AVIAN INFLUENZA UPDATE - MORE HUMAN CASES AND FIRST DEATHS

UNCLAS SECTION 01 OF 05 HANOI 001147 SIPDIS SENSITIVE SIPDIS STATE FOR EAP/MLS, EAP/EP, INR, OES/STC, OES/IHA, MED STATE PASS TO USAID FOR ANE AND GH STATE PASS TO HHS/OGHA (STIEGER/VALDEZ/BELL/HICKEY) CDC FOR OGHA (BLOUT/MCCALL) AND DIV-FLU (COX/MOHEN) DEPARTMENT OF DEFENSE FOR OSD/ISA/AP (STERN) HHS PASS TO FIC/NIH (GLASS) USDA PASS TO APHIS, FAS (OSTA AND OCRA),FSIS BANGKOK FOR RMO, CDC (MALISON),USAID (MACARTHUR/BRADY) BEIJING FOR HHS HEALTH ATTACHE (ROSS) PHNOM PENH FOR CDC INFLUENZA COORDINATOR(BRADY) ROME FOR FAO VIENTIANE FOR CDC INFLUENZA COORDINATOR (CORWIN) E.O. 12958: N/A TAGS: TBIO AMED AMGT CASC EAGR PINR KFLU VM SUBJECT: AVIAN INFLUENZA UPDATE - MORE HUMAN CASES AND FIRST DEATHS SINCE 2005 HANOI 00001147 001.2 OF 005 SENSITIVE BUT UNCLASSIFIED REF: A. HANOI 973; B. HANOI 1026; AND C. HANOI 1050 ¶1. (U) Summary. The Government of Vietnam (GVN) now reports a total of five confirmed human cases of highly pathologic H5N1 avian influenza A (AI) since May 1, including two deaths, the first since November 2005. There have been no associated cases among contacts and no common sources of infection. Since May 1, there have been over 100 animal AI outbreaks in 18 of Vietnam's 64 provinces and municipalities. Animal Health authorities report that the first shot of two in the first of two rounds of poultry vaccinations is complete in 43 provinces. ¶2. (SBU) The GVN has shipped the samples from the first two human cases to a World Health Organization (WHO) influenza collaborating center; shipping was delayed by procedural and logistical complications. End Summary. Summary of Human Cases -------------- ¶3. (U) Between 24 May and June 16, the Ministry of Health (MOH) reported five new cases of H5N1 infection including two deaths, bringing the national total to 98 cases and 44 deaths. These first reported cases since November 2005 include four men and one woman, all young adults (aged 19 to 30 years) living in rural areas of northern Vietnam. Two patients have died. Of the remaining three patients, two have recovered and been discharged from the hospital; one is hospitalized and in good condition. ¶4. (SBU) Each of the five cases was an isolated occurrence and we have seen no evidence of epidemiological links that would suggest a common source or person-to-person transmission. The source of infection is presumed to be the slaughter or preparation of sick poultry in three cases (chickens in two instances; duck in one); exposure to ducks and fighting cocks in the family in one case; and unknown in one case. ¶5. (SBU) MOH reports that all five cases resulted in investigations and further preventive measures were taken. A course of oseltamivir (Tamiflu) was given to individuals in close contact with the infected patient, supplemental information and educational materials were provided to local communities and environmental decontamination was organized. ¶6. (SBU) Although the MOH reports that the human and animal public health investigations and responses for control and containment have been prompt and thorough, two different sources in the Ministry of Agricultural and Rural Development (MARD) reported that they were not made aware of the cases by MOH in sufficient time to coordinate and direct local officials on the animal health side. (Comment: Post believes that provincial action could have occurred on the animal side as directed by local People's Committees and that MARD may have been out of the loop. We cannot confirm veterinary investigation or action. End Comment.) HANOI 00001147 002.2 OF 005 ¶7. (U) All but one of the five patients required intensive care and mechanical ventilation for respiratory failure. The overall survival rate for Vietnam patients remains high at 55 percent (54 of 98). There is no evidence to suggest a change in the clinical picture or response to therapy compared with previously treated patients in Vietnam. New and Updated Details of the Five Human Cases -------------- -- ¶8. (SBU) The first human case, a 30-year old man (alias PMP) who was thought to have been infected while slaughtering chickens for a wedding on May 5 (reftel B),recovered from respiratory failure and was discharged from the hospital after 16 days. It was reported that he received 10 days of oseltamivir and that the virus had been confirmed in his saliva, gastric contents, and excrement. Approximately 40 health care workers and 70 family members and other close contacts were administered prophylactic 7-day courses of oseltamivir. Epidemiologic investigations revealed only one contact with symptoms, a 16-year old niece with a mild upper respiratory illness who tested negative for H5N1 and recovered without consequence. Intensive area surveillance over the next week identified no further persons with suspect symptoms, and no outbreaks in poultry. ¶9. (SBU) The second case, a 19 year old man, had occupational exposure to chickens at a slaughter house on the outskirts of Hanoi (reftel C). He was working in Dong Anh District from May 13 to 18, returned home to Thai Nguyen Province May 19, complained of fever and abdominal pain May 20 to 23, and was hospitalized May 24. He quickly developed respiratory failure and acute respiratory distress syndrome (ARDS) and was transferred to a referral hospital in Hanoi on May 26. Test results confirmed the presence of the H5N1 influenza A virus. A joint human and animal investigation was unrevealing and all of the patient's coworkers were closely monitored. The patient is still hospitalized but breathing on his own and his condition is slowly improving. ¶10. (SBU) The third case, a 29-year old male (alias LNL and possibly female in a conflicting report) who is a staff member of the Local Youth's Union in Som Son Town, Thanh Hoa Province (about 150 km south of Hanoi) reportedly became ill on May 28 or 29. One press report stated that he had eaten a sick duck. MARD official reported to FAS staff that he had slaughtered chickens on May 25. He began to exhibit influenza-like symptoms on May 28 or 29 and was hospitalized on May 31 and treated with oseltamivir. He was discharged June 6. Positive results for H5N1 were available June 8. ¶11. (SBU) The fourth case is a 20-year old male from Ba Vi District, Ha Tay Province, less than 100 km west of Hanoi. Press reports indicate that ducks and fighting cocks were maintained by his family. He became symptomatic on June 2, hospitalized on June 8 and transferred to a referral hospital in Hanoi on June 10. He died the same day. Results from specimens tested positive for H5N1. This is the first human bird flu death in Vietnam since November 2005. Details of the case investigation are unknown at this time. HANOI 00001147 003.2 OF 005 ¶12. (SBU) The fifth case, a 28-year old female farmer from the Thanh Liem District of Northern Vietnam's Ha Nam Province (about 40 km south of Hanoi) exhibited fever and chest pain on June 4. She was admitted to the provincial hospital on June 6 and transferred to a referral hospital in Hanoi on June 8. Doctors diagnosed her with pneumonia. On June 12, test results confirmed the presence of H5N1. She died June 21, the second death since May 1, bringing the total to 44 since the end of 2003. The patient's exposure history is currently under investigation, including the collection of clinical specimens from 20 close contacts. ¶13. (SBU) Test results for two patients previously described as under investigation (reftel C) tested negative for H5N1. Several other reports of patients with influenza-like symptoms progressing to severe pneumonia, including at least three deaths, have been reported by MOH and media sources but have tested negative for H5N1. (Note: These reports are to be expected given the increased testing as a consequence of heightened awareness and the baseline occurrence of severe pneumonia from other causes. End Note) Sample Sharing -------------- ¶14. (SBU) The MOH gave approval for WHO-Vietnam to obtain confirmation of diagnosis for the first two cases. The WHO has sent a letter requesting approval for the remaining three. The specimens for the first two cases have been sent to the CDC in Atlanta, one of the four WHO influenza collaborating centers. ¶15. (SBU) The actual shipment of samples to Atlanta was delayed due to technical and bureaucratic obstacles. The specific issues included a) new personnel in more than one organization who were unfamiliar with the process of shipping the samples, b) one of the downloadable customs approval forms was illegible and not suitable for signature, c) the introduction of "new" requirements based on H5N1 being categorized as a select agent, d) non-functioning FAX numbers, and e) obstacles to amending and correcting forms already approved by USDA for importation. ¶16. (SBU) When issues were recognized, various staff, on both sides of the ocean, dropped what they were doing to solve the problems and worked after hours, in one case driving back in to work due to the time difference. The actual procedure for WHO counting and reporting a human case in Vietnam is not clear at this time. HHS/OS and CDC Hanoi are encouraging WHO-Vietnam and the National Institute of Epidemiology and Hygiene (NIHE) to examine these events in closer detail with CDC-Vietnam in order to a) improve the process and b) uncover what may be potentially systemic issues applicable to other countries. Continued Animal Outbreaks -------------- ¶17. (U) Vietnam continues to experience AI poultry outbreaks in all regions -- southern, central and northern -- of the country. The north has been particularly hard hit in this latest wave of HANOI 00001147 004.2 OF 005 outbreaks. Since the beginning of the fifth wave of poultry outbreaks in early May, 16 provinces and 2 municipalities have been affected; 13 of these are located in the northern region, including all provinces contiguous with the city of Hanoi. More than 100 outbreaks have occurred in approximately 70 communes in 40 districts; these have involved mostly waterfowl (ducks and geese) and to a much lesser degree, chickens. ¶18. (U) Media reports state that since the beginning of the fifth wave, nearly 200,000 poultry have died or been culled, 96 per cent of them ducks. Flocks of unvaccinated ducklings have been the most affected. Although the outbreaks have been easily contained because of early detection, culling, quarantine, environmental decontamination and ring vaccination, the potential for large scale outbreaks increases as these flocks mature and are released for free-grazing in the coming months. ¶19. (U) Poultry reared for consumption has been affected, as it is the presumed source of infection for all five recent human cases. Various markets have been sampled. A MARD Central Veterinary Diagnostic Center official reported to FAS staff that 62 of 1109 (5.6 percent) poultry sampled have tested positive for H5N1 virus. These samples were taken from birds in seven northern provinces and cities, namely Bac Giang, Ha Nam, Hanoi, Ha Tay, Hai Duong, Thai Binh and Vinh Phuc, and an province bordering China, Lang Son. The percentage positive in Lang Son was 12 percent. Sampling in two Hanoi retail markets yielded a positive fraction of 6 percent and in one Hanoi wholesale market, 14 percent. These statistics differ from those in the media. ¶20. (SBU) (Comment: These numbers seem high as an indicator of infection in healthy animals, i.e. detection by PCR, compared to studies in Thailand. More information is needed on species involved, sampling methodology, type of test, and whether waterfowl were vaccinated or unvaccinated before conclusions can be drawn from this report. End Comment.) Media Reports -------------- ¶21. (U) Numerous media reports have covered the stepped up response of the GVN, including explicit directives from the Prime Minister (PM). A media report quoted the PM as saying he expected "directed officials to take responsibility for bird flu" and that "penalties will be imposed on leading officials if a new outbreak occurs in their area." At the national steering committee meeting in mid-June, MARD proposed that an additional 200 million doses of animal vaccine should be imported; and there are continued concerns about vaccine efficacy. National media also reported that Vietnam reserves the right to quarantine incoming passengers from bird flu-hit countries. Ton Son Nhat International Airport in HCMC would screen incoming passengers by body temperature, a scenario they played out to combat SARS in previous years. USAID and CDC Activities -------------- HANOI 00001147 005.2 OF 005 ¶22. (U) NGOs and international organizations that receive USAID and CDC funds met on June 14th to discuss the methodology coordination of USAID-funded "Knowledge, Attitude and Practice" surveys carried out in Vietnam. These surveys have been used to gauge the awareness of households and backyard farmers about AI prevention and control. Participant organizations discussed methods to improve their data collection process, the feasibility of including several standard questions in future KAP surveys and target groups, which had previously been overlooked. ¶23. (U) The MOH's Vietnam Administration for Preventive Medicine (VAPM) hosted a launching ceremony on June 14 for HHS/CDC's 5-year cooperative agreement designed to build capacity around the framework of President's three pillars. The first-year FY2006 funding is 1.15 million USD; second year funding was cut from the projected figure of 1.3 million USD to the actual FY2007 of 525,000 USD. Ambassador Marine remarked that the new initiative complemented other USG supported projects (i.e., USAID, USDA, HHS/OS, and CDC). Vice Minister of Health Trinh Quan Huan said, "Prevention of an avian influenza pandemic by enhancing different levels of surveillance, rapid detection, and our response to outbreaks is critical in Vietnam." Press coverage was heavy and the reporting on this USG support was coupled with reports of the need for increased Vietnamese efforts to combat the current high level threat. ALOISI