VZCZCXRO1586
RR RUEHCHI RUEHDT RUEHHM RUEHNH
DE RUEHBK #3439/01 1720851
ZNR UUUUU ZZH
R 210851Z JUN 07
FM AMEMBASSY BANGKOK
TO RUEHC/SECSTATE WASHDC 7763
RUCPDOC/USDOC WASHINGTON DC
RUEATRS/DEPT OF TREASURY WASH DC
RUEHPH/CDC ATLANTA GA
RHMFIUU/DEPT OF HOMELAND SECURITY WASHINGTON DC
RUCNASE/ASEAN MEMBER COLLECTIVE
RUEHGO/AMEMBASSY RANGOON 4060

UNCLAS SECTION 01 OF 03 BANGKOK 003439 
 
SIPDIS 
 
SENSITIVE 
 
SIPDIS 
 
STATE FOR EAP/MLS AND EB 
COMMERCE FOR EAP/MAC/OKSA 
TREASURY FOR OASIA 
STATE PASS TO USTR FOR WEISEL 
STATE PASS TO FEDERAL RESERVE SAN FRANCISCO FOR DAN FINEMAN 
STATE PASS FEDERAL RESERVE NEW YORK FOR MATT HILDEBRANDT 
 
E.O. 12958: N/A 
TAGS: ECON EAID PGOV PHUM PREL TH
SUBJECT: MULTI-DRUG RESISTANT TUBERCULOSIS IN THAILAND: GLOBAL RISKS 
 
REFS:  A) Rangoon 588 B) Rangoon 134 
 
This is a joint-cable between the U.S. Embassy in Bangkok and the 
U.S. Embassy in Rangoon. 
 
Summary 
----------- 
 
¶1. Collaborative efforts between the CDC and the Thai Ministry of 
Public Health (MOPH) have improved the accuracy of testing and 
reporting of tuberculosis (TB) cases in Thailand. As a result, 
health authorities here better understand the prevalence of 
multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB. 
There are several hotspots for MDR TB in Thailand. Tak Province, 
located along the Burma/Thai border is one such hotspot, where 10% 
of culture-confirmed TB cases are MDR. Recently, two migrants from 
Burma were diagnosed with XDR TB in Tak. The emergence of XDR TB and 
the high rate of MDR TB in Tak Province are due to poor compliance 
of patients with TB treatment and lack of appropriate diagnostic and 
treatment services for populations originating in Burma. The 
political situation in Burma shows no signs of abating and the 
displaced will continue to travel into Thailand, some of them 
settling in refugee camps in Tak Province. Migrants will also 
continue to travel to Thailand as long as it offers better economic 
opportunity and access to higher quality health services. Without 
improvements in the diagnosis and treatment of TB patients in Burma, 
the numbers of MDR and XDR TB cases are expected to increase in 
Burma and subsequently Thailand. This potentially has global health 
implications due to the ongoing resettlement of refugees from Burma 
to the United States, as well as Thais traveling internationally. 
We recommend seeking HHS agreement to permit CDC personnel to travel 
to Burma to assist with reducing the spread of this threat. End 
Summary. 
 
¶2. Thailand's ability to accurately diagnose and effectively treat 
TB is improving.  However, many Thai health professionals still do 
not use sputum cultures to test for TB, which is the most accurate 
way to diagnose TB and MDR TB.  Sputum culture tests are time 
consuming, more expensive and require laboratory capabilities that 
are not available in many Thai hospitals.  The Thai MOPH - U.S. CDC 
Collaboration is currently trying to improve this situation by 
building laboratory capacity in five provinces in Thailand, 
including Tak.  In regards to treatment, most patients in Thailand 
do not receive directly observed therapy by a health care worker 
(DOT).  DOT involves medical staff or trained personnel directly 
observing the ingestion the TB medications. DOT is recommended by 
WHO and CDC as the most effective way to treat TB.   It protects the 
patient's health and prevents drug resistance by ensuring compliance 
with the drug regimen. Many Thai hospitals give patients the option 
of using DOT, but do not require it. Thailand's failure to use DOT 
may contribute to MDR. In 2001, 1% of all TB patients in Thailand 
had MDR TB.  Preliminary data from a Thai MOPH survey currently 
underway indicate that the number of MDR TB cases in Thailand may 
have doubled since then. CDC is currently working with the Thai MOPH 
to measure the number of XDR TB cases nationally in Thailand. 
 
¶3.  In Burma, a 2002/03 survey demonstrated 4% MDR TB among new 
patients and 15.5% among previously treated patients. Diagnosing and 
treating these patients is complicated by the overall poor state of 
the public health system, restrictions on the delivery of assistance 
in many areas, and conflict in border areas.  Reftels describe in 
more detail the challenges facing TB programs operating in Burma. 
Among the most important are: late case diagnosis, lack of a 
standardized treatment regimen, and inadequate funding for basic 
diagnostic tests and medications. 
 
¶4. Tak Province is a convenient crossing point for Burmese migrants 
and displaced persons. On June 7, 2007, a Doctors Without Borders TB 
clinic for Burmese migrants in Tak Province reported that 2 cases of 
XDR TB had been diagnosed in migrants from Burma; the diagnoses was 
confirmed by laboratory testing done at the Thai MOPH reference 
laboratory. Approximately 10% of all culture-confirmed cases in Tak 
Province are MDR TB, most of which are diagnosed in migrants from 
Burma. The emergence of XDR TB and the large number of MDR TB cases 
in Tak is directly caused by the weak infrastructure of the TB 
program in Burma and amplified by weaknesses in the Thai TB program. 
Migrants from Burma who are treated for TB in Thailand report that 
 
BANGKOK 00003439  002 OF 003 
 
 
TB clinics in Burma, particularly along the border, have limited or 
no staff and do not have a consistent supply of quality medicines. 
These migrants with TB report purchasing anti-TB medicines from 
pharmacies or private doctors in Burma and taking these medicines 
haphazardly. Normally, TB can be cured by taking medication for six 
months to one year. Failure to take medications consistently and 
correctly, poor quality of medications, and poor record keeping can 
disrupt the treatment process and cause the TB bacteria to become 
resistant to first-line and second-line (reserve) drugs. 
 
¶5.   A mobile population makes it particularly difficult to diagnose 
and treat TB.  In order to determine if TB is either MDR or XDR, a 
sputum sample must be sent to an appropriate lab, where a culture 
test is performed. After TB bacilli is grown in culture, the 
laboratory can test whether the bacteria is resistant to first and 
second line drugs.  This entire process takes approximately four to 
six weeks using the best techniques, and if the patient is mobile, 
it may be difficult to locate them once the results are known. In 
this case, the patient will not be able to receive treatment and 
could infect others. 
 
¶6. CDC and the Thai MOPH suspect that there are high rates of MDR TB 
in migrants and displaced people along the border between Thailand 
and Burma. Their suspicions are based on the fact that there is a 
high prevalence of MDR TB in the same populations in Tak Province 
and that XDR TB has now been identified in migrants from Burma. 
Furthermore, Burma does not have the medical infrastructure to 
accurately test and effectively treat TB. The political situation in 
Burma shows no signs of abating and it is reasonable to conclude 
that the flow of migrants and displaced people will not stop in the 
near future. Therefore, CDC expects that highly resistant strains of 
TB will continue to emerge in Burma, particularly along the border 
with Thailand. 
 
¶7. The increase in the number of cases of MDR and the emergence of 
XDR TB in Tak Province could have global health implications if 
allowed to continue unchecked.  This is best illustrated by the 
Hmong refugee resettlement in 2004 - 2005. Despite the CDC's best 
efforts to screen those bound for the US, 37 refugees were diagnosed 
with TB upon arrival in the U.S. and four of those cases were MDR. 
The increased mobility of Thais also poses a threat to the health of 
countries in Southeast Asia. Porous borders with Laos and Cambodia 
and an increased standard of living in Thailand make it possible for 
Thais to travel frequently throughout the region. Frequent travel, 
especially by airplane, could facilitate the spread of MDR TB. 
 
¶8.  Recently, USAID in Bangkok, the World Health Organization's 
office in Burma, and Embassy/Rangoon have requested assistance from 
CDC Bangkok staff in improving TB programs in Burma. However, we 
understand that CDC has been unable to respond to requests, because 
HHS policy does not permit travel to Burma. U.S. foreign policy 
permits humanitarian assistance to the people of Burma through 
non-governmental and multi-lateral organizations. USAID and the 
State Department currently have health programs operating in this 
manner in Burma. These programs include global health threats, such 
as Avian Influenza.  If permitted to travel to Burma, CDC personnel 
could assist State Department, USAID, and their partners (including 
multi-lateral organizations and non-governmental organizations) in 
assessing and addressing the threat of drug resistant TB, consistent 
with U.S. government foreign policy. 
 
 
Comment 
----------- 
 
¶9. In light of the current situation involving the transnational 
spread of XDR TB from Burma into Thailand, we request that the 
Department meet with HHS to change its policy on restricting CDC 
personnel from traveling to Burma. This is a regional health issue 
with potential global health and economic implications. Health 
organizations in Burma are unable to quell the spread of MDR TB in 
Burma by themselves and require technical assistance. Due to 
political repression and limited economic opportunity in Burma, 
migration is spreading MDR and XDR TB to Thailand. The Thai health 
authorities are better poised to diagnose and treat MDR TB than the 
Burmese, but their surveillance and treatment programs are still 
under development and we believe that most infected patients are not 
identified before leaving the border area. As a result, there is the 
 
BANGKOK 00003439  003 OF 003 
 
 
potential for the number of MDR cases to increase in Thailand and 
there is also the potential for it to spread to the U.S. (especially 
through U.S. policies for resettling certain refugee populations) 
and neighboring countries.  End comment. 
Boyce