VZCZCXRO0360
OO RUEHAST RUEHCHI RUEHCN RUEHDT RUEHHM RUEHLN RUEHMA RUEHPB RUEHPOD
RUEHTM RUEHTRO
DE RUEHHI #0278/01 0850915
ZNR UUUUU ZZH
O 260915Z MAR 09
FM AMEMBASSY HANOI
TO RUEHC/SECSTATE WASHDC 9384
INFO RUEAUSA/DEPT OF HHS WASHINGTON DC IMMEDIATE
RUEHHM/AMCONSUL HO CHI MINH 5717
RUEHZS/ASEAN REGIONAL FORUM COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE
RUEHGV/USMISSION GENEVA 1256
RUEAIIA/CIA WASHINGTON DC
RUEHPH/CDC ATLANTA GA
RHMFIUU/CDR USPACOM HONOLULU HI//J00/J2/J3/J5//
RHMFISS/CJCS WASHINGTON DC//J2/J3/J5//
RHEFDIA/DIA WASHINGTON DC//DHO-3//
RHEFAFM/DIRAFMIC FT DETRICK MD//MA-1A//
RUEKJCS/SECDEF WASHINGTON DC//USDP/ISA/AP//

UNCLAS SECTION 01 OF 04 HANOI 000278 
 
SENSITIVE 
SIPDIS 
 
STATE FOR EAP/MLS, INR, OES/IHB, S/GAC (JHOLLOWAY), MED 
STATE PASS TO USAID TO ASIA (MELLIS/DSHARMA/CJENNINGS) AND GH 
(IKOEK/ABLOOM/SBACHELLER) 
DEPARTMENT OF DEFENSE FOR OSD/ISA/AP 
CDC FOR DIRECTOR RBESSER, COGH (SBLOUNT), CCID (MCOHEN), AND DTBE 
(KCASTRO/EMCCRAY) 
HHS/OSSI/DSI PASS TO FIC/NIH (RGLASS/CSIZEMORE) AND OGHA 
(JKULIKOWSKI/ACUMMINGS/KMCLEAN) 
BANGKOK FOR RMO, CDC (MMALISON/SWHITEHEAD), USAID 
(MACARTHUR/CBOWES) 
BEIJING FOR HHS HEALTH ATTACHE (EYUAN) 
 
E.O. 12958: N/A 
TAGS: TBIO AMED SOCI KPAO VM
SUBJECT: WORLD TB DAY CELEBRATIONS HIGHLIGHT CHALLENGES IN VIETNAM 
 
REF: A. STATE 4510 AND B. STATE 17303 
 
HANOI 00000278  001.2 OF 004 
 
 
¶1. (U) Summary.  In commemoration of World TB Day, Vietnam 
celebrated the lives and stories of people affected by tuberculosis 
(TB).  The United States Government (USG) joined in GVN events and 
highlighted our commitment to prevention and control of the spread 
of this major global public health problem.  Within Vietnam, TB 
remains a leading cause of death from infectious disease and the 
World Health Organization (WHO) ranks Vietnam twelfth among 22 
high-burden countries.  On March 24, several Vietnamese newspapers 
featured articles based on an Embassy press release, detailing the 
broad and deep support from the USG for Vietnamese efforts to 
counter TB, while several Embassy officials attended World TB Day 
celebrations hosted by the Ministry of Health (MOH).  The U.S. 
PEPFAR program provides substantial assistance to persons 
co-infected by TB and HIV.  However, we need to support TB control 
as part of broader development in the setting of health sector 
reform.  End Summary. 
 
World TB Day Events 
------------------- 
 
¶2. (U) To commemorate the day, Post issued a press release detailing 
USG efforts to assist the GVN's National TB Program (NTP). 
Vietnamese media throughout the country picked up the release, which 
ran in major markets on March 23 and 24.  Mission Health Attache and 
USAID Representative attended the GVN celebration at the MOH, hosted 
by the NTP. During the event, Vice Minister Nguyen Thi Xuyen 
reaffirmed the GVN commitment to TB control, while noting continuing 
challenges, including inability to treat drug resistant TB, poor 
human resource capacity at the local level, the need to manage the 
increasing role of the private sector in health care delivery, and 
to better integrate and improve cooperation between the TB and HIV 
programs. 
 
¶3. (SBU) In his speech, the WHO Representative congratulated Vietnam 
on its successes, but implied that the GVN might be losing ground in 
the fight and urged the MOH to formally approve the establishment of 
a national STOP TB Partnership, a critical organ for political and 
financial commitment. 
 
TB in Vietnam 
------------- 
 
¶4. (U) The 2009 WHO global report, released on World TB Day, 
provides data with a two-year lag.  For 2007, Vietnam reported 
150,000 notified new cases for a rate of 171 per 100,000 population 
(all forms of TB), a decrease of one percent from 2006.  The 
epidemic claimed a recorded 22,000 lives, or 14 percent of all 
cases, in 2007.  Of the total cases, 8 percent were co-infected with 
HIV and 44 percent were deemed to be infectious at the time of 
diagnosis.  Fifty-six percent of all cases occurred in the southern 
20 provinces. 
 
¶5. (SBU) Results from a Dutch government-supported prevalence survey 
conducted by the GVN with technical assistance from the KNCV 
Tuberculosis Foundation has not yet been publicly released and is 
undergoing GVN internal review.  Informally, we have learned that 
the number of Vietnamese living with TB may be 60 percent greater 
than previously estimated by the WHO.  The prevalence survey and 
other research will also show that the HIV epidemic contributes to 
continued TB case numbers and related death rates.  The WHO 2009 
Global report states the "Survey findings have prompted the NTP to 
accelerate implementation of [strategies such as] private-public 
mix, advocacy and social mobilization, and other components of the 
Stop TB Strategy (Ref A and B), especially among population groups 
that have difficulty in accessing health-care services."  However, 
it took over 7 years to launch the prevalence survey due to GVN 
 
HANOI 00000278  002.2 OF 004 
 
 
delays, and observers are concerned this call for "acceleration" is 
insufficent. 
 
 
Drug Resistant TB 
----------------- 
 
¶6. (SBU) Like many countries, Vietnam now must confront 
multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. 
In recognition of the severity of the problem, Vice Minister of 
Health Nguyen Thi Xuyen will attend the upcoming summit on drug 
resistant TB in Beijing, scheduled for April 1 and will report on 
Vietnam's experience.  However, Vietnam's current 5-year strategy 
accounts for the diagnosis and treatment of only 1,500 of estimated 
6,000 persons currently suffering from MDR TB.  And after years of 
planning this program, which will establish five centers throughout 
the country, it has yet to begin.  According to some local experts, 
the current plan may not provide sufficient resources to get the job 
done for the first 1,500 cases and the NTP lacks lack sufficient 
diagnostic capacity and resources for the costs for the additional 
cases. 
 
TB in Vietnam Impacts U.S. Public Health 
---------------------------------------- 
 
¶7. (SBU) Immigrants and travelers from Vietnam are among the leading 
groups of persons diagnosed with TB disease in the United States. 
The U.S. Consulate in Ho Chi Minh City, which processes all 
Vietnamese immigrant visa applications, works with the International 
Organization on Migration and U.S. Centers for Disease Control and 
Prevention (CDC) to closely screen potential immigrants to minimize 
travelers to the United States with active TB disease (i.e., the 
more contagious form) -- currently an concerning 0.8 percent of 
applicants, some with drug-resistant strains.  However, even with 
new CDC technical recommendations and added screening capacity, we 
cannot catch every infected person, especially those who are 
non-contagious and asymptomatic.  This puts a strain on the U.S. 
public health system. 
 
The Vietnamese Response 
----------------------- 
 
¶8. (SBU) Largely powered by a strong long-term partnership between 
the Dutch and the NTP, the global TB community views Vietnam's 
historic response as among the best of the 22 high-burden countries. 
 [Note: a high burden country is defined as one of the set of 
countries that comprise 80 percent of the world's TB cases.]  The 
current achievements in TB control are the result of classic 
implementation of the WHO-promulgated "DOTS" strategy (Ref A and B). 
 Since 1996, Vietnam continues to meet WHO case detection and 
treatment targets; yet, its TB notification rate has not dropped. 
Meanwhile, pursuant to health sector reorganization, over 50 percent 
of the TB physicians in the country moved to non-TB work at district 
hospitals in 2007, placing a tremendous training burden on the 
program. 
 
¶9. (U) Unlike other health issues, the Vietnamese TB program does 
not face medium-term funding concerns, based on the current master 
plan.  In 2009, Vietnam's annual NTP budget is about USD 13 million 
is supported by about USD 4 million from The Netherlands, with most 
of the remaining USD 9 million split between the amounts from the 
Global Fund to Fight AIDS, Malaria and Tuberculosis (GF) and 
internal GVN budgeting.  Other partners, including the USG, provide 
lesser amounts.  The GVN budget amount has varied year-by-year, 
increased from 2008, but is still a few million dollars below the 
2002 level. 
 
¶10. (SBU) In 2009, the total cost of TB control in Vietnam is 
 
HANOI 00000278  003.2 OF 004 
 
 
estimated to be about 30 cents per person, of which 10 cents is from 
GVN sources and goes to the NTP.  Of the total amount the GVN spends 
on health, 3.3 percent goes to the TB control, down from 5.6 percent 
in 2006.  Experts feel these amounts do not fully reflect money 
spent below the central level, do not accurately account for 
out-of-pocket expenses, are substantially insufficient for quality 
TB control for the long-term in a country such as Vietnam given the 
current trajectory of health sector reform, and reflect overall low 
rates of GVN spending in health give.  [Note: According to WHO 
recommendations and GVN commitment, TB care should be 
free-of-charge.  However in Vietnam, other health-care related costs 
in the process of obtaining "free" TB care place an increasingly 
difficult barrier to diagnosis and treatment, especially for the 
poor and vulnerable.  End Note.] 
 
¶11. (SBU) While the NTP is preparing an application for GF Round 9, 
which will focus on the private sector and may request an additional 
USD 20 to 25 million over 5 years, the Dutch have stated that they 
are pulling out their funding beginning in 2011.  Moreover, some 
experts are coming to the realization that the master current plan 
while "100 percent funded" through 2011, is inadequate to address 
the problems at hand.  Therefore, the NTP needs to better coordinate 
existing resources and revise the current 2006-2011 master plan, 
relatively urgently.  To date, the MOH's haphazard approach to 
running the GF Country Coordinating Mechanism (CCM) covering all 
three diseases has made adequate stakeholder oversight difficult. 
 
Overall U.S. Support 
-------------------- 
 
¶12. (SBU) Since 1995, the United States has provided approximately 
USD 10 million to support Vietnamese anti-TB efforts.  Early 
assistance, much of which continues, included USAID-funded, 
CDC-implemented support for operations research, epidemiology 
training, and public health management training.  Current support, 
primarily through the PEPFAR program, builds upon many years of 
effort.  As part of overall Vietnam PEPFAR funding, which was USD 
88.8 million in FY 2008, funds dedicated to combating TB/HIV in 
Vietnam totaled USD 3.0 million.  To date, approved PEPFAR amounts 
for FY 2009 are USD 88.6 and 2.6 million, respectively.  Additional 
ongoing multi-year support for a WHO Medical Officer in the Western 
Pacific Regional Office and technical assistance is provided by the 
USAID Asia Regional Mission, complemented by technical and research 
assistance from the Division of Tuberculosis Elimination, at CDC. 
 
Substantial PEPFAR Achievement with a Focus on TB/HIV 
--------------------------------------------- -- 
 
¶13. (U) PEPFAR-funded TB initiatives include HIV testing for TB 
patients with referral for treatment for those who test positive, 
intensified efforts to identify persons with TB, and assistance to 
the MOH to develop a collaborative national protocol between TB and 
HIV programs in diagnosis, treatment, and management of TB in 
HIV-infected persons.  In 2008, over 20,000 TB patients were tested 
at more than 100 TB clinics in 19 provinces, which, with U.S. 
support, now provide HIV testing and counseling services.  In 
addition, over 100 USG supported HIV care sites in 30 provinces of 
Vietnam provide TB disease screening referral of HIV-infected 
patients to TB services for evaluation and treatment.  In 2008, the 
program screened more than 12,000 people living with HIV/AIDS 
suspected of being co-infected with TB.  Treatment for TB has been 
provided to more than 2,500 HIV-infected TB patients.  As part of a 
pilot program to prevent the development of TB, preventive therapy 
with the drug isoniazid is being given to 1,000 patients infected 
with HIV in the An Giang and Hai Phong Provinces and Ho Chi Minh 
City.  Additionally, in collaboration with the NTP, the USG is 
working to improve the quality of basic TB programs, upgrade 
laboratory infrastructure, and introduce new diagnostic 
 
HANOI 00000278  004.2 OF 004 
 
 
technologies. 
 
Applying U.S. Expertise in Infection Control 
------------------------------------------- 
 
¶15. (U) Given the importance of limiting the spread of infection, 
the USG has assisted upgrades to TB-related public health 
surveillance, improving health education on TB transmission, 
financial support for structural renovation in eight provincial 
hospitals and rehabilitation centers that manage patients with HIV 
and drug-resistant TB.  USG supports training for clinical staff and 
helps improve laboratory diagnosis of TB in eight provinces.  Hanoi, 
Ho Chi Minh City, Danang and Can Tho Provinces receive specialized 
support to test and treat cases of multi-drug resistant TB. 
 
¶16. (SBU) Comment.  TB remains a substantial public health threat to 
Vietnam, with impacts within the United States.  Though Vietnam is 
deserving of accolades on past performance, the recent challenges 
presented by health sector reform, combined with medium-term budget 
questions and the threat of drug resistant TB, justify a 
re-evaluation of the level and character of U.S. support for TB 
prevention efforts.  U.S. TB-related technical assistance, while 
long-standing, was modest until PEPFAR.  Even under PEPFAR, the 
focus remains predominantly on TB issues directly tied to the 
problem of TB/HIV.  In cooperation with our Vietnamese counterparts, 
we suggest that U.S. public health agencies consider a broader 
multilateral approach to support TB control in Vietnam.  Such a 
strategy must overcome intra-instructional GVN boundaries, take a 
broader view of surveillance, and tackle health sector reform and 
the nebulous private sector head on.  Such a broad, modern public 
health approach to national TB control in Vietnam will improve TB 
prevention and control in Vietnam and reduce the number of 
Vietnamese travelers and immigrants bringing TB into the United 
States.  End Comment. 
 
MICHALAK