US embassy cable - 04HANOI582

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 
 
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CURRENT STATUS 
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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". 
 
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CONCERNS 
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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. 
 
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REPORT ON REGIONAL WORKSHOP ON HUMAN INFLUENZA A H5N1 
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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. 
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WHO SEROPREVALENCE STUDY OF NURSES IN HANOI 
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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. 
 
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BRIEFING BY WHO/FAO/UNDP 
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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