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

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.

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

+ 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

- 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.

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

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

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

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

(%)
Number of
complicated
cases/ Rate
(%)
Number of
mortality/Rate
(%)
Male 1101 1101(53.7) 0 0
Female 950 950(46.3) 0 0
Total 2051 2051(100) 0 0
All of the 2051 treated cases responded well to Tamiflu, there no cases of
complications or deaths. Nationwide, the death rate was 0.5% [1] of which 43.59% were
under 15 years old, 82.05% were hospitalized after 3-10 days, 23.8% were pregnant
women, 54.7% had a history of chronic 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

19.11
65.53
7.31
3.07
0.15
0.07
0
10
20
30
40

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 or 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 and phases of influenza A (H1N1)
epidemic
105
0
50
100
150
200
250
300
350
400
450
Tuần1(24
-
30/6)
Tuần3(6

-
29/11)
T25 (7
-
13/12)
T27 (21
-
27/12)
Number of
…
Figure 2. Progress on the 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 15
th
and 17
th
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 was controlled and gradually reduced in late 2009.
3.3.2. Evolution on the serological strains of influenza in Huong Thuy District in
2008-2009

Figure 3. Distribution on the serological strains of influenza through focused
surveillance in Huong Thuy in the years of 2008-2009.
Influenza B is usually most common in summer from March to May. Influenza
AH1 usually increases in autumn and winter months from July to December. Influenza
AH3 usually occurs in spring and summer months from January to July. In 2009, an
Initial phase

8 Nam Đong 10 1 80
9 A Luoi 13 8 58
10 Other provinces 0 0 2
Total 122 56 2051
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 the lowest
ones were A Luoi and Phu Loc.
Table 9. Treatment results of influenza A (H1N1) patients in hospitals and in controlled
communities
No. Location
Number
of treated
patients
Treatment levels and results
In
hospitals
Recovery
rate
(%)
In
community

Recovery
rate
(%)
1 Phong Dien 88 63 100 25 100


community. The evaluation on progression of the disease situation in 2009 and the
results of the serological tests of influenza strains by focused surveillance in Huong
Thuy in the years 2008-2009 showed that the disease situation has been controlled and
decreased.
4. Conclusions
4.1. The identified characteristics of the epidemic of influenza A (H1N1), was
that it occurred mostly in the pupil and student group, and it spread rapidly through
direct contact, especially in crowded places. Cases were mostly clinically
mild, ,responded well to Tamiflu.
4.2. Solutions for the treatment of influenza A (H1N1) in controlled
communities in the province of Thua Thien Hue was consistent with the clinical
progression of the disease and the situation throughout the province. Treatment was
effectively administered for 47.2% of patients with influenza A (H1N1), and contributed 108
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 29
th
December, 2009 by Ministry of
Health on the situation of avian influenza A (H1N1).
2. Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, 24 Hours/Every Day -

3. Weekly epidemiological record. Relevé épidémiologique hebdomadaire. 20 November