Identifier
Created
Classification
Origin
09MONTEVIDEO212
2009-04-16 16:38:00
UNCLASSIFIED
Embassy Montevideo
Cable title:  

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

Tags:  SOCI TBIO EAGR WHO UY 
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R 161638Z APR 09
FM AMEMBASSY MONTEVIDEO
TO SECSTATE WASHDC 8951
INFO MERCOSUR COLLECTIVE
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
-------

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