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Cablegate: H1n1: Estonian Vaccination Plan Remains Uncertain

DE RUEHTL #0302/01 2720757
R 290756Z SEP 09



E.O. 12958: N/A

REF: REF A: 09 TALLINN 169; REF B: 09 SECSTATE 99088

1) (SBU) Summary. Despite otherwise solid pandemic planning,
Estonian health authorities have not placed an advance order for
H1N1 vaccine, and continue to work out the details on a national
campaign to vaccinate high risk groups for the H1N1 influenza virus
this fall. Preliminary plans propose a modest vaccination campaign
covering 2 - 5% of the population, focusing on high-risk groups.
However, authorities are scrambling to find sources of the vaccine,
seeking assistance from the EU. Some believe that there will be no
H1N1 vaccine available at all in Estonia this winter. Estonian
health authorities also have determined not to increase the
country's modest Tamiflu stockpile. Health authorities point to
science as the basis for their pandemic planning decisions, rather
than budget limitations. Post will continue to provide information
to the private American citizen community on the current H1N1
situation in Estonia, allowing them to consider appropriate
measures for their families. End Summary.

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General Planning

2) (U) The Estonian health authorities (Ministry of Social
Affairs, Health Care Board and Health Protection Inspectorate) have
taken a number of steps in recent years to prepare for a possible
pandemic. For example, the government has purchased additional
ventilators and expanded hospital's ICU capacity by one-third. In
addition, the Health Protection Inspectorate has engaged in
outreach on the pandemic, issuing guidelines to primary care
providers and ambulance workers on appropriate steps to be taken
for persons suspected of H1N1 infection. Guidelines have also been
issued to schools, and informational posters have been displayed at
ports of entry and places where large numbers of people congregate
(such as local festivals). A crisis management team, comprised of
representatives of various interested agencies, meets weekly.

3) (U) Recent legislation has granted greater powers to the
Estonian Health Care Board that can be invoked in the event of a
medical emergency, such as the ability to issue binding obligations
on medical providers. Already, the Health Care Board has issued a
guideline mandating that all hospitals treat H1N1 patients, if
needed (although specific hospitals have been designated to treat
such patients at this time).

H1N1 Vaccine

4) (SBU) The Estonian government has not placed any advance order
for H1N1 vaccine. Realizing that they are now at the back of the
line to get vaccine, the Estonian government is working with the EU
on a "joint procurement process," and is maintaining contact with
local representatives of vaccine manufacturers. One officer of the
Health Inspectorate speculated that some vaccine might become
available as countries move from a two-dose to a one-dose strategy
for adults, freeing up supply. When asked, health authorities are
reluctant to comment on the role of resources (in a time of
cascading budget cuts across all agencies of the Estonian
government). Conoff separately spoke with a prominent private
doctor in Tallinn who said that she expects no H1N1 vaccine to be
available in Estonia this winter on the private market as
manufacturers are fulfilling only orders from governments and
health organizations.

5) (SBU) Despite uncertainties on Estonia's ability to obtain
vaccine, the health authorities continue to work on a vaccination
campaign for the upcoming flu season which it hopes to be ready "on
paper" by the end of October. Public health officials have
"mapped" the financial resources needed to implement the program,
but have not commented on the likelihood of resources becoming
available. The proposed campaign would cover 2 - 5% of the
population, focusing on key risk groups, such as health care
workers, pregnant women and persons with chronic illnesses.
Initially, authorities indicated that they would use the national
health plan (Haigekassa) register to determine who would fall into
these categories (e.g., pregnant women or those with chronic
illnesses), but Conoff received assurances from the chairman of the
Estonian Health Board that resident American citizens (and other
foreigners) who are not covered under the Estonian national health
plan, but who are members of these high-risk groups, would be
eligible as well.


TALLINN 00000302 002 OF 002

6) (SBU) Earlier in the year, Estonian health authorizes
established a stockpile of 3,000 courses of Tamiflu, enough to
treat less than 0.3% of the population. Despite working under an
ECDC-approved "worst-case" scenario under which the 25% of the
country would be infected during an 8-week wave, with 5,000
"severe" cases, the authorities have determined not to increase the
size of the stockpile at this time. Again, authorities indicate
that the size of the stockpile is not determined by resources, but
rather by experts estimating expected demand for anti-virals. In
addition to the government reserve, Tamiflu remains widely
available on the public market in Estonia. Post regularly uses a
local internet site (www.raviminfo.ee) to track the number of
pharmacies offering Tamiflu, in order to gauge changes in demand.

The Current H1N1 Situation

7) (U) There have been 68 confirmed cases of H1N1 infection in
Estonia, including some American citizens (see Ref A) and one
member of the Embassy community. All have showed mild symptoms and
quickly recovered. Only a small number of patients have been
hospitalized, solely for isolation purposes. Health authorities
have confirmed that currently there is no sustained human-to-human
transmission of the H1N1 virus in Estonia, and so are applying a
containment strategy. Should sustained human-to-human transmission
occur, authorities will switch to a mitigation strategy, in
accordance with guidelines from the European Center for Disease
Control and Prevention (ECDC). Health authorities have promised
transparency should this change occur. (One of Post EAP's pandemic
influenza tripwires is triggered upon the commencement of sustained
human-to-human transmission in Estonia.)

Communicating with the American Community
--------------------------------------------- -------------------

8) (U) The Embassy maintains CA-approved language on its website
regarding general pandemic preparedness, accompanied by information
specific to Estonia, such as links to the Estonian Health
Inspection Protectorate's website and links to local pharmacy
information. In the event that Estonia successfully launches an
H1N1 vaccination program for high-risk groups, Post will reach out
to the American community to ensure that American citizens not
enrolled in the national health plan will be able to request the
vaccine. In addition, Post will ensure transparency with respect
to internal actions and recommendations made pursuant to Department
guidance on pandemic preparedness (Ref B).


9) (SBU) Estonian health authorities continue to go through the
motions to move forward with pandemic influenza planning, refusing
to acknowledge that a lack of resources has limited their options.
Taking advantage of complacency from the Estonian public due to the
mild nature of the H1N1 pandemic so far, health authorities appear
to be crossing their fingers that the country will avoid a severe
wave of H1N1 infections during the fall/winter flu season. Perhaps
conscious of criticism aimed at other EU countries that have
dedicated significant resources to obtain large quantities of
vaccine and anti-virals, Estonian health authorities' approach may
look wise in retrospect if the pandemic's worst-case scenarios do
not materialize and other countries appear to have overreacted.

10) (U) Meanwhile, Embassy continues to move forward with its own
pandemic influenza planning for the Mission community. Post formed
a Pandemic Influenza Working Group in April 2009, which provided
recommendations to the EAC for revisions to the EAP's pandemic
influenza tripwires and required actions. In addition, at the
request of the Working Group, Post has inventoried anti-virals and
personal protective equipment (PPE), while distributing additional
hand disinfectant throughout the chancery. Post's own procedures
were tested when a Mission employee became symptomatic with H1N1
influenza shortly after returning from the UK. Working with
Embassy nurse and the Estonian hospital designated to perform H1N1
testing, the employee and his family (including children who attend
the International School of Estonia) were isolated and he quickly
recovered. Post has shared information with the International
School of Estonia about pandemic planning. Post anticipates the
receipt of H1N1 vaccine from MED in order to implement its own
vaccination program this fall. End Comment.

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