URUGUAY: KEEPING AN EYE OUT FOR EMERGING AND RE-EMERGING

UNCLAS MONTEVIDEO 000212 WHA/BSC FOR MARY DASCHBACH OES/IHB FOR LISA MILLER E.O. 12958: N/A TAGS: SOCI TBIO EAGR WHO UY SUBJECT: URUGUAY: KEEPING AN EYE OUT FOR EMERGING AND RE-EMERGING INFECTIOUS DISEASES REF: A) STATE 002172, B) MONTEVIDEO 00107 Summary -------------- ¶1. While Uruguay has completed the epidemiological transition from infectious diseases to non-communicable diseases, it nevertheless faces an increasing incidence of diseases, such as parasitic diseases, traditionally linked to poverty and deteriorating social and environmental conditions. The GOU is currently implementing programs for the prevention, surveillance, and control of potentially emerging and re-emerging infectious diseases. The following report responds to Ref A, and examines the impact of infectious diseases in Uruguay and related policy developments. End Summary. Background: Uruguay -------------- ¶2. Population growth in Uruguay is almost flat. Several factors have contributed to the aging of Uruguay's population, including increasing life expectancy, decreasing fertility and mortality rates, and a strong emigration flow during the last decades. Concomitantly, Uruguay has completed its epidemiological transition from infectious diseases to non-communicable diseases. The burden of disease has changed mainly due to the aging of the population, unhealthy lifestyles (e.g. poor nutrition, obesity, and consumption of tobacco and alcohol). Chronic illnesses are now the main health problem in Uruguay, having replaced infectious diseases as the leading causes of illness, disability, and death in Uruguay (Ref B). ¶3. Poverty is also a problem. Preliminary 2008 data released by the GOU indicate that only 1.7 percent of the population remains below the income level characterized as indigent, where family income is unable to meet food needs, 21.7 percent remain below the poverty line based on essential household needs. An ugly aspect of the problem is that poverty and hardship in Uruguay have a young face: a much higher percentage of people under age 18 live in poverty than any other age group. This situation has led to a higher incidence of diseases traditionally linked to poverty, such as parasitic diseases. ¶4. Below are listed those existing, emerging, or re-emerging human infectious diseases found in Uruguay, grouped by causative agent: Viral Infectious Diseases -------------- ¶5. The GOU keeps a surveillance program for early detection of AVIAN INFLUENZA. Periodic sampling from commercial and backyard poultry production, as well as from wild birds, has never yielded a positive result, nor have any imported cases been seen. ¶6. The HUMAN IMMUNODEFICIENCY VIRUS (HIV) that causes AIDS appeared as early as 1983 in Uruguay. Even though the adult prevalence rate for the general population has always been less than 1 percent, the epidemic continues to show a growing trend, as reported by sentinel studies: 0.23 percent in 2001, 0.36 percent in 2002, and 0.45 percent in 2004. Prevalence rates higher than 5 percent are confined largely to highly vulnerable groups (male sexual workers, injecting drug users (IDU),other drug users, and prisoners). As of December 2008, a total of 10,767 HIV/AIDS cases had been reported to the National HIV/AIDS Program since the disease first appeared. Of those, 7,470 were HIV positive while 3,297 have/had AIDS. Of those, 1,761 are already deceased (a mortality rate of 53.4 percent). Out of the 9,006 persons living with HIV/AIDS, only an estimated 22 percent are receiving treatment. The remaining 78 percent is not, due to reasons ranging from abandonment of treatment to personal decisions in favor of alternative therapies. Patients not receiving Highly Active Anti-Retroviral Therapy (HAART) are more susceptible to opportunistic infections, with tuberculosis, cryptococcal meningitis, and P. jiroveci pneumonia the most prevalent in Uruguay. ¶7. The HIV infection pattern in Uruguay shows sexual transmission as the main mode of transmission of HIV in Uruguay (71 percent), followed by transmission through blood and blood products (25 percent),and perinatal transmission (4 percent). Heterosexual contacts are the predominant mode of sexual transmission (70.9 percent) followed by homosexual (27.5 percent) and bisexual transmission (16.6 percent). Among the blood transmission categories, unsafe drug-injecting practices are the main driving factor (98.9 percent). Men are the prime casualties of the epidemic (64.4 percent) while women account for 35.6 percent of the reported HIV infections. There has been a feminization of the epidemic, with the male/female ratio dropping from 8.5/1 in 1991 to 2.2/1 in 2006. There is a higher incidence (annual number of new infections) in the 25-34 age range. HIV/AIDS in children represents 3.9 percent of the accumulated cases today. Sixty percent of HIV positive mothers are estimated to have acquired the virus through sexual transmission, whereas the remaining 40 percent are mothers who are IDUs or whose sex partners are IDUs. ¶8. DENGUE, endemic in most countries in the Americas, is a re-emerging disease that the GOU is dealing with at the moment. The Aedes aegypti mosquito, the dengue vector, was again detected in Uruguay in 1997 after being absent since its eradication in 1958. In the past decades, there had been only four dengue cases in Uruguay, all of whom contracted the disease in other countries. However, last week Uruguay's health authorities confirmed the country's first case of domestic dengue fever, in a 30-year-old construction worker living in the northern department of Salto. The GOU immediately activated its dengue control plan. The patient has been isolated in a clinic, and potential breeding sites are being fumigated. ¶9. Uruguay was declared free of FOOT-AND-MOUTH-DISEASE (FMD) without vaccination in 1999. However, in 2000 the virus was reintroduced in the northeastern part of the country and recommendations of the World Organization for Animal Health were implemented to get the disease under control. In 2001, the disease re-emerged on the eastern coast and, since then, bovine vaccination was reinitiated. Uruguay now has the status of an FMD-free country with vaccination. Transmission from animals to people is exceptionally rare. ¶10. The HANTAVIRUS PULMONARY SYNDROME is a respiratory disease. The natural hosts of the virus are wild rodents found in rural areas. The first case in Uruguay was reported in 2004. Since then, the incident rate of the disease has remained low (0.22 cases per 100,000 people per year). ¶11. The last human case of RABIES in Uruguay had occurred in 1966. The decline in human rabies cases is attributable to the country's efforts to strengthen epidemiological surveillance, conduct mass canine vaccination campaigns, and treat infected persons. Nevertheless, in 2008, a farmer from Rivera, northern Uruguay, was bitten by a hematophagous (vampire) bat which subsequently tested positive for rabies. The farmer received post exposure prophylaxis. Other colonies were reported in Rivera but no human infections were registered. APHIS/USDA collaborated with the GOU's control efforts by donating mist nets. ¶12. There is currently no risk of YELLOW FEVER in Uruguay, although it may re-emerge in the future. Yellow fever vaccination is required for all travelers over 1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas, but is not recommended or required otherwise. Bacterial Infectious Diseases -------------- ¶13. Even though a few ANTHRAX cases have been registered in rural workers since 2000, this disease has been on the decline in Uruguay. ¶14. Several cases of BRUCELLOSIS are found in Uruguayan rural workers every year. However, estimates show that Uruguay, like most countries, is likely to have a number of undiagnosed or unreported cases of the disease. ¶15. There is currently no risk of CHOLERA in Uruguay. ¶16. LEPTOSPIROSIS in Uruguay is said to be an endemic disease with epidemic outbreaks. It is increasingly being reported, probably due to a greater awareness of the importance of this disease, largely caused by floods. The increasing poverty and spread of informal suburban settlements in the country are also thought to be contributing to the increase. In 2007, 106 cases were reported, almost double the amount reported in 2006 (64). The mortality rate has gone down, however, from 22 percent in 2000 to 8 percent at present. ¶17. The prevalence of TUBERCULOSIS (TB) in Uruguay used to be very low, partly due to the success of local TB control programs. However, this trend was reversed in the mid-1990s due to the expansion of the HIV/AIDS pandemic and the increasing poverty. In 2006, 910 new cases were registered. An estimated 14 percent of the new cases of TB were carriers of the HIV/AIDS infection. The co-infected patients (TB plus HIV/AIDS) are largely young adults, concentrated in the 25 to 34 year demographic. A unique situation occurs in Uruguay's overpopulated jails and prisons, where the incidence rate is 30 times greater than in the general population. ¶18. An excessive use of antibiotics is also posing a serious health risks to outpatients since it has contributed to the emergence and spread of antibiotic-resistant bacteria in Uruguay. Common pathogens such as Mycobacterium tuberculosis, Escherichia coli, Salmonella spp, Staphylococcus aureus, and Streptococcus pneumoniae have developed resistance to common antibacterial drugs, complicating treatment for the diseases they cause. In 2004, two major outbreaks caused by a strain of methicillin-resistant Staphylococcus aureus of community origin affected 417 people in Montevideo. Eighty percent were topical infections where the patients were treated on an outpatient basis. Four deaths were reported. The Ministry of Public Health set up a program aimed at the prevention, surveillance, and intervention to limit emerging antimicrobial resistance, targeted at both health workers and the general population. Parasitic Infectious Diseases -------------- ¶19. In Uruguay, CHAGAS DISEASE (American trypanosomiasis) is caused by the parasite Trypanosoma cruzi. Uruguay was able to completely halt vector-borne transmission by 1997. Since then, Uruguay is the first endemic country to successfully interrupt transmission nationwide. Surveillance and control efforts continue to avoid the reemergence of the disease. ¶20. HYDATIDOSIS (cystic echinococcosis) is a highly endemic parasitosis that, through massive public campaigns, has been drastically reduced in terms of prevalence among humans, ovine and bovine (intermediate hosts),and canines (definite host). Every year, at least 2 percent of the rural population is diagnosed with hydatidosis, although GOU health officials estimate that the disease is actually under diagnosed. The dog population in Uruguay is estimated to be very high (over 450,000) compared to human population (approximately 3,300,000),thus posing a severe sanitary problem since dogs are the final hosts. Human and animal hydatidosis were declared a national plague in 1965. ¶21. LEISHMANIASIS (both cutaneous and mucocutaneous) also occurs in the region, mostly in rural areas. ¶22. There is currently no risk of MALARIA in Uruguay, although it may re-emerge in the future. GOU Policies and Programs -------------- ¶23. The policies and programs that the GOU has implemented for the prevention, surveillance and control of infectious diseases, have resulted in high percentages of immune prevention coverage, success in the control of regional pathologies, and actions oriented towards emerging and re-emerging diseases. ¶24. An Expanded Immunization Program has been in place since 1982. The vaccines that are part of the schedule are offered free of charge and at all stages of life, and are mandatory before entry into the education system. This has resulted in vaccination coverage greater than 95 percent for the 11 vaccines included in the Program, which are: anti-tuberculosis vaccine (BCG),diphtheria, tetanus, whooping cough (pertussis),haemophilus influenzae type B, hepatitis B, poliomyelitis, mumps, rubella, measles, and chickenpox (varicella). In 2008, two additional vaccines (antipneumococcal heptavalent and anti-hepatitis A) were added to the Program. No cases of poliomyelitis, neonatal tetanus, diphtheria, measles, rubella, mumps, varicella, pertussis, etc. have been registered since the mid-1980s. ¶25. Since the onset of the HIV/AIDS epidemic in Uruguay, the GOU has developed several initiatives to deal with the problem. The establishment of a National AIDS Program was the starting point. Since 1991, access to free GOU-provided HAART coverage is guaranteed by law for all HIV/AIDS patients, from either the public or private sectors. Standard HIV/AIDS treatment protocols were also developed. The Vazquez administration is now in the process of applying to Round 9 of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The objectives of the Uruguayan proposal are to reduce HIV transmission in general and improve the quality of life of people living with HIV/AIDS. ¶26. Blood donation in Uruguay is voluntary according to national norms. Blood and blood derivatives must, by law, be screened for syphilis, viral hepatitis B, viral hepatitis C, HIV (anti HTLV-1 and 2),and Chagas disease. ¶27. Since agricultural products constitute about 65 percent of the value of the total exports of Uruguay, the GOU also places a high priority on food safety and animal/plant health. Important efforts are dedicated to the surveillance, prevention, and control of zoonoses. Note: A zoonosis is any infectious disease that may be naturally transmitted (in some instances, by a vector) from animals, both wild and domestic, to humans. End Note. Uruguay's efforts are usually complemented by assistance from the WHO and the Pan American Health Organization (PAHO),as was the case with the Southern Cone Initiative for the Elimination of Chagas Disease and the Southern Cone Subregional Program for the Control and Surveillance of Hydatid Disease. SCHANDLBAUER