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Cablegate: Taiwan Preps for Avian Flu

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




E.O. 12958: N/A
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

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.

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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

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

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

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.

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

- 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.


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

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

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.

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.


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