Cablegate: An Enhanced U.S. Role in Combating Avian Influenza (Ai)
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FM AMEMBASSY JAKARTA
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INFO RUEAUSA/DEPT OF HHS WASHINGTON DC
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DEPT ALSO PASS TO USDA/FAS/FAA/DYOUNG AND USDA/APHIS/ANNELLI
DEPT ALSO PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL
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TAGS: TBIO AMED CASC EAGR AMGT PGOV ID KFLU
SUBJECT: AN ENHANCED U.S. ROLE IN COMBATING AVIAN INFLUENZA (AI)
IN INDONESIA -- MONEY AND PEOPLE
REF: A) Jakarta 11582 B) Jakarta 11344
1. (U) This is an action request. Please see paragraph 3.
2. (SBU) Summary. After a slow start that led to the unchecked
spread of AI across much of Indonesia, the Government of
Indonesia (GOI) has developed a simplified AI strategy with re-
aligned priorities under a functioning National Committee for AI
Control and Pandemic Prevention. These developments represent an
important organizational advancement over the past year, and
offer donors a stronger foundation on which to base their AI
assistance efforts in the future. However, the GOI budget
including international donor assistance cannot meet the
requirements for its revised AI program, and the National
Committee has no committed funding beyond 2007.
3. (SBU) The moment is right for the USG to step up with a
significantly expanded AI assistance package to help the National
Committee implement its priorities--we estimate that a USG
contribution of $20 million a year in each of the next two years
would give Indonesia a real chance at permanently reducing the
level of AI in Indonesia's poultry population. Taking advantage
of an upcoming VVIP visit in late November to announce such an
assistance package would offer a superb opportunity to leverage
USG assistance into a stronger GOI public commitment to combating
AI. We also recommend promptly placing permanent staff from the
Centers for Disease Prevention and Control (CDC) and Animal and
Plant Health Inspection Service (APHIS) in Jakarta and
intensifying consultations with other donors so that GOI hears
concerted and coordinated guidance on managing AI. There may
also be an opportunity for the UN or other international
organizations to establish a data center to coordinate shared
resources for countries facing the onset of AI. End Summary.
4. (SBU) The USG has been a leader in the response to AI since
before Indonesia reported its first human outbreaks in June 2005.
Early on we developed a strategy that emphasized improving
surveillance, enhancing animal sector AI control, and stepping up
behavior change communications - the portions of Indonesia's
national strategy that the GOI has recently made its top three
priorities.
ROOTS OF GOI FAILURE FOR EARLY AI CONTROL
-----------------------------------------
5. (SBU) Indonesia was unprepared for the quick spread of AI
among its poultry population. Identified first in 2003, AI in
poultry has now spread to 29 of the country's 33 provinces.
Human infections have followed as a result of frequency of
contact, limited understanding of AI, social customs, and poor
poultry handling techniques. Numerous factors contributed to
creating an environment where the virus could pass quickly and
quietly to become epizoonotic within the avian populations.
--UNPREPARED, DECENTRALIZED GOVERNMENT. The GOI was slow to
grasp the enormity of its AI problem in 2004 and 2005.
Indonesia's highly decentralized government created overlapping
and unclear authority lines between central and district
governments that in turn resulted in non-standard operating
procedures and responses to outbreaks; inadequate surveillance
and failure to report outbreaks; inadequate culling and
vaccination procedures; and a lack of capacity to make proper
funding and policy decisions at the local level. The MOH and MOA
have not coordinated well. Nonetheless, community level programs
have produced strong results in surveillance, outbreak response,
and district level coordination between health and agriculture
officials. Community-based programs have also revealed a pool of
knowledge and concern about AI among villagers that can be
harnessed to create real change.
--INDONESIAN VILLAGE CULTURE. Indonesian village life is
conducive to creating disease conditions among poultry
populations. Indonesian families live in close proximity to their
uncaged poultry, raise chickens and ducks as a protein source,
and also keep pet birds. Children play with birds freely and
people sometimes sleep with birds in the house. Sensitive to
higher costs, residents ignore local regulations about bird
import and smuggle in birds from other markets when locally
supplied birds are too expensive.
--LACK OF TRUST BETWEEN MOA AND POULTRY PRODUCERS: A lack of
trust between larger poultry producers (Sectors 1 and 2) and the
MOA also severely inhibits efforts to combat AI. Outbreaks in
the Sectors 1 and 2 often go unreported, and MOA officials have
no authority to enter poultry production sites for animal health
reasons. Obtaining the buy in of large poultry producers will be
crucial for effectively controlling AI.
MORE RAPID PROGRESS IN 2006
---------------------------
6. (U) The GOI's national human health and animal health response
began to take shape in early 2006. In February, the GOI created
the National Committee for AI control and Pandemic Prevention
(National Committee) under Bayu Krisnamurthi. When a high
profile cluster of human cases occurred in North Sumatra in May
2006, key international partners (NAMRU-2, WHO, CDC, FAO)
proceeded to the site, resulting in rapid case confirmation,
epidemiologic assessment and subsequent genetic sequencing of
virus samples. In June, the GOI and WHO convened a panel of
international influenza and animal health experts on AI
management that made a set of important recommendations.
International experts complimented the GOI for convening the
meeting, but the MOH ultimately rejected the resulting report
because it was unwilling to admit that limited non-sustained
human-to-human transmission occurred during the outbreak.
7. (SBU) With USAID funding, FAO piloted an effective
Participatory Disease Surveillance and Participatory Disease
Response (PDS/PDR) program in 12 districts in the first quarter
of 2006. The program provided the first reliable reporting on
outbreaks in the backyard and informal poultry sector. An
International Expert panel identified the program as a model
program for district governments that offers the best hope yet to
reduce AI infection in Indonesia's poultry population. USAID,
AusAID and Japan provided funds to expand the program to 159
districts by June 2007.
8. (U) In August, the GOI launched the National Committee. Bayu
announced a refocused National strategy and animal control
program and also launched GOI's first national awareness
communication campaign. During the month, the National Committee
convened two donor meetings to map resources, identify funding
gaps and discuss animal control measures. The National Committee
announced a refocusing of Indonesia's AI strategy to focus on
three top priorities: 1) risk communication, information and
public awareness, 2) epidemiological surveillance on animals and
humans, and 3) AI control in animals. The GOI also made progress
in August and September implementing the Tangerang Trilateral
Project, but has a lot of bureaucratic hurdles to overcome, such
as working out a reimbursement mechanism. Since the August donor
meeting, international donors are expressing more confidence that
the GOI is on the right track and that Indonesia has turned the
corner on its struggle to control AI.
ROLE OF DONOR COMMUNITY
------------------------
9. (U) The U.S., Australia, Japan and World Bank are the major AI
donors in Indonesia. Australia is providing approximately $12
million to support WHO/MOH rapid response teams, stockpile
Tamiflu, and support the FAO's PDS/PDR program. In addition,
Australia is designing a new program covering detection,
prevention and management of AI in humans and animals. The
program will be part of an approximately $75 million Australian
commitment for emerging infectious diseases in the Asia Pacific
Region (the final amount that will go to Indonesia is unclear).
Japan provides the majority of its assistance through UNICEF for
communications, WHO for human health, and FAO/OIE for animal
health. The World Bank is finalizing a proposed $15 million, 2-
year program for animal surveillance and containment. This
program will include support for the PDS/PDR program,
compensation for culled birds, outbreak response vaccination, and
preventive vaccination. Other donor support includes $1.3
million from the Netherlands for animal vaccine trials and $6
million from Canada for human health, including purchase of
hospital equipment.
GAPS REMAIN
-----------
10. (SBU) The GOI is now on the right path to managing AI, but
Indonesia's enormous size makes tackling AI a huge task. Key gaps
include the following:
--MOH CAPACITY: The MOH needs a range of assistance to improve
its diagnostic capacity and response to human outbreaks. By
their own admission, the MOH lacks trained research technicians
and scientists who understand the scientific process or can
conduct assays. Only a long-term commitment to develop and
support the training of a cadre of scientists will alleviate this
problem. Moreover, rank and file health care workers have
critical training needs for patient diagnosis, case management,
and infection prevention.
--PUBLIC AWARENESS: Indonesia badly needs a more robust and
sustained AI public awareness campaign. The National Committee's
communications strategy is designed to increase public awareness
about AI so people can identify AI outbreaks in animals and AI
symptoms in people. In addition, the National Committee hopes to
change behavior to reduce the risk of and increase appropriate
responses to animal outbreaks and human infection. In August,
the GOI launched a national mass media campaign to reduce the
risk of human infection from animal outbreaks. Financial support
from UNICEF and the Government of Japan is sufficient to air
public service announcements (PSAs) through December 2006. USAID
is working with UNICEF to analyze results from the national
campaign and fine-tune messages. USAID is also supporting a
community level interpersonal communications effort to complement
the mass media campaign. USAID funding is sufficient to support
public awareness campaigns to cover 100 districts through July
2007. Additional funding is needed to purchase airtime for new
mass media messages to air in 2007 and 2008 ($6 million) and to
continue community level behavior change communications through
2007 ($2 million).
--SURVEILLANCE FOR ANIMALS AND HUMANS: The GOI needs increased
epidemiological surveillance of animals and humans including
active community-based surveillance for animal and human cases;
hospital based passive surveillance, and laboratory diagnostic
capacity. Capacity and skills within the GOI are severely
limited for surveillance. The USG is at the forefront of
surveillance efforts for both human and animals in Indonesia.
NAMRU-2, with financial support from CDC and DOD-GEIS, has
operated a hospital-based human influenza study in Indonesia
since 1999. In September 2005, USAID provided financial support
to NAMRU-2 to expand its study to include key AI risk areas. The
NAMRU-2 study has provided vital support to Indonesia in case
confirmation and to global AI research. NAMRU-2 has requested
authority to expand its human surveillance program to include
additional referral hospitals. Toward this end, almost a dozen
hospitals and/or health care centers have requested enrollment
into the surveillance network. However, officials at National
Institute of Health Research and Development (NIHRD) have not
approved this expansion.
USAID provided seed money to FAO's PDS/PDR program, which has
provided the first reliable reports of AI animal outbreaks and
improved rapid response and control measures. USAID is the
primary donor for this program, providing 2/3 of the funding, but
the success of the program has drawn support from other donors,
including AusAID, the Government of Japan, and the World Bank.
Additional funding is needed to support program operations in
currently covered districts over the next 2 years ($10 million
for 159 districts) and to expand the program to train and operate
the program in the remaining AI 150 endemic districts ($13
million).
--VACCINATION, CULLING AND COMPENSATION PROGRAMS: The GOI lacks
resources to fully implement the FAO guidance for animal control,
including focal culling with compensation and ring vaccination.
Over the next six months, USAID and the World Bank will pilot a
control plan for animal outbreaks. Experts will then use lessons
learned to further improve animal containment across Indonesia.
The USG strategy does not at this time fund compensation which,
under current endemic conditions, would cost about $150,000 per
district per year. Support for vaccination would help to free GOI
budget to more consistently pay compensation for culled birds.
Under current endemic conditions, an adequately resourced
targeted vaccination campaign would cost $50,000 per district per
year. The World Bank plans to support full vaccination coverage
of 12 districts over two years. Additional funding would be
necessary to cover the remaining 147 districts for one year ($7.3
million) and 288 districts for the second year ($14.4 million).
--MINISTRY OF AGRICULTURE LEADERSHIP AND INFRASTRUCTURE: Lack of
leadership and infrastructure within the Ministry of Agriculture
remains a critical gap in Indonesia's AI management. The MOA has
not consistently implemented standard operating procedures,
elevated AI as a priority for central and local agriculture
authorities, encouraged restructuring of the poultry industry,
and ensured adequate funding for AI surveillance and control.
Despite the fact that Indonesia is struggling with other animal
diseases, the MOA has not developed a cadre of animal health
extension officers. (Note: The strength of the FAO program is
that it is managed at the provincial level and implemented at the
district level.)
11. (SBU) The GOI also faces an across the board fiscal
sustainability problem that affects all of its anti-AI program.
The GOI's AI budget including international donor assistance
faces significant shortfalls in 2007, and the National Committee
has no committed funding beyond 2007.
THE PATH FORWARD
----------------
12. (SBU) With the National Committee up and running, and a
refocused AI strategy, and the piloting of a successful animal
surveillance and response program, the time is right for the USG
to step up with a significantly expanded AI assistance package.
We recommend Washington provide an additional $40 million in AI
funding ($20 million per year over a two-year period) to assist
the National Committee in implementing its priorities. Fully
funding the FAO PDS/PDR program in Indonesia's remaining AI-
endemic districts to manage the disease at the source is our top
priority. We would also use any new USG funds to support public
awareness programs and address other shortfalls that are
hindering the achievement of the National AI Committee's three
priorities. These programs offer the best hope yet to, over the
medium term, drive the "viral load" down in Indonesia's poultry
population, protect human health, and limit opportunity for the
virus to shift.
13. (SBU) In addition to sharply expanding USG assistance to the
National Committee, we also need more USG boots on the ground in
Indonesia. We are grateful for the continuing TDY assistance
from both CDC and APHIS. However, we need permanent animal and
human health experts assigned here quickly to build relationships
with key GOI staff and implement programs. If this is not
possible, we recommend CDC and APHIS develop rotations among a
small cadre of experts who have previously assisted in Indonesia.
The learning curve here is steep. Key GOI contacts work best
where relationships and trust are already developed. When APHIS
and CDC are fully operational in Jakarta, we expect that they
could draw on increased USG funding to expand their programs.
For example, APHIS could enlarge and fully fund planned
epidemiological training, laboratory training for sector 1 labs,
and pilot intensive area vaccination programs.
14. (SBU) Our strategy going forward should have a diplomatic
component as well. The recent European Union letter to the GOI
noting serious concerns with Indonesia's handling of AI
underscores the need to develop a coordinated diplomatic message
with other donor countries. This would ensure that senior GOI
officials are hearing concerted and coordinated guidance on
managing AI. This could benefit us directly. For example, the
GOI is resisting the idea of expanding NAMRU-2's hospital
surveillance program. A coordinated message from the donor
community about the need for additional human surveillance could
be very effective in persuading the GOI to allow NAMRU-2 to move
forward. A concerted diplomatic message, delivered both in
Jakarta and at major AI conferences, could also be helpful in
endorsing the success and importance of the National Committee,
securing additional GOI budgeted resources for AI, and convincing
the GOI to more openly share AI samples.
INDICATORS OF SUCCESS
---------------------
15. (SBU) Over the long term, we would be able to judge the
effectiveness of increased USG assistance by the number of human
infections and animal outbreaks. However, in the short-term,
improving the surveillance system would likely result in
increased reports of human cases and animal outbreaks. This was
the case when we expanded NAMRU-2's surveillance network and
piloted the FAO PDS/PDR program. Other factors, such as weather
conditions and cultural practices can also impact on the number
of reported outbreaks at any given time. The National AI
Committee, in collaboration with donors, is developing country
level indicators for Indonesia, and several USAID-funded programs
are jointly developing program specific performance indicators,
including intermediate indicators that can help inform program
impact. Examples include the level of active surveillance as
indicated by the number of health facilities engaged in
surveillance and reporting cases to MOH, the number of PDS/PDR
teams searching for AI outbreaks, the number of interviews
conducted by PDS/PDR teams, etc. Additional indicators could
include the level of outbreak/case response (e.g. the percentage
of reported suspect human cases or animal outbreaks investigated
within 24 hours).
LEARNING FROM INDONESIA
-----------------------
16. (SBU) The scale and complexity of Indonesia's struggle
against AI, and the size of the donor response, suggests that
Indonesia's experience may contain lessons for other AI-afflicted
countries. Indonesia could also surely benefit from real-time
knowledge of AI control efforts in other countries. Although
averting a pandemic is a scientific and medical challenge,
combating AI is also a long term management problem involving
coordination, logistics planning, organization and resources. We
recommend Washington consult closely with the UN, World Bank and
others to see what opportunities may exist to leverage technology
and institutional knowledge to develop tools for global
coordination. Such tools might have been very helpful to
Indonesia in its early efforts to contain AI. The UN or WHO
would likely be best positioned to lead the development of such
coordination tools, which might include some of the following:
--An international donor data base could provide an excellent
reference tool to not only monitor and record current donor
levels and functions but also to provide users with ideas for
additional programs. A government user in a country facing AI
for the first time might research other countries for ideas of
donor programs. An in-country user might pull off the latest
statistics in preparation of meetings. A Washington user could
sort donor efforts by country, by AI strategy, by year or any
other data element. The WHO might be a possible host for an
expansion of tools.
--A central website could also feature a range of useful
reference materials by country such as maps tracking bird and
human AI outbreaks, a who's who of key AI players for each
country, national strategic plans and a list of reference
materials.
--A central website could also feature useful templates and
descriptions of AI management best practices so that less time
and resources are spent in recreating the wheel in every country.
HEFFERN