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 
------- 
 
¶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