TURKEY: AVIAN INFLUENZA - ADDITIONAL INFORMATION

UNCLAS SECTION 01 OF 04 ANKARA 006884 SIPDIS STATE FOR EUR/RUS, OES/STC, EB/TPP/ATP, EB/TPP/BTA STATE ALSO PASS USAID FOR BLANCHET, TROSTLE AND CARROLL HHS FOR WSTEIGER/PBUDASHEWITZ FAS FOR ITP/MACKE/THOMAS, CMP/DLP/WETZEL FAS PASS FSIS AND APHIS VIENNA PASS APHIS BRUSSELS PASS APHIS/FERNANDEZ GENEVA PASS HEALTH ATTACHE E.O. 12958:N/A TAGS: TBIO SENV ECON EAGR EAID PREL AMED TU SUBJECT: TURKEY: AVIAN INFLUENZA - ADDITIONAL INFORMATION RESPONSE Ref: (A) STATE 209622 - REQUEST FOR INFORMATION ON AI (B) ANKARA 6838 - USAID ASSESSMENT AND RECOMMENDATION (C) ANKARA 6481 - AI AND PREPAREDNESS ASSESSMENT (D) ANKARA 6605 AND PREVIOUS SIT-REPS (E) ANKARA OCTOBER 19 E&E INITIAL RESPONSE ON AI ¶1. Summary. Turkey experienced one confirmed outbreak of the H5N1 strain of Avian Influenza in Balikesir in northwestern Turkey in early October without reports of human illness or deaths. Turkey has received generally high marks for its transparency, response, and containment of the outbreak, and could serve as a model country in the region (Refs). Following a USAID assessment visit, we concluded that Turkey needs to improve: 1) inter-agency coordination - including creation of a supra-ministerial AI czar; 2) its ability to respond to potential multiple outbreaks; 3) communication and education to farmers and consumers; 4) grassroots AI surveillance, and 5) surveillance of wild birds. Embassy has recommended that USAID work through the Embassy to focus support on AI surveillance/containment training and communication (Ref B). This cable responds comprehensively to Ref A request for information. End summary. Preparedness/Communication: -------------- ¶2. The Turkish Ministry of Agriculture and Rural Affairs (MARA) has the lead for surveillance and containment of potential avian influenza cases, and has received good marks for its containment, culling, and quarantine procedures implemented in the one outbreak so far discovered in the Balikesir area, located near the Sea of Marmara in northwestern Turkey. The Ministry of Health (MOH) coordinated with MARA on prophylaxis, surveillance, and treatment of workers. The two agencies are working closely with private industry to implement regular controls and tracking for industry workers. ¶3. In collaboration with the EU, MARA has developed an emergency contingency plan for limiting potential spread of AI (copy provided to USAID expert). Through an EU "twinning" project, training and emergency simulation activities were carried out by chance in Balikesir just one month before the outbreak, contributing to the quick and transparent response. It is not clear if the GOT would be able to respond to simultaneous multiple outbreaks. In addition there is some concern about the GOT's ability to provide compensation to farmers, particularly small landholders (private industry arranged for compensation for the Balikesir outbreak). Most outside and multinational organizations note the absence of a supra-ministerial body or czar that would be able to direct several independent ministries to take coordinated action in the event of a major animal or human outbreak. Finally, there is some concern with the GOT's ability to monitor wild bird populations and migrations. ¶4. The MOH has worked with WHO to develop a national pandemic plan. Although MOH officials described detailed elements of the plan, Embassy was unable to obtain a copy of the draft and it does not appear to be shared, approved, or tested by other parts of the GOT. Key elements are as follows: -Creation of a 70-member multi-agency (Health, Agriculture, Universities, Military, Pharmaceuticals, etc.) task force. In the event of a crisis, MOH would take the lead in tandem with the National Crisis Center which is under the Prime Ministry (Turkey National Emergency Agency; per normal disaster assistance procedures). -Action plan for providing information to the public. -Action plan for provision and coordination of health services, including surveillance, protection, isolation, precautions, triage, anti-viral measures, and extraordinary measures, such as increasing hospital bed capacity and/or identifying special hospitals for isolation or care (and closing public institutions, etc.) ¶5. Preparing for AI appears to be a high priority for the GOT; although, the lifting of the one outbreak quarantine has lowered some urgency, particularly in non-lead GOT agencies. The GOT will need assistance in generating effective communication to farmers and consumers. Turkish people do not have faith in the truthfulness of their government's reporting and assurances. Adequate compensation will be critical in ensuring that farmers accurately report potential cases. Embassy has not been able to review national laws, but understands that compensation for AI by the GOT is not clear in the law. ¶6. The international response to the Turkish outbreak has been robust. The EU and FAO both sent teams to Turkey in the aftermath of the outbreak. The World Bank is assessing requests from the GOT for assistance in combating both animal and possible human outbreak. FAO and the EU have been providing some training to Turkish veterinarians and Thailand and Canada have sent specialists to provide some technical assistance and information about AI. There are two collective concerns: 1) technical assistance in the way of information sharing and training should be provided in rural and local levels. 2) training should be conducted on a recurring basis and not as a single event. International observers lament the lack of a supra-ministerial czar or "go to" position, although MARA and MOH officials have separately been very helpful. ¶7. Turkey administers annual flu shots. Turkey does not produce WHO approved human trivalent influenza vaccine. The country does not produce- and for the moment- does not have plans to use influenza vaccine for poultry. The country is not developing an H5N1 vaccine. ¶8. Both MARA and MOH have identified communication and public awareness as a critical area. Both have told Embassy that they are actively engaged in communicating with the public, farmers, and poultry workers on education, surveillance, and precautions. The public is deeply concerned about AI, and is distrustful of GOT assurances; consumption of chicken has dropped dramatically. There is a need for better and more frequent communication from the GOT to farmers and consumers. Communications is a key aspect of MOH contingency planning. In the event of a pandemic, MOH would distribute posters, brochures, and other materials. MOH aims to establish a regular internet-based AI bulletin Surveillance/Detection: -------------- ¶9. MARA has first level responsibility for surveillance for AI outbreaks in animals. While MARA has told the Embassy that it has implemented active surveillance; it is difficult to assess the quality of the surveillance. The GOT has been quick to investigate and then dismiss false outbreaks elsewhere in the country. MARA has only one reference lab near Izmir and does not have capability to test for H5N1; it sent samples to the UK to gain the positive for H5N1. MOH also told Embassy that it is actively carrying out surveillance among people; it has two virology labs (Ankara National Influenza Center and Istanbul Medical School Viral Institute). Both MARA and MOH have extensive regional networks, but their level of inter-agency coordination may be weak and/or untested. ¶10. Both agencies have made requests to multilateral organizations for more laboratory and testing capacity, as well as testing kits. For equipment, the GOT and industry have requested incinerators to dispose of large numbers of animals, animal vaccines, protective equipment for workers, and upgrading of diagnostic equipment. On the human health side, the government is requesting protective equipment for health workers and supplies of antibiotics including Tamiflu. Most of the equipment and medicines will be provided under existing programs operated by the World Bank and European Union. ¶11. The two critical gaps that Post has identified it might play a role are local training/assistnace for MARA for surveillance/containment and communication. For technical assistance, the GOT has indicated that it would appreciate some type of technical training for local veterinarians and farmers. Most officials indicate that knowledge levels at central government offices, particularly in Ankara, Istanbul and Izmir were sufficient, but there has been little dissemination of information in rural areas. As a result, some recurring training in several areas of the country could be beneficial in stemming any animal outbreaks. Post could draw effectively on farmers unions, poultry associations and Ministry contacts to disseminate information and organize this effort. Currently, many countries are sending random speakers to the country. Post therefore emphasizes the need for recurring efforts. This would hopefully encourage the development of a mechanism to address any future outbreaks of AI or other diseases. Post also believes strongly that in-country training would be much more effective in reaching a larger portion of the population. ¶12. Second, there is a strong need for the creation of a public education program. Although, only 9000 birds had to be culled as a result of the one outbreak, poultry consumption decreased by 90 percent following the outbreak and is currently only 50 percent of normal. In addition, small and subsistence farmers need to be educated on the need for reporting and the proper steps that should be taken in case of any bird deaths. One possibility in addressing this issue would be to draw on information used worldwide on the outbreak, which could be tailored to the Turkish needs. The information could be disseminated through various organizations. ¶13. The media has been the chief vehicle for providing information about the animal outbreak. Information from the GOT has been better than expected, but still woefully short, leaving the media to generate and provide most information. The World Bank has suggested the creation of a spokesperson position at the supra-ministerial level to provide a central contact to disseminate information. Response/Containment -------------- ¶14. The GOT responded quickly to the Balikesir outbreak, establishing a 3 km quarantine zone and culling about 9000 birds (Refs). Farmers were compensated for their birds and the GOT has announced increased funding for contingency compensation reserves. In the event of multiple AI outbreaks, the adequacy of the funds might be tested, and the capacity of the MARA and MOH to respond and coordinate may be challenged. The MARA emergency contingency plan has guidelines for quarantine, culling, disinfection of facilities, and disposal. MARA is aiming to increase pre- positioning of personal protective gear, but has not achieved full coverage. The GOT has not employed wide animal vaccination as a containment measure, relying instead on surveillance. ¶15. The MOH has generated a national pandemic plan, but in the event of a public health crisis would likely not have adequate surge capacity. The MOH aims to identify potential high risk groups and stockpile adequate masks, antivirals, and other medicines, including special protective equipment for health workers. There are plans to work with the Red Crescent to increase hospital bed capacity and mobile units. The GOT currently has 5,000 boxes of Tamiflu and has written a letter of intent to Roche to seek to acquire one million treatments. The plan calls for imposing quarantines and social distancing measures; in the event of a pandemic crisis, the Prime Ministry national crisis center would have authority and willingness to close schools, public gatherings, and mass transit. The military would likely be available to enforce quarantines. ¶16. Turkey could serve as a model for transparent response for other countries in the region. Combined efforts of public, private, and international officials contributed to the good response to the outbreak. The relationship between public and private agriculture (i.e. poultry sector) has improved as a result of this crisis. The private commercial poultry sector has been providing training and some surveillance of farms, at least in those regions in close proximity to commercial areas. MCELDOWNEY