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
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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

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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
--------------

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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