A/S SIMONSON DISCUSSES COOPERATION ON AVIAN

UNCLAS SECTION 01 OF 06 HANOI 002192

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TAGS: AMED AMGT CASC EAGR TBIO VM AFLU
SUBJECT: A/S SIMONSON DISCUSSES COOPERATION ON AVIAN
INFLUENZA


1. (SBU) Summary: Assistant Secretary (A/S) Stewart
Simonson of the Department of Health and Human Services
(HHS) visited Vietnam on August 14-17 to discuss a
memorandum of understanding (MOU) on cooperation between HHS
and the Ministry of Health (MOH),as well as to discuss
Vietnam's efforts to combat Avian Influenza (AI). The
Government of Vietnam (GVN) wants a binding agreement rather
than an MOU. HHS is willing to consider an agreement
provided it can obtain first the necessary legal authority.
GVN officials told the Assistant Secretary that they were
eager to cooperate with the United States in developing
Vietnam's monitoring capacity and preparing for a possible
outbreak of AI. A/S Simonson stressed the critical need to
establish a Rapid Response Protocol (RRP),and committed the
USG to keeping information on possible outbreaks that the
GVN shares with it confidential. A/S Simonson also met with
representatives from the United Nations agencies to hear
their assessment of Vietnam's anti-AI efforts and their
proposed joint program. The A/S left Vietnam optimistic
that HHS and MOH could conclude a cooperative agreement in
time for the planned visit of HHS Secretary Michael O.
Leavitt, now delayed, for mid-October. End Summary.


2. (U) A delegation led by Stewart Simonson, Assistant
Secretary for Public Health Emergency Preparedness at the

SIPDIS
U.S. Department of Human and Health Services (HHS) visited
Vietnam August 14-17 to discuss a Memorandum of
Understanding (MOU) on health and medical sciences
cooperation between HHS and the Ministry of Health (MOH),as
well as efforts to prevent and contain the H5N1 Avian
Influenza (AI) virus. Accompanying the Assistant Secretary
were Dr. Amar Bhat, HHS Director of the Office of Asia and
the Pacific, HHS Office of Global Health Affairs; Dr. James
Le Duc, Director, Division of Viral and Rickettsial
Diseases, National Center for Infectious Diseases,
HHS/Centers for Disease Control and Prevention (CDC); and
Dr. Mary Chamberland, Medical Officer, HHS/CDC. During the
visit to Hanoi, the delegation met with representatives from
the MOH, the Ministry of Agriculture and Rural Development
(MARD),the Ministry of Planning and Investment (MPI) and
key United Nations agencies. Ambassador Marine or Acting
DCM Sam Watson, and Health Attache Dr. Marie Haring Sweeney
accompanied the Assistant Secretary to his meetings.

Productive Discussions with the MOH on the MOU
-------------- -


3. (U) A/S Simonson and his delegation held discussions on a
draft MOU on HHS-MOH cooperation with a GVN team led by MOH
Vice Minister Trinh Quan Huan. A/S Simonson stated that he
considers AI to be an extremely important issue for the HHS
Office of Public Health Emergency Preparedness. U.S. and
other experts believe that there is a narrow window of time
when medical and physical intervention can stop a pandemic.
The main reason for the Assistant Secretary's visit was to
determine what tools would be necessary for Vietnam to
respond during this critical period. He expressed his
appreciation for Vietnam's cooperation and the level of
transparency achieved to date, and his hope to build on this
foundation.


4. (U) The GVN proposed language that would change the
document under discussion from a MOU into a binding
agreement. The A/S said that he would be amenable to this
change, but stressed that the discussions would have to
proceed with the understanding that any agreement reached
would have to be approved by Washington. Both sides agreed
to bracket all words in the text that would constitute a
binding agreement pending the interagency concurrence on
Circular 175 authority for such an agreement. A/S Simonson
concluded by stating that the U.S. objective is to reach
agreement on a document for Secretary Leavitt to sign during
his planned visit in the fall.

The MOU: Need for Speedy Response and Confidentiality
-------------- --------------


5. (SBU) The A/S stressed that rapid response at the first
sign that the virus is changing is critical to have a chance
to prevent a pandemic. The United States and Vietnam would
have to agree on the general principles for rapid response
in the cooperation document, and to follow up with a more
detailed Rapid Response Protocol (RRP). These steps would
not only improve Vietnam's readiness in the event of a
pandemic, but would also help to identify possible U.S.
funding to fight AI in Vietnam. Vice Minister Huan
expressed the concern that Vietnam might be criticized
should the GVN announce an outbreak of AI prematurely, as
has happened in the past. A/S Simonson reassured the Vice
Minister that the intent of the United States is to enter "a
partnership with trust and confidence," in which information
shared between the two governments would be treated with the
utmost confidentiality, with no penalty for false alarms.
He repeated this message in subsequent meetings with other
ministries.

The MOU: Unresolved Issues
--------------


6. (U) The MOH asked to strike language in the agreement
relating to the President's Emergency Preparedness for AIDS
Relief (PEPFAR),arguing that it potentially duplicates the
PEPFAR paper that Vietnam is currently negotiating with the
United States. Noting that this language had been added at
Office of the Global AIDS Coordinator's request, A/S
Simonson agreed to convey Vietnam's concerns to Washington,
but stressed that he could not make any assurances that the
change would be accepted. The A/S agreed to include in
brackets Vietnam's proposal to expand language on
cooperation to include the areas of injury prevention and
rehabilitation, pharmaceutical regulatory issues, and food
safety. He noted, however, that these issues fall beyond
his mandate and within the jurisdiction of other HHS
agencies.

Joint FAO/WHO/UNDP Program
--------------


7. (U) On August 15, A/S Simonson met with UNDP
Representative Jordan Ryan, Dr. Peter Horby and Hitoshi
Murakami of the World Health Organization (WHO),Anton
Rychener and Dr. Astrid Tripodi1 from the Food and
Agriculture Organization (FAO) and a representative of the
World Bank. They provided a copy of the latest version of
the proposed Joint FAO/WHO/UNDP program to strengthen public
health emergency management in Vietnam, with a focus on AI.
Developed in response to a request from the GVN, the
proposal is now before Prime Minister Khai, who is expected
to approve it soon. The estimated budget required for the
program is USD 18.9 million over two years. A number of
donors have indicated interest in contributing funds. FAO's
Rychener emphasized that, while the GVN welcomed
international help, it wants the help to be "low key" and
supplemental to GVN's own efforts.


8. (U) FAO's representatives described the GVN's massive
pilot program to vaccinate poultry in two provinces. It is
important to get a first round of vaccinations nationwide
well underway by October, before the flu season and well
before the Tet holiday. In response to a question from the
Ambassador, Dr. Tripodi (FAO) said that the GVN has devised
a good system to reach all producers, including small
farmers, but pointed out that lack of funding is a problem.
The GVN has had to rely on volunteers to complete the first
round of vaccinations, a solution that is not viable in the
long run.


9. (U) Dr. Horby (WHO) emphasized that surveillance is
essential to evaluate the effects of the first round, and
that with adequate data, it may be possible to do focused
vaccinations in subsequent rounds. A/S Simonson asked if
there was a consensus among international experts that a
massive poultry vaccination campaign would be the best
approach. Both FAO and WHO representatives emphasized that
the vaccination program was based on a consensus of experts.
Dr. Horby said that WHO believes the vaccination program
will reduce human fatalities; the question is whether the
program will be sustainable in the long run.


10. (U) According the WHO representatives, the GVN has been
committed to using its own strain of virus to develop a
human vaccine. However, the WHO hopes the Ministry of
Science and Technology (MOST) will decide to use a strain
provided by the WHO. For the time being, MOST has blocked
the start of human trials. WHO noted that although Vietnam
can develop a vaccine, it lacks the manufacturing capacity
to produce it in the required quantities, even for domestic
use alone. A/S Simonson suggested that one option might be
producing the vaccine in a country with greater
manufacturing capacity.


11. (SBU) The UNDP, FAO and WHO representatives hope to see
a draft of Vietnam's National Emergency Plan in early
September. The agencies' advice is to think through the
full range of options, such as quarantine and closing
schools. Expressing doubt that MOH fully understands the
concept of rapid response, Horby called for greater
Vietnamese focus on training in that area. The plan would
not work if it exists only on paper. A public education
campaign is also important, since awareness among rural
farmers is low and their behavior has not changed. The only
outreach thus far has been a few posters and leaflets.


12. (SBU) In response to a question from the A/S, Dr. Horby
said it might take seven to ten days to diagnose a case of
AI that occurs in a remote area. On average, it would be
about five days before a sick person would be hospitalized,
usually in a district hospital. If the illness persisted,
the patient would be transferred to a provincial or tertiary
hospital and only then would samples be taken. Results from
the samples would take a day or more and would initially be
reported to MOH and only then to the hospital. If the
hospital has not previously had a case of human AI, the
illness might not be recognized immediately. Since early
detection of AI is crucial, this delay in identifying cases
is a serious problem, Dr. Horby concluded.


13. (SBU) Lack of diagnostic capacity is another serious
concern. Vietnam has only six diagnostic laboratories of
which two can perform the full range of tests. Only 20-50
samples can be processed per day, and inaccurate results are
a problem. The GVN has been reluctant to send samples
abroad for testing, in part because of an incident in which
a WHO lab in Tokyo provided results of their testing to a
scientific journal (Nature). The results indicated that the
Vietnamese tests resulted in a disproportionate number of
false negatives. As a result the GVN suspended all shipment
of samples for two months and the WHO had to work to
reestablish trust. The Minister of Health must now approve
sending positive samples abroad for retesting and does not
approve sending negative samples for retesting. This action
has implications for quality assurance.

Support for AI Cooperation from MPI
--------------


14. (U) The A/S expressed appreciation to Ministry of
Planning and Investment (MPI) Vice Minister Cao Viet Sinh,
for the Ministry's interest and involvement in the Agreement
for Economic and Technical Cooperation between the United
States and Vietnam. He stated that the purpose of his visit
is to identify additional investments that the United States
could make to help Vietnam fight AI, and asked whether there
were ways the United States could make the process smoother.
VM Sinh was well informed about the AI situation in Vietnam;
he responded that approval of U.S. investment in AI
containment efforts is a government priority, and that
implementing an agreement would have support at the highest
levels. Stressing that AI is the most dangerous threat
faced by the agricultural sector, the VM assured the A/S
that MPI was ready to cooperate.


15. (U) The VM stated that since the agricultural sector in
Vietnam is not industrialized, raising AI awareness among
small farmers is a critical component of an RRP. He also
singled out investments in personnel and equipment as
priorities. Regarding reporting, VM Sinh pointed to the
lack of communication links to small farms. At the end of
the meeting, A/S Simonson stressed that the United States is
interested in exchanging information in a confidential
manner.

Informal Discussion at the Ambassador's Residence
-------------- --------------


16. (U) The Ambassador hosted an August 16 luncheon in honor
of the A/S. Attendees included VM Trinh Quan Huan and other
officials from the Ministry of Health, VM Bui Ba Bong of the
Ministry of Agriculture and Rural Development, and Dr. Tran
Ngoc Thang, Head of Planning, International Cooperation and
Science Division at the Department of Animal Health. The A/S
said that he felt his meetings had been very constructive,
and that consensus on broad issues had been reached,
including on the critical issue of the need for rapid
response.


17. (U) Noting that farmers in two provinces had
participated in the pilot vaccination program very well, VM
Bong said that Vietnam would start a nationwide vaccination
program in September. The two biggest challenges will be
reaching small farmers and providing funding for the 1,000
staff needed in each province to administer the program. As
it stands, local governments are responsible for paying
staff salaries. 2Dr. Nguyen Tran Hien, Director of the
National Institute for Hygiene and Epidemiology, stated that
the highest risk of transmission is through exposure to sick
birds. He also noted another risky behavior: Vietnamese eat
some bird parts uncooked.


18. (U) GVN representatives described a high level of
cooperation between the central and local, or commune level,
governments on AI. VM Bong and A/S Simonson agreed on the
importance of further research into the mode of transmission
of the virus in order to plan for prevention and treatment.
Dr. Hien said that Vietnam is working to develop a vaccine
using both domestically produced monkey kidney cells and
cells provided by the WHO. Noting concerns previously
raised by international organizations over the use of
primary monkey kidney (PMK) cells, he stated that the GVN
will follow WHO established methods, but would also continue
working with the PMK. 3

In a side conversation with Dr. Sweeney, VM Huan indicated
that he was given the area of AI as part of his
responsibilities as Vice Minister. Up until now, Vice
Minister Liem was responsible for AI. 4

Meeting at the MARD
--------------


19. (U) The Ambassador accompanied A/S Simonson to a meeting
with Minister Cao Duc Phat of the Ministry of Agriculture
and Rural Development (MARD). Minister Phat said that
although AI outbreaks have greatly decreased in recent
months compared to the same period last year, he considers
the situation extremely serious, particularly as the winter
flu season approaches. He is also concerned that infected
chickens and ducks are increasingly asymptomatic.


20. (U) The Minister said that MARD had just initiated a
program to vaccinate all poultry in the country before
winter. The initial response of farmers has been very
encouraging, with the great majority willing to bring their
birds for vaccination. MARD also has implemented an
information campaign aimed at all types of producers,
particularly small backyard farmers, who own 65 percent of
all poultry. In the longer term, the MARD would like to
encourage larger production operations where there is less
contact between poultry and humans.


21. (U) Minister Phat echoed other officials in emphasizing
the need for increased monitoring capacity. He said the
most pressing need is for human resources, and the presence
of qualified technicians in the provinces as well as in
Hanoi. The Minister has made a request to the WHO, FAO, and
the U.S. Government to provide experts who will be able to
advise and assist the GVN with the vaccination program, and
monitoring of the disease.


22. (U) A/S Simonson said that he is working with the MOH on
an emergency plan to have resources ready in the event the
disease acquired increased transmissibility. He hopes the
plan will be ready in time for the visit by Secretary
Leavitt. He also noted the importance of looking at the AI
problem as both an animal and human health problem. In
answer to a question from the Ambassador, Minister Phat said
that MARD has not seen the disease spreading to other
species, although they have sent swine samples to Hong Kong
for testing.

Concluding Thoughts
--------------


23. (SBU) At an out-briefing with the Ambassador, A/S
Simonson stated that he felt very positive about his visit.
Besides working on the cooperative agreement, the delegation
had discussed ideas for building surveillance and response
capacity in Vietnam, and agreed that one possibility would
be to work with retired U.S. scientists and public health
officials. The Ambassador recommended that the USG focus on
bringing experts to Vietnam for extended TDY stints,
preferably three months or longer. He noted that the
primary need is for public health experts who could assist
in overseeing and coordinating survey work and sample
processing, rather than for research scientists.
Additionally, the language barrier can be significant;
interpreters should be hired to facilitate the efforts of
U.S. experts.


24. (U) A/S Simonson and his party cleared this message.

MARINE
_______________________________
1check spelling
2Best to delete this statement as it
3Dr. Hien actually said that they would be working on both
the WHO and the PMK cell line.
4Is this important enough to add