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

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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.


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


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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