EAC MEETING - JANUARY 13, 2006: AVIAN INFLUENZA,

UNCLAS SECTION 01 OF 06 SAN SALVADOR 000253 SIPDIS DS/IP/WHA, DS/IP/SPC, WHA/EX, E.O. 12958: N/A TAGS: ASEC AMGT ES KFAM KRIM AVIAN FLU SUBJECT: EAC MEETING - JANUARY 13, 2006: AVIAN INFLUENZA, TRIPWIRES AND RESPONSE PLAN, US EMBASSY SAN SALVADOR REF: SECSTATE 219189 ¶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 globally 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 countries. ¶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 Salvador. ¶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 vaccine. US Embassy Tripwires For Avian Influenza (AI) ¶I. (U)Only bird-to-bird and sporadic bird-to-human transmission ¶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 influenza.) ¶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 pills). ¶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 possible. ¶8. The Mission reviews its minimal staffing list of personnel. ¶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 influenza. ¶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 information. ¶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 made. 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 Hemisphere ¶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 months. ¶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 Salvador. ¶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 database. ¶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. Barclay