US embassy cable - 03HANOI655

UNCLAS SECTION 01 OF 03 HANOI 000655 
 
SIPDIS 
 
DEPT FOR CA/OCS/EMR FOR DGOODING, EAP/BCLTV FOR CJESS, EAP/EX 
FOR LBAER, JJENKINS, MED/EX FOR KHODAI, RMO/BKK FOR JKEYES, 
OES/IHA, WHA/BSC 
 
E.O. 12958: N/A 
TAGS: CASC, AMED, TBIO, SOCI, VM 
SUBJECT:  SARS IN HANOI: CURRENT SITUATION AND REQUEST FOR 
GUIDANCE 
 
REF:  HANOI 590 
 
1.  Please see action/guidance requests in paras 9 and 10. 
 
What Happened? 
-------------- 
 
2.  Hanoi is one of the areas most affected in the current, 
worldwide epidemic of Severe Acute Respiratory Syndrome (SARS). 
The first Hanoi case was identified February 26th, when an 
American citizen (Hanoi's "index patient") developed flu-like 
symptoms when traveling from Shanghai, China to Hanoi, Vietnam 
via Hong Kong.  On February 28th, he was admitted at the Hanoi 
French Hospital with fever, myalgia, and shortness of breath and 
was diagnosed with atypical pneumonia.  His condition 
deteriorated quickly, and on March 4th, he was medically 
evacuated to Hong Kong and admitted to the Princess Margaret 
Hospital, where he died on March 13.  Following his evacuation, 
22 health care workers (WHO report) developed similar flu -like 
symptoms and were admitted to the Hanoi French Hospital.  That 
hospital was closed to the public on March 8th, thus removing the 
only hospital with international level standards of health care 
and infection control practices.  An additional wave of health 
care workers and close family members has been admitted to the 
National Institute of Clinical Research on Tropical Medicine 
(NICRTM) at Bach Mai (the national hospital).  According to the 
CDC Vietnam office, which works closely with the NICRTM on 
HIV/AIDS care and treatment, infection control practices at this 
institute are minimal. 
 
Current Situation 
----------------- 
 
3.  WHO reports more than 40 cases in Hanoi, all with a direct 
link to either the index patient or health care workers who 
cared for him.  Thus far, all cases appear related to very close 
contact with an affected person. Officially, one additional 
person has died, a nurse from the Hanoi French Hospital, and 
several health care workers reportedly remain in critical 
condition requiring mechanical ventilation. 
 
What is it? 
----------- 
 
4.  Thus far, the agent causing the syndrome has not been 
identified.  According to CDC, the agent does not appear to be 
related to initial suspected pathogens such as the Hong Kong 
Avian influenza (H5N1), pneumonic plague, Hantavirus, or 
chlamydia.  However, the Hong Kong cases and the Hanoi index 
case may be related to a longer term epidemic of atypical 
pneumonia in southern China (Guangdong province).  WHO and CDC 
advisories suggest that transmission is consistent with direct 
contact with respiratory secretions of an infected patient.  The 
incubation period (time from exposure to first symptom onset) 
appears to be about 3 to 5 days in most affected patients, but 
may be as long as 7 to 10 days.  Initial symptoms are non- 
specific, and include high fever, muscle aches, and in some 
cases sore throat and dry cough.  Over time, many affected 
patients develop the typical diffuse, bilateral pneumonia. 
 
 
International Help 
------------------ 
 
5.  The Vietnam Ministry of Health has taken a lead in the 
epidemic investigation and has requested support from WHO 
(taking lead in coordinating international assistance), with 
additional technical support from CDC Atlanta (4 staff) and the 
CDC Vietnam Office.  Additional international experts from 
France, Australia, and Japan are now arriving in country.  As a 
result, WHO's coordination of the international response has 
been challenging. 
 
GVN Reaction 
------------ 
 
6.  The GVN was initially slow to provide widespread information 
or recommendations on precautionary measures, and may even have 
provided inappropriate recommendations.  However, later response 
has been appropriate.  An early response by GVN appeared to be 
an attempt to minimize publicity on the severity of the problem. 
Reality now has set in.  With international support, the GVN 
supported the isolation and closure of the Hanoi French Hospital 
and an attempt to prevent spread of the disease into the general 
community.  A unit of NICRTM at Bach Mai hospital has been set 
aside to quarantine patients.  Health officials carefully 
monitor exposed individuals for signs of infection and conduct 
contact tracing.  Vietnam Airlines and other airlines are 
currently screening passengers and have reportedly refused 
boarding to individuals exhibiting symptoms.  In the past few 
days, Vietnamese television has begun to publicize preventative 
measures.  On March 16, the GVN Ministry of Health (MOH) held an 
urgent meeting, which included several foreign experts in 
outbreak investigations and control. 
 
 
Reaction of other Embassies 
--------------------------- 
 
7.  The reactions of Embassies in Hanoi have been diverse.  Many 
Embassies are simply sharing the WHO press release with 
travelers to Vietnam.  At the opposite extreme, the Czech 
Embassy has closed its consular operations and is advising its 
citizens not to be in a closed space with large numbers of 
Vietnamese nationals.  According to and EU Embassy here, the 
French Ministry of Health has reportedly acknowledged that WHO 
has not issued a travel advisory warning against travel to 
affected areas, but has nonetheless issued a travel advisory of 
its own warning against non-essential travel.  The French 
Embassy reportedly is also issuing daily warden messages.  Our 
Embassy and ConGen have issued two warden messages - one last 
Wednesday, advising of the closure of the Hanoi French Hospital, 
and one last Friday, recommending precautionary measures to 
avoid exposure.  In addition, Hanoi has held "town-hall 
meetings" with the Embassy community to minimize panic and 
disseminate accurate information. 
 
8. ConGen Ho Chi Minh City reports that the consular corps there 
has been advised that the Tropical Disease Hospital has been 
designated as the primary receiving hospital for any potential 
SARS cases.  As of this writing, there are no confirmed SARS 
cases in HCMC, although local news reports refer to two possible 
cases.  The CDC Vietnam Office reports that infection control 
practices in Vietnam hospitals are minimal, and the likelihood 
of spread of the syndrome into the general community is fairly 
high.  The head of an international clinic with long experience 
in Vietnam has informally told us he expects the crucial point 
for HCMC to be later this week - probably Wednesday and after. 
ConGen will hold a mini-town hall meeting via digital 
videoconference tomorrow afternoon with resident Hanoi CDC 
medical personnel. 
 
 
Action Requests 
--------------- 
 
9.  Post strongly recommends that a travel advisory be issued 
immediately for Hanoi recommending against non-essential travel 
to Hanoi for the reasons outlined below. This travel advisory 
could be short term in nature, until it is clear that the 
outbreak of this potentially fatal syndrome is controlled.  The 
need for the continuation of the travel advisory would be re- 
assessed on a day-to-day basis. 
 
-- First, even before the outbreak, medical care in Vietnam is 
limited compared with many neighboring posts.  (Bangkok and 
Singapore are where we medevac people.)  With the closure of the 
Hanoi French Hospital and limited availability for medevac to 
Hong Kong (already over-extended), Singapore or Bangkok (both 
now refusing presumed SARS patients), few international level 
facilities are available in the region for new Hanoi SARS cases, 
and no international facilities exist in Hanoi for any medical 
emergency requiring hospitalization.   Even out-patient care is 
limited: the SOS Clinic receives only patients who have called 
ahead and been screened; the Hanoi Family Practice is screening 
patients at the door but, reportedly, is now referring patients 
suspected of SARS to Bach Mai hospital.  In essence, limited 
options exist for medical care of serious illnesses, and even 
non-serious conditions carry elevated risk (as people may be 
exposed to SARS while awaiting care). 
 
-- Secondly, tourists from southern China, Hong Kong, Taiwan and 
many other countries continue to stream into Vietnam via both 
northern and southern points of entry.  Given that SARS has 
already spread outside of the medical community in Hong Kong and 
southern China, it is highly probable that SARS will spread in 
Vietnam and lead to additional risk of exposure for travelers. 
Furthermore, because of the lack of availability of adequate 
medical care in Hanoi, some exposed patients have attempted to 
fly out of Vietnam to seek medical care elsewhere, thus exposing 
other passengers.  This practice clearly must be stopped as this 
leads to further spread of the epidemic and threat to other 
regions of the world. 
 
-- Finally, medical evacuation is difficult and expensive even 
on a limited basis.  If a more widespread epidemic occurs in 
Hanoi, evacuation will become unfeasible.  Medevac of official 
Americans will be equally difficult. 
 
10.  Lastly, Mission wishes to draw the Department's attention 
to the many TDY and PCS travelers that have been long scheduled 
to arrive and depart Vietnam over the next few days and weeks. 
PORTER