The Viet Nam One Health Strategic Plan for Zoonotic Diseases 2016-2020

Article 1. To issue the Viet Nam One Health Strategic Plan for Zoonotic Diseases, 2016–2020 (the Plan is attached).

Article 2. Implementation of the Plan: The Ministry of Agriculture and Rural Development will assume the prime responsibility for and coordinate with the Ministry of Health on the implementation of the Strategic Plan, with the following tasks: - To play a role as national focal point for international cooperation in zoonotic diseases prevention and control, guiding, monitoring, inspecting and urging the implementation of the Strategic Plan by related ministries, sectors and local authorities. - To organize the specific monitoring and assessment of the implementation of the Strategic Plan by agencies. - To coordinate closely with ministries and sectors whose mandates are related to zoonotic diseases prevention and control. 7 Based on the framework of the Strategic Plan, relevant agencies working in this area will formulate specific strategies, programs and action plans for their own agencies. Supervision of the progress in implementing the Plan will take place through the annual national One Health Forum hosted by the Ministry of Agriculture and Rural Development and the Ministry of Health with the participation of related ministries, sectors and signatories to the One Health Partnership Framework.

Article 3. This Decision comes into force from the date of signing. The Head of the Ministry Administrative Office, the Directors-General of the International Cooperation, Finance, Planning, Animal Health, and Livestock Production Departments; and the Director of the National Agricultural Extension Centre, the Director of the Viet Nam One Health Partnership for Zoonoses Secretariat and the Heads of related units are responsible to carry out this Decision. Recipients: ON BEHALF OF THE MINISTER - As listed in Article 3; THE VICE MINISTER - The Prime Minister (for reporting); - The Government Office; - Ministries: the Ministry of Health, the Ministry of Planning and Investment, the Ministry of Finance, the Ministry of Natural Resources and Environment, Vu Van Tam the Ministry of Education and Training, the Ministry of Science and Technology, the Ministry of Defense, (Signed and sealed) the Ministry of Public Security, and the Ministry of Industry and Trade; - Associations/Unions: the Viet Nam Farmers Union, the Viet Nam Red Cross Society, the Viet Nam Veterinary Association, the Viet Nam Animal Husbandry Association, the Viet Nam Animal Feed Association, and the Viet Nam Women’s Union; - The OHP Secretariat; - Archive: Ministry Archive, ICD (LMT 30). 8 MINISTRY OF HEALTH SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom - Happiness No.: 8225/BYT-DP Providing remarks on the National Hanoi, November 17,2016 One Health Strategic Plan, 2016–2020. To: The Ministry of Agriculture and Rural Development. In response to Official Letter No. 9151/BNN-HTQT dated October 28, 2016 of the Ministry of Agriculture and Rural Development on requesting comments on the Draft Viet Nam One Health Strategic Plan for Zoonotic Diseases, 2016–2020, after reviewing the Draft, the Ministry of Health has the following remarks: 1. The Ministry of Health agrees on the contents of the Draft Viet Nam One Health Strategic Plan for Zoonotic Diseases, 2016–2020, which has been developed by the Ministry of Agriculture and Rural Development in cooperation with relevant agencies of the Ministry of Health, the Viet Nam One Health Partnership for Zoonoses (OHP) Secretariat, and related ministries and agencies. 2. The Ministry of Health concords with the Ministry of Agriculture and Rural Development issuing the Viet Nam One Health Strategic Plan for Zoonotic Diseases, 2016–2020. The Ministry of Health shall cooperate closely with the Ministry of Agriculture and Rural Development and other related ministries and sectors during the implementation of inter-sectoral activities within the framework of the Plan. The Ministry of Health would like to share the above-mentioned remarks as a basis for the Ministry of Agricultural and Rural Development to consolidate and carry out the required procedures according to the regulations. With gratefulness. Recipients: ON BEHALF OF THE MINISTER - As mentioned above; THE VICE MINISTER - Minister Nguyen Thi Kim Tien (for reporting); - Archive: Ministry Archive, GDPM. Nguyen Thanh Long (Signed and Sealed) 9 CONTENTS 10 List of figures List of tables Abbreviations SUMMARY PLAN 15 i. Background 16 ii. Scope and purpose 16 iii. Target audience 17 iv. Guiding principles 17 v. Governance of the plan 18 vi. Goal, objectives and areas of focus 18 Seven One Health focus areas 1. Building One Health capacity 21 2. One Health approaches for managing human disease emergencies of zoonotic 26 origin 3. One Health approaches for managing zoonotic agents with pandemic potential 28 that are yet to emerge, especially in wildlife 4. One Health approaches for managing zoonotic influenza viruses with pandemic 30 potential 5. One Health approaches for managing rabies 32 6. One Health approaches for managing antimicrobial resistance 34 7. One Health approaches for managing other priority zoonotic diseases 36 TECHNICAL ANNEX 38 Introduction and background 39 i. Purpose 39 ii. Scope of this document 39 iii. Achievements 41 iv. Target audience 41 v. Guiding principles 42 vi. Governance of the plan 42 vii. Goal, objectives and focus areas 42 10 1. Building One Health capacity 43 1.1. Background 43 1.2. Strategic directions 43 1.3. Achievements in establishing One Health approaches in Viet Nam 44 1.4. Work underway 45 1.5. Alignment with existing policies/strategies 46 1.6. Key factors for success 50 1.7. Challenges and constraints 50 1.8. Targets 52 1.9. Budget 58 2. One Health approaches for managing human disease emergencies of zoonotic 60 origin 2.1. Background 60 2.2. Strategic directions 60 2.3. Achievements in establishing One Health approaches in Viet Nam 60 2.4. Work underway 60 2.5. Alignment with existing policies/strategies 61 2.6. Key factors for success 61 2.7. Challenges and constraints 61 2.8. Targets 61 2.9. Budget 62 3. One Health approaches for managing zoonotic agents with pandemic potential that 63 are yet to emerge, especially in wildlife 3.1. Background 63 3.2. Strategic directions 63 3.3. Achievements in establishing One Health approaches in Viet Nam 64 3.4. Work underway 64 3.5. Alignment with existing policies/strategies 64 3.6. Key factors for success 65 3.7. Challenges and constraints 65 3.8. Targets 65 3.9. Budget 66 11 4. One Health approaches for managing zoonotic influenza viruses with pandemic 67 potential 4.1. Background 67 4.2. Strategic directions 68 4.3. Achievements in establishing One Health approaches in Viet Nam 69 4.4. Work underway 69 4.5. Alignment with existing policies/strategies 71 4.6. Key factors for success 72 4.7. Challenges and constraints 73 4.8. Targets 74 4.9. Budget 77 5. One Health approaches for managing rabies 78 5.1. Background 78 5.2. Strategic directions 78 5.3. Achievements in establishing One Health approaches in Viet Nam 79 5.4. Work underway 79 5.5. Alignment with existing policies/strategies 80 5.6. Key factors for success 81 5.7. Challenges and constraints 82 5.8. Targets 83 5.9. Budget 84 6. One Health approaches for managing antimicrobial resistance 85 6.1. Background 85 6.2. Strategic directions 85 6.3. Achievements in establishing One Health approaches in Viet Nam 86 6.4. Work underway 86 6.5. Alignment with existing policies/strategies 89 6.6. Key factors for success 90 12 6.7. Challenges and constraints 90 6.8. Targets 91 6.9. Budget 93 7. One Health approaches to managing other zoonotic diseases 94 7.1. Background 94 7.2. Strategic directions 96 7.3. Achievements in establishing One Health approaches in Viet Nam 96 7.4. Work underway 96 7.5. Alignment with existing policies/strategies 96 7.6. Key factors for success 96 7.7. Challenges and constraints 97 7.8. Targets 97 7.9. Budget 98 7.10. Foodborne diseases 98 Appendix 1: List of selected One Health activities in Viet Nam from 101 2005-2020 by disease focus disease focus LIST OF FIGURES Figure 1: Relationship between the Viet Nam One Health Strategic Plan & the GHSA, IHR & APSED Figure 2: Viet Nam One Health Strategic Plan 2016-2020: goal, objective and focus areas Figure 3: H5 virus in Viet Nam in 2014 - an example of the genetic information on these viruses (courtesy of FAO Viet Nam) LIST OF TABLES Table 1. Selected list of government plans related to One Health Table 2. Human cases of influenza A(H5N1) Table 3. Reported rabies cases in humans, 2006-2015 Table 4. Reported rabies cases in humans, 2006-2015 Table 5. Progress in Viet Nam against the global strategic framework for rabies Table 6. Sub-objectives of the Viet Nam national AMR action plan Table 7. Priority zoonotic diseases as defined by the Government of Viet Nam 13 14 SUMMARY PLAN SUMMARY PLAN 15 SUMMARY PLAN The Viet Nam One Health Strategic Plan for Zoonotic Diseases 2016-2020 Background One Health approaches to manage In Viet Nam, zoonotic diseases pose diseases of animal origin include: a constant threat and have already caused major health, economic Activities where inter-sectoral and social impacts. As local and and interagency collaboration has global environments undergo rapid occurred or should occur toprovide the transformations, the risk of zoonoses best chance of improving health for and emerging diseases appears to be humans, animals and the environment increasing. The current consensus is that these Activities using Ecohealth approaches diseases are best managed using a to tackle complex disease problems. One Health, multi-sectoral approach Ecohealth approaches consider that encompasses prevention and environmental and social factors, and response (see box). Viet Nam is actors from various disciplines work already applying this approach. together with local stakeholders to devise and implement solutions to Scope and purpose these problems This One Health Strategic Plan (OHSP) sets out a 5-year plan for the continued development of Viet Both are related and both activities are Nam’s One Health capacities for needed to optimise the likelihood of reducing the health and other impacts containing and preventing diseases at the of zoonotic diseases. The emphasis is human-animal-environment interface. A on further development of core One One Health approach to zoonotic diseases Health competencies and selected does not mean that different departments/ attention on nationally defined players must work together to conduct all priority areas and diseases. activities. There will be situations where a multidisciplinary team is best equipped This document pulls together the to resolve problems, but in many cases various strands of current and One Health is about ensuring common planned work on zoonoses in Viet goals, timely sharing of knowledge and Nam where a One Health approach ensuring that the most appropriate people, will be applied, illustrates where organisations and agencies are engaged to multi-sector involvement is required find solutions to zoonotic disease control and describes the activities that will and prevention. be undertaken. It also highlights gaps in funding or areas where donor support will be required. 16 SUMMARY PLAN The OHSP: Builds on previous plans - the Viet Nam National Integrated Operational Program for Avian and Human Influenza (OPI), 2006-2010, and the Viet Nam National Integrated Operational Program on Avian Influenza, Pandemic Preparedness and Emerging Infectious Diseases (AIPED), 2011-2015 Provides a One Health interface for national plans (including those still under development) that connect with this 5-year plan such as those to strengthen health systems and to address specific diseases Includes the priority actions for addressing health threats posed by zoonotic diseases identified at the International Conference on Zoonotic Disease Prevention and Control, Ha Noi, August 2015 (ZDAP Conference). Is consistent with international and regional plans for specific zoonotic diseases and health issues (e.g. WHO Antimicrobial resistance, WHO/OIE/FAO rabies) Aligns with other international and regional initiatives that include One Health activities on zoonotic diseases such as the International Health Regulations (IHR 2005), the Asia Pacific Strategy for Emerging Diseases (APSED 2010), and the Global Health Security Agenda (GHSA) (See Figure 1, page 19). Target audience The OHSP provides a framework for anyone with an interest or stake in the control and prevention of zoonotic diseases in Viet Nam - this includes government and non-government agencies, teaching and research institutions, international financial institutions, donors and the public. Although this plan principally details activities for government and key partners, many of the underlying drivers of disease are related to human actions that can only be addressed with the participation of all parts of society in Viet Nam, particularly those involved in rearing domestic and wild animals, and handling animals and animal products. Actions will be taken in seven focus areas described below. Additional information on each of the elements of the plan is provided in expanded sections in the attached document. Guiding principles The 4 guiding principles for the OHSP are: 1. That it builds on work already undertaken through the OPI and AIPED on zoonotic diseases using a One Health approach. 2. That it is an integrative framework (rather than an operational plan) that overlies and links the various extant and planned programs and activities aimed at addressing zoonotic diseases using a One Health approach. 3. That One Health approaches require shared objectives among different partners and, in some cases, shared activities when this is the most efficient way to prevent disease and protect health. 17 SUMMARY PLAN 4. That strengthening capacity alone is not enough – improved capacity must be applied to tackle specific diseases of local concern. Governance of the plan Governance of this plan will occur through: An annual assembly with partners hosted by MARD and MOH with the participation of MONRE and other related ministries, sectors and stakeholders to report on progress. This assembly will be incorporated into the annual national One Health Forum of the One Health Partnership for Zoonoses. In this way, the partnership itself led by the key government ministries (MARD, MOH, MONRE) is formally responsible for achieving the objectives of the plan through collaborative governance. An annual written report produced by the One Health Partnership for Zoonoses summarising progress against key targets - this report will be used to facilitate action to overcome barriers to One Health approaches to zoonotic diseases. Goal, objectives and areas of focus (See Figure 2) To achieve the goal of Seven One Health focus areas have been reducing the health and identified to achieve these objectives by 2020 other impacts of zoonotic (Figure 2): diseases and diseases of 1. Building One Health capacity animal origin origin, the OHSP has the following 3 2. One Health approaches for managing objectives: human disease emergencies of zoonotic origin A. Strengthen One 3. One Health approaches for managing Health capacity for zoonotic agents with pandemic the prevention and potential that are yet to emerge control of all zoonotic diseases 4. One Health approaches for managing zoonotic influenza viruses with B. Enhance preparedness pandemic potential for a human emergency of animal 5. One Health approaches for managing origin rabies C. Apply One Health 6. One Health approaches for managing principles to limit the antimicrobial resistance public health impact of current priority 7. One Health approaches for managing zoonotic diseases other priority zoonotic diseases 18 GHSA priority capacities Agents with pandemic 3 potential yet to emerge Laboratory IHR core capacity National legislation, policy & financing Surveillance Coordination & national IHR potential hazards focal point communications Human resources APSED objective Strengthening 1 One Health capacity Viet Nam Prevent One Health Strategic Plan Detect Zoonotic events 5 of 7 focus areas are within the intersection of Prevent, Detect and Respond Reduce the risk of Zoonotic influenza 4 emerging diseases Sustainable collaborations Rabies 5 & partnerships Antimicrobial resistance 6 Early detection Food safety Other zoonotic diseases 7 including food borne illnesses Human disease 2 emergencies of zoonotic origin Effective preparedness Preparedness Rapid response Response Risk communications Respond Figure 1: Relationship between the GHSA, IHR, APSED & the Viet Nam One Health Strategic Plan SUMMARY PLAN 19 20 SUMMARY PLAN Figure 2: Viet Nam One Health Strategic Plan 2016 -2020: goal, objectives and focus areas Goal Reduce the health and other impacts of zoonotic diseases and diseases of animal-origin Objectives A Strengthen One Health capacity for prevention & control of all zoonotic diseases Focus areas One Health Capacity B Enhance preparedness for Emergency management a human emergency of & response animal origin Risk communications Human disease emergencies of zoonotic origin 2 Legal framework Governance & coordination Agents with pandemic potential yet to emerge 3 Prevention activities Surveillance C Apply One Health principles to limit the public health impact Laboratories of current priority zoonotic Workforce Specific objective to improve diseases emergency management & early Research 1 response systems given repeated Zoonotic influenza 4 zoonotic emergencies in Viet Nam in recent years. Rabies 5 One Health approach to health system strengthening in alignment with IHR (2005) & APSED (2010) Antimicrobial resistance 6 Other zoonotic diseases including food borne illnesses 7 Specific objective to address nationally defined priority zoonoses that pose a serious exisiting or potential threat & where considerable gains can be made by 2020 SUMMARY PLAN 1. Building One Health capacity Why is this necessary? Although much has been achieved in developing One Health capacity in Viet Nam - through work on avian influenza and other diseases supported by government, international agencies and donors - gaps remain. Work conducted in this focus area over the next 5 years will aim to fill these gaps, strengthening the platform on which One Health approaches to specific zoonotic diseases are built. This platform includes high-level coordination and support, suitably trained and resourced teams, as well as the legal framework and formal direction for different sectors to work together. Without these elements, One Health approaches are unlikely to be adopted and opportunities to prevent and control diseases at the human-animal-environment interface will be missed. The capacity to undertake risk assessments on potential drivers for emergence and re-emergence of zoonotic diseases and appropriate research are needed to advance One Health approaches to zoonotic diseases in Viet Nam. In addition, risk communications that raise awareness and result in appropriate behavioural change are essential to prevent emergence of new potential pandemic threats from farmed and wild animals, and in managing disease emergencies. Surveillance systems that can identify zoonotic and potential pandemic agents in both animals and humans are critical for One Health responses. These systems need to provide accurate and timely data that are fully analysed and shared. What will be done, how will it be done and who will do it? 1. GOVERNANCE AND COORDINATION - mechanisms to coordinate action across sectors including greater involvement of the environmental sector What How Who Well-defined national Establishment of a new, MARD, MOH, Office coordination mechanisms for unified, overall national of Government, zoonotic diseases linking animal steering committee MONRE, OHP health, human health, wildlife, environment and other government Clarification of the role USAID/P&R sectors that function during of the environmental emergency and non-emergency health sector in One periods Health activities addressing zoonotic diseases Application of Circular 16/2013 on zoonotic diseases 21 SUMMARY PLAN Engagement by government Ensuring industry, subject MARD, MOH, partners with key civil society and discipline specialists MONRE, NIHE, other organisations and external are identified and included members of the OHP stakeholders for specialised in One Health approaches information and advice (e.g. to control and prevention Civil Society clinical, public health, laboratory, of zoonotic diseases USAID/P&R risk communications, private through advisory panels sector, international partners etc.) and networks. and as partners in disease control and prevention programs Maintaining the One Health Provision of support for MARD, MOH, Partnership on Zoonoses the One Health Partnership MONRE, other and secretariat to ensure it can including involvement in members of the OHP continue to act as a national OHP activities organised platform for policy dialogue and UNDP, USAID/P&R knowledge management of One Health and zoonotic diseases, and to facilitate coordination of One Heath stakeholders Conducting joint investigations Application of relevant MARD, MOH at into zoonotic disease outbreaks provisions of Circular national and equivalent whenever this is appropriate 16/2013 agencies at provincial (including development of level guidelines for situations where joint investigations should be VOHUN, FAO, WHO, conducted) OIE, ADB, USAID/ P&R 2. LEGAL FRAMEWORK - the legislative framework to facilitate multi-sectoral cooperation What How Who Measures to ensure wider Training in implementation of MARD, MOH, adoption of Circular 16/2013 Circular 16/2013 MONRE and that provides a basis for enhanced provincial collaboration between Ministries counterparts, and Departments on zoonotic WHO, FAO diseases, especially at provincial and sub-provincial levels Additional legislation/directives/ Preparation of appropriate MARD, MONRE circulars for coordination directives under the Animal and formal engagement of the Health law and consideration of environmental sector and in extending relevant features of particular MONRE Circular 16 to include MONRE 22 SUMMARY PLAN 3. RISK ASSESSMENTS AND COMMUNICATIONS to target upstream determinants of disease emergence What How Who Build capacity to undertake risk Training programs in MARD, MOH, MONRE assessments at the human-animal- joint risk assessments environment interface through AVET and USAID/P&R, VOHUN, FETP and other WHO, FAO, OIE, ADB programs Improve risk communication Training in risk MOH, MARD, MONRE between authorities and to the communication for public on microbial hazards disease emergencies One Health emerging at the human-animal- and prevention of Communications Network, environment interface diseases farmers, animal traders FAO, WHO, ADB, USAID/ P&R, donors 4. LABORATORIES AND SURVEILLANCE SYSTEMS that support testing programs What How Who Enhance laboratory capacity and Provide appropriate MOH, MARD, NIHE quality management systems resources for undertaking tests and WHO, FAO, OIE, for application of USAID, ADB, WCS, US quality management CDC, donors systems Enhance data management Established following As above systems to allow rapid analysis the GHSA Roadmap and sharing of new findings within and across sectors as well as across borders Conduct well designed See focus area 3 See focus area 3 surveillance to ensure early detection of zoonotic pathogens especially those with pandemic potential 5. TRAINED ONE HEALTH WORKFORCE - a cadre of qualified staff to implement One Health activities What How Who Sufficient numbers of trained Adopt curriculum for MARD, MOH, MOF, professional staff are proficient One One Heatlh training and MONRE, MPI, VOHUN Health practitioners include One Health as an integral part of FETP and FAO, WHO, US CDC, AVET training USAID EPT-2 23 SUMMARY PLAN 6. APPROPRIATE ONE HEALTH RESEARCH What How Who Undertake appropriate research Identify gaps in MARD (research centres), to fill gaps in application of One knowledge, obtain MOH, MONRE, NIHE, Health approches to policy and funding, conduct OHP practice including research on research and regularly specific diseases share findings with OUCRU, CIRAD, ILRI, stakeholders including Universities including policy makers (annual those in VOHUN meetings) Undertake selected Farm locations MARD (DLP), MONRE environmental health research assessed for aimed at understanding the potential hotspots for drivers of disease emergence and pathogen emergence, measures to reduce risk to guide amplification and practice, for example, enhanced transmission (e.g. land use planning for the livestock effects of developing sector (see focus area 3) new livestock production zones) How will gains be measured? Success will be measured by the extent of change in each of the areas above and, more importantly, in decreases in case numbers, fatalities, and the number and size of outbreaks for the priority zoonotic infections/diseases. It is also expected that by 2020: All operational plans for zoonotic diseases will be aligned with the One Health Strategic Plan 2016-2020 with defined actions for relevant sectors of government at all levels and other partners. This includes clarification of the precise role of MONRE who are now a major partner. Government will progressively increase the share of financing for core programs related to zoonotic disease prevention and control (including human-animal-wildlife surveillance activities for priority zoonotic diseases) and development of IHR/PVS core capacities. Dedicated contingency funding for infectious diseases emergencies will have been identified, including exploration of opportunities presented by the World Bank’s Pandemic Emergency Financing Facility. Annual One Health meetings will be held supported by the One Health Partnership to share information on programs and projects and progress towards objectives. Funds required The expected cost of these One Health activities over the 5 years of the plan is approximately USD 10,000,000. 24 SUMMARY PLAN Funding for these activities is expected to come from a mix of government and donors (including USAID) with many of the activities falling within the EPT-2 program and plans of other donors such as the ADB, World Bank and via the GHSA funding envelope. For instance, the ADB Greater Mekong Subregion Regional Health Security Project (2016-2020) is expected to support MOH activities related to: Cross-border collaboration for communicable disease control in border areas [USD 3.8M] - this will encompass development of risk assessment tools and risk communications for mobile populations that may be relevant to other populations in Viet Nam and may address priority zoonoses such as rabies - this supports focus areas 1, 2, 3, 4, 5. Surveillance and outbreak response systems [20.8M] - this supports focus areas 1, 2, 3, 4 Laboratory services and hospital infection prevention and control measures [USD 46.2M] - this supports focus areas 1, 5, 6. 25 SUMMARY PLAN 2. One Health approaches for managing human disease emergencies of zoonotic origin Why is this necessary? Viet Nam must be prepared to manage any severe pandemic disease in humans resulting from the spillover of an animal pathogen. These events are rare but can have major, whole-of-society effects (even with relatively short local transmission chains) as illustrated by SARS, MERS and Ebola virus disease. A One Health approach involving coordinated inter-sectoral collaboration can mitigate the impact of these events. Well-designed and tested systems are required. Building on previous efforts, Viet Nam has indicated plans to establish an ongoing prime ministerial-level steering committee to coordinate responses and an Emergency Operations Centre is expected to become fully functional by 2020. Appropriate activation of the Emergency Operations Centre relies on high quality, timely surveillance systems. What will be done, how will it be done and who will do it? In the period from 2016-2020, the following will be developed to enhance the structures and processes critical for One Health approaches for emergency zoonotic diseases in humans: What How Who Steering committee for emergency Decisions at Prime Office of diseases will be operational Ministerial level Government, OHP, required on the nature MARD, MOH, of the coordinating MONRE mechanism USAID/P&R Role of Ministries other than MOH is Determine the role of MARD, MOH, fully defined other Ministries in the MONRE event of a disease that is yet to spillover to humans in Viet Nam (e.g. if H7N9 is detected in poultry but not yet in humans) A fully functional emergency Established following MOH, MARD, management centre suitable for the GHSA Roadmap MONRE responding to all hazards US CDC, US DoD 26 SUMMARY PLAN Revised and tested whole-of-society Existing plans renewed MOH, MARD, OHP pandemic preparedness plans and exercises or live outbreaks used to test US CDC, USAID/ these P&R, donors FAO, WHO Appropriate surveillance systems for Established following MARD, MOH disease emergencies the GHSA Roadmap Risk communication for outbreaks Build appropriate MARD, MOH, risk communication One Health packages in the event of Communications any disease emergency Network, WHO, by staff trained in this FAO, US CDC, discipline USAID/P&R How will gains be measured? The two major objectives will be that the emergency management centre is fully operational and that pandemic preparedness plans have been revised and tested. Funds required Approximately USD 2,000,000 will be required (excluding funds required for any actual emergency disease outbreak – see focus area 1 regarding dedicated funding for severe disease outbreaks). Resources are expected to be provided by government and through the GHSA funding envelope, ADB (risk communications, surveillance and outbreak response) and the World Bank. 27 SUMMARY PLAN 3. One Health approaches for managing zoonotic agents with pandemic potential that are yet to emerge, especially in wildlife Why is this necessary? Viet Nam has been classified as a global hotspot for the emergence of novel zoonotic agents with pandemic potential and has recognised the importance of decreasing the risks of disease emergence. Through the GHSA and the linked EPT2 programme of USAID, Viet Nam is working to identify potential zoonotic agents in high-risk species and settings, and to put in place measures to reduce the risk of their emergence. Environmental factors play an important role in these diseases and a broad One Health approach is needed to ensure success in preventing spill over and controlling them if they do. What will be done, how will it be done and who will do it? In the period from 2016-2020, the following will be undertaken to find out more regarding viral pathogens in important wildlife and farmed animals and to reduce the risk posed by these agents (see also focus area 4 for work done on zoonotic influenza viruses): What How Who Complete planned work on the Undertake testing of MARD and provincial identification of zoonotic and a range of animals for DARDs potential pandemic agents in viruses with pandemic animals prior to their emergence potential WCS, Livestock farmers and traders, Wildlife farmers and traders USAID/P&R, PREDICT-2 Improve capacity for early Undertake testing of MOH plus above detection of spillover to humans humans working in of potential pandemic infectious association with animals, agents especially clinical cases Implement measures to reduce Develop and introduce MARD, MOH, MONRE, the risk of emergence of novel industry/sector specific DIE agents for specific industries guidance on preventive measures FAO USAID/P&R, PREDICT-2 How will gains be measured? In the next 5 years through the EPT-2 programme and other activities it is expected that Viet Nam will have identified most of the potential zoonotic and pandemic risks in important wildlife species and will have introduced behavioural change programmes for selected sectors and “industries” to reduce the risk of disease emergence. 28 SUMMARY PLAN Funds required The budget required for this work is approximately USD 3,000,000. Most of the funding is expected to come from government including through ADB support for risk assessments in border areas and enhanced surveillance. Additional contributions will be provided by USAID through the EPT-2 program. 29 SUMMARY PLAN 4. One Health approaches for managing zoonotic influenza viruses with pandemic potential Why is this necessary? Zoonotic influenza viruses pose a major pandemic threat. Since 2003 when Influenza A(H5N1) virus became widespread in Viet Nam, many actions have been taken to contain it. The virus has not been eliminated and new, related strains have been repeatedly introduced to the country over the past 12 years. The risk of exposure of humans to the virus persists and, therefore, so too does the risk of emergence of a human-adapted pandemic strain of virus. H7N9 avian influenza, which has already been confirmed in more than 700 people in China, poses a major risk to Viet Nam and active surveillance programs for this disease will continue until such time as the agent is contained in China. It has not yet been detected in Viet Nam despite intensive risk- based surveillance. Swine influenza viruses can become human pandemic agents as demonstrated by H1N1 pdm (2009) and it is important to understand the risk posed by local strains of virus in pig populations. What will be done, how will it be done and who will do it? In the period from 2016-2020, the following will be undertaken to gain a greater understanding of zoonotic influenza viruses and to minimise the threat they pose to human health (see focus area 2 for actions that will be taken if a human influenza pandemic emerges): What How Who Monitoring programs for avian Regular surveillance in high risk MARD H5 HPAI and H7N9 (and other) areas and species influenza viruses in poultry and FAO other birds, and swine influenza USAID virus in pigs Effectiveness of vaccination Vaccination programs will MARD programs in poultry be reviewed and studied to determine whether vaccination FAO is reducing shedding of virus in USAID vaccinated ducks Progress towards elimination of Necessary work to determine the MARD H5Nx highly pathogenic avian feasibility of an H5 infection- influenza virus free zone will be undertaken FAO and, if feasible, measures will be USAID implemented to develop a virus- free zone in the south eastern region Surveillance of cases of human Human surveillance programs MOH, Hospitals, respiratory illness for novel will be reviewed and Sentinel sites influenza viruses of animal origin consolidated OUCRU 30 SUMMARY PLAN How will gains be measured? In the next 5 years, Viet Nam will consolidate monitoring programs that can detect and characterise changes in the nature of local influenza viruses or incursions of virus (H7N9) so that control and prevention programs can be modified. Poultry vaccination programmes for H5 influenza will be reviewed and, as necessary, modified. Viet Nam will have undertaken work to establish the feasibility of an H5 infection-free zone and, if feasible, will have commenced work to establish a zone. Surveillance of cases of human respiratory illness will continue with testing for influenza viruses of animal origin. All cases of zoonotic influenza will be investigated for evidence of sustained human-to-human transmission and to identify the source of the outbreak. Funds required The funding required for these activities is approximately USD 35,000,000 including the cost of poultry vaccination, half of which is expected to be paid for by the private sector. The ADB sub- regional health security project is expected to contribute to strengthened surveillance. 31 SUMMARY PLAN 5. One Health approaches for managing rabies Why is this necessary? Rabies is recognised as a high priority zoonotic disease for which a One Health approach should be applied. It is a disease that can be eliminated with a concerted, coordinated effort. Viet Nam will continue to attempt to control this disease in line with national plans, the ASEAN regional plan for rabies elimination, and the GHSA. Currently, less than 100 human cases are reported each year but there is a very high cost associated with the delivery of some 400,000 courses of post exposure prophylaxis. What will be done, how will it be done and who will do it? The main activities will be increased canine rabies vaccination, responsible dog ownership programs to reduce the number of wandering dogs in high risk areas, human post exposure prophylaxis for those exposed to a potentially rabid dog and also selective use of pre-exposure prophylaxis for high risk groups. What How Who Increased canine vaccination Support for vaccination MARD, Provincial (including improved data on dog campaigns at provincial DARD, OHCN populations) and district level so that levels of vaccination WHO, FAO, OIE, coverage are maintained GARC, doners above 70% Responsible dog ownership Behavioural change MARD, Provincial communications to DARD, OHCN reduce the number of free wandering dogs and WHO, FAO, OIE, to increase vaccination GARC, donors uptake and dog registration Post-exposure prophylaxis (PEP) for Introduction of district MOH, provincial and all humans bitten by a dog (or other treatment centres to all district level health mammal) that could have rabies high risk areas to reduce services, OHCN the need for travel for those requiring PEP Pre-exposure prophylaxis (PrEP) Identification of MOH, MARD, for high risk groups including dog high risk groups and provincial and district vaccinators, dog handlers and where implementation of a level health services necessary children in high risk areas vaccination program Improved capacity to diagnose Establishment/ MOH, MARD, NIHE rabies maintenance of quality assured testing capacity FAO, WHO, OIE for rabies in humans and Donors animals 32 SUMMARY PLAN How will gains be measured? Viet Nam is aiming to have no new human cases 1 of rabies in Viet Nam by 2020. This ambitious target will only be achieved if full cooperation is obtained from all stakeholders, in particular dog owners (who are required to pay for vaccination). Progress towards this goal will be measured by reductions in 3 year rolling averages of human cases. Funds required A minimum of USD 24,800,000 will be required, however, this does not cover many of the costs that will be borne by the general public which is expected to be USD 40-45,000,000 (e.g. costs to dog owners for canine vaccines and PEP for bites caused by their dogs). However, sufficient stocks of vaccine and PEP will be required. Funds from ADB may be required to support supplementary activities such as PrEP for children in high-risk border areas. 1 As human clinical cases are invariably fatal once clinical signs develop, cases equates to deaths. 33 SUMMARY PLAN 6. One Health approaches for managing antimicrobial resistance Why is this necessary? Resistant bacteria and viruses can arise in any place where there is indiscriminate use of antimicrobial drugs. Preliminary research and assessments suggest that Viet Nam already has major concerns with antimicrobial resistance (AMR) in hospitals, in the community and in livestock farms and aquaculture. A One Health approach is needed to protect existing antimicrobials given that resistance is transmissible between bacteria and resistant bacteria can be transmitted from one host to another. The overall goal is to reduce the quantities of antimicrobials used, institute systems of antimicrobial stewardship, improve infection control, and limit the use in animals of critically important antimicrobials for humans. What will be done, how will it be done and who will do it? Plans for containing AMR, based on the WHO global plan, have been developed and will be implemented during the next 5 years. What How Who Reduced use of antibiotics in Assess likely effectiveness and MARD, Provincial animals including improved feasibility of bans on the use of DARDs controls on antibiotics critical medically important antibacterial for human use agents for growth promotion in FAO, Feed livestock and drugs critical for industry, farmers human treatment. Where feasible, (livestock and introduce and enforce bans and aquaculture) require purchase by prescription only Reduced and improved use of Widespread implementation of MOH, Hospitals antibiotics in humans antibiotic stewardship programs and behavioural change campaigns General public, for the public pharmacists Improved data on Relevant information collected MARD, MOH, antimicrobial use and following the GHSA Roadmap NIHE antimicrobial resistance OUCRU, CIRAD Improved infection control and Widespread implementation of IPC MOH, Hospitals prevention (IPC) programs in programs in hospitals ADB hospitals Enhanced laboratory capacity Fund existing and new AMR MARD, MOH, for testing for AMR using testing laboratories NIHE quality assured programs ADB, donors Reduced environmental Reduced use of AM compounds in MARD, MOH, contamination with antibiotics farms and animals, and improved MONRE waste disposal Donors 34 SUMMARY PLAN How will gains be measured? Gains over the next 5 years will be measured by reductions in quantities of antibiotics used and through the number of effective antimicrobial stewardship and infection prevention and control programs in place. Funds required Much of the work on antimicrobial resistance is cost neutral, nevertheless there will be a need for funds for communications, enforcement of existing and new legislation, and antibiotic stewardship and IPC programs. It is estimated that USD 20,000,000 will be required for AMR activities. Funds are expected to be provided by government, the GHSA funding envelope, ADB (IPC programs) and other partners. 35 SUMMARY PLAN 7. One Health approaches for managing other zoonotic diseases Why is this necessary? A number of other zoonotic diseases are present in Viet Nam and cause significant health and economic losses but with little or no potential to become pandemic agents. During the next 5 years, work will progress on reducing the impact of the priority diseases - anthrax, leptospirosis and Streptococcus suis - using a One Health approach. Foodborne diseases of animal origin also cause a substantial burden of disease in Viet Nam and can best be tackled with a One Health approach. These diseases are caused by zoonotic agents such as Salmonella, Campylobacter, Listeria as well as parasitic diseases/agents like cysticercosis, hydatidosis, and fish-borne trematodes. Chemical contamination of animals and animal products represent a major food safety challenge and solutions require involvement of the environmental sector. These diseases are managed through mechanisms other than the One Health Partnership and are not considered in depth in this plan. Nevertheless some of the measures needed to improve food safety such as animal identification systems are also highly relevant for addressing chemical contamination of food. What will be done, how will it be done and who will do it? What How Who Anthrax control Improved public awareness in MARD, Provincial high risk areas and enhanced DARDs, OHCN, NIHE vaccination Farmers Streptococcus suis Behavioural change MOH, OHCN (where possible) especially consumption of raw pig products Leptospirosis Community awareness of the MARD, MOH, MONRE, dangers of leptospirosis in NIHE, OHCN periods of heavy rainfall Enhanced traceability of Practical animal identification MOH, MARD animals and residue testing systems such as pig tattoos linking animals in Farmers, traders slaughterhouses to individual Food safety working group farms or small scale traders Risk assessment of food Conduct a risk assessment to MARD, MOH, NIHE borne illness of animal help justify investments in origin this area World Bank, Food safety working group Circular 16 will be fully See focus area 1 MARD, MOH, (MONRE) implemented 36 SUMMARY PLAN How will gains be measured? Gains will be measured through assessment of progress in application of Circular 16/2013, through reductions in the number of cases of anthrax, and through assessment of adoption of behavioural change for risk factors for Streptococcus suis and leptospirosis. Gains in food safety are expected to be measured by progress towards animal identification systems and changes in case numbers for food-borne diseases of animal origin. Funds required Approximately USD 5,000,000 will be required for activities on other zoonotic diseases over the next 5 years (this figure does not include costs to manage human cases of these diseases). Funds for control, diagnosis and prevention of these diseases are anticipated to largely come from government but may be supplemented by funds from ADB, GHSA and the World Bank. 37 TECHNICAL ANNEX TECHNICAL ANNEX 38 TECHNICAL ANNEX Introduction and background information i. Purpose Microorganisms have always been crossing from animals to humans, This plan aims to reduce occasionally causing serious illness. This process appears to have the health and other accelerated over the past 50 years with a steady stream of novel and impacts of zoonotic re-emerging infectious agents crossing from wild and farmed animals diseases and animal-origin in different parts of the world to cause severe and widespread disease health concerns in Viet in humans (SARS, HIV, Nipah virus, MERS, Ebola virus disease Nam through achieving and many others). Each year one or more new diseases emerge that the following objectives: threatens global health. Strengthened One Avian influenza (H5N1), first detected in China in 1996, appeared Health capacity for as an urgent problem in Viet Nam and several other countries from zoonotic disease late 2003 through 2005. Not only did this virus cause severe disease control and prevention. in poultry, it also resulted in serious disease in humans, raising concerns of a potential severe human influenza pandemic. To address Enhanced preparedness this threat, Viet Nam produced the National Integrated Operational for a human emergency Program for Avian and Human Influenza (OPI) that guided control of animal origin and and prevention activities during 2006-2010. The Viet Nam Integrated improved control National Operational Program on Avian Influenza, Pandemic of zoonotic disease Influenza and Emerging Infectious Diseases (AIPED) expanded the outbreaks. scope of actions beyond zoonotic avian influenza to cover potentially serious emerging and re-emerging diseases during the period 2011- Application of One 2015. Under these programs, significant progress has been made Health capacity to limit from 2006 to 2015 in containing avian influenza and in preparing for the public health impact disease emergencies in line with the overall objective of reducing the of zoonotic influenza risk to humans and animals from avian influenza A(H5N1) and other viruses, antimicrobial emerging infectious diseases. resistance, and rabies, and reduce the risk The AIPED adopted a One Health approach as recommended by posed by agents in the International Ministerial Conference on Animal and Pandemic animals with pandemic Influenza (IMCAPI), held in Ha Noi in April 2010. The One Health potential that are yet to approach to disease control and prevention at the human-animal- emerge. environment interface is now recognised globally as the best method for effective control of emerging infectious diseases. Viet Nam is seen as a One Health leader because of its early adoption of this approach for the control of avian influenza. ii. Scope of this document This document provides additional information to support the Summary Plan on activities to be undertaken during 2016 to 2020 to achieve the goal of reducing the health and other impacts of zoonotic diseases and diseases of animal origin using a One Health approach. Activities are divided into the following seven focus areas, discussed in more detail in individual chapters: 1. Those activities aimed at general strengthening of capacity to control and prevent zoonotic diseases using a One Health approach to consolidate the One Health platform that has been established in Viet Nam over the last 10 years. 39 TECHNICAL ANNEX And those activities required to make progress against Major achievements (2011-15) specific diseases or groups of diseases including: Legislation to facilitate animal 2. One Health approaches to human disease and human health sector emergencies of recent animal origin (managing collaboration and information major health security threats from zoonotic sharing (Circular 16/2013). diseases). Passage of veterinary legislation 3. One health approaches to managing pandemic that provides greater scope for threats that are yet to emerge. controlling zoonotic diseases and 4. One Health approaches to managing zoonotic the use of antimicrobials. influenza (e.g. H5N1, H7N9, swine influenza Meeting minimum IHR standards viruses). for core capacities in 2014. 5. One Health approaches to managing rabies High-level political engagement with the Global Health Security 6. One Health approaches to antimicrobial Agenda (GHSA) including as resistance (e.g. multi-drug resistant organisms a lead country for the Zoonotic such as extended spectrum beta-lactamase Disease Action Package (ZDAP) resistant organisms, plasmid-mediated colistin and a contributing country for resistant enterobacteria) the Emergency Operations 7. One Health approaches to other important Centre (EOC) action package, resulting in the establishment of zoonotic diseases/agents with little or an emergency operations centre. no pandemic potential such as anthrax, leptospirosis, Streptococcus suis, brucellosis Exercises to test national and others pandemic planning and risk communications. One other group of diseases – foodborne illnesses of animal origin including diseases caused by Commitment to global plans on chemicals and by pathogens such as Salmonella, AMR and rabies. Campylobacter, Listeria, cysticercosis, hydatidosis, Drafting of a national plan to fish-borne trematodes - is briefly discussed because: address antimicrobial resistance There are likely to be benefits from a One Health (AMR). approach Rapid legislative and Control measures for these diseases have many administrative responses to links to those for the zoonotic diseases prepare for Ebola virus disease and Middle East Respiratory The One Health Partnership is increasingly playing Syndrome-Coronavirus (MERS- a role in supporting these activities CoV). This approach of covering general and specific Evolution of the national One aspects was adopted because both strategies are Health platform to a One Health needed to make progress in preventing, detecting and Partnership that now includes responding to zoonotic diseases. The Government wildlife and environment of Viet Nam has defined zoonotic disease priorities stakeholders including the and identified the major gaps in zoonotic disease 40 TECHNICAL ANNEX responses; it was therefore considered necessary to demonstrate the achievements expected in these Ministry of Natural Resources specific areas by 2020. Comprehensive zoonotic and Environment (MONRE). disease control plans under each of these specific focus areas, however, requires action across the Improved capacity to detect spectrum of prevent, detect and respond as described potential zoonotic and pandemic in the GHSA. This is illustrated in Figure 2 of the agents in wildlife and initial Summary Plan – each of the focus areas contains 2 to surveys on wildlife for these 3 elements of the GHSA. agents. Enhanced surveillance for avian This plan does not cover diseases that originated in influenza and other influenza animals but which have become well established viruses at the animal-human as human pathogens such as vector-borne diseases interface. where the transmission cycle has shifted to humans as the predominant host (e.g. dengue, chikungunya, Improved control of avian yellow fever). Management of these diseases is best influenza and no known incursion achieved using an Ecohealth approach. Nonetheless, of H7N9 virus. these diseases can still require an emergency response Changes to poultry markets, as seen, for example, with the teratogenic effects of slaughter points and farms aimed infection with Zika virus during pregnancy in South at improving food safety and America and the Pacific. disease control. More broadly, strengthened national One Health Developing an online reporting capacity may benefit efforts to control a range of other system for nationally notifiable diseases of humans and animals given the crucial role communicable diseases. of environmental factors and human behaviour in the emergence and persistence of many diseases. Enhanced laboratory capacity and improved turnaround times iii. Achievements for specimens. Considerable progress was made against the Establishment of VOHUN in objectives of AIPED to control infectious diseases at 2011 to train a One Health source and implement measures to prevent disease workforce. emergence, detect and respond rapidly to new high impact diseases in both animals and humans, and enhance preparations for the consequences of pandemic disease of humans. Major achievements over the period of AIPED (2011-15) are listed in the box. iv. Target audience The One Health Strategic Plan (OHSP) provides a framework for anyone with an interest or stake in the control and prevention of zoonotic diseases in Viet Nam - this includes government and non- government agencies, teaching and research institutions, international financial institutions, donors and the public. Although this plan principally details activities for government and key partners, many of the underlying drivers of disease are related to human actions that can only be addressed with the participation of all parts of society in Viet Nam, particularly those involved in rearing domestic and wild animals, and handling animals and animal products. 41 TECHNICAL ANNEX v. Guiding principles The 4 guiding principles for the OHSP are: 1. That it builds on work already undertaken through the OPI and AIPED on zoonotic diseases using a One Health approach. 2. That it is an integrative framework (rather than an operational plan) that overlies and links the various extant and planned programs and activities aimed at addressing zoonotic diseases using a One Health approach. 3. That One Health approaches require shared objectives among different partners and, in some cases, shared activities when this is the most efficient way to prevent disease and protect health. 4. That strengthening capacity alone is not enough – improved capacity must be applied to tackle specific diseases of local concern. vi. Governance of the plan Given the many stakeholders as well as the numerous plans referred to and activities listed under this framework, strong coordination is essential to achieving the objectives of the OHSP. The Viet Nam One Health Partnership for Zoonoses (OHP) and the OHP Secretariat played a critical role in facilitating coordination during the period of the OPI (2006-2010) and the AIPED (2011-2015) - it is expected that they will continue to facilitate coordination during the period of the OHSP (2016- 2020). Governance of this plan will occur through: An annual assembly with partners hosted by the Ministry of Agriculture and Rural Development (MARD) and the Ministry of Health (MOH) with the participation of the Ministry of Natural Resources and Environment (MONRE) and other related ministries, sectors and stakeholders to report on progress. This assembly will be incorporated into the annual national One Health Forum of the OHP. In this way, the partnership itself led by the key government ministries (MARD, MOH, MONRE) is formally responsible for achieving the objectives of the plan through collaborative governance. An annual written report produced by the One Health Partnership for Zoonoses summarising progress against key targets - this report will be used to facilitate action to overcome barriers to One Health approaches to zoonotic diseases. vii. Goal, objectives and areas of focus Figure 1 illustrates the relationship between the focus areas of the OHSP and 3 important regional and international initiatives that include One Health activities on zoonotic diseases - the International Health Regulations (IHR 2005), the Asia Pacific Strategy for Emerging Diseases (APSED 2010), and the Global Health Security Agenda (GHSA). Figure 2 summarises the goal, objectives and focus areas of the OHSP.and the Global Health Security Agenda (GHSA). 42 TECHNICAL ANNEX 1. Building One Health capacity 1.1. Background General strengthening of One Health capacity is vital to allow Viet Nam to detect, prevent and respond to zoonotic diseases. As described in the Summary Plan, One Health approaches are now recognised as the best way to achieve gains in these areas. Building One Health Capacity is not an end in itself – the capacity has to be used for action against specific zoonotic diseases. Strengthening is needed in a number of areas described in the Summary Document and this Technical Annex. 1.2. Strategic directions Continue to move towards a comprehensive, integrated approach to zoonotic disease threats through the development of legal and administrative structures and the inclusion of One Health approaches in all relevant government sectors. Establish the national governance, financial and coordination mechanisms for all hazards including disease emergencies as well as sustained mechanisms for longer-term prevention and control of priority zoonotic diseases. Move beyond self-reporting of IHR and PVS core capacities and regularly test functional capacities and planning including whole-of-society pandemic plans. Build on existing structures for developing, coordinating and sharing communications to the public during emergencies and non-emergency situations. Review, refine and fund surveillance programs for zoonotic diseases and institutionalise cross-sectoral information sharing including microbiological data from laboratories and epidemiological data from public health units. Carry on refining and upgrading national human and animal laboratory networks including linkages, diagnostic capacity for priority diseases and biosecurity and biosafety. Improve sharing of disease intelligence data with neighbours at key points of entry. Improve infection prevention and control in health facilities and at key points in the livestock production and marketing chain. Bring to bear the expertise of the environmental health sector in addressing environmental aspects critical to zoonotic disease emergence and prevention. Improve communications between authorities as well as to and from the public for disease emergencies and for risk reduction messaging for better control of zoonotic infections. Maintain progress on the development of a One Health literate workforce. Ensure that research is focused on answering key clinical, epidemiological, public health and policy questions, is shared among stakeholders, and applied to policy and practice. 43 TECHNICAL ANNEX 1.3 Achievements in establishing One Health approaches in Viet Nam 1.3.1. One Health coordination Since 2003, Viet Nam has made successive improvements toward a multi-sectoral approach to address zoonotic diseases in response to domestic threats such as strains of highly pathogenic avian influenza, external threats such as Ebola virus disease, and global initiatives to promote One Health and health security such as the Manhattan Principles on “One World, One Health”, the International Health Regulations (IHR), the Performance of Veterinary Services (PVS) and the new Global Health Security Agenda (GHSA). National planning has progressed from coordinated animal and human health activities to address avian influenza virus A/H5N1 under the OPI, 2006-2010, to a broader focus on emerging and re- emerging diseases under AIPED, 2011-2015, and then to a national One Health roadmap, 2015- 2016, that outlines collective engagement across sectors to prevent and control zoonotic diseases. A new One Health forum for policy dialogue and information sharing, the Viet Nam One Health Partnership for Zoonoses (OHP), brings together 27 national and international partners including the Ministry of Agriculture and Rural Development (MARD), the Ministry of Health (MOH), and the Ministry of Natural Resources and Environment (MONRE). This is indicative of high-level multi- sectoral commitment to managing the risks of disease at the human-animal-environment interface and extends the local One Health approach beyond the “four-way linking model” of GDPM, DAH, WHO and FAO. Two national steering committees - the National Steering Committee for Avian Influenza Prevention and Control (NSCAI, 2004) chaired by the Minister of MARD and the National Steering Committee for Human Influenza Pandemics Prevention and Control (NSCHP, 2006) chaired by the Minister of MOH – have been the principal mechanisms for national coordination of responses to zoonotic diseases during the periods covered by the OPI and the AIPED. Establishment of a new, unified, overall national steering committee has been proposed, with chairing at the level of Deputy Prime Minister. Design of this committee is currently under consideration. A range of other national steering committees is responsible for related areas where application of a One Health approach for additional health concerns at the human-animal-environment interface is highly relevant including the Steering Committee for Drug Resistance, the Central Steering Committee for Food Safety and Hygiene, and the National Committee for Climate Change. 1.3.2. Legislation to support One Health approaches Legislation has fostered cooperation between the animal and human health sectors with decrees and circulars governing surveillance, epidemiological investigations, biosafety in laboratories, and prevention, quarantine and other measures during major epidemics. The guidelines for coordinated prevention and control of zoonotic diseases (inter-ministerial circular No. 16/2013/TTLT-BYT- BNN&PTNT, dated May 27, 2013) are a key legal advance towards multi-sectoral cooperation. Viet Nam has built a legislative framework for the reporting of nationally notifiable infectious diseases in the public and private sectors, aspects of animal health (animal disease management, animal slaughter, processing of animal products, veterinary inspection procedures), and food standards and safety (chemical and veterinary medicine residues, microbiological contaminants). The legal basis for the diagnosis, management and response to potential novel pathogens, like Ebola virus and Middle East Respiratory Syndrome (MERS) coronavirus, was promptly issued. Legislation has also been passed to regulate the management of captive wildlife, prohibit trafficking, and protect wildlife and biodiversity.2 2 Strengthening Capacity for the Implementation of One Heath in Viet Nam. State management of captive wildlife in relation wildlife health and the risk of interspecies and zoonotic disease transmission. Report commissioned by the One Health Partnership for Zoonoses Secretariat Office, MARD. 2015 44 TECHNICAL ANNEX 1.3.3. Core capacities to support a One Health approach Viet Nam has achieved core capacities for identifying and responding to disease outbreaks and public health events stipulated under the International Health Regulations (IHR, 2005), and has implemented a number of recommendations from past evaluations of the Performance of Veterinary Services (PVS)3 including bolstering the legislative foundation for these services (particularly the Veterinary Law, 2015). In addition to the passive surveillance systems for people and animals, sentinel surveillance systems have been established for priority diseases in key sites. For example, border and market surveillance for avian influenza in poultry, and a national sentinel surveillance system in provincial health facilities for influenza-like-illness and severe acute respiratory infections. A large network of human health laboratories is part of the national communicable disease surveillance network including two national reference laboratories, 63 provincial public health laboratories and more than 200 health facility laboratories. Progressive improvements of diagnostic capacity, standards and biosafety have been made under the Viet Nam Laboratory Accreditation Scheme (VILAS), with some laboratories also seeking ISO certification. A framework for cross-sectoral laboratory information sharing is now in place. 1.3.4. One Health workforce A well-trained workforce capable of preventing and managing diseases of animal origin and working in multi-disciplinary teams is required. The Hanoi School of Public Health (HSPH), Hanoi Medical University (HMU), and the Faculty of Veterinary Medicine of the Viet Nam National University of Agriculture (VNUA) are foundation members of the South East Asian One Health University Network (SEAOHUN) supported through the EPT and EPT-2 programs. This academic network aims to build trans-disciplinary capacity to “respond to emerging and re-emerging infectious and zoonotic diseases”. 17 universities throughout Viet Nam are now part of the Viet Nam One Health University Network (VOHUN) and include faculties of medicine, public health, veterinary and animal sciences. In addition, the Field Epidemiology Training Program within MOH and the AVET program within MARD provide well-established in-service training schemes. 1.3.5. One Health activities An audit of One Health projects and programs in Viet Nam completed in 2015 identified 62 separate but related activities beginning in 2005 (see Appendix 1). These activities focused on strengthening capacities common to the prevention and control of all emerging or zoonotic diseases, as well as specific activities for avian influenza, antimicrobial resistance, rabies, diseases of poultry and pigs, and various zoonotic bacterial pathogens. Many of these activities will continue into the next 5-year period. The One Health Communications Network (OHCN), a working group within the One Health Partnership, provides a platform for experts from human health, livestock, wildlife and eco-health to share information and promote public awareness about reducing the risks and drivers of zoonotic diseases. 1.4. Work underway Viet Nam is a lead country in developing and implementing the Zoonotic Disease Action Package (ZDAP) of the Global Health Security Agenda (GHSA) and is a contributing country for the Emergency Operations Centres Action Package. This global partnership of almost 50 countries aims to drive progress to full implementation of IHR and the PVS pathway utilising the prevent-detect- respond framework. Local adaptation of these two action packages is in progress and is expected to 3 OIE PVS reports: 2006, 2010 45 TECHNICAL ANNEX complement other national One Health planning activities to address zoonotic diseases. While Viet Nam has put herself forward to achieve specific targets related to zoonotic diseases (prevent) and a national public health Emergency Operations Centre (respond), many of the other action packages are also important for functional ‘One Health’ capacity. Action packages related to prevention include antimicrobial resistance, biosafety and biosecurity, immunization; those related to detection support strengthening of national laboratory systems, real-time surveillance, disease reporting, and workforce development; and those related to response include linking public health with law and multi-sectoral responses, medical countermeasures and personnel deployment. It would be useful to regularly review developments made by GHSA member countries on these other action packages. A related endeavour, Phase Two of the Emerging Pandemic Threats Programme (EPT-2) that began in 2014, is supporting three main areas: the development of a Vietnamese One Health workforce (OHW) via the established VOHUN (see 1.3.4); preparedness and response functions (P&R) such as approaches to strategic planning, promoting a positive policy environment, sharing information across sectors, harmonising systems and assessing national capacity; and monitoring viruses with pandemic potential to guide surveillance and risk mitigation strategies (PREDICT-2, described in more detail in focus area 3, One Health approaches for managing zoonotic agents with pandemic potential that are yet to emerge, especially in wildlife.). EPT-2 builds on EPT-1 (2009- 2014) and activities on avian influenza that predominantly focused on controlling the threat posed by HPAI as well as identifying other potential threats at their source. Funded by USAID, EPT-2 is being implemented by a number of partners with technical collaboration from the U.S. Centers for Disease Control and Prevention (US CDC), the World Health Organization (WHO) and the Food and Agriculture Organization. Viet Nam is ahead of the curve in terms of having a well-established domestic One Health Platform, the One Health Partnership for Zoonoses. This partnership is continuing to work towards enhancing its role in coordination, policy dialogue and knowledge management for zoonotic diseases and will receive additional support via EPT-2. The involvement of MONRE provides an opportunity for greater inclusion of agro-ecosystem health elements in local One Health approaches with the potential to embrace a longer-term, more strategic approach to national health security. 1.5. Alignment with existing policies & strategies A number of domestic, regional and international plans provide an opportunity to align work on zoonotic diseases with other health system activities. Some of these plans specifically adopt a One Health approach for preventing and controlling zoonotic diseases; others are focused on different but interrelated areas. See Figure 1 in the Summary Plan for a diagrammatic representation of how the major international initiatives relate and overlap, and Figure 2 for how the OHSP links with these. 1.5.1. Domestic plans The Ministry of Health (MOH) has submitted the next 5-year plan preventive health for Government approval; MARD’s 5-year plan for the animal health sector was approved in 2014. This means that One Health activities related to zoonotic disease control will continue to be fitted to existing health priorities. An online human communicable disease notification system (Circular 54/2015/TT-BYT) is anticipated to be up and running from July 2016; this is expected to improve disease reporting and create new demands for public health protective action. Table 1 lists some of the current national plans that relate to One Health. 46 TECHNICAL ANNEX Table 1. Selected list of government plans related to One Health Type Plan Period General health The Vietnam national strategy on preventive medicine to 2010 2010-20 plans and orientations towards 2020 (Decision 225/2006- QĐ-TTG) Health Master Plan for the period 2016-2030 with a vision to 2016-30 2050 (forthcoming) National Program on occupational health (Decision 05/2016/ 2016-20 QĐ-TTg) National public health laboratory plan (forthcoming late 2016) Emergencies All-hazards contingency plan (forthcoming late 2016) Zoonoses Comprehensive Plan for Influenza/(re) Emerging Infectious 2011-15 Disease Pandemic Preparedness and Response in the Health Sector 2011 – 2015 with a vision to 2020 The national program to control and eliminate rabies (Decision 2011-15 2731/QĐ-BNNTY) Guidelines for coordinated prevention and control of zoonotic 2013 diseases (Inter-ministerial Circular No.16/2013/TTLT-BYT- BNN&PTNT) National One Health Roadmap 2015-16 National HPAI Plan 2013-17 National Agriculture sector plan for avian influenza prevention 2014-18 and control National plan on prevention and control of avian influenza 2014-18 H5N1 (438/QĐ-BNN-TY) Regulations on the prevention and response to zoonotic diseases 2016 in terrestrial animals (07/2016/TT-BNNPTNT) Action Plan for emergency response to influenza viral strains 2014 capable of causing human disease Action plan for preventing and controlling avian influenza A/ 2013 H7N9 (No 1126 /QĐ-BYT) AMR National action plan on against drug resistance (2174/QĐ-BYT) 2013-20 List and level of antibiotics permitted in feed for growth 2016 promotion (06/2016/TT-BNN) Guideline on the implementation of infection control in health 2009 facilities (18/TT-BYT) 47 TECHNICAL ANNEX Food safety Ensuring food safety in the transport, slaughter cattle, poultry 2014-20 (66/QĐ-BNN) The restructuring of husbandry sector towards increasing the 2014-20 added value and sustainable development (984/QĐ-BNN-CN) National Strategy for food safety 2011-2020 and a vision toward 2011-20 2030 (20/QĐ-TTg) Regulations on the control of slaughtering and veterinary 2016 hygiene inspection (09/2016/TT-BN) Allocation of tasks and cooperation among regulatory agencies 2014 in food safety management Environment National Program on pollution and environmental improvement 2016-20 The plan for implementation of national environmental 2020-30 protection strategy by 2020 with a vision to 2030 (Decision 166/QĐ-TTg) 1.5.2. Regional and international strategies The International Health Regulations (IHR, 2005) commit states to develop eight core capacities to identify, investigate and respond to public health events that may constitute an emergency of international concern: (1) national legislation, policy and financing; (2) coordination of nationwide resources and multi-sectoral partnerships; (3) surveillance; (4) response; (5) preparedness; (6) risk communications; (7) human resources; (8) laboratory. Viet Nam has met minimum (self-reported) core requirements and is now considering how to assess functional performance of national capacities against the updated IHR monitoring and evaluation framework. The World Organization for Animal Health (OIE) provides a similar framework for the progressive improvement in veterinary services with the tool for the evaluation of Performance of Veterinary Services (PVS). Unlike IHR, this assessment process has not yet evolved into a review of functional capacity. The Asia Pacific Strategy for Emerging Diseases (APSED) provides a strategic framework for advancing national core capacities required under IHR (2005) through focus on eight areas: (1) surveillance, risk assessment, and response; (2) laboratories; (3) zoonoses; (4) infection prevention and control; (5) risk communications; (6) public health emergency preparedness; (7) regional preparedness, alert, and response; and (8) monitoring and evaluation. The aims are to reduce risk, strengthen early detection, rapid response and preparedness, and build sustainable partnerships. APSED is currently in the process of being updated for the next 5-year period and will be a key document for the national zoonotic disease action plan to be aligned with. As discussed, the Global Health Security Agenda promotes the One Health model to prevent, detect and respond to emerging diseases. The tailoring of action packages on zoonotic diseases and 48 TECHNICAL ANNEX emergency operations centres is still in progress and will incorporate realistic targets for the next 5-year period. These are described in the GHSA roadmap for Viet Nam – the first version of which was released in September 2015.4 The 2010 ASEAN Ministerial Statement on “Cooperation on Animal Health and Zoonoses: HPAI and Beyond” provides a similar framework for animal and human health cooperation for priority zoonotic diseases including avian influenza, rabies, leptospirosis, food-borne salmonellosis and brucellosis among others. The Asian Development Bank (ADB) is assisting Viet Nam through the Greater Mekong Subregion Health Security Project (2017-2022) to improve: (1) cross-border communicable diseases control particularly for mobile populations and along economic corridors; (2) surveillance for communicable diseases including electronic notification systems and capacity for outbreak response; and (3) district laboratory services and infection prevention and control procedures in district hospitals. The project is intended to support elements of APSED. 1.5.3. One Health and the environment The newly adopted Sustainable Development Goals (SDGs) for the period 2016 to 2030 have a broader agenda than the previous Millennium Development Goals (MDGs). In addition to calling for strengthened country capacities for early warning, risk reduction and management of national and global health risks, the SDGs set targets related to social and environmental determinants of health that are relevant to the One Health approach. The following are examples of pertinent targets: Conservation, restoration, and sustainable use of ecosystems; Ecosystem and biodiversity values integrated into national and local planning, development processes, and poverty reduction strategies; Enhanced support for efforts to combat poaching and trafficking of protected species, including by increasing the capacity of local communities to pursue sustainable livelihood opportunities; Enhanced inclusive and sustainable urbanisation and capacity for participatory, integrated and sustainable human settlement planning and management; Environmentally sound management of chemicals and all wastes throughout their life cycle, in accordance with agreed international frameworks, and significantly reduced release into the air, water and soil to minimise their adverse impacts on human health and the environment; Climate change measures integrated into national polices, strategies and planning These targets implicitly recognise that changes to ecosystems can result in the emergence of zoonotic diseases and other diseases linked to animal products. Loss of biodiversity due to habitat fragmentation has been identified as the main driver for the marked increase of cases of Lyme disease in North America. Changes in climate will alter the distribution of vector-borne diseases adding to the other health and socio-economic problems that will occur as greenhouse gas concentrations rise. The environments in which livestock are reared and sold influence the types of diseases that occur and their potential for transmission to humans, as demonstrated by human infections of H5 and H7 influenza in improperly managed live poultry markets. Human modifications to ecosystems 4 See GHSA Roadmap at https://ghsagenda.org/docs/Vietnam-GHSA-5-year-RoadMap-2015.pdf 49 TECHNICAL ANNEX facilitated the spread of Nipah virus from bats to pigs and then to humans in Malaysia; contact between humans and bats in caves is now recognised as the main source of spillover of Marburg virus in Africa; and preparation of wild animals for food resulted in transmission of viruses such as SARS and Ebola virus from animals to people. Pollution of the environment with persistent organic pollutants can result in the accumulation of these chemicals in livestock products. Development in Viet Nam with changes to both natural and man-made ecosystems will increase the probability of emergence of new agents and risks from pollutants. For this reason, MONRE is an important partner in One Health activities aimed at control and prevention of diseases of animal origin, reflected in their active support for the One Health Partnership. SDG targets on supporting research and development of vaccines and medicines and providing access to affordable essential medicines and vaccines offer scope for applying the best possible resources to address zoonotic and neglected diseases for the human and animal health sectors. The Sendai Framework for Disaster Risk Reduction 2015-20305 will contribute towards achievement of the SDGs and applies to “small-scale and large-scale, frequent and infrequent, sudden and slow-onset disasters caused by natural or man-made hazards, as well as related environmental, technological and biological hazards and risks. It aims to guide the multi-hazard management of disaster risk in development at all levels as well as within and across all sectors.” This framework therefore has direct relevance to zoonotic disease prevention and response. The four priorities for action are: (1) understanding disaster risk; (2) strengthening disaster risk governance to manage disaster risk; (3) investing in disaster risk reduction for resilience; (4) enhancing disaster preparedness for effective response and to “Build Back Better” in recovery, rehabilitation and reconstruction. 1.6. Key factors for success Government commitment and leadership at all levels Strengthened governance structures with clear roles and responsibilities A strong legal framework and positive policy environment to facilitate inter-sectoral collaboration Inclusion of environmental health aspects for a more strategic application of One Health principles Close coordination between sectors and timely sharing of information Community engagement and mobilisation is critical to optimising zoonotic disease prevention and control efforts Technical and financial contributions of international partners are indispensable Incorporating research findings into policy and practice 1.7. Challenges & constraints The Ministry of Planning and Investment (MPI) has described general limitations of state structures that have relevance to key government One Health actors: “State fragmentation refers to the lack of clear hierarchy and assignment of roles and responsibilities both within the central government and between the centre and the provinces – and the inertia and inefficiencies this generates in formulating and implementing policy. Horizontal and vertical fragmentation of power has resulted in overlapping mandates with conflicting rules and decisions.”6 5 http://www.preventionweb.net/files/43291_sendaiframeworkfordrren.pdf 6 Page xxvii, International Bank for Reconstruction and Development/The World Bank and the Ministry of Planning and Investment of Viet Nam. Viet Nam 2035: Toward Prosperity, Creativity, Equity and Democracy. 2016. 50 TECHNICAL ANNEX In particular, outside of emergency situations formal channels for human and animal health sectors to communicate, share data and plan action are still being developed, despite the issuance of the inter-Ministerial Circular 16/2013. A review of agencies involved in the protection of wildlife indicated the need for improved clarity in roles and responsibilities of related agencies at all levels.7 Even sharing of information between departments within a single ministry can be problematic, particularly between departments with limited crossover in much of their work e.g. CITES administration and Department of Animal Health within in MARD. Another example of inefficiency could be the large number of public health laboratories throughout Viet Nam, which poses challenges to laboratory accreditation and sharing information across laboratories and to public health authorities. The 2015 Joint Annual Health Review noted the continued burden of communicable diseases including emerging diseases and antimicrobial resistance, weak surveillance systems, poor sharing of data between curative and preventive sectors, and the need for further development of preparedness plans and response capacity. This review also pointed to a number of underlying drivers of disease including climate change, urbanisation, industrialisation, and environmental pollution. As noted in the AIPED, the transformation of Viet Nam to a modern industrialised country by 20208 carries with it the potential for “increased anthropogenic stress on already over-burdened regional ecosystems (including agro-, aquatic, forest, wetland, coastal, and urban ecosystems). Unless managed, the “result is continued elevated risks to human health not only from zoonotic diseases, but also from a wide range of threats, including deterioration in water quality and air quality and ongoing loss of biodiversity”. There is still only limited recognition of the importance of upstream practices on downstream infectious disease risks. For example, developments and restructuring of the livestock industry with changes to land use, production zones or the distribution of livestock can introduce new risks from livestock waste including environmental damage and introduction of potential pathogens such as AMR bacteria. The current national plan is expected to result in an increase in livestock in the Central Highlands, which requires a proper assessment of the implications for the environment. Inadequate biosecurity measures in intensive production systems can amplify infectious diseases risks given the high number of uniform animals kept in confined spaces (e.g. swine and avian influenza). This risk can be exacerbated for livestock farms situated in areas with large numbers of wild animals, particularly where there is contact between poultry and wild birds. Wildlife farming also poses a potential threat. Farming of bar headed geese in China may have been a factor in the emergence of H5N1 in places such as Qinghai Lake with subsequent spread to other countries. Dong Nai province has a high concentration of wild life farms and a large livestock sector. The co-location of livestock and wildlife industries in this province, as well as the expectation that DongNai will form part of the H5 influenza free zone, warrants close attention to ensure pathogens do not spillover in either direction. Coupled with these risks is a limited capacity to enforce regulations and prosecute breaches that influence the risks of zoonotic diseases e.g. animal products with microbiological or chemical 7 Strengthening Capacity for the Implementation of One Heath in Viet Nam. State management of captive wildlife in relation wildlife health and the risk of interspecies and zoonotic disease transmission. MARD. 2015 8 11th Vietnam Communist Party Congress: “striving by 2020 to fundamentally transform Vietnam into a modern industrialized country 2020” 51 TECHNICAL ANNEX contamination above standards, use of banned medications in livestock, dispensing of human antibiotics without a prescription, maintenance of sound biosecurity practices etc. Large-scale livestock farming can reduce the risk of certain diseases through improved management and biosecurity when compared with small-scale commercial production but needs to be well managed – regulation can play a role in ensuring this happens. Limited engagement with social sciences and the non-government sector to develop effective communications to change behaviours for improved prevention and control of zoonotic diseases. Health education and communications has been identified as a key aspect of responding to emerging disease threats such as avian influenza. However, there is a general acknowledgement that health education and communications are “fragmented and have low effectiveness”9 and there is a risk that communications during crises that are not sufficiently clear or timely may increase rather than allay community concerns. Uncertain funding for core functions related to zoonotic disease control such as the national sentinel surveillance systems for influenza-like illness and severe acute respiratory infections. Overload of existing staff in MARD and MOH. For this reason, the plan focuses on a small number of important or potentially important zoonotic diseases. 1.8. Targets The principal targets for the next 5 years (as outlined in the Summary Plan) are as follows: Area Description Target Governance Well-defined national coordination Establishment of a new, & mechanisms for zoonotic diseases linking unified, overall national coordination animal health, human health, wildlife, steering committee environment and other government sectors that function during emergency and non- Application of Circular emergency periods 16/2013 on zoonotic diseases Clarifying the role of MONRE Engagement by government partners Ensuring industry, subject with key civil society organisations and discipline specialists and external stakeholders for are identified and included specialised information and advice in One Health approaches (e.g. clinical, public health, laboratory, to control and prevention risk communications, private sector, of zoonotic diseases international partners etc.) and as partners through advisory panels and in disease control and prevention programs networks. 9 Health Partnership Group (2011). Joint Annual Health Review 2011. Strengthening management capacity and reforming health financing to implement the five-year health sector plan 2011–2015. Viet Nam Ministry of Health. Ha Noi 52 TECHNICAL ANNEX Governance & Maintaining the One Health Provision of support for coordination Partnership on Zoonoses and the One Health Partnership secretariat to ensure it can continue to including involvement in act as a national platform for policy OHP activities organised dialogue and knowledge management of One Health and zoonotic diseases, and to facilitate coordination of One Heath stakeholders Conducting joint investigations into Application of relevant zoonotic disease outbreaks whenever provisions of Circular this is appropriate (including 16/2013 development of guidelines for situations where joint investigations should be conducted) Legal framework Measures to ensure wider adoption Training in implementation of Circular 16/2013 that provides of Circular 16/2013 a basis for enhanced collaboration between Ministries and Departments on zoonotic diseases, especially at provincial and sub-provincial levels Additional legislation/directives/ Preparation of directives circulars for coordination and formal under the Animal Health engagement of the environmental law & consideration of sector and in particular MONRE extending features of Circular 16 to include MONRE Risk Build capacity to undertake risk Training programs in joint assessments & assessments at the human-animal- risk assessments through communications environment interface AVET and FETP and other programs Improve risk communication Training in risk between authorities and to the public communication for on microbial hazards emerging at the disease emergencies and human-animal-environment interface prevention of diseases 53 TECHNICAL ANNEX Laboratories Enhance laboratory capacity and Provide appropriate quality management systems resources for undertaking tests and for application of quality management systems Enhance data management systems Established following the to allow rapid analysis and sharing GHSA Roadmap of new findings within and across sectors as well as across borders Conduct well designed surveillance See focus area 3 to ensure early detection of zoonotic pathogens especially those with pandemic potential Trained Sufficient numbers of trained Adopt curriculum for One Health professional staff are proficient One One Heatlh training and workforce Health practitioners include One Health as an integral part part of FETP and AVET training Appropriate Undertake appropriate research to Identify gaps in One Health fill gaps in application of One Health knowledge, obtain research approaches to policy and practice funding, conduct research including research on specific and regularly share diseases findings with stakeholders including policy makers (annual meetings) Undertake selected environmental Farm locations assessed health research aimed at for potential hotspots understanding the drivers of disease for pathogen emergence, emergence and measures to reduce amplification and risk to guide practice, for example, transmission (e.g. effects enhanced land use planning for the of developing new livestock sector (see focus area 3) livestock production zones) In addition to these principal targets, other targets that are expected to be met during the 5 years of the strategic plan include: Area Target Legal Review multi-sectoral legislative framework and regulatory guidelines framework to address zoonotic disease emergence and multi-sectoral responses to zoonotic diseases and address gaps. This includes incorporating environmental protection additions to veterinary and agricultural legislation. 54 TECHNICAL ANNEX Governance Improved and timely information sharing between human and animal and health sectors using established formal channels of communication (e.g. coordination reporting of human cases of zoonoses to MARD and reporting of animal disease outbreaks of zoonotic potential to MOH) in line with Circular 16/2013. Improved information sharing and cooperation between MARD, MONRE, and MOH to prevent and control environmental pollution from livestock production and the prevention of zoonotic disease transmission Defined indicators for monitoring and evaluation of central, regional, provincial and district level zoonotic disease coordination mechanisms Defined roles and responsibilities of agencies involved in managing and regulating wildlife farming, disease surveillance, conservation and trafficking, and agencies involved in environment and forest protection Prevention Infection control processes and antibiotic stewardship programs activities established in all reference and provincial hospitals Biosecurity measures established and enforced in large livestock and wildlife farms and for animal transport, and enhanced cleaning and disinfection of farms and markets Development of antibiotic stewardship guidelines for the livestock sector and improvement and enforcement of regulations of antibiotic use in animals Reduce illegal wildlife trafficking Improved risk assessment tools for the environment and the emergence of zoonotic diseases. Application of tools to define high-risk settings and to inform economic development projects, livestock restructuring and land-use changes Defined national environmental standards in relation to agricultural land use and agreed on methodology for assessing the receptive capacity of land for safe agricultural production Assessment of the excretion of heavy metals and dangerous substances from industry and its impact on the environment and the health of animals and people. Implement measure for control and management Strengthen capacity for pollution control and environmental protection in human and animal disease prevention and control units 55 TECHNICAL ANNEX Surveillance Improved surveillance systems: and reporting Established electronic communicable disease reporting system for human laboratories & public health units Established indicator-based surveillance for 42 priority human diseases Established event-based and syndromic surveillance system with evidence of animal and human health investigations of detected events/syndromes Established enhanced and sentinel surveillance among people and animals (including wildlife) for 5 priority zoonotic diseases and selected surveillance of high-risk animal groups Improved information sharing: Improved compatibility of animal and human health diagnostic and surveillance data collection systems to enhance rapid information sharing and move towards interoperable systems Improved information sharing across borders at key points of entry and joint planning to reduce the spread of disease across borders Reporting to OIE of detected listed diseases and to WHO of public health emergencies of international concern within designated time periods Improved capacity to analyse and interpret surveillance data in both the animal and human health sectors Laboratories All human and animal health laboratories meet national accreditation standards and biosafety/biosecurity requirements and all reference laboratories meet appropriate international accreditation (e.g. ISO 15189, 17025, 17043) with established procedures for ongoing external quality assurance A public health laboratory network that meets national standards for minimum reporting requirements for nationally notifiable communicable diseases (diagnostics, specimen referral pathways, quality assurance, data collection, reporting) Review of the structure of the public health laboratory network including the functions and number of laboratories and assessment of how to improve efficiencies Established mechanism for sharing information between animal and human health laboratories 56 TECHNICAL ANNEX Emergency Established emergency operations centre at national level with an management equivalent structure established in all regions and response Exercise(s) to test function of emergency operations centre and national pandemic/all hazards plans including at least one national disease emergency exercise that tests non-health impacts and whole-of-society responses At least one IHR joint external evaluation (coupled with a similar or preferably linked assessment of veterinary services) Evidence of joint outbreak investigations and management for zoonotic diseases Updated clinical and standard operating guidelines for the management of priority zoonotic diseases Workforce Separate and joint FETP and AVET training programs that are integrated into the staffing structure of MOH and MARD and other relevant institutions Completion of VOHUN curricula development for undergraduate and postgraduate courses including the addition of risk and behaviour change communications modules Continuing to increase the number of people trained in One Health approaches via VOHUN with the support of EPT-2 including expanding training for students who will work in the environment health sector and in-service training on One Health core competencies for preventive medicine and veterinary practitioners, as well as rangers responsible for managing the farming and transport of wild animals. Assess the impact of this training on practice and zoonotic disease outcomes Nationally defined number of human health and animal health epidemiologists to be trained in IHR and PVS core competencies by 2020 Risk Lines of communication during health emergencies: communication Established mechanisms for communications across and to lower levels of government during different phases of health emergencies Established mechanisms for communication between government and external agencies (e.g. NIHE) that can contribute specific expertise for the development of public health messages Established mechanisms for communicating to the public during health emergencies and for gathering information from the public to refine public messaging Involvement of social sciences in the development and assessment of joint risk and behaviour change communications for priority zoonoses to reduce the drivers of disease emergence and transmission at the human- animal-environment interface The One Health Communications Network continues to meet and develop appropriate communications material that is assessed for impact once delivered and used both in peace time and during disease outbreaks 57 TECHNICAL ANNEX Research Nationally defined research priorities for zoonotic diseases including research on health and livestock systems, social and Ecohealth aspects critical to zoonotic disease emergence, prevention and control, and the application of new tools to track and minimise the development of antimicrobial resistance Established mechanism for researchers and academics to periodically inform policy makers of new developments and apply research findings to policy and practice Annual national One Health Forum meetings Participation in key regional and global meetings and conferences to further refine the application of the One Health approach 1.9. Budget The breakdown of the minimum funds required for general strengthening of One Health capacity in Viet Nam is outlined below by area. At the district level, ADB is supporting the Viet Nam government with an USD 80 million loan through the Greater Mekong Subregion Health Security Project (2017-2022) to develop the public health workforce including training in outbreak response, risk analysis, risk communication and managing disease control campaigns. This project also supports the strengthening of district surveillance systems, district hospital infection prevention and control processes, and district laboratories. Governance and coordination - mechanisms to coordinate action across sectors, including greater involvement of the environmental sector. Contents Estimated minimum funds for 5 years Well defined national coordination mechanisms for $100,000 [GoV] zoonotic disease Engagement by GoV partners with key civil society $200,000 [GoV and donors] organisations & external stakeholders Maintaining One Health Partnership on Zoonoses $1,000,000 [GoV and donors] and secretariat Conducting joint investigations into zoonotic disease $500,000 [GoV and donors] outbreaks Legal framework - the legislative framework to facilitate multi-sectoral cooperation (and application of the framework) Contents Estimated minimum funds for 5 years Measures to ensure wider adoption of Circular $300,000 [GoV and donors] 16/2013 Additional legislation / directives / circulars $200,000 [GoV] 58 TECHNICAL ANNEX Risk assessments & communications to target upstream determinants of disease emergence Contents Estimated minimum funds for 5 years Build capacity to undertake risk assessment at the $1,000,000 [GoV and donors] human-animal-environment interface Improve risk communication on microbial hazards $1,200,000 [GoV and donors] emerging at the HAEI Surveillance systems & laboratories that support testing programs Contents Estimated minimum funds for 5 years Enhance laboratory capacity & quality management $2,000,000 [GoV and donors] systems Enhance data management systems to allow rapid $600,000 [GoV and donors] sharing & analysis of new findings Conduct surveillance to ensure early detection of See focus area 3 zoonotic pathogens especially those with pandemic potential Atrained One Health workforce Contents Estimated minimum funds for 5 years Adequate numbers of professional staff are trained in $1,000,000 [GoV and donors] One Health practices Appropriate One Health research Contents Estimated minimum funds for 5 years Undertake appropriate research to fill gaps in $2,500,000 [GoV and donors] application of One Health approaches including research on specific diseases Enhance land use planning for the livestock sector $400,000 [GoV and donors] 59 TECHNICAL ANNEX 2. One Health approaches for managing human disease emergencies of zoonotic origin 2.1. Background All countries need to be prepared to manage a severe pandemic disease resulting from the spillover of an animal virus (or other agent) into the human population. Severe pandemics, such as those caused by influenza, are rare events but when they occur will have major whole-of-society effects. A number of other diseases that emerged from animals and crossed to humans, such as SARS, MERS and Ebola virus disease, have posed and remain a threat to all countries, including Viet Nam; experiences demonstrate the extreme economic and social consequences of even relatively short local transmission chains of these diseases (e.g. SARS in 2003, MERS in South Korea in 2015). Preparation offers the best chance of averting prolonged crises and preventing avoidable morbidity and mortality. Ebola virus disease in West Africa demonstrated the challenges of coordination within government ministries and between government and international agencies, NGOs and the private sector. A One Health approach involving coordinated intersectoral collaboration is required for effective management of these events. Able command and control systems need to be well designed and regularly tested; rapid responses rely on efficient surveillance and data management systems to detect and report cases. The Ebola emergency also highlighted the initial failure of public communications to reduce the risk of transmission because messages were inadequately tailored to local communities. 2.2. Strategic directions Preparedness for disease emergencies requires: Appropriate coordination systems from the highest level of government Emergency management systems to identify and rapidly respond to outbreaks of human disease from zoonotic origin Dedicated funding independent of normal budgets 2.3. Achievements Viet Nam has previously established inter-ministerial steering committees to coordinate intersectoral responses to specific human disease emergencies of zoonotic origin, such as SARS and avian influenza H5N1, and other disease emergencies. The Prime Minister has been directly involved in chairing these mechanisms in peak outbreak risk periods. Emergency response plans have been drafted (e.g. the action plan for the prevention and control of influenza A(H7N9) in Viet Nam, decision No. 1126/QĐ-BYT, dated 5 April 2013) and some aspects have been tested in simulations and exercises with the support of the US-CDC and WHO. The development of an ongoing national inter-ministerial steering committee to deal with prevention and control of public health emergencies, including zoonoses, is currently under consideration. 2.4. Work underway Viet Nam has already built the physical infrastructure of the EOC within GDPM and commenced workforce training. Planning for activities in the next 5 years has commenced with the first iteration 60 TECHNICAL ANNEX of the GHSA roadmap for Viet Nam produced in September 2015. This is in the process of being updated and will provide the operational plans for building the capacity and functions of the EOC. 2.5. Alignment with existing strategies The Global Health Security Agenda was developed based on the recognition that the effects of infectious diseases emergencies can be mitigated through strengthened national and global capacity to prevent, detect and respond. This initiative aims to accelerate achievement of the core capacities required by the IHR and PVS frameworks. Viet Nam is leading the Emergency Operations Centre action package which has the following targets: (1) a public health EOC functioning according to minimum common standards; (2) trained EOC staff capable of activating a coordinated emergency response within 120 minutes of the identification of a public health emergency; (3) maintain trained, functioning, multi-sectoral rapid response teams; and (4) ‘real-time’ biosurveillance laboratory networks and information systems. 2.6. Key factors for success The main factors for success in this area are commitment from all players likely to be involved in an emergency response, appropriately trained staff at all levels; regular testing of emergency responses either through exercises or actual events; and, access to high-quality, timely surveillance data. 2.7. Challenges and constraints No specific contingency funds to manage disease emergencies (although funds are allocated for this purpose in the case of actual outbreaks or high risk of an outbreak and the World Bank’s Pandemic Emergency Financing Facility may provide external financial assistance). Ensuring the work of the emergency management centre remains relevant to those outside of MOH. For example, it is not yet clear how the EOC would operate if H7N9 virus was detected only in poultry before any human cases occurred. Maintaining sufficient numbers of trained staff to operate the EOC at all times. Coordinating with lower levels of the health system particularly given the non-uniform training of provincial and district response teams to conduct investigations, analyse data and institute control measures. Limited materials such as personal protective equipment and logistical support to conduct rapid responses. Sustaining surge capacity in public health laboratories for extended periods. Disease outbreaks are rarely as straightforward to manage as emergency plans suggest. Even in places with established emergency plans these are often found to be imperfect, as was the case with a number of developed countries that had imported cases of Ebola virus disease. The H1N1 pandemic in 2009 also demonstrated that plans had to be flexible and adapted as the outbreak continued, especially with the shift from containment to mitigation. 2.8. Targets Expected outcomes as described in the Summary Plan are listed below. The GHSA Roadmap also 61 TECHNICAL ANNEX sets out Intermediate targets for this focus area. Description Target Steering committee for emergency diseases will Decisions at Prime Ministerial level required on be operational the nature of the coordinating mechanism Role of Ministries other than MOH is fully Determine the role of other Ministries in the defined event of a disease that is yet to spillover to humans in Viet Nam (e.g. if H7N9 is detected in poultry but not yet in humans) A fully functional emergency management Established following the GHSA Roadmap centre suitable for responding to all hazards Revised and tested whole-of-society pandemic Existing plans renewed and exercises or live preparedness plans outbreaks used to test these Appropriate surveillance systems for disease Established following the GHSA Roadmap emergencies Risk communication for outbreaks Build appropriate risk communication packages in the event of any disease emergency by staff trained in this discipline Steering committee for emergency diseases will Decisions at Prime Ministerial level required on be operational the nature of the coordinating mechanism 2.9. Budget The expected expenditure in this area is estimated to be a minimum of USD 2 million. It will include funds from GoV and the GHSA funding envelope but does not include funds for actual outbreak responses. A portion of the USD 20.8 million funds allocated by the ADB Greater Mekong Subregion Health Security Project to improve surveillance and outbreak response capacity will be used to achieve targets in this focus area particularly related to staff training, exercises and the development of electronic notification systems that can provide more timely data. 62 TECHNICAL ANNEX 3. One Health approaches for managing zoonotic agents with pandemic potential that are yet to emerge, especially in wildlife 3.1. Background Infectious agents have crossed over from animals to humans for millions of years. However, this process appears to have accelerated over the past 50 years as a steady stream of infectious agents carried by wild and farmed animals have crossed over and caused severe disease in humans. Most of these diseases have caused only localised disease outbreaks rather than global pandemics (e.g. Ebola virus10, Nipah virus). Those that have spread globally, even if only responsible for few human cases relative to other diseases, have caused immense economic disruption (e.g. SARS in 200311, MERS in South Korea). Tremendous human health impacts have also been caused by vector borne agents transmitted by mosquitoes that thrive in urban environments (such as Zika virus), especially those that have developed human-to-human infection cycles largely independent of the original animal host species. The emergence of human immunodeficiency virus (first detected in the 1980s), Influenza A(H5N1) (1997 onwards), Nipah virus in Malaysia (1998), and SARS (2002-03) catalysed work to understand the drivers of disease emergence, recognition of global hotspots, and identification of potential agents and species that pose a threat to global health. These diseases also spurred development of One Health approaches. Viet Nam has experiences with a number of these diseases and the disruption that they can cause (e.g. Influenza A(H5N1), SARS) and is located within one of several identified global hotspots for disease emergence. For the past five years, Viet Nam has supported studies to identify potential pathogens, develop interventions that would help prevent emergence of new agents and prevent existing agents from re-emerging, and focused on building One Health capacity. This work has been supported by the USAID emerging pandemic threats programs (EPT-1, EPT-plus and EPT-2) as well as work on avian influenza.12 By gaining a greater understanding of the key risks at the human-animal-environment interface and the nature of these risks, Viet Nam can build better systems for prevention and response to these diseases of animal origin with pandemic potential. 3.2. Strategic directions Identifying potential pandemic agents before they emerge Detecting evidence of spillover from animals to humans of zoonotic agents, including newly emerging agents Preventing emergence through broad scale interventions 10 Although the Ebola virus disease outbreak in West Africa affected 3 nations severely with considerable concerns about the poor response to the outbreak in those countries, the nature of the causative agent meant that it could be prevented even if cases are imported. None of the 7 other countries that had imported cases experienced extensive outbreaks. 11 SARS was responsible for far fewer human deaths than the 2009 H1N1 pandemic, despite the latter often being described as a ‘mild’ pandemic. 12 https://www.usaid.gov/sites/default/files/documents/1864/EPT2-Narrative-508.pdf 63 TECHNICAL ANNEX 3.3. Achievements Among the many achievements in this area are the identification in Viet Nam of high risk practices such as bat guano farming, characterisation of areas with intensive wildlife farming, understanding patterns of trade, training in wild animal handling and sample collection, and the identification of a number of potential high risk agents. There has also been a shift in attitudes towards One Health and a greater acceptance of the importance of One Health training including consolidation of the Viet Nam One Health University Network (VOHUN). Laboratory capacity for detection of these agents has been enhanced and specific tests for a range of agents introduced to two laboratories, one in Ha Noi, at the Viet Nam National Agricultural University (VNUA) and one in Ho Chi Minh City, at the Regional Animal Health Office (RAHO6).13 Information has been collated on the regulation of wildlife in a project supported by the One Health Partnership. Information on risks associated with livestock and poultry production and market chains have been better defined. 3.4. Work underway The tightly linked EPT2 and GHSA programs are expected to extend throughout the 5-year period from 2016 to 2020 and to include activities aimed at understanding, preventing and controlling these agents in animals (domestic and wild) before they pose a threat to global health. The three overarching objectives of EPT-2 are: (1) prevention of the spillover, amplification, and spread of new zoonotic viruses; (2) early detection of new viruses when they do emerge; and (3) their timely and effective control. EPT-2 has 7 areas of strategic focus of which the following are directly related to detection and control of infectious agents that pose a threat to health security: Developing longitudinal data sets for understanding the biological drivers of viral evolution, spillover, amplification, and spread; Understanding the human behaviours and practices that underlie the risk of “evolution, spillover, amplification and spread” of new viral threats; and Promoting policies and practices that reduce the risk of virus evolution, spillover, amplification, and spread. Generic guidance on reducing the risk for new development projects have been produced14 and should be used for all new projects in which contact between wild animals and humans or livestock is expected to occur. 3.5. Alignment with existing strategies Work on emergence of zoonotic agents will align with the GHSA, APSED, the IMCAPI ministerial declaration and the activities of the international human and animal health agencies (WHO/FAO/ OIE). These Tripartite agencies are developing risk assessment tools for assessing and managing risks at the human-animal-environment interface (HAEI).15 WHO HQ has outlined the following objectives for work on zoonotic diseases at the HAEI:16 13 The full range of achievements through EPT’s Predict project in Viet Nam are available here http://www.vetmed.ucdavis.edu/ohi/ local_resources/pdfs/ chapters/35_predict_vietnam.pdf 14 See http://www.usaid.gov/what-we-do/global-health/pandemic-influenza-and-other-emerging-threats/programs/extractive- industry-engagement and http://www.chathamhouse.org/about/structure/global-health-security/extraction-industry-infectious-disease-risk-assessment-and- management-idramproject 15 http://www.rr-asia.oie.int/fileadmin/Regional_Representation/Programme/JTF_One_Health/2015_6th_Tripartite_Sapporo/ Presentations/11._JRA_on_Zoonotic_influenza_WONGSATHAPORNCHAI.pdf 16 http://www.who.int/foodsafety/about/flyer_zoonoses.pdf?ua=1 64 TECHNICAL ANNEX Strengthen national public health systems for existing and emerging threats at the HAEI Assist in assessing and managing health threats at the HAEI Provide frameworks, tools and international political support for cross-sectoral approaches Build national mechanisms for information sharing and joint risk assessment for zoonotic influenza and other threats at the HAEI, including sustainable inter-ministerial communication and collaboration Assess global public health risks posed by endemic, epidemic, and potential pandemic events Ensure coordination between WHO and international animal health organisations Viet Nam is one of the two lead countries for the Zoonotic Disease Action Package (ZDAP) of GHSA, and is playing a major role in its development and coordination. ZDAP provides guidance for Viet Nam and other countries on activities in this area. The five-year target for ZDAP is to adopt measured behaviours, polices and/or practices that minimise disease risk and the spillover of zoonotic diseases from wild and domestic animals into human populations. 3.6. Key factors for success The key factors required for success are sustained surveillance at the HAEI and sharing of information across sectors, successful engagement across sectors including trade, wildlife and land use sectors, and the application of new understandings of the drivers of disease to policy and practice. 3.7. Challenges and constraints The following constraints are expected to affect Viet Nam’s capacity to understand and contain potential emerging agents: Finding sufficient animals from each class to test and testing enough animals for early detection (short shedding time of some agents also affects the sensitivity of the system); Finding sufficient clinically affected humans in contact with animals; Finding culturally appropriate behavioural change strategies that can be applied successfully in a particular industry or sector (e.g. extractive industries); Distinguishing pathogens likely to result in health security events from organisms that will not cross the species barrier or cause significant disease in humans; Economic drivers of wildlife trade that promote risky behaviour; Mismatch between the rate of development of wildlife farming and capacity to regulate and provide appropriate technical services especially in the area of animal health; Challenges of data sharing between ministries and even within ministries; 3.8. Targets The main objectives as presented in the Summary Plan are as follows: 65 TECHNICAL ANNEX Description Target Complete planned work on the identification Undertake testing of a range of animals for of zoonotic and potential pandemic agents in viruses with pandemic potential animals prior to their emergence Improve capacity for early detection of spillover Undertake testing of humans working in to humans of potential pandemic infectious association with animals, especially clinical agents cases Implement measures to reduce the risk of Develop and introduce industry/sector specific emergence of novel agents for specific industries guidance on preventive measures Other targets include: Tests for a minimum of 4 virus families will be conducted in all relevant animal taxa – coronaviruses, filoviruses, paramyxoviridae and influenza viruses (see also the specific section on zoonotic influenza viruses); Established enhanced and sentinel surveillance among people and animals for 5 priority zoonotic diseases and selected surveillance of high-risk animal groups; Evidence of collection, recording, sharing and analysis of data across sectors. 3.9. Budget The minimum funds required to conduct this work over the next 5 years is estimated to be USD 3 million. The majority of the budget falls within the EPT-2 project supported by USAID with contributions from the GoV. 66 TECHNICAL ANNEX 4. One Health approaches for managing zoonotic influenza 4.1. Background Influenza viruses in animals represent an important on-going zoonotic and potential pandemic threat in Viet Nam. Each of the last three human pandemic influenza viruses involved either avian or swine influenza viruses in some way and Viet Nam already has almost 15 years of experiences in dealing with the pandemic threat posed by avian influenza viruses of the H5 subtype. Avian influenza (AI) viruses remain the main concern for Viet Nam. A number of different AI virus subtypes are involved - some are present in Viet Nam (e.g. H5N1, H5N6) and some occur in neighbouring countries or elsewhere (e.g. H7N9). The capacity of avian influenza viruses to evolve rapidly through point mutations and gene reassortment plus the many susceptible avian hosts that share environments (domestic and wild birds in farms and markets) allow new strains of influenza to emerge frequently in the region. H5N1 AI virus became widespread in Viet Nam in 2003-2004 resulting in the death or destruction of some 45 million head of poultry. It also caused serious disease in humans, raising concerns about its potential to cause a severe influenza pandemic if it developed the capacity to transmit readily between humans. This concern persists but the level of fear has diminished due largely to the fact that the virus remains (genetically) an avian virus. Although experimental studies suggest only a few mutations are required to allow airborne transmission in a mammalian model, the virus has not yet acquired this capability despite over 20 years of human exposure to this virus. All highly pathogenic H5 avian influenza viruses in Viet Nam are related to the Goose/Guangdong H5N1 AI virus detected in China in 1996. However, H5 AI viruses have evolved, forming different clades and genotypes, a number of which have become established in Viet Nam. Since 2013, new H5 subtypes have emerged, including H5N6, which are the dominant strain in China in 2016 (and have caused some human cases in China since 2014). Viruses of this subtype have also been found in Viet Nam and appear to be displacing earlier H5N1 strains. No human cases associated with this strain have been reported in Viet Nam. Human cases associated with H5N1 AI virus have decreased dramatically since the peak from 2003 to 2005 (Table 2). Much of this is attributed to the enhanced control of these viruses in poultry but some may be due to changes in pathogenicity of recent viruses for humans.17 Table 2. Human cases of influenza A(H5N1) 2003 - 05 2006 - 09 2010 - 14 2015 - June 2016 Total since 2003 93 (42 fatal) 19 (15 fatal) 15 (7 fatal) 0 127 (64 fatal) H7N9 viruses emerged in China in 2013 as a cause of severe zoonotic disease associated mainly with live poultry markets. Many more human cases and fatalities have been recorded in China as a result of infection with H7N9 virus than from H5 infection. So far, no cases of H7N9 infection 17 There have been few human cases of H5 avian influenza due to Clade 2.3.2.1c which has been the dominant strain in the past few years and despite being widespread and poorly controlled in China there have only been 16 cases of Clade 2.3.4.4 Influenza A(H5N6) to end-April 2016, despite circulating for several years. Given the differences in population (both human and avian) between China and Viet Nam the expectation is that there would be few H5N6 human cases in Viet Nam. Scientific studies on Clade 2.3.4.4 viruses demonstrate lower pathogenicity for mammals. 67 TECHNICAL ANNEX have been detected in Viet Nam (in poultry or humans), but if the virus remains poorly contained in China it will almost certainly enter Viet Nam based on previous experiences with H5 AI viruses.18 If this virus were to become established locally, it would trigger a major disease emergency and would almost certainly result in human cases if it were not identified soon after it enters the country. Unlike H5 viruses, the H7N9 virus has not been shown to cause clinical disease in infected poultry and detection requires active surveillance.19 Measures being implemented to prevent smuggling will reduce the risk of introduction to Viet Nam but it is unlikely that all illegal imports of poultry can be prevented as long as price differentials exist across the border between China and Viet Nam for the same product (e.g. day old chicks, spent hens). H5N6 virus, which emerged at about the same time as H7N9, still gained entry to Viet Nam despite the crackdown on smuggling to prevent spread of H7N9. Other avian influenza virus subtypes have also crossed the species barrier between animals and humans, including H9N2 (present across much of mainland Asia but so far not causing severe disease in humans), H6N6 and H10N8 (both causing a few human deaths in China). H9N2 AI viruses are regarded as important because they were the source of viral genes that are in part responsible for the high virulence of some H5 and H7N9 viruses in humans. Swine influenza viruses are widespread globally. The 2009 H1N1 swine influenza pandemic demonstrated that a swine influenza virus can cross the barrier to humans and cause a human influenza pandemic (albeit one that in that case was not particularly severe). Swine influenza viruses in the region, especially in China, are already showing signs of divergence away from human seasonal influenza strains and could once again emerge as a threat to human health as they did in 2009.20 The biology of swine influenza is complex with infection of pigs by human-adapted strains of virus also occurring, thereby adding to the influenza gene pool in swine.21 Avian influenza viruses have also been detected in swine on occasions providing opportunities for reassortment between mammalian and avian viruses if two viruses infect the same animal cells simultaneously. Influenza viruses in other species also need to be monitored. Farmed dogs in China have been found to harbour H3N2 viruses that were derived originally from avian viruses but which have obtained genes from human H1N1 2009 influenza virus. Other reassortant influenza viruses have also been detected in dogs in the Republic of Korea.22 4.2. Strategic directions Progressive control of infection and prevention/early detection and response to novel zoonotic influenza viruses with pandemic potential. It is noteworthy that H5N1 virus was first detected in China in 1996 but the first human cases of disease in Viet Nam did not occur 18 until 7 years later. 19 H5 AI viruses generally cause disease in infected chickens but infection can occur silently in domestic ducks and in poultry markets. Active surveillance is needed for all avian influenza viruses – passive surveillance systems will not detect a significant proportion of cases. Yang H. Prevalence, genetics, and transmissibility in ferrets of Eurasian avian-like H1N1 swine influenza viruses. Proc Natl Acad 20 Sci USA. 2016; 113(2):392-397 21 http://elifesciences.org/content/5/e12217v1 22 http://www.ncbi.nlm.nih.gov/pubmed/27138550 68 TECHNICAL ANNEX 4.3. Achievements in establishing One Health approaches in Viet Nam The containment of H5N1 highly pathogenic avian influenza in Viet Nam is recognised globally as a One Health success. Despite having more human cases than any other country by the end of 2005, a marked increase in the total poultry population including domestic ducks (from 220 million in 2005 to over 300 million in 2016), as well as conditions that facilitated transmission and persistence of these viruses such as the structure of the poultry industry, Viet Nam succeeded in reducing the number of human cases and the number of avian outbreaks. Containment was achieved through strong leadership from the highest levels of government, strong intersectoral coordination and strong support from donors and international agencies. Viet Nam has modified production and marketing practices in many areas so as to reduce the risk posed by these viruses. Vaccination is still being used as a tool for management of this disease and the vaccination programme is subject to regular reviews. H5N1 avian influenza was the catalyst for the production of the OPI (Green Book) covering activities from 2006 to 2010. This was followed by the AIPED for the period from 2011 to 2015 which Figure 3. H5 viruses in Viet Nam expanded the scope of the programme to other emerging diseases as in 2014 - an example of the genetic the importance of One Health approaches to disease management information on these viruses became evident. (courtesy of FAO Viet Nam) Viet Nam has recognised that virus elimination is a longer term objective and one that will only be achieved when the factors that allowed the virus to gain entry and persist change. The threat of resurgence remains given zoonotic avian influenza viruses continue to circulate in Viet Nam and the broader region. Circular 16/2013 also identifies zoonotic influenza as one of the priority zoonotic diseases for which information sharing is required. Based on experiences, studies and prevention and control efforts over the past decade, Viet Nam also now has a much greater understanding of the biology of H5 AI viruses including much better information on the genetic relationships between strains of virus in and outside of Viet Nam. Maps are being produced that demonstrate the location of outbreaks and these are tied to the clade of virus involved. (see Fig. 3) 4.4. Work underway AIPED pointed out that Viet Nam was in the consolidation phase for avian influenza control, having gone through a control phase in which emergency responses to outbreak were the main activity (as was the case in 2003-2004 when 45 million poultry were culled or died from the disease). The outbreak control activities have continued during the consolidation phase as required, but outbreaks were generally small and resulted in only relatively few birds being culled. The goal of the consolidation phase is to maintain the gains made in the control phase, and to reduce further the levels of circulating virus (in part through changes to the manner in which poultry are 69 TECHNICAL ANNEX reared and sold but also from other activities such as vaccination). Certain well managed farms were expected to demonstrate freedom from infection. The five-year period covered by AIPED resulted in a number of significant changes to some live poultry markets and to farm biosecurity that reduced the risk of infection. During this time many commercial chicken farms have remained free from evidence of infection and disease, as planned. During the five-year period from 2016 to 2020 it is expected that parts of the country will move to the eradication (elimination) phase. Viet Nam has already made some progress towards virus elimination, with a number of large commercial farms recognised as being and remaining free from H5 virus infection. The number of farms determined to be free from infection or disease will gradually increase, although this will require strengthening of passive surveillance systems so that any increase in mortality on farms is accompanied by submission of samples so that virus, if present, is detected. However, virus is still circulating, especially in the domestic duck population, and this will be more difficult to prevent unless greater controls are placed on the movement of ducks, thereby reducing the risk of onward transmission to other duck flocks and other types of poultry. So far, moves to produce a better commercial vaccine for ducks have not yielded a suitable product despite considerable global research into this area. A viral vector vaccine based on duck virus enteritis was expected to be available by 2015 but has still not been used widely in China. Nevertheless, vaccination remains one of the measures used to reduce viral shedding by ducks. The eradication phase is costly because of the increased surveillance requirements to ensure freedom,23 the increased costs associated with culling any infected flocks (regardless of whether they are showing signs of disease) and the cost of stringent movement controls. It will only be successful in places where there is relatively low heterogeneity in the poultry sector and is facilitated by centralised slaughtering of poultry rather than sale through traders and markets. Planned activities are laid out in the action plan for H5 avian influenza in the poultry sector for the period from 2014 to 2018. This plan recognises that provinces have different risk factors for and prevalence of H5 avian influenza (based on findings from active surveillance in markets and reports of disease through passive surveillance systems). At any point in time, provinces in Viet Nam fall within one of three categories: High risk - outbreaks detected in the past two years and/or high levels of virus contamination detected via active surveillance. This covers most of the provinces in the Red River and Mekong Deltas Low risk - no outbreaks reported for two years, some infection detected in active surveillance. This covers a number of provinces in the central and northern parts of Viet Nam Temporarily disease free - where outbreaks have not been reported for 5 years and active surveillance finds no or only occasional virus. This describes a number of provinces including some in the south east region and the central coast. The status of provinces will change over time as a result of increased/decreased rates of detection 23 When an exporting country makes a claim of disease freedom based on surveillance results, importing partners must have confidence that the claim is valid and that the surveillance has been carried out in such a way as to meet certain basic requirements. (Cameron 2012). This means that the demands for surveillance for disease freedom are usually greater than routine surveillance. 70 TECHNICAL ANNEX of virus and/or outbreaks of disease attributed to H5 virus. The five-year goal is to reduce the number of provinces categorised as high-risk. By 2018, Viet Nam is also aiming to establish disease free zone(s) in the south-eastern region, a site of marked increase in intensive poultry production in the period from 2010 to today. When the 2014-2018 plan was produced, these provinces were already regarded as being either free from infection or had limited evidence of infection; however several provinces in this area experienced outbreaks in 2014 and again in 2015-2016. Therefore, it is unlikely that zonal freedom from the virus will occur until at least 2020. The proposed free zone also includes Ho Chi Minh City, which responded aggressively and (largely) successfully to the H5 AI problem when it emerged by closing urban live poultry markets and shifting to sale of chilled poultry from centralised slaughter facilities. Development of this infection-free zone will need to be supported by strict control measures on poultry production, marketing and movements in the free regions and an appropriate combination of active and passive surveillance providing a high degree of confidence in claims regarding freedom from infection. The first step in this process is to ensure that development of a disease free zone is feasible and whether the resources needed to support it are available. This is only likely if the formation of a disease free zone provides access to lucrative export markets. Other elements of the poultry sector plan include on-going vaccination (focusing on ducks), which remains one of the largest costs of the programme, rapid response to disease outbreaks, continuing communication campaigns, and enhanced biosecurity measures. If monitoring and evaluation show that the situation is not improving as expected, it will be possible to reassess whether changes in the approach are needed. The effectiveness of vaccination programmes will need to be assessed (i.e. the extent to which they are reducing viral loads), especially given the large amount spent on this aspect, building on results from earlier studies including USAID’s GETS project. This is not currently included in the existing surveillance programme. On the human health side, all suspected cases of avian influenza will be tested and managed according to appropriate, standardised infection control procedures. MOH will inform MARD of the case and field investigations will be conducted to determine the source of infection, to assess whether other cases have gone undiagnosed and to ensure that onward transmission is not occurring (at present onward transmission of zoonotic avian influenza viruses in humans occurs sporadically and chains of transmission rarely extend beyond one generation). Investigations will be conducted as joint investigations where this avoids duplication and is cost effective. H7N9 - Plans for H7N9 avian influenza have also been prepared that cover scenarios ranging from no local infection to avian and human cases. Once human cases occur it is expected that this will be regarded as a disease emergency and will be managed accordingly (see focus area 2). At present the virus has not been detected and surveillance activities will continue in areas identified as being at high risk of introduction of the virus (mainly in northern provinces). If H7N9 were to occur it is likely that it would involve live poultry markets (as seen in China). Swine influenza - Some work has already been conducted through the EPT+ program to detect and characterise swine influenza viruses. This work will continue. 4.5. Alignment with existing strategies In 2010 ASEAN released an ambitious plan for elimination of H5N1 (and related) avian influenza from the region by 2020. Elimination by 2020 from ASEAN is a challenging target, but improvements 71 TECHNICAL ANNEX are occurring in disease control that will bring some countries, including Viet Nam, closer to this goal. The reality is that these viruses are likely to be present for at least another 10 to 15 years or longer unless there are major changes to the virus or in production and marketing systems and if neighbouring countries also managed to control the disease. Three key factors in the persistence of the virus are the smuggling of poultry from endemically infected countries; a large population of free-running ducks vaccinated with products that do not necessarily prevent virus shedding (if a vaccinated duck is subsequently infected)24; and poorly controlled movement and sale of poultry. At present there are too many niches where this virus can survive, including sufficient avian host species. The cost of a countrywide virus elimination programme would likely be over USD 100 million,25 with no guarantee of long term success. Even if it were possible to eliminate H5 virus from Viet Nam the risk of reinfection would remain very high. Changes are occurring in the poultry sector in Viet Nam but there are still hundreds of millions of poultry reared and sold under conditions of relatively weak biosecurity. It is possible for well managed farms to remain free from infection and it may be possible to develop disease free zones with an effective approach. The ASEAN H5 plan has seven strategic goals, all of which are included in activities to control H5 AI in Viet Nam: 1. Strengthening Veterinary Services for capacity development to prevent, control and eradicate animal diseases of economic and public health importance. 2. Achievement of disease-free status in progressive manner at compartment, zone, region and country levels. 3. Effective reduction of circulating HPAI virus in the environment leading to its progressive control and eradication. 4. Effective and rapid containment of infections and outbreaks in affected flocks or zones. 5. Effective surveillance capacity to detect and respond appropriately to the presence of H5N1 virus infection and other disease threats. 6. Sustainable market chain policies and intervention in reducing risks of spreading and contamination to poultry and human populations. 7. Enhancing and promoting biosecurity as a long term cost effective preventive measure to keep HPAI virus out of farms/flocks. 4.6. Key factors for success Viet Nam has a long history of dealing with zoonotic influenza and has learnt many lessons on how to minimise the risk of transmission to humans. Among the key factors needed for success are buy-in from all stakeholders to any new measure; the importance of recognising and gradually addressing constraints to virus elimination or control and enhancing the quality of support services, including veterinary services to the poultry sector. 24 This can occur with ducks given one dose of vaccine 25 The current plan for 5 years - which will not achieve freedom - is costed at $38 million. To achieve freedom while the current production systems are in place would require a major test and slaughter programme for duck flocks that could result in the destruction of 20 to 30 million head of ducks and other poultry. 72 TECHNICAL ANNEX 4.7. Challenges & constraints Effectiveness of vaccination and vaccination programme in ducks The AIPED pointed out that one of the main constraints to effective control of H5 HPAI is that existing duck vaccines, although able to reduce shedding and to protect ducks from disease, were still imperfect. One of the cornerstones of control of the disease in Viet Nam is the vaccination of ducks, aimed at reducing shedding of virus by these birds. This strategy is sound provided the effectiveness of the vaccination matches that of laboratory studies. Further work is still needed to determine the extent to which the existing vaccination programme is reducing viral shedding. The current programme relies on a single dose given to birds every 6 months (although there is variation in the field). Surveillance from markets suggest that a considerable number of ducks are still shedding virus (although the vaccination status of these birds is not always known) indicating that more work is required to ensure vaccination is achieving the expected result. Changes in the antigenic characteristics of viruses as new strains become established also make vaccination harder to apply. Studies to assess the effectiveness of vaccination need to be continued and will require support from donors. Illegal movements will be difficult to eliminate Long land borders and cross-border price differentials make it difficult to prevent all smuggling. The risk of a new strain of zoonotic avian influenza virus being introduced to Viet Nam is still high, including the risk of H7N9 introduction. In Viet Nam the movement of large consignments of poultry can be managed better through check points at farms and at the final destination as well as sealing of consignments, but small volumes of poultry transported by motor cycle are much harder to regulate and control. Experiences with Clade 2.3.2.1c and Clade 2.3.4.4 viruses demonstrate that viruses can move from the north to the south of the country (which was not a feature when the AIPED was prepared). If disease-free zones are to be developed it will be essential to prevent the uncontrolled movement of poultry into and through the zones. Wild birds could potentially carry virus into Viet Nam or into disease free zones It is considered highly likely that most H5 AI viruses in the past were introduced and spread within the country through trade in poultry, however the close association between wild birds and domestic poultry in places where birds are not confined allows for potential transfer between the two. In other parts of the world wild birds have played an important role in introduction of virus (e.g. South Korea). Few incentives to acquire status as being free from avian influenza Unless there are sound commercial reasons for establishing disease free zones, such as development of export markets for certain products (e.g. duck meat), then it may be difficult to convince provinces to invest the necessary resources to maintain freedom from infection within the zone. Difficulties of detecting H5 avian influenza infection in infected duck flocks or vaccinated chicken flocks Active surveillance in markets shows that some otherwise healthy birds sent to market are infected. The absence of clinical signs in many infected ducks means that intensive active surveillance is required to assess the status of infection on farms and to verify infection status in provinces aiming for freedom from disease. Experiences from earlier projects (e.g. GETS) suggest that it is easier to 73 TECHNICAL ANNEX detect virus in markets than it is in farms. Even when sentinel ducks were being monitored on farms few positive results were obtained when using virus isolation. The need for active surveillance to detect infection (H5 and H7N9 viruses) and the cost associated with collection and testing of samples Surveillance is expensive and this limits the number of samples that can be collected and tested. This has implications for testing to confirm “freedom from infection” especially if using virological testing for this purpose. The number of tests required to have a high degree of confidence of claims to “freedom” will be much higher than that currently being undertaken in these provinces. The cost of surveillance also has implications for the detection of H7N9 virus. Given the limited number of samples that can be collected and tested it may be possible for the virus to circulate for some time before being identified, complicating efforts to eliminate the virus. Quality of veterinary services Veterinary services still require additional strengthening and resources based on the results from the OIE PVS reviews. All provinces that are aiming for freedom from infection would need to commit sufficient resources to veterinary services to ensure that the standards have been met and followed. If international trade in products is to occur from a zone, then it will be necessary to demonstrate to trading partners that the area is free from infection. Additional resources will be required to meet this requirement. The nature of the poultry sector The poultry sector in Viet Nam is changing with greater intensification and a gradual shift away from live bird sales to centralised slaughtering (especially in the south of the country). There is still a large population of mobile ducks that move through the Mekong Delta, including cross-border movement between Viet Nam and Cambodia, and many millions of households still rear poultry. Limited possibilities for pre-emptive action in the event of detection of a potentially pandemic swine influenza virus Even if a swine influenza virus is found that has characteristics suggesting it might become a human pandemic agent it is doubtful that action will be taken to eliminate the virus given that the virus is likely to be widespread and the uncertainty about the actual (rather than potential) effects. The main response will be production of a pre-pandemic vaccine antigen for humans. Buy in from poultry traders to market closures in the event of human or avian H7N9 infections Control of avian influenza (H7N9) depends on support from market traders who will be required to close market stalls temporarily and in some cases permanently. Traders many not see the importance and value of this measure especially given the short-term costs. 4.8. Targets The major outcome by 2020 of the national plans as described in the Summary Plan are as follows: 74 TECHNICAL ANNEX Description Target Monitoring programs for avian Regular surveillance in high risk areas and species H5 HPAI and H7N9 (and other) influenza viruses in poultry and other birds, and swine influenza virus in pigs Effectiveness of vaccination Vaccination programs will be reviewed and studied to programs in poultry determine whether vaccination is reducing shedding of virus in vaccinated ducks Progress towards elimination of Necessary work to determine the feasibility of an H5 H5Nx highly pathogenic avian infection-free zone will be undertaken and, if feasible, influenza virus measures will be implemented to develop a virus-free zone in the south eastern region Surveillance of cases of human Human surveillance programs will be reviewed and respiratory illness for novel consolidated influenza viruses of animal origin Other important targets include: Continue efforts to reduce smuggling of poultry either through enforcement or creating cost- neutral legal trading channels; Management of any incursion of H7N9 virus in accordance with contingency plans; Better understanding of the range of swine influenza viruses in Viet Nam, including their pandemic potential; Investigate all human cases of zoonotic influenza assessing for source and onward transmission; Application of the Tripartite risk assessment tool for selected high-risk industries to assess risks and develop risk management plans. Additional targets from national strategies are listed below. Area Target 1. Status of provinces 1.1 Annual revision of status (high risk, low risk, interim disease-free) 1.2 Reducing the number of high risk provinces by 80% 2. Surveillance 2.1 Conduct passive surveillance on farms (poultry) 2.2 Conduct passive surveillance in zoos 2.3 Conduct planned active surveillance in markets 2.4 Conduct planned active surveillance on farms in H5 free area (poultry) 2.5 Conduct active surveillance on farms or slaughterhouses for swine influenza virus 2.6 Obtain information on genetic information on all virus isolates 2.7 Obtain information on antigenic characteristics of viruses especially those from fully vaccinated poultry and, as necessary, update vaccine antigens 2.8 Conduct appropriate surveillance to detect zoonotic influenza in humans including close contacts of confirmed cases 75 TECHNICAL ANNEX 3. Outbreak 3.1 Rapid culling of affected and in contact poultry with payment of compensation response 3.2 Movement management 3.3 Thorough investigation of all outbreaks to determine the source 3.4 Reporting to human health authorities of all human cases (this includes reports from clinicians and from laboratories to reduce the chance of missed reports) 3.5 Reporting to MARD of suspected and confirmed human cases 3.6 Provide appropriate communications to inform the public about risk and ways they can reduce the spread of disease, as well as actions the authorities are taking to protect the public 4. Poultry 4.1 Mandatory duck vaccination completed in selected provinces vaccination 4.2 Conduct appropriate post-vaccination monitoring to demonstrate the extent of the response to vaccination in selected provinces 4.3 Biennial reviews of results from vaccination to determine whether changes are needed to the programme 4.4 Introduction of new vaccine antigens when required 5. Quarantine 5.1 Restricted movement of poultry from areas where virus exists and especially & movement into disease free areas management 5.2 Enhanced border controls to minimise smuggling 6. Biosecurity 6.1 All poultry farms with > 2000 head meet biosecurity standards 6.2 Enhanced cleaning and disinfection of farms and markets 7. Communications 7.1 Produce appropriate materials to facilitate behavioural change 7.2 Share effective strategies/materials across sectors 8. Research 8.1 Conduct relevant research into H5 and other zoonotic influenza viruses to facilitate understanding of their ecology in Viet Nam 8.2 Determine the extent of circulation of low pathogenicity H5 viruses 8.3 Undertake research on the effectiveness of control measures, especially vaccination 8.4 Undertake research into any cases that occur in disease free zones to determine the likely source(s) of the virus 8.5 Support sharing of current knowledge among human and animal health providers, researchers, laboratory staff, and industry 9. Human 9.1 Test all suspected human cases of AI infections 9.2 Manage suspected and confirmed human cases of AI with appropriate infection control measures 9.3 Conduct contact tracing and investigate source of infection 9.4 Advise MARD (and other sectors/stakeholders as needed) of human cases of zoonotic influenza (+/- conduct joint field investigation to determine source of infection) 10. Monitoring & 10.1 Measure progress towards indicators established under specific work plans evaluation and targets 76 TECHNICAL ANNEX 4.9. Budget The minimum funds required for activities related to zoonotic influenza over the next 5 years is estimated at USD 45 million assuming that vaccination of poultry remains a core part of control and prevention. Most of this will be spent in the agriculture sector. The GoV will provide most of the funds with contributions from donors, especially for surveillance activities, and from the private sector (vaccination). 77 TECHNICAL ANNEX 5. One Health approaches for managing rabies 5.1. Background Rabies is an important zoonotic disease in Viet Nam responsible for 78 recorded human deaths in 2015 (Table 3).26 The majority of cases occur in the north of the country often in remote communities although cases of rabies in dogs were detected in 23 provinces in 2014, including lowland provinces. Disease is more frequent during hot seasons. Table 3. Reported rabies cases in humans, 2006-2015 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 82 131 91 68 78 110 58 105 67 78 Canine rabies is not a disease with pandemic potential but is of considerable significance regionally with all countries in the region committed to enhanced control and virus elimination. Rabies is also one of five priority zoonoses in Viet Nam.27 It is highly suited to a One Health approach, and provides a practical opportunity to develop effective inter-sectoral coordination and collaboration in Viet Nam. The main cost associated with rabies prevention are the direct and indirect costs of post- exposure prophylaxis for those potentially exposed to a rabid animal with some 400,000 courses administered each year at a cost exceeding USD 100 per course. 5.2. Strategic directions Elimination of human rabies cases in Viet Nam and the broader region depends on: Control of rabies in dogs, coupled with Universal post-exposure prophylaxis (PEP) in humans exposed to potentially rabid animals. Both aspects need to be addressed for sustainable control of the disease. Most human cases in Viet Nam occur as a result of contact with rabid dogs but cats can also play a role. Some cases have occurred via preparation of rabid dogs for food. Other wild mammals can also be infected with rabies virus but are not regarded as an important source of disease for humans. The focus of control should be on dogs (and to a lesser extent cats) but monitoring of other animal populations will continue. Rabies tends to be seasonal so public awareness campaigns need to be targeted to periods of high risk (hotter months). It is estimated that there are some 8 to 10 million dogs in Viet Nam. Dogs in villages are owned but are allowed to wander during the day. Turnover of dogs is relatively high, which has the potential to affect population immunity once intensive vaccination campaigns are implemented. Most cases of human rabies occur in remote communities. Control of rabies represents an important area for One Health activities in Viet Nam in the period from 2016-2020 and one for which significant measurable gains are expected to be made. 26 There is a possibility of under-reporting. See: http://www.who.int/wer/2016/wer9102.pdf 27 Circular No. 16/2013/TTLT-BYT-BNN dated on 27 May 2013. 78 TECHNICAL ANNEX 5.3. Achievements in establishing One Health approaches in Viet Nam Already a number of steps have been taken to improve rabies control in Viet Nam but more needs to be done to further reduce the number of cases and eventually eliminate the disease. Human rabies cases, a more accurate indicator than canine cases due to better reporting, has fallen from 400-500 people in the early 1990s to 78 cases in 2015. This reduction in human cases has been achieved through enhanced awareness, some improvements in dog vaccination coverage especially in high- risk provinces, and improved uptake of PEP with some 400,000 courses given each year following dog bites. Table 4 provides details of activities undertaken on rabies in Viet Nam in the recent past, some of which are on-going. Table 4. Reported rabies cases in humans, 2006-2015 Activity Donor Period Themes ASEAN Rabies 2015-2020 Regional strategy (development) Rabies transmission from neighbouring NAFOSTED 2015-2017 Surveillance, laboratory, countries research Standard operating procedures for rabies FAO 2015-2016 Information prevention and response in coordination sharing, reporting, between Animal and Human Health communications, control, sectors risk reduction Workshop on rabies 2016-20 FAO, WHO 2015-2016 Reviewing 2016-20 plan28 Institutional and inter-sectoral AusAID 2014-2015 Surveillance, control, strengthening for rabies control communications National Program on rabies prevention GoV 2011-2015 Response, behaviour & control change, coordination Highly pathogenic emerging and re- EU 2010-2014 Dog vaccination, risk emerging diseases (HPED) reduction, communication Partnership on global animal health & DRAFF 2009-2013 Prevention, risk reduction, biosecurity communications training 5.4. Work underway Viet Nam has made a number of commitments internationally and regionally to work towards canine rabies elimination making rabies control one of the most important goals for zoonotic diseases in the period from 2016 to 2020. A 5-year One Health operational plan for rabies control to 2020 (see expected outcomes below) has been drafted. This plan has as its strategic objective the 28 http://www.fao.org/vietnam/news/detail-events/en/c/409842/ 79 TECHNICAL ANNEX elimination of human cases by 2020, an ambitious objective that can only be achieved if there is strong commitment from stakeholders at all levels of the plan, including funding commitments for canine vaccination and improved access to PEP in remote communities. Viet Nam’s action plan for rabies control for the period from 2016-2020 adopts a One Health approach and covers all pillars of disease control for MARD and MOH and other involved partners. The goal is to have one overall plan for rabies control and prevention and a single steering committee. The implementation of this plan will include many partners including relevant government departments from central to local level, international agencies/partners, mass organisations, NGOs and the public. Joint training has been conducted29 and Circular 16/2013 includes rabies as one of the five diseases for which information will be shared and joint investigations conducted. 5.5. Alignment with existing policies & strategies WHO, OIE and other agencies have singled out rabies as a priority through the global strategic framework for rabies elimination released in 2015. The overall strategic goal of this framework is elimination of human rabies by 2030. The global strategic framework comprises five pillars – sociocultural, technical, organization, political and resources - each of which includes a number of elements. Table 5 summarises these and indicates progress in Viet Nam: (+) areas where there has been good progress; (+/-) areas where some work has been done but where more work is required; (-/+) areas where limited progress has been made; and (-) areas where major action is needed to fulfil requirements. Table 5. Progress in Viet Nam against the global strategic framework for rabies Pillars Elements Progress in Viet Nam Socio-cultural Building awareness +/- (covers a Promoting responsible dog ownership -/+ wide range of stakeholders Bite prevention and treatment programmes +/- including the Providing post-exposure prophylaxis +/- general public) Ensure community engagement -/+ Technical Need effective human and animal health services (fill the gaps) -/+ Vaccination – mass dog vaccination is the most cost effective +/- intervention Logistics – collect data on needs and meet these needs -/+ Diagnostics – appropriate lab support +/- Surveillance – support improved systems +/- Technical support +/- 29 Nguyen KA et al. Knowledge of rabies prevention in Vietnamese public health and animal health workers. Zoonoses Public Health. 2016 80 TECHNICAL ANNEX Organization The need for a One Health approach + Promote intersectoral collaboration + Establish good governance +/- Align work plans with national and regional priorities + Coordinate and combine human resources infrastructure and -/+ logistics Identify targets and their indicators +/- Monitor and evaluate national plans to ensure cost-effective, -/+ timely delivery Political Success depends on political will and support for elimination +/- Encourage request for a resolution through WHO and OIE - assemblies on elimination Establish and enforce appropriate legal frameworks -/+ Demonstrate the case for mass dog vaccination +/- Support active national and regional engagement + Resources Elimination spans several years and resources are required for the -/+ duration of the campaign Demonstrate the case for investment +/- Prepare business plans based on the global framework -/+ Encourage different forms of investment including private sector -/+ Although the categories used in Viet Nam’s integrated plan are not an exact match for the five pillars of the global strategic framework, all elements are present. Viet Nam has also aligned its national plan with the Stepwise Approach to Rabies Control developed by FAO and GARC,30 is the lead country for the ASEAN regional strategy on canine rabies elimination, and, with Indonesia, is also one of the two lead countries for the Zoonotic Diseases Action Package under the GHSA. 5.6. Key factors for success Key factors identified for success as described in the global strategic framework include: Long term political and social commitment. Community engagement. Sustainable vaccination of 70% of the at-risk dog population (reliant on an accurate dog register). Demonstrate that the system works by starting small and working up (e.g. one to two provinces). 30 http://caninerabiesblueprint.org/IMG/pdf/stepwise_approach_toward_rabies_elimination_sept_2014.pdf 81 TECHNICAL ANNEX Promote vaccine banks and other strategies to ensure sufficient supply of vaccines (human and canine) and immunoglobulin. Reaching remote, poor and vulnerable communities. Measurement of performance. Maintain trained and motivated personnel for implementation. 5.7. Challenges & constraints The main constraints for rabies control and elimination in Viet Nam include: Limited implementation of existing regulations. Limited political commitment and funding commitment at provincial levels. Difficulty in mobilising funds by provincial sub-departments of Agriculture. Ensuring provincial support for the programme which includes buy in by local authorities. Limited laboratory capacity for rabies diagnosis (three labs). Poor information on dog numbers, non-registration of dogs and allowing dogs to roam freely. Low canine vaccination coverage with only a few districts approaching required coverage levels. Ensuring sufficient resources to maintain high-level vaccination coverage for a number of years. The relatively short life span of dogs in Viet Nam that will rapidly reduce population immunity. Illegal imports of unvaccinated dogs from countries with poorly controlled rabies. Relatively high awareness about rabies at community level (despite limited outreach and education for dog owners and the general public) that does not convert to appropriate behaviours. Low proportion of bites treated with post-exposure prophylaxis which is a function of low community awareness and limited access to PEP. Rural and remote communities face particular challenges in accessing rabies post-exposure prophylaxis which is predominantly available in urban areas31. These constraints are linked. The most important constraints relate to ensuring buy in at all levels of the importance of canine virus control and eventual elimination from Viet Nam which, in turn, requires funding for canine vaccination and funds for delivery of PEP at least until the disease is very well controlled in dogs. Rabies vaccination of dogs will be required well beyond the 5-year time frame of this document. A share of the funds will need to be sourced from dog owners to continue this essential control measure beyond 2020 otherwise gains made in control will be lost, especially if neighbouring countries do not control rabies and illegal imports of live dogs from these countries continues to occur. A review of the program after the first 1-2 years of implementation will identify areas where progress Nguyen TH (2013). Rabies in Vietnam: Situation, Challenges and Prevention Strategies. Presentation given at the 9th Asian Rabies 31 Expert Bureau Meeting cited in www.who.int/rabies/epidemiology/Rabies_CP_Vietnam_09_2014.pdf 82 TECHNICAL ANNEX is not being made. Behavioural change programs will need to be carefully monitored and adapted if targets are not being achieved. Ecohealth approaches may be applied, involving local dog owners and other stakeholders, to understand the drivers of existing behaviours and measures that might result in appropriate modifications. 5.8. Targets The current objective of the Viet Nam national plan as listed in the summary plan is to strive for eliminating human rabies deaths/cases by 2020.32 This is an ambitious target given the challenges in sustaining vaccination coverage among canine populations of over 70% unless there is full commitment from all parties and sufficient funds provided by owners for canine vaccination. In other words, rabies may still be only partially controlled in canine populations by 2020, which will mean continued reliance on PEP and PrEP for disease prevention in humans. WHO has noted that the costs for post-exposure management account for nearly half of the total costs associated with rabies, so cost savings are only anticipated with sustained vaccination coverage among dogs.33 However, demand for PEP is unlikely to fall until there is confidence in rabies control measures in dogs, including evidence of very low prevalence, specific information on the vaccination status of dogs that bite and measures in place to monitor dogs that bite, as well as high levels of PrEP in high-risk communities. In addition, because many of the rabid dog cases occur in remote communities not all people bitten by a potentially rabid dog will choose to receive PEP and not all potential rabid dogs will be identified. The principal targets outlined in the Summary Plan are as follows: Description Target Increased canine vaccination Support for vaccination campaigns at provincial and district level so that levels of vaccination coverage are maintained above 70% Responsible dog ownership Behavioural change communications to reduce the number of free wandering dogs and to increase vaccination uptake and dog registration Post-exposure prophylaxis (PEP) for all humans Introduction of district treatment centres to all bitten by a dog (or other mammal) that could high risk areas to reduce the need for travel for have rabies those requiring PEP Pre-exposure prophylaxis (PrEP) for high risk Identification of high risk groups and groups including dog vaccinators, dog handlers implementation of a vaccination program and where necessary children in high risk areas Improved capacity to diagnose rabies Establishment/maintenance of quality assured testing capacity for rabies in humans and animals 32 By 2017, it may be necessary to review and revise this goal perhaps to aim for no human cases in a smaller number of high risk provinces in which pilot programmes are well implemented with strong provincial and district support, and to revert to the strategic vision of the OIE/WHO global framework of year 2030 for no human cases. It is noteworthy that Thailand, despite its marked reduction in canine rabies cases over the past 10 years, is yet to achieve the target of no human cases. 33 Rabies vaccines: WHO position paper. Weekly epidemiological record. No. 32, 2010, 85, 309–320 83 TECHNICAL ANNEX Other specific targets are, that by 2020: 70% of communes manage dog populations (through implementation of dog population management and responsible dog ownership programs); At least 70% of dogs are vaccinated at communal level; 70% of provinces report no rabies cases in animals; 20% decrease in human rabies cases annually (best measured using 3 year rolling averages). 5.9. Budget The minimum funding required for rabies control programs in Viet Nam over the next 5 years is approximately USD 24.8 million. This does not include the costs borne by the private sector (PEP for those bitten by potentially rabid dogs and payment for dog vaccination by dog owners which is estimated to be in the order of USD 40-45 million per annum). Funds from ADB may be available to support supplementary activities such as PrEP in children in high-risk border areas. A breakdown of budget by area is presented below: Area Estimated minimum funds for 5 years One Health approaches (including relevant meetings $2,250,000 [GoV] at local level) Information and communications $1,860,000 [GoV] Technical training $1,340,000 [GoV] Improved dog population management $11,600,000 [GoV] Strengthening Border controls $225,000 [GoV] Vaccines for humans and animals (high risk $3,800,000 [GoV] occupations and poor communities) Understanding the epidemiology of rabies $1,440,000 [GoV] Strengthen laboratory capacity $707,000 [GoV] Diagnosis and treatment of human cases $23,000 [GoV] Scientific research into rabies $1,500,000 [Donors] Developing policy and legislation $150,000 [GoV] 84 TECHNICAL ANNEX 6. One Health approaches to managing antimicrobial resistance 6.1. Background Antimicrobial resistance (AMR)34 is a growing concern globally35 with Asia acknowledged as an “epicentre of antimicrobial resistance”.36 Some of the highest rates of hospital and community- acquired resistant infections in Asia have been reported in Viet Nam.37 A paper published in 2013 from Viet Nam suggests that: “Antimicrobial resistance may represent the greatest global threat by an Emerging Infectious Disease issue. Its insidious nature may not have the cachet of SARS, pandemic influenza or Ebola but its impact on public health is likely to be far greater. Like other Emerging Infectious Diseases, drug resistance can quickly spread from one country to another and hence the need for concerted national and international action.”38 Antimicrobial resistance can arise in any place where there is poorly controlled use of antimicrobial drugs. Management and containment of this problem requires action in human and animal health and environmental sectors to reduce the number of untreatable bacterial infections that now occur both in and out of hospitals and the high levels of resistance in bacteria in animals, especially in livestock farms and aquaculture. Environmental dimensions are also important given the presence of antimicrobial drugs and resistant organisms in human and animal waste-water. In addition, many of the same principles of managing AMR can be applied to stewardship of treatments for other infectious diseases such as malaria, viruses and fungi. 6.2. Strategic directions The strategic direction for AMR can be summarised as “use less antimicrobials and use them wisely”. Human actions in health care, livestock production, environmental health and other related areas can either limit or accelerate the development of drug resistant bacteria. Reductions in AMR depend on improved and controlled use of existing drugs through better practices. Infection prevention through enhanced infection control in health care settings and biosecurity/preventive measures on farms and other places where animals are kept are also core components of the response to AMR. The overall objective of the Viet Nam antimicrobial action plan to 2020 is to promote prevention of drug resistance so as to ensure effective treatments for humans are available39 - “No action today, no cure tomorrow”. 34 The broad term antimicrobial resistance is used in this document to cover changes in resistance patterns in all classes of micro- organisms to drugs used in treatment and prevention. However, the main focus for the One Health approach is resistance in bacteria. 35 See http://www.princeton.edu/pei/news/S1473309913703189-main.pdf 36 Kang C-I, Song J-H. Antimicrobial Resistance in Asia: Current Epidemiology and Clinical Implications. Infection & Chemotherapy. 2013; 45(1):22-31. doi:10.3947/ic.2013.45.1.22. 37 Kim SH, et al. Changing Trends in Antimicrobial Resistance and Serotypes of Streptococcus pneumoniae Isolates in Asian Countries: an Asian Network for Surveillance of Resistant Pathogens (ANSORP) Study. Antimicrobial Agents and Chemotherapy. 2012; 56(3):1418-1426. doi:10.1128/AAC.05658-11. 38 Nguyen et al. Antibiotic use and resistance in emerging economies: a situation analysis for Viet Nam. BMC Public Health. 2013 13:1158 39 It is also important to have appropriate drugs available for animals. 85 TECHNICAL ANNEX 6.3. Achievements in establishing One Health approaches in Viet Nam The major achievements include: National, regional and international recognition of the magnitude of the problem and the need to manage and prevent AMR across sectors (MOH, MARD, MOIT, MONRE, WHO, FAO, US-CDC, OUCRU). Compilation of initial data on the extent of antimicrobial resistance in the animal and human health sectors and factors likely to be associated with AMR particularly through The Asian Network for Surveillance of Resistant Pathogens (ANSORP). Development of a national action plan (Decision No. 2174/QĐ-BYT, dated June 21, 2013). Official guidance on the management of the use of antibiotics in hospitals (Decision No. 772/ QĐ-BYT dated March 04, 2016 of the Ministry of Health). Establishment of an antibiotic stewardship program in 16 hospitals via the Viet Nam Resistance Project (VINARES) that monitors resistance patterns for hospital acquired infections in intensive care units, tracks antibiotic consumption, and institutes microbiological analyses to guide empiric and specific treatment. Establishing the National Hospital of Tropical Diseases as the national reference laboratory for AMR and the national reference hospital for antimicrobial stewardship. Participation in global and regional networks including the Global Antibiotic Resistance Partnership (GARP) which is supporting the establishment of a national reference laboratory for AMR and the implementation of the national action plan for AMR, and the Tokyo Meeting of Health Ministers on Antimicrobial Resistance (April 2016). Other activities have been conducted including regional work by FAO supported by USAID40 to understand and document AM use and AMR in livestock production industry, enhance awareness, promote AM stewardship and strengthen capacity in surveillance of AMR and residues in livestock. A network of laboratories is being established to provide AMR surveillance data. Studies on AM use have also been conducted by CIRAD. Other activities from the One Health matrix (Appendix 1) include: APEIR-AMR, IDRC, 2013-2015; Environmental and food reservoirs of AMR organisms, Vlir, 2013-15; Molecular epidemiology of AMR Salmonella/Campylobacter, NAFOSTED, 2012-15. 6.4. Work underway An integrated effort across a wide range of sectors is required to address AMR. In 2013 Viet Nam became the first country in WHO’s Western Pacific Region to approve a national action plan to combat Drug Resistance. An aide-memoire signed in June 2015 commits the Ministry of Health, Ministry of Agriculture and Rural Development, Ministry of Trade and Industry and Ministry of Natural Resources and Environment to coordinate and jointly implement the national action plan. The plan requires the formation of an inter-ministerial steering committee chaired by the Minster of Health with five subcommittees covering infection control; treatment; monitoring and inspection of use of AM in health facilities and communities and in farming; logistics; and education and communication. This committee will be required to coordinate with other related national coordination mechanisms related to One Health and the GHSA. 40 Antimicrobial Resistance (AMR) project (OSRO/RAS/502/USA) 86 TECHNICAL ANNEX Viet Nam’s AMR action plan contains 6 sub-objectives described below (Table 6). Provided there is buy-in and support from all involved parties, significant improvements can be made in the way antimicrobial drugs are used within the next 5 years as defined by a number of measurable and meaningful outcomes. Additional information on the extent of the problem is not needed before action is taken - sufficient information is already available to demonstrate there is a problem - although on-going measurement of the extent of the problem should continue as described in sub- objective 2 (AMR patterns in various organisms, and patterns of use in humans and animals). The first 5 sub-objectives of the AMR action plan are mainly within the remit of the Ministry of Health (MOH), however, key elements of some of these sub-objectives also involve the agriculture sector (for example, surveillance systems on the use of antibiotics and the development of drug resistance). The 6th sub-objective focuses explicitly on antibiotic use in livestock, poultry, aquaculture and cultivation, under the responsibility of MARD. Table 6. Sub-objectives of the Viet Nam national AMR action plan Sub-objective Description 1. Raise This important area requires a good understanding of the drivers of existing awareness of behaviours. As has been shown with other One Health issues, raising awareness antimicrobial is important but if it does not result in behavioural change then it will not resistance achieve the desired goal. For example, a number of antibiotics cannot be among the used legally in livestock in Viet Nam yet their use continues, suggesting that community and farmers see benefits in using these drugs and few disincentives from doing health workers so. This sub-objective also applies to farmers, veterinarians and veterinary paraprofessionals. 2. Strengthen On-going monitoring needs to be funded. Laboratories currently undertaking national this work and those planning to undertake this work need to maintain their surveillance capacity to perform the necessary testing using appropriate quality management systems on programmes. In the animal health area, capacity is needed to test for AM in the use of feed, wastewater and tissues as well as for determining resistance patterns of antibiotics and key organisms. Diagnostic services assist in determining whether diseases drug resistance in animals can be controlled by other means such as vaccination. While it is important to continue (and enhance) surveillance, sufficient evidence is already available to recognise that there is an urgent problem requiring immediate action through behaviour change to reduce demand, enforcement mechanisms to limit poor practices, and supply side measures 3. Ensure This applies to both human and animal health. If antimicrobial resistance adequate increases, then it will becomes more difficult to achieve this goal. It has already supplies been reported that the cost of antimicrobial treatments in hospitals is increasing of quality as more expensive drugs are required to replace those that are no longer effective medicines to in treating infections.41 meet the needs of people 41 Nguyen et al. Antibiotic use and resistance in emerging economies: a situation analysis for Viet Nam. BMC Public Health. 2013 13:1158 87 TECHNICAL ANNEX 4. Promote All hospitals are expected to have antimicrobial stewardship programs and the proper safe use proper use of antibiotics in the community is expected to improve. A review of of drugs prescribing practices in Viet Nam has led to an urgent call for change.42 5. Promote Infection control/prevention in hospitals and on farms are both recognised as infection control important elements for reducing the need for antimicrobial drugs and the spread of drug resistant organisms. While some investment is necessary to ensure infection control/farm biosecurity measures are in place, the main outcome is changes in behaviour (e.g. hand hygiene, following approved procedures, good animal husbandry practices, etc.). Over time, the savings from these measures are expected to offset their costs. Vaccination can also be used to prevent many diseases and reduce the need for antimicrobials, and will be promoted. 6. Promote Assessments of farming practices in Viet Nam has already shown that much proper, safe work needs to be done in changing the behaviour of farmers in the way they antibiotic use use antibiotics. These drugs are freely available, and mostly used as empirical in livestock, treatments without submission of samples for diagnostic tests. poultry, In many ways, it will be harder to change patterns of antimicrobial use in animals aquaculture and than in humans. A significant proportion of antimicrobial drugs for humans are cultivation used in hospitals where it is (relatively) easier to implement programmes on antimicrobial stewardship. Animals are reared on millions of separate farms and many para-veterinarians rely on antimicrobial drug sales as an important part of their income. During the next 5 years, the use of antibiotics in animals that are critical for treatment of human infections will be assessed. For example, Circular No.06/2016/TT-BNNPTNT dated May 31, 2016 from MARD defines the list of antibiotics that can be used in animal feed for growth promotion and their maximum concentrations. It applies until December 31, 2017. Review at that time provides an opportunity to modify the list of drugs that can be used for this purpose and also allows for consideration of any adverse consequences of proposed changes, such as increased use for therapy or disease control. The overall goal is to ensure proper use of antibiotics in animals and to improve controls on antibiotics that are critical for human use. One of the major drivers of improved use of antimicrobial drugs in aquaculture and strengthened enforcement programs has been the requirements of importing countries, rather than produce for local consumption. Resistance to viral infections has also been reported in some parts of the world as a result of illegal use of antiviral drugs in livestock. This area also needs to be examined in Viet Nam to ensure these drugs are not being used. Support for work on AMR will be provided during the next 5 years from a number of sources including the government, through the GHSA, and other initiatives including the Global Antibiotic Resistance Partnership (as well as disease-specific initiatives such as for tuberculosis, HIV and malaria that fall outside the scope of this plan). The overall goals are to reduce the quantities of antimicrobials used, establish appropriate systems of antimicrobial stewardship, and limit the use in animals of critically important antimicrobials for humans. 42 See Nguyen et al 2013 88 TECHNICAL ANNEX Resources are not the major constraint to improve use of antimicrobials. As stated elsewhere, it is possible for measures to tackle AMR to be cost neutral.43 Most of the improvements will come from behavioural and system changes. However these changes need full buy-in to the solutions from the highest level of government, in hospitals, in local clinics, pharmacies and veterinary supply stores as well as from the general public and farmers. The experiences with laws and enforcement of laws on motorcycle helmets in Viet Nam provide lessons for programmes on antimicrobial use. The problem of antimicrobial use in animals is compounded by an absence of a proper identification system for livestock. If an animal is found in a slaughterhouse to have been treated with an illegal antibiotic (through residue testing) it is not possible to trace this back to the farm of origin. Given the importance of livestock tracing for food safety, systems of animal identification will be assessed and, if feasible, implementation will commence by 2020 (see Section 7.10). 6.5. Alignment with existing policies & strategies WHO has developed a global action plan for antimicrobial resistance, endorsed at the 2015 World Health Assembly, with five objectives: 1. To improve awareness and understanding of antimicrobial resistance through effective communication, education and training; 2. To strengthen the knowledge and evidence base through surveillance and research; 3. To reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures; to optimise the use of antimicrobial medicines in human and animal health; 4. To develop the economic case for sustainable investment that takes account of the needs of all countries, and 5. To increase investment in new medicines, diagnostic tools, vaccines and other interventions. The WHO action plan highlights “the need for an effective “one health” approach involving coordination among numerous international sectors and actors, including human and veterinary medicine, agriculture, finance, environment, and well-informed consumers. The action plan recognises and addresses both the variable resources nations have to combat antimicrobial resistance and the economic factors that discourage the development of replacement products by the pharmaceutical industry.” One Health approaches are required because of the need for intersectoral collaboration, because misuse in one sector (e.g. livestock farming) can potentially affect others (e.g. human health) and also because of the considerable behavioural change that will be required to reduce the misuse of these drugs. A One Health approach is needed to protect existing antimicrobials especially given that resistance between bacteria can be transmissible and resistant bacteria in one species can transfer to other species through the environment or food chain. Already the global nature of this problem is evident with certain resistant strains of bacteria being detected in multiple locations around the globe, reviewed in detail elsewhere. Levels of use of antimicrobials in hospitals are much higher in Viet Nam than in European countries (defined doses per bed day) and resistance in a range of organisms in both animal and human pathogens has already been demonstrated including resistance to third and fourth generation cephalosporins and fluoroquinolones and carbapenem. Recent discoveries of colistin-resistance in carbapenem-resistant enterobacteria in a number of countries mean that suitable drugs are not available for treatment of infections with these organisms. 43 Nguyen et al. Antibiotic use and resistance in emerging economies: a situation analysis for Viet Nam. BMC Public Health. 2013 13:1158 89 TECHNICAL ANNEX A regional plan44 has also been developed that promotes three priority areas: 1. Strengthen development and implementation of comprehensive national plans to contain AMR and raise awareness in multiple sectors. 2. Improve surveillance of AMR and monitoring of antimicrobial use. 3. Strengthen health system capacity to contain AMR. Under each of these priority areas a number of steps and indicators are provided, with most of the indicators being qualitative. The Viet Nam national plan contains all of the elements of the global and regional WHO plans. MOH is the lead agency on human health and use of AM in health care settings with a large number of departments responsible for implementing specific components of the national action plan. MARD is the lead agency for use of AM in animal production and aquaculture and horticulture. 6.6. Key factors for success Behavioural change is key to progress in dealing with AMR. The entire population of Viet Nam is a stakeholder on this issue but special attention needs to focus on those using and prescribing the majority of antimicrobials. This occurs in health care settings and farms. Information is also needed on the quantities and types of antimicrobials being used so that changes in patterns of usage over time can be measured. 6.7. Challenges & constraints The challenges and constraints are well recognised and have been well described, as the following selected extracts from Nguyen et al 2013 demonstrate.45 “Patients, physicians, veterinarians, clinics and hospitals, and retailers – from large pharmacies to local drug sellers – have little motivation to weigh the negative impact of their antibiotic use on others, especially those in the future. Policy solutions must alter incentives for patients, physicians and others in the healthcare system to act in society’s best interests.” Many of the laws and processes necessary for sound regulation of the quality and use of drugs have been defined but remain inadequately implemented. Enforcement is still weak and has not achieved its intended objective. This will be an area of development in the next 5 years. “There are many barriers preventing effective enforcement of regulations designed to improve antimicrobial stewardship in developing countries: insufficient funding and lack of expertise, human resources and financial incentives. It is important to foresee possible negative consequences of enforcement: financial losses and reduced healthcare access. Accounting for this will improve policy implementation in these settings. Furthermore, it is important to know where to focus regulatory efforts: a focal point too far downstream may create targets too numerous or dispersed for enforcement to be feasible.” From a One Health perspective, there is also a challenge in ensuring the full integration of human health, livestock production and environmental health aspects of AMR prevention and control within the overall national approach. 44 http://www.wpro.who.int/entity/drug_resistance/documents/action_agenda.pdf?ua=1 45 See the Table 2 in Nguyen et al 2013 to have more information on constraints. 90 TECHNICAL ANNEX 6.8. Targets Activities will be conducted in each of the areas in the national action plan and as a result improvements are expected under each of the six sub-objectives (below) as described in the Summary Plan. A multitude of existing policies and processes provide a ready operational framework for implementation of the national action plan. Indicators for these are being developed. 6 sub-objectives of national action plan Target Reduced use of antibiotics in animals Assess likely effectiveness and feasibility of bans including improved controls on antibiotics on the use of medically important antibacterial critical for human use agents for growth promotion in livestock and drugs critical for human treatment. Where feasible, introduce and enforce bans and require purchase by prescription only Reduced and improved use of antibiotics in Widespread implementation of antibiotic humans stewardship programs and behavioural change campaigns for the public Improved data on antimicrobial use and Relevant information collected following the antimicrobial resistance GHSA Roadmap Improved infection control and prevention Widespread implementation of IPC programs in (IPC) programs in hospitals hospitals Enhanced laboratory capacity for testing for Fund existing and new AMR testing laboratories AMR using quality assured programs Reduced environmental contamination with Reduced use of AM compounds in farms and antibiotics animals, and improved waste disposal On the human health side and indicative of the establishment of health care processes for regulating the quality and use of antibiotics, tracking AMR infections and preventing in-hospital infections, the following outcomes are anticipated by 2020: Defined measure(s) to track antibiotic consumption and prescribing in tertiary hospitals. For example: A 50% reduction in the number of defined daily doses/100 bed-days will have been achieved from current levels. Estimates in the national action plan suggest that antimicrobial use in Vietnamese hospitals is around five times that of similar sized facilities in Europe. A 75% reduction in inappropriate post-operative antibiotic prophylaxis regimens. Defined measure(s) to track the effectiveness of infection control procedures in tertiary hospitals. For example, a 50% percent reduction in hospital-acquired infections in intensive care units with resistant organisms will be recorded as a result of changes in behaviour and improved infection control. (Current estimates suggest that one in four ICU patients are infected with a hospital- acquired infection and the systems for monitoring this have already been established in large hospitals through the VINARES project.) 91 TECHNICAL ANNEX Established national laboratory network of 18+ laboratories with ISO 15189 compliance and accreditation for AMR surveillance Under the six components of the national action plan the following targets have also been set: Component Targets 1.Raise awareness 1.1. Compile documents for training 1.2. Develop IEC materials 1.3. Organise communications activities 1.4. Assess knowledge of the community about AMR 2. Surveillance 2.1. Building appropriate laboratories including reference laboratories for system animal health - National Center for Veterinary Hygiene and Inspection – and human health – The National Hospital for Tropical Diseases 2.2. Quality management systems for laboratories (30 + labs) 2.3. Establish surveillance systems 2.4. Curriculum development for tertiary institutes 2.5. Continuing education for clinical microbiology lab staff 2.6. Develop cooperative programs with overseas institutions 2.7. Develop a database of antibiotic use and antibiotic resistance (human and animal) 3. Supply quality 3.1. Update documents listing essential medicines drugs 3.2. Invest in production/supply of quality drugs at reasonable prices 3.3. Implement management systems for ensuring drug quality 4.Safe use of drugs 4.1. Develop documents regulating rational antibiotic treatment in humans 4.2. Conduct training on good prescribing practice and pharmacy practice 4.3. Improve capacity of Council of Drugs and Treatment 4.4. Monitor and supervise safe use of drugs (as per 2.7) 4.5. Develop and use training material on clinical pharmacy practice 5. Strengthen 5.1. Improve documents on infection control infection control 5.2. Provide continuing education on and monitor infection control 5.3. Promote monitoring system for infection control 5.4. Enhance farm biosecurity measures and promote GAHP 6. Safe use of 6.1. Develop manuals on prescribing and use of antibiotics in animals drugs in animals 6.2. Develop a list of permitted antibiotics for animals (livestock, poultry, 6.3. Prescribe and enforce residue limits aquaculture) 6.4. Establish monitoring systems for appropriate use of antibiotics (as per 2.7) 6.5. Enhance control on discharge from farms that will contain AM and resistant bacteria (MONRE) 92 TECHNICAL ANNEX 6.9. Budget The minimum funds required for work on AMR using One Health approaches over the next 5 years is estimated to be in the order of USD 20 million. Funding is expected to come from government, the GHSA funding envelope, ADB and other partners. Budgets for individual components are being developed under the GHSA Roadmap. 93 TECHNICAL ANNEX 7. One Health approaches for managing other zoonotic diseases 7.1. Background A wide range of other zoonotic diseases occurs in Viet Nam. Streptococcus suis, leptospirosis and anthrax are included in Inter-ministerial Circular 16/2013 (along with avian influenza (H5) and rabies). A One Health perspective can help reduce the burden of illness from these diseases. The main diseases are listed in Table 7. Table 7. Priority zoonotic diseases as defined by the Government of Viet Nam Priority zoonosis Comments Anthrax Circular 16 disease Localised outbreaks associated with consumption of animals that died from anthrax Brucellosis Need to monitor given high levels in region, expansion of dairy sector and high volume of trade in live cattle with neighbouring countries. Leptospirosis Circular 16 disease No evident occupational risk but higher risk in rural communities. High prevalence of exposure in rats in southern Viet Nam. Streptococcus suis Circular 16 disease Some disease due to occupational exposure, consumption of raw pork or pig blood, but some with no known exposure to pork46 Other A range of other zoonotic agents occur or have occurred and could re-emerge. Most are associated with individual cases of disease rather than outbreaks Streptococcus suis causes meningitis and, occasionally, streptococcal toxic shock in humans. It is carried by many healthy pigs, though can also cause severe disease in pigs including septicaemia, meningitis and endocarditis. Most human cases are associated with butchering of pigs or pig meat and also with consumption of raw or undercooked pork products, including raw pig blood.47 A possible association between Porcine Reproductive and Respiratory Syndrome (PRRS) outbreaks in pigs and increased human cases of disease caused by Streptococcus suis has been reported in Viet Nam.48 This association suggests that control of non-zoonotic epidemic diseases of swine may help to prevent zoonotic diseases. Local research has demonstrated the difficulties in changing attitudes and practices towards consumption of raw pig blood through behavioural change communication and regulation.49 Nevertheless, there is a need to continue developing appropriate information for school curricula on the risk of infectious diseases (Streptococcus suis and other food-borne pathogens) with consumption of raw pork and pork blood including consumption of products from animals that appear healthy. Vaccines against Streptococcus suis are still some years away. 46 Nguyen THM et al. Streptococcus suis meningitis in adults in Vietnam. Clinical Infectious Diseases. 2008; 46(5):659-667 47 http://cid.oxfordjournals.org/content/48/5/617.long 48 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697300/ 49 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214319/ 94 TECHNICAL ANNEX Leptospirosis has been examined in a number of studies in Viet Nam50, 51 and the region but additional work is required to understand the disease and to determine the extent to which it occurs. It is under-recognised given it is difficult to diagnose both clinically and in the laboratory. Much of the disease appears to be water-borne and linked to heavy rainfall and flooding, but our knowledge about the risks associated with disease is incomplete. Climate change has the potential to increase the range and the risk of leptospirosis in Viet Nam. Livestock, pets and wild animals (especially rats) appear to be the main reservoirs for leptospires but the links between animals and humans is not always direct. Anthrax has caused 413 human reported cases and three deaths in northern Viet Nam between 2006 and 2011 and occasional outbreaks continue. All cases have been linked to slaughtering/eating dead ruminants.52 In areas where the disease is known to occur, vaccination for livestock will be used and combined with communication campaigns about the importance of not consuming dead ruminants. Other zoonotic diseases also occur in Viet Nam: Japanese encephalitis (JE) is a locally important cause of encephalitis especially in children and is associated with spillover of virus from either swine or wild birds. It is an epidemic- prone disease that can be controlled through increasing and sustaining vaccine coverage of a locally produced vaccine among eligible children with possible catch up of older age groups depending on the epidemiology of the disease.53 Currently, the national immunisation schedule includes 2 doses of JE vaccine (separated by 2 weeks) when a child is 12 months of age, and a 3rd dose when the child is 2 years old (vaccination of pigs is not recommended because of the difficulties associated with obtaining high level herd immunity given the rapid rate of turnover). Studies will continue to determine the major causes of encephalomyelitis in humans in Viet Nam building on those undertaken in the past. The data from these studies will help to guide JE vaccination strategies, detect any antigenic variants and identify other pathogens. Murine typhus54 occurs as a source of rat-borne disease transmitted by fleas and is controlled through both rodent and flea control. These activities will continue. Other zoonotic diseases that cause problems in other parts of Asia - and probably exist in Viet Nam but are rarely diagnosed - include brucellosis55 and bovine tuberculosis. The marked increase in size of the dairy sector could result in an increase in one or both of these diseases, although it is highly likely (based on testing) that imported dairy cattle and their progeny on large farms are free from infection. Nevertheless, there is considerable trade in other cattle in Viet Nam some of which move over long distances from other countries in the region and are only held in Viet Nam temporarily. Large markets provide opportunities for spread of these diseases. Brucellosis has become an important zoonotic disease in China, another country that has rapidly expanded its dairy sector. Plague caused by Yersinia pestis has not been diagnosed in Viet Nam for over 10 years but caused epidemics in the past. Q fever could occur in areas with high populations of goats. 50 http://www.ncbi.nlm.nih.gov/pubmed/10326104 http://www.ncbi.nlm.nih.gov/pubmed/25629781 51 http://www.ncbi.nlm.nih.gov/pubmed/25995736 52 http://www.ncbi.nlm.nih.gov/pubmed/25778504 53 Yen NT et al. A model immunization programme to control Japanese encephalitis in Viet Nam. J Health Popup Nutr. 2015; 33(1):207-2013 Hamaguchi S et al. Clinical and Epidemiological Characteristics of Scrub Typhus and Murine Typhus among Hospitalized Patients 54 with Acute Undifferentiated Fever in Northern Vietnam. Am J Trop Med Hyg. 2015; 92(5):972-978 55 http://www.rr-asia.oie.int/fileadmin/Regional_Representation/Programme/Emerg/2014_Brucellosis_Chiang_Mai/15.Vietnam.pdf 95 TECHNICAL ANNEX Zika virus, while not strictly within the framework of this plan as discussed in the Introduction, was originally a virus of zoonotic origin. It has emerged as a serious cause of human disease in South and Central America, the Caribbean and French Polynesia, affecting foetal development and associated with Guillian-Barre syndrome in some cases. Zika virus is present in Viet Nam, demonstrating the capacity of local mosquito populations to transmit the virus but the disease associated with local strains is generally mild. Studies will continue to characterise local viruses to define whether there is a local host animal population (See Focus Area 3) and to compare local strains with those from the Americas. Special attention will be paid to the capacity of local strains to cause disease during foetal development. If a strain of virus similar to that found in the Americas is detected in Viet Nam and is transmitting locally this would be handled as an emergency using capacity built for emergency disease management (see Focus Area 2, One Health approaches for managing human disease emergencies of zoonotic origin). 7.2. Strategic directions Application of One Health approaches for control, prevention and management of existing zoonotic diseases. 7.3. Achievements The main achievements on these zoonotic diseases include conducting of research (see 7.1) and development of guidance on directions for future work. 7.4. Work underway Work is expected to be conducted in the following areas for the following priority zoonotic diseases: Priority zoonosis Comments Leptospirosis Additional research, Public awareness, Interagency coordination/Circular 16 including case investigations Streptococcus suis Additional research, Public awareness, Interagency coordination/Circular 16 including case investigations Anthrax Vaccination, Public awareness, Interagency coordination/Circular 16 including case investigations Brucellosis/ Additional research including risk assessment of imported cattle, tuberculosis Management of major cattle market, Diagnostic tests and reagents (surveillance) Japanese encephalitis Human vaccination, Case investigations, Public awareness Other zoonotic Public awareness, Emergency contingency for severe disease outbreak diseases 7.5. Alignment with existing policies & strategies APSED will continue during this period and activities will be aligned with this program. The GHSA has action packages that encompass these diseases including the immunisation action package. 7.6. Key factors for success The main factors that result in success in managing zoonotic diseases are good surveillance and case 96 TECHNICAL ANNEX detection systems including laboratories capable of conducting appropriate tests for these diseases. It is critical to involve stakeholders in the development of appropriate disease control strategies. Vaccinations exist for some of these diseases and need to be implemented in accordance with agreed schedules with appropriate properly stored vaccines. 7.7. Challenges and constraints The major challenges and constraints for control and prevention of these diseases include: Under-reporting or under-ascertainment of diseases Lack of familiarity with requirements of Circular 16 especially at lower levels Resources for One Health approaches to these diseases Difficulties in changing behaviours 7.8. Targets The main targets by as provided in the Summary Plan are listed below. Description Target Anthrax control Improved public awareness in high risk areas and enhanced vaccination Reduction in burden of disease due to Behavioural change (where possible) especially Streptococcus suis consumption of raw pig products Reduction in burden of disease due to Community awareness of the dangers of Leptospirosis leptospirosis in periods of heavy rainfall Enhanced traceability of animals and residue Practical animal identification systems such as testing pig tattoos linking animals in slaughter houses to individual farms or small scale traders Risk assessment of food borne illness of Conduct a risk assessment to help justify animal origin investments in this area Circular 16 will be fully implemented at all See focus area 1 levels with reporting of all cases in the human and animal sector to both MOH and MARD (as well as their local counterparts) Over the next 5 years the following targetsare also expected to be achieved: Additional research to further define the extent of these diseases and to develop appropriate control and preventive measures, building on work already undertaken Communications to improve awareness about leptospirosis among the medical profession Improved diagnostic capacity for leptospirosis in human and animals Continued increase in the coverage of JE vaccine for children eligible under the National Immunisation Schedule with reductions in the number of human cases of Japanese encephalitis 97 TECHNICAL ANNEX Risk assessment on brucellosis from trade in ruminants from neighbouring countries 7.9. Budget The estimated minimum cost for activities on other zoonotic diseases is USD 5 million over the next 5 years. This figure does not cover the cost of treatment of human cases. 7.10. Foodborne diseases 7.10.1. Background Foodborne diseases resulting from the presence of pathogenic organisms or toxic chemicals in/ on food of animal origin are an important cause of morbidity and less commonly mortality in Viet Nam. The range of diseases and agents involved in Viet Nam has been reviewed56 and bacterial foodborne diseases were ranked in the top five conditions that should be prioritised for action based on disease severity, outbreak potential and public attention.57 Food safety in Viet Nam is recognised, in general, as a major issue by the public and an area in which major actions are expected to be taken in the next 5 years. Both the immediate effects of acute foodborne illness and the long-term effects of consumption of products that contain excess levels of persistent organic pollutants or other chemicals are of concern to the general public. Among the important foodborne bacterial pathogens are non-typhoidal Salmonella, Campylobacter species, verotoxigenic Escherichia coli and Listeriaspecies. A range of parasites are also foodborne, including toxoplasma, cysticercosis/taeniasis, trichinellosis and trematodes from fish. As a rule, reported cases of food poisoning represent only a small proportion of all cases. Contamination can occur anywhere along the chain from farm to consumer and some of the risks are mitigated through processing, including cooking. Fragmentation of the livestock sector into millions of producers with consequent difficulties in identifying individual poultry and pigs inhibit efforts to improve traceability. Nevertheless, aquaculture products destined for export are traceable and demonstrate that viable systems can be developed to improve food safety. Many of the measures implemented to prevent food-borne diseases of animal origin will have significant effects in containing and controlling other diseases. For example, residues of antimicrobial drugs have been implicated in the development of antimicrobial resistance58 as well as being potentially harmful to humans exposed to excessive levels. Methods used to test for residues in pigs at slaughter require a tracing system back to the farm of origin. Similar methods are also required for other chemicals such as illegal use of beta-agonists, including salbutamol and clenbuterol. At present, foodborne diseases are managed through other mechanisms including the Food Safety Network to which the One Health Partnership secretariat contributes. Therefore, they are not included as a core element of the 2016 – 2020 zoonotic disease One Health plan and are not dealt with in detail in this document. The One Health Partnership can, however, facilitate inter-ministerial action on foodborne diseases of animal origin and can help prevent duplication of activities in areas such as animal identification systems and the development and application of good animal husbandry practices (GAHP)59 which are also needed for the control of other zoonotic diseases. There is a common interest in improving aspects of transport, slaughter, handling and marketing for prevention of emerging infectious diseases and foodborne disease. 56 Carrique-Mas JJ et al. A review of food borne bacterial and parasitic zoonoses in Vietnam. Ecohealth. 2013; 10(4):465-489 57 Trang DT et al. Prioritization of zoonotic diseases of public health significance in Viet Nam. JIDC. 2015; 9(12):1315-1322 58 Residues probably play a lesser role than resistant organisms on or in food of animal origin. http://www.worldbank.org/en/results/2016/04/14/vietnam-better-food-safety-and-production-efficiency-with-good-animal- 59 husbandry-practices 98 TECHNICAL ANNEX The law on Food Safety was passed in 2011 with responsibility for animal products largely delegated to MARD. For MARD, the improvement of disease prevention along the chain from farm to household will continue during the next 5 years with a focus on GAHP and product/animal traceability. Importing countries (e.g. EU requirements for animal products)60 also play a role in driving food safety standards as has been seen with aquaculture products. This can be used as a major driver for improving food quality especially if these same procedures are used for local products. Much of the work on improving food safety requires behavioural change and it is necessary to involve stakeholders in developing appropriate solutions. In addition, major food companies also have quality management systems in place to ensure that products supplied in restaurants and supermarkets do not pose a risk to consumers. This expertise should be utilised. One Health approaches are gradually being implemented on food safety issues in Viet Nam and elsewhere. The Codex Alimentarius Commission, the body that sets standards for food, embodies the One Health approach. It was established by FAO and WHO to develop an international food code aimed at ensuring safe produce. 7.10.2. Work underway A number of agencies are involved in prevention and management of foodborne diseases from animal products in Viet Nam. A World Bank project includes a major food safety component (LIFSAP) and has introduced improvements to markets and slaughter points to reduce the risk of foodborne pathogens. This project also supports the introduction of good animal husbandry practices. In January 2016 a meeting was held at the World Bank in Viet Nam to assess the critical gaps and issues on food safety in Viet Nam as the first step towards a formal risk assessment. FAO and WHO are supporting the GoV in review of the food safety law to assess the implications of the law across multiple sectors; the review will be completed by 2019. The following extract from a report on a meeting on food safety issues highlights the range of stakeholders involved in food safety. “The Food Safety Working Group (FSWG) is an initiative to bring key Government Agencies/ Line ministries and development partners (DPs) together for joint policy dialogue and discussions on food safety issues in Viet Nam. It was created at the request of, and convened under the auspices of, the Deputy Prime Minister Vu Duc Dam at a meeting in June 2015 chaired by DPM Dam and benefits from the active participation of Office of Government (the designated focal point of coordination), Ministry of Health (MOH), Ministry of Agriculture and Rural Development (MARD), Ministry of Industry and Trade (MOIT) from the Government side and of the Food and Agriculture Organization (designated focal point among development partners), Asian Development Bank (ADB), Canadian Embassy, JICA, New Zealand Embassy, and the World Bank.” Meetings of the FSWG in January and March 2016 included participants from various departments and institutes within MARD including the National Ago-Forestry-Fisheries Quality Assurance Department (NAFIQAD), representatives from FAO, WHO, and the Ministry of Industry and Trade, One Health Partnership, the private sector, ADB, World Bank and various donor countries. 60 http://ec.europa.eu/food/fvo/act_getPDF.cfm?PDF_ID=10116 99 TECHNICAL ANNEX 7.10.3. Challenges and constraints The biggest constraint is the fragmentation of the livestock sector into millions of small farms, poor traceability and limited capacity for testing. Food handling practices from slaughterhouse through markets to final preparation by and for consumer (including the absence of appropriate refrigeration) provide conditions for pathogens to multiply in meat. The lack of enforcement results in use of chemicals that should not be employed in food animals. Persistent environmental contaminants are present in animal products from certain areas 7.10.4. Targets As described in the Summary Plan by 2020, it is expected that systems for identification of food animals going to slaughter will have been examined for feasibility, such as a tattoo system for pigs, to allow traceability of pigs and carcasses back to farms or traders. A risk assessment on food safety will have been completed highlighting areas where improvements to food safety are required and can be made. 100 TECHNICAL ANNEX

Appendix 1: List of selected One Health activities in Viet Nam from 2005-2020 by disease focus 101 TECHNICAL ANNEX 102 SUMMARY PLAN For more details please contact Vietnam One Health Partnership for Zoonoses (OHP) Ministry of Agriculture and Rural Development (MARD) B1 Building, No. 10 Nguyen Cong Hoan, Ba Dinh, Ha Noi Tel: +84 24 37713741 Fax: +84 24 37711362 Email: oh.partnership@onehealth.org.vn; oh.partnership@gmail.com Website: www.onehealth.org.vn 104