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Health insurance is essential in reducing or eliminating the financial constraint to accessing maternal health services caused by out-of-pocket payments. Also, it has a beneficial effect in minimizing maternal and child mortality. However, limited studies in Cambodia examined the association between health insurance coverage on antenatal care (ANC) utilization. Therefore, this study has examined the effect of health insurance coverage on ANC utilization in Cambodia. We utilized data from the 2021-2022 Cambodia Demographic and Health Surveys (CDHS), analyzing a total sample of 3,162 weighted women who gave birth within two years. Multiple logistic regression model using STATA V17 to assess the association between health insurance coverage with women who attended four or more ANC visits. About 24.9% of the women had health insurance coverage during 2021-2022. Most (86.1%) of women attended four or more ANC visits. Women with health insurance coverage were statistically significantly associated with attending four or more ANC visits with an adjusted odds ratio (AOR = 1.6; 95% CI: 1.1-2.4). Other factors significantly associated with attending four or more ANC visits include women with higher education (AOR = 3.1; 95% CI: 1.2-7.7), secondary education (AOR = 2.3; 95% CI: 1.5-3.5), richest households (AOR = 3.2; 95% CI: 1.5-6.8), and richer households (AOR = 1.9; 95% CI: 1.2-2.8). Pregnant women with health insurance coverage who had completed at least secondary education and had a better wealth index were more likely to attend at least four ANC visits. Thus, providing health insurance coverage and improving women's economic and educational may be essential to improving women's access to maternal health services in Cambodia.

BackgroundCollecting data on antimicrobial resistance (AMR) is an essential approach for defining the scope of the AMR problem, developing evidence-based interventions and detecting new and emerging resistances. Our study aimed to identify key factors influencing the implementation of a laboratory-based AMR surveillance system in Cambodia. This will add additional insights to the development of a sustainable and effective national AMR surveillance system in Cambodia and other low- and middle-income countries.MethodsKey informants with a role in governing or contributing data to the laboratory-based surveillance system were interviewed. Emerging themes were identified using the framework analysis method. Laboratories contributing to the AMR surveillance system were assessed on their capacity to conduct quality testing and report data. The laboratory assessment tool (LAT), developed by the World Health Organisation (WHO), was adapted for assessment of a diagnostic microbiology laboratory covering quality management, financial and human resources, data management, microbiology testing performance and surveillance capacity.ResultsKey informants identified inadequate access to laboratory supplies, an unsustainable financing system, limited capacity to collect representative data and a weak workforce to be the main barriers to implementing an effective surveillance system. Consistent engagement between microbiology staff and clinicians were reported to be a key factor in generating more representative data for the surveillance system. The laboratory assessments identified issues with quality assurance and data analysis which may reduce the quality of data being sent to the surveillance system and limit the facility-level utilisation of aggregated data. A weak surveillance network and poor guidance for outbreak response were also identified, which can reduce the laboratories’ opportunities in detecting critical or emerging resistance occurring in the community or outside of the hospital’s geographical coverage.ConclusionThis study identified two primary concerns: ensuring a sustainable and quality functioning of microbiology services at public healthcare facilities and overcoming sampling bias at sentinel sites. These issues hinder Cambodia’s national AMR surveillance system from generating reliable evidence to incorporate into public health measures or clinical interventions. These findings suggest that more investments need to be made into microbiology diagnostics and to reform current surveillance strategies for enhanced sampling of AMR cases at hospitals.

Acute Respiratory Infections (ARIs) are the leading cause of mortality and morbidity among children under 5 years old and about 1.3 million annually worldwide. Account for 33% of deaths among children under 5 years that occurred in developing countries. In Cambodia, ARIs prevalence in children under 5 years old was 20% in 2000, and 6% in 2014. Hence, the aimed to describe the trends of ARI symptoms among children aged 0-59 months over time using the 2000, 2005, 2010, and 2014 Cambodia Demographic and Health Survey (CDHS) and determined the relationships between socio-demographic, behavioral, and environmental factors with ARI symptoms. We analyzed existing children's data from 2000, 2005, 2010 and 2014 of Cambodia Demographic and Health Survey (CDHS) that used a two-stage stratified cluster sampling design. We limited our analysis to children born in the last five years prior to the surveys, alive and living in households during interview time. Data were pooled across the four survey years for 29,171 children aged 0-59 months. All statistics were carried out using STATA V16, and survey weights were taken into account for the survey design of the CDHS. We used multiple logistic regression to determine the main predictors of ARI symptoms among children under 5 years. ARI symptoms in the previous two weeks in children aged 0-59 months in Cambodia were 19.9% in 2000 to 8.6% in 2005 to 6.4% in 2010, and 5.5% in 2014. Factors independently associated with increased odds of ARI symptoms were children ages 6-11 months with adjusted odds ratio [AOR = 1.91; 95% CI: 1.53-2.38], 12-23 months [AOR = 1.79; 95% CI: 1.46-2.20], and 24-35 months [AOR = 1.41; 95% CI: 1.13-1.76], smoking mother [AOR = 1.61; 95% CI: 1.27-2.05], and using non-improved toilets in households [AOR = 1.20; 95% CI: 0.99-1.46]. However, the following factors were found to be associated with decreased odds of having ARI symptoms: Mothers with higher education [AOR = 0.45; 95% CI: 0.21-0.94], breastfeeding children [AOR = 0.87; 95% CI: 0.77-0.98], and children born into richest wealth quantile [AOR = 0.73; 95% CI: 0.56-0.95], respectively. Survey 2005 [AOR = 0.36; 95% CI: 0.31-0.42], 2010 [AOR = 0.27; 95% CI: 0.22-0.33], 2014 [AOR = 0.24; 95% CI: 0.19-0.30]. The trends of ARI symptoms among children under five in Cambodia significantly decreased from 2000-2014. Smoking mothers, young children ages (0-35 months), and using non-improved toilet in household are factors that independently increased the likelihood that children would develop ARI symptoms. Inversely, factors were found to be associated with decreased odds of having ARI symptoms: Mothers with higher education, breastfeeding children, and children born into the richest wealth quantile and Survey years. Therefore, government and child family programs must promote maternal education, particularly infant breastfeeding. The government ought to support maternal education and infant breastfeeding in the interest of early childhood care.

In February 2021, routine sentinel surveillance for influenza-like illness in Cambodia detected a human avian influenza A(H9N2) virus infection. Investigations identified no recent H9N2 virus infections in 43 close contacts. One chicken sample from the infected child’s house was positive for H9N2 virus and genetically similar to the human virus.

Introduction: The burden of influenza in Cambodia is not well known, but it would be useful for understanding the impact of seasonal epidemics and pandemics and to design appropriate policies for influenza prevention and control. The severe acute respiratory infection (SARI) surveillance system in Cambodia was used to estimate the national burden of SARI hospitalizations in Cambodia. Methods: We estimated age-specific influenza-associated SARI hospitalization rates in three sentinel sites in Svay Rieng, Siem Reap and Kampong Cham provinces. We used influenza-associated SARI surveillance data for one year to estimate the numerator and hospital admission surveys to estimate the population denominator for each site. A national influenza-associated SARI hospitalization rate was calculated using the pooled influenza-associated SARI hospitalizations for all sites as a numerator and the pooled catchment population of all sites as denominator. National influenza-associated SARI case counts were estimated by applying hospitalization rates to the national population. Results: The national annual rates of influenza-associated hospitalizations per 100 000 population was highest for the two youngest age groups at 323 for

Objectives: Following the launch of the Global Antimicrobial Resistance Surveillance System (GLASS), antimicrobial resistance (AMR) rates in many countries remain poorly described. This review provides an overview of published AMR data from Cambodia in the context of recently initiated national human and food-animal surveillance. Methods: PubMed and the Cochrane Database of Systematic Reviews were searched for articles published from 2000 to 2018, which reported antimicrobial susceptibility testing (AST) data for GLASS specific organisms isolated from Cambodia. Articles were screened using strict inclusion/exclusion criteria. AST data was extracted, with medians and ranges of resistance rates calculated for specific bug-drug combinations. Results: Twenty-four papers were included for final analysis, with 20 describing isolates from human populations. Escherichia coli was the most commonly described organism, with median resistance rates from human isolates of 92.8% (n = 6 articles), 46.4% (n = 4), 55.4% (n = 8), and 46.4% (n = 5) to ampicillin, 3rd generation cephalosporins, fluoroquinolones, and gentamicin respectively. Conclusions: Whilst resistance rates are high for several GLASS organisms, there were insufficient data to draw robust conclusions about the AMR situation in Cambodia. The recently implemented national AMR surveillance systems will begin to address this data gap. Keywords: Antimicrobial resistance, Cambodia, Bacteria, Review, One Health

Background: Tracking the emergence, introduction and spread of SARS-CoV-2 variants of concern are essential for informing public health strategies. In 2021, Cambodia faced two major epidemic waves of SARS-CoV-2 triggered by the successive rise of the Alpha and Delta variants., Methods: Phylodynamic analysis of 1,163 complete SARS-CoV-2 genomes from Cambodia, along with global sequences, were conducted between February and September 2021 to infer viral introductions, molecular epidemiology and population dynamics. The relationship between epidemic trends and control strategies were evaluated. Bayesian phylogeographic reconstruction was employed to estimate and contrast the spatiotemporal dynamics of the Alpha and Delta variants over time., Results: Here we reveal that the Alpha variant displays rapid lineage diversification, accompanied by the acquisition of a spike E484K mutation that coincides with the national implementation of mass COVID-19 vaccination. Despite nationwide control strategies and increased vaccination coverage, the Alpha variant was quickly displaced by Delta variants that exhibits a higher effective reproductive number. Phylogeographic inference indicates that the Alpha variant was introduced through south-central region of Cambodia, with strong diffusion rates from the capital of Phnom Penh to other provinces, while the Delta variant likely entered the country via the northern border provinces., Conclusions: Continual genomic surveillance and sequencing efforts, in combination with public health strategies, play a vital role in effectively tracking and responding to the emergence, evolution and dissemination of future emerging variants., Competing Interests: Competing interests: Y.C.F.S. and G.J.D.S. report grants from National Institutes of Health. All other authors declare no competing interests., (© 2024. The Author(s).)

The first case of coronavirus disease 2019 (COVID-19) in Cambodia was confirmed on 27 January 2020 in a traveller from Wuhan. Cambodia subsequently implemented strict travel restrictions, and although intermittent cases were reported during the first year of the COVID-19 pandemic, no apparent widespread community transmission was detected. Investigating the routes of severe acute respiratory coronavirus 2 (SARS-CoV-2) introduction into the country was critical for evaluating the implementation of public health interventions and assessing the effectiveness of social control measures. Genomic sequencing technologies have enabled rapid detection and monitoring of emerging variants of SARS-CoV-2. Here, we detected 478 confirmed COVID-19 cases in Cambodia between 27 January 2020 and 14 February 2021, 81.3 per cent in imported cases. Among them, fifty-four SARS-CoV-2 genomes were sequenced and analysed along with representative global lineages. Despite the low number of confirmed cases, we found a high diversity of Cambodian viruses that belonged to at least seventeen distinct PANGO lineages. Phylogenetic inference of SARS-CoV-2 revealed that the genetic diversity of Cambodian viruses resulted from multiple independent introductions from diverse regions, predominantly, Eastern Asia, Europe, and Southeast Asia. Most cases were quickly isolated, limiting community spread, although there was an A.23.1 variant cluster in Phnom Penh in November 2020 that resulted in a small-scale local transmission. The overall low incidence of COVID-19 infections suggests that Cambodia's early containment strategies, including travel restrictions, aggressive testing and strict quarantine measures, were effective in preventing large community outbreaks of COVID-19., (© The Author(s) 2023. Published by Oxford University Press.)

The rapid emergence of carbapenemase-producing gram-negative bacteria (CPGNB) is a global threat due to the high mortality of infection and limited treatment options. Although there have been many reports of CPGNB isolated from Southeast Asian countries, to date there has been no genetic analysis of CPGNB isolated from Cambodia. Sequence-based molecular epidemiological analysis enables a better understanding of the genotypic characteristics and epidemiological significance of antimicrobial-resistant (AMR) bacteria in each country, and allows countries to enact measures related to AMR issues. In this study, we performed on-site genomic epidemiological analysis of CPGNB isolated in Cambodia using a portable laboratory equipment called Bento Lab, which combines a PCR thermal cycler, microcentrifuge, gel electrophoresis apparatus, and LED transilluminator, along with the MinION nanopore sequencer. PCR targeting of major carbapenemase genes using Bento Lab revealed that two Escherichia coli isolates and one Acinetobacter baumannii isolate harbored carbapenemase genes: bla NDM , bla OXA-48 , and bla OXA-23 , respectively. The results of phenotypic diagnostic tests for CPGNB, such as the carbapenem inactivation method and double-disk diffusion test using a specific inhibitor of metallo-β-lactamases, were consistent with their AMR genotypes. Whole-genome sequencing analysis using MinION revealed that bla NDM-5 gene was carried on a 93.9-kb plasmid with IncFIA/IncFIB/IncFII/IncQ1 replicons, and bla OXA-181 gene was carried on a 51.5-kb plasmid with the IncX3 replicon in E. coli isolates. bla OXA-23 was encoded in two locations on the chromosome of A. baumannii . Plasmids carrying bla NDM-5 or bla OXA-181 in E. coli were highly structurally identical to plasmids prevalent in Enterobacterales in China and other countries, suggesting that they disseminated from a common evolutionary origin. Our findings demonstrate the potential impact of portable laboratory equipment on AMR bacteria research in hospitals and research centers with limited research facilities, and provide the first glimpse into the genomic epidemiology of CPGNB in Cambodia., Competing Interests: HY was employed by the company MicroSKY Lab., Inc., Tokyo, Japan. PB and BW were employed by the company Bento Bioworks Ltd., London, United Kingdom. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Hirabayashi, Yanagisawa, Takahashi, Yahara, Boeing, Wolfenden, Nov, Lorn, Veng, Ann, Darapheak, Shibayama and Suzuki.)

Background: Influenza virus circulation is monitored through the Cambodian influenza-like illness (ILI) sentinel surveillance system and isolates are characterized by the National Influenza Centre (NIC). Seasonal influenza circulation has previously been characterized by year-round activity and a peak during the rainy season (June-November)., Objectives: We documented the circulation of seasonal influenza in Cambodia for 2012-2015 and investigated genetic, antigenic, and antiviral resistance characteristics of influenza isolates., Patients/methods: Respiratory samples were collected from patients presenting with influenza-like illness (ILI) at 11 hospitals throughout Cambodia. First-line screening was conducted by the National Institute of Public Health and the Armed Forces Research Institute of Medical Sciences. Confirmation of testing and genetic, antigenic and antiviral resistance characterization was conducted by Institute Pasteur in Cambodia, the NIC. Additional virus characterization was conducted by the WHO Collaborating Centre for Reference and Research on Influenza (Melbourne, Australia)., Results: Between 2012 and 2015, 1,238 influenza-positive samples were submitted to the NIC. Influenza A(H3N2) (55.3%) was the dominant subtype, followed by influenza B (30.9%; predominantly B/Yamagata-lineage) and A(H1N1)pdm09 (13.9%). Circulation of influenza viruses began earlier in 2014 and 2015 than previously described, coincident with the emergence of A(H3N2) clades 3C.2a and 3C.3a, respectively. There was high diversity in the antigenicity of A(H3N2) viruses, and to a smaller extent influenza B viruses, during this period, with some mismatches with the northern and southern hemisphere vaccine formulations. All isolates tested were susceptible to the influenza antiviral drugs oseltamivir and zanamivir., Conclusions: Seasonal and year-round co-circulation of multiple influenza types/subtypes were detected in Cambodia during 2012-2015., (© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Background: Malnutrition in children is a major public health concern. This study aimed to determine the association between dietary diversity and stunting, underweight, wasting, and diarrhea and that between consumption of each specific food group and these nutritional and health outcomes among children., Methods: A nationally representative household survey of 6209 children aged 12 to 59 months was conducted in Cambodia. We examined the consumption of food in the 24 hours before the survey and stunting, underweight, wasting, and diarrhea that had occurred in the preceding 2 weeks. A food variety score (ranging from 0 to 9) was calculated to represent dietary diversity., Results: Stunting was negatively associated with dietary diversity (adjusted odd ratios [ORadj] 0.95, 95% confident interval [CI] 0.91-0.99, P = 0.01) after adjusting for socioeconomic and geographical factors. Consumption of animal source foods was associated with reduced risk of stunting (ORadj 0.69, 95% CI 0.54-0.89, P < 0.01) and underweight (ORadj 0.74, 95% CI 0.57-0.96, P = 0.03). On the other hand, the higher risk of diarrhea was significantly associated with consumption of milk products (ORadj 1.46, 95% CI 1.10-1.92, P = 0.02) and it was significantly pronounced among children from the poorer households (ORadj 1.85, 95% CI 1.17-2.93, P < 0.01)., Conclusions: Consumption of a diverse diet was associated with a reduction in stunting. In addition to dietary diversity, animal source food was a protective factor of stunting and underweight. Consumption of milk products was associated with an increase in the risk of diarrhea, particularly among the poorer households. Both dietary diversity and specific food types are important considerations of dietary recommendation.

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.