy to limit infection in the community, and limit the effects of the epidemic to the community and the departments/agencies activities. The total number of patients hospitalized from 24 th June, 2009 to 30 th Decmeber, 2009 was 2,051 cases which were almost all mild, well monitored, and isolated for treatment. There were 1,084 cases (52.8%) treated in hospitals, and 967 cases (47.2%) treated in controlled communities. The number of communes with patients that provided organised treatment in the community was 46%. Among 2,051 cases, the most affected age group was 10-19 (65.53%., The highest rate was among pupils and students(79.5%). The mean time for fever resolving after using Tamiflu was 1.75 days. There were no severe complications or deaths in the Province. The epidemic was controlled in the Province; till early 2010, cases were only scattered, and according to the evaluation indicators of a national focused influenza surveilance program in Huong Thuy, the rate of influenza A (H1N1) was sharply reduced. 1. Introduction The epidemic of influenza A (H1N1) arose in Mexico in April, 2009 and quickly spread out worldwide, and had a global pandemic alert level of 6/6 according to the WHO. According to the Announcement No. 83 from WHO, until 10 th January, 2010, there were more than 208 nations and territories that reported patients positive with 94 influenza A (H1N1), of which 13,554 died. Areas which had high infection of influenza A (H1N1) in the community were North Africa, South Asia, East and Southeast Europe. In Asian areas, there were reports of high deaths in some countries due to influenza type A (H1N1) infection such as India (1,119), Japan (145), China (continent, 714), South Korea (170), Australia (191), Thailand (196), and Malaysia (77). In Vietnam, the first case was identified at the Ho Chi Minh City Tropical Hopsital on 31 st May, 2009; until 20 th January, 2010, Vietnam reported 11,166 positive cases, in which 56 were killed. In Thua Thien Hue Province, the epidemic occured at the end of June, 2009, with the two peaks, one in September, and one in mid October and November (15 th and 17 th weeks), it then gradually reduced in winter (November and December). At the beginning of the epidemic at the end of June 2009, the first patient was a Vietnamese Australian coming from Australia who was hospitalized on 24 th June. After nearly two months, the epidemic spread widely to the community, where a cluster of cases first appeared in Huong Thuy district on the 14 th August, 2009, and then many clusters of cases appeared at schools such as Nguyen Hue and Gia Hoi High schools, and Vinh Ninh Primary school. After that the disease spread out to many schools in the Province. Patients were treated following the protocol of the Ministry of Health with the results of recovery and no death. Influenza A (H1N1) of type A was a communicable disease that was especially dangerous. The disease was caused by a new virus of type A (H1N1). This was a new virus which had not been reported before. This new virus had genetic materials from a recombination of influenza viruses from pigs and birds (not H5) and humans. Especially in Vietnam, there was circulation of avian flu, influenza A (H5N1), thus the risk of patients might have been coinfected with the two strains of H1 and H5 influenza viruses. This migh have resulted in the risk of recombination from genoms of the two virus strains to form a new virus strain, which would be very dangerous due to its characteristics of being transmitted easily like influenza A (H1N1) and being a serious disease like influenza A (H5N1). The organization of receiving treatment for influenza A (H1N1) patients that was suitable to the local situation was an urgent problem, which required a feasible and effective response which prevented deaths and avoided disruptions to the community and other social activities. To ensure these needs were met, we conducted the following study “An assessment of the treatment response for the epidemic of influenza A (H1N1) in Thua Thien Hue Province in 2009” to describe the appropriateness of the organization of the treatment response for confirmed and suspected influenza A (H1N1) patients in Thua Thien Hue Province, describe some characterisitics of patients diagnosed with comfirmed or suspected influenza A (H1N1) in Thua Thien Hue in 2009 and assess the results of the organization of treatment for influenza A (H1N1) in controlled communities in Thua Thien Hue in 2009. 95 2. Methodology 2.1. Research subjects: All patients who were clinically diagnosed and treated for influenza A at all hospitals in the province of Thua Thien Hue in 2009 including: Suspected cases: Cases with fever (over 38ºC), having at least one respiratory symptom such as upper respiratory infection, sore throat, cough, and having related epidemiologic factors (close contact with confirmed cases; arrived or lived at epidemiologic area; a cluster of cases) Possible cases: Where a case with flu syndrome had laboratory tests positive with influenza A but no confirmation of the type classification with tests for common flu viruses. Confirmed cases: Were the cases positive to influenza A (H1N1) with test Real- time RT-PCR or RT-PCR 2.2. Research methodology: Cross -sectional combined with intervention research. 2.3. Research period of time: The research was conducted during the period the epidemic occured in Thua Thien Hue Province, from 24 th June, 2009 to 31 st December, 2009. 2.4. Implementation approach: A survey and treatment for influenza A (H1N1) following Decision No. 2762 /QD-BYT dated on 31 st July, 2009 by the Minister of Ministry of Health on guidelines for diagnosis, treatment and prevention on spreading influenza A (H1N1) with the two following periods: 2.4.1. Period before the epidemic spreading to community: From the 24 th June, 2009 to 31 st August, 2009, the disease happened sporadically, without clusters of cases in the community, and treatment was organized through admission at Hue Central Hospital and Hospitals of District/City Health Centers. The protocol for treatment of influenza A/H1N1 from Ministry of Health was followed, while collecting data from daily reports on cases from District/City Health Centers and Thua Thien Hue Provincial Preventive Health Center. 2.4.2. The period when the disease spread to community: From 1 st September, 2009 to 31 st December, 2009, the disease quickly spread, and clusters of cases appeared in the community and in schools in the Province. In order to deal with the situation, an intervention to control the epidemic in the Province was implemented by the health sector as outlined below: 2.4.2.1. An assessment was conducted on treatment for influenza A/H1N1 at District/City Health Centers to determine clinical charisteristics of the epidemic. 2.4.2.2. The situation of the health network particitating in epidemic control and 96 prevention in the province was surveyed, including: - National and departments/sectors level + Hue Central Hospital with experienced health staff had enough capacity to direct the epidemic prevention as well as treatment admission for serious, complicated cases. They had organized an isolated area for treatment admission designed one- dimentionally following standards of Ministry of Health. They began with a scale of 20 beds, and has built a plan to meet a larger number of patients for screening and treatment when required. + Hospitals: Hue University of Medicine and Pharmacy, Transportation, Military Health 268 hospitals organized areas for screening check-ups of influenza A (H1N1) and were ready to participate to meet the epidemic prevention when necessary. - Provincial level: This included the Provincial Healh Department office, Preventive Health Center, and Social Disease Prevention Center, which had enough staff experienced in planning, directing, and organizing monitoring and management of epidemics at all levels. - District/City level + 100% of district hospitals organized isolated areas for treatment, designed one- dimentionally following Ministry of Health standards, and had built a plan to meet a larger number of patients for screening and treatment when required. + 100% of district hospitals had enough experienced health staff to treat common and high risk flu cases. + 100% of district hospitals had enough health staff to participate in supervision, support, treatment and management of epidemics in the community. - Commune/ward/town + 100% of communes/wards/towns hhad doctors at Commune Health Centers (CHC) who had been trained on epidemic surveillance, treatment and management, and enough capacity to meet the treatment in controlled communities. + 100% of CHCs have enough health staff to participate in epidemic management in the community. 2.4.2.3. Built a plan on treatment admission for influenza A (H1N1) in controlled communities, including 2.4.2.3.1. Objective: Supervision for early detection, managment and treatment of cases in the community. Ensuring treatment is in place for mild cases, referring for more serious cases, ensuring safety for patients and limiting the spread of the epidemic in the community. 97 2.4.2.3.2. Criteria on treatment of influenza A (H1N1) in controlled communities All DHCs arranged a screening room for all cases of flu and respiratory infection coming to the Centers for check-ups, or being referred from CHCs due to suspected influenza A (H1N1). If there was a diagnosis of possible influenza A (H1N1), tests, patient records and files, and consultations would be completed to confirm the diagnosis, and the treatment would be conducted following the protocol of the Ministry of Health. For those cases which were transferred to treat in a controlled community, the following criteria were necessary to ensure: Clinical disease conditions - Having epidemiologic factors: Within 7 days, the patient: + Lived or came from areas with avian influenza A (H1N1) (especially in areas where the epidemic spread out to community such as Hanoi, Ho Chi Minh City, Khanh Hoa, and Dong Nai). + Living in localities with cases which were confirmedly diagnosed with influenza A (H1N1) + Close contact with patients, or sources of disease: possible or confirmed influenza A (H1N1) + Clusters of cases: Where there were many cases of people with influenza infection or respiratory infections coming for check-ups within the same period of time. - Having clinical symptoms: Acute progress with some following symptoms: + Fever (fever ≤ 39ºC) + Respiratory symptoms: Acute respiratory infection, sore throat, dry cough (lungs without pathological sounds and no trouble in breathing). + No pathological background of chronic diseases (heart disease, diabetes, asthma, chronic bronchitis, etc.) + No the elderly, children under 5 years of age, pregnant women - Paraclinical tests: RT-PCR tests have confirmed positively for the virus strain of influenza A (H1N1) (if conditions permit). Conditions of family and patient: Treatment and measures to prevent infection must be complied with. If there were not adequate conditions for infection control (no isolation room, no antiseptic solution for cleaning supplies and treating personal effects) or no commitment to treatment, the patient must be transferred to isolated areas at the District/City Health Centers. 98 2.4.2.3.3. Organization of treatment in controlled communities For District/City Health Centers - Guiding and supervising CHCs to monitor and care for confirmed cases and implementing treatment following the protocol from the Ministry of Health. - Quickly assigning staff to coordinate with CHCs for timely referral of complicated cases - Arranging medical supplies, means of personal protection, sterilization chemicals, etc. for CHCs to treat the confirmed cases. - Organizing supervision and treating the environment at areas with confirmed cases in accordance with the Ministry of Health regulations. For Commune Health Centers - Receiving suspected or confirmed cases of influenza virus A (H1N1) or people with virus of influenza A which were eligible for the treatment in controlled communities to be transferred from DHCs, and deligating qualified staff to monitor the treatment of patients at home. - Tracking the status of patients twice a day: fever, general vital signs, dyspnea status, lung examination to detect abnormal sounds, general examination to detect new diseases that might arise, etc. (write results in the patient’s records). If one of the serious signs are detected such as fever over 39ºC, dyspnea, abnormal sounds in lungs or having other abnormal progress, CHCs must promptly report to DHC and referred to upper levels for appropriate treatment. - CHC staff provide medicine daily for home treatment, to guide and monitor patients on how to use medicine, and advise them on how to eat and rest, etc. - Advising patients and their families about isolation, limited exposure, wearing a mask, respiratory hygiene with ordinary antiseptic solutions, and routine hand washing with soap containing antiseptic ingredients. For patients and their family - Must commit to and comply with the treatment and measures to prevent infection, and arrange an isolation room, and antiseptic solutions to clean utensils and treat personal stuff. - In the course of treatment: patients must be isolated separately and exposure must be limited, a mask must be worn when in contact or going out. Patients have to sanitize their respiratory tract with ordinarily antiseptic solutions, use their own personal utensils, and wash hands frequently with soap with antiseptic. - They must clean the house daily with antiseptic solutions, keeping the doors 99 open. 2.4.2.3.4. Organization on surveillance and treatment of the epidemic in community Following Decision No. 1846/QD-BYT dated on 27 th May, 2009 by the Minister of Ministry of Health on guidelines on monitoring and prevention of the influenza A (H1N1) epidemic. 2.4.2.4. Organization on implementing the plan of treatment admission for influenza A/H1N1 in controlled communities, implementing monitoring and data collection from daily reports of District/City Health Centers and Thua Thien Hue Provincial Preventive Health Center. 2.5. Methods of data collection - Data from daily reports of District/City Health Centers and Thua Thien Hue Provincial Preventive Health Center. - Results of serological surveillance in Nha Trang Pasteur Institute and the National Epidemiology and Hygiene Institute. - Synthesized data on the treatment of influenza A (H1N1) epidemic of District/City Health Centers and Thua Thien Hue Provincial Preventive Health Center. 2.6. Data processing: Using Micosoft Office Excel 2003, SPPS 11.5. 3. Results and discussions 3.1. Description the suitability of the solution on organization of the treatment admission for confirmed and suspected influenza A (H1N1) patients in Thua Thien Hue Province 3.1.1. Description results of treatment on confirmed and suspected cases of influenza A (H1N1) in hospitals before implementation of the treatment in controlled communities: Table 1. Treatment results of confirmed and suspected cases of influenza A (H1N1) in hospitals before implementation of the treatment in controlled communities: No. of cases Age group Total cases (%) Recovery (%) Complication (%) Mortality (%) < 9 years 3 (2.72) 3 (2.72) 0 0 10-19 years 65 (59.1) 65 (59.1) 0 0 20-29 years 27 (24.5) 27 (24.5) 0 0 30-39 years 5 (4.56) 5 (4.56) 0 0 100 40-49 years 5 (4.56) 5 (4.56) 0 0 > 50 year 5 (4.56) 5 (4.56) 0 0 Total 110 (100) 110 (100) 0 0 Among 110 cases which were screened and had a suspected diagnosis of influenza A (H1N1) and were treated with Tamiflu recovered without complications through monitoring. The age group most infected was 10-19 year olds, accounting for 59.1%, the age group 20-29 comprised of 24.5%, and the lowest rate was in children aged less than 10 years. In the United States the age group of 0-4 was 19%, the age group of 5-18 was 26%, the age group of 25-49 was 24% and those over 50 years of age were 22%. This rate was consistent with epidemiological characteristics of how the disease spreads when in direct and close contact, especially in crowded places such as schools, factories, etc. There were two clusters of cases in Huong Thuy and Nguyen Hue High School, which showed that the epidemic was spreading out to the community. Table 2. Duration from using Tamiflu until ending fever of influenza A (H1N1) patients: Duration of treatment until patients’ fever resolves Number of patients Rate (%) Fever ending right after hospitalization 18 16.36 Fever ending after one day 34 30.91 Fever ending after two days 46 41.82 Fever ending after three days 9 8.18 Fever ending after four days 2 1.82 Fever ending after five days 1 0.91 Average time for ending fever at patients after taking Tamiflu was 1.5 days (1:51 ± 0.915), showed that the disease responded well to Tamiflu, progressing with mild disease. Comments: Influenza A (H1N1) had almost mild clinical condition, and responded well to Tamiflu, which occurred mainly in pupil and student groups and was spreading out to community. 3.1.2. Descripton the situation of the health network in the Province on the prevention of influenza A (H1N1) Thua Thien Hue Province is a specialized medical center of Central and Highland areas with Hue Central Hospital, the hospitals of departments/agencies and the health network of the health sector from the provincial to commune/ward/town. 101 Table 3. Distribution on capacity of the health network in the province in implementing the prevention of influenza A (H1N1) Level of treatment, supervision, treating epidemic Treatment capacity for influenza A (H1N1) Capacity of operations and supervision on influenza A (H1N1) prevention Serious disease with complication Mild disease with risk factors Mild disease with no risk factors Formulate plans and direct epidemic prevention Implement supervision and treatment of epidemic National level Yes Yes Yes Yes Yes Provincial level No No No Yes Yes District/City level No Yes Yes Yes Yes Commune/Ward/Town level No No Yes No Yes The health network in the province ensured the implementation of the epidemic prevention at all levels, especially at the grass roots health facility level to implement the treatment for cases of influenza A (H1N1) which were mild and without risk factors. The network had sufficiently professional and experienced staff in directing and organizing the treatment, and monitoring the treatment of epidemics in the community. 3.1.3. Description the treatment admission model of influenza A (H1N1) when the epidemic spread to community with large numbers of patients hospitalized every day Table 4. Surveying impact possibility of the treatment admission models of Influenza A (H1N1) when the epidemic spread to the community with large numbers of patients hospitalized every day Treatment model Mobilized resources Supporting resources Infection controlling capacity Influence possibilities to daily life and community activites Influence possibilities to health care at health facilities In Hue Central In place No Controllable Influence to families, relatives, Cause overload in 102 Hospital health staff hospital In District/City Hospitals In place Provincial level Controllable Influence to families, relatives, health staff Cause overload in hospital In community under control (CHC) In place Provincial and District levels Controllable Little influence Little influence Field hospital Need to mobilize participation of many departments/agencies Not well controllable Influence to teaching and study at schools; stop operations of agencies, etc. Cause shortage of human resource at health facilities mobilized to participate The response was according to the provisions of guidelines on surveillance and prevention of influenza A (H1N1) in Decision No. 1846/QD-BYT and guidelines on diagnosis, treatment and prevention of infection with influenza A (H1N1) in Decision No. 2762/QD-BYT by the Ministry of Health. In order to investigate possible impacts of the treatment admission model of Influenza A (H1N1) it has been shown that the establishment of field hospitals in the treatment of influenza A (H1N1) required more resources, particularly when a series of cases occured at many schools, enterprises, factories, offices, etc., and influence social and community activities, as well as issues of social security. The appropriate therapy model should have a low impact no health care in hospitals, community activities and issues of social security. This was the case with the approach in controlled communities. Comments: The clinical progression and the spread of Influenza A (H1N1) was surveyed, as was the capabilities of the health network. From this survey comparisons of the effectiveness of the therapy solutions of influenza A (H1N1 ) were made and used for provincial planning. Under the direction of the Ministry of Health and the Provincial Party Committee, from 31 st August, 2009, the Provincial Health Department used this information to direct the implementation of plans regarding the organization of treating influenza A (H1N1) in controlled communities in the province of Thua Thien Hue. The aim was to reduce overload in hospitals, actively managing resources, limit exposure, prevent the spread of disease and limit the influence of the epidemic on community [...]... similar to Canada, which had a rate of 71.4% amongst secondary school pupils (aged 13-17 years) The rate of spread was strong when in direct and close contact, especially in crowded places such as schools and kindergartens Comments: For the treatment results of influenza A (H1N1) in the province of Thua Thien Hue in 2009, clinical progress was mild, responded with Tamiflu, and with no complications... cases of influenza A (H1N1) which were treated in 2009 103 Among 2051 cases, the age group of 10-19 years was the most infected, accounting for 65.53%, the age group of 20-29 years had 7.31%, and infection rates were lower in the age group over 50 years In the United States the age group of 0-4 years was 19%, the age group of 5-18 years was 26%, and the age group of 25-49 years was 24%, and 22% for people... diseases; and 17.95% had history of cardiovascular disease The difference was not statistically significant between males and females (P> 0.05), nationwide: 57.3% of cases were male, and 42.7% were female 3.2.2 Distribution on the treatment results of influenza A (H1N1) by age group % 65.53 70 60 50 40 30 20 10 19.11 7.31 3.07 0.15 0.07 0 Figure 1 Rate by age group (%) and confirmed and suspected cases... December Influenza AH3 usually occurs in spring and summer months from January to July In 2009, an 105 epidemic of the new Influenza A (H1N1) occured worldwide The Influenza A (H1N1) completely replaced the influenza AH1 and other influenza strains from July to October, and decreased in November and then the influenza B and H3 recurrented 3.3.3 Treatment results of patients in hospitals and in controlled... situation of patients and phases of influenza A (H1N1) epidemic in 2009 The outbreak had two peaks in September and in mid-October and November (the 15th and 17th weeks) In this period, the health sector implemented the uniform treatment of influenza A (H1N1) in hospitals as well as in controlled communities, while enhancing the monitoring and treatment of the outbreak Therefore the outbreak situation...activities and social welfare 3.2 Description some characteristics of influenza A (H1N1) in Thua Thien Hue Province in 2009 3.2.1 Distribution on the treatment results of influenza A (H1N1) by gender Table 5 Treatment results of patients with diagnosed or suspected influenza A (H1N1) in Thua Thien Hue Province in 2009 No of cases Number of cases Number of recovery cases/ Rate (%) Number of complicated... Total The total number of hospitalized patients was 2,051 cases, which was distributed through 122/152 communes/wards/towns across the province, with 56/122 of them having patients treated in controlled communities, and a number of communes with many patients, areas convenient for monitoring and treatment The areas which had the highest number of patients were Hue City, Huong Thuy and Huong Tra and... programs as planned Comments: Organisation for the treatment of influenza A (H1N1) in controlled communities in the province of Thua Thien Hue has successfully treated 47.2% of patients in hospitals, thereby reducing health facility overload at other levels (especially in District/City Hospitals) The hospitals were deployed in parallel with routine health care in health facilities in addition to, and not... administered for 47.2% of patients with influenza A (H1N1), and contributed 107 to minimising overload at higher health facility levels (especially at Central and District levels), while limiting the impact of the epidemic to activities of the community and departments/agencies This facilitated stable social security and savings for the state budget REFERENCES 1 Announcement No 2694/TB-DPMT dated on 29th December,... mortality The age group and occupation most affected was pupils and students ,which was the group of people in the most crowded environment, which facilitated the fastest spread of the disease 3.3 Some evaluation on the effectiveness of organization on the treatment admission for influenza A (H1N1) in controlled communities in Thua Thien Hue Province in 2009 3.3.1 Progress on the situation of patients . North Africa, South Asia, East and Southeast Europe. In Asian areas, there were reports of high deaths in some countries due to influenza type A (H1N1) infection such as India (1,119), Japan (145),. Hospitals: Hue University of Medicine and Pharmacy, Transportation, Military Health 268 hospitals organized areas for screening check-ups of influenza A (H1N1) and were ready to participate to. or came from areas with avian influenza A (H1N1) (especially in areas where the epidemic spread out to community such as Hanoi, Ho Chi Minh City, Khanh Hoa, and Dong Nai). + Living in localities