DESPITE EFFECTIVE GOVERNMENT RESPONSE, DENGUE CONTINUES TO

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