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Background Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population. Methods and findings Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown. Conclusions To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises., Author(s): Jonathan A. Polonsky 1,2,*, Melissa Ivey 3, Md. Khadimul Anam Mazhar 4, Ziaur Rahman 5, Olivier le Polain de Waroux 1,6,7,8,9, Basel Karo 6,10, Katri Jalava 4, Sirenda Vong [...]

Human influenza A(H5N1) virus infections in Cambodia were first detected in January 2005. Twenty-one cases, including 19 (90.5%) deaths, were reported during 2005-2012. In January 2013, researchers at the Institut [...]

Objective To conduct assessments of Ebola virus disease preparedness In countries of the World Health Organization (WHO) South-East Asia Region. Methods Nine of 11 countries In the region agreed to be assessed. During February to November 2015 a joint team from WHO and ministries of health conducted 4-5 day missions to Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. We collected information through guided discussions with senior technical leaders and visits to hospitals, laboratories and airports. We assessed each country's Ebola virus disease preparedness on 41 tasks under nine key components adapted from the WHO Ebola preparedness checklist of January 2015. Findings Political commitment to Ebola preparedness was high in all countries. Planning was most advanced for components that had been previously planned or tested for influenza pandemics: multilevel and multisectoral coordination; multidisciplinary rapid response teams; public communication and social mobilization; drills in international airports; and training on personal protective equipment. Major vulnerabilities included inadequate risk assessment and risk communication; gaps in data management and analysis for event surveillance; and limited capacity in molecular diagnostic techniques. Many countries had limited planning for a surge of Ebola cases. Other tasks needing improvement Included: advice to inbound travellers; adequate isolation rooms; appropriate infection control practices; triage systems in hospitals; laboratory diagnostic capacity; contact tracing; and danger pay to staff to ensure continuity of care. Conclusion Joint assessment and feedback about the functionality of Ebola virus preparedness systems help countries strengthen their core capacities to meet the International Health Regulations. Objectif Realiser des evaluations de la preparation au virus Ebola dans des pays de la region Asie du Sud-Est de l'Organlsation mondlale de la Sante (OMS). Methodes Surles 11 pays de la region, neufontaccepted'etreevalues. De fevrler a novembre 2015, une equlpe composee de membres de l'OMS et des mlnisteres de la Sante ont effectue des missions de 4 a 5 jours au Bangladesh, au Bhoutan, en Indonesie, aux Maldives, au Myanmar, au Nepal, au Sri Lanka, en Thailande et au Timor-Leste. Nous avons recueilli des informations lors de discussions guidees avec des directeurs techniques et lors de visites dans des hopitaux, des laboratolres et des aeroports. Nous avons evalue la preparation de chaque pays au virus Ebola d'apres 41 taches relevant de neuf composantes cles, insplrees de la liste de controle de l'OMS pourfaire face au virus Ebola de janvier 2015. Resultats L'engagement politique en matiere de preparation au virus Ebola etait eleve dans tous les pays. La planification etalt plus avancee vis-a-vis des composantes qui avaient deja ete planifiees ou testees pour les pandemies de grippe: coordination multisectorielle et multi-nlveaux, equipes d'interventlon rapide multidlsclplinalres, communication publique et mobilisation sociale, exercices dans les aeroports internationaux et formation au port d'equipements de protection indlvlduelle. Les principales vulnerabilites etaient une mauvaise evaluation et communication des risques, des failles dans la gestion et l'analyse des donnees en vue de la surveillance, et des capacites limitees au niveau des techniques de diagnostic moleculaire. Dans de nombreux pays, la planification etait limltee en cas deflambee du virus Ebola. D'autres taches necessitaient des ameliorations, par exemple: les consells aux voyageurs entrant dans le pays, la mise a disposition de chambres d'isolement adequates, l'adoption de pratiques conectes de lutte contre la maladle, des systemes de triage dans les hopitaux, des capacites de diagnostic dans les laboratolres, la recherche des contacts et le paiement d'une prime de risque au personnel afin d'assurer la contlnuite des soins. Conclusion L'evaluatlon conjointe et la communication au sujet de la fonctionnalite des systemes de preparation au virus Ebola permettent aux pays de renforcer leurs capacites afin de respecter le Reglement sanitaire International. Objetivo Llevar a cabo evaluaciones de 1a preparacion ante el virus del Ebola en paises de la region del sudeste asiatico de la Organizacion Mundial de la Salud (OMS). Metodos Nueve de once paises de la region aceptaron ser evaluados. De febrero a noviembre de 2015, un equipo conjunto de la OMS y los ministerios de sanidad llevaron a cabo misiones de entre 4 y 5 dias en Bangladesh, Butan, Indonesia, Maldivas, Myanmar, Nepal, Sri Lanka, Tailandia y Timor-Leste. Se recopilo informacion a traves de conversaciones dirigidas con jefes tecnicos y visitas a hospitales, laboratorios y aeropuertos. Se evaluo la preparacion ante el virus del Ebola de cada pais en 41 tareas con 9 componentes clave adaptados de la lista de preparacion ante el ebola de la OMS de enero de 2015. Resultados El compromiso politico para la preparacion ante el ebola era elevado en todos los paises. La planificacion era mas avanzada para los componentes que habian sido previamente planificados o probados para pandemias de gripe: coordinacion de varios niveles y sectores, equipos de respuesta rapida multidisciplinares, comunicacion publica y movilizacion social, simulacros en aeropuertos internacionales y formacion sobre equipos de proteccion individual. Entre las principales vulnerabilidades se encontraba una evaluacion de riesgos y comunicacion de riesgos poco adecuadas, lagunas en la gestion y el analisis de datos para el control de acontecimientos y una capacidad limitada en tecnicas de diagnostico molecular. Muchos paises tenian una planificacion limitada en caso de que resurgieran casos de ebola. Entre otras tareas que necesitaban mejorar se encontraban: asesoria a viajeros entrantes, salas de aislamiento adecuadas, practicas de control de infecciones adecuadas, sistemas de clasificacion en hospitales, capacidad de diagnostico en laboratorios, localizacion de contactos y prima de peligrosidad para el personal para garantizar la continuidad de la atencion. Conclusion La evaluacion conjunta y los comentarios sobre la funcionalidad de los sistemas de preparacion ante el virus del Ebola ayudan a los paises a fortalecer sus capacidades principales para cumplir el Reglamento Sanitario Internacional., Introduction The 2013-2016 Ebola virus disease epidemic in West Africa was the largest ever reported, with 28616 cases and 11 310 deaths as of June 2016. (1) In August 2014, [...]

Problem In 2003, China's handling of the early stages of the epidemic of severe acute respiratory syndrome (SARS) was heavily criticized and generally considered to be suboptimal. Approach Following the SARS outbreak, China made huge investments to improve surveillance, emergency preparedness and response capacity and strengthen public health institutions. In 2013, the return on these investments was evaluated by investigating China's early response to the emergence of avian influenza A(H7N9) virus in humans. Local setting Clusters of human infection with a novel influenza virus were detected in China--by national surveillance of pneumonia of unknown etiology--on 26 February 2013. Relevant changes On 31 March 2013, China notified the World Health Organization (WHO) of the first recorded human infections with A(H7N9) virus. Poultry markets--which were rapidly identified as a major source of transmission of A(H7N9) to humans-- were closed down in the affected areas. Surveillance in humans and poultry was heightened and technical guidelines were quickly updated and disseminated. The health authorities collaborated with WHO in risk assessments and risk communication. New cases were reported promptly and publicly. Lessons learnt The relevant infrastructures, surveillance systems and response capacity need to be strengthened in preparation for future emergencies caused by emerging or existing disease threats. Results of risk assessments and other data should be released promptly and publicly and such release should not jeopardize future publication of the data in scientific journals. Coordination between public health and veterinary services would be stronger during an emergency if these services had already undertaken joint preparedness planning. Probleme En 2003, la gestion des premiers stades de l'epidemie du syndrome respiratoire aigu severe (SRAS) par la Chine a ete fortement critiquee et generalement consideree comme non optimale. Approche Apres l'epidemie de SRAS, la Chine a investi massivement pour ameliorer sa surveillance, sa preparation aux situations d'urgence et sa capacite de reponse, et pour renforcer les etablissements de sante publique. En 2013, le retour sur ces investissements a ete evalue par l'examen de la reponse precoce de la Chine a l'emergence du virus de la grippe aviaire A(H7N9) chez l'homme. Environnement local Des cas d'infection humaine au nouveau virus de la grippe ont ete detectes en Chine le 26 fevrier 2013 par le systeme de surveillance nationale des pneumonies d'etiologie inconnue. Changements significatifs Le 31 mars 2013, la Chine a notifie a l'Organisation mondiale de la Sante (OMS) les premieres infections humaines au virus A(H7N9) enregistrees. Les marches de volaille qui ont ete rapidement identifies comme des sources majeures de transmission du virus A(H7N9) a l'homme--ont ete fermes dans les zones touchees. La surveillance a ete renforcee chez l'homme et les volailles, et les recommandations techniques ont ete rapidement mises a jour et diffusees. Les autorites sanitaires ont collabore avec l'OMS dans les domaines de l'evaluation des risques et de la communication des risques. Les nouveaux cas ont ete signales rapidement et publiquement. Lecons tirees Les infrastructures concernees, les systemes de surveillance et la capacite de reponse doivent etre renforces en prevision des futures urgences causees par les menaces de maladies emergentes ou existantes. Les resultats des evaluations des risques et les autres donnees doivent etre communiques rapidement et publiquement, et ces communications ne doivent pas compromettre la publication ulterieure des donnees dans les revues scientifiques. La coordination entre les services de sante publique et les services veterinaires serait plus forte pendant une situation d'urgence si ces services avaient deja engage une planification prealable commune. Situacion En 2003, la gestion de China de las primeras etapas de la epidemia del sindrome respiratorio agudo severo (SRAS) se critico duramente y se considero Insuficiente por lo general. Enfoque Tras el brote de SRAS, China realizo grandes inversiones para mejorar la vigilancia, la preparacion para emergencias y la capacidad de respuesta, asi como para fortalecer las instituciones de salud publica. En 2013, se evaluo la rentabilidad de estas Inversiones mediante una investigacion sobre la respuesta temprana de China a la aparicion del virus de la gripe aviar A(H7N9) en humanos. Marco regional El 26 de febrero de 2013 se detectaron grupos de infecciones humanas con el nuevo virus de la gripe en China mediante la vigilancia nacional de la neumonia de etiologia desconocida. Cambios importantes El 31 de marzo de 2013, China comunico a la Organizacion Mundial de la Salud (OMS) las primeras infecciones humanas del virus A(H7N9) registradas. Los mercados de aves de corral, que se identificaron de inmediato como una fuente importante de transmision del virus A(H7N9) a los humanos, se cerraron en las zonas afectadas. Se reforzo la vigilancia en humanos y aves de corral a la vez que se actualizaron y difundieron las directrices tecnicas con rapidez. Las autoridades de salud colaboraron con la OMS en la evaluacion de los riesgos y la comunicacion de los riesgos. De inmediato, se anunciaron los nuevos casos publicamente. Lecciones aprendidas Deben reforzarse las infraestructuras pertinentes, los sistemas de vigilancia y la capacidad de respuesta como preparacion a las futuras emergencias causadas por la amenaza de enfermedades nuevas o existentes. Los resultados de las evaluaciones de riesgo y el resto de datos deben divulgarse rapida y publicamente, pero dicha divulgacion no debe poner en peligro la futura publicacion de los datos en las revistas cientificas. La coordinacion entre la salud publica y los servicios veterinarios seria mas fuerte durante una emergencia si estos servicios planificaran de antemano la preparacion conjunta., Problem Severe acute respiratory syndrome is a zoonotic viral infection that probably first occurred, in late 2002, in the south of Chinas Guangdong province. (1) Although the syndrome eventually spread [...]

Objective Dengue has been reportable in Cambodia since 1980. Virological surveillance began in 2000 and sentinel surveillance was established at six hospitals in 2001. Currently, national surveillance comprises passive and active data collection and reporting on hospitalized children aged 0-15 years. This report summarizes surveillance data collected since 1980. Methods Crude data for 1980-2001 are presented, while data from 2002-2008 are used to describe disease trends and the effect of vector control interventions. Trends in dengue incidence were analysed using the Prais-Winsten generalized linear regression model for time series. Findings During 1980-2001, epidemics occurred in cycles of 3-4 years, with the cycles subsequently becoming less prominent. For 2002-2008 data, linear regression analysis detected no significant trend in the annual reported age-adjusted incidence of dengue (incidence range: 0.7-3.0 per 1000 population). The incidence declined in 2.7% of the 185 districts studied, was unchanged in 86.2% and increased in 9.6%. The age-specific incidence was highest in infants aged < 1 year and children aged 4-6 years. The incidence was higher during rainy seasons. All four dengue virus (DENV) serotypes were permanently in circulation, though the predominant serotype has alternated between DENV-3 and DENV-2 since 2000. Although larvicide has been distributed in 94 districts since 2002, logistic regression analysis showed no association between the intervention and dengue incidence. Conclusion The dengue burden remained high among young children in Cambodia, which reflects intense transmission. The national vector control programme appeared to have little impact on disease incidence. Objectif La dengue est une maladie a declaration obligatoire au Cambodge depuis 1980. La surveillance virologique a commence en 2000 et une surveillance sentinelle a ete etablie dans six hopitaux en 2001. Actuellement, la surveillance nationale comprend un recueil passif et actif des donnees et la declaration des enfants de 0-15 ans hospitalises. Le present rapport resume les donnees de surveillance recueillies depuis 1980. Methodes Les donnees brutes de 1980-2001 sont presentees, alors que les donnees de 2002-2008 sont utilisees pour decrire des tendances de la maladie et l'effet des interventions au niveau du controle du vecteur. Les tendances sur l'incidence de la dengue ont ete analysees par la methode des moindres carres generalises (Prais-Winsten) pour series chronologiques. Resultats Pendant les annees 1980-2001, les epidemies se sont produites en cycles de 3-4 ans, les cycles devenant moins evidents par la suite. Pour les donnees de 2002-2008, l'analyse de regression lineaire n'a detecte aucune tendance significative de l'incidence annuelle declaree de la dengue ajustee selon l'age (fourchette d'incidence: 0,7-3,0 par 1 000 habitants). L'incidence a decline dans 2,7% des 185 districts etudies, elle a ete inchangee dans 86,2% et elle a augmente dans 9,6%. L'incidence specifique de I'age a ete plus elevee chez les nourrissons de < 1 an et les enfants de 4-6 ans. L'incidence a ete plus elevee pendant la saison des pluies. Les serotypes des quatre virus de la dengue (DENV) ont circule en permanence. Toutefois, le serotype predominant a alterne entre DENV-3 et DENV-2 depuis 2000. Bien qu'un larvicide ait ete distribue dans 94 districts depuis 2002, l'analyse de regression logistique n'a montre aucune association entre l'intervention et l'incidence de la dengue. Conclusion Le fardeau de la dengue est reste eleve parmi les jeunes enfants au Cambodge, ce qui reflete une transmission intense. Le programme national de controle du vecteur apparait comme ayant peu d'impact sur rincidence de la maladie. Objetivos La declaracion del dengue ha sido obligatoria en Camboya desde 1980. La vigilancia virologica se inicio en el ano 2000 y la vigilancia centinela se fijo en 2001 en se!s hospitales. En la actualidad, la vigilancia nacional comprende la recopilacion de datos activos y pasivos y la presentacion de informes de ninos hospitalizados de entre O y 15 anos. Este informe resume los datos de vigilancia recopilados desde 1980. Metodos Se presentan los datos brutos desde 1980 hasta 2001 y los datos obtenidos entre 2002 y 2008 se emplean para describir las tendencias de la enfermedad y el erecto de las intervenciones para el control del vector. Las tendencias de la incidencia del dengue se analizaron con el modelo basico de regresion lineal de Prais-Winsten para las series temporales. Resultados Entre 1980 y 2001 se preodujeron epidemias en ciclos de 3-4 anos, siendo los ciclos siguientes menos destacados. El analisis de regresion lineal no detecto, en los datos comprendidos entre 2002 y 2008, ninguna tendencia significativa en la incidencia anual del dengue comunicada y ajustada por edades (intervalo de incidencia: 0,7-3,0 por 1000 habitantes). La incidencia disminuyo en un 2,7% de los 185 distritos estudiados, se mantuvo sin cambios en e186,2% y aumento en el 9,6%. La incidencia especifica por edades fue mayor en los lactantes menores de un ano y en los ninos de entre cuatro y seis anos. La incidencia fue mayor en epocas de Iluvia. Los cuatro serotipos del virus del dengue (VDEN) estuvieron en circulacion de forma permanente, si bien el serotipo predominante se fue alternando entre el virus DEN-3 y el DEN-2 desde el ano 2000. A pesar de que se han distribuido larvicidas en 94 distritos desde el ano 2002, el analisis de regresion logistica no mostro relacion alguna entre dicha intervencion y la incidencia del dengue. Conclusion La carga del dengue siguio siendo elevada entre los ninos pequenos en Camboya, lo que refleja su elevada transmision. El programa nacional para el control de vectores tuvo poco impacto sobre la incidencia de la enfermedad., Background Over the past 30 years, dengue fever has emerged as the most important arthropod-borne viral disease of humans worldwide and is a major global public health problem, primarily in [...]

From 2004 through 2007, a total of 26 outbreaks of influenza A virus (H5N1) infection have occurred in poultry in Cambodia, and 7 human cases have been reported. Subtype H5N1 [...]

To understand transmission of avian influenza A (H5N1) virus, we conducted a retrospective survey of poultry deaths and a seroepidemiologic investigation in a Cambodian village where a 28-year-old man was [...]

Antimicrobial resistance (AMR) has become a major threat worldwide, especially in countries with inadequate sanitation and low antibiotic regulation. However, adequately prioritizing AMR interventions in such settings requires a quantification of the relative impacts of environmental, animal, and human sources in a One‐Health perspective. Here, we propose a stochastic quantitative risk assessment model for the different components at interplay in AMR selection and spread. The model computes the incidence of AMR colonization in humans from five different sources: water or food consumption, contacts with livestock, and interhuman contacts in hospitals or the community, and combines these incidences into a per‐year acquisition risk. Using data from the literature and Monte‐Carlo simulations, we apply the model to hypothetical Asian‐like settings, focusing on resistant bacteria that may cause infections in humans. In both scenarios A, illustrative of low‐income countries, and B, illustrative of high‐income countries, the overall individual risk of becoming colonized with resistant bacteria at least once per year is high. However, the average predicted incidence of colonization was lower in scenario B at 0.82 (CrI [0.13, 5.1]) acquisitions/person/year, versus 1.69 (CrI [0.66, 11.13]) acquisitions/person/year for scenario A. A high percentage of population with no access to improved water on premises and a high percentage of population involved in husbandry are shown to strongly increase the AMR acquisition risk. The One‐Health AMR risk assessment framework we developed may prove useful to policymakers throughout Asia, as it can easily be parameterized to realistically reproduce conditions in a given country, provided data are available. [ABSTRACT FROM AUTHOR]

Abstract Background Poultry represents an important sector in animal production, with backyard flocks representing a huge majority, especially in the developing countries. In these countries, villagers raise poultry to meet household food demands and as additional sources of incomes. Backyard production methods imply low biosecurity measures and high risk of infectious diseases, such as Newcastle disease or zoonosis such as Highly Pathogenic Avian Influenza (HPAI). We reviewed literature on biosecurity practices for prevention of infectious diseases, and published recommendations for backyard poultry and assessed evidence of their impact and feasibility, particularly in developing countries. Documents were sourced from the Food and Agriculture Organization (FAO) website, and from Pubmed and Google databases. Results A total of 62 peer-reviewed and non-referred documents were found, most of which were published recently (after 2004) and focused on HPAI/H5N1-related biosecurity measures (64%). Recommendations addressed measures for flock management, feed and water management, poultry trade and stock change, poultry health management and the risk to humans. Only one general guideline was found for backyard poultry-related biosecurity; the other documents were drawn up for specific developing settings and only engaged their authors (e.g. consultants). These national guidelines written by consultants generated recommendations regarding measures derived from the highest standards of commercial poultry production. Although biosecurity principles of isolation and containment are described in most documents, only a few documents were found on the impact of measures in family poultry settings and none gave any evidence of their feasibility and effectiveness for backyard poultry. Conclusions Given the persistent threat posed by HPAI/H5N1 to humans in developing countries, our findings highlight the importance of encouraging applied research toward identifying sustained and adapted biosecurity measures for smallholder poultry flocks in low-income countries.

To determine potential risk for bird-to-human transmission during influenza A virus (H5N1) outbreaks among backyard poultry in rural Cambodia, we collected environmental specimens. Viral RNA was detected in 27 (35%) [...]

Abstract Background In many Asian countries, Klebsiella pneumoniae (KP) is the second pathogen responsible for community-acquired pneumonia. Yet, very little is known about KP etiology in ALRI in Cambodia, a country that has one of the weakest medical infrastructures in the region. We present here the first clinico-radiological description of KP community-acquired ALRI in hospitalized Cambodian patients. Methods Through ALRI surveillance in two provincial hospitals, KP was isolated from sputum and blood cultures, and identified by API20E gallery from patients ≥ 5 years-old with fever and respiratory symptoms onset ≤14 days. Antibiotics susceptibility testing was provided systematically to clinicians when bacteria were isolated. We collected patients' clinical, radiological and microbiological data and their outcome 3 months after discharge. We also compared KP-related with other bacteria-related ALRI to determine risk factors for KP infection. Results From April 2007 to December 2009, 2315 ALRI patients ≥ 5 years-old were enrolled including 587 whose bacterial etiology could be assigned. Of these, 47 (8.0%) had KP infection; their median age was 55 years and 68.1% were females. Reported prior medication was high (42.5%). Patients' chest radiographs showed pneumonia (61.3% including 39% that were necrotizing), preexisting parenchyma lesions (29.5%) and pleural effusions alone (4.5%) and normal parenchyma (4.5%). Five patients had severe conditions on admission and one patient died during hospitalization. Of the 39 patients that were hospital discharged, 14 died including 12 within 1 month after discharge. Only 13 patients (28%) received an appropriate antibiotherapy. Extended-spectrum beta-lactamases (ESBL) - producing strains were found in 8 (17.0%) patients. Female gender (Odds ratio (OR) 2.1; p = 0.04) and diabetes mellitus (OR 3.1; p = 0.03) were independent risk factors for KP-related ALRI. Conclusions KP ALRI in Cambodia has high fatality rate, are more frequently found in women, and should be considered in diabetic patients. The extremely high frequency of ESBL-producing strains in the study is alarming in the context of uncontrolled antibiotic consumption and in absence of microbiology capacity in most public-sector hospitals.

Because avian influenza H5N1 infection risks are associated with exposure to infected poultry, we conducted a knowledge, attitudes, and practices survey of poultry-handling behavior among villagers in rural Cambodia. Despite [...]

Abstract Background Melioidosis is a disease caused by Burkholderia pseudomallei and considered endemic in South-East Asia but remains poorly documented in Cambodia. We report the first series of hospitalized pulmonary melioidosis cases identified in Cambodia describing clinical characteristics and outcomes. Methods We characterized cases of acute lower respiratory infections (ALRI) that were identified through surveillance in two provincial hospitals. Severity was defined by systolic blood pressure, cardiac frequency, respiratory rate, oxygen saturation and body temperature. B. pseudomallei was detected in sputum or blood cultures and confirmed by API20NE gallery. We followed up these cases between 6 months and 2 years after hospital discharge to assess the cost-of-illness and long-term outcome. Results During April 2007 - January 2010, 39 ALRI cases had melioidosis, of which three aged ≤2 years; the median age was 46 years and 56.4% were males. A close contact with soil and water was identified in 30 patients (76.9%). Pneumonia was the main radiological feature (82.3%). Eleven patients were severe cases. Twenty-four (61.5%) patients died including 13 who died within 61 days after discharge. Of the deceased, 23 did not receive any antibiotics effective against B. pseudomallei. Effective drugs that were available did not include ceftazidime. Mean total illness-related costs was of US$65 (range $25-$5000). Almost two-thirds (61.5%) incurred debt and 28.2% sold land or other belongings to pay illness-related costs. Conclusions The observed high fatality rate is likely explained by the lack or limited access to efficient antibiotics and under-recognition of the disease among clinicians, which led to inappropriate therapy.

Abstract Background The frequency of bloodborne pathogen healthcare-associated infections is thought to be high in developing Southeast Asian Countries. The underlying social-cultural logics contributing to the risks of transmission are rarely studied. This report provides some insights on the social and cultural factors that shape hygiene practices in Cambodian health care settings. Methods We conducted qualitative surveys in various public and private health facilities in Phnom Penh, the capital city and in provinces. We observed and interviewed 319 participants, health care workers and patients, regarding hygiene practices and social relationships amongst the health care staff and with patients. We also examined the local perceptions of hygiene, their impact on the relationships between the health care staff and patients, and perceptions of transmission risks. Data collection stem from face to face semi-structured and open-ended interviews and focus group discussions with various health care staffs (i.e. cleaners, nurses, midwives and medical doctors) and with patients who attended the study health facilities. Results Overall responses and observations indicated that hygiene practices were burdened by the lack of adequate materials and equipements. In addition, many other factors were identified to influence and distort hygiene practices which include (1) informal and formal social rapports in hospitals, (2) major infection control roles played by the cleaners in absence of professional acknowledgment. Moreover, hygiene practices are commonly seen as an unessential matter to be devoted to low-ranking staff. Conclusion Our anthropological findings illustrate the importance of comprehensive understanding of hygiene practices; they need to be considered when designing interventions to improve infection control practices in a Cambodian medical setting.

Abstract Background Dengue is endemic in Cambodia (pop. estimates 14.4 million), a country with poor health and economic indicators. Disease burden estimates help decision makers in setting priorities. Using recent estimates of dengue incidence in Cambodia, we estimated the cost of dengue and its burden using disability adjusted life years (DALYs). Methods Recent population-based cohort data were used to calculate direct and productive costs, and DALYs. Health seeking behaviors were taken into account in cost estimates. Specific age group incidence estimates were used in DALYs calculation. Results The mean cost per dengue case varied from US$36 - $75 over 2006-2008 respectively, resulting in an overall annual cost from US$3,327,284 in 2008 to US$14,429,513 during a large epidemic in 2007. Patients sustain the highest share of costs by paying an average of 78% of total costs and 63% of direct medical costs. DALY rates per 100,000 individuals ranged from 24.3 to 100.6 in 2007-2008 with 80% on average due to premature mortality. Conclusion Our analysis confirmed the high societal and individual family burden of dengue. Total costs represented between 0.03 and 0.17% of Gross Domestic Product. Health seeking behavior has a major impact on costs. The more accurate estimate used in this study will better allow decision makers to account for dengue costs particularly among the poor when balancing the benefits of introducing a potentially effective dengue vaccine.

Abstract Background There is little information about influenza disease among the Cambodian population. To better understand the dynamics of influenza in Cambodia, the Cambodian National Influenza Center (NIC) was established in August 2006. To continuously monitor influenza activity, a hospital based sentinel surveillance system for ILI (influenza like illness) with a weekly reporting and sampling scheme was established in five sites in 2006. In addition, hospital based surveillance of acute lower respiratory infection (ALRI) cases was established in 2 sites. Methods The sentinel sites collect weekly epidemiological data on ILI patients fulfilling the case definition, and take naso-pharyngeal specimens from a defined number of cases per week. The samples are tested in the Virology Unit at the Institut Pasteur in Phnom Penh. From each sample viral RNA was extracted and amplified by a multiplex RT-PCR detecting simultaneously influenza A and influenza B virus. Influenza A viruses were then subtyped and analyzed by hemagglutination inhibition assay. Samples collected by the ALRI system were tested with the same approach. Results From 2006 to 2008, influenza circulation was observed mainly from June to December, with a clear seasonal peak in October shown in the data from 2008. Conclusion Influenza activity in Cambodia occurred during the rainy season, from June to December, and ended before the cool season (extending usually from December to February). Although Cambodia is a tropical country geographically located in the northern hemisphere, influenza activity has a southern hemisphere transmission pattern. Together with the antigenic analysis of the circulating strains, it is now possible to give better influenza vaccination recommendation for Cambodia.

Abstract Background The average annual reported dengue incidence in Cambodia is 3.3/1,000 among children < 15 years of age (2002–2007). To estimate the economic burden of dengue, accurate cost-of-illness data are essential. We conducted a prospective, community-based, matched case-control study to assess the cost and impact of an episode of dengue fever and other febrile illness on households in rural Cambodia. Methods In 2006, active fever surveillance was conducted among a cohort of 6,694 children aged ≤ 15 years in 16 villages in Kampong Cham province, Cambodia. Subsequently, a case-control study was performed by individually assigning one non-dengue febrile control from the cohort to each laboratory-confirmed dengue case. Parents of cases and controls were interviewed using a standardized questionnaire to determine household-level, illness-related expenditures for medical and non-medical costs, and estimated income loss (see Additional file 1). The household socio-economic status was determined and its possible association with health seeking behaviour and the ability to pay for the costs of a febrile illness. Additional File 1 2006 cost study survey questionnaire, Cambodia. the questionnaire represents the data collection instrument that was developed and used during the present study. Click here for file Results Between September and November 2006, a total of 60 household heads were interviewed: 30 with dengue-positive and 30 with dengue-negative febrile children. Mean total dengue-related costs did not differ from those of other febrile illnesses (31.5 vs. 27.2 US$, p = 0.44). Hospitalization almost tripled the costs of dengue (from 14.3 to 40.1 US$) and doubled the costs of other febrile illnesses (from 17.0 to 36.2 US$). To finance the cost of a febrile illness, 67% of households incurred an average debt of 23.5 US$ and higher debt was associated with hospitalization compared to outpatient treatment (US$ 23.1 vs. US$ 4.5, p < 0.001). These costs compared to an average one-week expenditure on food of US$ 9.5 per household (range 2.5–21.3). In multivariate analysis, higher socio-economic status (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4–13.2), duration of fever (OR 2.1; 95%CI 1.3–3.5), and age (OR 0.8; 95%CI 0.7–0.9) were independently associated with hospitalization. Conclusion In Cambodia, dengue and other febrile illnesses pose a financial burden to households. A possible reason for a lower rate of hospitalization among children from poor households could be the burden of higher illness-related costs and debts.

Abstract Background In Cambodia, estimates of the malaria burden rely on a public health information system that does not record cases occurring among remote populations, neither malaria cases treated in the private sector nor asymptomatic carriers. A global estimate of the current malaria situation and associated risk factors is, therefore, still lacking. Methods A large cross-sectional survey was carried out in three areas of multidrug resistant malaria in Cambodia, enrolling 11,652 individuals. Fever and splenomegaly were recorded. Malaria prevalence, parasite densities and spatial distribution of infection were determined to identify parasitological profiles and the associated risk factors useful for improving malaria control programmes in the country. Results Malaria prevalence was 3.0%, 7.0% and 12.3% in Sampovloun, Koh Kong and Preah Vihear areas. Prevalences and Plasmodium species were heterogeneously distributed, with higher Plasmodium vivax rates in areas of low transmission. Malaria-attributable fevers accounted only for 10–33% of malaria cases, and 23–33% of parasite carriers were febrile. Multivariate multilevel regression analysis identified adults and males, mostly involved in forest activities, as high risk groups in Sampovloun, with additional risks for children in forest-fringe villages in the other areas along with an increased risk with distance from health facilities. Conclusion These observations point to a more complex malaria situation than suspected from official reports. A large asymptomatic reservoir was observed. The rates of P. vivax infections were higher than recorded in several areas. In remote areas, malaria prevalence was high. This indicates that additional health facilities should be implemented in areas at higher risk, such as remote rural and forested parts of the country, which are not adequately served by health services. Precise malaria risk mapping all over the country is needed to assess the extensive geographical heterogeneity of malaria endemicity and risk populations, so that current malaria control measures can be reinforced accordingly.

Abstract Background Injection overuse and unsafe injection practices facilitate transmission of bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Anecdotal reports of unsafe and unnecessary therapeutic injections and the high prevalence of HBV (8.0%), HCV (6.5%), and HIV (2.6%) infection in Cambodia have raised concern over injection safety. To estimate the magnitude and patterns of such practices, a rapid assessment of injection practices was conducted. Methods We surveyed a random sample of the general population in Takeo Province and convenience samples of prescribers and injection providers in Takeo Province and Phnom Penh city regarding injection-related knowledge, attitudes, and practices. Injection providers were observed administering injections. Data were collected using standardized methods adapted from the World Health Organization safe injection assessment guidelines. Results Among the general population sample (n = 500), the overall injection rate was 5.9 injections per person-year, with 40% of participants reporting receipt of ≥ 1 injection during the previous 6 months. Therapeutic injections, intravenous infusions, and immunizations accounted for 74%, 16% and 10% of injections, respectively. The majority (>85%) of injections were received in the private sector. All participants who recalled their last injection reported the injection was administered with a newly opened disposable syringe and needle. Prescribers (n = 60) reported that 47% of the total prescriptions they wrote included a therapeutic injection or infusion. Among injection providers (n = 60), 58% recapped the syringe after use and 13% did not dispose of the used needle and syringe appropriately. Over half (53%) of the providers reported a needlestick injury during the previous 12 months. Ninety percent of prescribers and injection providers were aware HBV, HCV, and HIV were transmitted through unsafe injection practices. Knowledge of HIV transmission through "dirty" syringes among the general population was also high (95%). Conclusion Our data suggest that Cambodia has one of the world's highest rates of overall injection usage, despite general awareness of associated infection risks. Although there was little evidence of reuse of needles and syringes, support is needed for interventions to address injection overuse, healthcare worker safety and appropriate waste disposal.