UPDATE ON VIETNAM'S LATEST HUMAN AVIAN INFLUENZA INFECTION

UNCLAS SECTION 01 OF 03 HANOI 000065 SENSITIVE SIPDIS STATE FOR EAP/MLS, EAP/EP, INR, OES/STC, OES/IHA, MED STATE PASS TO USAID TO ASIA (MELLIS/DSHARMA/CJENNINGS) AND GH (KHILL/DCARROLL) DEPARTMENT OF DEFENSE FOR OSD/ISA/AP (STERN) CDC FOR COGH (SBLOUNT),CCID (SREDD) AND DIV-FLU (NCOX/AMOHEN) HHS/OSSI/DSI PASS TO FIC/NIH (RGLASS) AND OGHA (DMILLER/MABDOO) USDA PASS TO APHIS, FAS (OSTA AND OCRA),FSIS BANGKOK FOR RMO, CDC (MMALISON),USAID (MACARTHUR/MBRADY/CBOWES), APHIS (NCARDENAS),REO (HHOWARD) BEIJING FOR HHS HEALTH ATTACHE (EYUAN) PHNOM PENH FOR CDC INFLUENZA COORDINATOR (BBRADY) ROME FOR FAO VIENTIANE FOR CDC INFLUENZA COORDINATOR (ACORWIN) E.O. 12958: N/A TAGS: TBIO AMED EAGR PINR KFLU VM SUBJECT: UPDATE ON VIETNAM'S LATEST HUMAN AVIAN INFLUENZA INFECTION AND SAMPLE SHARING REF: A. Hanoi 21; B. Beijing 31; C. 08 Geneva 1112; D. 07 Hanoi 890 HANOI 00000065 001.2 OF 003 ¶1. (U) Summary: Confirmed case number 107, an 8-year-old girl from Thanh Hoa province infected with the H5N1 strain clade 2.3.4 of highly pathogenic avian influenza (HPAI) was discharged from the hospital and will be counted towards the total number of human infections for 2008. The girl's 13-year-old sister died on January 2, 2009, following symptoms consistent with infection that met the World Health Organization (WHO) definition for a probable case. From 2007 to the present, MOH has shared isolates from 9 of the 14 confirmed human cases with the WHO Collaborating Center for Influenza (CC) system. Specimens from the last 3 cases are among the 5 not yet shared. We continue to work with partners in WHO and the Ministry of Health (MOH) to facilitate sample sharing and exchange of information. End Summary. Update of Human Infections, the Last Case of 2008 -------------- -- ¶2. (SBU) Earlier this month, MOH reported a laboratory confirmed case of HPAI in an 8-year-old girl. Although reported as the first case of 2009 (Ref A),she first exhibited symptoms on December 19 and is considered the sixth and last case of 2008 to be added to the WHO international compilation. She is the fifth case since 2004 and the first case since July 2007 to have been reported from Thanh Hoa. The total number of confirmed cases of A/H5N1 HPAI reported by Vietnam MOH to the WHO is now 107, of which 52 have been fatal. ¶3. (SBU) Citing the clinical history provided by the district medical officer, local CDC and WHO experts believe that the victim's 13-year-old sister, whose symptoms began on December 27 and who died on January 2, should be considered a probable case. The MOH has not declared the older sister as a probable case, noting that her principal symptoms at admission to the hospital were gastrointestinal: "stomach ache, very high fever and diarrhea." However hospital officials noted that the onset of her illness was heralded by "high fever and severe cough," similar to her 8 year-old sister, and the media reported that she experienced respiratory failure as well as other organ failure during her hospitalization. [Note: WHO defines a probable infection as "a person dying of an unexplained acute respiratory illness who is considered to be epidemiologically linked by time, place, and exposure to a probable or confirmed H5N1 case." The International Health Regulations (IHR) do not require that probable cases be reported, nor are they included in the official counts of cases complied by the WHO. Published references on the clinical signs and symptoms of A/H5N1 infections do describe the not uncommon occurrence of abdominal pain and diarrhea in A/H5N1 patients, including previous cases in Vietnam. End Note.] ¶4. (SBU) The Thanh Hoa occurrence may be the first in Vietnam since 2004-05 involving more than a single sporadic case, though this cannot be proven as the absence of clinical specimens from the 13-year-old precludes laboratory confirmation. Even with isolation of the causative virus, field and pathologic investigations at the time would not have been able to definitely determine whether the older sister became ill due to exposure to her younger sister. HANOI 00000065 002.2 OF 003 Sick Poultry Not Reported to Authorities -------------- ¶5. (SBU) On January 4, National Institute of Hygiene and Epidemiology (NIHE) of MOH conducted a field investigation with Provincial and District health authorities at Dien Tru Commune, where the case patients normally resided with their parents. Investigations uncovered unusual illness and deaths in poultry in the case hamlet and several other villages in the district in the weeks preceding the illness in the case patients, but information on poultry deaths apparently was not relayed to medical or veterinary authorities. According to a report from Thanh Hoa provincial DAH, 19 households in 6 of 12 hamlets of Dien Trung commune were found to have had sick or dead poultry, totaling 383 birds. The local authorities culled 7,800 poultry in 6 hamlets and implemented other stipulated poultry outbreak containment measures. No subsequent reports of poultry outbreaks in Thanh Hoa have been received. As of January 21, Thanh Hoa and Thai Nguyen are the two provinces with reported avian influenza outbreak activity within the prior 21 days. Field Investigation and Control Measures -------------- ¶6. (SBU) NIHE investigators identified and interviewed close contacts of the case patients. The parents were healthy. Of the contacts of the sisters in the community, only one, a 5-year-old neighbor boy, reported illness (i.e., fever). He was referred by the investigation team to the Ba Thuoc District Hospital for observation, diagnostic evaluation, and treatment. Testing of throat swabs from this boy and 37 close contacts at the time of the field investigation were negative for A/H5N1 by PCR testing at NIHE. Oseltamivir was delivered on January 5 from central stocks to Thanh Hoa Province health authorities for treatment of suspected cases and case contacts, and hospitalized children and close contacts of the case patient were treated. Close contacts were placed under daily surveillance by nursing staff from the local government health services. Virology of the New Human Infection -------------- ¶7. (SBU) NIHE confirmed A/H5N1 infection in the 8-year-old girl within 36 hours of being notified of the case suspect, and further identified through genome sequencing the virus as belonging to H5N1 clade 2.3.4. This virus has been circulating in northern Vietnam since its apparent introduction from China in 2005 and has been responsible for the last 15 human infections in Vietnam, the first identified in November of 2005. To date, we have not seen any human infections from a more recently introduced strain, such as clade 7, which has circulated in China for more than 2 years and was linked to the recent death of a Beijing woman (local media and Ref B). Clade 7 had been reported for the first time in Vietnamese poultry in a northern province adjacent to China in August 2008. Vietnam's Sample Sharing -------------- HANOI 00000065 003.2 OF 003 ¶8. (SBU) The GVN has provided isolates from 9 of the past 14 confirmed cases. The isolate from the 8-year-old girl is one of the five not submitted. [Note: Based on a WHO source, Ref C reported that Vietnam shared zero of five specimens from November 2007 through November 2008; however, a review of WHO CC records from CDC Atlanta shows that Vietnam has shared isolates from 4 of 6 cases with onsets of illness in that time period. End Note.] WHO Hanoi has formally written MOH after each reported human case, requesting the MOH to share an isolate. Typically, the MOH has submitted isolates based upon oral "approvals," without a written response and not through an established standardized procedure. NIHE has stored isolates for the five not sent to a WHO CC, and these could be made available for further analysis if MOH concurs. ¶9. (SBU) In August, CDC provided results to NIHE for 9 isolates shared, under the auspices of its role as a WHO CC. The value of this information in terms of detailed analysis and characterization of virus strains causing illness in Vietnam, including identification of a mutation linked to reduced oseltamivir susceptibility, cannot be overstated, especially when coupled with related technical assistance that has concretely established Vietnamese capacity and trust. This has added value in its support of longstanding (starting in 1998) scientific collaboration between NIHE and WHO CC, CDC Atlanta on virological and epidemiologic aspects of seasonal and A/H5N1 influenza in Vietnam. ¶10. (SBU) Given the unique pandemic threat of HPAI, local WHO and CDC technical experts have urged the GVN to share promptly an isolate or a clinical specimen from every human case of HPAI with the WHO CC system. In 2005, NIHE was designated a WHO National Influenza Center (NIC),able to confirm independently a case of A/H5N1 infection. The IHR stipulate that GVN need only send unusual or representative usual influenza virus isolates to a WHO CC. Unofficially, the MOH has pointed to these facts in discussing full and timely sample sharing with CDC Hanoi and WHO Hanoi. WHO and CDC continue to re-enforce with MOH the value to share all isolates promptly. We believe that progress is dependent upon continued strengthening of scientific and public health cooperative activities. Comment -------------- ¶11. (SBU) While we believe the previous in-depth analysis of Vietnam's position on sample sharing remains valid (Ref D),we note that ensuring MOH cooperation requires encouragement from WHO and CDC. In the absence of more stringent IHR requirements, we believe that our informal encouragement by CDC and WHO and our technical and programmatic support have been sufficiently effective. Ultimately we want Vietnam to promptly share all isolates of HPAI without outside pressure. In our judgment, at this point, a more aggressive tact could endanger current progress. In the event of a possibly evolving pandemic, it is probable that Vietnam would fully cooperate, as it did with SARS and in the first instance of HPAI in Vietnam. We are working with partners in WHO and the Ministry of Health (MOH) to facilitate a prompt exchange. End Comment. MICHALAK