Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos.

BACKGROUND: Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies. METHODS: The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders. RESULTS: There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities. CONCLUSIONS: This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes.

Ten-year persistence and evolution of Plasmodium falciparum antifolate and anti-sulfonamide resistance markers pfdhfr and pfdhps in three Asian countries.

BACKGROUND: The amplification of GTP cyclohydrolase 1 (pfgch1) in Plasmodium falciparum has been linked to the upregulation of the pfdhfr and pfdhps genes associated with resistance to the antimalarial drug sulfadoxine-pyrimethamine. During the 1990s and 2000s, sulfadoxine-pyrimethamine was withdrawn from use as first-line treatment in southeast Asia due to clinical drug resistance. This study assessed the temporal and geographic changes in the prevalence of pfdhfr and pfdhps gene mutations and pfgch1 amplification a decade after sulfadoxine-pyrimethamine had no longer been widely used. METHODS: A total of 536 P. falciparum isolates collected from clinical trials in Thailand, Cambodia, and Lao PDR between 2008 and 2018 were assayed. Single nucleotide polymorphisms of the pfdhfr and pfdhps genes were analyzed using nested PCR and Sanger sequencing. Gene copy number variations of pfgch1 were investigated using real-time polymerase chain reaction assay. RESULTS: Sequences of the pfdhfr and pfdhps genes were obtained from 96% (517/536) and 91% (486/536) of the samples, respectively. There were 59 distinct haplotypes, including single to octuple mutations. The two major haplotypes observed included IRNI-AGEAA (25%) and IRNL-SGKGA (19%). The sextuple mutation IRNL-SGKGA increased markedly over time in several study sites, including Pailin, Preah Vihear, Ratanakiri, and Ubon Ratchathani, whereas IRNI-AGEAA decreased over time in Preah Vihear, Champasak, and Ubon Ratchathani. Octuple mutations were first observed in west Cambodia in 2011 and subsequently in northeast Cambodia, as well as in southern Laos by 2018. Amplification of the pfgch1 gene increased over time across the region, particularly in northeast Thailand close to the border with Laos and Cambodia. CONCLUSION: Despite the fact that SP therapy was discontinued in Thailand, Cambodia, and Laos decades ago, parasites retained the pfdhfr and pfdhps mutations. Numerous haplotypes were found to be prevalent among the parasites. Frequent monitoring of pfdhfr and pfdhps in these areas is required due to the relatively rapid evolution of mutation patterns.

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.

Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Lao PDR.

BACKGROUND: Despite significant decline in malarial incidence and mortality in countries across the Greater Mekong Subregion, the disease remains a public health challenge in the region; transmission continues mainly among people who visit forests in remote areas, often along international borders, where access to primary healthcare is limited. In the absence of effective vector-control measures and limited exposure periods, malaria chemoprophylaxis has been proposed as a strategy to protect forest goers. As a rarely used approach for indigenous populations, questions remain about its feasibility and acceptability. Drawing on in-depth interviews with forest goers and stakeholders, this article examines opportunities and challenges for implementation of anti-malarial chemoprophylaxis for forest goers in Lao PDR. METHODS: In-depth interviews were conducted with 16 forest goers and 15 stakeholders in Savannakhet province, Lao PDR. Interview topics included experience of malaria prevention and health services, and perceptions of prophylaxis as a potential component of malaria elimination strategy. The interviews were transcribed and coded using inductive and deductive approaches for qualitative thematic analysis. RESULTS: In ethnically and geographically diverse villages, awareness of malaria risk prompts forest goers to protect themselves, albeit sub-optimally using available preventive measures. Stakeholders highlighted challenges for targeting at-risk populations and approaches to address forest malaria in southern Lao PDR. Among policymakers, choice and cost of anti-malarials, particularly their efficacy and source of funding, were key considerations for the feasibility of malaria prophylaxis. Acceptability of prophylaxis among forest goers was also influenced by the complexity of the regimen, including the number of tablets and timing of doses. Implementation of prophylaxis may be affected by a lack of transportation and communication barriers in remote communities. CONCLUSION: Adding prophylaxis to existing malaria control activities requires strengthening the capacity of local health workers in Lao PDR. Ideally, this would be part of an integrated approach that includes strategies to address the other febrile illnesses that forest goers describe as priority health concerns. The prophylactic regimen also requires careful consideration in terms of effectiveness and simplicity of dosing.

Factors associated with severe dengue in Savannakhet Province, Lao People's Democratic Republic.

This study aimed to describe the socio-demographic and clinical characteristics of dengue inpatients at a provincial hospital, and to identify factors associated with severe dengue. This is a retrospective study involving 402 dengue patients admitted to the Savannakhet Provincial Hospital, Lao People's Democratic Republic (Lao PDR), between January 2018 and April 2019. Socio-demographic factors, clinical signs and laboratory data on admission, final diagnosis, use of health care services before admission, admission date, and hospitalization period were collected from patient records. The number of dengue inpatients was higher in the rainy season than in the dry season. Of the 402 patients, 205 patients (51.0%) were finally diagnosed with severe dengue. Children aged <15 years had more symptoms, higher proportion of severe dengue (69.8% vs. 35.9%), and longer hospitalization (3.5 days vs. 3.0 days) than adults aged ≥15 years. In multivariable analyses, factors associated with severe dengue were nausea on admission (adjusted odds ratio=3.57, 95% CI=1.05-12.09, P=0.04) in children and persistent vomiting on admission (adjusted odds ratio=3.82, 95% CI=1.23-11.92, P=0.02) in adults. In adults, the creatinine level on admission was significantly higher in patients with a final diagnosis of severe dengue compared to the others. The proportion of severe dengue in our study was higher than that in other countries. Nausea and persistent vomiting on admission were suggested to be predictive factors for severe dengue. To reduce the incidence of severe dengue in Lao PDR, improvements in access to health care, referral system, and training of health care workers are needed.

A Comparison of Surface and Total Deltamethrin Levels of Insecticide-Treated Nets and Estimation of the Effective Insecticidal Lifetime.

The ability to anticipate the useful lifetime of an insecticide-treated mosquito net (ITN) would provide a proactive approach for planning net distribution programs. Therefore, we used an exponential decay model of deltamethrin depletion to predict the effective insecticidal lifetime of PermaNet® 2.0 nets used in the Lao PDR. Residual deltamethrin was measured using two nondestructive analytical field methods; X-ray fluorescence (total levels) and a colorimetric field test (surface levels) at 12 and 24 months postdistribution. The model assumes that the 12-month depletion rate can be used to predict future levels. The median total and surface deltamethrin levels for the Lao nets at 12 months were 31.2 and 0.0743 mg/m2, respectively. By defining a failed net as having total deltamethrin levels of less than 15 mg/m2 or a surface level less than 0.0028 mg/m2, it was predicted that 50% of the group of nets will fail at about 27 months after distribution.

Adherence to antihypertensive medications in rural Lao PDR: a prospective observational study.

BACKGROUND: Although hypertension is becoming more prevalent among the adult population of the Lao People's Democratic Republic (PDR), with a prevalence of approximately 20% in 2013, treatment adherence of patients with hypertension, especially those in rural areas, remains poorly understood. The objective of the present study was to examine the rate of medication adherence to antihypertensive medicines among outpatients with hypertension in rural districts of the Savannakhet. METHODS: A prospective observational study was conducted in Xepon, Phin, and Nong districts. The study population was outpatients aged 18 years or older who were prescribed antihypertensive medicines at three district hospitals between February and August 2017. Data were collected on the first day of treatment (day 0) and the day of follow-up (around day 7) through interviews with the patients and outpatient registration books. The medication adherence rate was determined using the four-item Morisky Medication Adherence Scale. The level of adherence was evaluated by the sum of the scale, with scores ranging from 0 to 4 points. The adherent group, namely those with a score of 0, and the non-adherent group, namely those with scores of 1 to 4 points, were compared. Fisher's exact test was used to identify factors associated with medication adherence. RESULTS: Of the 68 patients examined, 38.2% newly began treatment. Half of the patients (n = 34, 50.0%, 95% CI 0.38 to 0.62) adhered to medication instructions. The adherent group was more likely to have received written instructions when prescribed medication, compared to the non-adherent group (79.4% vs 55.9%, p = 0.068). Those who perceived that hypertension needs lifelong treatment were significantly more likely to adhere to the medication regimen (p = 0.028). CONCLUSIONS: Medication adherence was present among 50% of outpatients with hypertension who visited a district hospital. Therefore, providing written instructions to patients would be effective for improving medication adherence.

Development and Comparison of Dengue Vulnerability Indices Using GIS-Based Multi-Criteria Decision Analysis in Lao PDR and Thailand.

Dengue is a continuous health burden in Laos and Thailand. We assessed and mapped dengue vulnerability in selected provinces of Laos and Thailand using multi-criteria decision approaches. An ecohealth framework was used to develop dengue vulnerability indices (DVIs) that explain links between population, social and physical environments, and health to identify exposure, susceptibility, and adaptive capacity indicators. Three DVIs were constructed using two objective approaches, Shannon's Entropy (SE) and the Water-Associated Disease Index (WADI), and one subjective approach, the Best-Worst Method (BWM). Each DVI was validated by correlating the index score with dengue incidence for each spatial unit (district and subdistrict) over time. A Pearson's correlation coefficient (r) larger than 0.5 and a p-value less than 0.05 implied a good spatial and temporal performance. Spatially, DVIWADI was significantly correlated on average in 19% (4-40%) of districts in Laos (mean r = 0.5) and 27% (15-53%) of subdistricts in Thailand (mean r = 0.85). The DVISE was validated in 22% (12-40%) of districts in Laos and in 13% (3-38%) of subdistricts in Thailand. The DVIBWM was only developed for Laos because of lack of data in Thailand and was significantly associated with dengue incidence on average in 14% (0-28%) of Lao districts. The DVIWADI indicated high vulnerability in urban centers and in areas with plantations and forests. In 2019, high DVIWADI values were observed in sparsely populated areas due to elevated exposure, possibly from changes in climate and land cover, including urbanization, plantations, and dam construction. Of the three indices, DVIWADI was the most suitable vulnerability index for the study area. The DVIWADI can also be applied to other water-associated diseases, such as Zika and chikungunya, to highlight priority areas for further investigation and as a tool for prevention and interventions.

Association between physical activity and activity space in different farming seasons among rural Lao PDR residents.

BACKGROUND: Southeast Asia is experiencing a health transition, where non-communicable diseases (NCD) are exceeding communicable diseases. Despite NCDs accounting for roughly 60-85% of deaths in the region, many developing Southeast Asian countries are beginning to address the impacts of a physically inactive lifestyle for the first time. Our study aims to bridge this gap by objectively measuring physical activity in rural Lao PDR to reveal the association among physical activity, activity space, and seasonal variation. METHODS: Multiple waves of survey data were collected in Songkhon District, Lao PDR between March 2010 and March 2011. Adults aged between 18 and 65 were recruited (n = 48). A portable GPS recorded participants' activity and farmland locations and an accelerometer recorded participants' physical activity level and daily steps for seven consecutive days. Using a directional distribution tool in ArcGIS 10.5, the activity space area of each participant in each wave was calculated. Concurrently, participants recorded time spent on each daytime activity. Linear mixed models with the fixed effects as the observations from different waves and the random effects as individual participants were developed to identify factors associated with areas of activity space and counts of daily steps, respectively. RESULTS: A total of 48 respondents aged between 19 and 57 took part in the study. Half of the participants were females. Walking was found to be the most frequent travel mode. Females were physically less active, with a smaller activity space, and were more overweight than the males in the study. Participants were physically less active during the off-farming seasons. CONCLUSIONS: Findings contribute to the surveillance of risk factors needed to create healthy living environments. Our research is also one of the first to use empirical evidence demonstrating seasonal variations of rural residents' activities in mainland Southeast Asia.

Evolution of Multidrug Resistance in Plasmodium falciparum: a Longitudinal Study of Genetic Resistance Markers in the Greater Mekong Subregion.

Increasing resistance in Plasmodium falciparum to artemisinins and their artemisinin combination therapy (ACT) partner drugs jeopardizes effective antimalarial treatment. Resistance is worst in the Greater Mekong subregion. Monitoring genetic markers of resistance can help to guide antimalarial therapy. Markers of resistance to artemisinins (PfKelch mutations), mefloquine (amplification of P. falciparum multidrug resistance-1 [PfMDR1]), and piperaquine (PfPlasmepsin2/3 amplification and specific P. falciparum chloroquine resistance transporter [PfCRT] mutations) were assessed in 6,722 P. falciparum samples from Vietnam, Lao People's Democratic Republic (PDR), Cambodia, Thailand, and Myanmar between 2007 and 2019. Against a high background prevalence of PfKelch mutations, PfMDR1 and PfPlasmepsin2/3 amplification closely followed regional drug pressures over time. PfPlasmepsin2/3 amplification preceded piperaquine resistance-associated PfCRT mutations in Cambodia and reached a peak prevalence of 23/28 (82%) in 2015. This declined to 57/156 (38%) after first-line treatment was changed from dihydroartemisinin-piperaquine to artesunate-mefloquine (ASMQ) between 2014 and 2017. The frequency of PfMDR1 amplification increased from 0/293 (0%) between 2012 and 2017 to 12/156 (8%) in 2019. Amplification of PfMDR1 and PfPlasmepsin2/3 in the same parasites was extremely rare (4/6,722 [0.06%]) and was dispersed over time. The mechanisms conferring mefloquine and piperaquine resistance may be counterbalancing. This supports the development of ASMQ plus piperaquine as a triple artemisinin combination therapy.

Factors affecting the choice of delivery place in a rural area in Laos: A qualitative analysis.

BACKGROUND: Home delivery (HD) without skilled birth attendants (SBAs) are considered crucial risk factors increasing maternal and child mortality rates in Loa PDR. While a few studies in the literature discuss the choice of delivery in remote areas of minority ethnic groups; our work aims to identify factors that indicated their delivery place, at home or in the health facilities. METHODS: A community-based qualitative study was conducted between February and March 2020. Three types of interviews were implemented, In-depth interviews with 16 women of eight rural villages who delivered in the last 12 months in Xepon District, Savannakhet Province, Lao PDR. Also, three focus group discussions (FGDs) with nine HCPs and key-informant interviews of ten VHVs were managed. Factors affecting the choice of the delivery place were categorized according to the social-ecological model. RESULTS: Our sample included five Tri women and two Mangkong women in the HD group, while the FD group included three Tri women, two Mangkong women, one Phoutai woman, two Laolung women and one Vietnamese. Our investigation inside the targeted minority showed that both positive perceptions of home delivery (HD) and low-risk perception minorities were the main reasons for the choice of HD, on the individual level. On the other hand, fear of complication, the experience of stillbirth, and prolonged labour pain during HD were reasons for facility-based delivery (FD). Notably, the women in our minority reported no link between their preference and their language, while the HCPs dated the low knowledge to the language barrier. On the interpersonal level, the FD women had better communication with their families, and better preparation for delivery compared to the HD group. The FD family prepared cash and transportation using their social network. At the community level, the trend of the delivery place had shifted from HD to FD. Improved accessibility and increased knowledge through community health education were the factors of the trend. At the societal (national policy) level, the free delivery policy and limitation of HCPs' assisted childbirth only in health facilities were the factors of increasing FD, while the absence of other incentives like transportation and food allowance was the factor of remaining of HD. CONCLUSIONS: Based on the main findings of this study, we urge the enhancement of family communication on birth preparedness and birthplace. Furthermore, our findings support the need to educate mothers, especially those of younger ages, about their best options regarding the place of delivery. We propose implementing secondary services of HD to minimize the emergency risks of HD. We encourage local authorities to be aware of the medical needs of the community especially those of pregnant females and their right for a free delivery policy.

Barriers to the Digitization of Health Information: A Qualitative and Quantitative Study in Kenya and Lao PDR Using a Cloud-Based Maternal and Child Registration System.

Digitalization of health information can assist patient information management and improve health services even in low middle-income countries. We have implemented a mother and child health registration system in the study areas of Kenya and Lao PDR to evaluate barriers to digitalization. We conducted in-depth interviews with 20 healthcare workers (HCWs) who used the system and analyzed it qualitatively with thematic framework analysis. Quantitatively, we analyzed the quality of recorded data according to missing information by the logistic regression analysis. The qualitative analysis identified six themes related to digitalization: satisfaction with the system, mothers' resistance, need for training, double work, working environment, and other resources. The quantitative analysis showed that data entry errors improved around 10% to 80% based on odds ratios in subsequent quarters compared to first quarter periods. The number of registration numbers was not significantly related to the data quality, but the motivation, including financial incentives among HCWs, was related to the registration behavior. Considering both analysis results, workload and motivation to maintain high performance were significant obstacles to implementing a digital health system. We recommend enhancing the scope and focus on human needs and satisfaction as a significant factor for digital system durability and sustainability.

Impact of village health volunteer support on postnatal depressive symptoms in the remote rural areas of Lao People's Democratic Republic: a cross-sectional study.

BACKGROUND: Village health volunteers (VHVs) are responsible for providing primary care in the communities of Laos. Unlike other districts, in Xepon more than 90% of VHVs are male and therefore experience difficulties interacting with pregnant women. To improve outreach to pregnant women, especially among ethnic minorities, a new project was implemented by local municipalities in 2017: newly selected female VHVs were paired to work with existing male VHVs. The objective of this study was to compare the postnatal depressive symptoms of ethnic minority mothers supported by pair-VHVs and single-VHVs in remote rural areas of Lao People's Democratic Republic (PDR). METHODS: A cross-sectional study was conducted in March 2019. Mothers who had delivered a baby within 1 year preceding the study were recruited from 36 villages. Of the 305 mothers, 227 responded. The questionnaires included (1) demographic characteristics such as age, economic status, and birth experience; (2) self-decision to go to a health center/hospital to receive antenatal care; (3) type of VHVs (pair or single), support, and information from VHVs during pregnancy, support from husband and relationship with husband; (4) the Edinburgh Postnatal Depression Scale (EPDS). A Mann-Whitney U test, chi-square test, and multiple linear regression analysis were performed. Ethical approval was obtained from the University of the Ryukyus and National Ethics Committee for Health Research of Lao PDR. RESULTS: The average total EPDS score was 5.5 among mothers supported by pair-VHV and 7.0 among mothers supported by single-VHV. Results of the multiple linear regression analysis showed that the EPDS score was significantly lower among mothers supported by pair-VHV (ß=-1.18, p <0.05) even after adjusting for economic and biological factors. CONCLUSIONS: Mothers supported by pair-VHV had a significantly lower EPDS score than those supported by single-VHVs in this study area, suggesting that the support of male and female VHV pairs contributed to improving mental health status among ethnic minority mothers in remote rural areas of Lao PDR. Expanding the program to train female VHVs working with male VHVs is necessary for improving maternal and child health in a rural district of Lao PDR.

Correction: Doum, D., et al. Dengue Seroprevalence and Seroconversion in Urban and Rural Populations in Northeastern Thailand and Southern Laos. Int. J. Environ. Res. Public Health 2020, 17, 9134.

There was an error in the original article [...].

Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: a protocol for a prospective observational study.

INTRODUCTION: In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. METHODS AND ANALYSIS: This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28.Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. ETHICS AND DISSEMINATION: The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. TRIAL REGISTRATION NUMBER: NCT04285021.

Defining the burden of febrile illness in rural South and Southeast Asia: an open letter to announce the launch of the Rural Febrile Illness project.

In rural areas of South and Southeast Asia malaria is declining but febrile illnesses still account for substantial morbidity and mortality. Village health workers (VHWs) are often the first point of contact with the formal health system, and for patients with febrile illnesses they can provide early diagnosis and treatment of malaria. However, for the majority of febrile patients, VHWs lack the training, support and resources to provide further care. Consequently, treatable bacterial illnesses are missed, antibiotics are overused and poorly targeted, and patient attendance wanes along with declining malaria. This Open Letter announces the start of a new initiative, the Rural Febrile Illness (RFI) project, the first in a series of projects to be implemented as part of the South and Southeast Asian Community-based Trials Network (SEACTN) research programme. This multi-country, multi-site project will run in Bangladesh, Cambodia, Lao PDR, Thailand, and Myanmar. It will define the epidemiological baseline of febrile illness in nine remote and underserved areas of Asia where malaria endemicity is declining and access to health services is limited. The RFI project aims to determine the incidence, causes and outcomes of febrile illness; understand the opportunities, barriers and appetite for adjustment of the role of VHWs to include management of non-malarial febrile illnesses; and establish a network of community healthcare providers and facilities capable of implementing interventions designed to triage, diagnose and treat patients presenting with febrile illnesses within these communities in the future.

Knowledge, attitudes, and practices on climate change and dengue in Lao People's Democratic Republic and Thailand.

BACKGROUND: Dengue is linked with climate change in tropical and sub-tropical countries including the Lao People's Democratic Republic (Laos) and Thailand. Knowledge about these issues and preventive measures can affect the incidence and outbreak risk of dengue. Therefore, the present study was conducted to determine the knowledge, attitudes, and practices (KAP) among urban and rural communities and government officials about climate change and dengue in Laos and Thailand. METHODS: A cross-sectional KAP survey about climate change and dengue were conducted in 360 households in Laos (180 urban and 180 rural), 359 households in Thailand (179 urban and 180 rural), and 20 government officials (10 in each country) using structured questionnaires. Data analysis was undertaken using descriptive methods, principal component analysis (PCA), Chi-square test or Fisher's exact test (as appropriate), and logistic regression. RESULTS: Significant differences among the selected communities in both countries were found in terms of household participant's age, level of education, socioeconomic status, attitude level of climate change and KAP level of dengue (P < 0.05; 95% CI). Overall, participants' KAP about climate change and dengue were low except the attitude level for dengue in both countries. The level of awareness among government officials regarding the climatic relationship with dengue was also low. In Lao households, participants' knowledge about climate change and dengue was significantly associated with the level of education and socioeconomic status (SES) (P < 0.01). Their attitudes towards climate change and dengue were associated with educational level and internet use (P < 0.05). Householders' climate change related practices were associated with SES (P < 0.01) and dengue related practices were associated with educational level, SES, previous dengue experience and internet use (P < 0.01). In Thailand, participants' knowledge about climate change was associated with the level of education and SES (P < 0.01). Their attitudes towards climate change were associated with residence status (urban/rural) and internet use (P < 0.05); climate change related practices were associated with educational level and SES (P < 0.05). Dengue related knowledge of participants was associated with SES and previous dengue experience (P < 0.05); participants' dengue related attitudes and practices were associated with educational level (P < 0.01). CONCLUSION: The findings call for urgently needed integrated awareness programs to increase KAP levels regarding climate change adaptation, mitigation and dengue prevention to improve the health and welfare of people in these two countries, and similar dengue-endemic countries.

Dengue Seroprevalence and Seroconversion in Urban and Rural Populations in Northeastern Thailand and Southern Laos.

Dengue is the most rapidly spreading mosquito-borne viral disease in the world. The detection of clinical cases enables us to measure the incidence of dengue infection, whereas serological surveys give insights into the prevalence of infection. This study aimed to determine dengue seroprevalence and seroconversion rates in northeastern Thailand and southern Laos and to assess any association of mosquito control methods and socioeconomic factors with dengue virus (DENV) infection. Cross-sectional seroprevalence surveys were performed in May and November 2019 on the same individuals. Blood samples were collected from one adult and one child, when possible, in each of 720 randomly selected households from two urban and two rural sites in both northeastern Thailand and southern Laos. IgG antibodies against DENV were detected in serum using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Overall, 1071 individuals participated in the study. The seroprevalence rate was high (91.5%) across all 8 study sites. Only age and province were associated with seroprevalence rates. There were 33 seroconversions during the period from May to November, of which seven reported fever. More than half of the seroconversions occurred in the rural areas and in Laos. Dengue seroconversion was significantly associated with young age (<15 years old), female gender, province, and duration of living in the current residence. No socioeconomic factors or mosquito control methods were found to be associated with seroprevalence or seroconversion. Notably, however, the province with most seroconversions had lower diurnal temperature ranges than elsewhere. In conclusion, our study has highlighted the homogeneity of dengue exposure across a wide range of settings and most notably those from rural and urban areas. Dengue can no longer be considered to be solely an urban disease nor necessarily one linked to poverty.

Molecular epidemiology of resistance to antimalarial drugs in the Greater Mekong subregion: an observational study.

BACKGROUND: The Greater Mekong subregion is a recurrent source of antimalarial drug resistance in Plasmodium falciparum malaria. This study aimed to characterise the extent and spread of resistance across this entire region between 2007 and 2018. METHODS: P falciparum isolates from Myanmar, Thailand, Laos, and Cambodia were obtained from clinical trials and epidemiological studies done between Jan 1, 2007, and Dec 31, 2018, and were genotyped for molecular markers (pfkelch, pfcrt, pfplasmepsin2, and pfmdr1) of antimalarial drug resistance. Genetic relatedness was assessed using microsatellite and single nucleotide polymorphism typing of flanking sequences around target genes. FINDINGS: 10 632 isolates were genotyped. A single long pfkelch Cys580Tyr haplotype (from -50 kb to +31·5 kb) conferring artemisinin resistance (PfPailin) now dominates across the eastern Greater Mekong subregion. Piperaquine resistance associated with pfplasmepsin2 gene amplification and mutations in pfcrt downstream of the Lys76Thr chloroquine resistance locus has also developed. On the Thailand-Myanmar border a different pfkelch Cys580Tyr lineage rose to high frequencies before it was eliminated. Elsewhere in Myanmar the Cys580Tyr allele remains widespread at low allele frequencies. Meanwhile a single artemisinin-resistant pfkelch Phe446Ile haplotype has spread across Myanmar. Despite intense use of dihydroartemisinin-piperaquine in Kayin state, eastern Myanmar, both in treatment and mass drug administrations, no selection of piperaquine resistance markers was observed. pfmdr1 amplification, a marker of resistance to mefloquine, remains at low prevalence across the entire region. INTERPRETATION: Artemisinin resistance in P falciparum is now prevalent across the Greater Mekong subregion. In the eastern Greater Mekong subregion a multidrug resistant P falciparum lineage (PfPailin) dominates. In Myanmar a long pfkelch Phe446Ile haplotype has spread widely but, by contrast with the eastern Greater Mekong subregion, there is no indication of artemisinin combination therapy (ACT) partner drug resistance from genotyping known markers, and no evidence of spread of ACT resistant P falciparum from the east to the west. There is still a window of opportunity to prevent global spread of ACT resistance. FUNDING: Thailand Science Research and Innovation, Initiative 5%, Expertise France, Wellcome Trust.