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JOURNAL OF SCIENCE, Hue University, N0 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 31st 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 24th 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 24th June, 2009 to 30th 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 10th January, 2010,
there were more than 208 nations and territories that reported patients positive with
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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 31st May, 2009; until
20th 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 (15th and
17th 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 24th 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 14th 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.
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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 24th June, 2009 to 31st December,
2009.
2.4. Implementation approach: A survey and treatment for influenza A (H1N1)
following Decision No. 2762 /QD-BYT dated on 31st 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 24th June,
2009 to 31st 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 1st September,
2009 to 31st 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
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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.
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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.