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### Viewing cable 04HANOI582, VIETNAM - AVIAN FLU (AI) UPDATE #14

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Reference ID | Created | Released | Classification | Origin
--- | --- | --- | --- | ---
04HANOI582 | 2004-02-27 07:33 | 2011-08-25 00:00 | UNCLASSIFIED | Embassy Hanoi

`

    This record is a partial extract of the original cable. The full text of the original cable is not available.

` `

    UNCLAS SECTION 01 OF 04 HANOI 000582

    SIPDIS

    FOR CA/OCS/ACS/EAP; EAP/EX; EAP/BCLTV
    BANGKOK FOR RMO, CDC
    STATE PASS HHS
    USDA FOR FAS/PASS TO APHIS

    E.O. 12958: N/A
    TAGS: AMED AMGT CASC EAGR TBIO VM AFLU
    SUBJECT:  VIETNAM  - AVIAN FLU (AI) UPDATE #14

    --------------
    CURRENT STATUS
    --------------

    ¶1. U) The WHO investigative team continues to report 23
    confirmed human cases of H5N1, of which 15 have died. While
    the confirmed case count is unchanged, suspect cases are
    daily identified, many of which are ruled out.  One new case
    occurred in a district of a province that had not reported
    cases in poultry for many days.  Media reports expressed
    concern that this is a new outbreak, but because that
    province had previously reported 7 affected districts, the
    case is likely explained by "re-spread".

    --------
    CONCERNS
    --------

    ¶2. (U) Lack Of Complete Human Case Reporting - On February
    20, WHO representatives sent a letter to the Minister of
    Health (MOH) expressing their concern with the lack of
    transparency of case reporting from MOH.  There is no
    information from MOH on demographics or case descriptions.
    On February 23rd, WHO received a request from MOH to
    translate the letter into Vietnamese, indicating that the
    MOH is focusing attention on the letter. To date, MOH has
    not yet replied.

    ¶3. (U) Emphasis On Animals vs Humans - WHO representatives
    also expressed concern to the Deputy Prime Minister over the
    fact that animal issues of avian influenza are receiving
    more attention than human issues.  There are two indicators
    that this is true.   First, the Ministry of Agriculture and
    Rural Development (MARD) distributed an action plan to
    address short to long-term strategies for addressing avian
    influenza; but no such plan has been unveiled by the MOH.
    The second indicator is the placement of the MARD as the
    chairperson of the National Steering Committee to Combat
    Avian Influenza.

    ¶4. (U) Culling - There is still no reliable information on
    culling.

    ¶5. (U) Coordination Within The GVN - Planning and
    coordination within the MARD's Department of Animal Health
    is poor.  They are completely unaware of some of the
    research being done elsewhere in Vietnam (by other GVN
    entities) and there is no structure established for animal
    surveillance.  Some labs, such as NIHE, have been told to
    halt efforts to sequence H5N1 due to safety concerns, e.g.,
    use of live virus in a non-BSl3 laboratory, while other labs
    continue.

    ¶6. (U) Lab Delays - WHO reports that although NIHE is
    processing human specimens on the day of receipt, there are
    significant delays in the reporting of results to the
    hospitals.  The Tropical Medicine Center claims that there
    are outstanding results from several weeks ago.

    ¶7. (U) Lab Safety and Quality - WHO laboratory experts have
    met with staff from the National Pediatrics Hospital (NHP).
    Issues of biosafety and quality assurance remain, and need
    to be addressed.  WHO will prepare a report containing
    recommendations for improving lab performance and submit it
    to the MOH and to NHP.  WHO also plans to provide financial
    support to the molecular lab at NHP on condition that the
    recommendations are followed and that the laboratory is
    supported by NIHE.  NHP has processed (using PCR tests) 26
    influenza samples - none has been H5 positive.

    ¶8. U) Vaccine Distribution - 21000 Doses of Tamiflu have
    arrived for use as prophylaxis.  Despite the fact that WHO
    had suggested that about 5000 go to healthcare workers and
    the remainder for animal health, it appears that the
    majority have gone to healthcare workers.

    --------------------------------------------- ---------
    REPORT ON REGIONAL WORKSHOP ON HUMAN INFLUENZA A H5N1
    --------------------------------------------- ---------

    ¶9. (U) On February 19 and 20, the WHO, CDC and Thai Ministry
    of Public Health presented a workshop on human Influenza A,
    H5N1, for laboratory specialists and epidemiologists.
    Countries represented in the training included: Bangladesh,
    Brunei Darussalam, Cambodia, India, Indonesia, Lao,
    Malaysia, Myanmar, Pakistan, Philippines,
    Sri Lanka, Thailand and Vietnam.

    ¶10. (U) A description of country-specific surveillance
    programs and laboratory capacity illustrated the variation
    in capability and needs within the region.  Lack of capacity
    hampers the possibility of performing adequate serologic
    surveillance, as well as diagnoses.  A number of countries
    expressed concern about the ability to transport samples to
    reference laboratories, the availability of trained
    personnel, reagents, laboratory equipment, and capital to
    sustain a functioning laboratory.

    ¶11. (U) The WHO reference laboratory scientist in Hong Kong
    made a strong plea for countries to share their H5N1 viruses
    with the WHO lab so that there is a representative sample of
    circulating H5N1 strains for use in vaccine development and
    evaluation of any genetic drift.  Genotyping of the
    available samples show slight variations in the genome of
    currently circulating strains.  While
    Vietnam and Thailand have shared their H5N1 viruses with
    WHO or CDC, China has not.

    ¶12. (U) Information on the sensitivity of current Influenza
    A tests indicate that for any one person known to have
    Influenza A of any subtype (through positively tested
    contacts), there is a 33% chance that all the tests
    available to diagnose influenza will be negative.  This
    means that one third of all cases exhibiting symptoms caused
    by avian influenza, not to mention all of the mild or
    subclinical cases, will be missed.  Therefore, there is a
    high probability that cases of human infection of Influenza
    A/H5N1 are being missed.

    ¶13. (U) There was considerable discussion of the 1997 H5N1
    outbreak in Hong Kong.  In studies of persons likely to be
    exposed to poultry in the markets (poultry workers), 10% of
    the workers tested positive for H5N1 antibodies (meaning
    that they were infected), but showed no clinical symptoms of
    the disease.  The other 90% had no detectable circulating
    antibodies.  This means that transmission to humans is
    relatively low and that it is very likely that there are
    unapparent infections of H5N1.  Description of the outbreak
    included measures taken by Hong Kong to reduce the
    reintroduction of H5N1 into the bird market, including
    biosecurity, immunization and administrative controls.

    ¶14. (U) The representative of Vietnam for epidemiology (from
    the National Institute for Hygiene and Epidemiology) did not
    seem to be aware, or could not articulate clearly, what
    epidemiological studies were being conducted in Vietnam.

    ¶15. (U) CDC researchers working in HCMC as consultants for
    WHO expressed considerable frustration at the excruciating
    pace at which the GVN is moving to conduct a case control
    study of cases and close family members and a cohort study
    of people living in and around cases and unexposed
    individuals.  To date, data collection has not been started.

    ¶16. (U) A human vaccine strain for H5N1 has been developed
    that is safe enough for labs to work with, but induces
    antibodies to H5.  However, it needs much more testing.

    ¶17. (U) H5N1 is a fairly resistant virus and can live in
    water and moist feces at 4 degrees Celsius for up to 7 days.

    ¶18. (U) There was consensus in the epidemiology group of the
    need for a standard case definition for human influenza
    H5N1.  Country representatives expressed concern over the
    complexity of the definition.  As a result, representatives
    from WHO-WPRO volunteered to revise the case definition
    based on information about H5N1 learned during the past
    outbreak.

    ¶19. (U) One of the 'experts' noted that virus has been
    detected in raw poultry meat and egg yolks from infected
    birds.  Therefore, the current wisdom of eating only cooked
    poultry and eggs, or not at all, is appropriate in affected
    regions.

    ¶20. (U) A sample of 7,000 wild birds in China showed very
    low prevalence of H5N1 in wild birds - although they
    acknowledged that the virus was present in some.  The
    speaker also noted that wild birds tend not to be
    concentrated in areas where humans inhabited and were
    unlikely to pose a large threat to humans.
    -------------------------------------------
    WHO SEROPREVALENCE STUDY OF NURSES IN HANOI
    -------------------------------------------
    ¶21. (U) During the week of February 16, WHO collected data
    for a seroprevalence study of nurses at NHP who did, and did
    not treat patients with H5N1 infection. It is unclear how
    long it will take to analyze the questionnaire data and
    serum and laboratory where the serum will be analyzed. On
    February 23, WHO reported that 8 more nurses were surveyed
    and their serum was collected and frozen. The team in HCMC
    continues to negotiate with Vietnamese counterparts to
    conduct a similar study there.

    ------------------------
    BRIEFING BY WHO/FAO/UNDP
    ------------------------

    ¶22. (U) On February 19, WHO/FAO/UNDP held a briefing for
    Ambassadors on the status of avian influenza in Vietnam.
    Ambassador De Jong (Netherlands) and Jordan Ryan, UNDP
    representative, co-chaired the meeting.

    ¶23. (U) Case Descriptions - Dr. Peter Horby (WHO) described
    the cases and deaths in Vietnam and Thailand. He noted the
    distribution of cases is similar by sex (52 percent male),
    and most cases (2/3) are in children (with the remaining
    mainly confined to young adults under 40). In Vietnam, cases
    are clustered in provinces around and including Hanoi and
    HCMC.  This is believed to be a surveillance artifact --
    hospitals in the two cities are actively searching for
    cases, and surrounding provinces are more likely than others
    to refer very sick people to Hanoi or HCMC hospitals. Dr.
    Horby also showed an epi-curve, a distribution of cases over
    time, showing no rise but no drop in numbers of cases in
    humans thus far, suggesting this epidemic is still ongoing.
    If the epidemic were subsiding, the number of cases would
    drop off. He noted that the current epidemic now constitutes
    the largest known outbreak of avian influenza in humans.
    Prior outbreaks were in Hong Kong in 1997 with 18 cases
    (H5N1) and the Netherlands in 2002 which had 1 case.

    ¶24. (U) Case Descriptions Continued - Five virus strains
    from Vietnam have been genotyped thus far, and none
    contained human influenza genotypes suggesting that the
    reassortment to a new human strain has not occurred, at
    least in these cases.  These viruses are sensitive to
    oseltamivir (Tamiflu) but resistant to cheaper and more
    easily obtained antiviral drugs such as amantadine.

    ¶25. (U) WHO Activities - WHO described their activities to
    date.  Pascal Brudon, WHO country representative, described
    their primary objectives.  They are increasing capacity for
    labs to diagnose H5 and appropriately use Personal
    Protective Equipment (PPE) and for hospitals to
    Conduct active surveillance.  In Vietnam, passive
    surveillance is the norm.  Difficulties noted in
    surveillance were (1) promoting transparency with MOH, (2)
    encouraging MOH to actively follow cases to identify the
    likely source of infection and actively trace cases to rule
    out/in person-to-person transmission, (3) prevention of
    poultry-to-human transmission through training courses for
    cullers, use of PPE, providing drugs for early treatment of
    those diagnosed, and promoting information/education widely
    through the media.  Brudon felt FAO & WHO are doing "quite a
    good job" providing guidance and support to clinicians (a
    clinical team from Hong Kong was just brought in by WHO to
    consult on this issue).
    ¶26. (U) WHO Activities Continued - Brudon compared this
    outbreak to SARS, and noted that, with influenza, WHO has
    been able to achieve a lot very quickly (e.g., guidelines,
    surveys, active websites).  She noted the team is still
    concerned about the effectiveness of hospital surveillance
    and monitoring of cases.  She reiterated their attempts to
    encourage dialogue with the government about transparency.
    She noted that WHO's investigative team in Vietnam will be
    diminishing since a number of priority areas for WHO support
    are already completed.  She also mentioned that they are
    working with WHO headquarters in Geneva and their regional
    office on ways to help governments develop plans to ensure
    effective distribution of human vaccines when those are
    available. Availability of human vaccine is admittedly many
    months down the road, she stated.

    ¶27. (U) FAO Activities - Anton Rychner noted that domestic
    birds in 57 provinces, including 400 of Vietnam's 502
    districts (80 percent), were affected and 35 million birds
    have perished. He is frustrated that FAO now must pay to get
    data from the GVN, and voiced concern that the 3 phased
    effort (short-term, medium-term, long-term) promoted by the
    GVN was not comprehensive and it is unclear how it could be
    coordinated at various levels.  He noted that the GVN is now
    "limiting access" to his staff, and "shutting down
    communication lines."  He stated that he believes the GVN is
    "doing its best with limited resources" but that "the
    outbreak is not under control."  He asked Ambassadors to
    urge the GVN to be transparent about the details of the
    outbreak.  He also noted MARD's limited staff and the fact
    that only 4 officials there speak English and must work with
    all international efforts -- the demands on their time by
    internationals "are enormous".  Finally, Rychener introduced
    Dr. Tony Forman, a veterinarian, who is helping with FAO
    efforts.

    ¶28. (U) Donor Coordination - Jordan Ryan, UNDP
    representative, introduced Mr. Terje Skavdal from the UN
    Office of Coordination on Humanitarian Assistance (OCHA).
    Mr. Skavdal heads up the emergency response unit for OCHA
    for southern and eastern Asia, and arrived in Hanoi on
    February 15th.  Upon arrival, he met with Deputy Prime
    Minister Vu Khoan on the need for heightened coordination
    among various parts of government, and the DPM seemed very
    interested in promoting this.  Skavdal stated that based on
    his assessment the emergency is still ongoing, and it was
    not possible to establish a time frame on when it would be
    over.  He stressed the need to push for a strong
    multisectoral approach to deal with the emergency.  He
    encouraged good collaboration and use of the technical
    agencies (such as the UN) as much as possible, and
    consideration of needs (short-term, medium-term, and long-
    term) both for the UN groups and for the GVN.  It will be
    important to disseminate a list of needs to the donor
    community and NGOs, and to start information sharing to
    avoid overlaps/ensure efficient use of funds.  He will focus
    on 3 areas: (1) responsibility -- how best to support the
    GVN in adopting this, (2) similarity -- strategies that have
    worked in other settings, and (3) working on the lowest
    possible operation level to ensure efficient dispersal.  He
    notes they are still in the discussion phase and hope to
    look at various alternatives.
    BURGHARDT

`