WORLD TB DAY CELEBRATIONS HIGHLIGHT CHALLENGES IN VIETNAM

UNCLAS SECTION 01 OF 04 HANOI 000278

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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

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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

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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

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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

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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