Viewing cable 06JAKARTA7661
Title: NORTH SUMATRA AVIAN INFLUENZA CLUSTER - LESSONS

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06JAKARTA76612006-06-16 09:50:00 2011-08-30 01:44:00 UNCLASSIFIED//FOR OFFICIAL USE ONLY Embassy Jakarta
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PP RUEHCHI RUEHDT RUEHHM
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P 160950Z JUN 06
FM AMEMBASSY JAKARTA
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UNCLAS SECTION 01 OF 04 JAKARTA 007661 
 
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TAGS: TBIO AMED CASC EAGR AMGT PGOV ID KFLU
SUBJECT: NORTH SUMATRA AVIAN INFLUENZA CLUSTER - LESSONS 
LEARNED 
 
 
¶1. (SBU) Summary. The May 2006 avian influenza (AI) outbreak 
in a North Sumatra family represents the largest human H5N1 
cluster to date and brought with it intense worldwide media 
attention to Indonesia's AI response capacity.  A look back 
at the response to the cluster by the Government of 
Indonesia (GOI), the World Health Organization (WHO), and 
U.S. Government agencies reveals both positive and negative 
elements. On the positive side, the Ministry of Health 
(MOH), Ministry of Agriculture (MOA), and WHO quickly 
scrambled teams to North Sumatra upon learning of the 
outbreak and the testing process for samples collected from 
suspected AI cases went smoothly.  Both the WHO and GOI 
collaborated well with representatives of the Naval Medical 
Research Unit (NAMRU-2) and Centers for Disease Control and 
Prevention (CDC) in Indonesia under challenging 
circumstances.  Less positively, the WHO/MOH response teams 
were poorly organized and senior GOI Ministers struggled 
with public relations.  With the Ministry of Agriculture's 
(MOA) efforts to control AI in backyard poultry still in 
their infancy, we expect human AI cases to continue in 
Indonesia along with occasional family clusters.  End 
Summary. 
 
¶2. (SBU) On June 9, we gathered representatives from USAID, 
NAMRU-2, the Economic Section, and the CDC to review the 
combined GOI-WHO-USG response to the May 2006 North Sumatra 
AI cluster.  As of June 13, 8 blood-related members of a 
family in Simbelang village and Kabanjahe town, Karo 
District, North Sumatra Province have been identified as 
H5N1 cases, with 7 fatalities. Laboratories at the CDC 
and/or Hong Kong University have confirmed seven H5N1 cases. 
 
Challenging Outbreak Investigation 
---------------------------------- 
 
¶3. (SBU) In general, the circumstances of the cluster 
investigation proved highly challenging for all parties. 
The family and other residents of the towns were distrustful 
and suspicious of MOH staff from Jakarta and reluctant to 
cooperate.  In addition, the extended family and local 
community were hesitant to cooperate fully with outside 
health experts as a result of local superstitions, a general 
distrust of western infectious disease concepts, and the 
shock of the loss of seven members of their extended family. 
Such beliefs are common in Indonesia, and we expect similar 
cultural hurdles to arise in future cluster investigations. 
 
¶4. (SBU) Another complicating factor was that late reporting 
by the afflicted family delayed the initial recognition of 
the H5N1 cluster.  Clinicians at the local district hospital 
in Kabanjahe and Saint Elizabeth Hospital in Medan did not 
suspect H5N1 in the index case, likely because there had 
been few AI outbreaks reported among poultry flocks in the 
area.  As a result, doctors diagnosed the index case with 
pulmonary tuberculosis, and the subsequent six cases were 
not suspected as H5N1 cases until they were hospitalized at 
Adam Malik Hospital in Medan. 
 
Key Lessons Learned 
------------------- 
 
¶5. (SBU) In our view, the key lessons from the outbreak and 
subsequent cluster investigation include the following: 
 
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General 
------- 
 
--A noteworthy success of the outbreak investigation was the 
efficient cooperation between the MOH, NAMRU-2, the CDC, and 
the Hong Kong University Laboratory on specimen shipment, 
H5N1 testing, viral isolation and sequencing.  The 
Indonesian National Institute of Health Research and 
Development (Litbangkes) or NAMRU-2 tested samples received 
in Jakarta and reported initial results to health care 
responders in North Sumatra within 48 hours.  They shipped 
samples within 24 hours to the WHO-Influenza/H5N1 Reference 
Laboratories at the CDC and University of Hong Kong for 
confirmation and virus sequencing.  Within one week of the 
initial outbreak report, the CDC and HKU had confirmed the 
in-country results and completed full genome sequencing of 
isolated viruses.  As a result, scientists were able to 
conclude that the North Sumatra viruses did not appear to 
have acquired any characteristics that might suggest 
increased transmission among humans. 
 
--Given the successful and rapid collaboration on laboratory 
testing for suspected H5N1 clinical specimens, and the 
significant USG technical expertise and laboratory capacity 
on the ground in Indonesia, we are confident the USG will 
likely prove able to ascertain quickly whether the virus in 
future H5N1 case clusters has mutated in any significant 
way.  This should make it possible to make an informed 
judgment quickly about whether more robust USG response 
teams might be needed. 
 
GOI Response 
------------ 
 
--Several factors complicated hospital management of most of 
the H5N1 cases in the cluster.  Some family members felt 
distrust toward the government-operated hospital and 
suspicion that oseltamivir treatment had caused the deaths 
of the infected individuals.  There was in general a lack of 
cooperation with the medical management.  Family members 
refused to wear personal protective equipment (PPE) while 
having close contact with hospitalized cases, but were still 
allowed access to confirmed patients.  Hospital staff did 
not limit family member visitors and did not require family 
members to wear PPE. 
 
--More positively, the MOH quickly deployed a team to the 
area on May 10, just a day after it received reports of a 
possible family cluster.  The MOH added a NAMRU-2 clinician 
to the team, but only upon request from NAMRU-2, 
demonstrating that NAMRU-2 remains under-utilized as an in- 
country asset for outbreak response.  Despite difficulties 
with the family, MOH staff were able to obtain samples from 
patients and other family members and shared them promptly 
with NAMRU-2.  Both Litbangkes and NAMRU-2 worked together 
in the identification of all subsequent cases, including ill 
nurses that emerged weeks after the outbreak in N. Sumatra. 
 
--Although both the MOH and WHO responded promptly to the 
outbreak, both are plagued by the lack of a coordinated, 
well-staffed, and well-equipped rapid response team with 
standard operating procedures and pre-defined roles for team 
 
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members.  MOH staff held numerous meetings in Jakarta but 
there was little effective coordination in the field.   The 
WHO team worked with public health officials in Karo to 
conduct the key epidemiological investigations, but the MOH 
did not participate.  Should multiple AI clusters occur 
simultaneously, we expect the MOH would have a very 
difficult time mounting an effective response given the lack 
of standardized rapid response teams.  Building capacity in 
this area should be a priority for the WHO and CDC. 
 
--Throughout the outbreak, senior GOI officials were 
extremely reluctant to admit publicly that any form of human- 
to-human (H2H) transmission had taken place.  This is likely 
because of the perceived impact on Indonesia's economy, 
concern about causing panic, and lack of understanding about 
the distinction between limited H2H transmission and a 
pandemic form of the virus.  This reluctance continued even 
as evidence mounted that limited, but non-sustained H2H 
transmission was the most likely explanation for the 
cluster.  Not until June 11 did Coordinating Minister for 
Peoples' Welfare Aburizal Bakrie acknowledge publicly that 
limited and inefficient H2H transmission may have occurred; 
Minister of Health Siti Fadilah Supari has failed to make 
similar statements and declared that no H2H transmission 
occurred in North Sumatra.  We expect similar reluctance to 
admit H2H transmission in future clusters, although the 
UNICEF public relations campaign on AI now underway should 
help educate both GOI ministers and the public about AI and 
make a more sophisticated GOI public relations effort 
possible. 
 
-- The MOA response to reports of suspected human H5N1 
infections in North Sumatra was also swift, although 
subsequent coordination with partners and laboratory testing 
were inadequate.  The Director of Animal Health at the MOA 
traveled to North Sumatra to investigate possible animal 
H5N1 infections within 24 hours of learning of the suspected 
human cases.  He promptly collected samples of various 
poultry, swine, and possible environmental sources of H5N1 
(manure).  All samples were immediately brought to Jakarta 
for laboratory testing. 
 
--Less encouraging was the initial lack of coordination 
between the MOA and the UN Food and Agriculture Organization 
(FAO).  The MOA did not inform FAO of the suspected outbreak 
and investigation until USAID had already alerted the FAO 
about the situation.  The FAO is working with the MOA to 
improve coordination and has sent a joint MOA-FAO team to 
North Sumatra to conduct a more thorough animal 
investigation.  With support from USAID, FAO has accelerated 
implementation of the animal surveillance and response 
program in North Sumatra and will have trained teams in the 
field by the end of July.  Improved coordination and better 
laboratory practice should be priorities for USDA and FAO. 
 
WHO Response 
------------ 
 
--The WHO also responded quickly to the cluster, dispatching 
a half dozen experts from the WHO's Southeast Asia Regional 
Office (SEARO), Geneva and Jakarta to North Sumatra within 
one week of the outbreak reports.  All six worked well with 
the Karo District and North Sumatra Provincial health 
 
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authorities. 
 
--Cooperation between the WHO, NAMRU-2, and the CDC was also 
reasonably good.  Although individual WHO staffers were at 
times reluctant to share information on the outbreak with 
NAMRU-2 and/or the CDC, our relationships with the WHO 
office in Jakarta are on the upswing.  The WHO office in 
Jakarta has acknowledged the need to keep the USG better 
informed about outbreak investigations in Indonesia. 
 
U.S. Government Response 
------------------------ 
 
--The combination of NAMRU-2's relationships with 
Litbangkes, and CDC TDYer Dr. Timothy Uyeki's presence in 
Indonesia (and direct participation on the WHO team) gave 
the USG excellent access to the outbreak investigation. 
Although relations between NAMRU-2 and some Litbangkes staff 
are not warm, in this instance NAMRU-2 played a central role 
in the testing of samples and sent an Indonesian clinician 
to North Sumatra to participate in the outbreak 
investigation.  In the North Sumatra and previous clusters, 
Litbangkes has not directly invited NAMRU-2 to participate 
in epidemiological investigations, or given attribution, but 
has allowed NAMRU-2 to play a role in H5N1 testing.  We 
expect NAMRU-2's cooperation with Litbangkes to improve over 
time given the recent appointment of a new Director General 
at Litbangkes. 
 
--The presence of CDC influenza specialist Dr. Timothy Uyeki 
in Indonesia at the time of the outbreak proved to be a 
major advantage, particularly because Dr. Uyeki had already 
developed relationships with a number of WHO and Litbangkes 
staff.  In addition to providing badly needed technical 
expertise to the WHO outbreak investigation team, Dr. Uyeki 
also provided a crucial channel for information flow to the 
Embassy and USG agencies.  Given the likelihood of 
additional human AI clusters in Indonesia, we continue to 
recommend the CDC post a long-term TDY epidemiologist in 
Jakarta as soon as possible. 
 
--Given the GOI reluctance to publicly admit H2H 
transmission of AI, we believe it would be extremely 
difficult to convince them to accept a high profile USG 
rapid response team in the event of future clusters, unless 
there were very solid evidence the H5N1 virus had changed 
sufficiently to pose a pandemic threat.  We expect President 
Susilo Bambang Yudhoyono himself would need to approve a USG 
team after discussion by the Indonesian cabinet.  High-level 
diplomatic intervention by the Embassy and/or Washington 
agencies would almost surely be required.  Given these 
factors, Washington agencies may want to consider a more 
flexible response to future AI clusters in Indonesia where a 
few experts, perhaps drawn from regional USG offices, could 
quickly travel to Indonesia to augment the existing USG 
presence. 
 
AMSELEM