SECRETARY LEAVITT'S OCTOBER 10-11 VISIT TO THAILAND

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SUBJECT: SECRETARY LEAVITT'S OCTOBER 10-11 VISIT TO THAILAND


1. (U) Summary: In meetings with interlocutors during his
visit to Thailand October 10 and 11, HHS Secretary Leavitt
underscored the importance of transparency and
international cooperation in confronting the threat of
avian influenza (AI) and in planning containment and
pandemic preparedness efforts. The composition of the
Secretary's delegation - which included the Director of the

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U.S. Centers for Disease Control and Prevention (CDC),the
Director of the U.S. National Institute for Allergy and
Infectious Disease (NIAID),the Director General of the
World Health Organization (WHO),the Assistant Director
General of the Food and Agriculture Association(FAO),and
the President of the International Animal Health Code of
the World Organization for Animal Health (OIE) - itself
represented a model for international animal and human
health collaboration. Major topics for discussion included
the stockpiling of anti-virals (Tamiflu),human AI vaccine
research and production, training at the Thailand Field
Epidemiology Training Program (FETP),and continued close
collaboration between the Thai Ministry of Public Health
(MoPH) and the Bangkok-based U.S. CDC team. Secretary
Leavitt's activities in Thailand included a meeting with
Deputy Prime Minister Pinij Jarusombat, a meeting with
Minister of Health Dr. Suchai Charoenratanakul,
participation in a ceremony marking the 25th anniversary of
the Thailand MoPH-U.S. CDC Collaboration, a roundtable
discussion with International Organizations, and a visit to
Charoen Pokphand Foods PCL (CP),a large, commercial
poultry farm approximately 65 miles north of Bangkok. End
summary.

MoPH: IPAPI, Tamiflu Stockpile, Vaccines, and Training
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2. (U) The meeting at the MoPH was more like a roundtable
discussion with participation by the Secretary, CDC Director
Dr. Julie Gerberding, NIAID Director Dr. Anthony Fauci, WHO,
FAO, OIE, the Minister, and several heads of sections of
MoPH. Minister Suchai opened the meeting by stating that
Thailand appreciates the ten core principles of the
International Partnership on Avian Pandemic Influenza
(IPAPI) and intends to join the partnership. He also opened
the discussion of stockpiling anti-viral medications
(Tamiflu) by acknowledging that production capacity cannot
possibly meet current worldwide demand. (Swiss company
Roche is the sole producer of Osteltamavir, trade name
Tamiflu.) Minister Suchai said that the global shortage of
anti-virals creates a need for countries to pool their
resources to create a regional stockpile. He said that
Thailand would contribute 35,000 Tamiflu capsules,
representing 5 percent of Thailand's total stock, to a
Southeast Asia regional stockpile. He urged other
countries, including the U.S., to make a similar
contribution. He offered Thailand as a "staging point" for
a regional stockpile run by WHO, but said Thailand would
accept any location that countries in the region could agree
upon. (Note: Thailand's commitment to make a substantial
contribution to a regional stockpile even if not located on
Thailand's soil is an extraordinary step for Thailand to
make in terms of regional cooperation.)


3. (U) Secretary Leavitt agreed that the first step in
preventing an AI pandemic is international cooperation and
coordination. He said HHS was committed to supporting the
close relationship with the FETP. He also said that
containment of an outbreak within a specific locality is a
top priority, and acknowledged that pre-positioning of
supplies would be important in this effort. To that effect,
the Secretary said the U.S. can commit to contributing
personal protective equipment. He added, however, that HHS
was still considering whether to contribute to a regional
stockpile of Tamiflu.


4. (U) The Secretary and NIAID Director Dr. Fauci briefed
Minister Suchai on recent AI vaccine trials in the U.S. Dr.
Fauci said that preliminary results were promising - a
vaccine provided in a 4-dose regimen provided an immune
response that was predictive for protection against the
virus. In response to Thai long-standing requests to
collaborate with the U.S. on AI vaccine trials, the
Secretary and Dr. Fauci stated that the U.S. will share the

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results of its own trials with the Thais when they are
available, and that it will seek collaboration with Thailand
for a future trial. At this time, however, there is not
enough clinical material on hand to expand the trial to
other countries. The Secretary added that he would like to
see Thailand produce its own human vaccine, since even after
U.S.-Thai collaboration on trials takes place, production
capacity will still be limited.


5. (U) Minister Suchai asked for U.S. assistance to expand
the number of students from countries in the region to
attend the epidemiological training course offered at
Thailand's Field Epidemiology Training Program (FETP). The
Secretary said he was very gratified by the past success of

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this program and noted that several high-level health
officials from governments in the region are graduates of
the program. He said he is equally impressed by Thailand's
quick restructuring of the course content to focus on AI to
enhance the ability of healthcare workers in the region to
detect and investigate AI outbreaks. He said he will be
pleased to increase U.S. support in order to build up a
regional network of epidemiologists trained through the
program.


6. (U) Other participants at the meeting expressed their
views, as well: WHO Director General Jong-Wook Lee
emphasized the importance of transparency and timeliness in
reporting surveillance activities. FAO Assistant Director
General He Changchui encouraged good interagency
cooperation, especially between the MoPH and Ministry of
Agriculture and Cooperatives (MoAC). The President of OIE's
Terrestrial Animal Health Standards Commission Alejandro
Thiermann noted that efforts to contain AI should focus
activities to break the two most vulnerable links of
transmission - segregation of domestic poultry from wild
waterfowl and minimized contact between humans and poultry.

UN Organizations: More on IPAPI, Vaccines, and Stockpiles
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7. (U) At a luncheon and working meeting hosted by WHO and
attended by the Secretary and his delegation, the Thai MoPH,
and UN and other International Organizations, the earlier
discussions at the MoPH carried over on the same topics,
often by the same individuals. Secretary Leavitt led off
the meeting with a discussion of IPAPI, urging governments
to work closely with WHO and FAO and to follow open,
transparent, and timely reporting of animal and human cases
of AI. The Secretary added that current focus on AI should
not cause governments to neglect other infectious diseases
such as tuberculosis, malaria, and HIV/AIDS.


8. (U) WHO Director Lee welcomed the IPAPI initiative and
said that WHO and nations of the world must work closely
with the United States government to address the AI problem.
He emphasized that the economic effects of an avian flu
pandemic would be as severe as the cost in human lives. The
economic costs of the SARS outbreak several years ago has
been estimated to be greater than $30 billion globally, he
said, whereas the economic costs of an avian flu pandemic
would likely dwarf that figure. To prevent the enormous
costs in lives and damage to the global economy, nations
must act in collaboration to "pounce" on outbreaks with anti-
virals, culling, quarantine, and other measures to contain
an outbreak at its earliest stage.


9. (U) FAO Assistant Director General He Changchui agreed
that the primary emphasis should be to address an outbreak
at its source - in animals. To that end, he said that FAO
has been working closely with Southeast Asian governments,
WHO, the OIE and others. He said that FAO has spent $5.5
million since February 2004 on technical cooperation
projects addressing AI in animals with Thailand's MoAC and
with other government ministries in the region.


10. (U) The President of OIE's Terrestrial Animal Health
Standards Commission Alejandro Thiermann said that small
farmers in the region have paid the biggest price so far,
seeing their flocks culled often with inadequate or no
compensation. He said that the means to interrupt AI virus
transmission - segregating wild waterfowl from domestic
poultry, culling and vaccinations to prevent AI transmission
among domestic poultry, and minimizing human-poultry
interaction - are difficult to implement in Southeast Asia
where wild birds, poultry, and humans often live in close
proximity. He suggested that the smallest investment with
the biggest impact would be technical assistance to build
capacity in the region for surveillance, detection, and
prevention of outbreaks in animals.


11. (SBU) There followed a general discussion on vaccine
production. Margaret Chan, WHO Assistant Director General
& Representative of the Director General for Pandemic
Influenza, expressed concern about regulatory, licensing,
and liability issues, as well as a potential market failure
as traditionally companies worry about overproduction of
vaccines and slack demand. Presently, there is not enough
supply to meet worldwide demand, but will that demand be
sustained? NIAID Director Fauci agreed that sustained
demand for vaccine was an important issue that companies
will examine before ramping up production. Increasing
international demand for seasonal human influenza vaccines
is one approach to encourage vaccine manufacturers to
increase their vaccine production capacity. Such increased
capacity would become particularly important in the event
of a pandemic where hundreds of millions of doses would
need to be produced very rapidly.


12. (SBU) Thailand does not presently produce its own
influenza vaccines but does produce other human
vaccinations. Secretary Leavitt repeated his desire to see
Thailand and other countries in the region develop their
own vaccine manufacturing capacity. Secretary Leavitt said
that the U.S. was prepared to offer technical assistance to
Thailand and other nations to develop vaccine production
capacity. (Note: At a reception later that evening, the
Secretary emphasized to World Bank Thailand Country

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Director Ian Porter the importance of building Thailand's
capacity to produce a human AI vaccine. Mr. Porter,
listened, understood, but was non-committal on WB support.)


13. (SBU) Minister Suchai repeated his assertion that the
number one priority for Thailand was the creation of a
regional stockpile of Tamiflu. WHO Director General Lee
said that WHO has an MOU with Roche on a "virtual
stockpile" of Tamiflu whereby Roche has agreed to dispatch
up to 30 million doses (3 million treatment courses) of
Tamiflu anywhere in the world at WHO request should a human-
to-human outbreak occur. WHO would expedite customs
clearance in the host country and rush the shipment to the
local site of the outbreak. Dr. Lee expressed concern
about pooling of national resources because "when an
outbreak occurs, the reality is that countries will worry
about their own people first."


14. (SBU) Secretary Leavitt voiced his own concerns: The
U.S. uses stockpiling for several types of commodities, he
said, and this has not always been a workable strategy. He
noted that work still needs to be done on containment
strategies at the local level. For example, how do we
decide if an outbreak is containable? NIAID Director Fauci
added that another question should be addressed - are
current containment plans effective or realistic enough so
that stockpiling would have the desired impact? There
needs to be assurance, he said, that political will at the
top levels can be matched by implementation capability at
operational levels.

DPM: Thailand Helping Neighboring Countries
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15. (U) During his meeting with Deputy Prime Minister (DPM)
Phinij Jarusombat, who formally welcomed Secretary Leavitt
to Thailand on behalf of PM Thaksin, who was on travel to
Europe, Secretary Leavitt outlined the reasons for his visit
to Thailand, citing the urgency of the avian flu situation.
Secretary Leavitt noted he was accompanied by WHO Director

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General Lee and a staff of noted epidemiologists, which
underscored the gravity the AI situation. "An avian flu
case anywhere is a threat everywhere," said the Secretary,
as he expressed appreciation to the Royal Thai Government
for its efforts to combat the disease and its cooperation
internationally.


16. (U) The Deputy Prime Minister thanked Secretary Leavitt
and the U.S. government for its technical cooperation with
Thailand, and noted that Thailand itself has assisted
neighboring, less developed countries, with technical
cooperation. "Each country should help according to its
needs," he said. Noting that Thailand had not suffered a
human AI case since September, 2004, the DPM wished
Secretary Leavitt a productive visit.

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17. (U) At the close of the meeting, Secretary Leavitt said
the U.S. government welcomed PM Thaksin's decision, during
his recent meeting with President Bush, to lift Thailand's
ban on U.S. beef imports, and asked DPM Phinij how the
decision would be implemented. DPM said the decision would
be enacted following proper procedures, and cited the
Ministry of Agriculture's jurisdiction over the process.

Thailand MoPH-U.S. CDC Collaboration: 25 Year Anniversary
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18. (U) Secretary Leavitt, CDC Director Gerberding, and MoPH
Minister Suchai spoke at a colorful outdoor celebration of
the 25th anniversary of the Thailand MoPH-U.S. CDC
Collaboration. In his remarks, Minister Suchai reviewed the
history of the Collaboration and noted that the
Collaboration's activities in Thailand have focused mainly
on epidemiology training at the FETP, HIV/AIDS research and
programmatic activities through the HHS Global AIDS Program
and early-warning disease detection through HHS/CDC's
International Emerging Infections Program. Because of the
long MoPH-CDC partnership, he said, the Collaboration was
able to focus immediate attention on the avian influenza
outbreak last year and work together closely to answer
epidemiological, surveillance, and other important research
and public health questions.


19. (U) Secretary Leavitt praised the U.S.-Thai health
cooperation over the past quarter-century, especially on
infectious diseases such as HIV/AIDS, tuberculosis, severe
acute respiratory syndrome (SARS),and pandemic influenza.
He expressed condolence to Thailand for the heavy economic
and human costs Thailand has experienced recently from the
tsunami, as well as avian influenza, and thanked the Thai

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government for its offers of assistance after Hurricane
Katrina.


20. (U) CDC Director Gerberding said that the Thailand MoPH-
U.S. CDC Collaboration was the "jewel in the crown" of
international health collaborations and was pleased with the
success of the FETP. At the conclusion of the ceremony, a
placard carrying the logo of the Thailand MoPH-U.S. CDC
Collaboration was launched high into the sky by numerous
helium balloons of red, white, and blue - the colors of both
the Thai and U.S. flags.

Large-Scale Commercial Poultry Farm Visit: High Biosecurity
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21. (U) Secretary Leavitt and his delegation also visited a
large-scale commercial poultry farm owned and operated by
Charoen Pokphand Corporation (CP),the largest agricultural
company in Thailand and a leading exporter of chicken
products. The purpose of this visit was to demonstrate that
the commercial poultry industry in Thailand, which is geared
towards exports, has a self-serving interest in keeping AI
under control in Thailand as well as in neighboring
countries that could serve as virus reservoirs.


22. (U) The Secretary observed the operations of one of the
largest, vertically integrated commercial chicken farms and
processing plant in Thailand, and was particularly impressed
by the first rate biosecurity measures practiced at the
farm. CP company agreed to allow the Secretary and his
delegation inside the facilities only because the chickens
were only two days away from scheduled slaughter and
processing so that contamination was less of a concern than
would be the case if the chickens were younger. Even then,
the Secretary was made to don a hat, face mask, gown, and
two changes of boots, as well as undergo a disinfectant
spray before entering the facilities.


23. (U) Once inside CP officials briefed the Secretary on
farm procedures, emphasizing their care to ensure complete
segregation of their chickens from wild birds from the time
they are day-old chicks to birds ready for harvest. Contact
with human farm workers is also minimized through the use of
automated feeding and watering devices, and monitoring of
the temperature-regulated building through closed circuit TV
monitoring. The biosecurity features cut costs as well - a
single human overseer can look after more than 100,000
chickens.


24. (U) CP officials told the Secretary that because of the
possible negative impact on its poultry exports, Thailand
preferred these strict biosecurity measures to poultry
vaccinations - vaccinated poultry are difficult to
distinguish from poultry that have been exposed to AI, and
importing countries such as the EU would not import such
birds. Other countries in the region, by contrast, produce
poultry almost entirely for domestic consumption, and thus
are more interested in [developing and] using AI vaccines
for poultry.


25. (U) CP officials also noted that approximately 80
percent of Thailand's chicken meat exports (Thailand exports
only processed meat) come from large-scale farms. About 20
percent come from medium-sized farms that often have less
stringent biosecurity practices. CP officials emphasized,
however, that the threat from AI - to the general public and
to their own business - comes from the millions of families
engaged in "backyard" chicken farming where a family might
raise a dozen or less poultry for its own consumption. In
these types of households, chickens, ducks, and humans,
often share the same living space - a perfect setting for AI
transmission. When asked by the Secretary whether public
behavior could be modified so that "backyard" chicken
farming could eventually be phased out altogether and
chickens raised only under biosecure conditions, the CP
officials were not optimistic. This would require a change
in culture, they said, and even though it might be possible
to fathom such a change in Thailand, it is unlikely to occur
in our lifetimes in rural areas in other countries in the
region.


26. (U) Another item worth noting at the CP visit was the
comment by one of the company officials that they (CP)
regard the MoAC as an important "middle man" in getting the
biosafety word out to the larger community. This is an
interesting contrast to the U.S. model where agribusinesses
act as the community multiplier of good agricultural
practices and the government is the source of research and
policies.


27. (U) Secretary Leavitt and his delegation visited a
contract farm that provides some 8,000 birds to CP and
follows the biosafety methodologies developed by the larger
company. CP only buys some twenty percent of its birds from
farms provided they show adequate animal health practices.
Meeting the CP standards is not easy and CP plans to reduce
the number of contract farmers that it uses, eventually
bringing all bird production back under its own roof.


28. (U) Secretary Leavitt and the delegation did not have an
opportunity to clear this message.

Boyce