Đánh giá thực trạng năng lực sẵn sàng ứng phó với một số bệnh truyền nhiễm nhóm a tại cửa khẩu và sự chấp nhận của kiểm dịch viên y tế về một số giải pháp can thiệp TT TIENG ANH

MINISTRY OF EDUCATION MINISTRY OF HEALTH AND TRAINING HANOI MEDICAL UNIVERSITY HOANG VAN NGOC HEALTH SYSTEM'S READINESS AND CAPACITY FOR THE PREVENTION AND CONTROL OF TYPE A COMMUNICABLE DISEASES AND ACCEPTABILITY, FEASIBILITY OF INTERVENTIONS FOR IMPROVING HEALTHCARE WORKERS’ CAPACITY AT POINTS OF ENTRY Major field: Public Health Code: 62720301 SUMMARY OF PUBLIC HEALTH DOCTORAL THESIS HANOI - 2021 THE DISSERTATION IS COMPLETED AT HANOI MEDICAL UNIVERSITY 2 Academic supervisors: Assoc.Prof Tran Dac Phu, Ph.D – Ministry of Health Assoc.Prof Nguyen Dang Vung, Ph.D – Hanoi Medical University Reviewer 1: Reviewer 2: Reviewer 3: The dissertation has been presented to the dissertation doctoral Committee at the university level at Hanoi Medical University The dissertation can be found at: - Vietnam National Library - Library of Ha Noi Pharmacy University LIST OF PUBLICATIONS 3 Hoang Van Ngoc, Tran Dac Phu, Nguyen Dang Vung (2019) Knowledge of health care workers at Points of Entry about Yellow Fever, 2014 Journal of Preventive Medicine, 8(1106), 19-22 Hoang Van Ngoc, Tran Dac Phu, Nguyen Dang Vung (2019) Knowledge of health care workers at Points of Entry about avian influenza A(H7N9), 2014 Journal of Preventive Medicine, 1(1088), 19- 22 Hoang Van Ngoc, Tran Dac Phu, Nguyen Dang Vung (2021) The Effect Of Combining International Centers For Health Quarantine Into Centers For Disease Control And Prevention On Improving Border Health Quarantine VietNam medical journal N02 – July 80-84 INTRODUCTION According to the Law on Prevention of Communicable Diseases in Vietnam, communicable diseases (CDs) are classified into three types A, B, C according to their decreasing danger level Yellow fever and avian influenza A (H7N9) or “bird flu” are categorized in type A CDs World Health Organization (WHO) states that yellow fever and avian influenza A (H7N9) are two dangerous CDs that can constitute emergency public health events of international concern requiring quarantine and immunization - according to International Health Regulations 2005 (IHR 2005) 4 Vietnam contains expanded networks of transportation which is a favorable condition for importing CDs Building and strengthening the readiness and capacity for health system for prevention and control CDs at Points of Entry (PoEs) are keys to prevent and control importing these diseases from outside In Vietnam, the International Health Quarantine Centers (IHQC) are responsible for screening, monitoring, preventing, and rapidly responding to potential CDs and public health events that can import through PoEs into Vietnam Quarantine workers (QWs) at these centers require to be competent to prevent potential risks of pathogens, especially those in type A CDs Because HCWs’s working locations at PoEs are unstable, widely distributed, and rapidly changed, they are difficult to attend in-person training programs (called as the traditional method) Besides, the knowledge about CDs is rapidly changed in the literature that requires updating frequently To give recommendations about the development strategy of the health system at PoEs, we deployed a study entitled “The Health system’s readiness, capacity for the prevention and control of type A communicable diseases and acceptability, feasibility of interventions for improving healthcare workers’ capacity at Points of Entry” with two objectives: Describe the health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A(H7N9) at 13 International Health Quarantine Centers, 2014 Assess the acceptibility and feasibility of two capacity building interventions at some International Health Quarantine Centers, 2015 -2019 5 FEATURES OF THE DISSERTATION Our findings contributed scientific and practical evidence for the development strategy at PoEs in Vietnam It is the first study conducted on 13 IHQC in Vietnam We recruited 265 HCWs in the cross-sectional study to describe the health system’s readiness and capacity for the prevention and control of yellow fever and avian influenza A(H7N9) and 31 directors/vice directors and department heads in qualitative research on assessment of the acceptability and feasibility of two interventions for improving healthcare workers capacity Our findings found that: The prevalence of good knowledge, positive attitude, and good practice for prevention and control of yellow fever and avian influenza A(H7N9) were relatively low in quarantine workers in Vietnam With regard to yellow fever, 43% of HCWs had inaccurate knowledge of the disease causative agent – yellow fever virus; 46.4% of HCWs had inaccurate knowledge of transmission routes through mosquitoes; 60% of them did not identify the blood sample as a diagnostic specimen, and 30% did not know about preventive measures of yellow fever We recorded 65% of HCWs had attitudes that yellow fever is dangerous and extremely dangerous Most of them reported a need to educate passengers about yellow fever and to monitor strictly this disease at PoEs However, practices to prevent yellow fever were limited in HCWs Only 7% of them communicated of the diseases for passengers at PoEs With regard to avian influenza A (H7N9), 13% of HCWs had inaccurate knowledge of the disease causative agent - virus; 18.5% of HCWs had inaccurate knowledge of transmission routes from infected poultry to humans Most of them had the correct knowledge about the definitions for suspected and confirmed avian influenza A (H7N9) cases We recorded 70% of them had correct knowledge about the diagnostic specimens - the throat, nasal, and pharyngeal swabs Most of HCWs had attitudes that influenza A (H7N9) is dangerous and extremely dangerous, need to propagate to passengers and monitor at immigration points Most Centers were well-organized with sufficient necessary departments However, most lacked the number of quarantine officers compared to the Government’s requirement, especially those in the 6 health sector and having English certificated The equipment at the International Health Quarantine Center was insufficient, low yield, and error-prone Most had prevention plans for influenza A (H7N9), however, it's scant for yellow fever We recorded the shortage of contingency plans and simulation exercises for emergent events We evaluated the acceptability and feasibility of an educational intervention for improving healthcare workers' capacity that used online learning (E-learning) in training Knowledge of yellow fever and influenza A (H7N9) was significantly improved after the intervention (compared to before the intervention) and in the intervention group (compared to the group taught by traditional methods) We also assessed the impact of merging IHQC into the Centers for Disease Control (CDCs) to improve QWs’ capacity at six provinces and cities in Vietnam Most officials believed that the merging was necessary that helps to use financial and human resources in more effective ways After merging, they could require more human resources from different departments that help to quickly respond to emergent events On the other hand, other opinions indicated that the merging is unnecessary They were not sure that merging could reduce the financial burden for the government After merging, the process of working was heavy with an increasing quantity of workers but decreasing quality Our findings provide evidence for the Ministry of Health to develop strategies and appropriate plans for improving HCWs’ capacities at PoEs STRUCTURES The dissatation included 143 pages: Introduction pages, Chapter Overview 39 pages; Chapter Methods 25 pages; Chapter Results 40 pages; Chapter Discussion 34 pages; Conclusion and Recommendation 03 pages References 137 The thesis has 30 tables, charts, 13 pictures and appendixes Chapter OVERVIEW 1.1 Health quarantine in Vietnam By 2015, the health quarantine system in Vietnam is organized throughout from national to local levels, including 13 international health quarantine centers (IHQC) at 13 provinces and cities and 34 international health quarantine teams at the provincial/city CDCs 7 Health quarantine has been implemented at 77 international border gates, including 10 airports, 43 seaports, and 21 ground-crossing, three railways; and 54 large border gates, including 27 seaports and 27 ground-crossing in Vietnam The majority of the quarantine workload is carried out by 13 IHQC due to the high volume of imported and exported people and goods 1.2 Type A communicable disease According to No "the classification of communicable diseases" of the Law on Prevention and Control of Communicable Diseases (No 03/2007/QH12 dated 21/11/2007) in Vietnam, communicable diseases (CDs) are classified into three types - A, B, C according to their decreasing danger level Type A includes dangerous CDs that are capable of transmitting and spreading in the community very quickly These diseases have a high mortality rate with known or unknown pathogens 1.2.1 Yellow fever The disease causative agent is yellow fever virus that exists and multiplies in the cells of many kinds of mosquitoes, in which Aedes mosquitoes is the most common transmission vector In the environment, the virus has poor resistance They are easily killed by common chemical disinfectants, detergents, soap, heat (above 56C for 30 minutes), sunlight, and ultraviolet rays There is an estimate that about 200,000 cases of yellow fever recorded every year, of which about 30,000 people died In the 1980s, yellow fever surged and resurged in sub-Saharan Africa and South America Between 1985 and 2009, among 30,000 yellow fever cases were officially reported to WHO, of which 90% of cases recorded in Africa Vaccination is the most effective preventive measure against this disease Vietnam does not record a confirmed case of yellow fever so far However, preventing and managing the risk of importing this disease are important due to the surge of yellow fever cases in neighboring countries, such as China Therefore, strengthening the health quarantine system at PoEs becomes extremely important This system is considered as a first fence to detect, handle and manage these risks Another effective control measure is educating people to adhere control measures for managing the reproduction of Aedes mosquitoes in 8 residential areas These measures are similar to ones applying to control mosquitoes for dengue fever 1.2.2 Avian influenza A(H7N9) The disease causative agent is a new influenza virus subtype – avian influenza A(H7N9) virus This agent originated from poultry, which recombines from agents in wild birds and Asian birds The avian influenza A(H7N9) virus is continuing to adapt to mammals including humans Current evidence in the literature did not specify the transmission path of the avian influenza A(H7N9) virus Due to some initial hypotheses, some studies have shown that the virus is capable of transmitting from person to person in a narrow space or transmitting from human to human or bird to human However, we did not know how long does the contact takes to get the successful transmission The first confirmed case of avian influenza A (H7N9) virus was recorded in March 2013 in Shanghai, China Afterward, this disease was successfully spread to 14 other provinces and cities in China, of which the two provinces - Yunnan and Guangxi, shared borders with Vietnam From 2013 to 2017, there were 1,557 cases of avian influenza A (H7N9) in humans, of which 605 died The disease was divided into five epidemics, usually appearing in the winter-spring season every year No safety and distributed vaccine was produced to prevent avian influenza A (H7N9) virus in humans so far Some vaccines were testing for human safety while others successfully developed in laboratories in animals Since 2013, due to the fluctuation of the avian influenza A (H7N9) disease situation in China, the Vietnam government delegated the Ministry of Health to place many control measures to respond to this disease, including issuing the guideline for surveillance and definitions of suspected cases, confirmed cases, and close contact; monitoring critical cases at focal points and designated health facilities; monitoring entry passengers to screen and detect suspected cases; strengthening the system of laboratories nationwide; preparing quarantine places for suspected cases; establishing rapid response teams for CDs; promoting health communication at PoEs for passengers; promoting health communication in the community; updating the disease’s situation continuously; and coordinating with international organizations, such as WHO and CDCs, for advices in preventing plans 9 1.2.3 Knowledge, attitude, and practice to prevent and control communicable diseases Current evidence on assessing knowledge, attitudes, and practices (KAP) on the prevention of CDs among healthcare workers at PoEs are limited Some studies on KAP on the prevention of yellow fever and avian influenza A (H7N9) were performed on medical students; poultry buyers, sellers, consumers, and clinical healthcare workers at treatment facilities According to our literature review, no studies have been performed on community health workers at PoEs in both Vietnam and worldwide Interventions to improve KAP on prevention of CDs among HCWs at PoEs are still limited We found some evidence on evaluation of KAP interventions among HCWs who working in treatment facilities with the content about vaccine management, maternal and child health care, and pharmaceutical waste management 1.3 E-learning E-learning is a form of education whose content is distributed via websites, CDs, audio and video tapes Studiers and scholars used digital devices, such as computers, laptop, smart phones to participate in Elearning lesson Teachers and students can communicate through e-mail, teleconference, forums, and online seminars (audio / video conferencing) E-learning helps to train anytime, anywhere, and be flexible in choosing the appropriate courses and study methods It also saves time and travel costs for teachers and students Furthermore, both teachers and students can track the studying progress conveniently 1.4 Merging international health quarantine centers into the Centers for Disease Control to improve healthcare workers’ capacity Since 2015, the Ministry of Health (MoH) has issued a policy to streamline the political system to operate this system effectively The MoH decided to merge units with the same function in the preventive medicine system, including merging the International Health Quarantine Center (IHQC) into the Centers for Disease Control (CDCs) in provinces and cities Implementation of Resolution No 18, No 19-NQ / TW, National Conference (Session XII), Circular No 26 of the MoH, 2019, six provinces and cities have implemented this merging, 10 10 including Hanoi, Kontum, Da Nang, Quang Tri, An Giang and Dong Nai 1.5 Traning programs for healthcare workers at points of entry Since 2010, the General Department of Preventive Medicine (GDPM), MoH coordinated with the Institutes of Hygiene and Epidemiology and Pasteur Institutes to train healthcare workers at PoEs every year This course lasted four to five days with the contents including literature and practice about dangerous CDs and national and international legal documents The training course aimed to ensure that health quarantine officers have enough knowledge and skills to screen, monitor, and prevent CDs at PoEs The GDPM used traditional methods for training, i.e., conduct in-person courses However, due to the limited conditions in travel and time, a high prevalence of HCWs did not participate in this course Chapter METHODS 2.1 Objective 1: the health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A(H7N9) at 13 International Health Quarantine Centers 2.1.1 Participants and subjects - Objective 1.1 Knowledge, attitudes, and practives of HCWs for prevention and control yellow fever and avian influenza A(H7N9) at PoEs Healthcare workers at 13 International Health Quarantine Centers in Vietnam - Objective 1.2 Status of organization, human resources, facilities, equipment, operating mechanism, and dispatches and guidelines Facilities, equipment, reports, dispatches, and related documents at 13 IHQC in Vietnam; and directors, vice directors, headers at 13 IHQC in Vietnam 2.1.2 Locations and time - Objective 1.1 + Location: 13 IHQC in 13 provinces and cities in Vietnam, including Hanoi, Lang Son, Hai Phong, Quang Ninh, Lao Cai, Quang Tri, Da Nang, Kon Tum, Ho Chi Minh City, Dong Nai, Tay Ninh, Khanh Hoa, and An Giang + Time: January to October, 2014 - Objective 1.2 10 13 13 - Objective 2.1 We selected all HCWs at six IHQC Total HCWs at these six centers was 164 people In the control group and intervention group, the number of HCWs were 75 and 78, respectively The acceptance rates were 93,8% in the control groups and 92,9% in the intervention group - Objective 2.2 We recruited directors, vice directors and leaders who managed PoEs activities at 06 IHQC where conducted merging IHQC into CDCs In total, we employed 31 in-depth interview with 05 – 06 participants each province 2.1.5 Interventions - Objective 2.1 HCWs in the intervention group were trained with electronic documents about yellow fever and avian influenza A (H7N9) HCWs in the control group are trained using traditional methods which require inperson participation in training classes Teachers for both groups were experts from GDPM The training content was identical in both intervention and control groups - Objective 2.2 The MoH decided to merge units with a similar function in the preventive medicine system, including merging International Health Quarantine Centers into Centers for Diseases Control and Prevention in provinces and cities 2.1.6 Research tools - Objective 2.1 For the quantitiave study, we used a designated questionnaire was prepared by researchers from GDPM with the contribution of MoH and WHO For the qualitative study, a semi-structured questionnaire was used - Objective 2.2 A semi-structured questionnaire was prepared by researchers from GDPM with the contribution of MoH and WHO 2.1.7 Variables/indicators - Objective 2.1 We collected groups of variables and indicators of knowledge about yellow fever and avian influenza A (H7N9), acceptability, and feasibility to scale up E-learning for training HCWs at PoEs HCWs 13 14 14 who reached 70% true answers in the total questions were categorized as “Good knowledge” In questions with multiple answers, if HCWs did not mark all true answers, they were categorized as a wrong answer for this question, and therefore, did not count score Contents of the semi-structured questionnaire were satisfaction, acceptability, and feasibility to scale up E-learning for training HCWs at PoEs - Objective 2.2 Advantages, disadvantages, and actions to improve disadvantages in 1) Organization; 2) Facilities and equipment; 3) Plans to prevent imported cases and simulation exercises; 4) Human resources; 5) Financial capacity and mobilization; and 6) Surveillance and testing capacities 2.1.8 Data analysis Data from the quantitative study was cleaned and entered using EPIDATA 3.1 software, then extracted through SPSS 16.0 software for analysis Data from the recording files were taped and analyzed using thematic analyses Chapter RESULTS Objective 1: The health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A(H7N9) at 13 International Health Quarantine Centers 3.1 Objective 1.1: Knowledge, attitudes, and practives of quarantine workers for prevention and control yellow fever and avian influenza A(H7N9) at PoEs a Yellow fever Many QWs had incorrect knowledge about the disease causative agent which caused by bacteria (41.5%) 1.5% of them did not know the disease causative agent for yellow fever More than half of QWs had correct answers about the yellow fever transmission route, which is through mosquito-borne transmission (53.6%) Nearly 40% of them identified the tranmission route of yellow fever though human-tohuman transmission Table Knowledge about the testing sample for yellow fever Testing sample Frequenc Prevalance (%) y Respiratory tract fluid 57 21.5 14 15 15 Sputum 30.2 80 Endotracheal fluid 22 8.3 Blood 106 40 40% of QWs identified correctly the blood as the testing sample for diagnosis yellow fever 60% of them had incorrect knowledge about types of testing sample for yellow fever’s diagnosis through respiratory tract fluid (21.5%); sputum (30.2%) and endotracheal fluid (8.3%) Table Knowledge about the efficacy and useage of vaccines Knowledge Frequency Percentage (%) Yellow fever vaccines had lifelong immunity Yes 182 No 83 Yellow fever vaccines are available in Vietnam Yes 176 No 89 Vietnam provide international vaccination certificate Yes 168 No 97 68.7 31.3 66.4 33.6 63.4 36.6 More than one third of QWs knew that yellow fever vaccines are available in Vietnam and these vaccines had lifelong immunity 63% of them knew that Vietnam can issue international yellow fever vaccination certificate Table Attitude about the dangerous levels of yellow fever Levels Extremely dangerous Dangerous Normal A little dangerous No dangerous Frequency 37 136 72 17 Prevalance (%) 14 51.3 27.2 6.4 1.1 More than half of QWs had an attitude that yellow fever is dangerous (51.3%) and extremely dangerous (14%) Table Practice to prevent yellow fever Activities Provide vaccination certificate Yes No Examine vaccination certificate Yes 15 Frequency Prevalance (%) 40 225 15.1 84.9 70 26.4 16 16 No 195 Update high-risk regions Yes 68 No 197 Participate in monitoring insects Yes 168 No 97 Know at least one unit providing yellow fever vaccines Yes 20 No 245 73.6 25.7 74.3 63.4 36.6 7.5 92.5 Regular practices to prevent yellow fever were still limited in QWs in Vietnam The most common activity to prevent the yellow fever agent was participating in monitoring insects at IHQC Table Health communication at Centers Activities Frequency Prevalance (%) Communicate Yes 18 6,8 No 247 93,2 Types of communications Directly communicate 15 83,3 Distribute leaflet 16,7 6.7% QWs conducted health communication on yellow fever at Centers for passengers, in which, most of them communicated through direct conversation with passengers (83.3%) Figure The prevalence of good knowledge, positive attitude and good practive in preventing yellow fever (n=265) Approximately two-third of QWs had good knowledge, positive attitude and good practice in preventing yeallow fever “Every year, we conducted refresh training and retraining for QWs on managing and preventing type A CDs at IHQC, including yellow fever However, our communication has not been done with the passengers The Ministry of Health had limitted guidance on communicating this disease with passengers We have not seen any specific communication materials in Vietnam about yellow fever We vaccinated customers on request and provided certificates During vaccination, we advised customers on how to prevent yellow fever” – Leader of health quarantine department, Hanoi International Health Attitude Practice Quarantine Center b Avian influenza A(H7N9) 16 17 17 10.6% of QWs had incorrect knowledge about the disease causative agent of avian influenza A (H7N9) is bacteria Most QWs answered correctly the transmission route from poultry-to-human (81.5%) Table Knowledge about the prevention methods of avian influenza A(H7N9) Characteristics Frequency Prevalance (%) Health quarantine Yes 265 100 No 0 Quarantine’s subjects People 265 100 Vehicles 170 64,2 Goods 162 61,1 Others 3,4 Health declaration Required 265 100 Not required 0 Groups need strict quarantine Having travel history from infected regions 238 89,8 Transporting poultry 182 68,7 All people 55 20,8 Others 18 6,8 All QWs had correct knowledge about the need of health quarantine for influenza A (H7N9) Imported vehicles and goods were needed to health quarantine (64.2%, 61.1%, respectively) People had travel history from infected regions were ones needing strict quarantine for avian influenza A (H7N9) (89.8%) Table Attitude about the dangerous levels of avian influenza A(H7N9) Levels Frequenc Prevalance (%) y Extremely dangerous 131 49.6 Dangerous 124 47 Normal 2.7 A little dangerous 0.8 No dangerous 0 More than 80% of QWs had an attitude that the avian influenza A(H7N9) was dangerous and extremely dangerous 17 18 18 Table Practices to prevent avian influenza A(H7N9) Activties Frequency Prevalance (%) Using monitoring guideline Yes 204 77.0 No 61 23.0 Washing hands with soap frequently Yes 170 64.2 No 95 35.8 Wearing masks during shifts Yes 104 39.3 No 161 60.8 Using medical gloves in health examination Yes 187 70.6 No 78 29.4 Updating high-risk and infected regions frequently Yes 169 63.8 No 96 36.2 39.3% and 77% of QWs weared a protective mask when working and using monitoring guideline About one third of QWs washed hands with soap after contacting with poultry and a suspected case of the avian influenza A(H7N9) disease 70.6% of them used medical gloves in health examination and 63.8% updated influenza A (H7N9) information before the work shift Figure The prevalence of good knowledge, positive attitude and good practive in preventing avian A (H7N9) (n=265) More than two-thirds of QWs had good knowledge while most of them had positive attitude in preventing avian A (H7N9) at IHQC Nearly two-thirds of them had good practice in preveting this disease 3.2 Objective 1.2: Status of organization, human resources, facilities, equipment, operating mechanism, and dispatches and guidelines a, Organization Two IHQC in Dong Nai and Kon Tum did not have a Department of Laboratory Two IHQC in Lao Cai and Lang SonPractice did not have a Knowledge Attitude Faculty of Health Management 18 19 19 b, Human resources 12/13 IHQC did not have enough staff as the minimum requirement in Joint Circular No 08/2007/TTLT-BYT-BNV On average, each IHQC reached 72.5% of the number of workers according to this regulation c, Facilities and equipment Table Facilities and equipment Facilities and equipment Surveillance Thermal camera Handheld thermomerter Mosquito investigation kit A(H7N9) surveillance guideline Yellow fever surveillance guideline Health declaration form Information on infected regions Frequency Prevalance (%) 28 32 14 30 20 87.5 100 43.8 93.8 3.1 62.5 12.6 28 10 18 87.5 31.3 56.3 32 32 30 16 17 100 100 93.8 50.0 53.1 25 32 32 29 32 78.1 100 100 90.6 100 21.9 Samples Sample taking and preserving Vacines storage Sample takers Health communication Internet connected laptop Wakie-takie Led screen Leaflet for avian A(H7N9) Leaflet for yellow fever Video for A(H7N9) Video for yellow fever Health examination Isolated rooms Cars Essencial medicine cabinet First-aid kits PPEs Environment disinfection Automated disinfection system 19 20 20 ULV Electric chemical sprayer Sterilized chemicals Insecticide chemicals 30 24 30 29 93.8 75.0 94.8 90.6 Most of PoEs had equipped with thermal camera and handheld thermometers for screening people through immigration points (87.5 100%) However, the mosquito investigation kit, yellow fever surveillance guideline and information on infected regions worldwide were limited “The GDPM has issued a surveillance guideline for avian influenza A (H7N9) no record for yellow fever We have received legal documents from the Minist Department of Health to monitor yellow fever at PoEs”- Leader of Da Nang Inte Quarantine Center d, Operating mechanism “We should thanks to dangerous epidemics such as SARS, avian influenza A They provided invaluable knowledge on coordinating to prevent CDs After thes IHQC had received more attention from the Government and the community”International Health Quarantine Center Objective 2: the acceptibility and feasibility of two interventions for improving healthcare workers’capacity at Points of Entry, 2015 -2019 3.3 Objective 2.1: Acceptability and feasibility of an educational intervention for improving healthcare workers' capacity using Elearning in training 3.3.1 Yellow fever Table 10 The effectiveness of E-learning to improve yellow fever knowledge Control group (n=75) True knowledge Sources of infection Transmission route Common symptoms Case definition 20 n % n % n % n Before 63 84.0 55 73.3 52 69.3 35 After 65 86.7 65 86.7 60 80.0 49 Intervention group (n=78) Before 65 83.3 52 66.7 61 78.2 45 After 73 93.6 62 79.5 67 85.9 64 Effective index (%) A B Effecti veness (%) 3.2 12.4 9.2 18.3 19.2 0.9 15.4 9.8 -5.6 39.8 42.3 2.5 % Testing sample Required quarantine Passengers required quarantine Required health declaration Lifelong-immunity vaccine Vaccin availability in Vietnam International certificate for vaccinated Good knowledge n % n % n % n % n % n % n % n % 46.7 44 58.7 42 56.0 43 57.3 62 82.7 30 40.0 32 42.7 21 28.0 47 62.7 21 21 65.3 55 73.3 47 62.7 45 60.0 69 92.0 37 49.3 35 46.7 33 44.0 50 66.7 57.7 45 57.7 47 60.3 60 76.9 63 80.8 52 66.7 50 64.1 48 61.5 59 75.6 82.1 55 70.5 65 83.3 71 91.0 75 96.2 65 83.3 67 85.9 66 84.6 65 83.3 24.9 22.2 -2.7 12 38.1 26.1 4.7 18.3 13.6 11.2 19.1 7.9 23.3 24.9 1.6 9.4 34 24.6 57.1 37.6 -19.5 6.4 10.2 3.8 The proportion of participants who had good knowledge to yellow fever increased in both control and intervention groups (control group: before 62.7%, after 66.7%, 4% increased; intervention group: before 75.6%, after 83.3%, 7.7% increased) The intervention effectiveness was 3,8 3.3.2 Avian A(H7N9) Table 11 The effectiveness of E-learning to improve avian A(H7N9) Control group (n=75) True knowledge Before Sources of infection Transmission route Common symptoms Case definition Testing sample Prevention methods Monitoring procedure 21 SL % SL % SL % SL % SL % SL % SL % 61 81.3 57 76.0 52 69.3 32 42.7 45 60.0 44 58.7 403 57.3 After 71 94.7 67 89.3 66 88.0 59 78.7 62 82.7 65 86.7 57 76.0 Intervention group (n=78) Before After 67 85.9 54 69.2 58 74.4 40 51.3 48 61.5 44 56.4 48 61.5 77 98.7 66 84.6 70 89.7 60 76.9 61 78.2 62 79.5 62 79.5 Effective index (%) A B Effectiv eness (%) 16.5 14.9 -1.6 17.5 22.3 4.8 27 20.6 -6.4 84.3 49.9 34.4 37.8 27.2 -10.6 47.7 41 -6.7 32.6 29.3 -3.3 Good knowledge SL % 47 62.7 22 22 55 73.3 53 66 67.9 84.6 16.9 24.6 7.7 The proportion of participants who had good knowledge to Avian A(H7N9) increased in both control and intervention groups (control group: before 62.7%, after 73.3%, 10.6% increased; intervention group: before 67.9%, after 84.6%, 16.7% increased) The intervention effectiveness was 7.7 “I found this course is vivid, easy to remember, and can be rewinded We app this course for other diseases We could study more effective if the course can em reviewing questions after each lesson” – Officer of International Health Quarantin Son “Videos created by the General Department of Preventive Medicine are very copy them into a disk and send to local HCWs for training purpose HCWs could s anywhere Otherwise, we could post these video online for more convenient” - Offic Health Quarantine Center in Da Nang 3.4 Objective 2.2: Impact of merging IHQC into the Centers for Disease Control (CDCs) to improve QWs’ capacity The merging between International Health Quarantine Centers and Centers for Disease Control and Prevention had mixed oppinions While most leaders and directors from five provinces and cities indicated that the merging is necessary according to the Government’s policy, officials in Da Nang city showed their opposite oppinions “International health quarantine activities required a specific environment that consistently, urgently and throughout from the national level to each point of entry with the CDC created an additional layer of direction, which should slow d prevention activities” - Officer of CDC in Da Nang While other people believed that the merging is necessary After merging, people could use financial and human resources in a more effective way “The merging helps the management to be less cumbersome and difficult Officers of CDC in Dong Nai and Kon Tum The merging was not sure to work effectively and efficiently to reduce the financial burden for the government “Before merging, our center had a monetary source from health quarantine ser contributed to the budget of the center, increased salaries for workers, as well a Government’s budget every year.” - Officers of CDC in An Giang 22 23 23 Chapter DISCUSSION Objective 1: the health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A(H7N9) at 13 International Health Quarantine Centers 4.1 Objective 1.1: Knowledge, attitudes, and practives of HCWs for prevention and control yellow fever and avian influenza A(H7N9) at PoEs The HCWs’ knowledge about the disease causative agent and specimens of yellow fever and influenza A (H7N9) is not good We found that nearly 45% of HCWs did not know a virus is the cause of yellow; 60% of them did not know about the specimens to confirm yellow fever Besides, 10% of HCWs had incorrect knowledge about the disease causative agent and 12% of them did not know about the transmission route of avian influenza A (H7N9) This is an alert situation because yellow fever and avian influenza A (H7N9) were categorized as type A CDs, which could cause international events Although have not been recorded in Vietnam, but the prevention of these diseases at PoEs is important, which regulated in the Law on Communicable Diseases of Vietnam Yellow fever and influenza A (H7N9) belong to a dangerous disease requiring health quarantine according to the provisions of the International Health Regulations of the World Health Organization More than 80% of HCWs had attitudes about yellow fever and influenza A (H7N9) as dangerous and very dangerous levels, similar to the assessment of the need for communicating on the disease prevention at immigration points The good attitude of HCWs is an important factor that helps them practice control measures in the prevention of CDs The relationship between attitudes and practice has been proven in many health and sociological studies Attitudes and practice depend on the ability to access information, education and training about the disease Our findings indicated that 40% of HCWs have issued with yellow fever vaccination certificates It is well noted that about two thirds of HCWs washed their hands with soap after contacting with poultry or suspected cases and used gloves in health examination These practices help create a protective barrier between HCWs and potential transmission sources which reducing the ability of viruses to move from source of infection to HCWs or cross-transmission from patient to patient 23 24 24 through HCWs We recorded the limited number of HCWs used masks to prevent the transmission of virus from person to person through contact or droplets when sneezing or coughing 4.2 Objective 1.2: Organization, human resources, facilities, equipment, operating mechanism, and dispatches and guidelines We recorded two IHQC in Kon Tum and Dong Nai provinces did not establish a laboratory because they think it is not necessary They did not provide testing services at centers If they found a suspected case, the specimen can be sent to other testing facilities for testing and confirmation In addition, two IHQC in Lao Cai and Lang Son provinces did not establish a Faculty of Health Management A group of HCWs from the Faculty of Health Treatment was responsible for the function of vaccine application and prevention Therefore, although there is no Faculty of Health Management, all needed functions are still working Our findings showed that 60% of HCWs had medical majors, the rest were others No university and training institution provided an official training program on health quarantine even short-term training courses In Vietnam, there were only short-term training courses organized by the Ministry of Health with teachers from hygiene institutes and the General Department of Preventive Medicine This course lasted four to five days with the contents including literature and practice about dangerous CDs and national and international legal documents The training course aimed to ensure that health quarantine officers have enough knowledge and skills to screen, monitor, and prevent CDs at PoEs According to WHO guidelines, each point of entry should be equipped with prevention plans to respond to the epidemic This is the type of plan with a hypothetical epidemic content, from which response measures are taken Some PoEs had an annual prevention plan, however this is not the type of prevention plan in the emergent situation A contingency plan is intended to handle in a bogus situation, so in order to know whether to operate, apply in practice or not, it is necessary to organize a practice for simulation exercises at PoEs In fact, only a few (12.5%) of PoEs have conducted simulation exercises with avian influenza A (H7N9) and yellow fever Objective 2: the acceptibility and feasibility of two interventions for 24 25 25 improving healthcare workers’capacity at Points of Entry, 2015 -2019 4.3 Objective 2.1: Acceptability and feasibility of an educational intervention for improving healthcare workers' capacity using Elearning in training Applying e-learning for training HCWs at PoEs is effective, reflected in the improvement of knowledge of HCWs after intervention (compared to before intervention in the intervention group and compared between intervention to control group) We also acknowledged the opinion that the use of e-learning will be better if combined with interaction with the instructor when students need further clarification and explanation The benefits of e-learning fit the needs of HCWs In traditional methods, HCWs usually limited to participate in-person classes due to working conditions far from the center Our findings recorded that QWs could save money and time if the e-learning method scaled up throughout the PoEs system Most of PoEs are now equipped with computers and internet It is easy to study e-learning course at working places The flexibility of e-learning and reducing human and financial sources had been recorded in previous evidence in literature 4.4 Objective 2.2: Impact of merging IHQC into the Centers for Disease Control (CDCs) to improve QWs’ capacity Although there are many different opinions, most of participants believed that merging is appropriate that meets the desire to reduce the payroll, strengthen the management, and improve the professional capacity of health quarantine However, in practice, the implementation needs to base on each local condition to proceed in an appropriate way The merging should ensure the organization and human resource We found two forms of merging among six IHQC The first form is "entire" merging All units and departments of IHQC was merged with the entire units and departments of the CDCs without restructuring, except administrative departments Another form is merging and organizing specialized departments into a single department, and also reorganized administrative departments After three years of implementation, there is no evidence to assess which form is better, but the merging roadmap needs to be carefully considered according to each specific situation The change of organizational structure should 25 26 26 accompany the separation of functions and duties of each unit CONCLUSION Objective 1: the health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A(H7N9) at 13 International Health Quarantine Centers Knowledge, attitudes, and practives of HCWs for prevention and control yellow fever and avian influenza A(H7N9) at PoEs The prevalence of good knowledge, positive attitude, and good practice for prevention and control of yellow fever and avian influenza A(H7N9) were relatively low in quarantine workers in Vietnam Many workers had inaccurate knowledge of the disease causative agent and diagnostic specimens Most of them had attitudes that yellow fever and avian influenza A(H7N9) were categorized as dangerous and extremely dangerous that need health education at immigration points A low prevalence of participants practiced methods for diseases prevention and control at the Center was recorded Status of organization, human resources, facilities, equipment, operating mechanism, and dispatches and guidelines Most Centers were well-organized with sufficient necessary departments However, most lacked the number of quarantine officers compared to the Government’s requirement, especially those in the health sector and having English certificated The equipment at the International Health Quarantine Center was insufficient, low yield, and error-prone Most had prevention plans for influenza A (H7N9), however, it's scant for yellow fever We recorded the shortage of contingency plans and simulation exercises for emergent events Objective 2: the acceptibility and feasibility of two interventions for improving healthcare workers’capacity at Points of Entry, 2015 -2019 - Knowledge of yellow fever and influenza A (H7N9) was significantly improved after the intervention (compared to before the intervention) and in the intervention group (compared to the group taught by traditional methods) - The effectiveness of combining the International Health Quarantine Center into the Center for Disease Control and Prevention for improving border health quarantine activities has initially reduced the number of administrative staff However, further research is 26 27 27 required to explore this effect on responding to public health events the capacity of monitoring and RECOMMENDATION - It is necessary to improve the knowledge of HCWs about yellow fever and avian influenza A (H7N9), especially knowledge of the pathogen, transmission route and specimen of yellow fever; standards for identifying suspected and confirmed cases, identifying and sampling specimens diagnosed with influenza A (H7N9), ensuring better implementation of personal protective measures for yellow fever and influenza A (H7N9) at PoEs - We recommend to consolidate and invest in materials, equipment and tools for insect surveillance activities, communication, information updating, and sample taking and preserving There is a need to develop and follow technical documents on surveillance and handling of suspected cases, confirmed cases, infected vehicles and goods We should prepare standard procedures, communication documents, preventive response plans, simulation exercises to practice the response plans to yellow fever and influenza A (H7N9) at PoEs In addition, it is necessary to build up yellow fever surveillance and prevention activities at the regional and national level - There is a need to build and scale up e-learning in training HCWs at PoEs - We need to continue study and assess merging model between IHQC and CDCs to collect advantages, disadvantages and lesson learnt These evidence will provide recommendations for improving and supporting merging model for other unmerging centers 27 ... dissertation doctoral Committee at the university level at Hanoi Medical University The dissertation can be found at: - Vietnam National Library - Library of Ha Noi Pharmacy University LIST OF... testing capacities 2.1.8 Data analysis Data from the quantitative study was cleaned and entered using EPIDATA 3.1 software, then extracted through SPSS 16.0 software for analysis Data from the... were taped and analyzed using thematic analyses Chapter RESULTS Objective 1: The health system’s readiness and capacity for the prevention and cotrol of yelow fever and avian influenza A( H7N9) at