VZCZCXRO3176
OO RUEHAST RUEHCHI RUEHCN RUEHDT RUEHHM RUEHLN RUEHMA RUEHPB RUEHPOD
RUEHTM RUEHTRO
DE RUEHHI #0065/01 0230617
ZNR UUUUU ZZH
O 230617Z JAN 09
FM AMEMBASSY HANOI
TO RUEHC/SECSTATE WASHDC 9060
INFO RUEAUSA/DEPT OF HHS WASHINGTON DC IMMEDIATE
RUEHHM/AMCONSUL HO CHI MINH 5517
RUEHZS/ASEAN REGIONAL FORUM COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE
RUEHUL/AMEMBASSY SEOUL 3424
RUEHKO/AMEMBASSY TOKYO 5982
RUEHHK/AMCONSUL HONG KONG 1619
RUEHGZ/AMCONSUL GUANGZHOU 0015
RUEHCN/AMCONSUL CHENGDU 0378
RUEHIN/AIT TAIPEI 1640
RUEAIIA/CIA WASHINGTON DC
RUEHPH/CDC ATLANTA GA
RUEHRC/DEPT OF AGRICULTURE WASHINGTON DC
RHMFIUU/CDR USPACOM HONOLULU HI//J00/J2/J3/J5//
RHMFISS/CJCS WASHINGTON DC//J2/J3/J5//
RHEFDIA/DIA WASHINGTON DC//DHO-3//
RHEFAFM/DIRAFMIC FT DETRICK MD//MA-1A//
RUEKJCS/SECDEF WASHINGTON DC//USDP/ISA/AP//
RUEHSUN/USUN ROME IT

UNCLAS SECTION 01 OF 03 HANOI 000065 
 
SENSITIVE 
SIPDIS 
 
STATE FOR EAP/MLS, EAP/EP, INR, OES/STC, OES/IHA, MED 
STATE PASS TO USAID TO ASIA (MELLIS/DSHARMA/CJENNINGS) AND GH 
(KHILL/DCARROLL) DEPARTMENT OF DEFENSE FOR OSD/ISA/AP (STERN) 
CDC FOR COGH (SBLOUNT), CCID (SREDD) AND DIV-FLU (NCOX/AMOHEN) 
HHS/OSSI/DSI PASS TO FIC/NIH (RGLASS) AND OGHA (DMILLER/MABDOO) 
USDA PASS TO APHIS, FAS (OSTA AND OCRA), FSIS 
BANGKOK FOR RMO, CDC (MMALISON), USAID (MACARTHUR/MBRADY/CBOWES), 
APHIS (NCARDENAS), REO (HHOWARD) 
BEIJING FOR HHS HEALTH ATTACHE (EYUAN) 
PHNOM PENH FOR CDC INFLUENZA COORDINATOR (BBRADY) 
ROME FOR FAO 
VIENTIANE FOR CDC INFLUENZA COORDINATOR (ACORWIN) 
 
E.O. 12958: N/A 
TAGS: TBIO AMED EAGR PINR KFLU VM
SUBJECT: UPDATE ON VIETNAM'S LATEST HUMAN AVIAN INFLUENZA INFECTION 
AND SAMPLE SHARING 
 
REF: A. Hanoi 21; B. Beijing 31; C. 08 Geneva 1112; D. 07 Hanoi 890 
 
HANOI 00000065  001.2 OF 003 
 
 
¶1. (U) Summary: Confirmed case number 107, an 8-year-old girl from 
Thanh Hoa province infected with the H5N1 strain clade 2.3.4 of 
highly pathogenic avian influenza (HPAI) was discharged from the 
hospital and will be counted towards the total number of human 
infections for 2008.  The girl's 13-year-old sister died on January 
2, 2009, following symptoms consistent with infection that met the 
World Health Organization (WHO) definition for a probable case. 
From 2007 to the present, MOH has shared isolates from 9 of the 14 
confirmed human cases with the WHO Collaborating Center for 
Influenza (CC) system.  Specimens from the last 3 cases are among 
the 5 not yet shared.  We continue to work with partners in WHO and 
the Ministry of Health (MOH) to facilitate sample sharing and 
exchange of information.  End Summary. 
 
Update of Human Infections, the Last Case of 2008 
--------------------------------------------- -- 
 
¶2. (SBU) Earlier this month, MOH reported a laboratory confirmed 
case of HPAI in an 8-year-old girl.  Although reported as the first 
case of 2009 (Ref A), she first exhibited symptoms on December 19 
and is considered the sixth and last case of 2008 to be added to the 
WHO international compilation.  She is the fifth case since 2004 and 
the first case since July 2007 to have been reported from Thanh Hoa. 
 The total number of confirmed cases of A/H5N1 HPAI reported by 
Vietnam MOH to the WHO is now 107, of which 52 have been fatal. 
 
¶3. (SBU) Citing the clinical history provided by the district 
medical officer, local CDC and WHO experts believe that the victim's 
13-year-old sister, whose symptoms began on December 27 and who died 
on January 2, should be considered a probable case.  The MOH has not 
declared the older sister as a probable case, noting that her 
principal symptoms at admission to the hospital were 
gastrointestinal: "stomach ache, very high fever and diarrhea." 
However hospital officials noted that the onset of her illness was 
heralded by "high fever and severe cough," similar to her 8 year-old 
sister, and the media reported that she experienced respiratory 
failure as well as other organ failure during her hospitalization. 
[Note: WHO defines a probable infection as "a person dying of an 
unexplained acute respiratory illness who is considered to be 
epidemiologically linked by time, place, and exposure to a probable 
or confirmed H5N1 case." The International Health Regulations (IHR) 
do not require that probable cases be reported, nor are they 
included in the official counts of cases complied by the WHO. 
Published references on the clinical signs and symptoms of A/H5N1 
infections do describe the not uncommon occurrence of abdominal pain 
and diarrhea in A/H5N1 patients, including previous cases in 
Vietnam.  End Note.] 
 
¶4. (SBU) The Thanh Hoa occurrence may be the first in Vietnam since 
2004-05 involving more than a single sporadic case, though this 
cannot be proven as the absence of clinical specimens from the 
13-year-old precludes laboratory confirmation.  Even with isolation 
of the causative virus, field and pathologic investigations at the 
time would not have been able to definitely determine whether the 
older sister became ill due to exposure to her younger sister. 
 
 
HANOI 00000065  002.2 OF 003 
 
 
Sick Poultry Not Reported to Authorities 
---------------------------------------- 
 
¶5. (SBU) On January 4, National Institute of Hygiene and 
Epidemiology (NIHE) of MOH conducted a field investigation with 
Provincial and District health authorities at Dien Tru Commune, 
where the case patients normally resided with their parents. 
Investigations uncovered unusual illness and deaths in poultry in 
the case hamlet and several other villages in the district in the 
weeks preceding the illness in the case patients, but information on 
poultry deaths apparently was not relayed to medical or veterinary 
authorities.  According to a report from Thanh Hoa provincial DAH, 
19 households in 6 of 12 hamlets of Dien Trung commune were found to 
have had sick or dead poultry, totaling 383 birds.  The local 
authorities culled 7,800 poultry in 6 hamlets and implemented other 
stipulated poultry outbreak containment measures.   No subsequent 
reports of poultry outbreaks in Thanh Hoa have been received.  As of 
January 21, Thanh Hoa and Thai Nguyen are the two provinces with 
reported avian influenza outbreak activity within the prior 21 days. 
 
 
Field Investigation and Control Measures 
---------------------------------------- 
 
¶6. (SBU) NIHE investigators identified and interviewed close 
contacts of the case patients.  The parents were healthy.  Of the 
contacts of the sisters in the community, only one, a 5-year-old 
neighbor boy, reported illness (i.e., fever).  He was referred by 
the investigation team to the Ba Thuoc District Hospital for 
observation, diagnostic evaluation, and treatment.  Testing of 
throat swabs from this boy and 37 close contacts at the time of the 
field investigation were negative for A/H5N1 by PCR testing at NIHE. 
 Oseltamivir was delivered on January 5 from central stocks to Thanh 
Hoa Province health authorities for treatment of suspected cases and 
case contacts, and hospitalized children and close contacts of the 
case patient were treated.  Close contacts were placed under daily 
surveillance by nursing staff from the local government health 
services. 
 
Virology of the New Human Infection 
----------------------------------- 
 
¶7. (SBU) NIHE confirmed A/H5N1 infection in the 8-year-old girl 
within 36 hours of being notified of the case suspect, and further 
identified through genome sequencing the virus as belonging to H5N1 
clade 2.3.4.  This virus has been circulating in northern Vietnam 
since its apparent introduction from China in 2005 and has been 
responsible for the last 15 human infections in Vietnam, the first 
identified in November of 2005.  To date, we have not seen any human 
infections from a more recently introduced strain, such as clade 7, 
which has circulated in China for more than 2 years and was linked 
to the recent death of a Beijing woman (local media and Ref B). 
Clade 7 had been reported for the first time in Vietnamese poultry 
in a northern province adjacent to China in August 2008. 
 
Vietnam's Sample Sharing 
------------------------ 
 
 
HANOI 00000065  003.2 OF 003 
 
 
¶8. (SBU) The GVN has provided isolates from 9 of the past 14 
confirmed cases.  The isolate from the 8-year-old girl is one of the 
five not submitted.  [Note: Based on a WHO source, Ref C reported 
that Vietnam shared zero of five specimens from November 2007 
through November 2008; however, a review of WHO CC records from CDC 
Atlanta shows that Vietnam has shared isolates from 4 of 6 cases 
with onsets of illness in that time period. End Note.]  WHO Hanoi 
has formally written MOH after each reported human case, requesting 
the MOH to share an isolate.   Typically, the MOH has submitted 
isolates based upon oral "approvals," without a written response and 
not through an established standardized procedure.  NIHE has stored 
isolates for the five not sent to a WHO CC, and these could be made 
available for further analysis if MOH concurs. 
 
¶9. (SBU) In August, CDC provided results to NIHE for 9 isolates 
shared, under the auspices of its role as a WHO CC.  The value of 
this information in terms of detailed analysis and characterization 
of virus strains causing illness in Vietnam, including 
identification of a mutation linked to reduced oseltamivir 
susceptibility, cannot be overstated, especially when coupled with 
related technical assistance that has concretely established 
Vietnamese capacity and trust.  This has added value in its support 
of longstanding (starting in 1998) scientific collaboration between 
NIHE and WHO CC, CDC Atlanta on virological and epidemiologic 
aspects of seasonal and A/H5N1 influenza in Vietnam. 
 
¶10. (SBU) Given the unique pandemic threat of HPAI, local WHO and 
CDC technical experts have urged the GVN to share promptly an 
isolate or a clinical specimen from every human case of HPAI with 
the WHO CC system.  In 2005, NIHE was designated a WHO National 
Influenza Center (NIC), able to confirm independently a case of 
A/H5N1 infection.  The IHR stipulate that GVN need only send unusual 
or representative usual influenza virus isolates to a WHO CC. 
Unofficially, the MOH has pointed to these facts in discussing full 
and timely sample sharing with CDC Hanoi and WHO Hanoi.  WHO and CDC 
continue to re-enforce with MOH the value to share all isolates 
promptly.  We believe that progress is dependent upon continued 
strengthening of scientific and public health cooperative 
activities. 
 
Comment 
------- 
 
¶11. (SBU) While we believe the previous in-depth analysis of 
Vietnam's position on sample sharing remains valid (Ref D), we note 
that ensuring MOH cooperation requires encouragement from WHO and 
CDC.  In the absence of more stringent IHR requirements, we believe 
that our informal encouragement by CDC and WHO and our technical and 
programmatic support have been sufficiently effective.  Ultimately 
we want Vietnam to promptly share all isolates of HPAI without 
outside pressure.  In our judgment, at this point, a more aggressive 
tact could endanger current progress.  In the event of a possibly 
evolving pandemic, it is probable that Vietnam would fully 
cooperate, as it did with SARS and in the first instance of HPAI in 
Vietnam.  We are working with partners in WHO and the Ministry of 
Health (MOH) to facilitate a prompt exchange.  End Comment. 
 
MICHALAK