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Parasitology in Vietnam
Parasitology Today,vol. IO, no. 7, I994
247
Parasitology in Vietnam J.H. Cross Vietnam November I993 The population of Vietnam is approximately 70 million with 25 rnillion living in 27 provinces in the south. Malaria is one of the most important diseases countrywide, and, with aggressive treatment and control measures, the number of cases has decreased from 1.3 million in I976 to 465000 in 1989. Plasmodium the falcipxum is endemic throughout country, especially in the highlands; P. vivax is also endemic, blJt P. molariae is rare. There are over Z!O species of vector mosquitoes, with Anopheles sunda& considered to be the most important. Attempts are being made to treat severe and complicated cases and reduce mortality. All presently known antimalarials have been used in treatment, and some found to be ineffective (eg. Fansidar). Chloroquine-resistant P. folciparum is a major problem and mefloquin has been used, as well as at-temisinin, a derivative from the Chinese herbal drug Qing-,haosu. Insecticide (petmethrin)-impregnated bednets are also used to reduce infections. Emphasis is being made on early detection and treatment. Health education and chemical prophylaxis are also utilized in the control program. Ho Chi Minh City Arriving at the Ton Son Nut Airport in Ho Chi Minh City in 1993 was very different from arriving there during the late 1960s or early 1970s. The airport was a bustle of military activity in those days; today it is filled with commercial aircraft loading and unloading tourists from all parts of the world. The city is now a delightful and exciting place to visit. On our first day in the city we were taken to the Institute of Hygiene and Public Health and after a brief introduction to the Institute by the director, Cao Minh Chanh, a briefing was given on the public health administration, organization and activities of various programs. Parasitic as well as other infectious diseases arid conditions are problems throughout most of south 0
1994.Elsewer SctenceLtd
Vietnam: these include malaria, dengue, rabies, plague, cholera and diarrhea1 diseases. AIDS is making an appearance (and other problems for health administrators include malnutrition, pollution, occupational diseases and vehicular accidents). As elsewhere in Southeast Asia, intestinal parasites are widespread, especially in rural areas where poor sanitary conditions prevail. Ascaris lumbricoides, Tn’churis trichiura and hookworm have been reported in 62% of 2621 of the people examined in surveys. Opisthorchis viverrini has been reported in 37% of 668 people examined. It is of interest that 0. viverrini is endemic in south Vietnam and Qonorchis sinensis is endemic in the north. In other surveys, intestinal protozoa were common found, with Entamoeba histolytica found in about I% of the stools. Multiple infections were found in 10% of those examined. A visit was made to the Traditional Medicine Institute in Ho Chi Minh City. There was not much in parasitology to learn from this visit, but it was interesting to be informed of the philosophy of traditional medicine in Vietnam. Traditionalists consider the whole person and utilize medical science and technology along with basic theories of traditional medicine. Truong Thin, Director of the Institute, presented a lecture and answered questions. They have traditional methods of diagnosis and treatment utilizing medicinal herbs, acupuncture, exercise using Tai Chi (Chinese shadow boxing) and psychotherapy. Today, practitioners combine traditional and Western medicine. We were told that traditional medicine also has its specialists in general medicine, pediatrics, obstetrics and gynecology. Cho Quan Hospital is the infectious disease hospital for Ho Chi Minh City. It is also the Center for Tropical Diseases. The history of this institution and a briefing were given to us by Tran Tinh Hien, the Vice-director, and his assistants, Nguyen The Dung and Bui Minh Cuong. The hospital was established as a private institution for the treatment of sexually transmitted diseases in 1862. Later, it became the infectious disease hospital and had a
medical school. It established the Center for Tropical Diseases in 1989. In 1992, they had over 6000 cases of malaria, of which 10% were complicated P. fakiparum. An impressive intensive care unit has been established to carry out collaborative studies with Oxford University, with support of the Wellcome Foundation. Two enthusiastic young physicians from the UK are involved with these studies. A biomedical research laboratory equipped by the Wellcome Foundation was also operational. The Roche Asian Foundation also sponsors collaborative studies on the treatment of malaria. Other diseases seen at the hospital include cholera and other diarrheas, as well as dengue, hepatitis, typhoid, tetanus, diphtheria, measles, bacterial meningitis, rabies and amebiasis. A brief meeting was held with the staff of the Ho Chi Minh City Public Health Service and parasitologists from the College of Medicine and Pharmacy. Discussions were held on the prevalence of bancroftian filatiasis in the highlands, and the occurrence of visceral and cutaneous larva migrans. Gnathostome infections are reported as well as sparganosis. The use of animal (frog) poultices are responsible for the latter. The parasitologists are concerned that Schistosoma mekongi may be found in Vietnamese returning from Cambodia. Other important institutions in Ho Chi Minh City are the Cho Ray General Hospital with over 1000 beds and servicing south Vietnam and the Pasteur Institute which provides labor-a tory support to the Ministry of Health and carries out research, especially in virology. The group was not able to visit these facilities because of time limitations. We were taken to see a rural health clinic in Song Be Province, but first we visited the Health Service Center of the Province. We were given another briefing on the province and the para sitological problems. Malaria is highly endemic: in 1993, there were over 27000 cases of malaria: 382 severe cases and 60 fatal. Mefloquin and artemisinin are used in treatment and DDT spraying and permethrin-impregnated mosquito nets are used in
Porosjtology Today, vol. IO, no. 7, I994
248
control. At the time of our visit the province was training 30 young students in malaria diagnosis using old Russian microscopes. The trainees will be sent back to their villages, but there are no microscopes or supplies to take back with them. We left the health center and drove for two more hours to Phuoc Long Health Station. It was a vet-y pleasant ride and enabled us to see the countryside. The farmlands were well managed and we were surprised to see the acreage of cashew trees. We were told that cashews are one of the major Vietnamese exports. The health station was relatively new and provided basic health needs for over 100000 people, most of whom lived in the mountainous regions. It had over 80 beds and was well staffed, and was built with funds from the High Commission for Refugees. They had over 5000 cases of malaria, 90 severe and IO fatal in 1993. Many cases of amebiasis occur and night soil (human feces used as fertilizer) is used in many of the villages. Hanoi
Hanoi is the capital of Vietnam and the people are seemingly more conservative than people in Ho Chi Minh City. We were introduced to Hoang Dinh Cau, the Chairman of the Vietnam General Association of Medicine and Pharmacy (VGAMP) and were briefed on the organization. The membership of VGAMP comprises approximately 30000 medical doctors, 6000 pharmacists and 30000 nurses. The association publishes reviews and journals in Vietnamese, French and English. Hai Ba Trung Hospital is one of the two largest hospitals in Hanoi and has 600 beds, 700 staff and 200 physicians. Cao Van Vi& Deputy Director of the hospital, informed us that the Department of Infectious Disease and Tropical Medicine sees patients with hepatitis, tuberculosis, salmonellosis, malaria, paragonimiasis, taeniasis, cysticercosis (a great many), liver and intestinal flukes, hookworm, ascariasis and amebiasis. Filariasis with elephantiasis is seen in people from areas in Hai Hung Province. We were presented a case of paragonimiasis in an eight-year-old boy who had been treated for tuberculosis without improvement. He developed severe malaria and right-side hemiplegia. He was also treated at a traditional medicine center without response to the treatment. His sputum was eventually examined and Paragonimus eggs were
found. He was treated with praziquantel and the hemiplegia was gradually abating. The boy had eaten partially roasted crabs. There are two institutes under the Ministry of Health involved in parasitology and tropical medicine: the Intiitute of Malariology, Parasitology and Entomology (IMPE) and the Institute of Clinical Research in Tropical Medicine (ICRTM). The IMPE (Director: Li Dinh Cong) has one branch in Ho Chi Minh City and one in Hanoi and they carry out research and training, monitor diseases and have a number of polyclinics. Forty percent of the population live in malarious areas, with eight million people in high risk groups. Since I99 I, there has been an increase in prevalence and the control program is second in importance among seven govemmentsponsored programs. Soil-transmitted helminths are highly prevalent in the north, and the prevalence of clonorchiasis is 30%. Brugian filariasis ranges from IO to 30% in the north, and control measures involve mass treatment programs with diethylcarbamazine. The ICRTM (Director: Pham Song) is located in a series of buildings at the Bach Mai Hospital, a I I5 bed hospital that serves as a referral center for all types of infectious diseases (parasitic, viral, bacterial, etc.). There are 28 physicians, 4 I nurses and ancillary penonnel. Most of the cases of malaria are severe, involving cerebral and renal failure. Dengue hemorrhagic fever, tetanus, drug-resistant staphylococci infections, diphtheria, meningitis, measles, polio and rabies are also seen. We were impressed with the enthusiastic young staff who were anxious to present cases to us of amebic liver abscess and cerebral malaria. They also demonstrated a keen interest in collaborative studies. A visit was made to a rural health station in Dong Anh District that provides health care for over 9000 people. It is a well-organized station that provides primary health care. It has one physician and nine ancillary health personnel. Complicated cases were re-
ferred to health centers in nearby cities. Although the farms in the area were growing vegetables, there was a serious malnutrition problem, especially in the children. All of the best vegetables were sold in the market to obtain a small amount of money. Vet-y few of the crops were retained for home consumption, contributing to the malnutrition. Some aid to the health station and the community was coming from Japan and, during our visit, a small group of Japanese public health workers was also visiting. Acknowledgements An international group of scientists organized by the Citizen Ambassador Program of Spokane, Washington, USA, and co-ordinated by the Vietnam General Association of Medicine and Pharmacy (VGAMP) visited hospitals, public heaith and research laboratories in Ho Chi Minh City and Hanoi, 9- I7 November 1993. The delegation consisted of parasitologists, entomologists, physicians, biologists and laboratory technicians. Our group enjoyed this short visit to Vietnam. We found the people to be very friendly, the countryside delightful and as yet unspoiled by an influx of tourists. It was a professionally rewarding experience being able to see certain parasitic diseases for the first time for some of the group. The scientists we met were gracious hosts and were eager to discuss their problems. There are many problems, especially in malaria and there is a great need for assistance. The institutes involved in parasitology and tropical medicine are eagerly looking for foreign collaborators. There is an opportunity for all types of research, basic and applied. In addition to the scientific aspects of our trip, we also visited interesting historical and cultural centers, temples, churches, old buildings built by the French and relics of the Vietnam war. We stopped by the prison in Hanoi that was called the Hanoi Hilton by American POWs. We were told that it soon would be tom down and a hotel-shopping complex would be built on the site, possibly a luxurious Hilton hotel.
/ohn H Cross is at the Department ofpreventive Medicine and Biomettics, Uniformed Services University of the Health Sciences, 430 I Jones Sridge Road, Bethesda, MD 20814.4799, USA.
Special issues coming soon in immunology To&y September: B-cell signalling through surface accessory molecules, including: membrane immunoglobulin, CDl9, CD20, CD2I, CD22, CD40, CD45, C-type lectins and MHC class II. November: neuroendocrine-immune interactions: focusing on the physiology and pharmacology of immune development and regulation.
247
Parasitology in Vietnam J.H. Cross Vietnam November I993 The population of Vietnam is approximately 70 million with 25 rnillion living in 27 provinces in the south. Malaria is one of the most important diseases countrywide, and, with aggressive treatment and control measures, the number of cases has decreased from 1.3 million in I976 to 465000 in 1989. Plasmodium the falcipxum is endemic throughout country, especially in the highlands; P. vivax is also endemic, blJt P. molariae is rare. There are over Z!O species of vector mosquitoes, with Anopheles sunda& considered to be the most important. Attempts are being made to treat severe and complicated cases and reduce mortality. All presently known antimalarials have been used in treatment, and some found to be ineffective (eg. Fansidar). Chloroquine-resistant P. folciparum is a major problem and mefloquin has been used, as well as at-temisinin, a derivative from the Chinese herbal drug Qing-,haosu. Insecticide (petmethrin)-impregnated bednets are also used to reduce infections. Emphasis is being made on early detection and treatment. Health education and chemical prophylaxis are also utilized in the control program. Ho Chi Minh City Arriving at the Ton Son Nut Airport in Ho Chi Minh City in 1993 was very different from arriving there during the late 1960s or early 1970s. The airport was a bustle of military activity in those days; today it is filled with commercial aircraft loading and unloading tourists from all parts of the world. The city is now a delightful and exciting place to visit. On our first day in the city we were taken to the Institute of Hygiene and Public Health and after a brief introduction to the Institute by the director, Cao Minh Chanh, a briefing was given on the public health administration, organization and activities of various programs. Parasitic as well as other infectious diseases arid conditions are problems throughout most of south 0
1994.Elsewer SctenceLtd
Vietnam: these include malaria, dengue, rabies, plague, cholera and diarrhea1 diseases. AIDS is making an appearance (and other problems for health administrators include malnutrition, pollution, occupational diseases and vehicular accidents). As elsewhere in Southeast Asia, intestinal parasites are widespread, especially in rural areas where poor sanitary conditions prevail. Ascaris lumbricoides, Tn’churis trichiura and hookworm have been reported in 62% of 2621 of the people examined in surveys. Opisthorchis viverrini has been reported in 37% of 668 people examined. It is of interest that 0. viverrini is endemic in south Vietnam and Qonorchis sinensis is endemic in the north. In other surveys, intestinal protozoa were common found, with Entamoeba histolytica found in about I% of the stools. Multiple infections were found in 10% of those examined. A visit was made to the Traditional Medicine Institute in Ho Chi Minh City. There was not much in parasitology to learn from this visit, but it was interesting to be informed of the philosophy of traditional medicine in Vietnam. Traditionalists consider the whole person and utilize medical science and technology along with basic theories of traditional medicine. Truong Thin, Director of the Institute, presented a lecture and answered questions. They have traditional methods of diagnosis and treatment utilizing medicinal herbs, acupuncture, exercise using Tai Chi (Chinese shadow boxing) and psychotherapy. Today, practitioners combine traditional and Western medicine. We were told that traditional medicine also has its specialists in general medicine, pediatrics, obstetrics and gynecology. Cho Quan Hospital is the infectious disease hospital for Ho Chi Minh City. It is also the Center for Tropical Diseases. The history of this institution and a briefing were given to us by Tran Tinh Hien, the Vice-director, and his assistants, Nguyen The Dung and Bui Minh Cuong. The hospital was established as a private institution for the treatment of sexually transmitted diseases in 1862. Later, it became the infectious disease hospital and had a
medical school. It established the Center for Tropical Diseases in 1989. In 1992, they had over 6000 cases of malaria, of which 10% were complicated P. fakiparum. An impressive intensive care unit has been established to carry out collaborative studies with Oxford University, with support of the Wellcome Foundation. Two enthusiastic young physicians from the UK are involved with these studies. A biomedical research laboratory equipped by the Wellcome Foundation was also operational. The Roche Asian Foundation also sponsors collaborative studies on the treatment of malaria. Other diseases seen at the hospital include cholera and other diarrheas, as well as dengue, hepatitis, typhoid, tetanus, diphtheria, measles, bacterial meningitis, rabies and amebiasis. A brief meeting was held with the staff of the Ho Chi Minh City Public Health Service and parasitologists from the College of Medicine and Pharmacy. Discussions were held on the prevalence of bancroftian filatiasis in the highlands, and the occurrence of visceral and cutaneous larva migrans. Gnathostome infections are reported as well as sparganosis. The use of animal (frog) poultices are responsible for the latter. The parasitologists are concerned that Schistosoma mekongi may be found in Vietnamese returning from Cambodia. Other important institutions in Ho Chi Minh City are the Cho Ray General Hospital with over 1000 beds and servicing south Vietnam and the Pasteur Institute which provides labor-a tory support to the Ministry of Health and carries out research, especially in virology. The group was not able to visit these facilities because of time limitations. We were taken to see a rural health clinic in Song Be Province, but first we visited the Health Service Center of the Province. We were given another briefing on the province and the para sitological problems. Malaria is highly endemic: in 1993, there were over 27000 cases of malaria: 382 severe cases and 60 fatal. Mefloquin and artemisinin are used in treatment and DDT spraying and permethrin-impregnated mosquito nets are used in
Porosjtology Today, vol. IO, no. 7, I994
248
control. At the time of our visit the province was training 30 young students in malaria diagnosis using old Russian microscopes. The trainees will be sent back to their villages, but there are no microscopes or supplies to take back with them. We left the health center and drove for two more hours to Phuoc Long Health Station. It was a vet-y pleasant ride and enabled us to see the countryside. The farmlands were well managed and we were surprised to see the acreage of cashew trees. We were told that cashews are one of the major Vietnamese exports. The health station was relatively new and provided basic health needs for over 100000 people, most of whom lived in the mountainous regions. It had over 80 beds and was well staffed, and was built with funds from the High Commission for Refugees. They had over 5000 cases of malaria, 90 severe and IO fatal in 1993. Many cases of amebiasis occur and night soil (human feces used as fertilizer) is used in many of the villages. Hanoi
Hanoi is the capital of Vietnam and the people are seemingly more conservative than people in Ho Chi Minh City. We were introduced to Hoang Dinh Cau, the Chairman of the Vietnam General Association of Medicine and Pharmacy (VGAMP) and were briefed on the organization. The membership of VGAMP comprises approximately 30000 medical doctors, 6000 pharmacists and 30000 nurses. The association publishes reviews and journals in Vietnamese, French and English. Hai Ba Trung Hospital is one of the two largest hospitals in Hanoi and has 600 beds, 700 staff and 200 physicians. Cao Van Vi& Deputy Director of the hospital, informed us that the Department of Infectious Disease and Tropical Medicine sees patients with hepatitis, tuberculosis, salmonellosis, malaria, paragonimiasis, taeniasis, cysticercosis (a great many), liver and intestinal flukes, hookworm, ascariasis and amebiasis. Filariasis with elephantiasis is seen in people from areas in Hai Hung Province. We were presented a case of paragonimiasis in an eight-year-old boy who had been treated for tuberculosis without improvement. He developed severe malaria and right-side hemiplegia. He was also treated at a traditional medicine center without response to the treatment. His sputum was eventually examined and Paragonimus eggs were
found. He was treated with praziquantel and the hemiplegia was gradually abating. The boy had eaten partially roasted crabs. There are two institutes under the Ministry of Health involved in parasitology and tropical medicine: the Intiitute of Malariology, Parasitology and Entomology (IMPE) and the Institute of Clinical Research in Tropical Medicine (ICRTM). The IMPE (Director: Li Dinh Cong) has one branch in Ho Chi Minh City and one in Hanoi and they carry out research and training, monitor diseases and have a number of polyclinics. Forty percent of the population live in malarious areas, with eight million people in high risk groups. Since I99 I, there has been an increase in prevalence and the control program is second in importance among seven govemmentsponsored programs. Soil-transmitted helminths are highly prevalent in the north, and the prevalence of clonorchiasis is 30%. Brugian filariasis ranges from IO to 30% in the north, and control measures involve mass treatment programs with diethylcarbamazine. The ICRTM (Director: Pham Song) is located in a series of buildings at the Bach Mai Hospital, a I I5 bed hospital that serves as a referral center for all types of infectious diseases (parasitic, viral, bacterial, etc.). There are 28 physicians, 4 I nurses and ancillary penonnel. Most of the cases of malaria are severe, involving cerebral and renal failure. Dengue hemorrhagic fever, tetanus, drug-resistant staphylococci infections, diphtheria, meningitis, measles, polio and rabies are also seen. We were impressed with the enthusiastic young staff who were anxious to present cases to us of amebic liver abscess and cerebral malaria. They also demonstrated a keen interest in collaborative studies. A visit was made to a rural health station in Dong Anh District that provides health care for over 9000 people. It is a well-organized station that provides primary health care. It has one physician and nine ancillary health personnel. Complicated cases were re-
ferred to health centers in nearby cities. Although the farms in the area were growing vegetables, there was a serious malnutrition problem, especially in the children. All of the best vegetables were sold in the market to obtain a small amount of money. Vet-y few of the crops were retained for home consumption, contributing to the malnutrition. Some aid to the health station and the community was coming from Japan and, during our visit, a small group of Japanese public health workers was also visiting. Acknowledgements An international group of scientists organized by the Citizen Ambassador Program of Spokane, Washington, USA, and co-ordinated by the Vietnam General Association of Medicine and Pharmacy (VGAMP) visited hospitals, public heaith and research laboratories in Ho Chi Minh City and Hanoi, 9- I7 November 1993. The delegation consisted of parasitologists, entomologists, physicians, biologists and laboratory technicians. Our group enjoyed this short visit to Vietnam. We found the people to be very friendly, the countryside delightful and as yet unspoiled by an influx of tourists. It was a professionally rewarding experience being able to see certain parasitic diseases for the first time for some of the group. The scientists we met were gracious hosts and were eager to discuss their problems. There are many problems, especially in malaria and there is a great need for assistance. The institutes involved in parasitology and tropical medicine are eagerly looking for foreign collaborators. There is an opportunity for all types of research, basic and applied. In addition to the scientific aspects of our trip, we also visited interesting historical and cultural centers, temples, churches, old buildings built by the French and relics of the Vietnam war. We stopped by the prison in Hanoi that was called the Hanoi Hilton by American POWs. We were told that it soon would be tom down and a hotel-shopping complex would be built on the site, possibly a luxurious Hilton hotel.
/ohn H Cross is at the Department ofpreventive Medicine and Biomettics, Uniformed Services University of the Health Sciences, 430 I Jones Sridge Road, Bethesda, MD 20814.4799, USA.
Special issues coming soon in immunology To&y September: B-cell signalling through surface accessory molecules, including: membrane immunoglobulin, CDl9, CD20, CD2I, CD22, CD40, CD45, C-type lectins and MHC class II. November: neuroendocrine-immune interactions: focusing on the physiology and pharmacology of immune development and regulation.