VZCZCXRO4436
RR RUEHCHI RUEHCN RUEHGH RUEHHM
DE RUEHEG #2686/01 2421311
ZNR UUUUU ZZH
R 301311Z AUG 07
FM AMEMBASSY CAIRO
TO RUEHC/SECSTATE WASHDC 6736
INFO RUEHAM/AMEMBASSY AMMAN 1769
RUEHJA/AMEMBASSY JAKARTA 0119
RUEHBK/AMEMBASSY BANGKOK 0191
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RUEHDS/AMEMBASSY ADDIS ABABA 0296
RUEHUJA/AMEMBASSY ABUJA 0111
RUEHHM/AMCONSUL HO CHI MINH CITY 0003
RUEHCHI/AMCONSUL CHIANG MAI 0003
RUEHHK/AMCONSUL HONG KONG 0028
RUEHGH/AMCONSUL SHANGHAI 0006
RUEHCN/AMCONSUL CHENGDU 0003
RUEHSH/AMCONSUL SHENYANG 0016
RUEHGZ/AMCONSUL GUANGZHOU 0006

UNCLAS SECTION 01 OF 04 CAIRO 002686 
 
SIPDIS 
 
SENSITIVE 
SIPDIS 
 
E.O. 12958: N/A 
TAGS: TBIO KSCA KFLU EAGR PGOV EG
SUBJECT:  EGYPT AVIAN INFLUENZA (AI) UPDATES: VACCINATION 
CHALLENGES; CASES 37 and 38; USAID REVIEWS EXPECTATIONS FOR USD 24 
MILLION IN AI SUPPORT; NAMRU-3 PARTICIPATES IN JOINT FIELD 
INVESTIGATIONS 
 
REF: A) CAIRO 2046 
 B) Maxwell/Lange e-mail July 26 
 
SENSITIVE BUT UNCLASSFIED.  HANDLE ACCORDINGLY. 
 
¶1. (SBU)  Summary.  The U.S. Naval Medical Research Unit (NAMRU-3) 
participated in two field investigations of human Avian Influenza 
(AI) outbreaks with Government of Egypt (GOE) teams in Qena and 
Damietta where the use of improper field techniques by GOE teams and 
uncooperative local citizens initially led to inconclusive findings. 
 Under USAID's 3 year, $24 million program to combat AI in Egypt, 
GOE is developing a detailed implementation plan (DIP) to strengthen 
areas of weakness. 
 
¶2. (SBU) Summary continued.  Controlling AI in Egypt depends heavily 
on effective poultry vaccination programs, but problems persist in 
GOE efforts to reduce the virus load in poultry, a critical step in 
preventing AI outbreaks.  Serious problems with cold storage of AI 
vaccines persist, and government vets are unable to provide complete 
rural coverage due to a lack of vehicles.  Challenges remain in data 
collection, analysis of backyard flock surveillance, culling 
practices and behavior change in poultry-raising households. 
Mission-wide partners including USAID, APHIS, NAMRU-3 and CDC have 
continued consultations and training with GOE and NGO partners to 
address critical problem areas.  End summary. 
 
------------------- 
Latest Case Updates 
------------------- 
¶3. (U) On June 23, the Ministry of Health and Population (MOHP) 
confirmed the 37th human Avian Influenza (AI) case in Egypt.  A 
four-year-old boy from the Qena governorate (southern region) became 
ill three days after contact with dead birds.  Doctors administered 
Tamiflu within three hours after the appearance of symptoms.  After 
receiving treatment in Cairo at El-Bakry Hospital (where pediatric 
AI cases go), the boy recovered. 
 
¶4. (SBU) On July 23, the MOHP confirmed AI human case 38, a 
25-year-old woman from Damietta also infected after contact with 
dead birds.  After developing a fever, she told doctors at her local 
hospital that she had buried the dead birds.  Doctors confirmed AI 
infection and transferred her to Abbassia Chest Hospital in Cairo, 
where adult AI patients receive treatment.  She recovered and was 
discharged on July 30.  When NAMRU-3 joined a GOE field 
investigation team to Damietta, they learned that a neighbor's birds 
had also died but the neighbor used plastic bags to cover her hands 
and arms and thereby protected herself from AI exposure. 
 
¶5. (SBU) In a visit to Abbassia Chest Hospital, General Director Dr. 
Mahmoud Abdel Magid told econoff the hospital has 125 doctors, 150 
nurses and 20 isolation rooms in its intensive care unit (ICU). 
Econoff observed the patient from AI case 38 being treated in an ICU 
isolation room.  He also observed AI fliers posted with instructions 
on how to treat patients with AI symptoms.  Abdel Magid said 
patients with AI are not charged for treatment; a special budget 
from MOHP covers treatment expenses. 
 
------------------------------------ 
Ineffective Culling And Hiding Birds 
------------------------------------ 
¶6. (SBU) Cases 35, 36, 37 were all from the Qena governorate, with 
cases 35 and 37 from the Qena district of Naqada which prompted the 
culling of all domesticated birds in the district.  Three weeks 
after the cull, GOE officials allowed NAMRU-3 specialists to visit 
Qena with a joint Ministry of Health and Population (MOHP) and 
Ministry of Agriculture and Land Reclamation (MALR) team.  They 
observed that the poultry cull line was along a road, rather than a 
preferred natural barrier (i.e. river, wall, fence).  They also saw 
adult domesticated birds inside the cull zone; proper culling and 
follow-up procedures would have meant that only birds born after the 
cull would be found within the zone.  Ag Ministry advisor Dr. 
 
CAIRO 00002686  002 OF 004 
 
 
Hussein Soliman said people hide their birds in mosques when 
authorities come around.  General Organization of Veterinary 
Services (GOVS) representative Saber Abdel Aziz said the local 
people do not trust the authorities, who might vaccinate birds one 
day but come to cull them the next.  The father of the boy in case 
37 hid his birds when a GOE surveillance team visited, thus leaving 
his family susceptible to infection from the same birds that caused 
his son's illness.  NAMRU-3 also reported that before the outbreak, 
people in Qena had not seen GOE vets in more than six months (i.e. 
no active surveillance). 
 
-------------------- 
Statistical Overview 
-------------------- 
¶7. (U) Since registering its first human AI case in March 2006, 
there have been 38 cases in Egypt, of which 15 were fatal as of July 
¶2007.  The 38 confirmed cases were out of 3,502 cases tested for AI. 
 Egypt ranks third in the world for human cases (only Indonesia and 
Vietnam have more).  Thirty-six cases are from backyard flock owners 
and two from commercial farms.  Twenty-six patients were female and 
twelve male.  From Jan-July 2007, there have been 11 positive H5N1 
sites on commercial farms and 220 in backyard areas. 
 
--------------------------------------------- ------- 
Vaccine Problems: "Trust me, there is no cold chain" 
--------------------------------------------- ------- 
¶8. (SBU) The vaccination program for backyard flocks faces 
significant challenges.  Chairman of the Supreme National Committee 
for Combating Avian Influenza, Health Minister  Hatem El-Gabaly, 
told Ambassador and visiting Congressional Staff Delegation Grove 
that he believes some vets are keeping the vaccine for their own 
flocks, and using diluted vaccine or water when going to districts 
where they are responsible to vaccinate birds on behalf of the GOE. 
In other cases, he said vets were not going to the districts at all. 
 El-Gabaly added that GOE has vaccinated only 30 percent of the 150 
million birds in backyard flocks.  El-Gabaly said Egypt imports 
vaccines now but he envisions future vaccine production in Egypt. 
He said GOE needs USD 24 million to ramp-up vaccine production to 
one billion doses for use in Egypt and distribution to other African 
countries. 
 
¶9. (SBU) Abdel Nasser Abdel-Ghafar, MOHP Executive Director of 
Epidemiology and Disease Surveillance told econoff and GOE 
representatives: "Trust me, there is no cold chain.  By the end it's 
water, not vaccine."  Eight MALR representatives were present when 
Abdel-Ghafar made this statement; none disputed the claim.  A broken 
cold chain may explain results when NAMRU-3 took samples from birds 
in Qena that local vets claimed they had vaccinated but NAMRU-3 lab 
tests showed otherwise.  Mission members are currently working with 
GOVS to increase their technical capacity, which includes 
establishing and maintaining effective cold chain procedures. 
 
¶10. (U) Even when administering properly stored vaccine, problems 
persist in cataloging vaccinated birds.  During their field visit, 
NAMRU-3 reported difficulty confirming which birds were vaccinated 
(which could only be confirmed with lab results).  Some villagers 
also told the NAMRU-3 team that they took some birds, but not all, 
to the vaccination stations.  MALR Minister Amin Ahmed Abaza told 
emboffs that problems persist in dealing with backyard flocks.  He 
expanded that in cities, raising poultry is illegal yet when vets 
find these flocks, they are reluctant to seize them.  Vets are then 
forced to decide whether to vaccinate illegally kept birds. 
 
-------------------------- 
Behavior Change Challenges 
-------------------------- 
¶11. (U) During NAMRU-3's field investigation in Qena, they noted 
chicken cages had not been cleaned since the infections, still 
contained feathers and fecal matter, and no disinfectant was 
available.  Although the GOE-sponsored AI education programs stress 
hand washing and cleaning bird areas with disinfectant, in many poor 
communities there is no running water for washing hands and no 
 
CAIRO 00002686  003 OF 004 
 
 
access to disinfectant. 
 
¶12. (U) Minister Abaza told emboffs that behavioral change works 
best when people can see some economic or personal benefit.  He said 
that with no compensation program for backyard flocks, GOE must 
focus on convincing flock owners to protect their own health and 
their families.  He added that poultry sector reform must include 
financing for small flock owners to purchase cages for their birds. 
However, birds kept in cages must be fed, which is a very real cost 
for rural farmers.  Poultry remains an important source of income 
and protein for many rural families.  According to the Supreme 
National Committee for Combating Avian Flu, poultry represents 40 
percent of Egypt's protein intake, thus making highly pathogenic 
avian influenza (HPAI) a food security issue.  According to MOHP 
data, only 30 percent of poultry production includes proper 
slaughtering and chilling. 
 
¶13. (U) Using famous entertainers as spokespeople, the GOE is 
launching a communication campaign to encourage people to notify 
authorities of dead birds and seek treatment if they feel flu-like 
symptoms.  MOHP has a USD 446,000 budget for communication programs, 
including a 24-hour hotline, and has enlisted the aid of 13,000 
female health educators who go door-to-door in rural areas to talk 
about AI prevention and treatment. 
 
--------------------------------------------- --- 
USG Funding - Detailed Implementation Plan Steps 
--------------------------------------------- --- 
¶14. (U) USAID's Dennis Carroll, Director of the Avian and Pandemic 
Influenza Response Unit, visited Cairo July 31 - August 1 to meet 
with GOE officials regarding detailed implementation plans (DIP) 
required to release USAID funds (ref A).  In the first year of the 
three-year, USD 24 million program, USD 4 million is allocated to 
animal health, USD 2.5 million for human health programs, and USD 
1.5 million for awareness campaigns. 
 
¶15. (SBU) Rob Rooij from the United Nations Food and Agriculture 
Organization (FAO) commented on his team's role to strengthen GOVS, 
which he characterized as a "disaster" in its current state.  He 
lamented that GOVS is unable to collect meaningful data.  In cases 
when data is collected, it is not inputted, analyzed or shared.  The 
lack of data will complicate initial efforts to identify high-risk 
governorates.  Amira Kamal, head of the GOVS epidemiology group, 
responded that data collection will strengthen as the process moves 
forward. 
 
------------------------------------- 
Egypt's Place in the World and in Africa 
------------------------------------- 
¶16. (SBU) Minister El-Gabaly told the Ambassador that he will 
propose a U.S.-European-African forum on AI.  He does not believe 
the problem will come from Asia but rather Africa.  He purposely 
excluded Asia from the proposal, arguing that Asia takes all the 
global attention and funds.  He said the world would pay more 
attention to Africa "when you feel the danger coming but then it 
will be a little late."  We have not yet received El-Gabaly's 
proposal. 
 
¶17. (SBU) When asked to expound on Africa's role in AI preparedness, 
El-Gabaly said GOE offered to help Nigeria and Ethiopia but claims 
they declined "out of fear they would be exposed" for their lack of 
preparedness.  He commented that the only way to deal with them is 
pressure at international forums, and advised that donors should 
demand transparency when those countries ask for aid. 
 
--------------------------------------- 
Egypt's Pandemic Plan Still In Progress 
--------------------------------------- 
¶18. (SBU) El-Gabaly told econoff that Egypt's national pandemic 
plan, in development over the past eight months, is still not ready. 
 He said that the military has been "deeply engaged" with "a high 
level of commitment."  He added that military responsibilities will 
 
CAIRO 00002686  004 OF 004 
 
 
include guarding Tamiflu (GOE has 2.5 million doses), protecting 
doctors, culling birds, securing outbreak areas and controlling the 
movement of people. 
 
¶19. (U) Ideally, El-Gabaly said, Egypt needs USD 300 million in AI 
assistance but could manage with USD 100 million.  He said the focus 
should be training vets, acquiring vaccines, stockpiling Tamiflu and 
obtaining ventilators.  The Health Ministry is also collecting data 
on the Egyptian health infrastructure, including the number of 
doctors and nurses, beds and supplies. 
 
------------------------------------------ 
Crisis Management and Mission Preparedness 
------------------------------------------ 
¶20. (SBU) Minister El-Gabaly told the Ambassador that he believes an 
AI pandemic will hit Egypt between 2008 and 2011.  He claimed his 
ministry is well ahead of the Ministry of Agriculture in its 
preparations for such an emergency, although there is still much to 
do.  In the case of the Ministry of Agriculture, USG agencies have 
been concerned about the lack of an organized central effort to deal 
with AI, including a delay in naming the appropriate counterparts 
for USAID and international donors.  In a recent meeting with 
emboffs, Minister of Agriculture Abaza promised to permanently 
assign a group of officials to work with USAID and other donors on 
AI issues.  He also acknowledged the need for transparency, 
efficiency and accountability in the use of the USAID assistance. 
 
¶21. (SBU) At the same time that we are working with the GOE to 
improve its readiness, Post Avian Influenza Working Group is 
reviewing Mission preparedness including essential personnel lists, 
Tamiflu guidelines, tripwires, communication plans and a possible AI 
crisis management exercise (ref B).