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06SANSALVADOR253 2006-02-01 16:15:00 UNCLASSIFIED Embassy San Salvador
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E.O. 12958: N/A


1. (U) The Emergency Action Committe (EAC) convened on
January 13, 2006 to review, discuss and approve the Mission
Response Plan and Tripwires for the Avian Influenza.

2. (U) Overview: The persistence of the H5N1 avian influenza
since its appearance in Hong Kong in 1997 indicates that it
is unlikely to disappear from the environment. Moreover, it
has evolved gradually, increasing its lethality and
broadening the range of species that it can infect and kill.
Since December 2003 there has been sporadic and increasing
bird-to-human transmission. As of the week of January 15,
2006, about 166 persons have been infected and 82 have died
with avian influenza. The incidence among poultry workers has
been minimal, suggesting that, at this time, avian influenza
is not easily transmitted to humans. Human-to-human
transmission has not been documented (though it was suspected
in a handful of cases). There has never been a human epidemic
with an H5 influenza strain. Thus, the entire human race is
presumed to be highly susceptible, so all age groups are
expected to become seriously ill. Sustained human-to-human
transmission has not yet started anywhere. After widespread
use of amantadine and rimantidine in China, the H5N1
influenza A virus has become resistant to the anti-influenza
drugs amantadine and rimantidine. The neuroaminidase
inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) are
still effective most of the time, but resistance to Tamiflu
has been documented.

3. (U) Birds are spreading avian influenza in the way
scientists fear that a human-to-human contagion would be most
rapid?air travel. More importantly, the appearance of
highly pathogenic H5N1 among wild and domesticated birds in
Turkey was followed by cases of human infection.

4. (U) Should sustained human-to-human transmission of a
highly pathogenic H5N1 influenza begin, worldwide spread is
expected in days to weeks, despite efforts to contain the
virus by closing borders and quarantining ill persons. The
short incubation period, the spread of virus by infected
persons 2-3 days before they become ill, and the high
infectiosity of the virus will accelerate the development of
a pandemic. The effects could be so devastating that it
should be considered a ?global tsunami.?

5. (U) Identifying a human epidemic quickly is currently a
problem for countries such as El Salvador. The symptoms of
avian influenza are not distinguishable from other types of
influenza. Specimens will need to be sent to laboratories in
the US (the Centers for Disease Control (CDC)), if mailing
continues to be permitted.

6. (U) Worldwide planning for an eventual pandemic has the
following tenets:
z Continue monitoring of the bird pandemic
z Analyze changes in the virus as infection spreads
z Cull affected domestic bird populations
z Sharply increase the production and storage of
oseltamivir (Tamiflu).
z Accelerate the process of vaccine production.

7. (U) In the region of Mexico and Central America, Mexico,
Panama, and El Salvador may be at greatest risk for entry of
avian influenza. All three countries have seaports with
extensive trading with the nations of Far East Asia, and many
ships from these countries pass through the Panama Canal
daily. Also, Mexico and the countries of Central America are
on the flight path of numerous migrating birds. It is quite
possible that avian influenza could spread from Siberia to
Alaska and southward across the Western Hemispheric

8. (U) When formulating tripwires, the following facts and
assumptions were considered:

A. The H5N1 highly pathogenic avian influenza does not yet
exist in the Western Hemisphere.

B. H5N1 does not yet efficiently infect humans.

C. It is highly probable that sustained human-to-human
transmission of AI will begin in Far East Asia because the
number of birds infected there, the proximity of people to
birds, and, historically, the widespread present of a variety
of influenza viruses in that region.

D. Once sustained human-to-human transmission starts, it
is very likely to appear in multiple sites, and quickly
spread to distant countries. Therefore, early evacuation of
dependents to the US should occur when sustained
human-to-human transmission is documented anywhere (or it may
be too late).

E. In view of the much greater air travel to the United
States, AI is more likely to appear in the US before El

F. The presence of AI in any neighboring Central American
country should be considered equivalent to the presence of AI
in San Salvador, El Salvador.

G. All cross border traffic?land, sea, and air?will very
likely be blocked as soon as human-to-human transmission of
AI is suspected in El Salvador or its neighboring countries.

H. El Salvador does not have the medical resources to
treat more than a handful of patients infected with AI. El
Salvador will not, therefore, be able to a) accept patients
with AI from neighboring countries or b) effectively treat
large numbers of infected patients.

9. (U) The most important tripwire is the appearance of
sustained human-to-human transmission anywhere in the world.
At this point US Embassy San Salvador will have to take
immediate steps to evacuate dependents and non-essential
personnel to the US. The appearance of human-to-human
contagious AI in Central America would be the next most
important tripwire, requiring final preparations for
?sheltering in place,? long-term quarantine, and decisions
about when to initiate prophylactic treatment with
oseltamivir (Tamiflu).

10. (U) The Emergency Action Committee (EAC) will be required
to meet each time a tripwire occurs, in order to confirm that
the criteria for that tripwire has been met and to initiate
specific actions. When each tripwire is met, the Consular
section will need to issue a warden message to all Americans
living within El Salvador. The EAC will need to determine
what public announcements and travel warnings should be
recommended to the Department of State for issuance. Advice
should be obtained from Washington about press announcements.

11. (U) It is hoped that an effective vaccine will become
available before there is a pandemic. If a vaccine is
developed, the primary objective will be to vaccinate as many
as possible, as quickly as possible. The following tripwires
assume that the pandemic begins before there is a protective

US Embassy Tripwires
For Avian Influenza (AI)

I. (U)Only bird-to-bird and sporadic bird-to-human

A. No avian influenza in the Western Hemisphere (the
present situation)

1. Vigilance in reviewing reports from international
monitoring groups and international news

2. Information updates to the Mission from the RMO

3. Strongly recommend yearly influenza vaccinations for
all personnel (These are not protective against avian

4. Obtain additional personal protective equipment (PPE):
gloves, goggles, N95 masks, Tyvek suits; a stockpile of
antibiotics might be considered in order to treat secondary
bacteria pneumonias that commonly occur with influenza.

5. Individuals are advised that they may purchase
prescriptions of Tamiflu through their insurance company
pharmacy plans (current cost $180 for a ten-day course (20

6. Await DOS Office of Medical Services distribution of
Tamiflu, while making arrangements for storage in a
temperature-controlled, highly secure environment.

7. ?Administrative leave? plans are reviewed; staff
should prepare to perform as much work at home as might be

8. The Mission reviews its minimal staffing list of

9. Review host nation emergency plans to respond to an
avian influenza epidemic (The Hospital Neumologico was the
designated SARS hospital and is, along with Hospital Rosales,
also the designated hospital to treat victims of avian

10. Consular section initiates outreach to private American
citizens (Amcits) on AI preparedness. This includes
dissemination of the State department approved ?Fact Sheet?
and ?Frequently Asked Questions? via the Consular Warden
System and prominent display on the Embassy Internet home
page through the creation of a distinct ?Avian Influenza
button? on the website home page.

11. Consular and Economic sections and the RSO office
canvass American companies and organizations to determine
whether they have their own contingency plans in the event of
a pandemic.

12. Economic section canvasses airlines to determine
whether air carriers, which provide direct flights between El
Salvador and the United States, have contingency plans. Of
particular importance is whether these companies would
increase flights prior to an epidemic reaching the Western
Hemisphere and whether they have received information from
the host nation discussing criteria that would halt flights
if human-to-human transmission started.

B. Appearance of avian influenza in the Western
Hemisphere, perhaps including El Salvador

1. EAC meets to review, revise, if necessary, tripwires,
and implement required actions.

2. Heighten vigilance; contact host nation agencies
monitoring bird populations; contact public health services
surveying hospitals for the occurrence of human disease;
inform the host government of the Embassy?s intention to
release statement.

3. US Embassy issues a MGT notice, announcement in the
Embassy bulletin (the ?Volcano Views?), Consular Warden
Messages (CWM) advising avoidance of all birds and
handwashing after handling uncooked poultry products. The
Embassy adds the text of the CWM to the Avian Influenza link
on the Mission?s webpage.

4. The EAC reviews whether travel in the region should
remain unrestricted.

5. The Mission advises all employees and their dependents
to remain home if they develop respiratory illness and fever.
The Health Unit personnel, wearing personal protective
equipment (PPE), will visit them at home to evaluate and
treat the ill. In a Consular Warden Message, Amcits are
advised to quickly seek physician consultation if they
develop respiratory illness with fever.

6. Consular officers include avian influenza talking
points in their weekly appearances on local radio and
television programs and Internet chat rooms.

7. Prepare travel orders for non-essential personnel and
dependents, who would very likely be evacuated when
human-to-human transmission begins.

8. Section chiefs advise FSN employees that they should
keep their US visas current. US personnel are advised to
submit B referrals for nannies who might accompany their
families back to the US.

9. Embassy press officer releases a statement describing
the Embassy?s increased vigilance and offers advice about
personal protective measures that all should follow.

C. Documentation of bird-to-human transmission of AI in El
Salvador or the neighboring countries

1. EAC meets to assess situation and initiate actions
defined by established tripwires.

2. Both American and FSN personnel with fever and/or
respiratory illness are told to remain at home (on
Administrative leave) until 10 days after recovery.
American personnel will be advised to impose the same
restrictions on their home help.

3. The Health Unit staff uses PPE and infectious disease
precautions when evaluating persons with fever and
respiratory illness.

4. The Health Unit staff will use the influenza quick test
testing kit to test all ill individuals with symptoms
suspicious of influenza for influenza A and B.

5. Health Unit staff monitors the human cases closely
through communication with local health providers and,
possibly, visits to the hospital. If the victim is a private
American citizen, a Consular officer will be assigned to
monitor the situation with the Health Unit staff, in order to
communicate with family members.

6. The Health Unit staff and RSO group review use of PPE,
decontamination procedures, conditions that require use of
Tamiflu, and the provision of health care at the alternative
examination site. The Mission defines how contaminated
materials will be deposed.

7. The Embassy holds Town Hall meetings for the Embassy
community and private American citizens. The Mission strongly
advises avoiding contact with live birds and thoroughly
washing hands after handling chicken and other previously
butchered poultry in the kitchen.

8. Consular Warden Message communicates the advice
provided at the Town Hall meeting and additional information
is placed in the Embassy?s webpage on the avian influenza.

9. The Public Affairs officers will assume responsibility
for ?risk communication,? creating public messages to both
the Mission community and the host nation.

10. Meet with school officials to discuss tripwires for
school closure.

11. Based upon the number of reported cases, the EAC
reviews the need for voluntary departure of dependents.

12. The EAC assesses whether travel should be restricted in
some areas of the region.

13. The Mission begins use of a database to register all
official and private citizen Americans infected with avian
influenza cases.

14. The Mission will train a group of individuals to screen
visitors to the Embassy compound, using a questionnaire,
noting travel, contact with others who have traveled to an
epidemic region, and clinical symptoms of respiratory disease
and fever.

D. Apparent increase in bird-to-human transmission of AI
in El Salvador or neighboring countries

1. EAC meets to review information, assess whether this
new tripwire has occurred, and initiate additional actions.

2. The EAC restricts travel to regions reporting increase
bird-to-human transmission of AI.

3. The Health Unit and USAID AI working group will
communicate frequently with officials of the WHO, CDC,
government of El Salvador (GOES) investigating avian and
human infections. The EAC will be provided frequent updates,
and the EAC will meet when necessary to assess new events

4. Mission personnel and their dependents will be advised
to stockpile enough food and water for at least two weeks and
keep travel documents and personal items ready for rapid
evacuation to the US, should it become necessary.

5. Consular section updates warden messages and Embassy
webpage, as new information appears and new decisions are

II. (U) Clusters of human AI cases, AI affecting entire
families, increased infection among health care workers, or
other events that suggest possible human-to-human
transmission, anywhere in the world

A. Case clusters occurring, but not in the Western

1. EAC meets frequently to follow developments, assessing
the possibility that sustained human-to-human transmission
has started.

2. The Embassy prohibits Mission personnel to travel to
the region where AI clusters have been discovered.

3. Non-essential staff and dependents are advised to
prepare luggage and travel documents and to be on stand-by
for ordered departure.

4. The Mission continues with full staffing.

5. Personnel should increase stockpiles of water and food,
in order to survive a house quarantine of weeks, perhaps

6. Consular Warden Message and Embassy webpage are updated.

B. Case clusters in the Western Hemisphere

1. EAC meets frequently to monitor events and respond
quickly in initiating new actions.

2. Mission requests authorized departure for all
dependents to return to the United States.

3. The Embassy prohibits travel to countries with case
clusters (and perhaps the adjacent countries), except the US,
where only the affected states should be avoided.

4. The Mission stops hosting public events and advises
personnel to avoid public gatherings.

5. Consular section sends warden messages announcing
authorized departure of dependents and suggesting that
private Amcits consider returning to the US. Travel
restrictions for official personnel and the new policy of
social avoidance are also publicized.

6. Health Unit sets up outdoor or alternative patient
evaluation site (perhaps the pool area or the visitor parking
lot). Persons with fever and respiratory illness are not
allowed on the compound. Persons who have returned recently
from the country with case clusters are requested to remain
at home with self-imposed quarantine for 10 days.

7. The Mission screens all visitors for possible contact
with persons with AI, travel to the areas of case clusters,
and respiratory symptoms.

8. The Consular section informs the State Department that
it has suspended service to persons with respiratory illness
or fever. Consular section meets with Health Unit staff to
discuss precautions in meeting with visa applicants.

III. (U) Sustained human-to-human transmission of avian
influenza documented

A. Avian influenza epidemic confined to regions outside
the Western Hemisphere

1. EAC meets frequently to analyze new information and
implement new decisions.

2. The Embassy requests ordered departure for all
non-essential personnel and remaining dependents.

3. Increase frequency of Mission and Consular Warden
Messages to update the Mission and Amcits on Embassy actions.

4. The EAC reviews plans for the evaluation and treatment
of infected persons and the means of transport of ill persons
to local hospitals.

5. The Embassy prohibits travel to regions with
human-to-human transmission.

6. Travel within the Western Hemisphere will probably be
permitted, with the understanding that freedom of travel may
become quickly restricted everywhere. Travel restrictions
need to be reviewed day-to-day.

7. The EAC re-emphasizes advice to remaining Mission
personnel need to stockpile additional water and food in
preparation for possible prolonged home quarantine.

8. The Mission reviews its plans to stockpile water and
food, in considering the remaining Mission personnel may have
to move to the Embassy compound for security reasons.

9. Mission screens all individuals entering the compound.

10. The Consular section limits visa applicants to
emergency cases only.

B. Avian influenza spreads to the US, Mexico, neighboring
Central American countries, or El Salvador itself (All
regional and other international travel is likely to be
restricted; the host nation?s borders will very likely be
closed; medical evacuations will not be allowed, nor is it
likely that they will be possible.)

1. EAC meets to review, revise, and initiate new actions.

2. Mission issues advice for persons becoming ill: stay at
home until respiratory distress or other condition requires
transfer to a local hospital. The risk of transfer to a
hospital where other AI-infected patients must be weighed
against the severity of the illness.

3. Health Unit staff, wearing PPE, will visit ill persons
at home, when necessary. The Health Unit is closed. The
Mission will set up tents and a decontamination area in the
visitor parking lot (outside the walls of the Embassy
compound), should the Health Unit staff have to examine an
ill employee. Tongue depressors and nebulizer treatments
should not be used as these increase respiratory droplet
production; thermometers and an oximeter are essential (and
both are stocked in the HU). The HU staff will need to follow
decontamination procedures after each patient exposure.

4. Health Unit staff monitors the status of hospitalized
personnel, reporting to the Consular section, who will report
to families and others.

5. The consular section closes to the public.

6. The Consular section drafts a travel warning and
requests State Department approval and dissemination. All
incoming official travel is prohibited, unless the persons
are needed to investigate and combat the AI pandemic.
Private Amcits are strongly advised to avoid travel to El

7. Mission informs the State Department that persons in
neighboring countries infected with AI cannot be transferred
to El Salvador, due to inadequate medical facilities.

8. Mission and Consular Warden Messages are disseminated
frequently, updating official Americans and private Amcits
about Embassy advice and actions. The Embassy webpage is
updated day-to-day.

9. The Mission records details of all Americans, Mission
personnel and private citizens, who become sick, quarantined,
or hospitalized with avian influenza in the established

10. Consider dividing the Marine Security Guard into two
groups, which live separately (in order to try to avoid loss
of all MSG personnel to illness simultaneously).

11. The Mission initiates plan to distribute Tamiflu to
Health Care workers, who will use it prophylactically while
visiting patients.

12. Mission considers distributing Tamiflu to all of the
staff who have remained at Post. The Health Unit staff
determines when individuals should use Tamiflu. Tamiflu will
initially be used only if an avian influenza exposure or
symptoms compatible with illness has occurred.

13. Use local ambulance services, if available, to transfer
ill American personnel to hospitals. The Mission will
commandeered a van from the employee association to use for
patient transport. The front (driver) section of the vehicle
should be sealed off from the patient transport section.
After use, the vehicle will need to be washed with dilute
Clorox. When HU staff needs to transport these individuals,
they should do so in PPE and follow decontamination
procedures afterwards (at the Mission decontamination site in
the visitor parking area and again at their residence).

14. The Mission works with the host nation to determine
morgue location and procedures to transfer the dead to the
morgue. The Consular section is informed in order to record
information and notify families.

15. RSO determines how to best protect American Mission
personnel confined to their residences.

16. In discussion with the RSO, the EAC determines if, for
security reasons, the American Mission community should move
to the Embassy compound. In this event, water and food
supplies should be consolidated at the Embassy compound. Of
note, in a pandemic, the Mission must consider the
possibility that the local guard force may become disabled by
illness, limiting the ability to defend the Embassy compound.

17. If Mission employees are moved to the Embassy compound
to live, the Mission may decide to use one or two of the
nearby residences to house and treat ill patients, until such
time that they require hospitalization.