EGYPT AVIAN INFLUENZA (AI) UPDATES: VACCINATION

UNCLAS SECTION 01 OF 04 CAIRO 002686

SIPDIS

SENSITIVE
SIPDIS

E.O. 12958: N/A
TAGS: TBIO KSCA KFLU EAGR PGOV EG
SUBJECT: EGYPT AVIAN INFLUENZA (AI) UPDATES: VACCINATION
CHALLENGES; CASES 37 and 38; USAID REVIEWS EXPECTATIONS FOR USD 24
MILLION IN AI SUPPORT; NAMRU-3 PARTICIPATES IN JOINT FIELD
INVESTIGATIONS

REF: A) CAIRO 2046
B) Maxwell/Lange e-mail July 26

SENSITIVE BUT UNCLASSFIED. HANDLE ACCORDINGLY.


1. (SBU) Summary. The U.S. Naval Medical Research Unit (NAMRU-3)
participated in two field investigations of human Avian Influenza
(AI) outbreaks with Government of Egypt (GOE) teams in Qena and
Damietta where the use of improper field techniques by GOE teams and
uncooperative local citizens initially led to inconclusive findings.
Under USAID's 3 year, $24 million program to combat AI in Egypt,
GOE is developing a detailed implementation plan (DIP) to strengthen
areas of weakness.


2. (SBU) Summary continued. Controlling AI in Egypt depends heavily
on effective poultry vaccination programs, but problems persist in
GOE efforts to reduce the virus load in poultry, a critical step in
preventing AI outbreaks. Serious problems with cold storage of AI
vaccines persist, and government vets are unable to provide complete
rural coverage due to a lack of vehicles. Challenges remain in data
collection, analysis of backyard flock surveillance, culling
practices and behavior change in poultry-raising households.
Mission-wide partners including USAID, APHIS, NAMRU-3 and CDC have
continued consultations and training with GOE and NGO partners to
address critical problem areas. End summary.

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Latest Case Updates
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3. (U) On June 23, the Ministry of Health and Population (MOHP)
confirmed the 37th human Avian Influenza (AI) case in Egypt. A
four-year-old boy from the Qena governorate (southern region) became
ill three days after contact with dead birds. Doctors administered
Tamiflu within three hours after the appearance of symptoms. After
receiving treatment in Cairo at El-Bakry Hospital (where pediatric
AI cases go),the boy recovered.


4. (SBU) On July 23, the MOHP confirmed AI human case 38, a
25-year-old woman from Damietta also infected after contact with
dead birds. After developing a fever, she told doctors at her local
hospital that she had buried the dead birds. Doctors confirmed AI
infection and transferred her to Abbassia Chest Hospital in Cairo,
where adult AI patients receive treatment. She recovered and was
discharged on July 30. When NAMRU-3 joined a GOE field
investigation team to Damietta, they learned that a neighbor's birds
had also died but the neighbor used plastic bags to cover her hands
and arms and thereby protected herself from AI exposure.


5. (SBU) In a visit to Abbassia Chest Hospital, General Director Dr.
Mahmoud Abdel Magid told econoff the hospital has 125 doctors, 150
nurses and 20 isolation rooms in its intensive care unit (ICU).
Econoff observed the patient from AI case 38 being treated in an ICU
isolation room. He also observed AI fliers posted with instructions
on how to treat patients with AI symptoms. Abdel Magid said
patients with AI are not charged for treatment; a special budget
from MOHP covers treatment expenses.

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Ineffective Culling And Hiding Birds
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6. (SBU) Cases 35, 36, 37 were all from the Qena governorate, with
cases 35 and 37 from the Qena district of Naqada which prompted the
culling of all domesticated birds in the district. Three weeks
after the cull, GOE officials allowed NAMRU-3 specialists to visit
Qena with a joint Ministry of Health and Population (MOHP) and
Ministry of Agriculture and Land Reclamation (MALR) team. They
observed that the poultry cull line was along a road, rather than a
preferred natural barrier (i.e. river, wall, fence). They also saw
adult domesticated birds inside the cull zone; proper culling and
follow-up procedures would have meant that only birds born after the
cull would be found within the zone. Ag Ministry advisor Dr.

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Hussein Soliman said people hide their birds in mosques when
authorities come around. General Organization of Veterinary
Services (GOVS) representative Saber Abdel Aziz said the local
people do not trust the authorities, who might vaccinate birds one
day but come to cull them the next. The father of the boy in case
37 hid his birds when a GOE surveillance team visited, thus leaving
his family susceptible to infection from the same birds that caused
his son's illness. NAMRU-3 also reported that before the outbreak,
people in Qena had not seen GOE vets in more than six months (i.e.
no active surveillance).

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Statistical Overview
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7. (U) Since registering its first human AI case in March 2006,
there have been 38 cases in Egypt, of which 15 were fatal as of July

2007. The 38 confirmed cases were out of 3,502 cases tested for AI.
Egypt ranks third in the world for human cases (only Indonesia and
Vietnam have more). Thirty-six cases are from backyard flock owners
and two from commercial farms. Twenty-six patients were female and
twelve male. From Jan-July 2007, there have been 11 positive H5N1
sites on commercial farms and 220 in backyard areas.

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Vaccine Problems: "Trust me, there is no cold chain"
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8. (SBU) The vaccination program for backyard flocks faces
significant challenges. Chairman of the Supreme National Committee
for Combating Avian Influenza, Health Minister Hatem El-Gabaly,
told Ambassador and visiting Congressional Staff Delegation Grove
that he believes some vets are keeping the vaccine for their own
flocks, and using diluted vaccine or water when going to districts
where they are responsible to vaccinate birds on behalf of the GOE.
In other cases, he said vets were not going to the districts at all.
El-Gabaly added that GOE has vaccinated only 30 percent of the 150
million birds in backyard flocks. El-Gabaly said Egypt imports
vaccines now but he envisions future vaccine production in Egypt.
He said GOE needs USD 24 million to ramp-up vaccine production to
one billion doses for use in Egypt and distribution to other African
countries.


9. (SBU) Abdel Nasser Abdel-Ghafar, MOHP Executive Director of
Epidemiology and Disease Surveillance told econoff and GOE
representatives: "Trust me, there is no cold chain. By the end it's
water, not vaccine." Eight MALR representatives were present when
Abdel-Ghafar made this statement; none disputed the claim. A broken
cold chain may explain results when NAMRU-3 took samples from birds
in Qena that local vets claimed they had vaccinated but NAMRU-3 lab
tests showed otherwise. Mission members are currently working with
GOVS to increase their technical capacity, which includes
establishing and maintaining effective cold chain procedures.


10. (U) Even when administering properly stored vaccine, problems
persist in cataloging vaccinated birds. During their field visit,
NAMRU-3 reported difficulty confirming which birds were vaccinated
(which could only be confirmed with lab results). Some villagers
also told the NAMRU-3 team that they took some birds, but not all,
to the vaccination stations. MALR Minister Amin Ahmed Abaza told
emboffs that problems persist in dealing with backyard flocks. He
expanded that in cities, raising poultry is illegal yet when vets
find these flocks, they are reluctant to seize them. Vets are then
forced to decide whether to vaccinate illegally kept birds.

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Behavior Change Challenges
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11. (U) During NAMRU-3's field investigation in Qena, they noted
chicken cages had not been cleaned since the infections, still
contained feathers and fecal matter, and no disinfectant was
available. Although the GOE-sponsored AI education programs stress
hand washing and cleaning bird areas with disinfectant, in many poor
communities there is no running water for washing hands and no

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access to disinfectant.


12. (U) Minister Abaza told emboffs that behavioral change works
best when people can see some economic or personal benefit. He said
that with no compensation program for backyard flocks, GOE must
focus on convincing flock owners to protect their own health and
their families. He added that poultry sector reform must include
financing for small flock owners to purchase cages for their birds.
However, birds kept in cages must be fed, which is a very real cost
for rural farmers. Poultry remains an important source of income
and protein for many rural families. According to the Supreme
National Committee for Combating Avian Flu, poultry represents 40
percent of Egypt's protein intake, thus making highly pathogenic
avian influenza (HPAI) a food security issue. According to MOHP
data, only 30 percent of poultry production includes proper
slaughtering and chilling.


13. (U) Using famous entertainers as spokespeople, the GOE is
launching a communication campaign to encourage people to notify
authorities of dead birds and seek treatment if they feel flu-like
symptoms. MOHP has a USD 446,000 budget for communication programs,
including a 24-hour hotline, and has enlisted the aid of 13,000
female health educators who go door-to-door in rural areas to talk
about AI prevention and treatment.

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USG Funding - Detailed Implementation Plan Steps
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14. (U) USAID's Dennis Carroll, Director of the Avian and Pandemic
Influenza Response Unit, visited Cairo July 31 - August 1 to meet
with GOE officials regarding detailed implementation plans (DIP)
required to release USAID funds (ref A). In the first year of the
three-year, USD 24 million program, USD 4 million is allocated to
animal health, USD 2.5 million for human health programs, and USD
1.5 million for awareness campaigns.


15. (SBU) Rob Rooij from the United Nations Food and Agriculture
Organization (FAO) commented on his team's role to strengthen GOVS,
which he characterized as a "disaster" in its current state. He
lamented that GOVS is unable to collect meaningful data. In cases
when data is collected, it is not inputted, analyzed or shared. The
lack of data will complicate initial efforts to identify high-risk
governorates. Amira Kamal, head of the GOVS epidemiology group,
responded that data collection will strengthen as the process moves
forward.

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Egypt's Place in the World and in Africa
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16. (SBU) Minister El-Gabaly told the Ambassador that he will
propose a U.S.-European-African forum on AI. He does not believe
the problem will come from Asia but rather Africa. He purposely
excluded Asia from the proposal, arguing that Asia takes all the
global attention and funds. He said the world would pay more
attention to Africa "when you feel the danger coming but then it
will be a little late." We have not yet received El-Gabaly's
proposal.


17. (SBU) When asked to expound on Africa's role in AI preparedness,
El-Gabaly said GOE offered to help Nigeria and Ethiopia but claims
they declined "out of fear they would be exposed" for their lack of
preparedness. He commented that the only way to deal with them is
pressure at international forums, and advised that donors should
demand transparency when those countries ask for aid.

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Egypt's Pandemic Plan Still In Progress
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18. (SBU) El-Gabaly told econoff that Egypt's national pandemic
plan, in development over the past eight months, is still not ready.
He said that the military has been "deeply engaged" with "a high
level of commitment." He added that military responsibilities will

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include guarding Tamiflu (GOE has 2.5 million doses),protecting
doctors, culling birds, securing outbreak areas and controlling the
movement of people.


19. (U) Ideally, El-Gabaly said, Egypt needs USD 300 million in AI
assistance but could manage with USD 100 million. He said the focus
should be training vets, acquiring vaccines, stockpiling Tamiflu and
obtaining ventilators. The Health Ministry is also collecting data
on the Egyptian health infrastructure, including the number of
doctors and nurses, beds and supplies.

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Crisis Management and Mission Preparedness
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20. (SBU) Minister El-Gabaly told the Ambassador that he believes an
AI pandemic will hit Egypt between 2008 and 2011. He claimed his
ministry is well ahead of the Ministry of Agriculture in its
preparations for such an emergency, although there is still much to
do. In the case of the Ministry of Agriculture, USG agencies have
been concerned about the lack of an organized central effort to deal
with AI, including a delay in naming the appropriate counterparts
for USAID and international donors. In a recent meeting with
emboffs, Minister of Agriculture Abaza promised to permanently
assign a group of officials to work with USAID and other donors on
AI issues. He also acknowledged the need for transparency,
efficiency and accountability in the use of the USAID assistance.


21. (SBU) At the same time that we are working with the GOE to
improve its readiness, Post Avian Influenza Working Group is
reviewing Mission preparedness including essential personnel lists,
Tamiflu guidelines, tripwires, communication plans and a possible AI
crisis management exercise (ref B).