Published on April 21, 2005 - When an influenza pandemic strikes, hospitals throughout the country will have to cope with a sudden, major influx of patients. Although aware that such a scenario may be imminent, doctors face a host of challenges that are impeding their efforts to prepare. This is the final part of a three-part series.

In the midst of last year’s H5N1 avian-flu outbreak, about 17 confirmed human cases showed up in almost as many hospitals across Thailand. Dr Anucha Apisarnthanarak of Thammasat University Hospital managed one of those cases, and has since been working hard to ensure his experience will help his peers.

“It was not your typical bird-flu case,” he says. “The patient had diarrhoea and a fever, no respiratory problems or other flu-type symptoms.”

Only after pneumonia developed and more extensive background checks revealed contacts with poultry, was bird flu suspected. Lab reports finally confirmed an H5N1 infection the day after the patient died.

Anucha has since published several articles about the case, including the first addressing “atypical” H5N1 infections.

His experience, combined with that of recent cases in Vietnam where two H5N1 patients also lacked respiratory ailments but had encephalitis (swelling of the brain), has prompted international medical experts to alert healthcare providers to the need to broaden their views about the symptoms associated with H5N1 infection in humans.

Anucha believes most healthcare providers need to greatly improve their ability to identify emerging infectious diseases now that the country is threatened with a new pandemic virus.

“I don’t think all hospitals are ready, given the way things are now,” Anucha says. “For example, we still expect young doctors with the least experience to examine incoming patients. This may lead to delayed recognition of disease and miss the chance to interrupt its transmission in time.”

Identifying H5N1 is further compromised by the time it takes to get confirmation of an infection. “Rapid” influenza tests for H5N1 done at hospitals can give false results. Samples must also be sent to Bangkok for more comprehensive testing. A year ago this took several days. Now, hospitals receive results within 24 hours.

These viruses can be tricky, agrees Dr Achara Chaovavanich, director of Bangkok’s Bamrasnaradura Hospital, which specialises in infectious diseases.

“What we need is a ‘Mister Bird flu’ [a specialist doctor] in every hospital who will keep everyone updated,” she says, but acknowledges that this is some way from being achieved.

The Influenza Foundation of Thailand, headed by leading microbiologist Dr Prasert Thongcharoen is emphasising education as well.

It has launched a nationwide influenza training programme for doctors and healthcare workers in the provinces. Last month the foundation organised a workshop for hundreds of doctors and healthcare workers in Chiang Mai and has a similar event planned for Khon Kaen in August.

The National Strategic Plan for Influenza Pandemic Preparedness, approved by the Cabinet on January 25, provides ample rationale for improving preparedness.
While not specifically addressing an H5N1 outbreak, the plan recommends healthcare professionals prepare for 10 to 40 per cent of the population to be infected. That is between 6.5 million and 26 million people.

Achara, who helped to develop the plan, stresses the importance of every hospital developing and implementing its own response programme.

Her hospital recently completed its response programme, but it has not been practised, nor has it been used for any hospital-wide preparedness effort.

Most other hospitals, she believes, have yet to approach square one. Anucha points to a survey in 2003 that sought to determine how well Thai hospitals could respond to something like Sars (Severe Acute Respiratory Syndrome). It was found that many hospitals were not ready to properly handle this type of a disease outbreak. “I’m not sure the situation would be much different today,” he says. “I would like to encourage hospitals to get more prepared to cope with a pandemic.”

Cost-cutting dangers

One indicator, he says, is that most hospitals lack what are known as “negative pressure rooms” to isolate patients with infectious diseases. Low air pressure in these rooms means air always flows in to them, and never out. His Thammasat Hospital received Bt2 million last year to build two such rooms, but construction has been delayed because of bureaucratic red tape. Planners at the Public Health Ministry agree that better hospital infrastructure is needed to limit transmission as well as to create confidence among healthcare workers. Dr Kamnuan Ungchusak, director of the Public Health Ministry’s Epidemiology Bureau, says plans are in the works to build negative pressure rooms at every provincial hospital.

“More than half of the 76 provinces are in the process of building one,” Kamnuan says. “Hopefully, we can provide a room at every district hospital as well.”

Chao Phraya Yommarat Hospital in Suphan Buri hopes to add three such rooms to its 600-bed facility. But Dr Nithi Prachongkarn, who handled Thailand’s first avian-flu case there, recognises their limitations. “My director and I talk about how to prepare our hospital [for a pandemic], but nothing is written on paper yet,” he says. “We are looking for a site to build three isolation rooms, but those won’t be enough for something like a pandemic.

“By that time we may have patients filling the parking lots and wondering where to put them.”

Nurse Kanokporn Thongpubeth, who works with Anucha at Thammasat Hospital, stresses that there’s also a need for much lower-tech equipment for the personal protection of healthcare workers. To control costs, Kanokporn says, nurses must re-use masks that cost Bt40 to Bt50 apiece.

“Some of us wear a normal cheaper particle mask on top of an N95 mask so that we can reuse the N95 mask the next day,” she says. “It’s not a policy from our management, but we all know we have a limited supply.”

The national pandemic plan states that Bt584 million will be used for purchasing medical equipment between now and 2007. So far there are no plans stating when or how any of the money will make its way to hospitals.

Potentially, the greatest shortage facing hospitals during a pandemic will be staff. Microbiologist Prasert recalls that during the 1957 Asian Flu epidemic, he and just one other doctor were left to handle all the patients at his Siriraj Hospital unit because most of the doctors became sick.

Some fear doctors and medical staff may even desert hospitals before they get sick, as occurred in Taiwan during the Sars outbreak in 2003.

“This is a highly ethical issue,” Anucha says. “Doctors have no right to run away. Theirs is a moral responsibility.” But he concedes that not all doctors think the same way.

Dr Tawee Chotpitayasunondh, who is in charge of stockpiling programmes for Thailand’s preparedness, has heard his students joking about this.

“I asked them how they thought they could run away from it. I told them if they stayed and worked, I would give them medicine to protect themselves.”
The medicine he refers to includes antiviral drugs that can prevent the onset, or minimise the affects of, some viruses. He’s working to acquire such medicines as part of Thailand’s pandemic stockpiling programme.

Other doctors point out that there is a need to recognise the limitation of hospitals during a pandemic. Dr Surachet Sathitniramai, chief of Prachin Buri Provincial Public Health Office, observes that in the US, people are taught basic nursing skills so they can treat family members in their homes. Prachin Buri hosted a case of human bird flu last September. The patient died. “We have to start thinking about this now,” he says. “What’s needed most is a clear policy of what to do when hospitals are overwhelmed.

“When do we need help from the military [to set up field healthcare units]? And most important of all, how do we take care of people who cannot come to hospital?”

Such initiatives may be a long way off, says a key member of the Public Health Ministry’s team that responded to last year’s bird flu crises.

“It’s all too quiet now,” he says. “I feel like a runner who was sprinting at full speed, then, all of a sudden, I had to stop.” He says his colleagues feel the same way. Programmes were rushed into action when they were needed, but once the crisis abated, so did the resources.

Kanokporn and other nurses who have cared for bird flu patients see the same problem from a different perspective.

“We were on high alert for self protection for a while, but practices naturally waned as there have been no cases this year. I personally feel we have to work harder to reinforce this preparedness and continue to educate members of the public to protect themselves.”

Nantiya Tangwisutijit
The Nation