Lessons from the front lines: How Thailand eliminated bird flu

Dr. Prasert Auewarakul was a newly minted virologist with an interest in HPV and HIV research and had recently returned from his postdoctoral research at the Harvard T.H. Chan School of Public Health when H5N1 was first detected in his native Thailand in 2004. “I jumped right in,” he said.

Dr. Auewarakul was working in the country’s only functioning BSL-3 lab – the only biosecure lab that could be used to study highly contagious infectious agents or toxins. He and his colleagues began culturing the virus and studying its mutations. Soon he spotted his worst fear, a mutation that allowed the virus to more efficiently jump from animals to humans.

“The mutation wasn’t enough for efficient human-to-human transmission,” recalled Dr. Auewarakul, who immediately alerted Thailand’s Department of Disease Control. Fortunately, that particular mutation did not spread further, but it left a lasting impression on the virologist about the potential spread of the deadly virus.

H5N1 went on to infect 25 people in Thailand, killing 17 of them, before the country was able to stop its spread in among humans in 2006 and in animals a few years after that.

As H5N1 continues its current march across the planet, Exemplars News spoke with Dr. Auewarakul about how Thailand stopped the spread of the virus at the time, how its success against H5N1 informed its efforts to limit the spread COVID-19, and what other countries can learn from its experience.

From 2004 to 2006, Thailand detected and stopped the human transmission of H5N1 (bird flu). What were some key actions Thailand took to respond to this public health emergency?

Dr. Auewarakul: Vietnam, Cambodia, and other countries and regions struggled to contain H5N1, but Thailand was able to control the epidemic earlier than other countries. This was a priority for the government for multiple reasons, including to protect human health and our economy. Thailand was, at that time, a huge poultry exporter. Farmers in thousands of villages relied on poultry for their livelihoods, and when we reported the presence of H5N1 other countries barred our poultry exports.

We did a few things differently from our neighbors that allowed us to stop the spread of the virus. We banned the use of the H5N1 vaccine in poultry. That was our policy. Why? Because when that vaccine is used in poultry, early detection is more difficult. And we used rapid detection and culling instead. Because we knew that early detection was the key for stopping the spread of infection either in animals or humans. Also, when vaccines are used, the infection of H5N1 doesn’t lead quickly to the death of the flock. So, there is a higher possibility of low-level infections that can go undetected. It is easier to contain the virus in poultry if there are mass die-offs. Also, a lot of countries banned exports of poultry from areas that used the vaccine.

We recognized that farmers’ cooperation was critical. So, the government offered them full compensation – 100% initially and 75% later on in the epidemic – when their poultry had to be culled. More than 62 million poultry were culled or killed by the virus. We also stopped all transportation of poultry in the country. And we improved biosafety at poultry farms. In fact, it shifted the poultry industry in Thailand from small producers who raised the birds in their yards to larger, industrial production with sophisticated biosafety protocols.

The government also established a group of experts to consult with the Department of Disease Control and the agricultural development departments. When there is any emergency, the DDC calls for a consultation. This is often a temporary mechanism to expedite communication between academia and policymakers in many countries about emerging pathogens. Communication between academics to public health officials is critical and should be permanent. The threat isn’t over. It is wrong to be complacent. And it doesn’t need a lot of investment. We also did rigorous contact tracing, isolation, and quarantines for any human cases.

What lessons did the country learn from that outbreak and how were they applied to inform decision-making during COVID-19?

Dr. Auewarakul: The H5N1 outbreak prompted the country to launch a Pandemic Preparedness Plan. The government saw there was a real need for such a plan. The plan is regularly updated, and the authorities engage in tabletop exercises to ensure a state of readiness.

During the H5N1 outbreak, Thailand also expanded its Surveillance and Rapid Response Teams, first launched during the earlier SARS outbreak. The teams, which are usually about five people, including at least one field epidemiologist and public health experts, are skilled at containing pathogens. They have the training and ability to identify an emerging threat and respond to it. And they are in every province, in district hospitals and provincial health offices, not just the capital.

During COVID, they [SSRT] played an important role at the beginning. They engaged in contact tracing, isolation, and quarantines. We had a lot of tourists in early 2020, many of them from Wuhan China. That was very difficult. They didn’t get any sleep.

Today, the Rapid Response Teams regularly investigate clusters of unusual disease that look like an emerging infectious disease. When there is no emerging threat, they work in public health offices controlling other infectious diseases, like providing education to people on Dengue prevention. But when there is a threat, they shift their focus.

The government also has a resource it can call on during these challenges that is worth noting. In 1984, Thailand launched a training program mostly for doctors and veterinarians, the Field Epidemiology Training Program, offered by the Department of Disease Control. The program, which is based on the US CDC’s Epidemic Intelligence Service, is part of their continuing education for people who want to be epidemiologists. As part of the three-year program, trainees go out and do outbreak investigation. There is always an outbreak of one sort or another here in Thailand. So, they go out and investigate and conduct contact tracing.

Each year, about 10 people graduate from the program. Which doesn’t sound like a lot, but it adds up. We now have about 200 doctors and veterinarians who have been through the program, are aware of and scanning for emerging threats, and can be called upon during a public health emergency. And since 1998, the program has also accepted participants from other Asian countries.

What role have Thailand’s Village Health Volunteers (VHV) played in preventing and responding to epidemics and how their duties have shifted to respond to disease threats?

Dr. Auewarakul: They played an important role in early detection of H5N1 in poultry. This should have been the work of the Department of Agriculture, but they didn’t have the staff at the time. So, the Village Health Volunteers worked alongside district officers from the department of agriculture to suppress H5N1. They were mainly looking for any chickens or poultry that was dying.

During the COVID-19 pandemic, the Village Health Volunteers helped prevent the initial spread of COVID-19 in rural Thailand. They worked with provincial and district officers to suppress the spread of COVID for two years until Thailand could access the COVID-19 vaccine. For example, anyone who traveled during the COVID-19 lockdown, the Village Health Volunteer would hear about it and tell them to stay in their house. The volunteers would even bring them supplies, such as food, so they didn’t need to go out and possibly infect other people. And if people got sick, the VHV would get them medical attention right away.

How important is community buy-in and what lessons does Thailand offer in this regard?

Dr. Auewarakul: It should be noted that success in containing COVID, in Thailand and many of its neighbors until we had the vaccine, depended on public cooperation.

What we asked of the Thai people was to protect public health. It was bad for our economy and a trade-off, but the government has the respect and trust of the people. When the government told people to stay home, they stayed home – people here didn’t leave their houses. Even though there was no enforcement mechanism, people complied. The result was that we saved more lives, although we suffered economically.

In the future, we should either suppress emerging pathogens early and completely, or make vaccines available much earlier. Following COVID-19, new vaccine technology will allow for much faster development. Vaccine production capability should be developed in developing countries to ensure vaccine availability and self-reliance in future pandemics.

Editor's Note: For more insights into Thailand's response to the early phase of the COVID-19 pandemic, visit Exemplars in Global Health's research on the subject.