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Cablegate: Most Recent Cholera Outbreak Recedes

VZCZCXRO8432
OO RUEHCHI RUEHCN RUEHDT RUEHHM RUEHLN RUEHMA RUEHPB RUEHPOD
DE RUEHHI #0588/01 1410717
ZNR UUUUU ZZH
O 200717Z MAY 08
FM AMEMBASSY HANOI
TO RUEHC/SECSTATE WASHDC 7851
INFO RUEAUSA/DEPT OF HHS WASHINGTON DC IMMEDIATE
RUEHHM/AMCONSUL HO CHI MINH 4740
RUEHZS/ASEAN REGIONAL FORUM COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE
RUEHPH/CDC ATLANTA GA
RUEHRC/DEPT OF AGRICULTURE WASHINGTON DC
RUCPDOC/DEPT OF COMMERCE WASHINGTON DC
RUEHSUN/USUN ROME IT

UNCLAS SECTION 01 OF 03 HANOI 000588

SENSITIVE
SIPDIS

STATE FOR EAP/MLS, EAP/EP, INR, OES/STC, OES/IHA, MED
STATE PASS TO USAID FOR ANE AND GH
HHS/OSSI/DSI PASS TO OGHA (WSTIEGER/LVALDEZ), FIC/NIH (RGLASS), AND
FDA (MPLAISER)
CDC/COGH FOR SBLOUT/KMCCALL/RARTHUR/RCHITALE, PASS TO
NCZVED/DFBMD/EDEB (RTAUXE/EMINTZ) AND GDD, IEIP, DEOC
USDA PASS TO APHIS, FAS (OSTA AND OCRA), FSIS
BANGKOK FOR RMO, CDC (MMALISON/SMALONEY/AHENDERSON), USAID/RDM/A
(CBOWES/JMACARTHUR), APHIS (NCARDENAS), REO (JWALLER)
BEIJING FOR HHS HEALTH ATTACHE (BROSS)
ROME FOR FAO

E.O. 12958: N/A
TAGS: TBIO AMED AMGT CASC EAGR PINR VM
SUBJECT: MOST RECENT CHOLERA OUTBREAK RECEDES

REF: A. HANOI 421 B. HANOI 408 C. HANOI 383 D. 07 HANOI 2071 E. 07
HANOI 2012

HANOI 00000588 001.2 OF 003


1. (SBU) Summary. Officials report that Vietnam's most recent
outbreak of severe acute diarrhea is winding down. Though the
Government of Vietnam (GVN) again responded promptly and
effectively, victims from northern provinces that traveled to other
parts of the country infected other people, demonstrating the ease
with which a cholera outbreak could spread and spin out of control.
As in 2007, substantial numbers of victims tested positive for
cholera. While tentatively linked to the consumption of dog meat,
shrimp paste and raw vegetables, Vietnamese and international public
health officials continue to study the outbreak, its causes, and
exposure pathways. Vietnam now must move beyond response to focus
on prevention and general food safety improvements. End Summary.

Outbreak Details
----------------

2. (U) After flaring up in March, the most recent cholera outbreak
began to die out at the end of April. As of early May, authorities
reported 2,781 cases of severe acute watery diarrhea, of which 396
tested positive for cholera, compared to 1,991 total cases and 295
positive cholera tests in late 2007 (Ref D). The outbreak began in
Hanoi in early March and then moved to neighboring Ha Tay Province.
Hanoi reported the highest numbers, with 1,123 severe acute diarrhea
patients between March 6 and April 28, of whom at least 44 tested
positive for cholera, followed by Ha Tay with 691 cases.
Authorities again highlighted that this outbreak, like the 2007
outbreaks, resulted in no deaths. Though a few central provinces,
along with Ho Chi Minh City in the south (Ref B), reported isolated
cholera cases, health officials reported that infections resulted
from contact with persons who had traveled to northern Vietnam and
brought the bacteria with them.

Likely Causes
-------------

3. (SBU) Scientists from the World Health Organization (WHO) (with
technical support from the U.S. Centers for Disease Control and
Prevention [CDC]) and National Institute of Hygiene and Epidemiology
(NIHE) staff of the Vietnamese Ministry of Health (MOH) are
conducting epidemiological investigations backed by laboratory
testing to find the primary vehicles of transmission of the disease.
Experts have identified several possible vehicles for the spread of
cholera, primarily dog meat, shrimp paste, raw vegetables, and
unhygienically prepared foods. Many victims reported recent
consumption of dog meat -- and, although very hard to culture from
foodstuffs, subsequent tests found Vibrio cholerae in three dog meat
samples. This is of particular concern as Hanoi's estimated 4
million residents consume up to ten to fifteen tons of dog meat
daily. (Note: Dogs are not known to carry or become ill from
infection with Vibrio cholerae; therefore the source of these
bacteria on dog meat samples probably comes from cross contamination
by infected food-handlers or by shellfish, which can become
colonized with Vibrio cholerae in their natural environment).
Additionally, some farmers use human feces to fertilize vegetables
and herbs consumed by restaurant patrons. Sewage discharged from
passenger trains traveling out of the northern provinces provides a
further potential source (Ref A).

Severe Acute Diarrhea or Cholera? Still Unclear
--------------------------------------------- --

4. (SBU) As in the past, questions remain about how to refer to this
outbreak. Jean-Marc Olive, WHO Country Representative, reluctantly
agreed with the GVN to use the title "acute diarrhea epidemic partly
sourced from cholera" to describe the initial outbreak. Though the
Ministry of Health readily acknowledged the large number of cholera
victims, the Prime Minister's office directed the MOH to generally
refer to "severe acute diarrhea" and only use the term cholera for
specific cases that had tested positive for the bacteria. While

HANOI 00000588 002.4 OF 003


this label may pass the smell test, some local media have raised
questions as to whether this title will cause Vietnamese citizens to
change their risky behaviors. Vice Minister of Health Trinh Quan
Huan defended use of the name and stated that referring to the
outbreak as "cholera" would not cause people to improve sanitation
practices. After all, Vietnamese know they should not eat sick
chickens, but many still do and many men continue to have
unprotected sex despite well-publicized warnings that they should
use condoms. However, according to a recent survey by an online
newspaper, many Vietnamese were not concerned by the epidemic
because they thought it was just another diarrhea outbreak. In
private discussions with the GVN, CDC and WHO experts noted that
most of the people with acute watery diarrhea have cholera and that
it makes public health sense to label this event as such.
Fortunately, clinicians in Vietnamese hospitals and clinics treat
every case of acute watery diarrhea as cholera.

Concerns About Possible Future Outbreaks
----------------------------------------

5. (SBU) Though the most recent outbreaks appear to have involved
the relatively mild El Tor biotype of Vibrio cholerae, serogroup O1,
international health experts are examining whether this bacteria
could be an altered Vibrio cholerae O1 El Tor strain. This form has
a higher pathogenicity (resulting in more aggressive disease) than
the El Tor strain that has been circulating the world in the past 20
years. Samples taken in April from 18 rivers, canals and lakes, and
drainages in Hanoi, Ha Tay Province and Thanh Hoa Province revealed
high levels of the bacterium Vibrio cholerae (though it is unclear
whether this Vibrio cholerae matched the serotypes that cause
cholera in humans). The WHO's Olive warned that hot, humid and
rainy summer weather is conducive to the spread of the bacteria.
International public health experts also noted the possibility that
the rare, and more pathogenic Classic biotype of Vibrio cholerae
bacterium may have combined with El Tor in Vietnam. An altered El
Tor could spread more quickly, widely and strongly. The NIHE
continues to conduct research on the bacterium and, according to
newspaper accounts, plans to present its results to the public later
this month.

GVN Response
------------

6. (U) In early April, Prime Minister Nguyen Tan Dung announced the
outbreak's potential threat to public health, socio-economic
development, tourism, and investment and emphasized the importance
of raising public awareness about the danger of the epidemic. The
GVN then initiated a multi-pronged approach to respond to the latest
outbreak focusing on better dissemination of information on disease
prevention, proper cooking techniques and the need to purchase safe
and hygienic foods. Already, well-prepared health establishments
had stockpiled enough medicine and rehydration salts for effective
treatment of patients. Soon after early outbreak reports, Hanoi
authorities began a more aggressive inspection program for food
vendors that led to the closing of dozens of shops. Hanoi's Health
Department Head Le Anh Tuan noted that Hanoi contained 16,000
street-side food stalls, only 40 percent of which had been granted
food safety and hygiene permits. In response to the cholera
outbreaks and other food safety concerns (Ref E), the Vietnam Food
Administration announced plans to hire 8,500 food safety officers to
inspect food storage and preparation in restaurants and street
vendors.

Possible Vaccine
----------------

7. (U) According to NIHE Director Dr. Nguyen Tran Hien, the Vaccine
and Bio-Technology Products No. 1 Company (VABIOTECH), an
independent pharmaceutical spin off of NIHE, has developed a new
oral cholera vaccine. Recent vaccine trials in India showed the new
vaccine induced protective antibodies in 65 percent of adults and 87
percent of children after two doses that lasted for 2 years. The

HANOI 00000588 003.2 OF 003


present vaccine produces protective antibodies in 30 percent of
those immunized. VABIOTECH, which began developing the new cholera
vaccine in early 2006, plans to market the drug under the trademark
of MORACVAX. The company and the International Vaccine Institute
successfully tested MORACVAX on 200 people in Vietnam and India in
2006. The new vaccine will cost around 20,000 Vietnamese Dong
(approximately 1.25) per dose -- three times more than the existing
cholera vaccine. International experts have yet to clearly weigh in
on the efficacy and role of the new vaccine.

Comment
-------

8. (SBU) Once again, Vietnam quickly and effectively responded to an
outbreak of severe acute diarrhea. However, this most recent
outbreak -- with more total cases and more test results positive for
cholera than the initial epidemic in late 2007 (Ref D) -- highlights
the need for better prevention. As the rainy season begins, health
experts worry about new and possibly larger or more virulent
outbreaks. At the same time, any forward-looking measures designed
to prevent future outbreaks will need to address sanitation and
hygiene at Vietnam's tens of thousands of informal food vendors and
take long-range measures to reduce fecal contamination of food and
water in general. Though vaccinations may help to limit cholera,
Vietnam should focus on upgrading food safety, drinking water
quality and sanitation systems -- solutions that will pay public
health dividends beyond cholera control. Additionally, Vietnam
must upgrade food hygiene standards and raise the standards of
vendors that do not meet those requirements. We have heard that
Vietnamese health officials have been hesitant to crack down on dog
meat venues due to powerful business interests. The GVN must
empower health inspection teams to act, regardless of political
influence, if it wants to prevent the next outbreak before it
begins.

MICHALAK

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