Reemergence of Chikungunya virus in Cambodia.

Chikungunya virus (CHIKV), probably Asian genotype, was first detected in Cambodia in 1961. Despite no evidence of acute or recent CHIKV infections since 2000, real-time reverse transcription PCR of serum collected in 2011 detected CHIKV, East Central South African genotype. Spatiotemporal patterns and phylogenetic clustering indicate that the virus probably originated in Thailand.

Emergence of vaccine-derived poliovirus type 2 after using monovalent type 2 oral poliovirus vaccine in an outbreak response, Philippines.

Objective: In response to an outbreak of circulating vaccine-derived poliovirus (cVDPV) type 2 in the Philippines in 2019-2020, several rounds of supplementary immunization activities using the monovalent type 2 oral poliovirus vaccine (OPV) were conducted for the first time in the Western Pacific Region. After use of the monovalent vaccine, the emergence of vaccine-derived poliovirus unrelated to the outbreak virus was detected in healthy children and environmental samples. This report describes the detection of this poliovirus in the Philippines after use of the monovalent type 2 OPV for outbreak response. Methods: We describe the emergence of vaccine-derived poliovirus unrelated to the outbreak detected after supplementary immunization activities using the monovalent type 2 OPV. This analysis included virus characterization, phylogenetic analyses and epidemiological investigations. Results: Three environmental samples and samples from six healthy children tested positive for the emergent vaccine-derived poliovirus. All isolates differed from the Sabin type 2 reference strain by 6-13 nucleotide changes, and all were detected in the National Capital Region and Region 4, which had conducted supplementary immunization activities. Discussion: Since the 2016 removal of type 2 strains from the OPV, vaccine-derived poliovirus outbreaks have occurred in communities that are immunologically naive to poliovirus type 2 and in areas with recent use of monovalent OPV. To prevent the emergence and further spread of cVDPV type 2, several interventions could be implemented including optimizing outbreak responses by using the monovalent type 2 OPV, accelerating the availability of the novel type 2 OPV, strengthening routine immunization using inactivated polio vaccine and eventually replacing OPV with inactivated poliovirus vaccine for routine immunization.

Field epidemiology training programmes in the Asia-Pacific: what is best practice for supervision?

INTRODUCTION: Field epidemiology training programmes (FETPs) emphasize competency-based training and learning by doing. Supervision of FETP trainees is critical for programmes to achieve learning outcomes. We sought to address a knowledge gap regarding what constitutes effective FETP supervision. METHODS: We investigated FETP supervision using a mixed-methods approach. Quantitative data were collected through a survey of FETP directors. Qualitative data included written feedback from the survey and a focus group discussion (FGD) conducted with FETP supervisors at the 8th South-East Asia and Western Pacific Bi-regional TEPHINET Conference. FGD questions focused on effective supervisory qualities and activities and challenges to effective supervision. We calculated descriptive statistics for quantitative data and analysed qualitative data using a deductive content analysis approach. RESULTS: Eleven FETP directors responded to the survey and 23 participated in the FGD. Overall, supervision was seen as very important for trainee outcomes. Participants identified the different roles of academic and field supervisors but emphasized the importance of an enabling and supporting attitude towards trainees. Soft skills and interpersonal abilities were among the most important qualities identified for effective supervision. Key challenges identified included a lack of consistency in supervisors' technical knowledge and the difficulty of finding candidate supervisors with sufficient interest, availability and motivation for supervision. DISCUSSION: Several practical recommendations arose from this study for supervision in FETPs, including recruiting and training supervisors with a more holistic range of skills. Our findings also provide key points for current FETP supervisors to consider to improve their own practice.

Protecting children from rabies with education and pre-exposure prophylaxis: A school-based campaign in El Nido, Palawan, Philippines.

BACKGROUND: Rabies remains endemic in the Philippines. A study was conducted in El Nido, Palawan, Philippines to: (i) detect the true incidence of animal bites in school children aged 5-14 years using active surveillance and compare these data to estimates from the existing passive surveillance system, (ii) evaluate the impact of rabies prevention education and pre-exposure prophylaxis (PrEP) on animal bite incidence, and (iii) assess the health economic impact of the interventions. METHODOLOGY AND PRINCIPAL FINDINGS: A cohort of 4,700 school children was followed-up for any suspect rabies exposures between January 2011 and December 2012. Data on animal bite incidence from the study cohort were compared to that obtained from a review of consultation records at the Animal Bite Treatment Center (ABTC). PrEP was offered to children in all 27 public elementary schools in El Nido (in January to February 2012). Teachers were given a manual for integrating rabies in the public elementary school curriculum during the school year 2012-13. Active surveillance of the cohort revealed a higher incidence of suspect rabies exposures than that from passive surveillance. Despite a decrease in the number of Category III bites, there was no significant decrease in overall bite incidence as a result of the interventions. However, there was an increase in rabies awareness among school children in all grade levels. There was also a high level of acceptability of PrEP. Children who received PrEP and subsequently were bitten only needed two booster doses for post-exposure prophylaxis, resulting in substantial cost-savings. CONCLUSIONS/SIGNIFICANCE: The true burden of animal bites remains underestimated in ABTC records. PrEP is advantageous in selected population groups, i.e. school-aged children in rabies endemic areas with limited access to animal and human rabies prevention services. Educating school children is beneficial. Strengthening veterinary interventions to target the disease at source is important.

The evaluation of operating Animal Bite Treatment Centers in the Philippines from a health provider perspective.

BACKGROUND: The Philippine government has an extensive network of 513 Animal Bite Treatment Centers (ABTCs) to supply rabies post exposure prophylaxis (PEP), reaching over 1 million bite victims in 2016. The network was evaluated using a review of existing national and provincial data, key informant interviews and surveys in sample ABTCs to determine the cost-effectiveness of this network in preventing human rabies deaths. METHODOLOGY AND PRINCIPAL FINDINGS: One urban and one rural ABTC in each of three selected provinces were studied in more detail. PEP delivery generally followed national guidance based on best practices, but there was evidence of operational challenges in supplying all ABTCs with adequate biologics and recently trained staff. Funding was contributed by different levels of government and in some clinics, patients paid for a significant fraction of the total cost. From a health provider perspective including both fixed and variable costs, the average PEP course delivered cost USD 32.91 /patient across urban ABTCs (with higher patient throughput) and USD 57.21 /patient across rural ABTCs. These costs suggests that PEP provision in the Philippines cost USD 37.6 million in 2016, with a cost per life saved of USD 8,290. An analysis of the 2,239 suspected rabies deaths from 2008 to 2016 showed no significant decline, and from 2014-16 an average of 8,534 years of life were lost annually. The incidence of rabies deaths from 2014-16 was not clearly related to the provision of ABTCs (per 100,000 population) or human population density, but deaths were more common in higher income provinces. CONCLUSIONS/SIGNIFICANCE: In the context of comprehensive rabies control (including dog vaccination and public awareness) ways to reduce this high expenditure on PEP should be explored, to most cost-effectively reach the elimination of human rabies deaths. This paper is accompanied by another containing data on the operation of ABTCs network from a patient perspective.

The evaluation of Animal Bite Treatment Centers in the Philippines from a patient perspective.

BACKGROUND: The Philippines has built an extensive decentralised network of Animal Bite Treatment Centers (ABTCs) to help bite victims receive timely rabies post-exposure prophylaxis (PEP) at little cost. This study surveyed patients in the community and at ABTCs of three provinces to assess animal bite/scratch incidence, health-seeking behaviour and PEP-related out-of pocket expenses (OOPE). METHODOLOGY AND PRINCIPAL FINDINGS: During community surveys in 90 barangays (neighbourhoods), 53% of households reported at least one animal bite /scratch injury over the past 3 years, similar across urban and rural barangays. Overall bite/scratch incidences in 2016-17 were 67.3, 41.9 and 48.8 per 1,000 population per year for Nueva Vizcaya, Palawan and Tarlac respectively. Incidences were around 50% higher amongst those under 15 years of age, compared to -those older than 15. Household awareness of the nearest ABTCs was generally over 80%, but only 44.9% sought proper medical treatment and traditional remedies were still frequently used. The proportion of patients seeking PEP was not related to the distance or travel time to the nearest ABTC. For those that did not seek medical treatment, most cited a lack of awareness or insufficient funds and almost a third visited a traditional healer. No deaths from bite/scratch injuries were reported. A cohort of 1,105 patients were interviewed at six ABTCs in early 2017. OOPE varied across the ABTCs, from 5.53 USD to 37.83 USD per patient, primarily dependent on the need to pay for immunization if government supplies had run out. Overall, 78% of patients completed the recommended course, and the main reason for non-completion was a lack of time, followed by insufficient funds. Dog observation data revealed that 85% of patients were not truly exposed to rabies, and education in bite prevention might reduce provoked bites and demand for PEP. An accompanying paper details the ABTC network from the health provider's perspective.

The Philippines Field Management Training Program (FMTP): strengthening management capacity in a decentralized public health system.

OBJECTIVES: The decentralization of the Philippines' health sector in 1991 sought to improve the efficiency of local health resource allocation; however, local officials were unprepared for the increased responsibility. In 1999 the Philippines Department of Health, with assistance from the US Centers for Disease Control and Prevention (CDC), implemented the Philippines Field Management Training Program (FMTP) to provide local health officials with the managerial skills needed to perform their new, more responsible jobs. This paper addresses whether the FMTP has provided participants with useful managerial skills needed for their more responsible positions. METHODS: The method involved reviewing program outcomes, including results of applied management improvement projects the participants completed to solve managerial problems. RESULTS: Between 2000 and 2010, 294 participants completed the FMTP and many were later promoted to more responsible positions. The participants also completed 204 applied management improvement projects resulting in documented improvements in service delivery, information systems, logistics, health insurance, policy and laboratory outcomes. Examples of their successes are included in this paper. CONCLUSIONS: The results provide compelling evidence that managers are using the skills learned to solve significant managerial problems.

Epidemiological and virological characteristics of influenza viruses circulating in Cambodia from 2009 to 2011.

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.

Vibrio parahaemolyticus enteritis outbreak following a wedding banquet in a rural village - Kampong Speu, Cambodia, April 2012.

INTRODUCTION: Foodborne outbreaks are common in Cambodia, but only a few investigations documenting the etiology and source have been conducted. In April, we learnt of 49 acute diarrhoea cases in a village following a wedding banquet. We undertook an investigation to identify the pathogen, source and mode of transmission. METHODS: We interviewed banquet hosts and food handlers to obtain the menu and guest list. Guests were asked about signs and symptoms and onset of illness, time of meal and food or drinks consumed. Rectal swabs were taken from 13 cases for culture. A case-control study was undertaken; cases were guests who had acute diarrhoea within three days after the wedding and controls were guests who remained well during the same time period. RESULTS: There were 256 guests. Of 69 interviewees, 52 got sick (attack rate 75%). Aside from diarrhoea, cases had abdominal pain (94%), vomiting (48%), nausea (42%) and fever (25%). Incubation periods ranged from seven to 51 hours (median 16.5). Rectal swabs from three cases grew Vibrio parahaemolyticus. Among the food and drinks served, vegetable salad with raw octopus was the only one associated with illness (odds ratio: 6.6, 95% confidence interval: 1.3-36.1, P = 0.01). DISCUSSION: Vegetable salad with raw octopus was the suspected vehicle for transmission of this Vibrio parahaemolyticus enteritis outbreak. Messages regarding the risks from eating raw seafood were disseminated, and food handlers were advised to cook seafood to high temperatures. Efforts to improve foodborne disease surveillance and food safety are being undertaken.

Implementing the new International Health Regulations in the Pacific--challenges and opportunities.

The newly revised International Health Regulations, i.e. IHR (2005), adopted by the World Health Assembly in May 2005, are the legally binding international instruments for preventing and controlling international spread of disease while avoiding unnecessary interference with international traffic and trade. IHR (2005), which will enter into force in June 2007, set out new obligations for detection, assessment and notification of and response to public health events of international concern. In particular, under the IHR (2005), each Member State is required to notify WHO directly of any event that may consititue a public health emergency of international concern. Although the implementation of the new IHR to contribute to regional and global health security will be very challenging in the Pacific, they provide new opportunities for the Pacific Island Countries and areas (PICs) to build, strengthen and maintain their core capacities for surveillance and response. This article describes the major changes in the new Regulations and discusses the opportunity of using existing mechanisms for the implementation of IHR (2005). In the PICs, while strengthening the capacity of national public health surveillance and response systems is essential and the key to the effective implementation of the new Regulations, the Pacific Public Health Surveillance Network (PPHSN) can also be utilized to facilitate the IHR implementation, including disseminating updated information related to IHR such as WHO guidelines and capacity building, whenever possible.