NORTH SUMATRA AVIAN INFLUENZA CLUSTER - LESSONS

UNCLAS SECTION 01 OF 04 JAKARTA 007661 SIPDIS SIPDIS SENSITIVE DEPT FOR EAP/IET, A/MED AND G/AIAG (Lange) DEPT FOR OES/FO, OES/EID, OES/PCI, OES/STC AND OES/IHA DEPT PASS TO USDA/FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG DEPT ALSO PASS TO USDA/FAS/MOLSTAD AND FAS/ICD/PETRIE DEPT ALSO PASS TO USDA/FAS/FAA/DYOUNG AND USDA/APHIS DEPT ALSO PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL DEPT ALSO PASS TO HHS/STEIGER AND BHAT PARIS FOR FAS/AG MINISTER COUNSELOR CANBERRA FOR APHIS/DHANNAPEL ROME FOR FAO USPACOM ALSO PASS TO J07 E.O. 12958: N/A TAGS: TBIO AMED CASC EAGR AMGT PGOV ID KFLU SUBJECT: NORTH SUMATRA AVIAN INFLUENZA CLUSTER - LESSONS LEARNED ¶1. (SBU) Summary. The May 2006 avian influenza (AI) outbreak in a North Sumatra family represents the largest human H5N1 cluster to date and brought with it intense worldwide media attention to Indonesia's AI response capacity. A look back at the response to the cluster by the Government of Indonesia (GOI),the World Health Organization (WHO),and U.S. Government agencies reveals both positive and negative elements. On the positive side, the Ministry of Health (MOH),Ministry of Agriculture (MOA),and WHO quickly scrambled teams to North Sumatra upon learning of the outbreak and the testing process for samples collected from suspected AI cases went smoothly. Both the WHO and GOI collaborated well with representatives of the Naval Medical Research Unit (NAMRU-2) and Centers for Disease Control and Prevention (CDC) in Indonesia under challenging circumstances. Less positively, the WHO/MOH response teams were poorly organized and senior GOI Ministers struggled with public relations. With the Ministry of Agriculture's (MOA) efforts to control AI in backyard poultry still in their infancy, we expect human AI cases to continue in Indonesia along with occasional family clusters. End Summary. ¶2. (SBU) On June 9, we gathered representatives from USAID, NAMRU-2, the Economic Section, and the CDC to review the combined GOI-WHO-USG response to the May 2006 North Sumatra AI cluster. As of June 13, 8 blood-related members of a family in Simbelang village and Kabanjahe town, Karo District, North Sumatra Province have been identified as H5N1 cases, with 7 fatalities. Laboratories at the CDC and/or Hong Kong University have confirmed seven H5N1 cases. Challenging Outbreak Investigation -------------- ¶3. (SBU) In general, the circumstances of the cluster investigation proved highly challenging for all parties. The family and other residents of the towns were distrustful and suspicious of MOH staff from Jakarta and reluctant to cooperate. In addition, the extended family and local community were hesitant to cooperate fully with outside health experts as a result of local superstitions, a general distrust of western infectious disease concepts, and the shock of the loss of seven members of their extended family. Such beliefs are common in Indonesia, and we expect similar cultural hurdles to arise in future cluster investigations. ¶4. (SBU) Another complicating factor was that late reporting by the afflicted family delayed the initial recognition of the H5N1 cluster. Clinicians at the local district hospital in Kabanjahe and Saint Elizabeth Hospital in Medan did not suspect H5N1 in the index case, likely because there had been few AI outbreaks reported among poultry flocks in the area. As a result, doctors diagnosed the index case with pulmonary tuberculosis, and the subsequent six cases were not suspected as H5N1 cases until they were hospitalized at Adam Malik Hospital in Medan. Key Lessons Learned -------------- ¶5. (SBU) In our view, the key lessons from the outbreak and subsequent cluster investigation include the following: JAKARTA 00007661 002 OF 004 General -------------- --A noteworthy success of the outbreak investigation was the efficient cooperation between the MOH, NAMRU-2, the CDC, and the Hong Kong University Laboratory on specimen shipment, H5N1 testing, viral isolation and sequencing. The Indonesian National Institute of Health Research and Development (Litbangkes) or NAMRU-2 tested samples received in Jakarta and reported initial results to health care responders in North Sumatra within 48 hours. They shipped samples within 24 hours to the WHO-Influenza/H5N1 Reference Laboratories at the CDC and University of Hong Kong for confirmation and virus sequencing. Within one week of the initial outbreak report, the CDC and HKU had confirmed the in-country results and completed full genome sequencing of isolated viruses. As a result, scientists were able to conclude that the North Sumatra viruses did not appear to have acquired any characteristics that might suggest increased transmission among humans. --Given the successful and rapid collaboration on laboratory testing for suspected H5N1 clinical specimens, and the significant USG technical expertise and laboratory capacity on the ground in Indonesia, we are confident the USG will likely prove able to ascertain quickly whether the virus in future H5N1 case clusters has mutated in any significant way. This should make it possible to make an informed judgment quickly about whether more robust USG response teams might be needed. GOI Response -------------- --Several factors complicated hospital management of most of the H5N1 cases in the cluster. Some family members felt distrust toward the government-operated hospital and suspicion that oseltamivir treatment had caused the deaths of the infected individuals. There was in general a lack of cooperation with the medical management. Family members refused to wear personal protective equipment (PPE) while having close contact with hospitalized cases, but were still allowed access to confirmed patients. Hospital staff did not limit family member visitors and did not require family members to wear PPE. --More positively, the MOH quickly deployed a team to the area on May 10, just a day after it received reports of a possible family cluster. The MOH added a NAMRU-2 clinician to the team, but only upon request from NAMRU-2, demonstrating that NAMRU-2 remains under-utilized as an in- country asset for outbreak response. Despite difficulties with the family, MOH staff were able to obtain samples from patients and other family members and shared them promptly with NAMRU-2. Both Litbangkes and NAMRU-2 worked together in the identification of all subsequent cases, including ill nurses that emerged weeks after the outbreak in N. Sumatra. --Although both the MOH and WHO responded promptly to the outbreak, both are plagued by the lack of a coordinated, well-staffed, and well-equipped rapid response team with standard operating procedures and pre-defined roles for team JAKARTA 00007661 003 OF 004 members. MOH staff held numerous meetings in Jakarta but there was little effective coordination in the field. The WHO team worked with public health officials in Karo to conduct the key epidemiological investigations, but the MOH did not participate. Should multiple AI clusters occur simultaneously, we expect the MOH would have a very difficult time mounting an effective response given the lack of standardized rapid response teams. Building capacity in this area should be a priority for the WHO and CDC. --Throughout the outbreak, senior GOI officials were extremely reluctant to admit publicly that any form of human- to-human (H2H) transmission had taken place. This is likely because of the perceived impact on Indonesia's economy, concern about causing panic, and lack of understanding about the distinction between limited H2H transmission and a pandemic form of the virus. This reluctance continued even as evidence mounted that limited, but non-sustained H2H transmission was the most likely explanation for the cluster. Not until June 11 did Coordinating Minister for Peoples' Welfare Aburizal Bakrie acknowledge publicly that limited and inefficient H2H transmission may have occurred; Minister of Health Siti Fadilah Supari has failed to make similar statements and declared that no H2H transmission occurred in North Sumatra. We expect similar reluctance to admit H2H transmission in future clusters, although the UNICEF public relations campaign on AI now underway should help educate both GOI ministers and the public about AI and make a more sophisticated GOI public relations effort possible. -- The MOA response to reports of suspected human H5N1 infections in North Sumatra was also swift, although subsequent coordination with partners and laboratory testing were inadequate. The Director of Animal Health at the MOA traveled to North Sumatra to investigate possible animal H5N1 infections within 24 hours of learning of the suspected human cases. He promptly collected samples of various poultry, swine, and possible environmental sources of H5N1 (manure). All samples were immediately brought to Jakarta for laboratory testing. --Less encouraging was the initial lack of coordination between the MOA and the UN Food and Agriculture Organization (FAO). The MOA did not inform FAO of the suspected outbreak and investigation until USAID had already alerted the FAO about the situation. The FAO is working with the MOA to improve coordination and has sent a joint MOA-FAO team to North Sumatra to conduct a more thorough animal investigation. With support from USAID, FAO has accelerated implementation of the animal surveillance and response program in North Sumatra and will have trained teams in the field by the end of July. Improved coordination and better laboratory practice should be priorities for USDA and FAO. WHO Response -------------- --The WHO also responded quickly to the cluster, dispatching a half dozen experts from the WHO's Southeast Asia Regional Office (SEARO),Geneva and Jakarta to North Sumatra within one week of the outbreak reports. All six worked well with the Karo District and North Sumatra Provincial health JAKARTA 00007661 004 OF 004 authorities. --Cooperation between the WHO, NAMRU-2, and the CDC was also reasonably good. Although individual WHO staffers were at times reluctant to share information on the outbreak with NAMRU-2 and/or the CDC, our relationships with the WHO office in Jakarta are on the upswing. The WHO office in Jakarta has acknowledged the need to keep the USG better informed about outbreak investigations in Indonesia. U.S. Government Response -------------- --The combination of NAMRU-2's relationships with Litbangkes, and CDC TDYer Dr. Timothy Uyeki's presence in Indonesia (and direct participation on the WHO team) gave the USG excellent access to the outbreak investigation. Although relations between NAMRU-2 and some Litbangkes staff are not warm, in this instance NAMRU-2 played a central role in the testing of samples and sent an Indonesian clinician to North Sumatra to participate in the outbreak investigation. In the North Sumatra and previous clusters, Litbangkes has not directly invited NAMRU-2 to participate in epidemiological investigations, or given attribution, but has allowed NAMRU-2 to play a role in H5N1 testing. We expect NAMRU-2's cooperation with Litbangkes to improve over time given the recent appointment of a new Director General at Litbangkes. --The presence of CDC influenza specialist Dr. Timothy Uyeki in Indonesia at the time of the outbreak proved to be a major advantage, particularly because Dr. Uyeki had already developed relationships with a number of WHO and Litbangkes staff. In addition to providing badly needed technical expertise to the WHO outbreak investigation team, Dr. Uyeki also provided a crucial channel for information flow to the Embassy and USG agencies. Given the likelihood of additional human AI clusters in Indonesia, we continue to recommend the CDC post a long-term TDY epidemiologist in Jakarta as soon as possible. --Given the GOI reluctance to publicly admit H2H transmission of AI, we believe it would be extremely difficult to convince them to accept a high profile USG rapid response team in the event of future clusters, unless there were very solid evidence the H5N1 virus had changed sufficiently to pose a pandemic threat. We expect President Susilo Bambang Yudhoyono himself would need to approve a USG team after discussion by the Indonesian cabinet. High-level diplomatic intervention by the Embassy and/or Washington agencies would almost surely be required. Given these factors, Washington agencies may want to consider a more flexible response to future AI clusters in Indonesia where a few experts, perhaps drawn from regional USG offices, could quickly travel to Indonesia to augment the existing USG presence. AMSELEM