RECOGNIZING THREAT, TAIWAN PREPS FOR AVIAN FLU

UNCLAS SECTION 01 OF 07 TAIPEI 000058

SIPDIS

STATE FOR EAP/RSP/TC AND OES/IHA
STATE PASS TO AIT/W
USDA FAS FOR APHIS/VS, IS
HHS FOR ERICA ELVANDER

E.O. 12958: N/A
TAGS: TBIO AMED EAGR ECON EAID TW
SUBJECT: RECOGNIZING THREAT, TAIWAN PREPS FOR AVIAN FLU

REF: A) 2004 STATE 23762 B) 2004 TAIPEI 0249 C) 2003

TAIPEI 03339 D) 2004 TAIPEI 00479 E) 2004 TAIPEI 04021



1. Summary. Taiwan has thus far managed to avoid Avian
Influenza since early 2004. Following the outbreak of H5N2
Low Pathogenic Avian Influenza (LPAI) in Taiwan in early
2004 and the outbreaks of H5N1 High Pathogenic Avian
Influenza (HPAI) in neighboring countries both last year and
this year, however, Taiwan has been proactive in preparing
for the worst. Reftel D provides post's February 2004
responses to Department questionnaire regarding Avian
Influenza. Based on further proactive steps undertaken by
Taiwan authorities, this cable provides updated responses to
the questionnaire. The primary change since last February
is that Taiwan has drafted a major influenza prevention and
response plan. Previously, Taiwan had relied upon its SARS
preparation and response plan. Now Taiwan has also prepared
influenza-specific plans. Those plans include the
establishment of a new emergency response center at Taiwan's
Center for Disease Control. Further, Taiwan has committed
to invest a total of NT$6 billion (USD 187 million) towards
developing and manufacturing influenza vaccines. In
addition, Taiwan has also culled an additional 270,000 birds
since February. Given Taiwan's proximity to the many other
countries in the region facing the threat of outbreaks of
Avian Influenza, it may be only a matter of time before
Taiwan's preparations are put to the test. End Summary.

Surveillance for Animal Influenza
--------------

Q. Is there active of passive animal surveillance for Animal
Influenza in country?

A. Taiwan has an active surveillance program on commercial
poultry, wild fowl, and migratory birds.


Q. Who is the Point of Contact in the Ministry of
Agriculture?

A. Dr. Ying Yeh, Deputy Director General,
Bureau of Animal and Plant Health, Inspection and Quarantine
(BAPHIQ),Council of Agriculture (COA).


Q. Where are animal diagnostic laboratory samples tested for
influenza?

A. Initially samples are tested at the four Regional Poultry
Health Centers and confirmed by the National Institute of
Animal Health in Tamshui, Taipei County. Taiwan uses PCR
testing, DNA sequencing and pathogenicity index testing to
establish the type and pathogenicity of the influenza.


Q. Is laboratory capacity sufficient or would assistance be
welcome?

A. Capacity is sufficient.


Q. Are results being communicated to national officials?

A. Yes. BAPHIQ reports to COA, which reports to the
Executive Yuan (Cabinet).

Culling Practices
--------------


Q. How is culling defined and practiced?

A. When tests establish that Avian Influenza is present on
a farm, whether it is Low Pathogenic (LPAI) or High
Pathogenic (HPAI),the farm is depopulated. To date, Taiwan
has only detected LPAI and that was in early 2004 (except in
spring 2004 when six ducks with H5N1 HPAI were detected in
Kinmen island. These ducks were later determined to be
contraband smuggled from Mainland China). Birds are
euthanized via their feed or water and then incinerated.
Farms are disinfected. Based on the 1997 Foot and Mouth
Disease outbreak, Taiwan has a great deal of experience in
dealing with serious animal disease outbreaks. Taiwan also
has a relatively modern veterinary and quarantine
infrastructure.


Q. Are culling protocols available to be sent to DC?

A. The Animal Contagious Disease Prevention Statute is
available in Chinese.


Q. Are cullers adequately protected?

A. Yes, cullers wear masks, boots, gloves, and protective
clothing.


Q. Are cullers being adequately trained to use PPE?

A. Yes, the staff of the local Livestock Disease Control
Center supervises the cull and trains the cullers.


Q. Would they benefit from training assistance

A. Not needed.


Q. Are culled carcasses adequately disposed of?

A. Yes, carcasses are disposed of by incineration.


Q. How many have already been culled?

A. During 2004, 380,000 birds were culled.

Movement of avian livestock
--------------


Q. What measures are in effect to control movement of
poultry (and birds) within the country.

A. Farms on which AI is suspected or detected are isolated
and, if detection is confirmed, the farms are depopulated.
Farms within a 3-kilometer radius of a farm on which AI is
detected are subject to movement control and intensive
surveillance for 6 months.

Vaccination
--------------


Q. Has vaccine for Avian influenza been applied to poultry
in the country? If so, what type and approximately what
proportion are?

A. Vaccination for AI is not permitted, although BAPHIQ
suspects that individual farmers have been illegally using
vaccines based on the Mexican AI strain.

Animal Demographics Overview
--------------

Taiwan has a modern poultry and livestock industry. Both
poultry and swine are produced on medium-to-large scale
farms with regular service by professional veterinarians.
Farms are devoted to a single species and are widely
separated. The major poultry species are modern broilers
and layers, traditional colored chickens, and ducks as well
as a small population of geese and turkeys. There are
132,000 poultry farms with a total bird population of 415
million. There are 13,000 swine farms with a total pig
population of about 7 million. Statistics are not available
on the proportion of the population engaged in poultry/swine
production, but if we multiply 145,000, the total number of
poultry and swine farms, by an estimated average work force
of 5 persons, the total work force is 725,000 or about 3
percent of the population. There are 3 major poultry
wholesale markets that BAPHIQ and DOH have placed under
close surveillance. In addition, live poultry is sold and
slaughtered in the traditional markets scattered throughout
Taiwan's cities and towns. Vendors have been educated by
local authorities to be aware of signs of AI and practice
good sanitation in their slaughter. However, the
traditional markets would be a cause for concern if Taiwan
were to have an outbreak of HPAI.

Trainers
--------------

Q. Are certified trainers available to teach workers about
the use of PPE throughout the country? How many? Who would
pay trainers to give the training sessions? Are funds
available? What are the estimated costs?

A. Local Livestock Disease Prevention Center personnel have
been trained to use PPE and then train the workers assigned
to a cull.


Q. Are trainers available to teach workers about safe
culling methods throughout the country? Who would pay
trainers to give sessions? What are the estimated costs?

A. Local Livestock Disease Prevention Center personnel have
been trained to teach workers to do a safe cull.

Surveillance for influenza-like illness in humans:
-------------- --------------

Q. Have health care providers been alerted to be aware of
any extra-ordinary cases of influenza-like illness?


A. Yes. Taiwan's Center for Disease Control (TCDC) has
classified Avian Influenza, or "Novel flu" - as a
"notifiable communicable disease." Notifiable communicable
diseases must be reported to the TCDC and the central
government is authorized to take extraordinary efforts to
contain such diseases.

Further, Taiwan has committed to invest a total of NT$6
billion (USD 187 million) towards developing and
manufacturing influenza vaccines. The plan is to devote ten
percent of the budget on vaccine research and development.
With the highest levels of political support, Taiwan health
officials are working hard to secure the monies to fulfill
this commitment.

In addition to Taiwan's plans to develop a vaccine and
Taiwan's existing strategies to prevent, contain and respond
to SARS (see reftel C),TCDC has drafted a five-year
"Influenza Preparation and Prevention Plan" (Flu plan). The
Flu plan details extensive strategies for trying to
distinguish among SARS, influenza A/B and Novel flu and
provides guidelines to medical workers to minimize confusion
between the various types of viruses during the influenza
season. The plan is currently awaiting Executive Yuan
approval.

The Flu plan includes a 5-level Influenza Response System.
The "Alert Level" is activated when there is one or more H5
or H7 strain of virus detected domestically or there are any
confirmed cases of bird-to-human transmission on High
Pathogenic Avian Influenza Strain abroad. "Level A1" is
activated when there is at least one confirmed case of human-
to-human transmission outside of Taiwan. "Level A2" is
activated when there is no indication of local transmission,
but there is at least one confirmed case of bird-to-human
transmission and/or a laboratory suspected case and/or a
suspected imported case in Taiwan. "Level B" is activated
when there are one or more confirmed cases of primary human-
to-human transmission in Taiwan. "Level C" is activated
when there are confirmed secondary human-to- human
transmission cases within Taiwan. TCDC has responsibility
for responding at the Alert and A1 levels, DOH becomes
responsible at the A2 and B levels, and the Executive Yuan
takes over at level C.
Based on the above response levels, Taiwan has a
surveillance program for Avian Influenza and SARS at its
borders. Taiwan is currently operating at the Alert level.
At this level, TCDC urges all travelers to countries with
avian influenza outbreaks to avoid touching raw poultry in
those places. In addition, all inbound passengers are
required to complete health survey forms and undergo
temperature checks. Passengers with fevers or forms
indicating illness are further assessed prior to
immigration. At the Alert and A1 levels, Nasopharyngeal
washing or Throat Swabs are taken from any inbound
passengers with fevers in excess of 38 C and a history of
unprotected contact or exposure to the virus. Those
passengers are also required to take a full course of the
anti-viral oseltamivir. At the A1 level and/or above, in
addition to the above measures, passengers from the affected
areas are required to self-monitor for fevers twice a day
for 10 days. At level B and/or above, medical doctors will
be posted at the borders to assist in these processes. Also
at level B, any outbound passenger with a fever over 38 C,
must obtain a doctor's note confirming the person has been
Avian influenza-free for at least 24 hours, before they can
depart. Finally, at level B and above, any passengers
suspected of having avian influenza will be sent by
ambulance to the designed hospitals for further management,
where a series of lab tests will be conducted.

Hospital Infection Control Measures
--------------

Q. Have hospital infection control practices been put in
place? What type of systems are in place for care and
isolation and/or quarantine of patients with suspected cases
of Avian Influenza?


A. TCDC's Flu plan's hospital infection control measures
include: a program to detect and survey fever patients
promptly; implementation of a standard operating procedure
for infection control in all hospitals; recruitment of
qualified epidemiologists to help prevent inter-hospital
transmissions by modeling outbreaks, a plan to evaluate
nursing procedures to facilitate reorganizations that might
be necessary; institution of fever surveillance and alert
programs; establishment of a mechanism to assess the
efficacy and efficiency of hospital infection control
programs; the provision of comprehensive and intensive
infection control training for hospital staff, plans to
prevent any unsafe or unnecessary transportation of patients
with a communicable disease; and protocols for waste
handling and personal hygiene. Taiwan has 740 negative
pressure beds available for use.

In addition to the measures above, TCDC requires all
hospitals and clinics to ask flu patients if they have had
any contact with poultry or farm owners. Any patients who
have had such contact are given the antiviral medication of
oseltamivir (trademarked as Tamiflu) for five days. Subject
patients are required to have follow-up checkups.

Finally, Taiwan has ordered a total of 2.5 million doses of
influenza vaccine for this flu season - 500,000 for children
and 2 million for adults. Already 410,000 children and 1.62
million adults have been vaccinated. Health workers, babies
between six and 24 months, senior citizens over 65, people
with serious diseases, and workers in the avian and
husbandry industries are provided shots free of charge.
TCDC has also stockpiled 1.3 million oseltamivir tablets
(enough medication to treat 130,000 influenza cases). Thus
far, only 10 percent has been used. TCDC is planning to
increase its stock of oseltamivir to 23 million tablets (so
that Taiwan will have enough doses to treat 10 percent of
its population).

Samples
--------------

Q. Are samples being obtained from potential human cases of
Avian Influenza?

A. Taiwan currently does not have any potential human cases
of avian influenza.

Number of Human Cases
--------------

Q. Can you estimate the approximate number of human cases?

A. Again, thus far Taiwan has no human cases. Taiwan has
not detected any cases of High Pathogenic Avian Flu H5N1.

Laboratory Surveillance and Capacity
--------------

Q. Where is laboratory surveillance done?

A. CDC has contracted with several labs stationed in major
medical centers all over the island including: National
Taiwan University Hospital, Veterans General Hospital and
Kaohsiung Medical University Hospital. Offshore islands in
Kinmen and Matsu are to report to labs in the northern part
of Taiwan and the island of Penghu will report to a lab in
Kaohsiung. The general lab surveillance is done by TCDC.
In addition to the 12 contracted P3-level laboratories
throughout the island, TCDC has a plan to set up more
laboratories if needed, in order to conduct more tests in a
shorter time.


Q. Is Laboratory Capacity sufficient?

A. Laboratory capacity is sufficient.

Availability of Respirators
--------------

Q. What is the availability of N-95 respirators or
equivalent? Of goggles? And of surgical gloves? Can more be
purchased? Does the country have resources to purchase a
sufficient number of respirators, goggles and surgical
gloves to ensure that all workers receive as many
respirators as needed?

A. TCDC is responsible for N-95 respirators or equivalent,
surgical gloves, goggles and garments for health care
workers. According to TCDC, currently the stock of
respirators and gloves for healthcare workers is sufficient.
COA is responsible for the purchase of protection supplies
for poultry industry workers and has adequate supplies on
hand. TCDC is also committed to work with COA to ensure
that it obtains whatever supplies are needed.

Communications
--------------

Q. Are results being communicated to national officials and
between Ministries?

A. Laboratory surveillance results are being communicated to
relevant agencies and ministries. In addition, TCDC, the
Department of Health, the Bureau of National Health
Insurance, COA and other relevant government agencies have
been working very closely together since the emergence of
Avian Influenza earlier this year. Intra and interagency
collaboration and coordination is excellent.



Q. What sort of communications policies and practices are
in place concerning Avian Influenza?

A. TCDC has designed and will soon open a new emergency
response center at its headquarters to implement its
emergency response plans in the event of an influenza, SARS
or other infectious disease outbreak.

TCDC's draft Flu Plan also details who, when and how to
report on a probable Novel flu patient. It also specifies
how and when each level of government should respond to a
reported case. Furthermore, it establishes a new alerting
network, which will enable the TCDC to directly communicate
instructions with local health officials using mobile phones
as soon as a case is reported. It also provides protocols
for cooperation across ministries.

Finally, the Government Information Office (GIO) is working
closely with all relevant government agencies and is
responsible for all official public announcements regarding
the disease. The main points of contact for AIT are the COA
and TCDC.

Need for U.S. Assistance
--------------

Q. Can U.S. experts from HHS, USDA and other agencies be of
help?

A. Since Taiwan is not yet confronting Highly Pathogenic
Avian Influenza, no assistance is necessary at this time.
In the past, Taiwan has been quick to request assistance
when needed. As the situation develops, we will keep on top
of the matter.

Weaknesses/strengths in system
--------------

Q. What weaknesses (and strengths) has post observed in the
host's attempt to contain avian flu?

A. Thus far, Taiwan has been able to avoid an outbreak of
Highly Pathogenic H5N1. Taiwan appears to be very proactive
in its efforts to prevent, detect and respond to an avian
influenza outbreak. Given Taiwan's proximity to the many
other countries facing the disease, however, it may only be
a matter of time before Taiwan's precautionary measures are
put to the test. Taiwan CDC's infection control, fever
surveillance efforts are particularly strong due to its
significant preparations for another potential SARS outbreak
and the H5N2 Low Pathogenic outbreak in Taiwan in early

2004. COA and the livestock industry also learned from their
experience with the major 1997 Foot and Mouth Disease
outbreak that also resulted in significant investment in
disease prevention, surveillance and control infrastructure,
including the establishment of BAPHIQ in August 1998.
Taiwan also benefits from the fact that it is an island,
which affords a certain degree of protection. Taiwan
recently raised the level of criminal punishment for
smuggling livestock and poultry so that it is equivalent to
the penalties for smuggling arms or people.

One potential threat is that a large number of migratory
birds, which are potential AI carriers, over-winter in
Taiwan. However, farmers have been instructed to use
netting and fencing to keep migratory birds away from their
flocks. Another potential threat is the integrity of
Taiwan's national health-care infrastructure. As reported
in reftel E, unless Taiwan finds the political will to raise
premiums and co-pays and/or institutes major reforms, the
entire health-care infrastructure is at risk of financial
ruin. No matter how good Taiwan's flu plan may be, it will
require a solvent health-care delivery system to make it
work.

PAAL