Identifier
Created
Classification
Origin
06LIMA176
2006-01-17 12:40:00
UNCLASSIFIED//FOR OFFICIAL USE ONLY
Embassy Lima
Cable title:  

EMBASSY LIMA AVIAN INFLUENZA TRIPWIRES

Tags:  AMGT ASEC CASC AMED KFLO AEMR TBIO PE 
pdf how-to read a cable
VZCZCXRO3181
PP RUEHRG
DE RUEHPE #0176/01 0171240
ZNR UUUUU ZZH
P 171240Z JAN 06
FM AMEMBASSY LIMA
TO RUEHC/SECSTATE WASHDC PRIORITY 8141
INFO RUEHBO/AMEMBASSY BOGOTA 2845
RUEHBU/AMEMBASSY BUENOS AIRES 2183
RUEHBR/AMEMBASSY BRASILIA 6440
RUEHCV/AMEMBASSY CARACAS 8918
RUEHLP/AMEMBASSY LA PAZ 2915
RUEHQT/AMEMBASSY QUITO 9919
RUEHSG/AMEMBASSY SANTIAGO 0073
RUEHSO/AMCONSUL SAO PAULO 1641
RUEHRG/AMCONSUL RECIFE 0025
UNCLAS SECTION 01 OF 12 LIMA 000176 

SIPDIS

SENSITIVE
SIPDIS

STATE FOR S/ES-O/CMS, WHA, OES
BRASILIA FOR ESTH HUB JSTORY

E.O. 12958: N/A
TAGS: AMGT ASEC CASC AMED KFLO AEMR TBIO PE
SUBJECT: EMBASSY LIMA AVIAN INFLUENZA TRIPWIRES

REF: STATE 219189

UNCLAS SECTION 01 OF 12 LIMA 000176

SIPDIS

SENSITIVE
SIPDIS

STATE FOR S/ES-O/CMS, WHA, OES
BRASILIA FOR ESTH HUB JSTORY

E.O. 12958: N/A
TAGS: AMGT ASEC CASC AMED KFLO AEMR TBIO PE
SUBJECT: EMBASSY LIMA AVIAN INFLUENZA TRIPWIRES

REF: STATE 219189


1. Summary: (SBU) Embassy Lima's EAC approved tripwires and
Embassy responses prepared by its Avian Influenza Working
Group (AIWG). Post has taken or has in process the
Department's recommended immediate preparedness measures.
The AIWG has agreed that efficient and sustained human-to-
human transmission, anywhere in the world, and any cases of
human AI in Peru, will be key tripwire events in an AI
pandemic. Adequate medical care would not be available in
Lima in the event of a Pandemic. Post recommends serious
consideration of authorized departure after the earliest
tripwires, but has kept its action plan flexible. Despite
limitations in GOP capability, the medical and avian
expertise at post will enable it to make rapid and
appropriate judgments. End Summary.

SITUATION IN PERU
--------------

2. (SBU) Peru's hospitals will be completely overwhelmed in
the event of Pandemic Influenza. Peru is a medically austere
post, with no large sophisticated hospitals as are found in
Colombia, Chile, Argentina or Brazil. The Regional Medical
Officer (RMO) at post recommends hospitalization only at
several small private hospitals in Lima. There are perhaps
30 adequate intensive care beds in Lima, with around 20
ventilators, all of which would be unavailable in a
pandemic.


3. (SBU) Post may be able to shelter in place for 3 to 4
weeks, but two weeks is a more realistic maximum. Civil
disorder and food and other commodities disruption, as well
as an inability to medically care for the sickest patients,
would probably produce a calamity for post should we shelter
in place. RMO feels that the health and safety of our
personnel would be best served by an authorized departure
from Peru immediately after the WHO declares the start of a
pandemic anywhere in the world.

AVIAN INFLUENZA WORKING GROUP
--------------

4. (U) The Embassy Lima Avian Influenza (AI) Working Group
(AIWG) has met and discussed immediate actions, potential

tripwires and possible Embassy activities in response to
these tripwires. Participants on the AIWG include
representatives from the Health Unit (HU)/Regional Medical
Officer, the Naval Medical Research Center Detachment
(NMRCD),USAID, Consular (CON),RSO, MAO, ECON, FAS and PAO.
Many AIWG members are also on the Emergency Action
Committee. Other sections with assets that could be used to
deal with an outbreak, such as Narcotics Affairs Section
(NAS) and DEA were consulted.


5. (U) Despite limitations in GOP and private medical
capability, the medical/health and avian expertise at post
represented by NMRCD, FAS, RMO and USAID will enable the
AIWG to make rapid and appropriate judgments to confirm
tripwires and responses. For this reason tripwire responses
contain maximum flexibility, with most situations calling
for consideration of authorized or ordered departure
requests.



TRIPWIRES AND RESPONSES
--------------

6. (U) The AIWG agreed that the key tripwire event in a
Pandemic Influenza outbreak among humans is the following:
"Efficient and sustained human-to-human transmission."
Once this tripwire is met, it will trigger a series of
immediate Embassy activities (as listed under tripwires five
and six below). The medical experts on the AIWG advised
that if an efficient and sustained human-to-human
transmission should emerge, it will become fairly obvious
within one or two weeks, with many people contracting
influenza, including health care workers taking care of
patients.


7. (U) Other tripwires warrant attention, as they could
indicate a change in the nature of the virus, but not to the

LIMA 00000176 002 OF 012


extent of an efficient and sustained human-to-human
transmission. These tripwires are the following: "A spike
in the number and/or broadening geographic spread of animal
to human cases" and "Sustained human-to-human transmission
through close, prolonged contact." Specific scenarios also
have been discussed and actions recommended below, but
within the context of the broader tripwires.


8. (U) The AIWG agreed that the location of a tripwire event
- in a neighboring country, in a rural or isolated section
of the home country, or near or within the city where the
Embassy or other USG facility is located - is an important
factor to consider. Parts of Peru, including Iquitos, are
accessible only by air or river boat. Iquitos has a
substantial USG presence (NMRCD staff and frequent visitors
from other agencies); other towns east of the Andes such a
Pucallpa have fairly constant USG official presence.
Communications regarding AI would include the Consular Agent
in Cuzco as appropriate. Our Peace Corps volunteers (PCV)
are grouped in certain areas, most of them isolated.


9. (U) These tripwires are based on assumptions that should
sustained human-to-human transmission become a reality:
- The disease could spread rapidly, both within a particular
country and internationally.
- Once the World Health Organization has declared that a
human pandemic has started, travel by commercial aviation
will become limited as countries react to control the spread
of the disease.
- An effective human vaccine will still not be available.
- Availability of effective therapy will be limited.
- Public reaction to an outbreak, even solely among poultry,
could be fueled by sensational media reporting and a
proclivity for mass demonstrations, causing a public
reaction out of proportion to the situation and making GOP
and the Embassy's response more difficult.
- Embassy personnel and dependants will want to return to
the U.S. unless there is a significant PI outbreak there.
- It may nevertheless be medically safer for personnel to
remain in Peru.
- Avoiding a double standard for non-official Americans, and
to what extent to include LES in AI/PI preparations, will
require careful navigation.
- NMRCD-Iquitos, while primarily an entomology facility,
will be the only laboratory in northern Peru capable of
effecting testing for avian flu; it will probably remain
operating where a peripheral USG facility might otherwise be
closed so that employees could relocate to Lima.
- Timely and appropriate communications with the Mission's
FSN staff will be key for an organized response to a
pandemic.


10. (U) Any of the tripwires discussed below could occur
independently of each other. It is also possible that two
or more tripwires could occur sequentially or
simultaneously. In the course of discussions, it was
apparent that certain actions need to take place now, before
any tripwires are met, in order to be fully prepared in
advance.


11. (U) These tripwires are designed to stimulate maximum
advance planning, to identify key events that will require
rapid response to protect Post personnel and facilities, and
to describe the (foreseeable) scope of issues that will need
to be addressed under specific scenarios. At the same time,
Post recognizes that real-time judgments will need to be
based on actual data and factors present in the situation --
which may not be anticipated in this document.


12. (U) This report lists (A) actions that require immediate
attention, (B) tripwires and responses, and (C) specific
scenarios.


13. (U) (A) Actions to be taken immediately in preparation
for an Avian Influenza (AI) outbreak in humans (Pandemic
Influenza - PI):

- Provide Mission fact sheets for staff (American and FSN)
and dependents in Lima and in Iquitos and other cities where
Narcotics Affairs Section (NAS) or other Mission employees

LIMA 00000176 003 OF 012


are located. (Already done as part of EAP.)

- Mission prepares a drawdown list and a list of minimum
emergency personnel. (Note: Emergency personnel in the
context of an AI outbreak likely will be different from the
usual list compiled by the EAC for other types of
emergencies. The Mission will plan to retain more NMRCD,
FAS, and USAID staff than are on the basic EAC drawdown
list, and some persons on the current basic EAC list may not
be essential for an AI outbreak.) (In Progress)

- Conduct inventory of supplies of Tamiflu and protective
equipment, including gowns, gloves, protective eyewear,
alcohol-based cleansers, and N95 respirators. (Done)

- Determine what more is needed and procure the additional
needed supplies. Decide how to allocate Tamiflu, masks, and
other equipment between Embassy Lima and NMRCD-Iquitos. (In
progress)

- Advise family members to keep at least a 2-week supply of
food and water at this time, as they should in the event of
any unforeseen emergency occurring overseas. (Already done
as part of EAP and Embassy community outreach.)

- Offices should evaluate mechanisms for conducting work
from home or other locations under conditions of a pandemic
requiring limiting access to Mission offices. (In progress.)

- Develop a contingency plan of action for directly
supporting potential embassy evacuees from neighboring posts
with limited medical resources. (Already done as part of EAP
for dealing with political unrest causing evacuation from
neighboring posts. Note: this is a low priority as Lima
would not be an advisable evacuation point for neighboring
country U.S. Missions.)

- Prepare pre-planned packets - including travel orders to
the extent possible - for potential Mission evacuees under
an authorized departure, to avoid a last minute backlog.
(Travel order requests are already on file for mission
members per EAC SOP; Mission is working on preparation of
draft travel orders.)

- Continue to monitor GOP ability to detect, contain and
treat AI cases in birds and humans. (ECON, AID, NMRCD and
FAS are doing this.)

- Meet with Roche Peru medical director to assess
availability of Tamiflu in Lima. (ECON - in Progress)

- Involve Commissary Board in developing plan to stock
appropriate items and how to transfer to members (and non-
members, in emergency) without compromising financial
integrity. (In progress)

- GSO to develop authorization for Embassy community to have
increased number of filled water containers on hand. (In
progress)

- Confirm secure location of Tamiflu and other essential
materials. (Done)

- Hold Town Hall meeting, simultaneously using warden system
to inform AmCit community. (Scheduled)


14. (U) (B) TRIPWIRES AND RESPONSES:

TRIPWIRE ZERO

Any human case of H5N1 influenza appearing in Peru, or human
case of H7N7 (or other avian, or pandemic flu),presumably
transmitted from birds or other animals, appears in Peru,
without evidence of sustained human-to-human transmission.
(Note: despite lack of clear danger of PI, Embassy and
Peruvian public concern will be high.)

- AIWG meets to confirm tripwire. NMRCD-Iquitos
participates by telephone.


LIMA 00000176 004 OF 012


- Restrict official and unofficial travel to affected areas,
bird markets and similar facilities. (exception below)

- Release a warning announcement to Mission personnel and
warden message to private American citizens, and post the
warning announcement on the Embassy website. Prepare talking
points for domestic and international press.

- Provide detailed briefing to Embassy staff. Communicate
pertinent information to the Embassy community by way of
venues such as town hall meetings, the embassy web site and
newsletter articles. AIWG meets with FSN committee
representatives.

- Consider sending NMRCD or USAID expert to area to verify
situation.

- ECON, FAS, NMRCD contact key GOP agency contacts to assess
situation. These agencies include:

- SENASA (Min. of Ag. Animal Inspection Service) (FAS, ECON)

- Min. of Health (NMRCD, USAID, ECON)

- INDECI (Disaster/Civil Defense Agency)(MAAG, USAID, ECON)

- Defense Ministry (MAAG, DAO)- Police (Ministry of
Interior) (RSO)


15. (U) TRIPWIRE ONE

A spike in the number and/or broadening geographic spread of
animal to human cases or sustained human-to-human
transmission through close, prolonged contact in a
neighboring country in South America (Colombia, Ecuador,
Bolivia, Chile, Brazil),but not in Peru. Consider this
tripwire if situation occurs in an Asian country with which
Peru has extensive trade, such as China. This is
particularly significant if there are multiple,
geographically diverse clusters, or if a cluster occurs in a
major transit hub. (No efficient and sustained human-to-
human cases.)

- AIWG meets to confirm tripwire. NMRCD-Iquitos
participates by telephone.

- Restrict travel to the affected country or affected areas
within the country, except for NMRCD, FAS, or other
personnel involved in possible investigation/containment
efforts. (No restrictions on these personnel returning to
Lima.)

- Coordinate with U.S. Mission in the affected country
regarding that Mission's plans for possible public
announcements, warden messages, or plans for evacuating
personnel.

- Provide Mission fact sheet or briefings for staff
(American and FSN) and dependents in Lima and in other USG
facilities as appropriate.

- AIWG meets with FSN committee representatives.

- Ensure that any public announcements or travel warnings
issued by neighboring posts are transmitted to American
citizens (AmCits) in Peru; publish the updates on the
Consular Section's web site. Consider a public announcement
to private American citizens.

- Consider requesting authorized departure of U.S. family
members and non-emergency personnel. Have evacuation plans
for both the well and ill.

- Institute screening practices for all visitors to U.S.
Government facilities and consider limiting visitor numbers.

- Consider mandatory sick leave for any employee who shows
any influenza (flu)-like symptoms or has a family member
with flu-like symptoms. Information will be disseminated
regarding the details of flu symptoms. Monitoring by the

LIMA 00000176 005 OF 012


Health Unit.

- Consider use of prophylactic oseltamivir (Tamiflu) by U.S.
and LES staff in positions that require frequent contact
with the public.


16. (U) TRIPWIRE TWO

A spike in the number and/or broadening geographic spread of
animal to human cases or sustained human-to-human
transmission through close, prolonged contact in rural Peru
or in an isolated section of Peru, but not in Lima. (No
efficient human-to-human cases.)

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates.

- Restrict travel to the affected region(s) of the country
except for NMRCD, FAS, or other personnel involved in
possible investigation/containment efforts. (No
restrictions on these personnel returning to Lima.)

- In coordination with the Dept, issue public announcement,
warden message, or travel warning and update website
cautioning American citizens against nonessential travel to
the affected region(s). Provide press guidance for the
potential use of the Mission, neighboring posts, the
Department and concerned government agencies.

- Provide Mission fact sheet and schedule briefings for
staff (American and FSN) and dependents in Lima and other
USG facilities as appropriate. Fact sheet would detail the
episode(s) and suggest means of disease prevention. The
notice will also be posted on the Embassy website. AIWG
meets with FSN committee representatives.

- Consider reduction to emergency consular services only.

- Consider requesting authorized departure. Consider
requesting ordered departure. Consider implementing
selective administrative leave for those Americans who
remain at post, and LES employees. Consider other options
for minimizing workplace exposure, like telecommuting.

- Order mandatory sick leave for any employee who shows any
flu-like symptoms or has a family member with flu-like
symptoms.

- Consider home quarantine and limiting venues of human-to-
human contact, such as commnity gatherings.

- Consider screening of all visitors to the chancery and
other USG facilities, and recommend use of protective gear,
especially surgical masks, to those with frequent contact
with visitors. (Note: Due to limited supply of N95 masks and
lack of necessity for their use at this time, the N95 would
not be required.)

- Health Unit to initiate appropriate use of prophylactic
oseltamivir (Tamiflu) by minimal U.S. and LES staff
remaining on the job.


17. (U) TRIPWIRE THREE

A spike in the number and/or broadening geographic spread of
animal to human cases or sustained human-to-human
transmission through close, prolonged contact near or within
Iquitos, Pucallpa, or other NAS facilities.

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates.

- Town meetings are held and fact sheets distributed. AIWG
meets with FSN committee representatives.

- Restrict travel to affected areas except for NMRCD, FAS,
or other personnel involved in possible
investigation/containment efforts. (No restrictions on these
personnel returning to Lima.)


LIMA 00000176 006 OF 012


- In coordination with the State Department, issue public
announcement, warden message, or travel warning and update
website advising American citizens to defer all non-
emergency travel to affected areas. Prepare press guidance
and issue press release outlining the new guidance.
Coordinate public affairs and media activities with NMRCD-
Iquitos.

- Implement home quarantine of any staff or dependents that
have been in contact with a person confirmed to have an AI
infection.

- Embassy Lima maintains operations, but maintains close
monitoring.

- Emergency Action Committee meets regularly and coordinates
closely with NMRCD-Iquitos and other USG facilities to
determine next steps as tripwire circumstances develop.
Next steps could include the following:

- Close NAS or other USG facilities outside of Lima, reduce
NMRCD-Iquitos to minimal staff, and reduce services and
operations to emergency Consular services and other
designated services and operations.

- Consider authorized departure of dependents. Authorized
departure of non-emergency staff. (Note: In deciding whether
to authorize departure, the EAC should take into account not
only the medical risk, which may be minimal, but also the
perceived risk by employees and family members.)

- Ensure that staff purchase additional supplies of food and
water.

- Depending on level of public inquiries, embassy Lima
establishes a call center for inquiries from American public
and the press.


18. (U) TRIPWIRE FOUR

A spike in the number and/or broadening geographic spread of
animal to human cases or sustained human-to-human
transmission through close, prolonged contact near or within
Lima. (still no efficient human-to-human transmission.)

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates.

- Town meetings held and fact sheets distributed. AIWG
meets with FSN committee representatives.

- Cancel (deny Country Clearance for) incoming official
travel to Peru, except for personnel involved in
investigative/containment efforts, or as otherwise deemed
necessary by COM.

- In coordination with the State Department, issue or revise
warden message, and travel warning and update website urging
all American citizens to defer all non-emergency travel to
Peru. (Prepare press guidance and issue press release
outlining the new guidance.) Coordinate public affairs and
media activities with NMRCD-Iquitos.

- Implement home quarantine of any staff or dependents that
have been in contact with a person confirmed to have an AI
infection.

- Embassy Lima maintains full service operations, but
maintains close monitoring.

- Consular Section reduces visa appointments to a minimum to
reduce risk of spreading disease within the Embassy and to
make more staff available to provide emergency assistance to
American citizens.

- Emergency Action Committee meets regularly and coordinates
closely with NMRCD-Iquitos and other USG facilities to
determine next steps as tripwire circumstances develop.
Next steps could include the following:


LIMA 00000176 007 OF 012


- Close USG facilities outside of Lima, reduce NMRCD-Iquitos
to appropriate staffing level, and/or Embassy to minimal
staff, reduce services and operations to emergency Consular
services and other designated services and operations.

- Consider requesting authorized departure of dependents and
non-emergency staff. (Note: In deciding whether to request
authorized departure, the EAC should take into account not
only the medical risk, which may be minimal, but also the
perceived risk by employees and family members.)

- Except for designated emergency American and FSN staff,
all others remain home (administrative leave) or on
authorized departure.

- HU and designated EAC members meet with school
administrators to review advisability of closing the
schools.

- Ensure that staff purchase additional supplies of food and
water.

- Social restrictions (restrict movements of all personnel
in the city, restrict social events/gatherings, restrict
participating in sporting events, etc.).

- Depending on level of public inquiries, embassy Lima
establishes a call center for inquiries from American public
and the press.


19. (U) TRIPWIRE FIVE

Efficient and sustained human-to-human transmission in a
neighboring country in South America, or a country with
which Peru has substantial trade in avian products, such as
China.

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates.

- Restrict travel to the affected country, except for NMRCD,
FAS, or other personnel involved in possible
investigation/containment efforts. (Note: Need to determine
what type of quarantine/restrictions by GOP authorities may
be placed on these personnel returning to Peru.)

- Coordinate with U.S. Mission in the affected country
regarding that Mission's plans for possible evacuation of
personnel to Lima. (Note: See Scenario One below.)

- Provide Mission briefings for staff (American and FSN) and
dependents in Lima and in USG facilities outside of Lima.
AIWG meets with FSN committee representatives.

- MED and designated EAC members meet with school
administrators to review advisability of closing the
schools.

- Embassy staffs and equips a situation room. Uses cleared
press guidance.

- Maintain normal Consulate and Embassy operations, but
maintain close monitoring.

- Embassy Emergency Action Committee meets regularly and
coordinates closely with NMRCD-Iquitos and other USG
facilities to determine next steps as tripwire circumstances
develop. Next steps could include:

- Reduction to emergency CON services; suspension of some
services.

- Close USG facilities outside of Lima, reduce NMRCD-Iquitos
and/or Embassy to appropriate staffing, and reduce services
and operations to emergency Consular services and other
designated services and operations.

- Consider requesting authorized departure for dependents
and non- emergency personnel. (Note: Authorized departure
will be dependent on possible Government of Peru

LIMA 00000176 008 OF 012


restrictions on outgoing travel and on possible U.S.
restrictions on incoming travel.)

- Except for designated emergency American and FSN staff,
all others remain home (administrative leave) or on
authorized departure; children remain home from school or
on authorized departure.

- Ensure that staff purchases additional supplies of food
and water.

- Social restrictions (restrict movements of all personnel
in the city, restrict social events/gatherings, restrict
participating in sporting events, etc.).


20. (U) TRIPWIRE SIX

Efficient and sustained human-to-human transmission in an
isolated section of Peru.

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates in person or by telephone.

- Issue revised travel warning and update website advising
American citizens to defer all non-emergency travel to Peru.

- Consider requesting authorized or ordered departure of
dependents and non- emergency personnel. (Note: Authorized
departure will be dependent on possible Government of Peru
restrictions on outgoing travel and on possible U.S.
restrictions on incoming travel.)

- Cancel all incoming official travel, except for personnel
involved in investigative/containment efforts, or as
otherwise deemed necessary by COM.

- Provide Mission briefings for staff (American and FSN) and
dependents and to school administrators at schools used by
American staff in Lima; recommend
schools close. AIWG meets with FSN committee
representatives.

- Embassy and NMRCD-Iquitos at minimal staff, reduction to
emergency Consular services, suspension of designated
services and operations. Closure of other USG facilities
such as NAS-supported bases. PCV are pulled back to Lima
and stay with volunteer host families from Embassy
Community.

- Except for designated emergency American and FSN staff,
all others remain home (administrative leave) or on
authorized departure; children remain home from school or on
authorized departure.

- Ensure that staff purchase additional supplies of food and
water.

- Social restrictions (restrict movements of all personnel
in the city, restrict social events/gatherings, restrict
participating in sporting events, etc.).

- Split the Marine Security Guard detachment into two
separate and independent units. (In the event individuals
in one unit acquire the disease, the other unit can still
ensure proper coverage of classified materials.)

- Restrict visitor access to Mission buildings. If entry
into Mission buildings is necessary to conduct business,
visitors must go through screening procedures to include
temperature monitoring and/or questionnaire related to
symptoms/exposure. (Note: There are no studies that provide
verification regarding effectiveness of these procedures.
They also will not identify people who are contagious but
asymptomatic or have minimal symptoms. The level of
restrictions on access to Mission facilities should depend
on the particular circumstances at that moment.)

- Embassy staffs and equips a situation room and a call
center for inquiries from American public and the press.


LIMA 00000176 009 OF 012


- Establish a database listing details of any American
citizen, hospitalized, quarantined, or ill at home.

- HU closely monitors availability of medical/hospital
facilities in Lima.

- MAO closely monitors availability of outgoing commercial
flights.

- Embassy EAC meets regularly and coordinates closely with
NMRCD-Iquitos to determine next steps as tripwire
circumstances develop. Next steps could include:

- Restrict/prohibit visitor access to internal Mission
facility offices.

- Reduction of staff at NMRCD-Iquitos to those performing AI-
related duties.

- Consider ordered departure of non-emergency personnel and
dependents with authorized departure of designated emergency
personnel on a case-by-case basis. (Note: Ordered or
authorized departure will be dependent on possible
Government of Peru restrictions on outgoing travel and on
possible U.S. restrictions on incoming travel.)

- Suspension of additional Embassy services and operations.

- In coordination with the State Department, revise Travel
Warning to add message advising Americans to leave Peru.

- Update website and issue public announcements as
necessary.

- Per State 183776 (10/05/2005),prophylactic treatment with
Tamiflu will be considered only for staff that are required
to be in direct contact with potentially infected persons.

- Assist in evacuation of private American nationals. (Note:
Significant evacuation from Lima may not be
feasible/advisable for a variety of reasons including the
size of the post, limited availability of air transport, the
potential and added risk of acquiring influenza at crowded
airports or on long international flights during a true
pandemic, travel restrictions and possible quarantine
measures. Therefore, a complete evacuation of all Mission
personnel and closure of Embassy Lima is not/not
anticipated.)


21. (U) TRIPWIRE SEVEN

Efficient and Sustained human-to-human transmission, as
evidenced by clusters of cases in Lima. This is particularly
significant if there are multiple diverse clusters, or a
cluster is not safely isolated.

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates in person or by telephone.

- AIWG meets with FSN committee representatives.

- Order mandatory reduction to emergency consular services.
Consider closing consular section.

- Implement ordered departure, if airlines are still
servicing Lima.

- Implement administrative leave for non-emergency LES
(FSNs). Consider other options for minimizing workplace
exposure, like telecommuting.

- Order mandatory sick leave for any employee who shows any
flu-like symptoms or has a family member with flu-like
symptoms.

- Screen all visitors to chancery and USG facilities, and
use of protective gear, including N95 masks by those
employees with significant contact with the public.

- Initiate appropriate prophylactic use of oseltamivir

LIMA 00000176 010 OF 012


(Tamiflu) by LES staff remaining on the job and by American
employees and family members remaining at post.

- Issue public announcement to private American community.

- Consider shelter in place order by COM. Use Embassy
warden system to maintain contact with employees.

- Implement drawdown of Embassy staff to AI/PI drawdown
list; rest of Amcit staff are on administrative leave.


22. (U) TRIPWIRE EIGHT

Efficient and sustained human-to-human transmission anywhere
in the world. (Note: due to frequency of air travel between
Lima and North America, Asia and Europe, Embassy would
consider spread to Lima as probable.)

- AIWG meets to confirm that tripwire has been met. NMRCD-
Iquitos participates.

- AIWG meets with FSN committee representatives.

- Restrict travel to the affected country.

- Provide Mission fact sheet and town meeting for staff
(American and FSN) and dependents in Lima and in USG
facilities outside of Lima.

- Maintain normal Consulate and Embassy operations, but
maintain close monitoring.

- Embassy Emergency Action Committee meets regularly and
coordinates closely with NMRCD-Iquitos and other USG
facilities to determine next steps as tripwires develop.

- Request authorized departure for dependents and non-
emergency personnel. (Note: Authorized departure will be
dependent on possible Government of Peru restrictions on
outgoing travel and on possible U.S. restrictions on
incoming travel.) Prioritize departure for persons at high
risk for medical complications of influenza.

- Ensure that staff purchases additional supplies of food
and water.


23. (U) C. SPECIFIC SCENARIOS:

SCENARIO ONE

A neighboring post evacuates personnel to Lima. (Note: this
scenario is unlikely as Lima is not an appropriate recipient
of evacuees in the event of a PI.)

- If scenario occurs outside of the context of Tripwire Six
(above),the Embassy MAO in coordination with its sub-
sections will implement the following procedures:

- Identify suitable temporary lodging arrangements for the
evacuees.

- Establish procedures for the evacuees to receive
administrative services such as cashing checks, use of
commissary, access to the Medical Unit, filing travel
vouchers, etc.

- Designate sponsors for the evacuees.

- Assist school age children to enroll into temporary
classes in appropriate school if the evacuation period is
extended beyond two weeks.

- If scenario occurs within the context of Tripwire Six
(above),incoming personnel should be diverted to other
points. Incoming personnel who have already arrived in
Peru will be placed on ordered departure.


24. (U) SCENARIO TWO

Reported saturation of available medical facilities in

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Lima/Peru.

- Response assumes Scenario Two takes place within the
context of PI outbreak in Lima or outside Lima with cases
transported to Lima. Many dependents and staff likely will
have already been evacuated. Emergency Action Committee
meets to discuss next steps, which could include:

- Staff reduction at NMRCD-Iquitos and NMRCD-Callao. Recall
to Lima of PCV and NAS employees.

- Request ordered departure of non-emergency personnel and
dependents with authorized departure of designated emergency
staff on a case-by-case basis. (Note: Ordered or authorized
departure will be dependent on possible Government of Peru
restrictions on outgoing travel and on possible U.S.
restrictions on incoming travel.)


25. (U) SCENARIO THREE

International commercial flights departing Peru are severely
curtailed or halted or are fully booked.

- Emergency Action Committee meets to discuss next steps,
which could include:

- Except for designated emergency American and FSN staff,
all others remain home (administrative leave).

- HU and designated EAC members meet with school
administrators to review advisability of closing the
schools.

- Ensure that staff purchase additional supplies of food and
water.

- Consider social restrictions (restricting social
events/gatherings, sporting events, etc.)

- Evacuation of non-emergency personnel and dependents out
of Peru via commercial airlift, via U.S. military flights
out through Lima, or by sea. (Note: Both Air and Sea are
viable methods for conducting an evacuation of non-
combatants. Military assets, however, are not pre-
positioned or "waiting" to execute; they would have to be
diverted from support of combat operations in Iraq. Once
the COM or SECSTATE requests assistance from the SECDEF or
CDR USSOUTHCOM, the method of conducting the
evacuation will be decided by military mission planners once
the requirements are actually known - response time, number
of personnel to be evacuated, destination,
availability of resources, location, etc. Based on an air
evacuation, negotiations by State for the destination would
have to be conducted. The most likely choice would be
the Southern United States, or if travel to the U.S. is
restricted, Santiago or Bogot. Evacuation of non-emergency
personnel and dependents by sea is outlined in the Emergency
Action Plan. Any evacuation related to avian influenza,
however, must take into account possible Government of Peru
restrictions on outgoing travel and on possible Chilean
and/or U.S. restrictions on incoming travel.


26. (U) SCENARIO FOUR

A Mission staff member, a student, teacher, or other staff
at a school used by Mission families is suspected of having
contracted avian influenza.


- At the request of the HU, can offer limited testing of
Mission personnel and family members. All samples would be
sent to the U.S. for confirmation, but NMRCD can provide a
reliable although non-FDA approved result within a few hours
of receiving the sample.

- If patient is a Mission staff member or dependent, HU
begins therapeutic treatment of the patient with Tamiflu.

- Home quarantine of patient and anyone who has had direct
contact with patient.

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- Per State 183776 (10/05/2005) The HU will consider
prophylactic Tamiflu treatment only for persons required to
be in direct contact with potentially infected persons. In
general, treatment with Tamiflu will be restricted to those
who become ill rather than for prevention in persons without
symptoms. "This strategy includes withholding medication
from asymptomatic close contacts of those with known
illness, such as family members, until clinical symptoms
appear." In addition, American citizens not eligible for
DOS medical program benefits, non-ICASS contributors, and
those outside the official community will not have access to
these Tamiflu stockpiles.

POC AND DOD PERSONNEL
--------------

27. (U) All DOD personnel are under COM authority. The
individuals with Top Secret clearances who will update the
Tripwire Reporting and Integrated Planning System (TRIPS)
are ARSO Kory HAMMOND and ECONoff Howell Howard.

STRUBLE