US embassy cable - 05TAIPEI3713

UNCLAS SECTION 01 OF 08 TAIPEI 003713 
 
SIPDIS 
 
STATE PLEASE PASS TO AIT/W, EAP/RSP/TC AND OES/IHA 
HHS PLEASE PASS TO ERIKA ELVANDER 
 
E.O. 12958: N/A 
TAGS: AMED, AMGT, CASC, ECON, SENV, SOCI, TBIO, TW, ESTH, Domestic Politics 
SUBJECT: TAIWAN PREPS FOR AVIAN FLU 
REF: A) 2005 SECSTATE 151549 B) 2005 TAIPEI 00058 C) 2004 
 
TAIPEI 0249 D) 2003 TAIPEI 03339 E) 2004 TAIPEI 00479 F) 
2005 TAIPEI 01881 G) 2005 TAIPEI 03598 
 
Summary 
------- 
1. Summary.  With the exception of one H5N1 high pathogenic 
avian influenza (HPAI) illegal shipment of ducks, which was 
caught and destroyed, Taiwan has thus far managed to avoid 
H5N1 HPAI.  Nonetheless, drawing on its experience with SARS 
in 2003, Taiwan has made extensive preparations to combat a 
potential HPAI pandemic.  President Chen Shui-bian chaired a 
National Secuirty meeting on August 19 to emphasize the 
political will to prevent and contain any pandemic and to 
update Executive Agencies on Taiwan's December 29, 2004 
Influenza Prevention and Response plan. 
2. The Response Plan includes: a disease alerting and 
reporting system, disease surveillance and collaboration at 
all levels of government, border controls, a protocol for 
personal temperature monitoring, a hospital disease 
prevention and control network, epidemiological studies, 
case investigation protocols, facilities usage and controls, 
communication measures and vaccination plans, the 
establishment of a new emergency response center at Taiwan's 
Center for Disease Control (TCDC), and a program to 
stockpile the anti-viral influenza pharmaceutical 
oseltamivir (Tamiflu).  Taiwan has also allocated NT$27 
billion (USD 844 million) for long-term plans to develop and 
manufacture influenza vaccines.  Between December 2003 and 
March 2004, Taiwan also has culled a total of 380,000 birds 
potentially infected with the low pathogenic avian influenza 
(LPAI) (H5N2). 
3.  Comment.  This report constitutes AIT's response to 
reftel A.  Overall, Taiwan appears to be very proactive in 
its efforts to prevent, detect and respond to an avian 
influenza outbreak.  Taiwan, however, could do more to 
ensure that all government agencies have contingency plans 
in place and to urge the private sector and individuals to 
prepare.  End Summary and Comment. 
 
Priority Issue 
--------------- 
4. Taiwan learned the lessons of the 2003 SARS crisis. 
Taiwan has been continually drafting, reviewing and revising 
its response to another potential SARS outbreak and now to a 
potential influenza pandemic since the abatement of SARS in 
the summer of 2003.  Taiwan claims that of the 168 World 
Health Organization recommendations for preparing for an 
HPAI outbreak, Taiwan has met 122.  This cable provides an 
overview of Taiwan's preparation plans to date. 
 
5. On August 19, President Chen Shui-bian called a senior 
staff meeting at the National Security Council (NSC) on 
avian influenza to emphasize to his Cabinet and the public 
the priority Taiwan is placing on preparing for a potential 
HPAI outbreak.  At the NSC meeting, Chen emphasized the 
importance of learning from mistakes made in countering the 
SARS epidemic in 2003.  He urged health authorities to 
enhance their international public health network in order 
to closely monitor global efforts to prepare for the 
potential of an increase in human-to-human transmission. He 
also urged that the public and private sectors work closely 
together in preparing for a massive influenza outbreak. 
 
6. Taiwan has appropriated a special budget of NTD 27 
billion (USD 844 million) for all measures to 
prevent/contain a potential epidemic: NTD 21 billion (USD 
656.5 million) for prevention programs and supplies, NTD 6 
billion (USD 187.5 million) for the research and development 
of vaccines and anti-virals.  In line with a suggestion made 
by the AIT Director at a recent meeting with Minister of 
Health Hou Sheng-mou (reftel G), the Council of Agriculture 
(COA) has also recently committed NTD 1 billion (USD 31.2 
million) to buy nets to cover Taiwan's poultry and swine 
farms in order to minimize migratory bird and domestic 
livestock interaction. 
 
Taiwan Unaffected Thus Far 
-------------------------- 
7.  To date, Taiwan has only detected six ducks with H5N1 
HPAI.  Those ducks were detected in spring 2004 in Kinmen 
island.  The ducks were immediately destroyed and later 
determined to be contraband smuggled from Mainland China. 
HPAI has yet to be found on the main island of Taiwan. 
Thus, despite being surrounded by countries struggling to 
deal with HPAI, Taiwan remains H5N1-free.  That being said 
Taiwan has had to tackle a weaker strain of the bird flu 
virus, LPAI/H5N2.  To deal with LPAI, Taiwan has thus far 
culled approximately 380,000 birds.  Nonetheless, Taiwan 
fully recognizes that the HPAI/H5N1 risk will increase this 
fall when large numbers of migratory birds arrive in Taiwan. 
In addition, officials are concerned that live birds 
smuggled from HPAI-infected countries remain a potential 
channel for introducing the disease into Taiwan. 
Human Surveillance System 
------------------------- 
8.  Taiwan's Center for Disease Control (TCDC) has drafted a 
five-year "Influenza Preparation and Response Plan" (Flu 
plan).  Taiwan has also established a reporting and alert 
system to facilitate and accelerate domestic reporting and 
laboratory surveillance.  450 contract "sentinels for novel 
influenza sampling" have been set up, which cover 90% of 
townships in Taiwan.  A new alerting network has also been 
established.  Once a novel flu case is confirmed, TCDC's 
draft Flu Plan also details who, when and how to report on a 
probable  flu patient.  It 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.  Moreover, the plan requires 
455 elementary schools distributed throughout Taiwan to 
report on all unusual cases of school absences on a weekly 
basis. 
 
Notifiable Disease 
------------------ 
9. In the face of grave warnings by the World Health 
Organization about HPAI, TCDC listed HPAI -  flu - as a 
"statutory communicable disease" effective December 29, 
2004.  Notifiable communicable diseases must be reported to 
the TCDC and the central government is authorized to take 
extraordinary efforts to contain such diseases. 
 
TCDC's 5-level Influenza Response System 
---------------------------------------- 
10. On average, during the winter months, Taiwan suffers 
from an estimated three million cases of influenza per year. 
 Thus, TCDC's flu plan includes a comprehensive system to 
distinguish among SARS, influenza A/B and  influenza, giving 
guidelines to the medical workers to minimize confusion 
between the various types of viruses during the influenza 
season.  Similar to SARS prevention and control measures, 
TCDC has implemented a 5-level Influenza Response System. 
 
a) Level 0/Alert: no human-to-human transmission globally 
and no domestic avian-to-human transmission 
 
b) Level A1: confirmed cases of human-to-human transmission 
outside of Taiwan. 
 
c) Level A2: confirmed cases of domestic bird-to-human 
transmission; a laboratory suspected case in Taiwan; or an 
imported suspected case, but no signs of local human-to- 
human transmission. 
 
d) Level B: one or more confirmed cases of initial human-to- 
human transmission reported domestically. 
 
e) Level C: Secondary human-to-human transmission reported 
domestically. 
 
11. At the 0 level, COA has the lead for HPAI directives. 
At the A1 and A2 levels, DOH will take the lead.  At the B 
and C levels, the Executive Yuan will take the lead.  As 
there are no confirmed cases of human-to-human transmission 
abroad, Taiwan is currently at the 0 level. 
 
Border Surveillance 
------------------- 
12. Based on the above response levels, Taiwan has a 
surveillance program for avian influenza and SARS at its 
borders.  At the 0/Alert Response level, TCDC urges all 
travelers to countries with avian influenza outbreaks to 
avoid touching raw poultry in those places.  All incoming 
are subjected to temperature checks.  Passengers with fevers 
are further assessed prior to immigration.  At the 0/Alert 
and A1 levels, Nasopharyngeal washing or Throat Swabs are 
taken from any inbound passengers with fevers in excess of 
38 degrees.  In addition, at the A1 level and 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 
degrees must obtain a doctor's note confirming the person 
has been 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 assessment, 
where a series of lab tests will be conducted. 
 
Hospital Infection Control Measures 
------------------------------------ 
13. TCDC's Flu plan's hospital infection control measures 
include: detecting and surveying fever patients promptly; 
implementing a standard operating procedure for infection 
control in all hospitals; recruiting qualified 
epidemiologists to help prevent inter-hospital transmissions 
by modeling outbreaks, evaluating nursing procedures to 
facilitate reorganizations that might be necessary; 
instituting fever surveillance and alert programs; 
establishing a mechanism to assess the efficacy and 
efficiency of hospital infection control programs; providing 
comprehensive and intensive infection control training for 
hospital staff, preventing any unsafe or unnecessary 
transportation of patients with a communicable disease; and 
implementing protocols for waste handling and personal 
hygiene.  In addition to having 546 negative pressure beds 
available for use, the government has recently adopted a 
plan to allow for a quick conversion of several sports 
stadiums throughout Taiwan into large-scale isolation 
facilities as necessary.  It also has contingency plans for 
closing all large public spaces in the event of an outbreak. 
 
 
14. 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. 
 
15. Finally, enhanced nosocomial (intra-hospital) infection 
control measures have been in place since SARS.  TCDC now 
has a network for epidemic control, which includes two 
national hospitals, six regional hospitals and 18 county 
hospitals throughout Taiwan.  Hospitals in the network will 
be activated in accordance with the needs of a flu 
pandemic. 
 
Flu vaccine 
----------- 
16. Healthcare professionals administered over 2 million 
doses (almost 9 percent of Taiwan's population) of seasonal 
influenza vaccine during the 2004-2005 season.  Senior 
citizens over 65, children between 6 months and 3 years old, 
those with serious diseases, healthcare workers, workers in 
avian industries and health case workers were provided 
vaccines free of charge.  Taiwan's flu season does not 
typically begin until December so vaccines for the upcoming 
season have not yet been administered, but a similar 
vaccination plan is in place for the 2005-2006 season.  For 
the long-term, Taiwan has set aside USD 187.5 million for 
the research, development and production of a flu vaccine. 
Academia Sinica, the National Health Research Institute and 
Industrial Technology Research Institute are already working 
in close collaboration to develop and produce vaccines on an 
expedited basis.  They hope to be able to produce vaccines 
in five to seven years. 
 
Antivirals 
---------- 
17. Taiwan was the first government in the world to purchase 
oseltamivir (Tamiflu) stockpiles.  According to the 
Department of Health (DOH), Taiwan currently has a stockpile 
of about 160,000 packs of 10 tablets of oseltamivir (each 
pack of 10 tablets is enough for one full course of 
treatment), enough for treating 0.7 percent of Taiwan's 
population.  DOH is hoping to increase the stockpile to 
cover 4 percent of Taiwan's population by the summer of 
2006, with the ultimate goal of growing the stockpile to be 
able to treat 10 percent of Taiwan's population.  Taiwan 
also has just recently adopted plans to research, develop 
and produce its own anti-virals on an expedited basis. 
Furthermore, Taiwan gives oseltamivir to patients with: 
 
- influenza-like illnesses over 65 years of age; 
 
- over 12 years of age with a pulmonary or cardiovascular 
disease; 
 
- poultry farmers; 
 
- soldiers; 
 
- and cases and contacts of influenza-like illness clusters 
in health care institutions are provided with Oseltamivir 
for prophylaxis. 
 
Laboratory Facilities 
--------------------- 
18. CDC has contracted with nine P3-level laboratories 
located in major medical centers around Taiwan to conduct 
all human AI flu tests.  The hospitals include:  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.  In addition to the nine contracted 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.  COA works with a single accredited laboratory 
in Tamshui. 
 
Sampling Criterion of Novel Influenza 
------------------------------------- 
19. Patients with pneumonia, epidemiological exposure and 
patients with criteria clinical influenza symptoms who 
deteriorate rapidly without explanation will be sampled. 
Criteria clinical symptoms refers to any case that is shown 
by throat swab or serum test to show type A flu but not 
subtype H1 or H3, or any case that has both X-ray-confirmed 
pneumonia and conjunctivitis.  Such cases will be 
immediately provided oseltamivir (Tamiflu) while further 
tests for subtype H5 and H7 are conducted.  Epidemiological 
exposure is defined as patients with flu symptoms who have 
had exposure within 10 days of illness onset to one of the 
following three potential exposure routes: 
 
- domestic birds/livestock (or fecal matter) or a novel 
influenza suspected case; 
 
- places abroad where human-to-human transmission has 
occurred or animals have tested positive within the past 
three months; 
 
- a HPAI testing/research laboratory. 
 
Recruitment of New Physicians 
----------------------------- 
20. Following SARS, Taiwan revised TCDC's organizational 
structure so that it could attract and employ 27 new 
physicians, increasing the number of physician at TCDC from 
3 to 30.  These new regulations have allowed doctors to get 
higher salaries and to be exempt from taking the civil 
service examination.  In addition, doctors who choose to 
work for TCDC are provided with an additional financial 
incentives/rewards to entice them to leave careers in 
hospitals or clinics.  These changes were made directly as a 
result of recommendations made to President Chen Shui-bian 
by USCDC representatives during SARS. 
 
Availability of Respirators and Protective Wear 
--------------------------------------------- -- 
21. TCDC is responsible for supplying N-95 respirators or 
equivalent, surgical gloves, goggles and garments for health 
care workers.  Currently TCDC has 25 million masks (for a 
total population of 23 million), 4 million protective 
garments and a large supply of gloves for healthcare 
workers.  COA is responsible for the purchase of protection 
supplies for poultry industry workers and also has adequate 
supplies on hand.  TCDC is also committed to work with COA 
to ensure that it obtains whatever supplies are needed. 
 
International Collaboration 
--------------------------- 
22. Taiwan places high priority on international 
collaboration to address the threat of an HPAI pandemic.  In 
particular Taiwan is hoping to work closely with the United 
States, Japan, Hong Kong, Singapore, the United Kingdom, 
Australia for enhanced cooperation.  Taiwan has recently 
donated 600,000 courses of treatment of oseltamivir to 
Vietnam, in part to help out a neighbor, in part to 
demonstrate its willingness and ability to address cross- 
border issues.  Taiwan also has plans in place to educate 
and provide support for Taiwan businessman in China and 
Vietnam regarding HPAI prevention. 
 
23. Regarding Taiwan's relationship and communication with 
AIT, Taiwan is extremely open and committed to building on 
the very positive working relationship with the US Centers 
for Disease Control (USCDC) and AIT established during SARS. 
Taiwan learned its lessons from SARS.  Following initial 
attempts to cover up SARS cases in early 2003 when the 
disease first struck Taiwan, after AIT and USCDC 
interventions, Taiwan completely changed its ways. 
Following the abatement of SARS in summer 2003, eager to 
build upon the positive relationship with the USCDC, Taiwan 
has consistently contacted the USCDC and AIT immediately 
upon learning of infectious disease outbreaks (i.e., Taiwan 
immediately informed AIT of a SARS infection at a laboratory 
in late 2003, a Tuberculosis outbreak in a hospital in late 
2003 and of recent outbreaks of meliodosis and entervirus 
infections in Taiwan).  AIT is confident of Taiwan's 
commitment to openness and collaboration.  AIT's key 
contacts on this issue include:  Minister of Health Hou 
Sheng-mou, Council of Agriculture Minister Lee Ching-lung, 
Taiwan Center for Disease Control Director General Steve 
Kuo, Director of Animal Health Research Institute Sung Hwa- 
tsung and Executive Yuan Secretary General Lee Ying-yuan. 
 
SIPDIS 
 
Animal Demographics Overview 
----------------------------- 
24. 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 the Bureau of Animal and Plant Health 
Inspection and Quarantine (BAPHIQ) and DOH have placed under 
close surveillance.  In addition, live poultry is sold and 
slaughtered in  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. 
 
Surveillance for Animal Influenza 
--------------------------------- 
25. Taiwan has an active surveillance program on commercial 
poultry, wild fowl, and migratory birds.  Of the 
approximately 230,000 migratory birds that pass through 
Taiwan annually, currently 2,000-3,000 fecal samples are 
tested for HPAI and LPAI each year.  Furthermore, COA is 
compiling a contact database of every chicken, duck and bird 
farm and every poultry market.  If there is an HPAI 
outbreak, this database will help in implementing 
preventative measures. 
 
Movement of Avian Livestock 
--------------------------- 
26. To minimize the risk of interaction between migratory 
birds and domestic livestock, Taiwan has established a Task 
Force on Preventing Animal Infectious co-chaired by Minister 
Without Portfolio Hu Sheng-cheng (concurrent Chairman of the 
Council Economic Planning and Development), COA Chairman Lee 
Ching-lung and DOH Minister Hou Sheng-mou.  In line with a 
suggestion made by the AIT Director at a recent meeting with 
Minister of Health Hou Sheng-mou (reftel G), the taskforce 
recently agreed that COA would commit NTD $1 billion (USD 
31.2 million) to subsidize 6,700 poultry farms and 12,900 
swine farms to build nets over their farms in an effort to 
minimize interactions between wild birds and domestic 
livestock. 
 
27. In addition, farms on which AI is suspected or detected 
are isolated and, if detection is confirmed, the farms are 
depopulated.  Furthermore, poultry within a 3-kilometer 
radius of a farm on which AI is detected are subject to 
movement control and intensive surveillance for 6 months. 
Illegal smuggling of livestock is also a concern.  In an 
effort to reduce this potential vector, 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. 
 
Poultry Laboratory Testing 
--------------------------- 
28. Animal samples are tested for influenza at four Regional 
Poultry Health Centers and then 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.  Laboratory capacity is sufficient and the 
results are communicated to COA. 
 
Culling Practices 
----------------- 
 
29. Culling takes place 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.  Cullers 
wear masks, boots, gloves and protective clothing and are 
trained and supervised by the Livestock Disease Control 
Center.  In the past, cullers were not given prophylaxis 
anti-virals, however, the plan is to provide oseltamivir to 
cullers in the future.  To date, 380,000 birds have been 
culled.  Culling protocols are available in Chinese.  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. 
Animal Vaccination 
------------------ 
30. At this time, vaccination for AI is not permitted, 
although BAPHIQ suspects that individual farmers have been 
illegally using vaccines based on the Mexican AI strain. 
However, COA is currently revisiting this issue at this time 
to consider the adoption of an animal influenza vaccine 
plan. 
 
Interagency Collaboration 
-------------------------- 
31. 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 together since the emergence of LPAI in early 
2004. For instance, Taiwan's Coast Guard is tasked with 
reporting to TCDC any fishermen coming from the affected 
area detected with a fever.  Similarly, the COA reports to 
TCDC any smuggled bird from the HPAI affected areas.  The 
Straits Exchange Foundation (SEF) is in touch with the PRC 
regarding border control measures.  SEF also disseminates 
the domestic border control information and HPAI 
information/guidance to Taiwan businessmen in China. 
Finally, a joint COA-DOH health drill is planned for October 
to test emergency avian influenza outbreak measures. 
 
Risk Communication 
------------------ 
 
32. Following SARS, TCDC designed and built a new emergency 
response center at its headquarters (modeled after the USCDC 
center) to implement its emergency response plans in the 
event of an influenza, SARS or other infectious disease 
outbreak.  In addition, the Government Information Office 
(GIO) is working closely with all relevant government 
agencies and is responsible for all official public 
announcements regarding the disease.  While the risk 
communication mechanisms are in place, the message could be 
strengthened further.  Many government agencies and most 
private sector companies and individual citizens do not have 
contingency plans in place.  Taiwan needs to do a better job 
communicating the importance of contingency planning. 
 
Comment 
------- 
33. 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 countries 
experiencing the disease, it may only be a matter of time 
before Taiwan's precautionary measures are put to the test. 
TCDC's infection control and 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 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, however, could do more to ensure that 
all government agencies have contingency plans in place and 
to urge the private sector and individuals to prepare. 
 
KEEGAN