US embassy cable - 05TAIPEI58

UNCLAS SECTION 01 OF 07 TAIPEI 000058 
 
SIPDIS 
 
STATE FOR EAP/RSP/TC AND OES/IHA 
STATE PASS TO AIT/W 
USDA FAS FOR APHIS/VS, IS 
HHS FOR ERICA ELVANDER 
 
E.O. 12958: N/A 
TAGS: TBIO, AMED, EAGR, ECON, EAID, TW 
SUBJECT:   RECOGNIZING THREAT,  TAIWAN PREPS FOR AVIAN FLU 
 
REF:      A) 2004 STATE 23762 B) 2004 TAIPEI 0249 C) 2003 
 
TAIPEI 03339 D) 2004 TAIPEI  00479 E) 2004 TAIPEI 04021 
 
 
1. Summary. Taiwan has thus far managed to avoid Avian 
Influenza since early 2004.  Following the outbreak of H5N2 
Low Pathogenic Avian Influenza (LPAI) in Taiwan in early 
2004 and the outbreaks of H5N1 High Pathogenic Avian 
Influenza (HPAI) in neighboring countries both last year and 
this year, however, Taiwan has been proactive in preparing 
for the worst.  Reftel D provides post's February 2004 
responses to Department questionnaire regarding Avian 
Influenza.  Based on further proactive steps undertaken by 
Taiwan authorities, this cable provides updated responses to 
the questionnaire.  The primary change since last February 
is that Taiwan has drafted a major influenza prevention and 
response plan.  Previously, Taiwan had relied upon its SARS 
preparation and response plan.  Now Taiwan has also prepared 
influenza-specific plans.  Those plans include the 
establishment of a new emergency response center at Taiwan's 
Center for Disease Control.  Further, Taiwan has committed 
to invest a total of NT$6 billion (USD 187 million) towards 
developing and manufacturing influenza vaccines.  In 
addition, Taiwan has also culled an additional 270,000 birds 
since February.  Given Taiwan's proximity to the many other 
countries in the region facing the threat of outbreaks of 
Avian Influenza, it may be only a matter of time before 
Taiwan's preparations are put to the test.  End Summary. 
 
Surveillance for Animal Influenza 
--------------------------------- 
Q. Is there active of passive animal surveillance for Animal 
Influenza in country? 
A.  Taiwan has an active surveillance program on commercial 
poultry, wild fowl, and migratory birds. 
 
Q.  Who is the Point of Contact in the Ministry of 
Agriculture? 
A. Dr. Ying Yeh, Deputy Director General, 
Bureau of Animal and Plant Health, Inspection and Quarantine 
(BAPHIQ), Council of Agriculture (COA). 
 
Q. Where are animal diagnostic laboratory samples tested for 
influenza? 
A. Initially samples are tested at the four Regional Poultry 
Health Centers and confirmed by the National Institute of 
Animal Health in Tamshui, Taipei County.  Taiwan uses PCR 
testing, DNA sequencing and pathogenicity index testing to 
establish the type and pathogenicity of the influenza. 
 
Q. Is laboratory capacity sufficient or would assistance be 
welcome? 
A. Capacity is sufficient. 
 
Q. Are results being communicated to national officials? 
A.  Yes. BAPHIQ reports to COA, which reports to the 
Executive Yuan (Cabinet). 
 
Culling Practices 
----------------- 
 
Q. How is culling defined and practiced? 
A.  When tests establish that Avian Influenza is present on 
a farm, whether it is Low Pathogenic (LPAI) or High 
Pathogenic (HPAI), the farm is depopulated.  To date, Taiwan 
has only detected LPAI and that was in early 2004 (except in 
spring 2004 when six ducks with H5N1 HPAI were detected in 
Kinmen island.  These ducks were later determined to be 
contraband smuggled from Mainland China). Birds are 
euthanized via their feed or water and then incinerated. 
Farms are disinfected.  Based on the 1997 Foot and Mouth 
Disease outbreak, Taiwan has a great deal of experience in 
dealing with serious animal disease outbreaks.  Taiwan also 
has a relatively modern veterinary and quarantine 
infrastructure. 
 
Q. Are culling protocols available to be sent to DC? 
A. The Animal Contagious Disease Prevention Statute is 
available in Chinese. 
 
Q.  Are cullers adequately protected? 
A.  Yes, cullers wear masks, boots, gloves, and protective 
clothing. 
 
Q. Are cullers being adequately trained to use PPE? 
A. Yes, the staff of the local Livestock Disease Control 
Center supervises the cull and trains the cullers. 
 
Q. Would they benefit from training assistance 
A.  Not needed. 
 
Q. Are culled carcasses adequately disposed of? 
A. Yes, carcasses are disposed of by incineration. 
 
Q. How many have already been culled? 
A. During 2004, 380,000 birds were culled. 
 
Movement of avian livestock 
--------------------------- 
 
Q. What measures are in effect to control movement of 
poultry (and birds) within the country. 
A.  Farms on which AI is suspected or detected are isolated 
and, if detection is confirmed, the farms are depopulated. 
Farms within a 3-kilometer radius of a farm on which AI is 
detected are subject to movement control and intensive 
surveillance for 6 months. 
 
Vaccination 
----------- 
 
Q.  Has vaccine for Avian influenza been applied to poultry 
in the country?  If so, what type and approximately what 
proportion are? 
A.  Vaccination for AI is not permitted, although BAPHIQ 
suspects that individual farmers have been illegally using 
vaccines based on the Mexican AI strain. 
 
Animal Demographics Overview 
---------------------------- 
 
Taiwan has a modern poultry and livestock industry.  Both 
poultry and swine are produced on medium-to-large scale 
farms with regular service by professional veterinarians. 
Farms are devoted to a single species and are widely 
separated.  The major poultry species are modern broilers 
and layers, traditional colored chickens, and ducks as well 
as a small population of geese and turkeys.  There are 
132,000 poultry farms with a total bird population of 415 
million.  There are 13,000 swine farms with a total pig 
population of about 7 million.  Statistics are not available 
on the proportion of the population engaged in poultry/swine 
production, but if we multiply 145,000, the total number of 
poultry and swine farms, by an estimated average work force 
of 5 persons, the total work force is 725,000 or about 3 
percent of the population.  There are 3 major poultry 
wholesale markets that BAPHIQ and DOH have placed under 
close surveillance.  In addition, live poultry is sold and 
slaughtered in the traditional markets scattered throughout 
Taiwan's cities and towns.  Vendors have been educated by 
local authorities to be aware of signs of AI and practice 
good sanitation in their slaughter.  However, the 
traditional markets would be a cause for concern if Taiwan 
were to have an outbreak of HPAI. 
 
Trainers 
-------- 
Q.  Are certified trainers available to teach workers about 
the use of PPE throughout the country?  How many?  Who would 
pay trainers to give the training sessions?  Are funds 
available?  What are the estimated costs? 
A.  Local Livestock Disease Prevention Center personnel have 
been trained to use PPE and then train the workers assigned 
to a cull. 
 
Q. Are trainers available to teach workers about safe 
culling methods throughout the country?  Who would pay 
trainers to give sessions?  What are the estimated costs? 
A.  Local Livestock Disease Prevention Center personnel have 
been trained to teach workers to do a safe cull. 
 
Surveillance for influenza-like illness in humans: 
--------------------------------------------- ----- 
Q.  Have health care providers been alerted to be aware of 
any extra-ordinary cases of influenza-like illness? 
 
A.  Yes. Taiwan's Center for Disease Control (TCDC) has 
classified Avian Influenza, or "Novel flu" - as a 
"notifiable communicable disease." Notifiable communicable 
diseases must be reported to the TCDC and the central 
government is authorized to take extraordinary efforts to 
contain such diseases. 
 
Further, Taiwan has committed to invest a total of NT$6 
billion (USD 187 million) towards developing and 
manufacturing influenza vaccines.  The plan is to devote ten 
percent of the budget on vaccine research and development. 
With the highest levels of political support, Taiwan health 
officials are working hard to secure the monies to fulfill 
this commitment. 
 
In addition to Taiwan's plans to develop a vaccine and 
Taiwan's existing strategies to prevent, contain and respond 
to SARS (see reftel C), TCDC has drafted a five-year 
"Influenza Preparation and Prevention Plan" (Flu plan).  The 
Flu plan details extensive strategies for trying to 
distinguish among SARS, influenza A/B and Novel flu and 
provides guidelines to medical workers to minimize confusion 
between the various types of viruses during the influenza 
season.  The plan is currently awaiting Executive Yuan 
approval. 
 
The Flu plan includes a 5-level Influenza Response System. 
The "Alert Level" is activated when there is one or more H5 
or H7 strain of virus detected domestically or there are any 
confirmed cases of bird-to-human transmission on High 
Pathogenic Avian Influenza Strain abroad.  "Level A1" is 
activated when there is at least one confirmed case of human- 
to-human transmission outside of Taiwan.  "Level A2" is 
activated when there is no indication of local transmission, 
but there is at least one confirmed case of  bird-to-human 
transmission and/or a laboratory suspected case and/or a 
suspected imported case in Taiwan.  "Level B" is activated 
when there are one or more confirmed cases of primary human- 
to-human transmission in Taiwan.  "Level C" is activated 
when there are confirmed secondary human-to- human 
transmission cases within Taiwan.  TCDC has responsibility 
for responding at the Alert and A1 levels, DOH becomes 
responsible at the A2 and B levels, and the Executive Yuan 
takes over at level C. 
Based on the above response levels, Taiwan has a 
surveillance program for Avian Influenza and SARS at its 
borders.  Taiwan is currently operating at the Alert level. 
At this level, TCDC urges all travelers to countries with 
avian influenza outbreaks to avoid touching raw poultry in 
those places.  In addition, all inbound passengers are 
required to complete health survey forms and undergo 
temperature checks.  Passengers with fevers or forms 
indicating illness are further assessed prior to 
immigration.  At the Alert and A1 levels, Nasopharyngeal 
washing or Throat Swabs are taken from any inbound 
passengers with fevers in excess of 38 C and a history of 
unprotected contact or exposure to the virus.  Those 
passengers are also required to take a full course of the 
anti-viral oseltamivir.  At the A1 level and/or above, in 
addition to the above measures, passengers from the affected 
areas are required to self-monitor for fevers twice a day 
for 10 days.  At level B and/or above, medical doctors will 
be posted at the borders to assist in these processes.  Also 
at level B, any outbound passenger with a fever over 38 C, 
must obtain a doctor's note confirming the person has been 
Avian influenza-free for at least 24 hours, before they can 
depart.  Finally, at level B and above, any passengers 
suspected of having avian influenza will be sent by 
ambulance to the designed hospitals for further management, 
where a series of lab tests will be conducted. 
 
Hospital Infection Control Measures 
----------------------------------- 
Q.  Have hospital infection control practices been put in 
place?  What type of systems are in place for care and 
isolation and/or quarantine of patients with suspected cases 
of Avian Influenza? 
 
A.  TCDC's Flu plan's hospital infection control measures 
include: a program to detect and survey fever patients 
promptly; implementation of a standard operating procedure 
for infection control in all hospitals; recruitment of 
qualified epidemiologists to help prevent inter-hospital 
transmissions by modeling outbreaks, a plan to evaluate 
nursing procedures to facilitate reorganizations that might 
be necessary; institution of fever surveillance and alert 
programs; establishment of a mechanism to assess the 
efficacy and efficiency of hospital infection control 
programs; the provision of comprehensive and intensive 
infection control training for hospital staff, plans to 
prevent any unsafe or unnecessary transportation of patients 
with a communicable disease;  and protocols for waste 
handling and personal hygiene.  Taiwan has 740 negative 
pressure beds available for use. 
 
In addition to the measures above, TCDC requires all 
hospitals and clinics to ask flu patients if  they have had 
any contact with poultry or farm owners.  Any patients who 
have had such contact are given the antiviral medication of 
oseltamivir (trademarked as Tamiflu) for five days.  Subject 
patients are required to have follow-up checkups. 
 
Finally, Taiwan has ordered a total of 2.5 million doses of 
influenza vaccine for this flu season - 500,000 for children 
and 2 million for adults.  Already 410,000 children and 1.62 
million adults have been vaccinated.  Health workers, babies 
between six and 24 months, senior citizens over 65, people 
with serious diseases, and workers in the avian and 
husbandry industries are provided shots free of charge. 
TCDC has also stockpiled 1.3 million oseltamivir tablets 
(enough medication to treat 130,000 influenza cases).  Thus 
far, only 10 percent has been used.  TCDC is planning to 
increase its stock of oseltamivir to 23 million tablets (so 
that Taiwan will have enough doses to treat 10 percent of 
its population). 
 
Samples 
-------- 
Q. Are samples being obtained from potential human cases of 
Avian Influenza? 
A. Taiwan currently does not have any potential human cases 
of avian influenza. 
 
Number of Human Cases 
--------------------- 
Q. Can you estimate the approximate number of human cases? 
A.  Again, thus far Taiwan has no human cases.  Taiwan has 
not detected any cases of High Pathogenic Avian Flu H5N1. 
 
Laboratory Surveillance and Capacity 
------------------------------------ 
Q. Where is laboratory surveillance done? 
A.   CDC has contracted with several labs stationed in major 
medical centers all over the island including:  National 
Taiwan University Hospital, Veterans General Hospital and 
Kaohsiung Medical University Hospital.  Offshore islands in 
Kinmen and Matsu are to report to labs in the northern part 
of Taiwan and the island of Penghu will report to a lab in 
Kaohsiung.  The general lab surveillance is done by TCDC. 
In addition to the 12 contracted P3-level laboratories 
throughout the island, TCDC has a plan to set up more 
laboratories if needed, in order to conduct more tests in a 
shorter time. 
 
Q.  Is Laboratory Capacity sufficient? 
A.  Laboratory capacity is sufficient. 
 
Availability of Respirators 
--------------------------- 
Q.  What is the availability of N-95 respirators or 
equivalent?  Of goggles? And of surgical gloves? Can more be 
purchased?  Does the country have resources to purchase a 
sufficient number of respirators, goggles and surgical 
gloves to ensure that all workers receive as many 
respirators as needed? 
A. TCDC is responsible for N-95 respirators or equivalent, 
surgical gloves, goggles and garments for health care 
workers.  According to TCDC, currently the stock of 
respirators and gloves for healthcare workers is sufficient. 
COA is responsible for the purchase of protection supplies 
for poultry industry workers and has adequate supplies on 
hand.  TCDC is also committed to work with COA to ensure 
that it obtains whatever supplies are needed. 
 
Communications 
-------------- 
Q.  Are results being communicated to national officials and 
between Ministries? 
A. Laboratory surveillance results are being communicated to 
relevant agencies and ministries.  In addition, TCDC, the 
Department of Health, the Bureau of National Health 
Insurance, COA and other relevant government agencies have 
been working very closely together since the emergence of 
Avian Influenza earlier this year.  Intra and interagency 
collaboration and coordination is excellent. 
 
 
Q.  What sort of communications policies and practices are 
in place concerning Avian Influenza? 
A. TCDC has designed and will soon open a new emergency 
response center at its headquarters to implement its 
emergency response plans in the event of an influenza, SARS 
or other infectious disease outbreak. 
 
TCDC's draft Flu Plan also details who, when and how to 
report on a probable Novel flu patient.  It also specifies 
how and when each level of government should respond to a 
reported case.  Furthermore, it establishes a new alerting 
network, which will enable the TCDC to directly communicate 
instructions with local health officials using mobile phones 
as soon as a case is reported.  It also provides protocols 
for cooperation across ministries. 
 
Finally, the Government Information Office (GIO) is working 
closely with all relevant government agencies and is 
responsible for all official public announcements regarding 
the disease.  The main points of contact for AIT are the COA 
and TCDC. 
 
Need for U.S. Assistance 
------------------------ 
Q.  Can U.S. experts from HHS, USDA and other agencies be of 
help? 
A.  Since Taiwan is not yet confronting Highly Pathogenic 
Avian Influenza, no assistance is necessary at this time. 
In the past, Taiwan has been quick to request assistance 
when needed.  As the situation develops, we will keep on top 
of the matter. 
 
Weaknesses/strengths in system 
------------------------------ 
Q. What weaknesses (and strengths) has post observed in the 
host's attempt to contain avian flu? 
A. Thus far, Taiwan has been able to avoid an outbreak of 
Highly Pathogenic H5N1.  Taiwan appears to be very proactive 
in its efforts to prevent, detect and respond to an avian 
influenza outbreak.  Given Taiwan's proximity to the many 
other countries facing the disease, however, it may only be 
a matter of time before Taiwan's precautionary measures are 
put to the test.  Taiwan CDC's infection control, fever 
surveillance efforts are particularly strong due to its 
significant preparations for another potential SARS outbreak 
and the H5N2 Low Pathogenic outbreak in Taiwan in early 
2004. COA and the livestock industry also learned from their 
experience with the major 1997 Foot and Mouth Disease 
outbreak that also resulted in significant investment in 
disease prevention, surveillance and control infrastructure, 
including the establishment of BAPHIQ in August 1998. 
Taiwan also benefits from the fact that it is an island, 
which affords a certain degree of protection.  Taiwan 
recently raised the level of criminal punishment for 
smuggling livestock and poultry so that it is equivalent to 
the penalties for smuggling arms or people. 
 
One potential threat is that a large number of migratory 
birds, which are potential AI carriers, over-winter in 
Taiwan.  However, farmers have been instructed to use 
netting and fencing to keep migratory birds away from their 
flocks.  Another potential threat is the integrity of 
Taiwan's national health-care infrastructure.  As reported 
in reftel E, unless Taiwan finds the political will to raise 
premiums and co-pays and/or institutes major reforms, the 
entire health-care infrastructure is at risk of financial 
ruin.  No matter how good Taiwan's flu plan may be, it will 
require a solvent health-care delivery system to make it 
work. 
 
PAAL