Dr. Waraluk Tangkanakul PoE Team Leader, Thailand

Deputy director and Chief of International Communicable Diseases section, Bureau of General Communicable Diseases

Department of Disease Control, Ministry of Public Health, Thailand E. Mail : hapdocw@gmail.com

International Health Regulations, 2005 implementation at Point of Entries in

Thailand

Main content

• Implementation of IHR, 2005 in Thailand

• Pictures represent actual implementations from 15 June 2007 to 2016

• MERS confirmed case in Thailand and control measures

The National IHR Focal Point for Thailand (Department of Disease Control)

- Cabinet endorsement: Adoption and implementation

of IHR since 15 June 2007 - Approval of the National IHR Strategic Plan (2007-2012)

20 November 2007. Approval of the plan extension until 2016

- Implement Global Health Security to Border provinces

in 2014

IHR Implementation in Thailand : Background

I International H Health Regulations, 2005

• Link IHR implementation to ASEAN Economic Community Community • Establish 5 working groups (by each of the 5 hazards) under the Sub-committee on Multi-sectoral Coordination • Link with the Global Health Security Agenda at the 31 border provinces

IHR Implementation in Thailand : from 2014

I International H Health Regulations, 2005

The National IHR Focal Point for Thailand (Department of Disease Control)

Infection, Epidemic

Zoonotic,EIDs

Food Safety

Chemical

Radio-Nuclear

NFP

Sub-NFP

Sub-NFP

Sub-NFP

Sub-NFP

Sub-NFP

NFP- LAB (DMSC)

NFP – PoE (GCD, DDC)

National and Subnational IHR,2005 Focal Point in Thailand

NFP –(BOE, DDC)

INTERNATIONAL HEALTH REGULATIONS : IHR 2005

Thailand National Core Capacity Capacities

• Legal framework

• Coordination and collaboration

• Epidemiology Surveillance

• Rapid Response

• Hospital Preparedness and Infection Control

• Laboratory

• Quarantine officer

Committees Public Health

emergency surveillance

Laboratory System

Point of Entry

Integrated Coordination

Global Health Security Agenda

ท่าอากาศยานแม่ฟ้าหลวง

พรมแดนแม่สาย

ท่าอากาศยานสุวรรณภมู ิ

ท่าอากาศยานเชยีงใหม ่

พรมแดนแม่สอด

พรมแดนสงัขละบุร ี(เจดยีส์ามองค)์

พรมแดนบ้านพุน้ํารอ้น

ท่าเรอืกรุงเทพ

ท่าอากาศยานดอนเมอืง

ท่าอากาศยานหวัหนิ

พรมแดนสงิขร

ท่าเรอืประจวบครีขีนัธ ์

ท่าเรอืระนอง

ท่าเรอืภเูกต็

ท่าอากาศยานภเูกต็

ท่าอากาศยานกระบี่

ท่าเรอืกระบี่

พรมแดนปาดงัเบซาร ์

พรมแดนสะเดา

พรมแดนบ้านประกอบ พรมแดนเบตง พรมแดนสุไหงโกลก

พรมแดนบูเก๊ะตา

ท่าอากาศยานหาดใหญ่

ท่าเรอืสงขลา

ท่าเรอืนครศรธีรรมราช ท่าเรอืเกาะสมุย

ท่าอากาศยานเกาะสมุย

ท่าเรอืเกาะสชีงั

ท่าเรอืแหลมฉบงั และท่าเรอืศรรีาชา

พรมแดนบ้านหาดเลก็

ท่าเรอืมาบตาพุด

ท่าอากาศยานอู่ตะเภา

พรมแดนบ้านผกักาด

พรมแดนบ้านแหลม พรมแดนคลองลกึ

พรมแดนชอ่งจอม (กาบเชงิ)

พรมแดนภสูงิห ์(ชอ่งสะงาํ)

พรมแดนชอ่งเมก็ พรมแดนมุกดาหาร(ท่าเรอื)

พรมแดนสะพานมติรภาพ ๒

พรมแดนนครพนม (ท่าเรอื)

พรมแดนสะพานมติรภาพ ๓

พรมแดนบงึกาฬ

ท่าอากาศยานอุดรธาน ี

พรมแดนท่าลี ่

พรมแดนวดัหายโศก

พรมแดนสะพานมติรภาพ ๑

พรมแดนสถานีรถไฟหนองคาย

พรมแดนหว้ยโก๋น

ท่าอากาศยานแม่สอด

พรมแดนตากใบ

พรมแดนสะพานมติรภาพ4 ท่าเรอืเชยีงแสน

ท่าอากาศยานสนราธวิาส

พรมแดนท่าลี ่

พรมแดนบ้านภดูู่

ท่าอากาศยานสุโขทยั

ท่าอากาศยานพษิณุโลก

ท่าเรอืสตัหบี

ท่าอากาศยานอุบลราชธาน ี

ท่าอากาศยานสุราษ

ท่าเรอืสุราษ

ท่าเรอืกนัตงั

ท่าเรอืตาํมะลงั

พรมแดนวงัประจนั

ท่าเรอืปัตตาน ี

18 IHR Designated PoE

17 airports, 18 ports and 33 ground crossings 18 IHR authorized ports

PoE committee as a vital structure to develop core capacities

PoE NFP Committee meeting

National PoE conference, 2016

PoE evaluation team under PoE NFP: 2015

Samui airport and port Songkhla port

Bangkok port Laem Chabang port Chiang Khong Ground crossing

Don Mueang Int airport

Chaing San port Phuket airport Phuket port

Chaing Mai airport Krabi airport

PoE evaluation team under PoE NFP: 2016

12 Targets Strategy, Department of Disease Control, Thailand

Infectious Diseases

Zoonosis

Food safety

Chemical

Prevention

Detection

Response

IHR 2005 [DDC]

GHS [DDC and others

Source: Sopon Mekthon, Director General, Department of Disease Control

Radiological & nuclear

Point of entry

Source: Sopon Mekthon, Director General, Department of Disease Control

12 Targets Strategy, Department of Disease Control, Thailand

AIM OF IHR, 2005

[DDC]

Prevention

Infectious Diseases

Zoonosis

Food safety

Chemical

Radiological & nuclear

Hospital Infectious control

Detection Laboratory

Point of entry

Surveillance

Response SRRT

Emergency Operation Center (EOC) Prevent & detect

& Response Field Epidemiologist

GHS

Quarantine office day : 3 August 2016

• ICAO, IMO and IHR 2005, for detection of communicable diseases

• Airport: Fever at least 38 degree celsius with at least 1 clinical manifestation

1. appearing obviously unwell

2. persistent coughing

3. impaired breathing

4. persistent diarrhea

5. persistent vomiting

6. bruising or bleeding without injury

7. confusion of recent onset

8. skin rash

• For port and ground crossing additional : enlarge lymph node, jaundice and

seizure

Sign and Symptoms surveillance at PoE

No fever

Fever

•Health questionnaire (T.8) •Health beware card

Rest 30 min. Ear thermometer

Medical examination

Thermal check

Fever ≥ 38 oC

Custom clearance

���� �.8

��� �����Ū��

Immigration check + submit

T.8 Giving health advisory and health

beware card

Control measures at airport

Hospital

BOE No contact

history

Suspected

T.8

Report of illness

Report ‘No’ →collected box

T. 8, Questionnaire

DATABASE FOR DETECT, REPORT AND RESPONSE

Port, Airport, Ground crossing Database Thailand : PAGTH

2013 Develop online system and trial 2014 Implementation 2015 Expand system

PAGTH

For both routine and Emergency situation

Report and Response at PoE

No. Airport Total

flights Total Hajj First flight

1 Narathiwat airport

(Thai airways) 4 1,167 1 Oct 2015 4 Oct 2015

2 Hat Yai international airport (Thai airways) 11 3,150 30 Sep 2015 14 Oct 2015

3 Phuket international airport (3airlines) 10 602 4 Oct 2015 25 Oct 2015

4 Suvarnabhumi airport

(9 airlines ) 56 5,481 30 Sep 2015 26 Oct 2015

Total 81 10,400

The Hajj pilgrims arrival by airport during 30 September to 26 October , 2015

reference : Department of Religious Affairs

Last Flight

On arrival screening results

Airport Total Hajj

The hajj arrival to

arrival to airport

airport

PUI* URI Refer

Narathiwat

1,167 1,154

18

(1.55% )

651

(56.41 %)

21

(1.81% )

Hat Yai

3,095 3,121 27

(0.86 % )

346

(1.08%)

29

(0.92% )

Phuket

890 903 8

(0.88% ) 0

8

(0.88% )

Suvarnabhumi

5,248 5,142 8

(0.15%)

316

(6.14%)

8

(0.15%)

Total

10,400 10,350 61

(0.58 %)

1,313

(12.68)

66

(0.63% )

Main content

• Implementation of IHR, 2005 in Thailand

• Pictures represent actual implementations from 15 June 2007 to 2016

• MERS confirmed case in Thailand and control measures

MERS Situation, Thailand

18 June 2015: - 75 years old - Oman - Pneumonia

24 Jan 2016: - 77 years old - Oman - Pneumonia

seeking medical treatment

No epidemiological linkage between 2 cases 24

15/6/15 15/6/15 16 - 19/6/15 20/6/15

- Entered Thaialnd

-no fever at check point

-No fever, cough, exhausted

-Take taxi to the hotel in Bangkok rest for a while and take another taxi to hospital

- Collecting 1 specimens

-18 June 2015, move to Bamrasnaradura Infectious Diseases Institute, Department of Disease Control , Ministry of Public Health. Collect 4 specimens and be proved by laboratory diagnosis as 2 confirmation test Hospital contact (High risk) 17 persons Total high risk 38 and low risk 125 persons

16 contact persons on aircraft (high risk) 125 (low risk)

Contact case 2 persons (Taxi driver)

-Getting better

-negative for MERS

Timeline: Contact tracing and related events on First confirmed case of MERS – CoV in Thailand

- Male, 75 yr old - Lived in Oman as a fisherman with history of drinking camel milk - To get treatment for his respiratory symptoms at private hospital which started on 10 June

3 Contact persons (Son and cousin)

Case Investigation

24th July 25th

July

28th July

Taxi L

Hotel Y

26th July

Hotel Z

Hospital D

Hospital C

KU 411

Fatigue, chill No fever

27th July

Hospital B

-Fever, rhinorrhea -Sore throat, productive cough -BT40 ̊C, Injected pharynx, lungs clear -upE & Orf1a gene weakly positive

Hospital A

-Fever -Rhinorrhea -Sore throat, non-productive cough -BT40.2 ̊C

Taxi L

3rd case

26

Closed Contact Investigation

Closed contact

High risk (cases) 55

Father& grandmother (cases) 2

Flight and airport staffs (cases) 21

Taxi drivers (cases) 3

Hotel staffs (cases) 6

Healthcare personnel (cases) 23

Low risk (cases) 137

Results

27

Number of Closed Contacts

Taxi L

Hotel Y

Hotel Z

Hospital D

Hospital C

KU 411

Hospital B

Hospital A

Taxi L

High risk 23 cases

High risk 3 cases

High risk 17 cases

High risk 6 cases

High risk 4 cases

High risk 2 cases

Results

28

Father & grandfather

Closed contact (Transit to Manilla)

Index case

*

Closed contact

Blank Normal

Closed Contact in Flight and Airport

Status Job type Type of quarantine Follow up

High risk (23 cases)

- Passengers 21 cases - Flight cleaner 2 cases

- Hospital 6 cases - Hotel 3 cases - Can’t quarantine 14 (11 cases went back to their countries, 3 cases can’t contact)

- No abnormal symptom - TS and NPS day 1 and day 12: Negative

Countries: Kuwait 16, Egypt 3, Italy 2, German 1, England 1

Results

29

Place Department Environmental Study Results

Airport Aircraft

Airport - Having isolation pathway for respiratory patient - Airport officers did not wear masks

Screening system at the airport

Results At Suvarnabhumi airport

Cleaning personnels used gloves while cleaning but did not wear masks

Concourse E,F Thermoscan(NCTI) >36.5 ̊C - Fever>36.5 ̊C - RS symptoms - From risk areas

- -

+

+

Seat map KU 411

T.8 Health Questionaire Port Health Office

+

II

III

I

Airport Control Tower 30

Results Prevention and Control Measure

Category Prevention and Control Measure

MERS case Isolation at BIDI for prevent transmission and clinical management

Close contact Quarantine: follow-up clinical and laboratory - High risk :hospital and hotel quarantine - Low risk: self monitoring

Patient contact areas Disinfected patient contact surfaces with alcohol

HCP Encouraged health personnel: - Constantly apply MERS screening and early detection - Use proper PPE for RS patient

Public Communication to encourage: - Hygiene - Self protection - Symptoms monitoring

31

Discussion (1)

• Delay of detection at the airport - No fever: can’t be detected by thermoscan • All 3 confirmed cases cannot detect by Non-

contact infrared thermometers (NCTI) - Case 1: BT at private hospital 37.8 C, 38.3 C - Case 2: BT at private hospital 38.2 C - Case 3: BT at private hospital 40.2 C

32

Discussion (2)

• Possible causes: cannot detect by thermoscan - Previous treatment (take antipyretic drugs)in case 1,2 - No fever in that time - Middle East clothes - Travellers crowd - Environmental temperature change (at night time) • Screening system at port of entry may miss the cases:

incubation period, mild symptoms, sub temperature, take antipyretic drugs, travelers crowed, refuse to present themselves to port health office

33

34

Discussion (3)

• Imported cases and important of screening at entry point - The MERS cases in Thailand were imported from the Middle East by people seeking medical treatments (medical tourism) - Difficult to prevent importation of MERS therefore we need proper screening and early detection to decrease transmission of disease - Case definition: WHO compare with Thailand guideline (used by Middle East): Probable case suspected in acute febrile respiratory illness of any severity but in Thailand include the patient that have not got fever but have URI or LRI symptom in to probable case definition + PUI definition 35

Discussion (4)

• Cannot detect patient on the aircraft - Case 1: dyspnea, cough, obviously unwell - Case 2: dyspnea, persistent cough, obviously unwell - Case 3: Fatigue, chill, no fever IHR

36

International Civil Aviation Organization (ICAO)

Annex 9, Chapter 8, Paragraph 8.15

37