H1N1 IN PAKISTAN

UNCLAS SECTION 01 OF 02 ISLAMABAD 000143

SIPDIS

E.O. 12958: N/A
TAGS: SOCI TBIO ECON PGOV PREL PK
SUBJECT: H1N1 IN PAKISTAN

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1. (SBU) Summary: Pakistan has 148 officially confirmed cases of
H1N1, but the country's extremely limited disease surveillance
capacity leads top Pakistani public health officials to believe that
infection is dramatically under-reported. Pakistan's National
Institute of Health (PNIH) and the U.S. Center for Disease Control
(CDC) have tried to implement H1N1 monitoring, but their efforts
have been frustrated by a lack of reporting from regional hospitals
and labs. The GOP has made some attempt to organize for a
large-scale H1N1 outbreak, prepositioning Tamiflu across the country
and preparing for the two million doses of H1N1 vaccine due to
arrive by February. However, poor Ministry of Health leadership has
the potential to hinder the establishment of an efficient H1N1
vaccination effort in Pakistan. End Summary.

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Shaky Disease Surveillance Efforts
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2. (SBU) Pakistan's first confirmed case of H1N1 was announced by
the GOP on August 10, 2009. As of January 1, the number of cases
officially confirmed by the GOP stands at 148, with 13 deaths
officially attributed to the virus. However, contacts at the
Ministry of Health, Pakistani National Institute of Health (PNIH)
and the Resident Advisor for the U.S. Center for Disease Control
(CDC) all agree that actual numbers of H1N1 cases and deaths are
certainly much higher than those given by the GOP.


3. (SBU) Dr. Arif Zaka, National Program Manager for the National
Influenza Program at the Ministry of Health, speculated that the
actual number of H1N1 deaths in Pakistan was likely in the range of
25-30. Dr. Rana Jawad Asghar, the CDC's Resident Advisor in
Pakistan, said that the death toll was at least 30, but lamented
that "we don't have a surveillance system, so if people are dying we
just don't know."


4. (SBU) Despite an incomplete picture of H1N1 incidence in the
country, the GOP has made some credible efforts to, in the words of
NIH's Dr. Birjees, "prepare for the worst possible case." Dr. Zaka
reported that in November each province had received Tamiflu stocks
totaling 27,000 doses to NWFP, 30,000 doses to Sindh, 50,000 doses
to Punjab and 7,000 doses to Balochistan. Without good disease
detection it is difficult to know whether these 114,000 doses will
significantly alleviate the H1N1 burden in Pakistan.


5. (SBU) The CDC has established a sentinel program at five
hospitals across the country - one in each province and an
additional site in Islamabad. These sites are collecting data on
the H1N1 tests run at the hospitals, but even managing these few
sites is a challenge. According to the CDC's Dr. Jawad, "half the
time the samples are not sufficient and patients disappear before we
can identify them and retest."


6. (SBU) The PNIH has asked all labs in Pakistan to inform NIH if
they have a positive sample for H1N1 so that some tracking of the
disease can occur at the national level. However, according to PNIH
Executive Director Dr. Birjees Mazher Kazi, the only lab sharing
information with PNIH is Aga Khan University Hospital in Karachi.
"Others are probably testing," said Dr. Birjees, "and we do not have
a monopoly on the test. But it is difficult to handle the
nationwide public health challenge without better information." The
PNIH can retest those samples that are forwarded to them in 24
hours, but lab technicians echo their CDC colleagues' worries about
poor sample quality and the inability to retest patients.

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Questionable MoH Leadership
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7. (SBU) In addition to the many systemic public health challenges
Pakistan faces as it battles H1N1, contacts at the CDC and PNIH both
question the ability of Dr. Arif Zaka, the government's appointed
Influenza Program Manager, to spearhead Pakistan's H1N1 efforts.
The PNIH's Dr. Birjees confided to EconOff that Dr. Zaka "does not
have the right background for his job" and CDC Dr. Jawad told
EconOff "we're double-tracking everything Dr. Zaka does because we
have no confidence it will get done otherwise."


8. (SBU) In his meeting with EconOff, Dr. Zaka lent credence to the
CDC and Pakistani NIH's assessment, presenting four different
bizarre theories about H1N1, its origins, its vaccine and the public
health response to the virus. He variously accused WHO of actively

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spreading the virus because it has not acted on Zaka's advice to add
flight attendants to the "high risk" category for H1N1; repeated
information he found on a blog questioning the efficacy of the H1N1
vaccine, saying "we just don't know what will happen to the people
who get this shot - it could be quite bad;" and postulated that
health care workers would need to lie in order to avoid vaccinating
high risk individuals by force if they refuse the vaccine. Finally,
Dr. Zaka claimed that "some people" believe H1N1 was created in a
lab in the United States and is being spread around the world so
American companies can make money selling the vaccine.


9. (SBU) Dr. Zaka reported that two million doses of H1N1 vaccine
are due to arrive in Pakistan this month, which his office plans to
distribute in the same manner in which the Tamiflu was disbursed.
Dr. Zaka speculated, however, that the vaccine is not really
necessary: "if it does work, it will only prevent the flu 99.9% of
the time and this flu already has an incidence rate of less than 1
percent."


10. (SBU) Comment: The GOP has made some efforts to work
proactively and prepare for an increased incidence of H1N1 in the
country. PNIH Director Dr. Birjees assesses, however, that GOP is
largely "in denial" about the severity and degree of mortality of
H1N1. While that assessment may be overstated, Post believes that,
without an effective disease surveillance program, it will remain
all too easy for the GOP to ignore the scope of H1N1 prevalence in
Pakistan. Complicating efforts to fight the disease, H1N1
prevention efforts are not the GOP's first priority. "Right now,
more people are dying in bombs in Pakistan," said Dr. Birjees of
H1N1 prevalence. "Compared to this, the flu seems a very small
problem." Finally, the highly questionable leadership of Dr. Zaka
and his range of conspiracy theories does not inspire confidence:
upon hearing that EconOff had received the H1N1 vaccine an alarmed
Dr. Zaka retreated behind his desk and wished the officer luck in
handling the inevitable health repercussions.


PATTERSON