SARS IN HANOI: CURRENT SITUATION AND REQUEST FOR

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