VZCZCXRO6459
RR RUEHCHI RUEHDT RUEHHM RUEHNH
DE RUEHHI #2099/01 3540916
ZNR UUUUU ZZH
R 200916Z DEC 07
FM AMEMBASSY HANOI
TO RUEHC/SECSTATE WASHDC 6907
INFO RUEHHM/AMCONSUL HO CHI MINH 4083
RUCNASE/ASEAN MEMBER COLLECTIVE
RUEHHI/SCIENCE AND TECHNOLOGY COLLECTIVE
RUEHKT/AMEMBASSY KATHMANDU 0100
RUEHRO/AMEMBASSY ROME 0262
RUEHSV/AMEMBASSY SUVA 0026
RUDKIA/AMCONSUL CHIANG MAI 0017
RUEHCN/AMCONSUL CHENGDU 0333
RUEHGZ/AMCONSUL GUANGZHOU 0836
RUEHHK/AMCONSUL HONG KONG 1312
RUEHSH/AMCONSUL SHENYANG 0339
RUEHIN/AIT TAIPEI 1542
RUEHGV/USMISSION GENEVA 1220
RUEAUSA/DEPT OF HHS WASHINGTON DC
RUEHPH/CDC ATLANTA GA
RUEHRC/DEPT OF AGRICULTURE WASHINGTON DC
RUEHRC/USDA FAS WASHDC 0062
RUEKJCS/SECDEF WASHINGTON DC//USDP/ISA/AP//
RHMFISS/CJCS WASHINGTON DC//J2/J3/J5//
RHEFDIA/DIA WASHINGTON DC//DHO-3//
RHMFIUU/CDR USPACOM HONOLULU HI//J00/J2/J3/J5//
RUEAIIA/CIA WASHINGTON DC
UNCLAS SECTION 01 OF 05 HANOI 002099
SIPDIS
SENSITIVE
SIPDIS
DEPARTMENT FOR EAP/EX; EAP/MLS; EAP/EP; EAP/PD
DEPARTMENT FOR OES/STC/MGOLDBERG AND PBATES; OES/PCI/ACOVINGTON;
OES/IHA/DSINGER AND NCOMELLA
DEPARTMENT FOR CA/OCS/ACS/EAP
DEPARTMENT PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL
CDC ATLANTA FOR COGH (SDOWELL/RARTHUR) AND DVID(LPETERSEN)
HHS/OSSI/DSI PASS TO OGHA (WSTIEGER/LVALDEZ/CHICKEY)
USDA FOR OSEC AND APHIS
USDA FOR FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG
USDA/FAS FOR FAA/YOUNG, MOLSTAD, ICD/PETTRIE, ROSENBLUM
DEPARTMENT OF DEFENSE FOR OSD/ISA/AP FOR LEW STERN
PARIS FOR FAS/AG MINISTER COUNSELOR/OIE
ROME FOR FAO
BANGKOK FOR REO WALLER AND RDM/A (CBOWES/JMACARTHUR)
KATHMANDU FOR REO ADAMS
SUVA FOR REO MURPHY
E.O. 12958: N/A
TAGS: TBIO EAID SOCI PGOV AMED AMGT CASC KPAO VM
SUBJECT: DESPITE EFFECTIVE GOVERNMENT RESPONSE, DENGUE CONTINUES TO
PLAGUE VIETNAM
REF: A. HANOI 1954 B. BANGKOK 4603
HANOI 00002099 001.2 OF 005
1. (SBU) Summary. Annual numbers of dengue cases continue to rise
in Vietnam, particularly in the Mekong Delta region. Though the
Government of Vietnam (GVN) has a comprehensive national program to
control dengue, it cannot eliminate the disease. Instead,
ecological factors, including the growth of urban characteristics in
rural areas, promote dengue's continued occurrence. With no vaccine
in sight, Vietnam is looking at creative methods to limit the
population of dengue-carrying mosquitoes, though the feasibility and
effectiveness of large-scale application of these methods remains
unclear. The United States provides modest but critical dengue
assistance via USAID/RDM/A, though a Vietnam-based World Health
Organization (WHO) public health specialist questioned the need for
substantially increased support. End summary.
Dengue Cases Increasing
-----------------------
2. (U) Dengue fever is endemic in Vietnam, circulating throughout
the year, but particularly prevalent in the hot, rainy months of
July and August. Historically, dengue cases are concentrated in
southern Vietnam but occur in all regions. Nationally, an estimated
70 million people (out of a total population of 84 million) are at
risk from the disease. Annual numbers fluctuate in a cyclic fashion
over time, and in some years the disease may be epidemic. During the
last large outbreak in 1998, Vietnam reported 192,796 cases with 408
fatalities. Although cases subsequently fell, they again appear to
be on the upswing. Over the first ten months of 2007, Vietnam
reported over 75,000 cases of dengue, with 64 deaths, increases of
51 percent and 45 percent respectively compared with the same period
in 2006. Consistent with the past, 86 percent of these cases
occurred in the south, with the majority in Ho Chi Minh City or
provinces located in the Mekong Delta. Central provinces accounted
for almost 9,000 cases, while the central highlands and northern
provinces reported few infections. Though dengue fever cases
typically peak in the summer, Ministry of Health (MOH) officials
reported nearly 2,000 cases per week through October.
Dengue Epidemiology
-------------------
3. (U) The Aedes mosquitoes, which feed outdoors throughout the day
with peaks of activity in the early morning and late afternoon,
spread dengue. The virus life cycle requires to-and-fro passage
between mosquitoes and humans for survival. The flight range of the
Aedes is within a few households, limiting the scope of outbreaks.
In Vietnam, household water containers are the classic Aedes
breeding sites, along with discarded objects that can hold water,
HANOI 00002099 002.2 OF 005
such as tires, bottles, jars, and cans. Extension of piped water
services has not limited dengue, as many locals store water in
inadequately covered jars in order to let sediments settle. Most
Vietnamese in the south have been exposed as children to infection
with one or more of the four serotypes of dengue virus, resulting in
some protection in adulthood. However, persons can become infected
with one serotype, develop immunity, but still be susceptible to
other serotypes, which makes it difficult to analyze and interpret
data related to morbidity and the effectiveness of dengue preventive
measures.
4. (SBU) Dengue thrives in urban environments, but is not strictly
an urban disease. Indeed, experts see increased spread of dengue
into rural areas that develop "urban" characteristics such as
uncovered collections of clear water that serve as breeding sites
for Aedes mosquitoes. According to Dr. Antonio Montresor, Public
Health Specialist at the WHO, as long as there are humans and clear
water breeding sites, dengue can thrive. Recent flooding in central
Vietnam will have little impact on dengue disease activity as the
turbulent and dirty floodwaters are not suited for dengue mosquito
breeding (ref A). Dr. Duane Gubler, Director of the Asia Pacific
Institute of Tropical Medicine and Infectious Diseases at the
University of Hawaii, stated that human ecology (mobility and social
factors), housing construction, herd immunity and mosquito density
constituted the primary factors affecting a dengue outbreak.
Additionally, according to Gubler, contrary to popular belief, no
solid evidence supports the theory that the re-emergence of dengue
is due to climate change. Per Montresor, economic development
appears to have limited impact on dengue as evidenced by continued
outbreaks in Singapore, a city-state with high public hygiene
standards. Consistent with comments by Montresor and Gubler,
Vietnamese public health officials noted several possible reasons
for difficulties in control of dengue, including complex weather
patterns favorable for mosquito breeding, the lack of dengue fever
vaccines, the occurrence of multiple dengue serotypes, and the
impact of urbanization and human migration.
Vietnamese Response Manages,
But Does Not Eliminate Dengue
-----------------------------
5. (SBU) The Vietnamese response to dengue has focused on pragmatic
solutions to manage, not eliminate, the disease. In 2001, Vietnam
adopted a WHO-recommended prevention strategy stressing
surveillance, behavioral change, and mosquito control, which covers
nearly all provinces. According to WHO's Montresor, over time,
Vietnam has developed significant practical experience identifying
and treating dengue. Vietnam focuses on education programs for
medical professionals and impacted populations and encourages
HANOI 00002099 003.2 OF 005
hospitals and health clinics to share information. The GVN has
developed standardized protocols for dengue identification and
treatment, which importantly contribute to low mortality. Per
Montresor, Vietnam spends a "few" million dollars each year on
dengue programs.
GVN Considering New Responses
-----------------------------
6. (U) Vietnam's health minister has raised concerns about a
spreading dengue outbreak and the MOH is seeking government approval
to include dengue along with HIV/AIDS in a national prevention
program that targets social and dangerous diseases. In response to
the recent increase, Vice Minister Huan asked the MOH Preventive
Medicine Department to revise dengue prevention regulations and
instructions to make them more appropriate to reality on the ground,
including more prompt spraying in response to reports of dengue
(Note: public health experts question the efficacy of spraying to
control dengue).
A Mesocylops a Day Keeps the Dengue Away
----------------------------------------
7. (SBU) Vietnam is looking at other interventions to control
dengue-carrying mosquitoes and has become a world leader in
community control studies using an indigenous natural mosquito
predator, Mesocyclops (ref B). These microscopic crustaceans are
placed in mosquito breeding sites where they attack and kill
developing mosquitoes. While pilot projects have shown some
success, urban control has been elusive. Montresor noted
difficulties in expanding beyond the pilot stage and stated that
such a project may be too labor intensive to justify. Montresor
worried that Vietnam might be overspending on this public health
research project, which, even though it is developing technical
research capacity, might not lead to substantial reductions in
dengue.
Successful Anti-Malaria Campaign
Not Applicable to Dengue
--------------------------------
8. (U) Due to differences between the carrier mosquitoes, Vietnam
cannot use its successful malaria control efforts to address dengue.
Vietnam has limited malaria through vector control, primarily
artemisinin-impregnated mosquito nets. However, the dengue-carrying
Aedes mosquito bites during the day, making mosquito nets and
spraying much less effective (Note: the GVN continues to spray as
part of its dengue prevention efforts). Instead, routine control
efforts focus on preventing mosquito breeding in water containers.
HANOI 00002099 004.2 OF 005
Dengue treatment also lags behind that of malaria, and public health
practitioners try to reduce symptoms and save lives. Further, while
treatment reduces dengue mortality, it does not interrupt
transmission.
Vietnam's Efforts Appear to Have Limited Dengue
--------------------------------------------- --
9. (SBU) Montresor noted that dengue infection rates vary greatly
over time due to ecological reasons unrelated to human
interventions. Therefore, it is very difficult to determine if
interventions work. At the same time, however, Vietnam's extremely
low mortality rate likely indicates the effectiveness of its
training for medical professionals in best treatment practices,
especially the management of patients with dengue hemorrhagic fever
(DHF). By means of comparison, Vietnam has reported the same number
of deaths as Cambodia, despite four times the number of infections.
Vietnam Not In Desperate Need for More Resources
--------------------------------------------- ---
10. (SBU) According to Montresor, the Vietnamese dengue effort does
not need significant new funds, though it could use some additional
money to improve existing educational efforts and improve training.
Although some public health experts disagree, Montresor saw little
value to putting money into increased surveillance, as once a dengue
outbreak detected, it would be too late to apply control measures.
When a vaccine has been developed, Vietnam will need support to
scale up and integrate dengue vaccinations into overall its overall
vaccination campaign, but this likely will not happen for several
years.
U.S. Assistance
---------------
11. (SBU) The USAID Regional Mission in Bangkok, as part of a
regional initiative, funds WHO programs in Vietnam to 1) strengthen
dengue diagnosis (clinical and laboratory) and case management at
provincial and district levels, 2) pilot a school-based vector
control model at commune level, 3) enhance capacity in and support
the implementation of containing dengue outbreaks and 4) strengthen
technical and managerial capacity of the national dengue control
program. WHO also provides in-kind technical support to GVN dengue
projects and seeks to pair the GVN with overseas sources of money
targeted to promote Vietnamese health education programs,
particularly those that improve the capacity of medical personnel to
quickly recognize and treat dengue. Additionally, the Division of
Vector-borne Infectious Diseases (DVBID) of the Centers for Disease
HANOI 00002099 005.2 OF 005
Control (CDC), in the past actively collaborated with the Pasteur
Institute and the National Institute of Hygiene and Epidemiology on
dengue prevention.
Comment
-------
12. (U) While dengue infections are up, mortality remains low,
evidencing the effectiveness of Vietnam's strategy to promote high
standards of clinical care of the disease. At the same time, lack
of a vaccine and increased breeding grounds for the mosquitoes that
carry the disease ensure that Vietnam's efforts will not seriously
reduce infections. While foreign assistance should continue to
support Vietnam's pragmatic efforts, funds that support global
vaccine research will have the greatest long-term impact on dengue
in Vietnam.
MICHALAK