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### Viewing cable 05TAIPEI3713, TAIWAN PREPS FOR AVIAN FLU

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Reference ID | Created | Released | Classification | Origin
--- | --- | --- | --- | ---
05TAIPEI3713 | 2005-09-08 23:54 | 2011-08-23 00:00 | UNCLASSIFIED | American Institute Taiwan, Taipei

`

    This record is a partial extract of the original cable. The full text of the original cable is not available.

` `

    UNCLAS SECTION 01 OF 08 TAIPEI 003713

    SIPDIS

    STATE PLEASE PASS TO AIT/W, EAP/RSP/TC AND OES/IHA
    HHS PLEASE PASS TO ERIKA ELVANDER

    E.O. 12958: N/A
    TAGS: AMED AMGT CASC ECON SENV SOCI TBIO TW ESTH
    SUBJECT: TAIWAN PREPS FOR AVIAN FLU
    REF: A) 2005 SECSTATE 151549 B) 2005 TAIPEI 00058 C) 2004

    TAIPEI 0249 D) 2003 TAIPEI 03339 E) 2004 TAIPEI 00479 F)
    2005 TAIPEI 01881 G) 2005 TAIPEI 03598

    Summary
    -------
    ¶1. Summary.  With the exception of one H5N1 high pathogenic
    avian influenza (HPAI) illegal shipment of ducks, which was
    caught and destroyed, Taiwan has thus far managed to avoid
    H5N1 HPAI.  Nonetheless, drawing on its experience with SARS
    in 2003, Taiwan has made extensive preparations to combat a
    potential HPAI pandemic.  President Chen Shui-bian chaired a
    National Secuirty meeting on August 19 to emphasize the
    political will to prevent and contain any pandemic and to
    update Executive Agencies on Taiwan's December 29, 2004
    Influenza Prevention and Response plan.
    ¶2. The Response Plan includes: a disease alerting and
    reporting system, disease surveillance and collaboration at
    all levels of government, border controls, a protocol for
    personal temperature monitoring, a hospital disease
    prevention and control network, epidemiological studies,
    case investigation protocols, facilities usage and controls,
    communication measures and vaccination plans, the
    establishment of a new emergency response center at Taiwan's
    Center for Disease Control (TCDC), and a program to
    stockpile the anti-viral influenza pharmaceutical
    oseltamivir (Tamiflu).  Taiwan has also allocated NT$27
    billion (USD 844 million) for long-term plans to develop and
    manufacture influenza vaccines.  Between December 2003 and
    March 2004, Taiwan also has culled a total of 380,000 birds
    potentially infected with the low pathogenic avian influenza
    (LPAI) (H5N2).
    ¶3.  Comment.  This report constitutes AIT's response to
    reftel A.  Overall, Taiwan appears to be very proactive in
    its efforts to prevent, detect and respond to an avian
    influenza outbreak.  Taiwan, however, could do more to
    ensure that all government agencies have contingency plans
    in place and to urge the private sector and individuals to
    prepare.  End Summary and Comment.

    Priority Issue
    ---------------
    ¶4. Taiwan learned the lessons of the 2003 SARS crisis.
    Taiwan has been continually drafting, reviewing and revising
    its response to another potential SARS outbreak and now to a
    potential influenza pandemic since the abatement of SARS in
    the summer of 2003.  Taiwan claims that of the 168 World
    Health Organization recommendations for preparing for an
    HPAI outbreak, Taiwan has met 122.  This cable provides an
    overview of Taiwan's preparation plans to date.

    ¶5. On August 19, President Chen Shui-bian called a senior
    staff meeting at the National Security Council (NSC) on
    avian influenza to emphasize to his Cabinet and the public
    the priority Taiwan is placing on preparing for a potential
    HPAI outbreak.  At the NSC meeting, Chen emphasized the
    importance of learning from mistakes made in countering the
    SARS epidemic in 2003.  He urged health authorities to
    enhance their international public health network in order
    to closely monitor global efforts to prepare for the
    potential of an increase in human-to-human transmission. He
    also urged that the public and private sectors work closely
    together in preparing for a massive influenza outbreak.

    ¶6. Taiwan has appropriated a special budget of NTD 27
    billion (USD 844 million) for all measures to
    prevent/contain a potential epidemic: NTD 21 billion (USD
    656.5 million) for prevention programs and supplies, NTD 6
    billion (USD 187.5 million) for the research and development
    of vaccines and anti-virals.  In line with a suggestion made
    by the AIT Director at a recent meeting with Minister of
    Health Hou Sheng-mou (reftel G), the Council of Agriculture
    (COA) has also recently committed NTD 1 billion (USD 31.2
    million) to buy nets to cover Taiwan's poultry and swine
    farms in order to minimize migratory bird and domestic
    livestock interaction.

    Taiwan Unaffected Thus Far
    --------------------------
    ¶7.  To date, Taiwan has only detected six ducks with H5N1
    HPAI.  Those ducks were detected in spring 2004 in Kinmen
    island.  The ducks were immediately destroyed and later
    determined to be contraband smuggled from Mainland China.
    HPAI has yet to be found on the main island of Taiwan.
    Thus, despite being surrounded by countries struggling to
    deal with HPAI, Taiwan remains H5N1-free.  That being said
    Taiwan has had to tackle a weaker strain of the bird flu
    virus, LPAI/H5N2.  To deal with LPAI, Taiwan has thus far
    culled approximately 380,000 birds.  Nonetheless, Taiwan
    fully recognizes that the HPAI/H5N1 risk will increase this
    fall when large numbers of migratory birds arrive in Taiwan.
    In addition, officials are concerned that live birds
    smuggled from HPAI-infected countries remain a potential
    channel for introducing the disease into Taiwan.
    Human Surveillance System
    -------------------------
    ¶8.  Taiwan's Center for Disease Control (TCDC) has drafted a
    five-year "Influenza Preparation and Response Plan" (Flu
    plan).  Taiwan has also established a reporting and alert
    system to facilitate and accelerate domestic reporting and
    laboratory surveillance.  450 contract "sentinels for novel
    influenza sampling" have been set up, which cover 90% of
    townships in Taiwan.  A new alerting network has also been
    established.  Once a novel flu case is confirmed, TCDC's
    draft Flu Plan also details who, when and how to report on a
    probable  flu patient.  It specifies how and when each level
    of government should respond to a reported case.
    Furthermore, it establishes a new alerting network, which
    will enable the TCDC to directly communicate instructions
    with local health officials using mobile phones as soon as a
    case is reported.  It also provides protocols for
    cooperation across ministries.  Moreover, the plan requires
    455 elementary schools distributed throughout Taiwan to
    report on all unusual cases of school absences on a weekly
    basis.

    Notifiable Disease
    ------------------
    ¶9. In the face of grave warnings by the World Health
    Organization about HPAI, TCDC listed HPAI -  flu - as a
    "statutory communicable disease" effective December 29,
    ¶2004.  Notifiable communicable diseases must be reported to
    the TCDC and the central government is authorized to take
    extraordinary efforts to contain such diseases.

    TCDC's 5-level Influenza Response System
    ----------------------------------------
    ¶10. On average, during the winter months, Taiwan suffers
    from an estimated three million cases of influenza per year.
     Thus, TCDC's flu plan includes a comprehensive system to
    distinguish among SARS, influenza A/B and  influenza, giving
    guidelines to the medical workers to minimize confusion
    between the various types of viruses during the influenza
    season.  Similar to SARS prevention and control measures,
    TCDC has implemented a 5-level Influenza Response System.

    a) Level 0/Alert: no human-to-human transmission globally
    and no domestic avian-to-human transmission

    b) Level A1: confirmed cases of human-to-human transmission
    outside of Taiwan.

    c) Level A2: confirmed cases of domestic bird-to-human
    transmission; a laboratory suspected case in Taiwan; or an
    imported suspected case, but no signs of local human-to-
    human transmission.

    d) Level B: one or more confirmed cases of initial human-to-
    human transmission reported domestically.

    e) Level C: Secondary human-to-human transmission reported
    domestically.

    ¶11. At the 0 level, COA has the lead for HPAI directives.
    At the A1 and A2 levels, DOH will take the lead.  At the B
    and C levels, the Executive Yuan will take the lead.  As
    there are no confirmed cases of human-to-human transmission
    abroad, Taiwan is currently at the 0 level.

    Border Surveillance
    -------------------
    ¶12. Based on the above response levels, Taiwan has a
    surveillance program for avian influenza and SARS at its
    borders.  At the 0/Alert Response level, TCDC urges all
    travelers to countries with avian influenza outbreaks to
    avoid touching raw poultry in those places.  All incoming
    are subjected to temperature checks.  Passengers with fevers
    are further assessed prior to immigration.  At the 0/Alert
    and A1 levels, Nasopharyngeal washing or Throat Swabs are
    taken from any inbound passengers with fevers in excess of
    38 degrees.  In addition, at the A1 level and above, in
    addition to the above measures, passengers from the affected
    areas are required to self-monitor for fevers twice a day
    for 10 days.  At level B and/or above, medical doctors will
    be posted at the borders to assist in these processes.  Also
    at level B, any outbound passenger with a fever over 38
    degrees must obtain a doctor's note confirming the person
    has been influenza-free for at least 24 hours, before they
    can depart.  Finally, at level B and above, any passengers
    suspected of having avian influenza will be sent by
    ambulance to the designed hospitals for further assessment,
    where a series of lab tests will be conducted.

    Hospital Infection Control Measures
    ------------------------------------
    ¶13. TCDC's Flu plan's hospital infection control measures
    include: detecting and surveying fever patients promptly;
    implementing a standard operating procedure for infection
    control in all hospitals; recruiting qualified
    epidemiologists to help prevent inter-hospital transmissions
    by modeling outbreaks, evaluating nursing procedures to
    facilitate reorganizations that might be necessary;
    instituting fever surveillance and alert programs;
    establishing a mechanism to assess the efficacy and
    efficiency of hospital infection control programs; providing
    comprehensive and intensive infection control training for
    hospital staff, preventing any unsafe or unnecessary
    transportation of patients with a communicable disease; and
    implementing protocols for waste handling and personal
    hygiene.  In addition to having 546 negative pressure beds
    available for use, the government has recently adopted a
    plan to allow for a quick conversion of several sports
    stadiums throughout Taiwan into large-scale isolation
    facilities as necessary.  It also has contingency plans for
    closing all large public spaces in the event of an outbreak.

    ¶14. In addition to the measures above, TCDC requires all
    hospitals and clinics to ask flu patients if they have had
    any contact with poultry or farm owners.  Any patients who
    have had such contact are given the antiviral medication of
    oseltamivir (trademarked as Tamiflu) for five days.  Subject
    patients are required to have follow-up checkups.

    ¶15. Finally, enhanced nosocomial (intra-hospital) infection
    control measures have been in place since SARS.  TCDC now
    has a network for epidemic control, which includes two
    national hospitals, six regional hospitals and 18 county
    hospitals throughout Taiwan.  Hospitals in the network will
    be activated in accordance with the needs of a flu
    pandemic.

    Flu vaccine
    -----------
    ¶16. Healthcare professionals administered over 2 million
    doses (almost 9 percent of Taiwan's population) of seasonal
    influenza vaccine during the 2004-2005 season.  Senior
    citizens over 65, children between 6 months and 3 years old,
    those with serious diseases, healthcare workers, workers in
    avian industries and health case workers were provided
    vaccines free of charge.  Taiwan's flu season does not
    typically begin until December so vaccines for the upcoming
    season have not yet been administered, but a similar
    vaccination plan is in place for the 2005-2006 season.  For
    the long-term, Taiwan has set aside USD 187.5 million for
    the research, development and production of a flu vaccine.
    Academia Sinica, the National Health Research Institute and
    Industrial Technology Research Institute are already working
    in close collaboration to develop and produce vaccines on an
    expedited basis.  They hope to be able to produce vaccines
    in five to seven years.

    Antivirals
    ----------
    ¶17. Taiwan was the first government in the world to purchase
    oseltamivir (Tamiflu) stockpiles.  According to the
    Department of Health (DOH), Taiwan currently has a stockpile
    of about 160,000 packs of 10 tablets of oseltamivir (each
    pack of 10 tablets is enough for one full course of
    treatment), enough for treating 0.7 percent of Taiwan's
    population.  DOH is hoping to increase the stockpile to
    cover 4 percent of Taiwan's population by the summer of
    2006, with the ultimate goal of growing the stockpile to be
    able to treat 10 percent of Taiwan's population.  Taiwan
    also has just recently adopted plans to research, develop
    and produce its own anti-virals on an expedited basis.
    Furthermore, Taiwan gives oseltamivir to patients with:

    - influenza-like illnesses over 65 years of age;

    - over 12 years of age with a pulmonary or cardiovascular
    disease;

    - poultry farmers;

    - soldiers;

    - and cases and contacts of influenza-like illness clusters
    in health care institutions are provided with Oseltamivir
    for prophylaxis.

    Laboratory Facilities
    ---------------------
    ¶18. CDC has contracted with nine P3-level laboratories
    located in major medical centers around Taiwan to conduct
    all human AI flu tests.  The hospitals include:  National
    Taiwan University Hospital, Veterans General Hospital and
    Kaohsiung Medical University Hospital.  Offshore islands in
    Kinmen and Matsu are to report to labs in the northern part
    of Taiwan and the island of Penghu will report to a lab in
    Kaohsiung.  In addition to the nine contracted laboratories
    throughout the island, TCDC has a plan to set up more
    laboratories if needed, in order to conduct more tests in a
    shorter time.  COA works with a single accredited laboratory
    in Tamshui.

    Sampling Criterion of Novel Influenza
    -------------------------------------
    ¶19. Patients with pneumonia, epidemiological exposure and
    patients with criteria clinical influenza symptoms who
    deteriorate rapidly without explanation will be sampled.
    Criteria clinical symptoms refers to any case that is shown
    by throat swab or serum test to show type A flu but not
    subtype H1 or H3, or any case that has both X-ray-confirmed
    pneumonia and conjunctivitis.  Such cases will be
    immediately provided oseltamivir (Tamiflu) while further
    tests for subtype H5 and H7 are conducted.  Epidemiological
    exposure is defined as patients with flu symptoms who have
    had exposure within 10 days of illness onset to one of the
    following three potential exposure routes:

    - domestic birds/livestock (or fecal matter) or a novel
    influenza suspected case;

    - places abroad where human-to-human transmission has
    occurred or animals have tested positive within the past
    three months;

    - a HPAI testing/research laboratory.

    Recruitment of New Physicians
    -----------------------------
    ¶20. Following SARS, Taiwan revised TCDC's organizational
    structure so that it could attract and employ 27 new
    physicians, increasing the number of physician at TCDC from
    3 to 30.  These new regulations have allowed doctors to get
    higher salaries and to be exempt from taking the civil
    service examination.  In addition, doctors who choose to
    work for TCDC are provided with an additional financial
    incentives/rewards to entice them to leave careers in
    hospitals or clinics.  These changes were made directly as a
    result of recommendations made to President Chen Shui-bian
    by USCDC representatives during SARS.

    Availability of Respirators and Protective Wear
    --------------------------------------------- --
    ¶21. TCDC is responsible for supplying N-95 respirators or
    equivalent, surgical gloves, goggles and garments for health
    care workers.  Currently TCDC has 25 million masks (for a
    total population of 23 million), 4 million protective
    garments and a large supply of gloves for healthcare
    workers.  COA is responsible for the purchase of protection
    supplies for poultry industry workers and also has adequate
    supplies on hand.  TCDC is also committed to work with COA
    to ensure that it obtains whatever supplies are needed.

    International Collaboration
    ---------------------------
    ¶22. Taiwan places high priority on international
    collaboration to address the threat of an HPAI pandemic.  In
    particular Taiwan is hoping to work closely with the United
    States, Japan, Hong Kong, Singapore, the United Kingdom,
    Australia for enhanced cooperation.  Taiwan has recently
    donated 600,000 courses of treatment of oseltamivir to
    Vietnam, in part to help out a neighbor, in part to
    demonstrate its willingness and ability to address cross-
    border issues.  Taiwan also has plans in place to educate
    and provide support for Taiwan businessman in China and
    Vietnam regarding HPAI prevention.

    ¶23. Regarding Taiwan's relationship and communication with
    AIT, Taiwan is extremely open and committed to building on
    the very positive working relationship with the US Centers
    for Disease Control (USCDC) and AIT established during SARS.
    Taiwan learned its lessons from SARS.  Following initial
    attempts to cover up SARS cases in early 2003 when the
    disease first struck Taiwan, after AIT and USCDC
    interventions, Taiwan completely changed its ways.
    Following the abatement of SARS in summer 2003, eager to
    build upon the positive relationship with the USCDC, Taiwan
    has consistently contacted the USCDC and AIT immediately
    upon learning of infectious disease outbreaks (i.e., Taiwan
    immediately informed AIT of a SARS infection at a laboratory
    in late 2003, a Tuberculosis outbreak in a hospital in late
    2003 and of recent outbreaks of meliodosis and entervirus
    infections in Taiwan).  AIT is confident of Taiwan's
    commitment to openness and collaboration.  AIT's key
    contacts on this issue include:  Minister of Health Hou
    Sheng-mou, Council of Agriculture Minister Lee Ching-lung,
    Taiwan Center for Disease Control Director General Steve
    Kuo, Director of Animal Health Research Institute Sung Hwa-
    tsung and Executive Yuan Secretary General Lee Ying-yuan.

    SIPDIS

    Animal Demographics Overview
    -----------------------------
    ¶24. Taiwan has a modern poultry and livestock industry. Both
    poultry and swine are produced on medium-to-large scale
    farms with regular service by professional veterinarians.
    Farms are devoted to a single species and are widely
    separated.  The major poultry species are modern broilers
    and layers, traditional colored chickens, and ducks as well
    as a small population of geese and turkeys. There are
    132,000 poultry farms with a total bird population of 415
    million. There are 13,000 swine farms with a total pig
    population of about 7 million.  Statistics are not available
    on the proportion of the population engaged in poultry/swine
    production, but if we multiply 145,000, the total number of
    poultry and swine farms, by an estimated average work force
    of 5 persons, the total work force is 725,000 or about 3
    percent of the population. There are 3 major poultry
    wholesale markets that the Bureau of Animal and Plant Health
    Inspection and Quarantine (BAPHIQ) and DOH have placed under
    close surveillance.  In addition, live poultry is sold and
    slaughtered in  traditional markets scattered throughout
    Taiwan's cities and towns.  Vendors have been educated by
    local authorities to be aware of signs of AI and practice
    good sanitation in their slaughter.  However, the
    traditional markets would be a cause for concern if Taiwan
    were to have an outbreak of HPAI.

    Surveillance for Animal Influenza
    ---------------------------------
    ¶25. Taiwan has an active surveillance program on commercial
    poultry, wild fowl, and migratory birds.  Of the
    approximately 230,000 migratory birds that pass through
    Taiwan annually, currently 2,000-3,000 fecal samples are
    tested for HPAI and LPAI each year.  Furthermore, COA is
    compiling a contact database of every chicken, duck and bird
    farm and every poultry market.  If there is an HPAI
    outbreak, this database will help in implementing
    preventative measures.

    Movement of Avian Livestock
    ---------------------------
    ¶26. To minimize the risk of interaction between migratory
    birds and domestic livestock, Taiwan has established a Task
    Force on Preventing Animal Infectious co-chaired by Minister
    Without Portfolio Hu Sheng-cheng (concurrent Chairman of the
    Council Economic Planning and Development), COA Chairman Lee
    Ching-lung and DOH Minister Hou Sheng-mou.  In line with a
    suggestion made by the AIT Director at a recent meeting with
    Minister of Health Hou Sheng-mou (reftel G), the taskforce
    recently agreed that COA would commit NTD $1 billion (USD
    31.2 million) to subsidize 6,700 poultry farms and 12,900
    swine farms to build nets over their farms in an effort to
    minimize interactions between wild birds and domestic
    livestock.

    ¶27. In addition, farms on which AI is suspected or detected
    are isolated and, if detection is confirmed, the farms are
    depopulated.  Furthermore, poultry within a 3-kilometer
    radius of a farm on which AI is detected are subject to
    movement control and intensive surveillance for 6 months.
    Illegal smuggling of livestock is also a concern.  In an
    effort to reduce this potential vector, Taiwan recently
    raised the level of criminal punishment for smuggling
    livestock and poultry so that it is equivalent to the
    penalties for smuggling arms or people.

    Poultry Laboratory Testing
    ---------------------------
    ¶28. Animal samples are tested for influenza at four Regional
    Poultry Health Centers and then confirmed by the National
    Institute of Animal Health in Tamshui, Taipei County.
    Taiwan uses PCR testing, DNA sequencing and pathogenicity
    index testing to establish the type and pathogenicity of the
    influenza.  Laboratory capacity is sufficient and the
    results are communicated to COA.

    Culling Practices
    -----------------

    ¶29. Culling takes place when tests establish that avian
    influenza is present on a farm.  Whether it is Low
    Pathogenic (LPAI) or High Pathogenic (HPAI), the farm is
    depopulated.  To date, Taiwan has only detected LPAI and
    that was in early 2004 (except in spring 2004 when six ducks
    with H5N1 HPAI were detected in Kinmen island.  These ducks
    were later determined to be contraband smuggled from
    Mainland China).  Birds are euthanized via their feed or
    water and then incinerated.  Farms are disinfected.  Cullers
    wear masks, boots, gloves and protective clothing and are
    trained and supervised by the Livestock Disease Control
    Center.  In the past, cullers were not given prophylaxis
    anti-virals, however, the plan is to provide oseltamivir to
    cullers in the future.  To date, 380,000 birds have been
    culled.  Culling protocols are available in Chinese.  Based
    on the 1997 Foot and Mouth Disease outbreak, Taiwan has a
    great deal of experience in dealing with serious animal
    disease outbreaks.  Taiwan also has a relatively modern
    veterinary and quarantine infrastructure.
    Animal Vaccination
    ------------------
    ¶30. At this time, vaccination for AI is not permitted,
    although BAPHIQ suspects that individual farmers have been
    illegally using vaccines based on the Mexican AI strain.
    However, COA is currently revisiting this issue at this time
    to consider the adoption of an animal influenza vaccine
    plan.

    Interagency Collaboration
    --------------------------
    ¶31. Laboratory surveillance results are being communicated
    to relevant agencies and ministries.  In addition, TCDC, the
    Department of Health, the Bureau of National Health
    Insurance, COA and other relevant government agencies have
    been working together since the emergence of LPAI in early
    ¶2004. For instance, Taiwan's Coast Guard is tasked with
    reporting to TCDC any fishermen coming from the affected
    area detected with a fever.  Similarly, the COA reports to
    TCDC any smuggled bird from the HPAI affected areas.  The
    Straits Exchange Foundation (SEF) is in touch with the PRC
    regarding border control measures.  SEF also disseminates
    the domestic border control information and HPAI
    information/guidance to Taiwan businessmen in China.
    Finally, a joint COA-DOH health drill is planned for October
    to test emergency avian influenza outbreak measures.

    Risk Communication
    ------------------

    ¶32. Following SARS, TCDC designed and built a new emergency
    response center at its headquarters (modeled after the USCDC
    center) to implement its emergency response plans in the
    event of an influenza, SARS or other infectious disease
    outbreak.  In addition, the Government Information Office
    (GIO) is working closely with all relevant government
    agencies and is responsible for all official public
    announcements regarding the disease.  While the risk
    communication mechanisms are in place, the message could be
    strengthened further.  Many government agencies and most
    private sector companies and individual citizens do not have
    contingency plans in place.  Taiwan needs to do a better job
    communicating the importance of contingency planning.

    Comment
    -------
    ¶33. Thus far, Taiwan has been able to avoid an outbreak of
    Highly Pathogenic H5N1.  Taiwan appears to be very proactive
    in its efforts to prevent, detect and respond to an avian
    influenza outbreak.  Given Taiwan's proximity to countries
    experiencing the disease, it may only be a matter of time
    before Taiwan's precautionary measures are put to the test.
    TCDC's infection control and fever surveillance efforts are
    particularly strong due to its significant preparations for
    another potential SARS outbreak and the H5N2 Low Pathogenic
    outbreak in Taiwan in early 2004.  COA and the livestock
    industry also learned from their experience with the major
    1997 Foot and Mouth Disease outbreak that resulted in
    significant investment in disease prevention, surveillance
    and control infrastructure, including the establishment of
    BAPHIQ in August 1998.  Taiwan also benefits from the fact
    that it is an island, which affords a certain degree of
    protection.  Taiwan, however, could do more to ensure that
    all government agencies have contingency plans in place and
    to urge the private sector and individuals to prepare.

    KEEGAN

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