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Summary: An outbreak investigation was conducted during February–March 2005 to determine the cause of several sudden deaths occurring in Pailin Province, Cambodia. Sixty-seven patients presented with non-febrile poisoning-like symptoms and 15 died of coma, including 53% children under 10 years old. Symptoms included sore throat (92%), sore lips (73%), swollen tongue (54%) and gastrointestinal signs (41%). A plant locally called prik was the source of poisoning (97.0 vs. 28.7%, odds ratio 74.3, P <0.001). Patients may have confused the edible Melientha suavis Pierre with Urobotrya siamensis Hiepko, both from the Opiliaceae family. This was the first report of Urobotrya poisoning and its clinical manifestations. [Copyright &y& Elsevier]

An initial challenge to apply relevant social psychological knowledge to the HIV/AIDS epidemic in Cambodia has grown, using a Lewinian 'action research' perspective, into a multi-sectoral research and health intervention programme. This addresses inequalities in literacy, employment, poverty and the risk of dying from HIV/AIDS. At the level of the individual, it seeks behavioural change to 100% condom use for women and men at risk. At the social level, a pyramidal 'peer educator' training program is initiated, while at the community, institutional and international levels, hiring policies of hotels and the health policies of globalised businesses are challenged to contribute proactively to the campaign against the spread of HIV/AIDS. While a grass-roots community (NGO) group works locally to improve the situation of married women and the 'beer girls' of Siem Reap, students in several countries are organising internet sites concerning the ethical and fair-trade practices of international beer companies profiting from the sales of these beer-girls, who are now 20% HIV positive. [ABSTRACT FROM AUTHOR]

Continuous professional development is important for improving professional competencies, such as cognitive knowledge, technical skills, behaviors, and attitudes. Trainees who complete training programs can have a positive influence on their workplaces. However, it is challenging to establish a process that can facilitate individual learning and help achieve training outcomes in educational and clinical workplaces. In Cambodia, a tumultuous history has played a part in the deficit of adequately prepared nursing faculty. Since the faculty development is vital to ensuring the quality of education, the application of upgraded nursing programs has started in 2011. After the completion of upgraded program, an immediate post-training study was conducted in 2014. Results showed that some faculty members did not accept trainees because they lacked an understanding about nursing concepts. The current study aimed to evaluate the medium-term outcomes of an established program that can improve nursing education and to identify relevant factors in light of the institutional development of educational and clinical facilities in Cambodia. A qualitative study incorporating focus group discussions, key-informant interviews, and teaching document reviews was performed with a thematic analysis using the four-level training evaluation model of Kirkpatrick. Finally, factors influencing outcomes were assessed based on the Bronfenbrenner's ecological system theory. Five themes for behavior and three themes for results were identified as medium-term outcomes from an institutional development aspect. The major enabling factors for the above-mentioned themes were the support of institutional managers, continuous networking among trainees, and supportive national policy. Compared with the immediate post-training study findings, the perceived medium-term outcomes became more strategically focused. Then, the impact of training at a considerably broader scale within the workplace was discussed. The findings highlighted the importance of medium-term program delivery and monitoring if one understands the role played in stimulating outcomes. Moreover, the importance of contextual factors including the influence of managers and policy environment were emphasized., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Symptom assessment and quality of life (QoL) are considered two of the most important factors in the overall care of cancer patients. Although cancer is one of the leading causes of death after communicable disease in Cambodia, the QoL of Cambodian cancer patients has not been examined previously. This study aimed to describe the QoL of cancer patients in Cambodia., Methods: A cross-sectional study was conducted with cancer patients who visited Khmer-Soviet Friendship Hospital in Phnom Penh. Two hundred patients participated in this study. The inventory comprised two previously validated scales: the Center for Epidemiological Studies Depression Scale-10 (CESD-10) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Descriptive analyses, independent samples t-tests, and Pearson's correlation analysis were performed to examine the differences and relationship between study variables., Results: The mean global health score was 51.62, and 58.5% of the participants had depressive symptom. The global health score was statistically significantly lower in depressive patients. The QoL was negatively correlated with depression, but positively and significant correlated with physical function, role function, emotional function, cognitive function, and social function., Conclusion: This study is the first to describe the QoL of Cambodian cancer patients. Our findings suggest that more attention should be paid to psychological concerns and symptom management in Cambodian cancer patients. Appropriate management could be effective in improving the QoL of cancer patients., (© 2019 John Wiley & Sons, Ltd.)

Background: Following Cambodia's implementation of the 100% condom use program with enforcement of condom use and STI treatment services for sex workers in 2001, sexually transmitted infection and HIV declined markedly. In 2008, Cambodia implemented a law to ban brothel-based sex work. We reported trends in unprotected vaginal intercourse with sex workers among heterosexual men buying sex before (2003-2008) and after (2009-2012) the brothel ban in Cambodia. We also determined the association of brothel ban with these men's reports of unprotected intercourse with sex workers., Methods: In this serial cross-sectional study, we collected yearly behavioural data on random cross-sectional samples of heterosexual men buying sex who attended the only government health centre in Siem Reap for voluntary confidential counselling and testing (VCCT) between 2003 and 2012. We used multivariable Poisson regression analysis on the 10-year data of 976 men to obtain the adjusted prevalence ratio (aPR) of unprotected intercourse in the last 6 months by brothel closure., Results: Men buying sex from non-brothel-based sex workers increased almost 3-fold from 17% in 2007-2008 before brothel closure to 55% in 2011-2012 after brothel closure (p < 0.001). Unprotected intercourse with sex workers in the last week increased significantly from 37% (2003-2004) before brothel closure to 65% (2011-2012) after brothel closure. This increase corresponded closely with the increase in self-reported unprotected intercourse from 35% to 61% by the sex workers (n = 1805) attending the same clinic for VCCT. Brothel closure was associated with an increased risk (aPR: 1.65; 95% CI: 1.40-1.94) of unprotected intercourse with sex workers. HIV prevalence in the heterosexual men declined significantly from 26% in 2003-2004 to 4.8% in 2007-2008 and 0 case in 2009-2010 before increasing to 5.6% in 2011-2012., Conclusion: Our findings suggest that the brothel ban had led to an increase in unprotected intercourse with all sex workers for men buying sex. This effect could be attributed to reduced condom access, a consequence of the lack of feasibility to implement the 100% condom use program following the brothel ban. The ban on brothels in Cambodia should be reviewed.

Little is known about circulation of influenza and other respiratory viruses in remote populations along the Thai-Cambodia border in western Cambodia. We screened 586 outpatients (median age 5, range 1-77) presenting with influenza-like-illness (ILI) at 4 sentinel sites in western Cambodia between May 2010 and December 2012. Real-time reverse transcriptase (rRT) PCR for influenza was performed on combined nasal and throat specimens followed by viral culture, antigenic analysis, antiviral susceptibility testing and full genome sequencing for phylogenetic analysis. ILI-specimens negative for influenza were cultured, followed by rRT-PCR for enterovirus and rhinovirus (EV/RV) and EV71. Influenza was found in 168 cases (29%) and occurred almost exclusively in the rainy season from June to November. Isolated influenza strains had close antigenic and phylogenetic relationships, matching vaccine and circulating strains found elsewhere in Cambodia. Influenza vaccination coverage was low (<20%). Western Cambodian H1N1(2009) isolate genomes were more closely related to 10 earlier Cambodia isolates (94.4% genome conservation) than to 13 Thai isolates (75.9% genome conservation), despite sharing the majority of the amino acid changes with the Thai references. Most genes showed signatures of purifying selection. Viral culture detected only adenovirus (5.7%) and parainfluenza virus (3.8%), while non-polio enteroviruses (10.3%) were detected among 164 culture-negative samples including coxsackievirus A4, A6, A8, A9, A12, B3, B4 and echovirus E6 and E9 using nested RT-PCR methods. A single specimen of EV71 was found. Despite proximity to Thailand, influenza epidemiology of these western Cambodian isolates followed patterns observed elsewhere in Cambodia, continuing to support current vaccine and treatment recommendations from the Cambodian National Influenza Center. Amino acid mutations at non-epitope sites, particularly hemagglutinin genes, require further investigation in light of an increasingly important role of permissive mutations in influenza virus evolution. Further research about the burden of adenovirus and non-polio enteroviruses as etiologic agents in acute respiratory infections in Cambodia is also needed.

Background: The Cambodian National Influenza Center (NIC) monitored and characterized circulating influenza strains from 2009 to 2011., Methodology/principal Findings: Sentinel and study sites collected nasopharyngeal specimens for diagnostic detection, virus isolation, antigenic characterization, sequencing and antiviral susceptibility analysis from patients who fulfilled case definitions for influenza-like illness, acute lower respiratory infections and event-based surveillance. Each year in Cambodia, influenza viruses were detected mainly from June to November, during the rainy season. Antigenic analysis show that A/H1N1pdm09 isolates belonged to the A/California/7/2009-like group. Circulating A/H3N2 strains were A/Brisbane/10/2007-like in 2009 before drifting to A/Perth/16/2009-like in 2010 and 2011. The Cambodian influenza B isolates from 2009 to 2011 all belonged to the B/Victoria lineage represented by the vaccine strains B/Brisbane/60/2008 and B/Malaysia/2506/2004. Sequences of the M2 gene obtained from representative 2009-2011 A/H3N2 and A/H1N1pdm09 strains all contained the S31N mutation associated with adamantanes resistance except for one A/H1N1pdm09 strain isolated in 2011 that lacked this mutation. No reduction in the susceptibility to neuraminidase inhibitors was observed among the influenza viruses circulating from 2009 to 2011. Phylogenetic analysis revealed that A/H3N2 strains clustered each year to a distinct group while most A/H1N1pdm09 isolates belonged to the S203T clade., Conclusions/significance: In Cambodia, from 2009 to 2011, influenza activity occurred throughout the year with peak seasonality during the rainy season from June to November. Seasonal influenza epidemics were due to multiple genetically distinct viruses, even though all of the isolates were antigenically similar to the reference vaccine strains. The drug susceptibility profile of Cambodian influenza strains revealed that neuraminidase inhibitors would be the drug of choice for influenza treatment and chemoprophylaxis in Cambodia, as adamantanes are no longer expected to be effective.

Introduction: Human influenza infection poses a serious public health threat in Cambodia, a country at risk for the emergence and spread of novel influenza viruses with pandemic potential. Prior pandemics demonstrated the adverse impact of influenza on poor communities in developing countries. Investigation of healthcare resource distribution can inform decisions regarding resource mobilization and investment for pandemic mitigation., Methods: A health facility survey performed across Cambodia obtained data on availability of healthcare resources important for pandemic influenza response. Focusing on five key resources considered most necessary for treating severe influenza (inpatient beds, doctors, nurses, oseltamivir, and ventilators), resource distributions were analyzed at the Operational District (OD) and Province levels, refining data analysis from earlier studies. Resources were stratified by respondent type (hospital vs. District Health Office [DHO]). A summary index of distribution inequality was calculated using the Gini coefficient. Indices for local spatial autocorrelation were measured at the OD level using geographical information system (GIS) analysis. Finally, a potential link between socioeconomic status and resource distribution was explored by mapping resource densities against poverty rates., Results: Gini coefficient calculation revealed variable inequality in distribution of the five key resources at the Province and OD levels. A greater percentage of the population resides in areas of relative under-supply (28.5%) than over-supply (21.3%). Areas with more resources per capita showed significant clustering in central Cambodia while areas with fewer resources clustered in the northern and western provinces. Hospital-based inpatient beds, doctors, and nurses were most heavily concentrated in areas of the country with the lowest poverty rates; however, beds and nurses in Non-Hospital Medical Facilities (NHMF) showed increasing concentrations at higher levels of poverty., Conclusions: There is considerable heterogeneity in healthcare resource distribution across Cambodia. Distribution mapping at the local level can inform policy decisions on where to stockpile resources in advance of and for reallocation in the event of a pandemic. These findings will be useful in determining future health resource investment, both for pandemic preparedness and for general health system strengthening, and provide a foundation for future analyses of equity in health services provision for pandemic mitigation planning in Cambodia.

The agents of human febrile illness can vary by region and country suggesting that diagnosis, treatment, and control programs need to be based on a methodical evaluation of area-specific etiologies. From December 2006 to December 2009, 9,997 individuals presenting with acute febrile illness at nine health care clinics in south-central Cambodia were enrolled in a study to elucidate the etiologies. Upon enrollment, respiratory specimens, whole blood, and serum were collected. Testing was performed for viral, bacterial, and parasitic pathogens. Etiologies were identified in 38.0% of patients. Influenza was the most frequent pathogen, followed by dengue, malaria, and bacterial pathogens isolated from blood culture. In addition, 3.5% of enrolled patients were infected with more than one pathogen. Our data provide the first systematic assessment of the etiologies of acute febrile illness in south-central Cambodia. Data from syndromic-based surveillance studies can help guide public health responses in developing nations.

Human respiratory syncytial virus (HRSV) is the leading cause of hospitalization of children aged <5 years due to respiratory illness in industrialized countries, and pneumonia is the leading cause of mortality among children aged <5 years worldwide. Although HRSV was first identified in 1956, a preventative vaccine has yet to be developed. Here we report the results of the first study to investigate the circulation and genetic diversity of HRSV in Cambodia among an all-ages population over 5 consecutive years. The incidences of HRSV infection among all-ages outpatient and hospitalized populations were equivalent, at 9.5% and 8.2%, respectively. Infection was most prevalent among children aged <5 years, with bronchiolitis being the most frequently observed clinical syndrome in the same age group. Circulation of HRSV was seasonal, typically coinciding with the rainy season between July and November annually. Strains belonging to HRSV groups A and B were detected with equivalent frequencies; however, we observed a potentially biennial shift in the predominant circulating HRSV genotype. The majority of HRSV group B strains belonged to the recently described BA genotype, with the exception of 10 strains classified as belonging to a novel HRSV group B genotype, SAB4, first reported here.

A cohort of Japanese encephalitis (JE) survivors in Cambodia and Viet Nam were assessed at least 4 months after hospital discharge in order to understand the extent of disability after JE. We used a simple assessment tool which focuses on the impact on daily life. In total, 64 disability assessments were conducted: 38 in Cambodia and 26 in Viet Nam. In Cambodia, 4 (11%) children had severe sequelae, suggesting the children would likely be dependent, 15 (39%) had moderate sequelae and 17 (45%) had mild sequelae. In Viet Nam, two (8%) persons had severe sequelae, five (19%) had moderate sequelae and eight (31%) had mild sequelae. In many JE-endemic areas there are no multi-disciplinary teams with sophisticated equipment to assess patients after JE disease. This assessment tool can assist with patient management and generate data to support the need for programmes to prevent disease and improve outcomes for survivors.

Low income countries in Southeast Asia are in a region at risk of emerging infectious diseases, notably SARS, H5N1 influenza and H1N1 influenza. Efforts have focused largely upon early outbreak response, though with the emergence of pandemic influenza, countries in the region are having to prepare to implement mitigation measures. We review the challenges for strategy and operation faced by two low income countries, Cambodia and Lao People's Democratic Republic (PDR), and highlight successes in planing and implementation to date as well as identifying needs and challenge that may hinder the future effectiveness of control measures.

This study aimed to evaluate the cost and effectiveness of introducing a live, attenuated vaccine (SA 14-14-2) against Japanese encephalitis (JE) into the immunization program. The study demonstrated that SA 14-14-2 immunization is cost-effective in controlling JE in Cambodia compared to no vaccination. Averting one disability-adjusted life year, from a societal perspective, through the introduction of SA 14-14-2 through routine immunization, or a combination of routine immunization plus a campaign targeting children 1-5 or 1-10 years of age, costs US$22, US$34 and US$53, respectively. Sensitivity analyses confirmed that there was a high probability of SA 14-14-2 immunization being cost-effective under conditions of uncertainty., ((c) 2010 Elsevier Ltd. All rights reserved.)

The liver fluke, Opisthorchis viverrini, causes serious public-health problems in the Lower Mekong Basin. This study aimed to clarify whether O. viverrini populations may be genetically divided into sub-specific taxa. We collected 6 populations of O. viverrini from different places in Cambodia, Lao PDR, and Thailand, along both sides of the Mekong River, and analyzed the population structure of these using the mitochondrial nad1 gene as a marker. The results of the DNA polymorphism measurements, by theta-w (thetaw) and -pi (thetapi) values, neutrality tests, and mismatch distribution, suggested that the population of O. viverrini has expanded under the influence of purifying selection and selective sweep. The analysis of molecular variance (AMOVA) test revealed no significant genetic differences among the O. viverrini populations on opposite sides of the Mekong River. O. viverrini haplotypes occurred in multiple populations, and no distinct geographical clade. The star-like haplotype network confirmed a demographic expansion of the O. viverrini population. Overall, the genetic data from these populations suggested that the postulated existence of an O. viverrini species complex should be rejected. The bio-geographical diversity of O. viverrini populations should be explored further, using other appropriate markers and a wider range of samples from geographically different areas.

The epidemiology, symptomology, and viral aetiology of endemic influenza remain largely uncharacterized in Cambodia. In December 2006, we established passive hospital-based surveillance to identify the causes of acute undifferentiated fever in patients seeking healthcare. Fever was defined as tympanic membrane temperature >38 degrees C. From December 2006 to December 2008, 4233 patients were screened for influenza virus by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). Of these patients, 1151 (27.2%) were positive for influenza. Cough (68.8% vs. 50.5%, P < 0.0001) and sore throat (55.0% vs. 41.9%, P < 0.0001) were more often associated with laboratory-confirmed influenza-infected patients compared to influenza-negative enrollees. A clear influenza season was evident between July and December with a peak during the rainy season. Influenza A and B viruses were identified in 768 (66.3%) and 388 (33.7%) of the influenza-positive population (n = 1153), respectively. In December 2008, passive surveillance identified infection of the avian influenza virus H5N1 in a 19-year-old farmer from Kandal province who subsequently recovered. From a subset of diagnostic samples submitted in 2007, 15 A(H1N1), seven A(H3N2) and seven B viruses were isolated. The predominant subtype tested was influenza A(H1N1), with the majority antigenically related to the A/Solomon Island/03/2006 vaccine strain. The influenza A(H3N2) isolates and influenza B viruses analysed were closely related to A/Brisbane/10/2007 or B/Ohio/01/2005 (B/Victoria/2/87-lineage) vaccine strains, respectively. Phylogenetic analysis of the HA1 region of the HA gene of influenza A(H1N1) viruses demonstrated that the Cambodian isolates belonged to clade 2C along with representative H1N1 viruses circulating in SE Asia at the time. These viruses remained sensitive to oseltamivir. In total, our data suggest that viral influenza infections contribute to nearly one-fifth of acute febrile illnesses and demonstrate the importance of influenza surveillance in Cambodia.

Influenza-Like Illness (ILI) sentinel surveillance was initiated by the Communicable Disease Control Department (CDC), Ministry of Health, Cambodia and its partners to evaluate the epidemiology of influenza and identify the circulating strains. The surveillance started in late 2006 in four sentinel sites. The objectives of this study were 1) to document the incidence of LI and confirmed influenza cases reported in the national surveillance system from 2006 to 2008, just after the system and the definition were revised, 2) to identify the strains of influenza virus, 3) to compare the major demographic and clinical characteristics between ILI patients having positive and negative tests for influenza virus. An ILI case was defined as having a fever of at least 38 degrees C (axillary), cough or sore throat. A total of 155,866 ILI cases were reported to the CDC from 4 sentinel sites in Cambodia from August 2006 to December 2008. Specimens were collected in 1.8%. Of these, 9.6% tested positive for influenza. Influenza was observed to occur mainly from August to December, with a clear seasonal peak in October, as shown in the data from 2008. A new case definition beginning in August 2008 resulted in a decrease in weekly RI reported cases (from an average of 1,474 cases to 54 cases) and the proportion of positive tests for influenza increased (5.3% vs 29.3%). Influenza and ILI are seasonal in Cambodia. A higher body temperature was used to define ILI, which improved the influenza positivity rates.

Objectives: To describe the results from two years of Japanese encephalitis (JE) sentinel surveillance in Cambodia., Methods: Sentinel site surveillance for JE in children aged 15 years and under was implemented in Cambodia in mid-2006. It was integrated into the routine meningoencephalitis surveillance system. Six hospitals were selected as sentinel sites. Epidemiological information and diagnostic specimens were collected from each patient presenting with meningoencephalitis. Cerebrospinal fluid and sera were tested for presence of immunoglobulin M antibodies against JE and dengue viruses by an ELISA. Surveillance data from 2006 to 2008 were analysed., Results: Of 586 patients presenting with meningoencephalitis, 110 (19%) were confirmed to have JE. The percentage of confirmed JE cases at individual sentinel sites ranged from 13% to 35% of all meningoencephalitis cases. Mean age was 6.2 years, with 95% of JE cases in children aged 12 years and under. Cases occurred year-round in both 12-month reporting periods., Conclusions: JE is an important cause of meningoencephalitis in Cambodian children. As JE is a vaccine-preventable disease, an immunization programme could result in a considerable reduction in morbidity and mortality from JE among children in Cambodia.

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.

Small liver flukes, Clonorchis sinensis and Opisthorchis viverini, are fish-borne trematodes (FBTs) causing significant public health problems in Asia. While C. sinensis is distributing mainly in far east Asia, O. viverini is distributing in Indochina peninsula. Recently, however, the geographical distributions of those small liver flukes were proven to be far wider than expected. Nevertheless, little is known about the epidemiology of small liver flukes in Cambodia. The present study is, therefore, aimed at clarifying the status of small liver fluke infections in various species of freshwater fish in southern Cambodia. A total of 1479 freshwater fish, 1316 (89%) comprised of 20 different species of the cyprinoid family and 163 (11%) belonging to 8 families of non-cyprinoids, were collected during May 2007 and February 2008, and the presence of small liver fluke metacercariae was examined by the compression method. Small liver fluke metacercariae were found in 10 species of cyprinoids with the infection rate ranging 2.1-66.7% and the mean intensity of infection of 1.0-15.0 (range: 1-65). For the speciation, adult worms were obtained by experimental infection in hamsters. The small liver fluke found in this study were identified as Opisthorchis viverrini by the morphological features of adult worms, and this identification was confirmed by partial COI sequencing of the metacercariae.

Problem: Recent progress in vaccine availability and affordability has raised prospects for reducing death and disability from neurological infections in children. In many Asian countries, however, the epidemiology and public health burden of neurological diseases such as Japanese encephalitis and bacterial meningitis are poorly understood., Approach: A sentinel surveillance system for Japanese encephalitis was developed and embedded within the routine meningoencephalitis syndromic surveillance system in Cambodia in 2006. The sentinel surveillance system was designed so surveillance and laboratory testing for other etiologies of neurological infection could be incorporated., Local Setting: The Communicable Disease Control department of the Ministry of Health in Cambodia worked with partners to establish the sentinel surveillance system., Relevant Changes: The sentinel surveillance system has provided important information on the disease burden of Japanese encephalitis in Cambodia and is now providing a platform for expansion to incorporate laboratory testing for other vaccine-preventable neurological infections in children., Lessons Learned: Sentinel surveillance systems, when linked to syndromic reporting systems, can characterize the epidemiology of meningoencephalitis and identify the proportion of hospital-based neurological infection in children that is vaccine preventable. Integrated systems enable consistency in data collection, analysis and information dissemination, and they enhance the capacity of public health managers to provide more credible and integrated information to policy-makers. This will assist decision-making about the potential role of immunization in reducing the incidence of childhood neurological infections.

Background: Between January 2005 and April 2006, six patients of influenza A/H5N1 virus infection were reported in Cambodia, all with fatal outcome., Objectives: We describe the virological findings of these six H5N1 patients in association with clinical and epidemiologic findings., Study Design: Broncho-alveolar lavage, nasopharyngeal, throat and rectal swabs and sera were cultured for virus isolation and viral load quantified in clinical specimens by real-time RT-PCR. We compared sequences obtained from different body sites within the same patient to detect viral quasi-species., Results: H5N1 virus strains isolated in Cambodia belong to genotype Z, clade 1 viruses. H5N1 viruses were isolated from serum and rectal swab specimens in two patients. The haemagglutinin gene sequences of the virus in different body sites did not differ. Amino acid substitutions known to be associated with a change in virus binding were not observed., Conclusion: The high frequency of virus isolation from serum and faecal swabs highlights that H5N1 is likely to be a disseminated infection in humans and this has implications for antiviral treatment, biosafety in clinical laboratories and on risks for nosocomial and human-to-human transmission. There were no tissue-specific adaptive mutations in the HA gene from viruses isolated from different organs.