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