Secretary of Health and Human Services, Under Secretary for Democracy and Global Affairs, and U.S. Agency for International Development on U.S. Government Efforts to Combat Avian Influenza

MR. ERELI: Good afternoon, everyone. If I might ask, first of all, that you turn off your cell phones, so that we can have a ring-free briefing. We are very pleased and honored to welcome today to the State Department three senior officials of the U.S. Government, including a Cabinet Secretary, for a briefing on U.S. Government efforts to combat avian influenza.

Under Secretary of State for Democracy and Global Affairs Paul Dobriansky will kick things off, followed by Secretary of Health and Human Services Michael Leavitt and Agency for International Development Andrew Natsios to talk about this issue. Then we will take your questions. I would ask that for the benefit of our briefers, that you identify yourself and your organization when you ask the question. Thank you.

Under Secretary Dobriansky.

UNDER SECRETARY DOBRIANSKY: Thank you for coming today to discuss the Administration's efforts to lead a concerted, coordinated and effective international response to the threat posed by avian flu. I am pleased to be joined by Health and Human Services Secretary Michael Leavitt and USAID Administrator Andrew Natsios.

Over the last week and a half Secretary Leavitt and I traveled to Southeast Asia visiting Thailand, Cambodia, Laos, Vietnam, Indonesia, Singapore and Malaysia. Our delegation included representatives from the Department of Agriculture, Dr. James Butler, who is here with us today, USAID Administrator of Global Health, Kent Hill, who is also here today. We also have representatives from the National Institutes of Health, the Centers for Disease Control, as well as Dr. Lee, accompanied us, the Director General of the World Health Organization and representatives of the Food and Agricultural Organization, the FAO, and the World Organization for Animal Health, the OIE.

During our trip, we were focused on concrete actions designed to strengthen surveillance, preparedness, containment and rapid response and determine the needs especially of those countries that are in need of capacity building.

Let me now invite Secretary Leavitt to begin by discussing the trip and maybe some of the programmatic areas that HHS is supporting.

Secretary Leavitt.

SECRETARY LEAVITT: Thank you. For those of you who have not covered this issue, perhaps I should characterize a little of the general subject. If you think for a moment about the world, as though it were a vast forest, susceptible to fire, whenever a fire starts, there is a spark. If we are able to be where the spark ignites, we have the capacity to simply put it out. If it's allowed to smolder for a time, it can grow beyond containment in a rapid fashion.

Our purpose in going to Southeast Asia was, at least in my sense, was first of all, to begin developing a network of surveillance. So we would have the capacity -- we'll have the capacity to determine at the earliest possible moment when this virus or if this virus achieves a person-to-person transmission. Currently, what we have is a disease that is primarily an animal disease -- that is to say it is being transmitted among birds and, in some cases, animals. It is uncertain at this point whether or not it will ever achieve a high level of efficiency in going between people. Now we have had very limited experience where we have seen the virus go from birds to people, but we have not yet seen the virus go from people to people.

A very important part of our doctrine as a country in dealing with this is the idea that if person-to-person transmission occurs anywhere, there is risk everywhere and that's well characterized by the Southeast Asian area. There, of course, is there -- microbes know no borders and they are no
respecter of sovereignty. And so our purpose is to help that region of the country -- that region of the world, achieve surveillance in a fashion that they can determine quickly when it occurs so that they can get to the site and contain.

We were also there for the purpose of developing relationships of cooperation and transparency. Decisions will be made rapidly and, therefore, having those relationships and cooperative agreements in place will be of importance. And we also needed to achieve some level of situational awareness to have a chance to see what is actually happening on the ground.

The delegation spent a fair amount of time visiting, for example, rural farming areas. We went to wet markets. We visited families that had actually contracted avian flu and had a chance to talk in some detail with them about their experience and how they received it. We met with governments, primarily for the purpose of strengthening local preparedness and response capabilities. Because our doctrine that if it happens anywhere, there's risk everywhere, we have great benefit in ensuring that we're part of that network.

We entered into cooperative agreements with several of the governments. We indicated to them a willingness to be of assistance. The U.S. Government has allocated $25 million between Health and Human Services and USAID -- which will be detailed in a moment -- for direct investment on this problem in the next year. That is of course, on top of an ongoing and a quite robust set of relationships that exist already. We have military, naval laboratories in that region that form an important part of the public health construct for the region.

We'll primarily be investing in laboratory capacity, in surveillance, in training. Many of those who were involved in the public health labs in that region have been trained either at the Centers for Disease Control or at the National Institute of Health. There are ongoing relationships. We have people on the ground in nearly all of those countries.

So I'll characterize it as a very helpful trip. We had, I think, came away with some confidence that we have relationships in the area that we can depend on to give us information and make our investments count. I'm sure you'll have questions and I'll be prepared to answer them when we've finished our opening statements. Thank you.

UNDER SECRETARY DOBRIANSKY: Thank you, Mr. Secretary. Now I'd like to invite Administrator of USAID, Andrew Natsios, to come to the podium.

ADMINISTRATOR NATSIOS: Thank you very much. I did not accompany the team on the
-- the delegation on the trip but Kent Hill, who is the Assistant Administrator of the Bureau of Global Health within AID did. We have now obligated $13.7 million to prevent the -- and contain the spread of avian flu in Southeast Asia. And in particular, $10 million came from the Emergency Supplemental Budget for the Tsunami and we took $3.7 million from other programs and redirected into this. So by the end of the last fiscal year, by September 30th, we had moved: $3.5 million for Vietnam; $1.6 million for Laos; $2.2 million for Cambodia; $3.2 million for Indonesia; and $500,000 for China. And there's $2.7 million that we've committed now to support regional activities in that area.

I've written to all of the USAID mission directors in our 80 missions around the world where we actually have Foreign Service officers on the ground. There are another 40 countries in which we have private organizations working with us. These are general AID programs and I've alerted them all, although we are just beginning the assessment of the situation on the ground in terms of the preparedness condition of the countries that we're working in. I've alerted them all that it is their responsibility in the field, working with Centers for Disease Control, who have field offices as well, to work together along with the United States Department of Agriculture, which also has agricultural officers in the embassies, to try to begin preparation for this in a worldwide fashion.

So far, the money that I've explained will be used for the following purposes. We have already purchased and prepositioned personal protective gear in Southeast Asia that workers can put on so that they don't get infected if they go out to destroy poultry, for example, or treat cases of avian flu among people.

Secondly, we have now begun to train and equip teams of people who will be responding to incidents. Third, we're now designing a communications and public education campaign. We call it "Social Marketing," which will be designed to educate the public in terms of what warning signs to see, how to report in each of the countries what they see. There are some practices like in some countries there's a custom of drinking poultry blood after they slaughter an animal, just as a sort of a traditional practice. That is something that is not a wise idea under these circumstances because that spreads the disease. People need to know these things in order to protect themselves.

We're working with CDC on laboratory diagnosis equipment. And we're also designing incentive systems for farmers to report because, of course, you know what happens when the farmer reports that they have an incidence of avian flu in the their barnyard. They come in and they kill all the birds. And it is not exactly an incentive for people to cooperate. And so we're working with the ministries and the governments in the countries that we're in to design a system to reverse that incentive, so there's an incentive for them to report rather than not to report, because we need immediate information so that immediate action can be taken. If there's any breakdown in the communications systems or the transparency of this, the effort that Secretary Leavitt just described, to step on the spark before it gets into the conflagration will fail.

And finally, AID works as its business model through networks: NGO networks, women's networks, agricultural networks, farmers’ cooperatives, business networks around the world, and of course, NGO networks, which is our biggest network. These are indigenous NGOs. They're international NGOs. We have now mobilized our NGO partner organizations through ACVFA, which is our mechanism in AID for speaking to the NGO community. And we're about to go out to talk to the business community, particularly multinationals, to see if their networks can also assist with the provision of information, of surveillance and monitoring to tell us what's going on, because information is critical to make this all work properly. Thank you very much.

UNDER SECRETARY DOBRIANSKY: At September's United Nations General Assembly meeting, President Bush announced the International Partnership on Avian and Pandemic Influenza, which is a voluntary coalition built on a set of core principles that underscores the vital need to elevate the handling of avian flu on national agendas, to improve coordination of international activities, such as information sharing, the development of vaccines and accelerated capacity-building for those affected countries that currently lack health-related infrastructure.

I think that the visit underscores that our partnership is working well. We had, during the visit, meetings at the highest levels in all of these countries, involving not just the health and agriculture ministries, but also the foreign ministers, prime ministers, presidents. It provided an opportunity to exchange information and to take stock of what steps needed to be taken together next.

The U.S. Government has devoted a total of some $38 million to our international efforts to support the most affected countries, which are in need of capacity building: Vietnam, Laos, Cambodia and Indonesia. In the three categories that we have focused on are surveillance. It refers to timely and accurate sharing of information, working closely as well with international organizations: the World Health Organization, the Food and Agricultural Organization and the World Organization for Animal Health. And in that context of surveillance, let me give you some examples of what is being done. The training of national veterinary staff in these countries, to also provide financial, technical, commodity support to monitor disease in domestic and wild birds, increasing the capacity of national public health staff to detect new infections and ensure timely and accurate laboratory diagnosis.

Also USAID, for example, is working with FAO on early warning systems, as you referred to, basically the establishment of networks to communicate rapidly information concerning cases, providing mobile laboratory kits. The Secretary mentioned the military labs. In Indonesia, we have the NAMRU-2 facility, it's a military lab. It plays an important role in terms of the strengthening of surveillance efforts.

The second area is preparedness. What we're talking about here is it refers to ensuring that countries make this a priority and take the necessary steps to do so, as well as engage in developing vaccines and stockpiling medicines and equipment. Some of the steps here are examples of what we are doing include, providing support to ministries of health in the development of comprehensive national pandemic preparedness plans, also supporting health ministries and conducting pandemic preparedness trainings and simulations. Also another area is USAID is working with FAO and WHO to engage agriculture and health ministries and other relevant ministries to increase regional and international coordination.

Finally on response and containment, here which refers to providing immediate access to international teams and committing to rapid containment measures, to give you some examples of what we are doing in this area, Administrator Natsios referred to the protective gear to be used in case of avian flu emergency. It's the prepositioning through the Office of Foreign Disaster Assistance, to be provided to Cambodia, Laos, Vietnam and Indonesia.

Also quite important is establishing training and supporting rapid response teams to enable appropriate disease containment measures, for example, in animal populations. Here are some of the concrete steps and actions taken include: building local capacity to cull and dispose of infected or exposed animals. In addition, the Administration is preparing a new request to the Congress for additional funds for both our international and domestic needs.

In general, I would say that our message of cooperation and common cause was well received through out the region. While we are working with countries, in some cases that lack some capacity to prepare for and respond to a pandemic flu, I see a heightened understanding of both the problem and the need to confront it together. Countries realize that the cost of taking action is significantly less than the cost of a pandemic.

I'd now like to suggest that we come forward and open it up for questions.

MR. CASEY: Okay, once again, if you could please identify yourselves and your news organization for the benefit of our briefers. Let's go right here.

QUESTION: Thank you. Two questions: One, how much more money are you going to ask Congress for this? And two, should there be any concern of people flying into the U.S. from those Asian countries affected now by the epidemic?

SECRETARY LEAVITT: I will let others answer the money question. Let me talk about -- what we have is an animal disease at this point. No one in the United States has been affected directly by -- has been infected. And to this point, we have not identified any birds or animals with the virus. It has not yet achieved person-to-person efficient transmission. If at any point it does, it changes the dimension of this problem. Until such time as we see that kind of person-to-person transmission, we will continue to treat it as an animal disease. Now that doesn't mean it's not a serious matter and we're taking it very seriously, but we have not yet -- it has not turned into a human pandemic disease. It is simply an animal disease at this point.

UNDER SECRETARY DOBRIANSKY: May I just make a quick comment on the resource question. I think not only this trip, but also the variety of missions that have been conducted by USAID, HHS, USDA and the State Department -- and there have been several to the region, which have provided an assessment of needs -- and the recent trip I think also provides more information about needs in the area, that will factor into our deliberations about needs. Also as coordinating through our partnership with others, the international partnership, and taking stock of not only that region, but broader issues and we're in that process now.

QUESTION: After meeting all these various governments in Southeast Asia, did you come away with the impression that they were determined to be transparent and open in reporting new cases? And were there any instances where you are feeling a little uneasy because of the huge obvious economic impact of being honest and open, that some governments may not be as transparent as you'd like?

UNDER SECRETARY DOBRIANSKY: I'll make a comment. I think that in terms of the meetings that we had and the engagement and this is not only the first because all of these countries also have sent representatives here to the State Department for our senior officials meeting as part of the international partnership. There's active engagement that is taking place. I think that there are networks that are being set up and refined in terms of providing for early warning. I think that it is -- I feel that these countries are engaging and I think that our trip has assisted in really providing for closer relationships, not only among our respective ministries, but also I would say especially with many of the technical experts -- the work of the WHO or the FAO, the OIE on the ground in each of these areas. They were invited by Secretary Leavitt and I think that was crucial, especially in terms of rapid response.

QUESTION: And were any countries that concern you that they may be not taking enough action?

UNDER SECRETARY DOBRIANSKY: I would say that I think all of these countries we have engaged and I think that we are in the process of moving forward and taking the right steps.

SECRETARY LEAVITT: I'll just comment that we did, in fact, see evidence of countries taking this very seriously. I think it's also important to recognize they're dealing with a complex and difficult situation. In almost all of these countries, large segments of their economy are made up of small farms and a centuries-old cultural practice where animals and birds and people live in the same area. Most of these are subsistence farms. They average $600-$800 annual income a year. And the importance of the birds they have to their lives is highly relevant.

I visited a family in Vietnam that actually contracted avian flu. It's a family of five -- wonderful people. I sat on the floor in their room -- in their living area and had them describe for me what had occurred. They count on the chickens that they have and some rice wine that they produce out of their fields to support their family.

When the village leaders came to them and said, "We've got to destroy your animals," it was blow. They concluded that they would eat the chickens that hadn't been sick. And when they began to process the chickens, invited their friends and family over, so that it wouldn't be wasted. A week later, the father became ill. Two hours later, he became violently ill and he described it the ailment that attacked him. He said, "It was like the cough I had -- every time I coughed, it was like I was coughing my lungs up." And it was a very serious experience. Two hours later, their little girl began to show the same symptoms. The wife described the worry she had. It was highly significant. She said, "I was horrified at what was happening, but I was most concerned that their health care could continue because the only asset we had that could be converted to money were the chickens and they were already gone."

I mean that's the difficulty of the circumstance that these countries are dealing in. It's quite manageable for them, in my judgment, so long as it continues to be a bird-to-person transmission. We will likely see additional cases, given the nature of the circumstance. But if it goes to a person-to-person transmission, then they're dealing with a much different problem and they know that and they're anxious to have our help. And early surveillance, of course, is the most important part of it -- being able to get an ongoing steady and reliable stream of isolates because this virus is going to continue to mutate and evolve. And for us to be able to help them, they know we need both lab capacity and the ability to get samples, so that the CDC and at our naval labs and other places, we can determine how best to respond.

QUESTION: Would one of you please address the specific question, following up on the earlier one of countries cooperating, of Indonesia specifically, are they being transparent enough, aside from the fact that you're engaged in starting to have meetings? And secondly, can you address the question of a vaccine and supplies?

SECRETARY LEAVITT: There is a global dearth of vaccine manufacturing capacity and it is represented in that region of the world as it is in all others. We did have a chance to visit the laboratories where various of the countries are working on vaccines, Vietnam, in particular. We talked at length about how we could be helpful to them in creating clinical trials that would measure the effectiveness and the safety of their vaccine. But it remains for them, as it does all other regions of the world, a dilemma, should this become a person-to-person transmitted disease.

QUESTION: (inaudible).

SECRETARY LEAVITT: Again, I think it's important to look at this as a region because the nature of the borders and the nature of the practices in that region personify the point that if it is
-- if there's person-to-person transmission anywhere there is risk everywhere. There are different challenges for each of those countries. Obviously Indonesia is spread over a long and large area. They have the same kind of cultural farming practices that I spoke of earlier. We met with the President of Indonesia. He spoke forcefully about the desire to protect his people and to cooperate with us. We spent a considerable amount of time with the Agriculture Minister and the Health Minister, both spoke forcefully of their desire. We talked with them about laboratory capacity and ways in which we could help.

But all of that aside, it's clear that they are dealing with complex, difficult situations, which in some cases porous borders that make the task they have challenging.

UNDER SECRETARY DOBRIANSKY: If I may just add to that one quick footnote, and that is I mentioned that in Indonesia we've been focusing very specifically on working with them on surveillance efforts, especially given the geographical challenge and they have been engaging. We have -- I think worked concretely, tangibly together towards establishing a more effective surveillance system.

ADMINISTRATOR NATSIOS: Could I just add one comment here? I want to thank Secretary Leavitt for giving copies of the "Great Influenza" by John Barry. I have no royalty investment in the book, but it's a brilliant piece of writing about the 1918 influenza epidemic worldwide, but specifically in the U.S. It killed, he estimates, maybe as many as 50 to 100 million people within a six-month period, that's how rapidly it spread. And what he says -- what he argues in the book is that because of suppression of information, some of it by self-censorship by the news media in 1918, it was not widely known until after the pandemic was over that this was going on. People knew about it by word-to-word conversation because the media was not reporting it. You can tell by the international media now, all you have to do is look at the major media outputs, that is not happening now. It's quite the opposite.

We have to avoid anybody panicking over it, but one thing is not going to happen this time, it's not going to get suppressed in terms of public information. Public information on a sustained basis over a period of time will begin to sensitize all levels of bureaucracy, even in autocratic governments. Because, you know you can't control the internet, you can't control radio -- people who listen to this stuff. That will discipline our public systems and will, I think, influence the behavior of people, even at the village level, if they understand the nature of the threat and how we have to combat it.

So public information and communication, as long as it's accurate, it provides substantive information on actions that people should take, will have the effect of disciplining the world's system to be more open and more cooperative on this. Systems don't naturally cooperate. There has to be some incentive to do that. And I think the news media by their way in which they report on this, could influence this in a positive way.

QUESTION: Mr. Secretary, as a Greek correspondent, I'm very concerned about recent reports of the arrival of the avian virus and in a Greek island of the Aegean Sea. Therefore, I'm wondering if you have to say anything about this issue?

SECRETARY LEAVITT: The virus has begun to use wild birds as its carrier. And it will go across predictable migratory flyways. It has been carried now into other countries, notably Turkey, Romania, others that have been mentioned. And there is no reason to think it will not go to more. And I -- it is a natural phenomenon that is both predictable and certain.

QUESTION: Were you in touch with the Greek and the European authorities on this matter (inaudible)?

SECRETARY LEAVITT: Yes. We have had ongoing conversations with ministers of health. I'll be meeting in Ottawa next week again with health ministers from throughout the world. We met in Geneva several months ago to discuss this. It's an ongoing and robust conversation.

QUESTION: The surveillance program that is going on in Russia right now and has been ongoing for a while through the BioIndustry Initiative, how can you say that that program and that surveillance program might be used as a model for the new surveillance programs in new regions of the world?

ADMINISTRATOR NATSIOS: I just came back from Russia and met with the Deputy Minister of Health, the Deputy Director of their Emergency Management Agency, EMERCON and then we went up to St. Petersburg and met the director of the Russian Influenza Institute, which has some really fine scientists who've been tracking this. That is, in fact, their only focus is influenza in this institute in St. Petersburg. The doctor who's the head of that institute described the surveillance system they've set up. It appeared to me -- from the two-hour briefing he gave us -- quite efficient in terms of reporting incidents. I don't know about the specific surveillance. If you're talking about the same system that the doctor described to me, it did track the outbreak in the -- I guess, this is southern Russian toward the Caucuses in Central Asia, which apparently are related to these bird patterns, as Secretary Leavitt just mentioned, migratory bird patterns. They did go in very rapidly and destroy the domesticated bird populations that were infected and they explained to us how they did it. It appeared to me to be effective. I can't tell from one briefing operationally whether it is a model for the rest of the world, but it does appear that they've got a system in place and they're attempting to test it to see whether it works.

SECRETARY LEAVITT: Can I just comment on the surveillance generally? I mentioned the family I visited in Vietnam. That was an example of surveillance working very well. That village was knowledgeable about avian influenza. They have begun to cull birds and that was the reason that those birds were destroyed and the point at which he caught it. There was a small clinic in the village commune that had -- where a doctor had been notified of the symptoms to look for and fortunately saw them.

On the one hand, in another Asian country, I got up very early in the morning and went off to a wet market where I walked around large cages of turkeys and ducks and chickens and pigs all in the same area. And I happened to wake a woman up who was sleeping there who was a pig farmer who had driven 600 kilometers the night before with her pigs on the top of her bus next to a group of chickens and had and was going to get up the next morning and sell them and return home. She lives in a very remote area where there isn't television or media or otherwise and she was not familiar to the extent she had heard of avian influenza, but was not in a position to have had the same treatment as my friend in the village in Vietnam.

So there's a wide variety of practices that we observe and wide variety of surveillance available. And the difficulty with the challenge that is faced by these governments that we want to be helpful to is that they're dealing with a situation where there isn't always a health care system where a person can report to and that's the difference in the variety of different circumstances that we're focused on helping.

MR. CASEY: That's all the time we're going to be able to have for you today. Appreciate you all coming. Thank you all.

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