VZCZCXRO1402
RR RUEHBZ RUEHDU RUEHGI RUEHJO RUEHMA RUEHMR RUEHPA RUEHRN RUEHTRO
DE RUEHYD #0877/01 2560903
ZNR UUUUU ZZH
R 120903Z SEP 08
FM AMEMBASSY YAOUNDE
TO RUEHC/SECSTATE WASHDC 9249
INFO RUEHZO/AFRICAN UNION COLLECTIVE 0201
RUEHPH/CDC ATLANTA GA
RUEAIIA/CIA WASHDC
RHMFISS/HQ USAFRICOM STUTTGART GE
RUEKJCS/DIA WASHDC

UNCLAS SECTION 01 OF 04 YAOUNDE 000877 
 
SENSITIVE 
SIPDIS 
 
E.O. 12958: N/A 
TAGS: CM KHIV PGOV PREL SOCI TBIO KFLU
SUBJECT: CAMEROON ILL-PREPARED FOR AN INFECTIOUS DISEASE 
OUTBREAK 
 
¶1. (SBU)  Summary:  Public health threats in Cameroon include 
the possibility of meningitis, cholera, or polio outbreaks, 
and cases of these diseases are recorded every year.  While 
not currently present in Cameroon, ebola and Avian Influenza 
(AI) are also considered threats.  The Government of 
Cameroon's (GRC) Ministry of Public Health is responsible for 
infectious disease research, surveillance, and planning. 
USAID, the Centers for Disease Control and Prevention, the 
Peace Corps and the U.S. Department of Defense are working in 
Cameroon to strengthen the GRC's capacity to respond to 
infectious disease threats.  The GRC has made some progress 
in preparing for possible cases of AI.  However, because of 
poor management and coordination, the lack of reliable 
disease information, and ineffective surveillance, the GRC is 
ill-prepared for any major disease outbreak.  End summary. 
 
Public Health Threats 
--------------------- 
 
¶2. (U)  Significant infectious disease threats in Cameroon 
include cerebrospinal meningitis, cholera, and poliomyelitis 
(polio). Relatively few cases of each disease are confirmed 
each year but each incidence has the potential to spread into 
a major outbreak.  The ebola virus has been confirmed along 
Cameroon's Gabon and Republic of Congo borders, and although 
it has not yet been recorded in more central parts of the 
country, disease spread is an imminent threat.  Cameroon's 
last confirmed cases of H5N1 AI were reported in 2006, but 
recent cases in Nigeria are a reminder of the continuing 
regional threat. 
 
¶3. (U)  The Ministry of Public Health (MINSANTE)'s 
Epidemiology Service reports approximately twenty meningitis 
cases in Cameroon each year.  The majority of these cases 
occur in the North and Far North provinces (which lie in the 
meningitis belt).  However, in the past six years the disease 
has progressively moved south into the West, Southwest, and 
Northwest provinces.  The death rate among meningitis 
patients in Cameroon is reportedly very low, and high-risk 
populations have been educated in meningitis detection.  The 
Epidemiology Service has reported approximately 50-100 cases 
of cholera per year occurring in Douala and the surrounding 
Littoral Province since 1998, always during the region's 
rainy season from September through October. Twenty to thirty 
cases have been reported per year in the Far North Province 
during that region's rainy season from May through July.  In 
2005, Cameroon's most severe outbreak of cholera occurred in 
Douala, with approximately 1,000 cases reported between March 
and October.  Although Cameroon came close to the eradication 
of polio in 2005, there have since been a number of isolated 
cases entering into the country from Nigeria.  Most cases of 
polio in the past three years have been recorded in close 
proximity to the Nigerian border, and MINSANTE has restarted 
a vaccination and education program along the border. 
 
¶4. (U)  Cameroon has never had a confirmed case of ebola, but 
cases have been confirmed near the Cameroonian border in the 
forests of both Congo and Gabon.  MINSANTE and the Johns 
Hopkins Cameroon Program, an emerging disease research 
facility under the auspices of Johns Hopkins University and 
UCLA, agree that the reason why ebola has yet to enter 
Cameroon is a mystery; the forest spans the borders, and 
similar village behavior (i.e. eating dead animals found in 
the forest) is present in all three countries. The nature of 
ebola is such that a case is easily distinguished from other 
diseases, and area health services are confident any past 
ebola cases in Cameroon would have been recognized as such. 
 
¶5. (U)  Cameroon has had two officially recorded AI 
outbreaks, both occurring in March 2006, in the Far North 
Province near the Chadian and Nigerian borders.  Experts here 
believe the H5N1 virus arrived in Cameroon via Nigeria. 
There have been no reported cases of human AI in Cameroon. 
In July, two outbreaks of AI were reported in the northern 
Nigerian states of Katsina and Kano.  On August 11, the FAO 
announced the detection of a new strain of Highly Pathogenic 
AI in Nigeria.  The newly discovered virus strain is the 
first of its kinds detected in Africa, raising concerns that 
infected poultry are being transferred through international 
trade or through the illegal movement of poultry.  Although 
Nigeria's confirmed cases are approximately 375 - 450 miles 
away from the Cameroon border, any AI outbreak in the region 
poses a threat to Cameroon because of the open channels for 
virus introduction created by informal and unreported 
cross-border trade. 
 
Public Health Management 
 
YAOUNDE 00000877  002 OF 004 
 
 
------------------------ 
 
¶6. MINSANTE is the Government of Cameroon's (GRC) primary 
authority on infectious diseases, but the Ministry of 
Livestock, Fisheries, and Animal Industries (MINEPIA), the 
Ministry of Defense, and the Ministry of Scientific Research 
and Innovation (MINRESI) also have committees or programs 
focused on the issue.  In MINSANTE, infectious disease 
players include the Epidemiology Service (for research on 
epidemic-prone diseases), the National Epidemiology Board 
(for the surveillance of epidemic-prone diseases that fall 
under the WHO's International Health Regulations of 2005), 
the Directorate for Disease Control (for authority on all 
diseases not touched upon by the WHO regulations), and the 
Division of Operational Research (for general disease 
research). HIV/AIDS and tuberculosis have 
individually-focused programs within MINSANTE. 
 
Is Cameroon Ready? 
------------------ 
 
¶7. (SBU)  The National Epidemiology Board, a consultative 
board serving under the Minister of Public Health, is 
responsible for the surveillance of meningitis, cholera, and 
polio.  The current surveillance program is unreliable and 
inefficient.  The country is divided into ten Provincial 
Delegations, which are each divided into Health Districts 
according to population, with 80,000-100,000 inhabitants per 
district. Each of these is further divided into eight to ten 
Health Areas composed of 10,000 inhabitants.  In principal, 
all epidemic-prone disease data is sent weekly from the 
Health Area administrators to the Health Districts, where all 
reports for the district are synthesized and sent to the 
Provincial Delegations.  The data is again collated for 
transmission to the Director for Disease Control at MINSANTE. 
 A senior official of the National Epidemiology Board 
divulged that in actuality, infectious disease data comes 
into MINSANTE once every three months on average.  He stated 
that "for those who care about public health," the 
surveillance system is a "sorry" effort. 
 
¶8.  (U)  The National Epidemiology Board has a Rapid 
Intervention Team prepared to be first responders when an 
infectious disease case is reported.  However, the director 
of the National Epidemiology Board told us that because of 
the lack of surveillance, this team often arrives in villages 
to find an epidemic already on the downturn.  In 2005, the 
team was sent to a meningitis outbreak in the Far North 
province to find that the epidemic had been ravaging one 
district for three weeks.  Because provincial MINSANTE 
workers had analyzed case data at a provincial level, the 
number of cases had not been deemed extraordinary, and the 
epidemic went unreported. 
 
¶9.  (U)  Hospitals in Cameroon lack the preparation, 
training, and resources needed to handle an outbreak.  In 
order to understand the sector challenges, Emboff visited a 
major parastatal hospital, Caisse National de la Prevoyance 
Sociale (CNPS), one of four large hospitals in Yaounde. 
CNPS' Director of Medicine reports that all doctors receive 
training to recognize infectious diseases, but nurses do not 
"because it is the doctor who makes the diagnosis." In all 
cases that are not immediately life threatening, a patient 
must first pay a consultation fee in order to be seen by a 
nurse.  In Yaounde hospitals, this consultation fee ranges 
from approximately $1.40 to $11.40.  Rural hospitals 
generally do not have the equipment or the expertise needed 
to take lab samples for aid in diagnosis, so patients are 
treated empirically based on symptoms.  This also occurs in 
the larger urban hospitals if a patient is unable to pay the 
cost of testing.  Even when samples are sent to a lab, 
results are sometimes disregarded as unreliable, particularly 
for tests that require specific temperature or time-frame 
conditions.  Post's Health Practitioner reported that in the 
majority of hospitals a fever is always treated as malaria 
and diarrhea is always treated as typhoid fever.  Hospitals 
are especially unprepared to react to an airborne outbreak 
because of the unavailability of quality isolation rooms. 
Most hospital beds are separated only by curtains, and no 
hospital rooms have individual ventilation systems.  At CNPS, 
doors to occupied "isolation" rooms were found wide open into 
the hospital's main corridor.  All hospitals are overseen by 
MINSANTE's Hospital Commission and they reportedly forward 
all patient data to this commission every month. 
 
Avian Influenza 
--------------- 
 
YAOUNDE 00000877  003 OF 004 
 
 
 
¶10. (U)  Although Cameroon has a national plan for AI, it was 
not implemented during the 2006 outbreaks.  Most funding for 
AI is channeled through the Common Fund for the Control of 
Avian Influenza in Cameroon, a joint initiative between the 
GRC, UNDP, European Union, and USAID. The GRC's AI 
Coordinator, Dr. Inrombe Jermias, acts as national director 
of the Common Fund.  The GRC's Interministerial Committee 
(French acronym, CIM) on AI, which has been in place since 
before the outbreaks, still exists on paper, but is otherwise 
defunct. 
 
¶11. (U)  The line between the Common Fund Project and 
GRC-funded AI projects is blurry. The Common Fund keeps 
approximately $70,000 in reserves to be mobilized for poultry 
compensation if an outbreak occurs.  Currently the Common 
Fund oversees the Epidemiological Surveillance Network 
(French acronym, RES), but this program is due for handover 
to the Ministry of Livestock, Fisheries, and Animal 
Industries (MINEPIA) in January.  Under RES, 48 MINEPIA 
employees, and 15 MINSANTE employees were equipped with 
mobile phones, personal GPS devices, and personal protective 
equipment (PPE), and dispatched throughout the country, with 
at least two employees in each of the ten provinces, to take 
samples in rural areas and report back to MINEPIA.  AI 
training in sample collection and lab protocol has been 
completed by 200 MINEPIA and MINSANTE employees in the 
Southern cities of Limbe and Bamenda, and similar training is 
planned for the North and Far North provinces. 
 
¶12. (U) The CIM stepped up its efforts to control poultry and 
poultry product trade across the Nigeria-Cameroon border 
after the 2006 outbreaks by adding six border posts and 
training all border post employees in AI protocol. However, 
there appears to be confusion as to which government body 
should take responsibility for the border posts, and 
employees report going unpaid since April. In late July, 
following the AI outbreaks in Nigeria, MINEPIA published a 
report noting that border supervision in the North and Far 
North provinces needs to be improved, but did not address how 
this can be achieved.  Dr. Inrombe told Emboff that the 
majority of border posts lack the resources they need (such 
as road barriers to block cars, plaques with information on 
AI, 24-hour personnel, and means to destroy any poultry or 
poultry products).  The Common Fund is planning a training 
trip along the Nigeria-Cameroon border in the North and Far 
North provinces to sensitize the population in the villages 
nearest the border to the risks associated with AI. 
 
¶13. (U)  A public awareness campaign of flyers, posters, 
radio, and information packets handed out to poultry farms 
has been effective. MINSANTE has worked to train health 
facility workers on how to recognize AI symptoms, and how and 
where to send questionable cases or information in an 
emergency.  Each of the ten provinces currently stocks at 
least eight doses of Tamiflu vaccine for AI treatment 
(donated by WHO).  Because of the lack of isolation rooms in 
all provincial hospitals, in March the Common Fund steering 
committee began a proposal for the acquisition of a mobile 
hospital with the capacity for total quarantine, and Dr. 
Inrombe reports they are currently working to procure $70,000 
needed in funding for this effort. 
 
¶14. (U)  The CIM had planned a multi-group simulation 
exercise for May 2008 to include MINEPIA, MINSANTE, the 
Ministry of Communication (MINCOM), the Ministry of Defense, 
and the Common Fund, but did not acquire the needed funding 
to actually run the drill. The Common Fund has since taken 
over planning, and reports the simulation exercise will 
happen in November 2008. The scenario will reportedly include 
one or more cases of human AI at Bafoussam Hospital 
(Bafoussam is one of three poultry-raising centers in 
Cameroon, along with Yaounde and Douala). 
 
The U.S. Role 
------------- 
 
¶15. (U)  USAID supports Cameroon in the prevention of 
mother-to-child transmission of HIV/AIDS and in other HIV and 
malaria prevention efforts.  USAID provides technical 
assistance to the Country Coordinating Mechanism for the 
Global Fund for AIDS, Tuberculosis and Malaria.  USAID 
supports Cameroon's AI control efforts through $20,000 
donated to the to the National Veterinary Laboratory (French 
acronym, LANAVET), in the northern city of Garoua, to expand 
and improve the national capacity to collect and analyze 
samples taken from suspected cases of Highly Pathogenic AI. 
 
YAOUNDE 00000877  004 OF 004 
 
 
USAID also donated 5,750 sets of AI personal protective 
equipment, the last of which were delivered to the Common 
Fund on August 12, 2008.  The Centers for Disease Control and 
Prevention (CDC) was engaged in HIV/AIDS research in Cameroon 
from 2002 to 2008. Currently, the CDC is transitioning to an 
HIV/AIDS care, treatment, and prevention program under the 
President's Emergency Plan for AIDS Relief (PEPFAR).  The 
USG-funded Walter Reed Johns Hopkins Cameroon Program 
(WRJHCP), based in Yaounde, is comprised of international 
health and epidemiology departments from Johns Hopkins 
University Bloomberg School of Public Health, and a 
laboratory and field office for the U.S. Military HIV 
Research Program (USMHRP).  Through the Defense HIV/AIDS 
Prevention Program (DHAPP), the Department of Defense donated 
$420,000 in an ongoing project to upgrade the Yaounde 
Military Hospital Laboratory and to support remote military 
health clinics.  The Peace Corps has 30 Community Health 
Volunteers (out of a total of about 140 Volunteers in the 
country) working across Cameroon to assess and address health 
issues, including education and capacity building related to 
combating infectious diseases. 
 
Comment 
------- 
 
¶16. (SBU)  MINSANTE officials recognize major shortcomings in 
the country's preparations for possible disease incidences, 
and are refreshingly open when discussing them.  However, in 
the case of any large-scale infectious disease outbreak at 
this time, the GRC would be hard-pressed to respond 
effectively.  Without organized disease surveillance, 
particularly outside major city centers, the chances of early 
detection and containment of an outbreak are low.  Although 
the GRC has competent experts writing up the plans and 
manning the various response teams, organization and planning 
are lacking.  The number of government bodies with a hand in 
infectious disease programming creates confusion and fosters 
complacency and blame-passing.  Because of this, MINSANTE's 
plans are half-baked at best, and even then, only on paper. 
 
¶17. (SBU)  The GRC is perhaps better prepared to deal with a 
few cases of H5N1 AI than it is to deal with a large-scale 
outbreak of a more common infectious disease.  Nonetheless, 
AI planning appears to be stuck in its preliminary phases. 
Major problem areas include domestic and wild bird 
surveillance, unregulated cross-border trade, a lack of 
needed resources, and disorganization within the government. 
In February 2007, Cairo's Naval Medical Research Unit 
(NAMRU-3) visited Cameroon, and reported that the country was 
"lucky" the two AI cases in 2006 failed to spread.  If a mass 
poultry die-off is reported next week, it is unlikely the GRC 
would be able to effectively put its plans in motion.  The 
assumption within the GRC and hospitals seems to be that 
human AI will never happen here. 
 
¶18.  (SBU)  The problems in the health sector are symptomatic 
of broader governance challenges in Cameroon.  Coordination, 
planning, and project implementation are highly dysfunctional 
throughout the government.  Decisionmaking--when it exists at 
all--is slow and highly centralized across the board.  This 
is partly the result of corruption and a bloated bureaucracy 
- both of which plague the health sector as well as others - 
but also the product of poor leadership, adversity to risk, 
weak planning capabilities and inefficient administrative 
practices.   USG engagement in the sector, specifically in 
combating infectious diseases, helps mitigate these problems 
as well as assisting to fill a public health gap with serious 
national implications. Mission efforts to promote good 
governance and fight corruption include the health sector. 
GARVEY