WORLD TB DAY CELEBRATIONS HIGHLIGHT CHALLENGES IN VIETNAM

UNCLAS SECTION 01 OF 04 HANOI 000278 SENSITIVE SIPDIS STATE FOR EAP/MLS, INR, OES/IHB, S/GAC (JHOLLOWAY),MED STATE PASS TO USAID TO ASIA (MELLIS/DSHARMA/CJENNINGS) AND GH (IKOEK/ABLOOM/SBACHELLER) DEPARTMENT OF DEFENSE FOR OSD/ISA/AP CDC FOR DIRECTOR RBESSER, COGH (SBLOUNT),CCID (MCOHEN),AND DTBE (KCASTRO/EMCCRAY) HHS/OSSI/DSI PASS TO FIC/NIH (RGLASS/CSIZEMORE) AND OGHA (JKULIKOWSKI/ACUMMINGS/KMCLEAN) BANGKOK FOR RMO, CDC (MMALISON/SWHITEHEAD),USAID (MACARTHUR/CBOWES) BEIJING FOR HHS HEALTH ATTACHE (EYUAN) E.O. 12958: N/A TAGS: TBIO AMED SOCI KPAO VM SUBJECT: WORLD TB DAY CELEBRATIONS HIGHLIGHT CHALLENGES IN VIETNAM REF: A. STATE 4510 AND B. STATE 17303 HANOI 00000278 001.2 OF 004 ¶1. (U) Summary. In commemoration of World TB Day, Vietnam celebrated the lives and stories of people affected by tuberculosis (TB). The United States Government (USG) joined in GVN events and highlighted our commitment to prevention and control of the spread of this major global public health problem. Within Vietnam, TB remains a leading cause of death from infectious disease and the World Health Organization (WHO) ranks Vietnam twelfth among 22 high-burden countries. On March 24, several Vietnamese newspapers featured articles based on an Embassy press release, detailing the broad and deep support from the USG for Vietnamese efforts to counter TB, while several Embassy officials attended World TB Day celebrations hosted by the Ministry of Health (MOH). The U.S. PEPFAR program provides substantial assistance to persons co-infected by TB and HIV. However, we need to support TB control as part of broader development in the setting of health sector reform. End Summary. World TB Day Events -------------- ¶2. (U) To commemorate the day, Post issued a press release detailing USG efforts to assist the GVN's National TB Program (NTP). Vietnamese media throughout the country picked up the release, which ran in major markets on March 23 and 24. Mission Health Attache and USAID Representative attended the GVN celebration at the MOH, hosted by the NTP. During the event, Vice Minister Nguyen Thi Xuyen reaffirmed the GVN commitment to TB control, while noting continuing challenges, including inability to treat drug resistant TB, poor human resource capacity at the local level, the need to manage the increasing role of the private sector in health care delivery, and to better integrate and improve cooperation between the TB and HIV programs. ¶3. (SBU) In his speech, the WHO Representative congratulated Vietnam on its successes, but implied that the GVN might be losing ground in the fight and urged the MOH to formally approve the establishment of a national STOP TB Partnership, a critical organ for political and financial commitment. TB in Vietnam -------------- ¶4. (U) The 2009 WHO global report, released on World TB Day, provides data with a two-year lag. For 2007, Vietnam reported 150,000 notified new cases for a rate of 171 per 100,000 population (all forms of TB),a decrease of one percent from 2006. The epidemic claimed a recorded 22,000 lives, or 14 percent of all cases, in 2007. Of the total cases, 8 percent were co-infected with HIV and 44 percent were deemed to be infectious at the time of diagnosis. Fifty-six percent of all cases occurred in the southern 20 provinces. ¶5. (SBU) Results from a Dutch government-supported prevalence survey conducted by the GVN with technical assistance from the KNCV Tuberculosis Foundation has not yet been publicly released and is undergoing GVN internal review. Informally, we have learned that the number of Vietnamese living with TB may be 60 percent greater than previously estimated by the WHO. The prevalence survey and other research will also show that the HIV epidemic contributes to continued TB case numbers and related death rates. The WHO 2009 Global report states the "Survey findings have prompted the NTP to accelerate implementation of [strategies such as] private-public mix, advocacy and social mobilization, and other components of the Stop TB Strategy (Ref A and B),especially among population groups that have difficulty in accessing health-care services." However, it took over 7 years to launch the prevalence survey due to GVN HANOI 00000278 002.2 OF 004 delays, and observers are concerned this call for "acceleration" is insufficent. Drug Resistant TB -------------- ¶6. (SBU) Like many countries, Vietnam now must confront multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. In recognition of the severity of the problem, Vice Minister of Health Nguyen Thi Xuyen will attend the upcoming summit on drug resistant TB in Beijing, scheduled for April 1 and will report on Vietnam's experience. However, Vietnam's current 5-year strategy accounts for the diagnosis and treatment of only 1,500 of estimated 6,000 persons currently suffering from MDR TB. And after years of planning this program, which will establish five centers throughout the country, it has yet to begin. According to some local experts, the current plan may not provide sufficient resources to get the job done for the first 1,500 cases and the NTP lacks lack sufficient diagnostic capacity and resources for the costs for the additional cases. TB in Vietnam Impacts U.S. Public Health -------------- ¶7. (SBU) Immigrants and travelers from Vietnam are among the leading groups of persons diagnosed with TB disease in the United States. The U.S. Consulate in Ho Chi Minh City, which processes all Vietnamese immigrant visa applications, works with the International Organization on Migration and U.S. Centers for Disease Control and Prevention (CDC) to closely screen potential immigrants to minimize travelers to the United States with active TB disease (i.e., the more contagious form) -- currently an concerning 0.8 percent of applicants, some with drug-resistant strains. However, even with new CDC technical recommendations and added screening capacity, we cannot catch every infected person, especially those who are non-contagious and asymptomatic. This puts a strain on the U.S. public health system. The Vietnamese Response -------------- ¶8. (SBU) Largely powered by a strong long-term partnership between the Dutch and the NTP, the global TB community views Vietnam's historic response as among the best of the 22 high-burden countries. [Note: a high burden country is defined as one of the set of countries that comprise 80 percent of the world's TB cases.] The current achievements in TB control are the result of classic implementation of the WHO-promulgated "DOTS" strategy (Ref A and B). Since 1996, Vietnam continues to meet WHO case detection and treatment targets; yet, its TB notification rate has not dropped. Meanwhile, pursuant to health sector reorganization, over 50 percent of the TB physicians in the country moved to non-TB work at district hospitals in 2007, placing a tremendous training burden on the program. ¶9. (U) Unlike other health issues, the Vietnamese TB program does not face medium-term funding concerns, based on the current master plan. In 2009, Vietnam's annual NTP budget is about USD 13 million is supported by about USD 4 million from The Netherlands, with most of the remaining USD 9 million split between the amounts from the Global Fund to Fight AIDS, Malaria and Tuberculosis (GF) and internal GVN budgeting. Other partners, including the USG, provide lesser amounts. The GVN budget amount has varied year-by-year, increased from 2008, but is still a few million dollars below the 2002 level. ¶10. (SBU) In 2009, the total cost of TB control in Vietnam is HANOI 00000278 003.2 OF 004 estimated to be about 30 cents per person, of which 10 cents is from GVN sources and goes to the NTP. Of the total amount the GVN spends on health, 3.3 percent goes to the TB control, down from 5.6 percent in 2006. Experts feel these amounts do not fully reflect money spent below the central level, do not accurately account for out-of-pocket expenses, are substantially insufficient for quality TB control for the long-term in a country such as Vietnam given the current trajectory of health sector reform, and reflect overall low rates of GVN spending in health give. [Note: According to WHO recommendations and GVN commitment, TB care should be free-of-charge. However in Vietnam, other health-care related costs in the process of obtaining "free" TB care place an increasingly difficult barrier to diagnosis and treatment, especially for the poor and vulnerable. End Note.] ¶11. (SBU) While the NTP is preparing an application for GF Round 9, which will focus on the private sector and may request an additional USD 20 to 25 million over 5 years, the Dutch have stated that they are pulling out their funding beginning in 2011. Moreover, some experts are coming to the realization that the master current plan while "100 percent funded" through 2011, is inadequate to address the problems at hand. Therefore, the NTP needs to better coordinate existing resources and revise the current 2006-2011 master plan, relatively urgently. To date, the MOH's haphazard approach to running the GF Country Coordinating Mechanism (CCM) covering all three diseases has made adequate stakeholder oversight difficult. Overall U.S. Support -------------- ¶12. (SBU) Since 1995, the United States has provided approximately USD 10 million to support Vietnamese anti-TB efforts. Early assistance, much of which continues, included USAID-funded, CDC-implemented support for operations research, epidemiology training, and public health management training. Current support, primarily through the PEPFAR program, builds upon many years of effort. As part of overall Vietnam PEPFAR funding, which was USD 88.8 million in FY 2008, funds dedicated to combating TB/HIV in Vietnam totaled USD 3.0 million. To date, approved PEPFAR amounts for FY 2009 are USD 88.6 and 2.6 million, respectively. Additional ongoing multi-year support for a WHO Medical Officer in the Western Pacific Regional Office and technical assistance is provided by the USAID Asia Regional Mission, complemented by technical and research assistance from the Division of Tuberculosis Elimination, at CDC. Substantial PEPFAR Achievement with a Focus on TB/HIV -------------- -- ¶13. (U) PEPFAR-funded TB initiatives include HIV testing for TB patients with referral for treatment for those who test positive, intensified efforts to identify persons with TB, and assistance to the MOH to develop a collaborative national protocol between TB and HIV programs in diagnosis, treatment, and management of TB in HIV-infected persons. In 2008, over 20,000 TB patients were tested at more than 100 TB clinics in 19 provinces, which, with U.S. support, now provide HIV testing and counseling services. In addition, over 100 USG supported HIV care sites in 30 provinces of Vietnam provide TB disease screening referral of HIV-infected patients to TB services for evaluation and treatment. In 2008, the program screened more than 12,000 people living with HIV/AIDS suspected of being co-infected with TB. Treatment for TB has been provided to more than 2,500 HIV-infected TB patients. As part of a pilot program to prevent the development of TB, preventive therapy with the drug isoniazid is being given to 1,000 patients infected with HIV in the An Giang and Hai Phong Provinces and Ho Chi Minh City. Additionally, in collaboration with the NTP, the USG is working to improve the quality of basic TB programs, upgrade laboratory infrastructure, and introduce new diagnostic HANOI 00000278 004.2 OF 004 technologies. Applying U.S. Expertise in Infection Control -------------- ¶15. (U) Given the importance of limiting the spread of infection, the USG has assisted upgrades to TB-related public health surveillance, improving health education on TB transmission, financial support for structural renovation in eight provincial hospitals and rehabilitation centers that manage patients with HIV and drug-resistant TB. USG supports training for clinical staff and helps improve laboratory diagnosis of TB in eight provinces. Hanoi, Ho Chi Minh City, Danang and Can Tho Provinces receive specialized support to test and treat cases of multi-drug resistant TB. ¶16. (SBU) Comment. TB remains a substantial public health threat to Vietnam, with impacts within the United States. Though Vietnam is deserving of accolades on past performance, the recent challenges presented by health sector reform, combined with medium-term budget questions and the threat of drug resistant TB, justify a re-evaluation of the level and character of U.S. support for TB prevention efforts. U.S. TB-related technical assistance, while long-standing, was modest until PEPFAR. Even under PEPFAR, the focus remains predominantly on TB issues directly tied to the problem of TB/HIV. In cooperation with our Vietnamese counterparts, we suggest that U.S. public health agencies consider a broader multilateral approach to support TB control in Vietnam. Such a strategy must overcome intra-instructional GVN boundaries, take a broader view of surveillance, and tackle health sector reform and the nebulous private sector head on. Such a broad, modern public health approach to national TB control in Vietnam will improve TB prevention and control in Vietnam and reduce the number of Vietnamese travelers and immigrants bringing TB into the United States. End Comment. MICHALAK