The Impact of Preparedness in Defying COVID-19 Pandemic Expectations in the Lower Mekong Region: A Case Study.

Dire COVID-19 expectations in the Lower Mekong Region (LMR) can be understood as Cambodia, the Lao PDR, Myanmar, Thailand, and Vietnam have stared down a succession of emerging infectious disease (EID) threats from neighboring China. Predictions that the LMR would be overwhelmed by a coming COVID-19 tsunami were felt well before the spread of the COVID-19 pandemic had been declared. And yet, the LMR, excepting Myanmar, has proved surprisingly resilient in keeping COVID-19 contained to mostly sporadic cases. Cumulative case rates (per one million population) for the LMR, including or excluding Myanmar, from January 1 to October 31 2020, are 1,184 and 237, respectively. More telling are the cumulative rates of COVID-19-attributable deaths for the same period of time, 28 per million with and six without Myanmar. Graphics demonstrate a flattening of pandemic curves in the LMR, minus Myanmar, after managing temporally and spatially isolated spikes in case counts, with negligible follow-on community spread. The comparable success of the LMR in averting pandemic disaster can likely be attributed to years of preparedness investments, triggered by avian influenza A (H5N1). Capacity building initiatives applied to COVID-19 containment included virological (influenza-driven) surveillance, laboratory diagnostics, field epidemiology training, and vaccine preparation. The notable achievement of the LMR in averting COVID-19 disaster through to October 31, 2020 can likely be credited to these preparedness measures.

Laboratory-based and office-based risk scores and charts to predict 10-year risk of cardiovascular disease in 182 countries: a pooled analysis of prospective cohorts and health surveys.

BACKGROUND: Worldwide implementation of risk-based cardiovascular disease (CVD) prevention requires risk prediction tools that are contemporarily recalibrated for the target country and can be used where laboratory measurements are unavailable. We present two cardiovascular risk scores, with and without laboratory-based measurements, and the corresponding risk charts for 182 countries to predict 10-year risk of fatal and non-fatal CVD in adults aged 40-74 years. METHODS: Based on our previous laboratory-based prediction model (Globorisk), we used data from eight prospective studies to estimate coefficients of the risk equations using proportional hazard regressions. The laboratory-based risk score included age, sex, smoking, blood pressure, diabetes, and total cholesterol; in the non-laboratory (office-based) risk score, we replaced diabetes and total cholesterol with BMI. We recalibrated risk scores for each sex and age group in each country using country-specific mean risk factor levels and CVD rates. We used recalibrated risk scores and data from national surveys (using data from adults aged 40-64 years) to estimate the proportion of the population at different levels of CVD risk for ten countries from different world regions as examples of the information the risk scores provide; we applied a risk threshold for high risk of at least 10% for high-income countries (HICs) and at least 20% for low-income and middle-income countries (LMICs) on the basis of national and international guidelines for CVD prevention. We estimated the proportion of men and women who were similarly categorised as high risk or low risk by the two risk scores. FINDINGS: Predicted risks for the same risk factor profile were generally lower in HICs than in LMICs, with the highest risks in countries in central and southeast Asia and eastern Europe, including China and Russia. In HICs, the proportion of people aged 40-64 years at high risk of CVD ranged from 1% for South Korean women to 42% for Czech men (using a ≥10% risk threshold), and in low-income countries ranged from 2% in Uganda (men and women) to 13% in Iranian men (using a ≥20% risk threshold). More than 80% of adults were similarly classified as low or high risk by the laboratory-based and office-based risk scores. However, the office-based model substantially underestimated the risk among patients with diabetes. INTERPRETATION: Our risk charts provide risk assessment tools that are recalibrated for each country and make the estimation of CVD risk possible without using laboratory-based measurements. FUNDING: National Institutes of Health.

Appropriate body mass index and waist circumference cutoff for overweight and central obesity among adults in Cambodia.

BACKGROUND: Body mass index (BMI) and waist circumference (WC) are used in risk assessment for the development of non-communicable diseases (NCDs) worldwide. Within a Cambodian population, this study aimed to identify an appropriate BMI and WC cutoff to capture those individuals that are overweight and have an elevated risk of vascular disease. METHODOLOGY/PRINCIPAL FINDINGS: We used nationally representative cross-sectional data from the STEP survey conducted by the Department of Preventive Medicine, Ministry of Health, Cambodia in 2010. In total, 5,015 subjects between age 25 and 64 years were included in the analyses. Chi-square, Fisher's Exact test and Student t-test, and multiple logistic regression were performed. Of total, 35.6% (n = 1,786) were men, and 64.4% (n = 3,229) were women. Mean age was 43.0 years (SD = 11.2 years) and 43.6 years (SD = 10.9 years) for men and women, respectively. Significant association of subjects with hypertension and hypercholesterolemia was found in those with BMI ≥ 23.0 kg/m(2) and with WC >80.0 cm in both sexes. The Area Under the Curve (AUC) from Receiver Operating Characteristic curves was significantly greater in both sexes (all p-values <0.001) when BMI of 23.0 kg/m(2) was used as the cutoff point for overweight compared to that using WHO BMI classification for overweight (BMI ≥ 25.0 kg/m(2)) for detecting the three cardiovascular risk factors. Similarly, AUC was also significantly higher in men (p-value <0.001) when using WC of 80.0 cm as the cutoff point for central obesity compared to that recommended by WHO (WC ≥ 94.0 cm in men). CONCLUSION: Lower cutoffs for BMI and WC should be used to identify of risks of hypertension, diabetes, and hypercholesterolemia for Cambodian aged between 25 and 64 years.

Epilepsy in Cambodia-treatment aspects and policy implications: a population-based representative survey.

INTRODUCTION: We tested two treatment strategies to determine: treatment (a) prognosis (seizure frequency, mortality, suicide, and complications), (b) safety and adherence of treatment, (c) self-reported satisfaction with treatment and self-reported productivity, and policy aspects (a) number of required tablets for universal treatment (NRT), (b) cost of management, (c) manpower-gap and requirements for scaling-up of epilepsy care. METHODS: We performed a random-cluster survey (N = 16510) and identified 96 cases (≥1 year of age) in 24 villages. They were screened by using a validated instrument and diagnosed by the neurologists. International guidelines were used for defining and classifying epilepsy. All were given phenobarbital or valproate (cost-free) in two manners patient's door-steps (March 2009-March 2010, primary-treatment-period, PTP) and treatment through health-centers (March 2010-June 2011, treatment-continuation-period, TCP). The emphasis was to start on a minimum dosage and regime, without any polytherapy, according to the age of the recipients. No titration was done. Seizure-frequency was monthly and self-reported. RESULTS: The number of seizures reduced from 12.6 (pre-treatment) to 1.2 (end of PTP), following which there was an increase to 3.4 (end of TCP). Between start of PTP and end of TCP, >60.0% became and remained seizure-free. During TCP, ∼26.0% went to health centers to collect their treatment. Complications reduced from 12.5% to 4.2% between start and end of PTP and increased to 17.2% between start and end of TCP. Adverse events reduced from 46.8% to 16.6% between start and end of PTP. Nearly 33 million phenobarbital 100 mg tablets are needed in Cambodia. CONCLUSIONS: Epilepsy responded sufficiently well to the conventional treatment, even when taken at a minimal dosage and a simple daily regimen, without any polytherapy. This is yet another confirmation that it is possible to substantially reduce direct burden of epilepsy through means that are currently available to us.

Assessment of total cardiovascular risk using WHO/ISH risk prediction charts in three low and middle income countries in Asia.

BACKGROUND: Recent research has used cardiovascular risk scores intended to estimate "total cardiovascular disease (CVD) risk" in individuals to assess the distribution of risk within populations. The research suggested that the adoption of the total risk approach, in comparison to treatment decisions being based on the level of a single risk factor, could lead to reductions in expenditure on preventive cardiovascular drug treatment in low- and middle-income countries. So that the patient benefit associated with savings is highlighted. METHODS: This study used data from national STEPS surveys (STEPwise Approach to Surveillance) conducted between 2005 and 2010 in Cambodia, Malaysia and Mongolia of men and women aged 40-64 years. The study compared the differences and implications of various approaches to risk estimation at a population level using the World Health Organization/International Society of Hypertension (WHO/ISH) risk score charts. To aid interpretation and adjustment of scores and inform treatment in individuals, the charts are accompanied by practice notes about risk factors not included in the risk score calculations. Total risk was calculated amongst the populations using the charts alone and also adjusted according to these notes. Prevalence of traditional single risk factors was also calculated. RESULTS: The prevalence of WHO/ISH "high CVD risk" (≥20% chance of developing a cardiovascular event over 10 years) of 6%, 2.3% and 1.3% in Mongolia, Malaysia and Cambodia, respectively, is in line with recent research when charts alone are used. However, these proportions rise to 33.3%, 20.8% and 10.4%, respectively when individuals with blood pressure > = 160/100 mm/Hg and/or hypertension medication are attributed to "high risk". Of those at "moderate risk" (10- < 20% chance of developing a cardio vascular event over 10 years), 100%, 94.3% and 30.1%, respectively are affected by at least one risk-increasing factor. Of all individuals, 44.6%, 29.0% and 15.0% are affected by hypertension as a single risk factor (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg or medication). CONCLUSIONS: Used on a population level, cardiovascular risk scores may offer useful insights that can assist health service delivery planning. An approach based on overall risk without adjustment of specific risk factors however, may underestimate treatment needs.At the individual level, the total risk approach offers important clinical benefits. However, countries need to develop appropriate clinical guidelines and operational guidance for detection and management of CVD risk using total CVD-risk approach at different levels of health system. Operational research is needed to assess implementation issues.

Comprehensive evaluation of the psychosocial parameters of epilepsy: a representative population-based study in Prey Veng (Cambodia).

PURPOSE: We conducted a population-based study of epilepsy in Prey Veng (Cambodia) to explore self-esteem, fear, discrimination, knowledge-attitude-practice (KAP), social-support, stigma, coping strategies, seizure-provoking factors, and patient-derived factors associated with quality of life (QOL). METHODS: The results are based on a cohort of 96 cases and matched controls (n = 192), randomly selected from the same source population. Various questionnaires were developed and validated for internal consistency (by split-half, Spearman-Brown prophecy, Kuder-Richardson 20), content clarity and soundness. Summary, descriptive statistics, classical tests of hypothesis were conducted. Uncorrected chi-square was used. Group comparison was done to determine statistically significant factors, for each domain, by conducting logistic regression; 95% confidence interval (CI) with 5% (two-sided) statistical significance was used. KEY FINDINGS: All questionnaires had high internal consistency. Stress was relevant in 14.0% cases, concealment in 6.2%, denial in 8.3%, negative feelings in public in 3.0%. Mean self-esteem was 7.5, range 0-8, related to seizure frequency. Mean discrimination was least during social interactions. Coping strategies were positive (e.g. look for treatment). Postictal headache, anger, no nearby health facility, etc. were associated with QOL. SIGNIFICANCE: The reliability of our questionnaires was high. A positive social environment was noted with many infrequent social and personal prejudices. Not all populations should (by default) be considered as stigmatized or equipped with poor KAP. We addressed themes that have been incompletely evaluated, and our approach could therefore become a model for other projects.

Inequalities in non-communicable diseases and effective responses.

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

Epilepsy in Asia: a Cambodian experience.

Epilepsy is particularly challenging for resource-poor countries and in turn for Asia which is likely to have greater challenges in terms of treatment cost and deficit, premature mortality, health transitions, population and poverty size, etc. Here we present an example of working in one of the resource-poor 'least-talked-about' populations to demonstrate that finding financial means and achieving cross-country cooperation over a long period of time is possible even in countries with currently limited resources. Conducting such cooperation could be a model for other initiatives. Scientific, capacity-building, and political tools should be employed to generate local representative data and influence government policies. These measures can be of immediate benefit for patients in these countries.

Population-based study of epilepsy in Cambodia associated factors, measures of impact, stigma, quality of life, knowledge-attitude-practice, and treatment gap.

PURPOSE: Identify epilepsy-associated factors and calculate measures of impact, stigma, quality of life (QOL), knowledge-attitude-practice (KAP) and treatment gap in Prey Veng, Cambodia. METHODS: This first Cambodian population-based case-control study had 96 epileptologist-confirmed epilepsy cases and 192 randomly selected matched healthy controls. Standard questionnaires, which have been used in similar settings, were used for collecting data on various parameters. Univariate and multivariate regression was done to determine odds ratios. Jacoby stigma, 31-item QOL, KAP etc were determined and so were the factors associated with them using STATA software. Treatment gap was measured using direct method. KEY FINDINGS: Multivariate analyses yielded family history of epilepsy, difficult or long delivery, other problems beside seizures (mainly mental retardation, hyperthermia), and eventful pregnancy of the subject's mother as factors associated with epilepsy. There was high frequency of seizure precipitants esp. those related to sleep. Population attributable risk (%) was: family history (15.0), eventful pregnancy of subject's mother (14.5), long/difficult birth (6.5), and other problem beside seizures (20.0). Mean stigma (1.9±1.1, on a scale of 3) was mainly related to treatment efficacy. Mean QOL (5.0±1.4 on a scale of 10) was mainly related to treatment regularity. Cause or risk factor could be determined in 56% of cases. Treatment gap was 65.8%. SIGNIFICANCE: Factors in pre- and perinatal period were found to be most crucial for epilepsy risk in Cambodia which inturn provides major prevention opportunities. A global action plan for treatment, stigma reduction and improvement of QOL should be set-up in this country.

Individual-based primary prevention of cardiovascular disease in Cambodia and Mongolia: early identification and management of hypertension and diabetes mellitus.

BACKGROUND: To assess the coverage of individual-based primary prevention strategies for cardiovascular disease (CVD) in Cambodia and Mongolia: specifically the early identification of hypertension and diabetes mellitus, major proximate physiological CVD risk factors, and management with pharmaceutical and lifestyle advice interventions. METHODS: Analysis of data collected in national cross-sectional STEPS surveys in 2009 (Mongolia) and 2010 (Cambodia) involving participants aged 25-64 years: 5433 in Cambodia and 4539 in Mongolia. RESULTS: Mongolia has higher prevalence of CVD risk factors than Cambodia--hypertension (36.5% versus 12.3%), diabetes (6.3% versus 3.1%), hypercholesterolemia (8.5% versus 3.2%), and overweight (52.5% versus 15.5%). The difference in tobacco smoking was less notable (32.1% versus 29.4%).Coverage with prior testing for blood glucose in the priority age group 35-64 years remains limited (16.5% in Cambodia and 21.7% in Mongolia). Coverage is higher for hypertension. A large burden of both hypertension and diabetes remains unidentified at current strategies for early identification: only 45.4% (Cambodia) to 65.8% (Mongolia) of all hypertensives and 22.8% (Mongolia) to 50.3% (Cambodia) of all diabetics in the age group 35-64 years had been previously diagnosed. Approximately half of all hypertensives and of all diabetics in both countries were untreated. 7.2% and 12.2% of total hypertensive population and 5.9% and 16.1% of total diabetic population in Cambodia and Mongolia, respectively, were untreated despite being previously diagnosed.Only 24.1% and 28.6% of all hypertensives and 15.9% and 23.9% of all diabetics in Mongolia and Cambodia, respectively were adequately controlled. Estimates suggest deficits in delivery of important advice for lifestyle interventions. CONCLUSIONS: Multifaceted strategies are required to improve early identification, initiation of treatment and improving quality of treatment for common CVD risk factors. Periodic population-based surveys including questions on medical and treatment history and the context of testing and treatment can facilitate monitoring of individual-based prevention strategies.

First-ever, door-to-door cross-sectional representative study in Prey Veng province (Cambodia).

PURPOSE: To estimate the lifetime prevalence of epilepsy in Prey Veng province (Cambodia). METHODS: Door-to-door screening was performed using a random cluster survey whereby all people >1 year of age were screened for epilepsy by using a validated and standardized questionnaire for epilepsy in tropical countries. Suspected epilepsy patients identified by the questionnaire were revisited and examined by epileptologists. The confirmation of epilepsy was based on an in-depth clinical examination. Electroencephalograms were recorded at the community dispensary. KEY FINDINGS: Five hundred three potential epilepsy cases were identified from 16,510 screened subjects, and 96 were diagnosed to have epilepsy. An overall prevalence of 5.8 per 1,000 [95% confidence interval (CI) 4.6-7.0 per 1,000] was obtained. Generalized epilepsy (76%) was more common than partial epilepsy (12.5%). Three cases were of generalized myoclonic epilepsy (3.1%) and one case each (1.0%) were of absence and olfactory partial epilepsy. Six cases (5.2%) had more than one seizure type [one case with absence + generalized tonic-clonic (GTC), one case each with GTC + partial seizures with secondary generalization and absence + generalized myoclonic seizures and absence + simple partial seizures, and two cases with GTC + complex partial seizures]. Electroencephalography (EEG) studies revealed spike and wave discharges in 43.8%, focal spikes in 21.0%, generalized slow waves in 19.2%, and generalized slowing of background in 15.7%. SIGNIFICANCE: This is the first population-based study in Cambodia that had epilepsy as a primary objective, and compared to Western and neighboring countries it shows a lower prevalence.

Determinants of utilisation of intrapartum obstetric care services in Cambodia, and gaps in coverage.

BACKGROUND: Facility delivery and skilled birth attendance are two of the most effective strategies for decreasing maternal mortality. The objectives of this study were to further define utilisation of these services in Cambodia and to uncover socio-economic or location-specific coverage gaps that may exist. METHODS: We performed a cross-sectional analysis of the 2005 Cambodia Demographic Health Survey (CDHS) to determine prevalence, and determinants, of service utilisation. RESULTS: Out of 6069 women aged 15-49 years, 77% delivered at home, three-fourths without a skilled birth attendant. Poverty, lower education and rural residence were associated with the highest likelihood of poor utilisation of services. Discussion. While there has been an overall increase in facility deliveries and skilled birth attendance since 2000, improvements have been spread unevenly across the population, benefiting mostly urban, wealthier and better educated women. While recent financing initiatives and health system developments appear to have further increased service utilisation since 2005, the extent of their reach to the most vulnerable populations, and their ultimate impact on maternal mortality reduction, remain to be elucidated. CONCLUSION: Further expanding successful initiatives, particularly among vulnerable populations, is essential. Longitudinal evaluation of ongoing strategies and their impact remains critical.

Health system strengthening in Cambodia-a case study of health policy response to social transition.

OBJECTIVES: Cambodia, following decades of civil conflict and social and economic transition, has in the last 10 years developed health policy innovations in the areas of health contracting, health financing and health planning. This paper aims to outline recent social, epidemiological and demographic health trends in Cambodia, and on the basis of this outline, to analyse and discuss these policy responses to social transition. METHODS: Sources of information included a literature review, participant observation in health planning development in Cambodia between 1993 and 2008, and comparative analysis of demographic health surveys between 2000 and 2005. RESULTS: In Cambodia there have been sharp but unequal improvements in child mortality, and persisting high maternal mortality rates. Data analysis demonstrates associations between location, education level and access to facility based care, suggesting the dominant role of socio-economic factors in determining access to facility based health care. These events are taking place against a background of rapid social transition in Cambodian history, including processes of decentralization, privatization and the development of open market economic systems. Primary policy responses of the Ministry of Health to social transition and associated health inequities include the establishment of health contracting, hospital health equity funds and public-private collaborations. CONCLUSIONS: Despite the internationally recognized health policy flexibility and innovation demonstrated in Cambodia, policy response still lags well behind the reality of social transition. In order to minimize the delay between transition and response, new policy making tactics are required in order to provide more flexible and timely responses to the ongoing social transition and its impacts on population health needs in the lowest socio-economic quintiles.

Determinants of skilled birth attendance in rural Cambodia.

OBJECTIVE: To identify the determinants of skilled and unskilled birth attendance. METHOD: Population-based survey in a rural area in Cambodia, of women aged 15-49 years who had delivered during the previous 3-month period. An analytical framework based on Andersen's behavioural model served to identify determinants according to delivery place (facility vs. non-facility), birth attendant at home births (skilled vs. unskilled), and change of birth attendant during delivery (changed vs. unchanged). We used logistic regression to analyse the data. RESULTS: Of 980 women included in the analyses, 19.8% had skilled attendants present during delivery. The determinants of facility delivery were different from those for having skilled attendants assisting in home births. In case of facility deliveries, previous contact with a skilled attendant through antenatal care was a significant determinant. In case of home births, the type of birth attendant (i.e. skilled or unskilled) at the preceding delivery was a significant determinant. CONCLUSION: Community-based programmes need to reach primiparas, because once a woman has delivered with the aid of an unskilled attendant, she is five to seven times less likely to seek skilled help than a primipara.

Community-based surveillance: a pilot study from rural Cambodia.

OBJECTIVE: This study seeks to assess the performance of a community-based surveillance system (CBSS), developed and implemented in seven rural communes in Cambodia from 2000 to 2002 to provide timely and representative information on major health problems and life events, and so permit rapid and effective control of outbreaks and communicable diseases in general. METHODS: Lay people were trained as Village Health Volunteers (VHVs) to report suspected outbreaks, important infectious diseases, and vital events occurring in their communities to local health staff who analysed the data and gave feedback to the volunteers during their monthly meetings. RESULTS: Over 2 years of its implementation, the system was able to detect outbreaks early, regularly monitor communicable disease trends, and to provide continuously updated information on pregnancies, births and deaths in the rural areas. In addition, the system triggered effective responses from both health staff and VHVs for disease control and prevention and in outbreaks. CONCLUSION: A CBSS can successfully fill the gaps of the current health facility-based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Its replication or adaptation for use in other rural areas in Cambodia and in other developing countries is likely to be beneficial and cost-effective.