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