Asymptomatic Enteric Virus Infections and Association with the Gut Microbiome in Rural Residents of Northern Laos.

Viral gastrointestinal infections are an important public health concern, and the occurrence of asymptomatic enteric virus infections makes it difficult to prevent and control their spread. This study aimed to determine the prevalence of and factors associated with asymptomatic enteric virus infection in adults in northern Laos. Fecal samples were collected from apparently healthy participants who did not report diarrhea or high fever at the time of the survey in northern Laos, and enteric viruses were detected using polymerase chain reaction (PCR) and reverse transcription (RT)-PCR. Individual characteristics, including the gut microbiome, were compared between asymptomatic carriers and noncarriers of each enteric virus. Of the participants (N = 255), 12 (4.7%) were positive for norovirus genogroup I (GI), 8 (3.1%) for human adenovirus, and 1 (0.4%) for norovirus GII; prevalence tended to be higher in less-modernized villages. Gut microbial diversity (evaluated by the number of operational taxonomic units) was higher in asymptomatic carriers of norovirus GI or human adenovirus than in their noncarriers. Gut microbiome compositions differed significantly between asymptomatic carriers and noncarriers of norovirus GI or human adenovirus (permutational analysis of variance, P <0.05). These findings imply an association between asymptomatic enteric virus infection and modernization and/or the gut microbiome in northern Laos.

Health system utilization and perceived quality among adults in Lao PDR: evidence from a nationally representative phone survey.

BACKGROUND: The World Health Organization (WHO) defines quality health services as being effective, safe, people-centered, timely, equitable, integrated and efficient. It is critical to understand people's perspectives and care experiences to measure progress against these goals. However, many low- and middle-income governments do not routinely collect such information. In this study, we aim to measure health systems performance from the perspective of the adult population of users and non-users in Lao PDR. METHODS: Using the People's Voice Survey (PVS), a novel phone-based survey designed to integrate people's voices into primary care performance measurement, we conducted a cross-sectional survey of the general adult (18+) population in Lao PDR in 2022. We analyzed health care utilization patterns, user-reported quality of care, and coverage of key preventive health services. Data from the most recent MICS survey was used to create sampling weights generating nationally representative estimates. RESULTS: A total of 2007 adults completed interviews in approximately 3.5 months. About two thirds (65%) of respondents reported visiting a health facility in the past year and, of these, the majority (61%) visited a hospital as opposed to a health center or clinic. Among those that recently visited health facilities, 28% rated their experience as "poor" or "fair". 16% had unmet need for care and 12% reported discrimination during treatment in the past year. 12% of women over 50 years old reported receiving a mammogram and 59% of adults reported receiving blood pressure screening in the previous year. CONCLUSIONS: The study presents data from the first nationally representative survey in Lao PDR to measure health system performance. The results indicate that, despite progress towards universal coverage of health insurance in Lao PDR, significant gaps remain, particularly with respect to bypassing of primary care facilities, significant unmet need for care, experiences of discrimination, and overall low perceptions of quality of care.

Protocol for integrated solutions for healthy birth, growth and development: a cluster-randomised controlled trial to evaluate the effectiveness of a mixed nutrition intervention package in reducing child undernutrition in Lao People's Democratic Republic.

INTRODUCTION: While Lao People's Democratic Republic has seen economic gains in recent years, one-third of children aged 5 years and under are stunted. There is a need for evidence around clinically effective and cost-effective integrated nutrition-specific and nutrition-sensitive interventions in the local context. METHODS AND ANALYSIS: We aim to conduct a cluster-randomised control trial to test the effectiveness of an integrated package of community-based nutrition-specific and nutrition-sensitive interventions compared with the standard government package of nutrition actions. The trial will be in six districts within the province of Vientiane. We will recruit pregnant women in their third trimester and follow the children born to them every 6 months until 18 months of age. A total of 256 villages (serviced by 34 health centres) will be randomised to a control arm or an intervention arm using a minimisation algorithm. The primary outcome is the prevalence of stunting among children aged 6, 12 and 18 months. The secondary outcomes include prevalence of low birth weight and wasting among children aged 6, 12 and 18 months. Analyses for the primary and secondary outcomes will be conducted at the mother-infant dyad level and adjusted for the cluster randomisation. The difference in prevalence of low birth weight, wasting and stunting between control and intervention groups will be assessed using Pearson's χ2 tests and 95% CIs for the group difference, adjusted for clustering. ETHICS AND DISSEMINATION: The trial protocol was approved by the Alfred Human Research Ethic Committee (Ref: 227/16) and the Lao National Ethics Committee for Health Research (Ref: 81). The trial was registered with the Australian New Zealand Clinical Trials Registry on 28 April 2020 (ACTRN12620000520932). The results will be disseminated at different levels: study participants; the local community; other Lao stakeholders including policymakers; and an international audience. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry: ACTRN12620000520932.

Financial burden and health-seeking behaviors related to chronic diseases under the National Health Insurance Scheme in Bolikhamxay Province, Lao PDR: a cross-sectional study.

BACKGROUND: Chronic diseases pose a serious threat to health and longevity worldwide. As chronic diseases require long periods of treatment and may become serious conditions, the ensuing financial burden is often worse than that for non-chronic diseases. In 2016, the Lao PDR implemented the National Health Insurance (NHI) system, which covers select provinces. However, data on health service accessibility and the financial burden on households, especially those with chronically ill members covered by the NHI, are scarce. METHODS: This study used a cross-sectional design. Data collection was conducted in Bolikhamxay province (population = 273,691), from January 15 to February 13, 2019. In total, 487 households, selected through stratified random sampling, were surveyed via questionnaire-based interviews. Healthcare service usage and financial burden were examined. RESULTS: A total of 370 households had at least one member with self-reported health issues within the last 3 months prior to the interview, while 170 had at least one member with a chronic condition. More than 75% of the households accessed a health facility when a member experienced health problems. The majority of households (43.2%) spent the maximum value covered by the NHI, but households in the second largest group (21.4%) spent 10 times the maximum value covered by the NHI. The prevalence of catastrophic health expenditure (i.e., health-related expenditure equivalent to > 20% of total income) was 25.9% (20% threshold) and 16.2% (40% threshold). Through logistic regression, we found that the major factors determining financial catastrophes owing to health problems were household members with chronic illness, hospitalization, household poverty status, household size (for both the 20 and 40% thresholds), visiting a private facility (20% threshold), and distance from the province to the referral hospital (40% threshold). CONCLUSIONS: The NHI system has had a positive effect on households' access to health facilities. However, catastrophic health expenditure remains high, especially among chronically ill patients. Facilities under the NHI system should be improved to provide more services, including care for chronic conditions.

Primary health care situations in remote rural villages of the Savannakhet province, Lao People's Democratic Republic.

BACKGROUND: To improve the health of the rural population in the Lao People's Democratic Republic (Lao PDR), the government has emphasized a primary health care approach in the Health Sector Reform Strategy by 2025. The objective of the present study was to describe the health-related situations of remote rural villages of the Lao PDR to inform strategies for promoting primary health care in such villages. METHODS: Ten remote rural villages were purposively selected from the catchment areas of two health centers in the Xepon district, Savannakhet province. The surveyors collected data by conducting a questionnaire-based interview with village health volunteers and by observing the village environment in 2018. The survey focused on village situations on the eight elements of primary health care (health education; food supply and nutrition; safe water and basic sanitation; maternal and child health care; immunization; prevention and control of locally endemic diseases; treatment of common diseases and injuries; and provision of essential drug). RESULTS: The common health problems were diarrhea, followed by malaria, and cough. The identified possible risk factors for the health problems were not washing hands with soap, open defecation, not boiling drinking water, not exclusively breastfeeding, presence of animal feces on the village ground, absence of garbage management system, not using a bed net when sleeping in the forest, and exposure to indoor cooking and tobacco smoke. In many villages, villagers were not able to eat enough food and did not eat protein-rich food and vegetables daily. CONCLUSIONS: Potential risk factors for the reported common health problems were often prevalent in the study villages. Villagers can address most of these risk factors, as interventions to address such risk factors do not require a large financial input. There is a need for intersectoral actions between the health and other sectors to address food shortages and indoor air pollution due to indoor cooking using biomass fuel.

Impact of modernization on urinary concentrations of arsenic, cadmium, lead, and selenium in rural residents of Northern Laos.

OBJECTIVES: The impacts of modernization on toxic heavy metal exposure and essential trace element intake in indigenous populations of subsistence societies are unknown. We assessed urinary trace element concentrations in rural residents of Northern Laos and examined associations with levels of modernization. METHODS: A cross-sectional study was conducted comprising 380 residents of three villages in Northern Laos with different levels of modernization. We surveyed general characteristics and measured the weight and height of 341 participants. Arsenic, cadmium, lead, and selenium concentrations were measured in spot urine samples by inductively coupled plasma mass spectrometry. We examined associations between urinary trace element concentrations and variables related to modernization (village, roofing material, possessions index [total number of possessions], and body mass index [BMI]) using multilevel analyses with household as a random effect, after adjusting for sex, age, and smoking status. RESULTS: Urinary concentrations of arsenic and cadmium were high, while those of lead and selenium were low in comparison to previous reports of populations in non-contaminated regions or without excess/deficiency. We observed associations between urinary trace element concentrations and village-level modernization: lead and selenium concentrations were higher in more modernized villages and cadmium concentration was highest in the least modernized village. Urinary arsenic concentration was not predicted by the modernization level of a village, although we observed significant differences among villages. In addition, urinary selenium concentration was higher in participants inhabiting more modernized houses. CONCLUSION: Modernization of villages may impact toxic heavy metal exposure and selenium intake in rural residents of Northern Laos.

Developing a national health research agenda for Lao PDR: prioritising the research needs of stakeholders.

BACKGROUND: Currently the health research system in Lao PDR is fragmented and largely donor led. Capacity among national public health institutes is limited to select priority research questions for funding. OBJECTIVE: The objective of this capacity building and practice-oriented study is to describe the process and outcome of the first National Health Research Agenda for Lao PDR and how the agenda contributes to institutional capacity of the Ministry of Health, in order to contribute to evidence-informed public health policy making. METHOD: This activity used a mixed-methods approach. The overall design is based on principles of the interactive Learning and Action approach and consists out of 6 phases: (1) identification of needs, (2) shared analysis and integration, (3) nation-wide prioritization of research domains, (4) exploring specific research questions, (5) prioritization of research avenues, (6) dialogue and planning for action. The process involved interviews with experts in health policy and research (n = 42), telephone-based survey with district, provincial and national health staff (n = 135), a two-round Delphi consultation with experts in health policy and research (n = 33), and a workshop with policymakers, researchers, international organisations and civil society (n = 45) were held to gather data and conduct shared analysis. RESULTS: 11 research domains were identified and prioritised: Health-seeking behaviour; Health system research; Health service provision; Mother and child health (MCH); Sexual & reproductive health; Health education; Non-communicable diseases (NCDs); Irrational drug use; Communicable diseases (CDs); Road traffic accidents; Mental health. Within these domains over 200 unique research questions were identified. CONCLUSION: Our approach led to a comprehensive, inclusive, public health agenda for Lao PDR to realise better informed health policies. Questions on the agenda are action-oriented, originating in a desire to understand the problem so that immediate improvements can be made. The agenda is used within the MoH as a tool to fund and approve research.

The prevalence of underweight and overweight/obesity and its correlates among adults in Laos: a cross-sectional national population-based survey, 2013.

PURPOSE: The study aimed to assess the prevalence of underweight and overweight or obesity and their sociodemographic, lifestyle, and health factors in a national adult population in Lao People's Democratic Republic (PDR) (Laos). METHODS: A national cross-sectional study based on a stratified cluster random sampling was conducted in 2013. The total sample included 2531 individuals 18-64 years, (females = 59.3%; mean age 38.7 years, SD = 12.8) from Laos. Questionnaire interview, blood pressure and anthropometric measurements, and biochemistry tests were conducted. Multinomial logistic regression was utilized to determine the association between sociodemographic, lifestyle and health status factors, and underweight and overweight or obesity relative to normal weight. RESULTS: Using Asian criteria for body mass index (BMI) classification, 9.7% of the population was underweight (BMI < 18.5, kg/m2), 47.5% had normal weight (BMI 18.5-22.9 kg/m2), 17.5% overweight (23.0-24.9 kg/m2), 19.6% class I obesity (BMI 25.0-29.9 kg/m2), and 5.6% class II obesity (BMI ≥ 30.0 kg/m2) (or 42.8% overweight, class I or class II obesity). In adjusted multinomial logistic regression, female sex (adjusted relative risk ratio-ARRR 0.67, confidence interval-CI 0.45, 0.99), current tobacco use (ARRR 1.57, CI 1.02, 2.41), and having no hypertension (ARRR 0.50, CI 0.26, 0.97) were associated with underweight, and middle and older age (ARRR 1.79, CI 1.41, 2.25), being Lao-Tai (ARRR 1.37, CI 1.06, 1.76), urban residence (ARRR 1.62, CI 1.20, 2.17), having meals outside home (ARRR 1.36, CI 1.04, 1.77), no current tobacco use (ARRR 0.57, CI 0.34, 0.59), low physical activity (ARRR 1.39, CI 1.01, 1.92), having hypertension (ARRR 2.52, CI 1.94, 3.26), and dyslipidaemia (ARRR 1.56, CI 1.21, 2.00) were associated with overweight or obesity. CONCLUSION: A dual burden of both adult underweight and overweight or obesity was found in Laos. Sociodemographic, lifestyle, and health status risk factors were identified for underweight and overweight or obesity, which can help in guiding public health programmes to address both these conditions. LEVEL OF EVIDENCE: Level V, descriptive cross-sectional survey.

Iron status and inherited haemoglobin disorders modify the effects of micronutrient powders on linear growth and morbidity among young Lao children in a double-blind randomised trial.

Some studies found that providing micronutrient powder (MNP) causes adverse health outcomes, but modifying factors are unknown. We aimed to investigate whether Fe status and inherited Hb disorders (IHbD) modify the impact of MNP on growth and diarrhoea among young Lao children. In a double-blind controlled trial, 1704 children of age 6-23 months were randomised to daily MNP (with 6 mg Fe plus fourteen micronutrients) or placebo for about 36 weeks. IHbD, and baseline and final Hb, Fe status and anthropometrics were assessed. Caregivers provided weekly morbidity reports. At enrolment, 55·6 % were anaemic; only 39·3 % had no sign of clinically significant IHbD. MNP had no overall impact on growth and longitudinal diarrhoea prevalence. Baseline Hb modified the effect of MNP on length-for-age (LAZ) (P for interaction = 0·082). Among children who were initially non-anaemic, the final mean LAZ in the MNP group was slightly lower (-1·93 (95 % CI -1·88, -1·97)) v. placebo (-1·88 (95 % CI -1·83, -1·92)), and the opposite occurred among initially anaemic children (final mean LAZ -1·90 (95 % CI -1·86, -1·94) in MNP v. -1·92 (95 % CI -1·88, -1·96) in placebo). IHbD modified the effect on diarrhoea prevalence (P = 0·095). Among children with IHbD, the MNP group had higher diarrhoea prevalence (1·37 (95 % CI 1·17, 1·59) v. 1·21 (95 % CI 1·04, 1·41)), while it was lower among children without IHbD who received MNP (1·15 (95 % CI 0·95, 1·39) v. 1·37 (95 % CI 1·13, 1·64)). In conclusion, there was a small adverse effect of MNP on growth among non-anaemic children and on diarrhoea prevalence among children with IHbD.

Intestinal helminth infections in HIV-infected patients in Savannakhet after establishment of an HIV registration network in Lao People's Democratic Republic.

BACKGROUND: In Lao People's Democratic Republic (PDR), which borders China, Vietnam, Cambodia, Thailand, and Myanmar, the number of HIV-infected patients has increased in recent years. HIV-infected patients diagnosed in Lao PDR are enrolled in a registration network and receive antiretroviral therapy (ART) covered by governmental financial support. Based on the registration network, we investigated intestinal helminth infections and coinfection with HTLV-1 in HIV-infected patients treated with an early intervention using ART in Lao PDR. METHODS: This cross-sectional study of all 252 HIV-infected patients at Savannakhet Provincial Hospital, located in the southern part of Lao PDR, was conducted between February and March 2018. Socioepidemiological information and clinical information were collected from a registration network database and by questionnaire administered to participants. Microscopic examination of intestinal helminth infections in stool samples and particle agglutination for anti-HTLV-1 antibody in plasma were performed. RESULTS: The median age of all 252 participants was 39 years old (range, 18-59). Based on the registration network database, there were 156 (61.9%) HIV-infected patients with a CD4-positive cell count ≥ 200 cells/µL and 146 (57.9%) with an HIV viral load < 250 copies/mL. Among 212 stool samples, 75 (35.4%) were found to contain one or more intestinal helminth species, including Opisthorchis viverrini (16.5%), Strongyloides stercoralis (10.8%), hookworm (10.4%), and Taenia saginata (3.3%). This rate of intestinal helminth infections was lower than that of a previous report conducted before the establishment of the registration network for HIV-infected patients in Lao PDR. There was no significant association between intestinal helminth infections and a lower CD4-positive T cell count or higher HIV viral load. HIV-infected patients with anti-HTLV-1 antibody positivity were not found in this cohort. CONCLUSION: The registration network and an early intervention using ART may provide good medical care and improve the clinical course of HIV-infected patients in Lao PDR. However, the incidence of intestinal helminth infections remains high at 35.4%. The development of a specific medical care system for helminth infection for HIV-infected patients is necessary.

Malaria elimination in Lao PDR: the challenges associated with population mobility.

Although the Lao People's Democratic Republic (Lao PDR) is comparatively small landlocked country with patterns of both in- and out-migration, its human migration situation has been poorly studied. This is despite all of the country's 18 provinces sharing both official and unofficial border checkpoints with neighboring countries. Economic reforms in the last decade have seen a gradual increase in the promotion of foreign investment, and main towns and transportation networks have been expanding thus offering new opportunities for livelihoods and economic activities.In the last decade, there has also been a significant reduction of reported malaria cases in Lao PDR and while this is an important prerequisite for eliminating malaria in the country, malaria outbreaks reported in the last four years suggest that population mobility, particularly in the south, is an important factor challenging current control efforts.Bolder investment in social sector spending should be geared towards improving health service provision and utilization, ensuring equitable access to primary health care (including malaria) through efforts to achieve universal health coverage targets. This should be extended to populations that are mobile and migrants. The local government plays a critical role in supporting policy and enforcement issues related to private sector project development in the provinces. Cross-border initiatives with neighboring countries, especially in terms of data sharing, surveillance, and response, is essential. Mechanisms to engage the private sector, especially the informal private sector, needs to be explored within the context of existing regulations and laws. Existing and new interventions for outdoor transmission of malaria, especially in forest settings, for high-risk groups including short- and long-term forest workers and their families, mobile and migrant populations, as well as the military must be combined into integrated packages with innovative delivery mechanisms through social marketing approaches. This should happen at multiple points in the mobility pathway and involve the private sector rather than being fully reliant on the national malaria vertical programThis article based on the review of existing literature from abstracts and full texts, includes published, peer-reviewed English language literature sourced through PubMed and grey literature sources through Google and Google Scholar. The review included also case reports, sector reports, conference proceedings, research reports, epidemiology studies, qualitative studies, and census reports in both Lao and English languages. The authors used the search terms: malaria and mobile populations, malaria control program and elimination, health system performance, malaria outbreak, Lao PDR; and included articles published until June 2015.

The role of domestic dogs in the transmission of zoonotic helminthes in a rural area of Mekong river basin.

Dogs have been bred since ancient times for companionship, hunting, protection, shepherding and other human activities. Some canine helminth parasites can cause significant clinical diseases in humans as Opisthorchis viverrini causing cholangiocarcinoma in Southeast Asian Countries. In this study, socio-cultural questionnaire, canine parasitological analysis, necropsy, parasite molecular confirmation and dog roaming data were evaluated in Savannakhet, Lao-PDR, a typical Mekong Basin area. Dog owners comprised 48.8% of the studied population, with 61.2% owning one dog, 25.1% 2 dogs, 8.5% 3 dogs and 1.8% owning more than 4 dogs. Data from GPS logger attached to dogs showed they walked from 1.4 to 13.3 km per day, covering an area of 3356.38m2 average, with a routine of accessing water sources. Thirteen zoonotic helminth species were observed. Causative agents of visceral and cutaneous larva migrans occurred in 44.1% and 70% of the samples respectively. Spirometra erinaceieuropaei was detected in 44.1% of samples. Importantly, O. viverrini was found in 8.8% of samples. Besides the known importance of dogs in the transmission of Ancylostoma spp., Toxocara spp. and S. erinaceieuropaei, the observed roaming pattern of dogs confirmed it as an important host perpetuating O. viverrini in endemic areas; their routine access to waterbodies may spread O. viverrini eggs in a favorable environment for the fluke development, facilitating the infection of fishes, and consequently infecting humans living in the same ecosystem. Therefore, parasitic NTDs control programs in humans should be done in parallel with parasite control in animals, especially dogs, in the Mekong River basin area.

Soil-transmitted helminth infections and risk factors in preschool children in southern rural Lao People's Democratic Republic.

The current widespread school-based control of soil-transmitted helminth (STH) infections is also advocated for preschool children. The objective of this study was to assess infection with STHs as well as their determinants in preschool children (<60 months) in southern rural Lao People's Democratic Republic (Lao PDR). A cluster survey was carried out from October to December 2006 in three districts of Savannakhet Province. The prevalence of Ascaris lumbricoides, hookworm and Trichuris trichiura was 27.4% (95% CI 27.0-27.6%), 10.9% (95% CI 10.7-11.0%) and 10.9% (95% CI 10.7-11.1%), respectively. Of the children studied, 28.4% had a monoparasitic infection and 9.3% had a polyparasitic infection. Older children had a higher risk for hookworm infection [odds ratio (OR) = 1.75, 95% CI 1.03-3.01; P = 0.041] and multiple infections (OR = 1.81, 95% CI 1.01-3.20; P = 0.044). Low socioeconomic status was associated with A. lumbricoides (OR = 0.61, 95% CI 0.38-0.98; P = 0.043) and monoparasitic infections (OR = 0.62, 95% CI 0.38-0.99; P = 0.049). In Lao PDR, deworming of preschool children is warranted. Preventive measures should address important risk factors. Health education regarding personal hygiene, appropriate water management and the construction and proper use of latrines are additional essential elements.