UNCLAS SECTION 01 OF 04 SOFIA 001962

SIPDIS

DEPT FOR EUR/NCE, SCOTT BRANDON

E.O. 12958: N/A
TAGS: TBIO ECON PREL SOCI BG KSTH WHO
SUBJECT: BULGARIA'S PREPARATION FOR AVIAN FLU

REF: STATE 206992


1. (U) The following is post's response to reftel:

A) PREPAREDNESS/COMMUNICATION

--Does the government have a preparedness plan/strategy for
preventing avian flu from becoming a pandemic and containing
a pandemic once it occurs? If the country has a strategy,
how capable is it of implementing it?


2. (U) The Bulgarian government has developed a preparedness
plan for preventing and containing avian flu. In the area
of veterinary affairs, two major official documents regulate
the surveillance and control of AI. These documents are the
"Surveillance Program for Newcastle Disease and Avian
Influenza" (Dated 2000) and Ordinance #47 (Dated November
2002), "The Measures for Prevention and Fight against the
Avian Influenza." Both documents were approved by the
Minister of Agriculture and Forests and have been
implemented since 2001-2002. Ordinance #47 has been
harmonized with the EU Directive 92/40. The Surveillance
Program for Newcastle Disease and Avian Influenza is under
revision and will be updated in 2006 in accordance with the
latest EU directive on Avian Influenza 464/2005.


3. (U) The GOB also has drafted a National Pandemic Plan,
which is currently before the cabinet, and established a
national AI crisis task force. The task forces meets weekly
and includes experts from 7 ministries as well as
independent scientists. The major problem, however, is that
the country does not have the financial resources to
implement their plan. The national task force requested 7-8
million leva (4-5 million USD)from the 2006 budget, but will
receive only 2.5 million leva (1.5 million USD), according
to the recent draft budget. The Health Ministry, which will
get 2 million leva (1.2 million USD) rather than the 5
million leva (3 million USD) requested, has said that
without appropriate funding, they will not be able to
respond to an AI outbreak.

--How truthful will the government be in reporting the scope
of any disease outbreak among people? Among animals? What

incentives could be offered that would likely result in more
transparency?


4. (U) We have no reason to doubt the government's
willingness to report any cases of avian flu among the human
population. Many officials have told us that an outbreak of
bird flu in Bulgaria is inevitable given the number of
confirmed cases in neighboring countries. The National
Avian Flu Crisis Task Force has requested 1 million
Bulgarian leva (approximately 670,000 USD) from the Finance
Ministry to compensate farmers for culled birds for the rest
of 2005. An additional 1.7 million leva (1 million USD) has
been requested for 2006. This money should encourage
farmers to truthfully report an outbreak of disease in their
livestock by providing protection against personal economic
ruin. Additional financial compensation for farmers would
be the best incentive to ensure greater transparency in
reporting. However, the Agricultural Ministry is slated to
receive only 500,000 leva (300,000 USD) for AI, which is
insufficient.

--Where does preparing for an avian flu human pandemic rank
among government priorities? Who and what would most
influence the country to give the issue a higher priority?
Who is the key "go-to" person, office or department (i.e
Minister for Health, Prime Minister, etc.) for USG officials
to engage on this issue?


5. (U) Preparing for an avian flu human pandemic has ranked
moderately high among the government's priorities,
particularly after cases of avian flu were confirmed in
neighboring Turkey and Romania. However, public interest
and pressure on the government to develop a response has
subsided over time and the issue has become less of a
priority for the government. AI still is a key priority for
the Health and Agriculture Ministries. A confirmed case of
avian flu in Bulgaria would be the strongest catalyst
encouraging the country to make AI an even higher priority.
The Health Minister Radoslav Gaidarski and Agriculture
Minister Nihat Kabil are the two officials primarily
responsible for leading Bulgaria's Avian Flu response.
Gaidarski heads the National AI Crisis Task Force and Kabil
is his deputy. The Health Ministry and the National
Veterinary Service in the Agriculture Ministry are the lead
bodies charged with Bulgaria's response effort. Prime
Minister Sergey Stanishev, however, is the most important
person who can energize the work of the ministries, find
badly-needed funds, and insure AI remains a high priority.

--Have national laws been reviewed to ensure that they are
consistent with the international health regulations and do
not pose barriers to avian influenza detection, reporting,
containment, or response?

6. (U) Most of the laws Bulgaria utilizes for AI
surveillance and prevention have been harmonized with EU
directives and are consistent with international health
regulations. Bulgaria is using EU and WHO directives as the
basis for its rapid response to AI.

--Is the host country already working with international
organizations or other countries on the avian flu issue?
Are government leaders likely to ask for assistance from the
U.S. or other countries? Would government leaders be
receptive to messages from U.S. leaders through a bilateral
approach, at a multilateral forum such as the UN (WHO, FAO,
etc.) or APEC, or through bilateral contacts by a third
country? What would the country want from the U.S. in
return for its efforts?


7. (U) The vet service regularly coordinates its activities
with the WHO, OIE and to some extent FAO. This is a working
relationship that was established in the past. Bulgaria is
not part of the IPAPI, as they depend on guidance from the
EU. One example of Bulgaria's cooperation with the EU on
this issue was a two-day AI simulation exercise held near
the town of Vratza in August with the support of TAIEX
bureau (Technical Assistance and Information Exchange) of
EU. The exercise was done after a two-day avian influenza
seminar, in which two EU experts trained 28 regional
Veterinary Services chief animal health officers, the New
Castle Disease and Avian Influenza reference laboratory
specialists, and veterinary staff from the headquarter of
the National Veterinary Medical Services (NVMS). A team of
two EU experts met with the GOB on October 18-20 to assess
Bulgaria's assessment capabilities and readiness on AI.
They felt Bulgaria was taking adequate measures, but
reportedly could not offer any direct assistance--other than
consultancy services and possibly some testing kits--because
Bulgaria is not yet an EU member.


8. (U) The GOB has requested U.S. assistance for AI and we
have facilitated the visit of a U.S. academic specialist to
consult with the National Veterinary Service on diagnosing
AI. USAID also is trying to find funding for supplies and
equipment. According to the National Veterinary Service and
Ministry of Health we (USDA Foreign Agriculture Services and
USAID) were the first bilateral mission to meet with them
and listen to their concerns and discuss needs. Bulgarian
officials are likely to be most receptive to messages from
US leaders that are delivered in conjunction with the EU
given the country's current focus on EU integration.
Otherwise, Bulgaria would likely be receptive to high-level
bilateral approaches.

--Does the country currently administer annual flu shots? If
not, might it consider doing so? What is the production
capability (i.e. how many doses of the annual trivalent flu
vaccine can the country make) for the human influenza
vaccines in the country? Does the country produce influenza
vaccine for poultry and if so how much? If the country is
developing an H5N1 vaccine, where is it in production and
testing? Any licensing issues? Is there a liability shield
for foreign makers/donors or vaccines? If not, any
prospects of one being enacted?


9. (U) In cases of emergency, vaccinations (conventional
anti-virus vaccination) will be provided to those people
surrounding the area around the outbreak. Vaccination of
poultry can be done in the same area, but only after
explicit instructions from the Agriculture Ministry and
should be done with an EU origin vaccine. Bulgaria is not a
producer of influenza vaccines for either humans or poultry.
The Nation Veterinary Services indicated they would need
1000 regular flu vaccines and 1000 Tami flu doses for their
front line staff to protect them in the event of an
outbreak. The Health Ministry has requested 3.5 million
leva (2.1 million USD) for protective vaccines for 2006,
which would cover 5% of the population (high risk
population). None of these funds are for the National
Veterinary Services' front line staff.

--How well informed is the population about the avian flu
threat and about measures they should take to mitigate the
threat? What mechanisms are available for providing
additional information to the population, particularly in
rural areas and how effective are these measures?


10. (U) The national media is very active in keeping the
general public aware of issues surrounding AI. Daily
reports have been published on all regional and national
issues related to AI. Most newspapers and radio promote
interviews with researchers and experts about the nature of
AI and the precautions which can be taken. The emphasis has
been both on the effects to the poultry industry and related
feed/grain industry and on the human health side of the
problem. Some publications have been overly strident in
their reporting and caused some panic among the public. In
October a dead bird found on the capital's main shopping
street resulted in the area being sealed off and traffic
being diverted during the evening rush hour.


11. (U) Additionally, 40,000 copies of a special AI pamphlet
were developed and distributed to mayors, hunters, the
poultry industry, and veterinarians. The pamphlet briefly
describes the clinical signs, the disease mechanism and
diagnostic methods of AI, as well as measures which should
be taken for prevention, surveillance and the fight against
AI. However, the pamphlet does not provide complete farm
management information to the poultry industry nor what
recommendations, practical steps and specific precautions
should be taken to keep the farms safe. The National
Veterinary Service needs further financial assistance for
development, printing and distribution of more and improved
information materials as well as support for covering a
wider audience.

B) SURVEILLANCE/DETECTION

--How capable are the medical and agriculture sectors at
detecting a new strain of influenza among people or animals
respectively? How long might it take for cases to be
properly diagnosed, given other endemic diseases? Can
influenza viruses be subtyped in the country, if so by who,
and if not where are they sent? Does the country send
samples to a WHO/EU/U.S. reference laboratory?


12. (U) The medical profession has a limited ability to
detect new strains of influenza in people. The Ministry of
Health has issued instructions to the general practitioners
for better diagnosis of influenza. However, like many
countries, the flu is underreported in Bulgaria. In order
for a doctor to formally diagnose the flu, she or he must
draw two blood samples from the patient and submit them to
the country's CDC. The length of this process and the cost
encourages doctors to formally avoid diagnosing and
documenting a case of the flu. Doctors tend to list another
symptom and then prescribe a general medication that will
address the flu symptoms.


13. (U) Bulgaria has a laboratory in each district city for
diagnosing human samples. Most of these labs are not
equipped for all diagnostic options. There is one reference
lab in Sofia at The National Center for Infectious and
Parasitic Diseases which covers all diagnostic options.
There is only one lab in Sofia for diagnosing animal
samples. Diagnosis typically takes 5 to 7 days. Bulgaria
has a limited ability to subtype viruses. The country sends
its samples to Waybridge, England, for referencing.

--What are the critical gaps that need to be filled in order
to enhance the country's disease detection and outbreak
response capabilities? What is the country's greatest need
in this area from the U.S. or international organizations?


14. (U) Bulgaria has trained people and one reference lab in
the capital, Sofia, where they have carried out monitoring
and surveillance simulations in the past. However, while
they have the technical capability, they sorely lack
equipment. There is a need for a lab in the northeast at
the migratory corridor or at least a mobile lab to respond
quickly to testing requirements. Currently there is up to a
10 hour delay getting samples from the field to the only lab
in the country in Sofia. Additional funds are needed for
transportation and field consumables. The Bulgarians would
like to have, at the minimum, a mobile laboratory to be
situated in the northeast part of the country and have their
Sofia lab upgraded. In addition to laboratory equipment,
the current lab staff(only 5 people) need better training in
the practical use of this equipment. New equipment is
needed and new trained staff should be hired as well in case
of an outbreak.

C) Response/Containment

--Does the country have a stockpile of mediations,
particularly of antivirals, and if so how much? If some has
been ordered, how much and when is it expected? Does the
country have a stockpile of pre-positioned personal
protective gear?


15. (U) The country does not have a stockpile of antivirus
vaccines or personal protective equipment for the veterinary
and medical staff exposed to risk on a daily basis.
Currently available stocks are in limited quantities and are
sufficient for regular implementation of the AI surveillance
program and regular lab testing. There is no money to
purchase these items and the need is urgent. The lack of
resources make it impossible to stockpile vaccines,
protective equipment, antibiotics, etc. To the best of our
knowledge the Ministry of Health intends to purchase 200,000
units of Tamiflu and 200,000 units of Remantadine, if they
receive the approval of the Council of Ministries for funds.

--What is the rapid response capacity for animal and human
outbreaks? Are there guidelines in place for the culling
and vaccinations of birds, disinfection of facilities, and
limitations on animal movement?


16. (U) The GOB is using directives from the EU and WHO as
guidance when mounting a campaign to respond to a human
outbreak of H5NI influenza. It is a phased response with
trip wires recommended by the EU and WHO. Within 24 hours
the healthcare professionals can be mobilized. A number of
hospitals have been designated as first responders. The
Ministry of Health is prepared to ratchet up an information
campaign should the specific trip wire be activated.
Implementation will depend on the number of people affected.
For a small outbreak of up to 60 people, the primary
hospital will be the new military hospital, which has 60
beds, new ventilators and isolation rooms. Should the
pandemic get out of control, Bulgaria, like many countries
will find itself short of beds, diagnostics, anti-viral
medication, and protective gear.


17. (U) The veterinary service currently is at a high alert
level and ready for an emergency situation. The service's
response is based on international directives with set
guidelines for culling animals and disinfecting areas. The
service has practiced its response to AI in simulated
exercises. In a case of an outbreak, a quarantine zone
will be established within 3 and 10 kilometers of the
infection, depending on the situation. In case of highly
contagious diseases with important economic and social
effects, such as AI, the Veterinary Service acts in
coordination with police and military units which are placed
at the quarantine zones and control the movement of people,
vehicles and products.


18. (U) The capacity of the veterinary service is limited in
terms of both sufficient lab staff and lab equipment.
Contingency planning does not meet the requirements for
larger scale outbreaks. Sampling is not risk based, the
number of samples submitted exceeds the capacity of the
reference lab and thus the lab response is rather slow. In
case of an emergency situation or a confirmed outbreak, the
number of lab personnel will be inadequate to process the
expected higher number of samples.

--How willing and capable is the government of imposing
quarantines and social distancing measures (closing schools,
public gatherings, mass transit)? Would its military
enforce quarantines?


19. (U) The government is capable of imposing quarantines on
a smaller scale and has some experience in this regard from
past influenza epidemics. A larger scale outbreak, however,
would be a challenge for Bulgaria given limited resources
and insufficient infrastructure.

BEYRLE