CAMEROON ILL-PREPARED FOR AN INFECTIOUS DISEASE

UNCLAS SECTION 01 OF 04 YAOUNDE 000877 SENSITIVE SIPDIS E.O. 12958: N/A TAGS: CM KHIV PGOV PREL SOCI TBIO KFLU SUBJECT: CAMEROON ILL-PREPARED FOR AN INFECTIOUS DISEASE OUTBREAK ¶1. (SBU) Summary: Public health threats in Cameroon include the possibility of meningitis, cholera, or polio outbreaks, and cases of these diseases are recorded every year. While not currently present in Cameroon, ebola and Avian Influenza (AI) are also considered threats. The Government of Cameroon's (GRC) Ministry of Public Health is responsible for infectious disease research, surveillance, and planning. USAID, the Centers for Disease Control and Prevention, the Peace Corps and the U.S. Department of Defense are working in Cameroon to strengthen the GRC's capacity to respond to infectious disease threats. The GRC has made some progress in preparing for possible cases of AI. However, because of poor management and coordination, the lack of reliable disease information, and ineffective surveillance, the GRC is ill-prepared for any major disease outbreak. End summary. Public Health Threats -------------- ¶2. (U) Significant infectious disease threats in Cameroon include cerebrospinal meningitis, cholera, and poliomyelitis (polio). Relatively few cases of each disease are confirmed each year but each incidence has the potential to spread into a major outbreak. The ebola virus has been confirmed along Cameroon's Gabon and Republic of Congo borders, and although it has not yet been recorded in more central parts of the country, disease spread is an imminent threat. Cameroon's last confirmed cases of H5N1 AI were reported in 2006, but recent cases in Nigeria are a reminder of the continuing regional threat. ¶3. (U) The Ministry of Public Health (MINSANTE)'s Epidemiology Service reports approximately twenty meningitis cases in Cameroon each year. The majority of these cases occur in the North and Far North provinces (which lie in the meningitis belt). However, in the past six years the disease has progressively moved south into the West, Southwest, and Northwest provinces. The death rate among meningitis patients in Cameroon is reportedly very low, and high-risk populations have been educated in meningitis detection. The Epidemiology Service has reported approximately 50-100 cases of cholera per year occurring in Douala and the surrounding Littoral Province since 1998, always during the region's rainy season from September through October. Twenty to thirty cases have been reported per year in the Far North Province ;during that region's rainy season from May through July. In 2005, Cameroon's most severe outbreak of cholera occurred in Douala, with approximately 1,000 cases reported between March and October. Although Cameroon came close to the eradication of polio in 2005, there have since been a number of isolated cases entering into the country from Nigeria. Most cases of polio in the past three years have been recorded in close proximity to the Nigerian border, and MINSANTE has restarted a vaccination and education program along the border. ¶4. (U) Cameroon has never had a confirmed case of ebola, but cases have been confirmed near the Cameroonian border in the forests of both Congo and Gabon. MINSANTE and the Johns Hopkins Cameroon Program, an emerging disease research facility under the auspices of Johns Hopkins University and UCLA, agree that the reason why ebola has yet to enter Cameroon is a mystery; the forest spans the borders, and similar village behavior (i.e. eating dead animals found in the forest) is present in all three countries. The nature of ebola is such that a case is easily distinguished from other diseases, and area health services are confident any past ebola cases in Cameroon would have been recognized as such. ¶5. (U) Cameroon has had two officially recorded AI outbreaks, both occurring in March 2006, in the Far North Province near the Chadian and Nigerian borders. Experts here believe the H5N1 virus arrived in Cameroon via Nigeria. There have been no reported cases of human AI in Cameroon. In July, two outbreaks of AI were reported in the northern Nigerian states of Katsina and Kano. On August 11, the FAO announced the detection of a new strain of Highly Pathogenic AI in Nigeria. The newly discovered virus strain is the first of its kinds detected in Africa, raising concerns that infected poultry are being transferred through international trade or through the illegal movement of poultry. Although Nigeria's confirmed cases are approximately 375 - 450 miles away from the Cameroon border, any AI outbreak in the region poses a threat to Cameroon because of the open channels for virus introduction created by informal and unreported cross-border trade. Public Health Management YAOUNDE 00000877 002 OF 004 -------------- ¶6. MINSANTE is the Government of Cameroon's (GRC) primary authority on infectious diseases, but the Ministry of Livestock, Fisheries, and Animal Industries (MINEPIA),the Ministry of Defense, and the Ministry of Scientific Research and Innovation (MINRESI) also have committees or programs focused on the issue. In MINSANTE, infectious disease players include the Epidemiology Service (for research on epidemic-prone diseases),the National Epidemiology Board (for the surveillance of epidemic-prone diseases that fall under the WHO's International Health Regulations of 2005), the Directorate for Disease Control (for authority on all diseases not touched upon by the WHO regulations),and the Division of Operational Research (for general disease research). HIV/AIDS and tuberculosis have individually-focused programs within MINSANTE. Is Cameroon Ready? -------------- ¶7. (SBU) The National Epidemiology Board, a consultative board serving under the Minister of Public Health, is responsible for the surveillance of meningitis, cholera, and polio. The current surveillance program is unreliable and inefficient. The country is divided into ten Provincial Delegations, which are each divided into Health Districts according to population, with 80,000-100,000 inhabitants per district. Each of these is further divided into eight to ten Health Areas composed of 10,000 inhabitants. In principal, all epidemic-prone disease data is sent weekly from the Health Area administrators to the Health Districts, where all reports for the district are synthesized and sent to the Provincial Delegations. The data is again collated for transmission to the Director for Disease Control at MINSANTE. A senior official of the National Epidemiology Board divulged that in actuality, infectious disease data comes into MINSANTE once every three months on average. He stated that "for those who care about public health," the surveillance system is a "sorry" effort. ¶8. (U) The National Epidemiology Board has a Rapid Intervention Team prepared to be first responders when an infectious disease case is reported. However, the director of the National Epidemiology Board told us that because of the lack of surveillance, this team often arrives in villages to find an epidemic already on the downturn. In 2005, the team was sent to a meningitis outbreak in the Far North province to find that the epidemic had been ravaging one district for three weeks. Because provincial MINSANTE workers had analyzed case data at a provincial level, the number of cases had not been deemed extraordinary, and the epidemic went unreported. ¶9. (U) Hospitals in Cameroon lack the preparation, training, and resources needed to handle an outbreak. In order to understand the sector challenges, Emboff visited a major parastatal hospital, Caisse National de la Prevoyance Sociale (CNPS),one of four large hospitals in Yaounde. CNPS' Director of Medicine reports that all doctors receive training to recognize infectious diseases, but nurses do not "because it is the doctor who makes the diagnosis." In all cases that are not immediately life threatening, a patient must first pay a consultation fee in order to be seen by a nurse. In Yaounde hospitals, this consultation fee ranges from approximately $1.40 to $11.40. Rural hospitals generally do not have the equipment or the expertise needed to take lab samples for aid in diagnosis, so patients are treated empirically based on symptoms. This also occurs in the larger urban hospitals if a patient is unable to pay the cost of testing. Even when samples are sent to a lab, results are sometimes disregarded as unreliable, particularly for tests that require specific temperature or time-frame conditions. Post's Health Practitioner reported that in the majority of hospitals a fever is always treated as malaria and diarrhea is always treated as typhoid fever. Hospitals are especially unprepared to react to an airborne outbreak because of the unavailability of quality isolation rooms. Most hospital beds are separated only by curtains, and no hospital rooms have individual ventilation systems. At CNPS, doors to occupied "isolation" rooms were found wide open into the hospital's main corridor. All hospitals are overseen by MINSANTE's Hospital Commission and they reportedly forward all patient data to this commission every month. Avian Influenza -------------- YAOUNDE 00000877 003 OF 004 ¶10. (U) Although Cameroon has a national plan for AI, it was not implemented during the 2006 outbreaks. Most funding for AI is channeled through the Common Fund for the Control of Avian Influenza in Cameroon, a joint initiative between the GRC, UNDP, European Union, and USAID. The GRC's AI Coordinator, Dr. Inrombe Jermias, acts as national director of the Common Fund. The GRC's Interministerial Committee (French acronym, CIM) on AI, which has been in place since before the outbreaks, still exists on paper, but is otherwise defunct. ¶11. (U) The line between the Common Fund Project and GRC-funded AI projects is blurry. The Common Fund keeps approximately $70,000 in reserves to be mobilized for poultry compensation if an outbreak occurs. Currently the Common Fund oversees the Epidemiological Surveillance Network (French acronym, RES),but this program is due for handover to the Ministry of Livestock, Fisheries, and Animal Industries (MINEPIA) in January. Under RES, 48 MINEPIA employees, and 15 MINSANTE employees were equipped with mobile phones, personal GPS devices, and personal protective equipment (PPE),and dispatched throughout the country, with at least two employees in each of the ten provinces, to take samples in rural areas and report back to MINEPIA. AI training in sample collection and lab protocol has been completed by 200 MINEPIA and MINSANTE employees in the Southern cities of Limbe and Bamenda, and similar training is planned for the North and Far North provinces. ¶12. (U) The CIM stepped up its efforts to control poultry and poultry product trade across the Nigeria-Cameroon border after the 2006 outbreaks by adding six border posts and training all border post employees in AI protocol. However, there appears to be confusion as to which government body should take responsibility for the border posts, and employees report going unpaid since April. In late July, following the AI outbreaks in Nigeria, MINEPIA published a report noting that border supervision in the North and Far North provinces needs to be improved, but did not address how this can be achieved. Dr. Inrombe told Emboff that the majority of border posts lack the resources they need (such as road barriers to block cars, plaques with information on AI, 24-hour personnel, and means to destroy any poultry or poultry products). The Common Fund is planning a training trip along the Nigeria-Cameroon border in the North and Far North provinces to sensitize the population in the villages nearest the border to the risks associated with AI. ¶13. (U) A public awareness campaign of flyers, posters, radio, and information packets handed out to poultry farms has been effective. MINSANTE has worked to train health facility workers on how to recognize AI symptoms, and how and where to send questionable cases or information in an emergency. Each of the ten provinces currently stocks at least eight doses of Tamiflu vaccine for AI treatment (donated by WHO). Because of the lack of isolation rooms in all provincial hospitals, in March the Common Fund steering committee began a proposal for the acquisition of a mobile hospital with the capacity for total quarantine, and Dr. Inrombe reports they are currently working to procure $70,000 needed in funding for this effort. ¶14. (U) The CIM had planned a multi-group simulation exercise for May 2008 to include MINEPIA, MINSANTE, the Ministry of Communication (MINCOM),the Ministry of Defense, and the Common Fund, but did not acquire the needed funding to actually run the drill. The Common Fund has since taken over planning, and reports the simulation exercise will happen in November 2008. The scenario will reportedly include one or more cases of human AI at Bafoussam Hospital (Bafoussam is one of three poultry-raising centers in Cameroon, along with Yaounde and Douala). The U.S. Role -------------- ¶15. (U) USAID supports Cameroon in the prevention of mother-to-child transmission of HIV/AIDS and in other HIV and malaria prevention efforts. USAID provides technical assistance to the Country Coordinating Mechanism for the Global Fund for AIDS, Tuberculosis and Malaria. USAID supports Cameroon's AI control efforts through $20,000 donated to the to the National Veterinary Laboratory (French acronym, LANAVET),in the northern city of Garoua, to expand and improve the national capacity to collect and analyze samples taken from suspected cases of Highly Pathogenic AI. YAOUNDE 00000877 004 OF 004 USAID also donated 5,750 sets of AI personal protective equipment, the last of which were delivered to the Common Fund on August 12, 2008. The Centers for Disease Control and Prevention (CDC) was engaged in HIV/AIDS research in Cameroon from 2002 to 2008. Currently, the CDC is transitioning to an HIV/AIDS care, treatment, and prevention program under the President's Emergency Plan for AIDS Relief (PEPFAR). The USG-funded Walter Reed Johns Hopkins Cameroon Program (WRJHCP),based in Yaounde, is comprised of international health and epidemiology departments from Johns Hopkins University Bloomberg School of Public Health, and a laboratory and field office for the U.S. Military HIV Research Program (USMHRP). Through the Defense HIV/AIDS Prevention Program (DHAPP),the Department of Defense donated $420,000 in an ongoing project to upgrade the Yaounde Military Hospital Laboratory and to support remote military health clinics. The Peace Corps has 30 Community Health Volunteers (out of a total of about 140 Volunteers in the country) working across Cameroon to assess and address health issues, including education and capacity building related to combating infectious diseases. Comment -------------- ¶16. (SBU) MINSANTE officials recognize major shortcomings in the country's preparations for possible disease incidences, and are refreshingly open when discussing them. However, in the case of any large-scale infectious disease outbreak at this time, the GRC would be hard-pressed to respond effectively. Without organized disease surveillance, particularly outside major city centers, the chances of early detection and containment of an outbreak are low. Although the GRC has competent experts writing up the plans and manning the various response teams, organization and planning are lacking. The number of government bodies with a hand in infectious disease programming creates confusion and fosters complacency and blame-passing. Because of this, MINSANTE's plans are half-baked at best, and even then, only on paper. ¶17. (SBU) The GRC is perhaps better prepared to deal with a few cases of H5N1 AI than it is to deal with a large-scale outbreak of a more common infectious disease. Nonetheless, AI planning appears to be stuck in its preliminary phases. Major problem areas include domestic and wild bird surveillance, unregulated cross-border trade, a lack of needed resources, and disorganization within the government. In February 2007, Cairo's Naval Medical Research Unit (NAMRU-3) visited Cameroon, and reported that the country was "lucky" the two AI cases in 2006 failed to spread. If a mass poultry die-off is reported next week, it is unlikely the GRC would be able to effectively put its plans in motion. The assumption within the GRC and hospitals seems to be that human AI will never happen here. ¶18. (SBU) The problems in the health sector are symptomatic of broader governance challenges in Cameroon. Coordination, planning, and project implementation are highly dysfunctional throughout the government. Decisionmaking--when it exists at all--is slow and highly centralized across the board. This is partly the result of corruption and a bloated bureaucracy - both of which plague the health sector as well as others - but also the product of poor leadership, adversity to risk, weak planning capabilities and inefficient administrative practices. USG engagement in the sector, specifically in combating infectious diseases, helps mitigate these problems as well as assisting to fill a public health gap with serious national implications. Mission efforts to promote good governance and fight corruption include the health sector. GARVEY