Assessment of dual practice among physicians in Cambodia

BACKGROUND

Dual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health.

METHODS

Data were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals.

RESULTS

Of 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only.

CONCLUSIONS

As policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.

Quality of life and its social determinants for patients with schizophrenia and family caregivers in Cambodia

Due to inadequate human and financial resource support, the development of mental health services in Cambodia has been undertaken by various non-governmental organizations (NGOs). Schizophrenia is the most common functional psychotic disorder, causing severe and chronic symptoms, and the programs provided by the NGOs should have enhanced the quality of life (QoL) of patients and their caregivers; however, epidemiological research, which is a driving force behind the recognition of mental health as a global public health concern, is lacking for schizophrenia in Cambodia. This study therefore aimed to create QoL evaluation questionnaires available in Khmer (the Cambodian language) for patients with schizophrenia and family caregivers, and to identify the social determinants and predictors of their QoL. This cross-sectional study recruited 59 patients and 59 caregivers attending three clinics operated by two NGOs: the Transcultural Psychosocial Organization (TPO) Cambodia and the Supporters for Mental Health (SUMH) Cambodia. We conducted linguistic validation of the Schizophrenia Quality of Life Questionnaire 18-item version (S-QoL 18) and the Schizophrenia Caregiver Questionnaire (SCQ), then analyzed correlations between the QoL dimensions and socio-demographic factors. The main findings of this study were as follows: 1) the newly created Khmer versions of S-QoL 18 and SCQ are relatively good psychometric tools that are suitable for research to identify patients’ and caregivers’ needs to improve their QoL; and 2) engaging in paid work or being of the post-Khmer Rouge generation results in higher QoL for patients, but having low household economic status or being affected by chronic disease leads to lower QoL for family caregivers. These findings are useful for enabling community mental health professionals and aid organizations to create programs to lessen the patient and caregiver burden in Cambodia. Further research is necessary to develop practical projects that will improve patients’ and caregivers’ QoL in various clinical settings in Cambodia.

The impacts of degradation, deforestation and restoration on mangrove ecosystem carbon stocks across Cambodia

Mangrove forest conservation can help reduce global C emissions. Despite this benefit to climate change mitigation and adaptation, mangrove forests are being deforested or degraded at an alarming rate, though restoration efforts may offset these losses. The impacts of deforestation to C stocks are relatively intuitive and result in significant decreases in C stocks. It remains unclear how degradation from selective harvesting of trees affects C stocks or how effective restoration efforts are at restoring C stocks. Furthermore, total ecosystem C (TEC) stocks of pristine mangroves can significantly vary spatially. To address these issues, we conducted an intensive, national assessment of mangrove forests across Cambodia using a grid approach to: 1) examine how land use land cover (i.e., pristine, deforested, degraded, and restored forests) impacts TEC stocks, and 2) how TEC stocks vary spatially across the country. TEC stocks from deforested mangroves were always lower than pristine forests, resulting in an overall loss of 60% C (480 Mg C ha^-1). However, TEC stocks from degraded and 25-year-old restored mangroves forests did not differ from pristine forests. Mean TEC in mangroves was 784.7 ± 30.1 Mg C ha^-1, decreasing from 957.2 ± 32.8 Mg C ha^-1 in the northern region to 628.9 ± 33.1 Mg C ha^-1 in the central region to 386.2 ± 19.1 Mg C ha^-1 in the southern region of Cambodia. Intensive sampling in mangroves across Cambodia verified impacts of deforestation reported elsewhere, revealed the lack of degradation impacts on TEC stocks, and demonstrated the effectiveness of restoration on TEC stocks after only 25 years. Our gridded sampling approach was able to capture spatial variability across Cambodia and provide a more realistic TEC stock information that can be used for national reporting or participation in C markets.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND

Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs.

METHODS

We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries.

RESULTS

Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education.

CONCLUSIONS

In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Cambodian Developmental Milestone Assessment Tool (cDMAT): Performance reference charts and reliability check of a tool to assess early childhood development in Cambodian children

BACKGROUND

Childhood development milestones are essential skills that define how children participate in their environment socially, physically, and intellectually. A culturally-sensible and environmentally-appropriate tool is needed to assess their performance and detect disabilities at an early stage.

METHOD

This observational study aimed to create reference charts of performances among healthy rural and semi-rural Cambodian children aged 0-83 months for each milestone using the Denver II-based Cambodian Development Milestone Assessment Tool (cDMAT). Inter-observer reliability testing yielded Kappa scores.

RESULTS AND CONCLUSION

1330 children included in the analyses represented an average population sample with similar gender balance, expected poverty distribution and the illiteracy rate among their mothers (81% with no or attended <7th-grade education). While gender, poverty and the mother's education level were not found to be confounding factors, the child's school enrolment status was (p < 0.005). The performance reference charts document the PASS ratios from which age onwards <25%, 25-75%, 75-90%, 90-99% and 99-100% of the children in each monthly cohort can perform a particular milestone. The mean inter-observer reliability ranged from substantial (Kappa 0.61 for delay) to excellent (Kappa 0.84 for immediate) in all domains. The performance reference charts of a culturally-sensible and environmentally-appropriate cDMAT can be used in Cambodia with special attention given to the child's school enrolment as it was found to be a confounding factor affecting child development. Creating a small-scale pilot program linking the cDMAT to early intervention would help raise awareness and create local expertise on early childhood development.

A flood of models: Mekong ecologies of comparison

In recent decades, scientists have developed a wide array of hydrological, hydrodynamic, and other models to understand the dynamics of the Mekong River Basin. Indeed, the area has been described as 'flooded' with models. Drawing on STS and the philosophy of modeling - which has described models as mediating instruments - the first half of this article discusses how and why this proliferation has occurred, focusing on the Cambodian context. Highlighting that models are developed comparatively, with reference to one another, the analysis shows how they have generated a partially connected ecology of comparisons. As each model makes its own image of the Mekong, the ecology as a whole creates a kaleidoscopic effect. In principle, this ecology is important for that of environmental policy-making. In practice, however, it is tremendously difficult for scientists to bridge the ecologies. Examining two cases of NGO-based modeling aiming to influence policy, the second half of the paper offers a comparative analysis of the challenges modeling knowledge faces in Mekong environmental politics.

Featured counter-trafficking program: Trauma recovery for victims of sex trafficking

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes a mental health program within Agape Restoration Center (ARC), a residential treatment center in Phnom Penh, Cambodia. Development of the mental health services program was based on a modified version of an evidence-based trauma-focused cognitive behavioral therapeutic modality developed in the U.S (Cohen, Mannarino, & Deblinger, 2006, 2012).

Cambodian Remarried Women Are at Risk for Domestic Violence

Divorce rates continue to rise, especially in urban centers, which in turn contributes to increasing numbers of women who remarry. While remarriage is one of the only options for survival for divorced women, especially those from low socioeconomic status, remarriage also brings with it increased stressors of financial strain and the strain of blended families. This study tested the hypothesis that remarried women compared with first-time married and divorced women are at increased risk for domestic violence. The sample was drawn from the Cambodia Demographic and Health Survey, consisting of 1,560 women with the average age of 31.64. Results showed that 20% of women reported emotional violence and 14%, physical violence. Based on hierarchical multiple regressions, this study found that remarried women were more likely to experience physical and emotional abuse than women in their first marriage or women who remain divorced/not in union. Further interaction analyses showed that domestic violence varies depending on place of residence, number of children younger than 5 years, partners' education, and wealth index. Rural residents who were in poorest and poorer groups and urban residents in their poorer and middle groups of their wealth index showed high risk of domestic violence. Remarried women with two or three children younger than 5 years showed highest risk of domestic violence. Additional three-way interaction analysis revealed that remarried women residing in rural/urban areas with a spouse having no education and/or primary level of education were at highest risk of domestic violence. The study lends support to the structural role of the power of male dominance on women's social and emotional well-being. This study suggested that to reduce men's perceived domination, structural intervention that includes implementing gender-responsive curriculum in formal education, as well as strengthening domestic violence law enforcement would help reduce domestic violence against women.

Evaluation of the CareStart™ glucose-6-phosphate dehydrogenase (G6PD) rapid diagnostic test in the field settings and assessment of perceived risk from primaquine at the community level in Cambodia

Background

Primaquine is an approved radical cure treatment for Plasmodium vivax malaria but treatment can result in life-threatening hemolysis if given to a glucose-6-phosphate dehydrogenase deficient (G6PDd) patient. There is a need for reliable point-of-care G6PD diagnostic tests.

Objectives

To evaluate the performance of the CareStart™ rapid diagnostic test (RDT) in the hands of healthcare workers (HCWs) and village malaria workers (VMWs) in field settings, and to better understand user perceptions about the risks and benefits of PQ treatment guided by RDT results.

Methods

This study enrolled 105 HCWs and VMWs, herein referred to as trainees, who tested 1,543 healthy adult male volunteers from 84 villages in Cambodia. The trainees were instructed on G6PD screening, primaquine case management, and completed pre and post-training questionnaires. Each trainee tested up to 16 volunteers in the field under observation by the study staff.

Results

Out of 1,542 evaluable G6PD volunteers, 251 (16.28%) had quantitative enzymatic activity less than 30% of an adjusted male median (8.30 U/g Hb). There was no significant difference in test sensitivity in detecting G6PDd between trainees (97.21%), expert study staff in the field (98.01%), and in a laboratory setting (95.62%) (p = 0.229); however, test specificity was different for trainees (96.62%), expert study staff in the field (98.14%), and experts in the laboratory (98.99%) (p < 0.001). Negative predictive values were not statistically different for trainees, expert staff, and laboratory testing: 99.44%, 99.61%, and 99.15%, respectively. Knowledge scores increased significantly post-training, with 98.7% willing to prescribe primaquine for P.vivax malaria, an improvement from 40.6% pre-training (p < 0.001).

Conclusion

This study demonstrated ability of medical staff with different background to accurately use CareStart™ RDT to identify G6PDd in male patients, which may enable safer prescribing of primaquine; however, pharmacovigilance is required to address possible G6PDd misclassifications.

Standardized framework for evaluating costs of active case-finding programs: An analysis of two programs in Cambodia and Tajikistan

INTRODUCTION

Over the years, technological and process innovations enabled active case finding (ACF) programs to expand their capacities and scope to have evolved to close gaps in missing TB patients globally. However, with increased ACF program's operational complexity and a need for significant resource commitments, a comprehensive, transparent, and standardized approach in evaluating costs of ACF programs is needed to properly determine costs and value of ACF programs.

METHODS

Based on reviews of program activity and financial reports, multiple interviews with program managers of two TB REACH funded ACF programs deployed in Cambodia and Tajikistan, we first identified common program components, which formed the basis of the cost data collection, analysis, reporting framework. Within each program component and sub-activity group, cost data were collected and organized by relevant resource types (human resource, capital, recurrent, and overhead costs). Total shared, indirect and overhead costs were apportioned into each activity category based on direct human resource contribution (e.g. a number of staff and their relative level of effort dedicated to each program component). Capital assets were assessed specific to program components and were annualized based on their expected useful life and a 3% discount rate. All costs were assessed based on the service provider perspective and expressed in 2015 USD.

RESULTS

Over the two program years (April 2013 to December 2015), the Cambodia and Tajikistan ACF programs cumulated a total cost of $336,951 and $771,429 to screen 68,846 and 1,980,516 target population, bacteriologically test 4,589 and 19,764 presumptive TB, diagnose 731 and 2,246 TB patients in the respective programs. Recurrent costs were the largest cost components (54% and 34%) of the total costs for the respective programs and Xpert MTB/RIF (Xpert) testing incurred largest program component/activity cost for both programs. Cost per screening was $0.63 and $0.10 and cost per Xpert test was $25 and $18; Cost per TB case detected (Xpert) was $373 and $343 in Cambodia and Tajikistan.

CONCLUSIONS

Results from two contextually and programmatically different multi-component ACF programs demonstrate that our tool is fully capable of comprehensively and transparently evaluating and comparing costs of various ACF programs.

Setting research priorities for tackling climate change

Addressing the complex issues related to climate change requires multiple innovative approaches to identify research priorities involving multidisciplinary research teams. Participatory approaches with a variety of perspectives were used to gain insights into critical issues such as defining and understanding sustainable intensification, climate smart agriculture, and soil fertility prioritization in sub-Saharan Africa. This analysis drew on the foundation principles of participatory research and fundamental facilitation skills, while grounded in scientific knowledge and understanding of these complex issues. This approach essentially incorporates the relevant principles of participatory learning and action, primarily designed for development projects, with a new set of players within the research and policy domain. The results of three case studies that utilized participatory techniques with a set of multidisciplinary research teams are presented. The case studies were: (i) Feed the Future Sustainable Intensification Innovation Lab (SIIL) proposal development grounded in country-led and national priorities in Bangladesh, Tanzania, and Cambodia; (ii) climate smart agriculture and sustainable intensification assessment and priority setting in Rwanda; and (iii) soil fertility prioritization in sub-Saharan Africa. We discuss how the future directions of such initiatives were shaped for improved outcomes.

Age-Appropriate Feeding Practices in Cambodia and the Possible Influence on the Growth of the Children: A Longitudinal Study

Age-appropriate feeding practice (ADF) during early childhood are vital for optimal nutrition. This longitudinal study determined the effect of selected risk factors and ADF, as described by the National Nutritional Recommendations, on linear and ponderal growth of children below 24 months of age. Weight and length measures were used to calculate z-scores of anthropometric measures by WHO standards. The prevalence of stunting increased from 13.2% to 32.4% over time, while prevalence of wasting remained stable (14.5%). At first visit, 43% of children of all ages complied with ADF criteria, a proportion which decreased to 7.1% in follow-up. The quality of feeding practices for children above 12 months of age was the poorest, where at the last visit, only 6% complied with the criteria for ADF. The linear mixed-effect models found the association between ADF and ponderal growth to be significant (weight-for-height estimate: 0.05 SD). In Cambodia, Ratanakiri province, ADF was the second largest determinant for ponderal growth. We recommend province specific public health actions. For children above 6 months, the quantity of food given needs to be increased, followed by the meal frequency. Mothers' educational level, improved sanitation, and drinking water quality were among strongest predictors of a child's growth.

Sanitation and Collective Efficacy in Rural Cambodia: The Value Added of Qualitative Formative Work for the Contextualization of Measurement Tools

Community-level action may be required to achieve the levels of sanitation uptake necessary for health gains. Evidence suggests that collective action is influenced by collective efficacy (CE)—a group’s belief in its abilities to organize and execute action to achieve common goals. The extent to which it is necessary to fully contextualize existing CE measurement tools, in order to conduct meaningful assessments of the factors influencing CE perceptions, is not well understood. This study examines the value added of contextualizing an existing CE measurement tool using qualitative formative research. We employed a modified grounded theory approach to develop a contextualized CE framework based on qualitative data from rural Cambodian villages. The resulting framework included sub-constructs that were pertinent for the rural Cambodian context for which an existing, hypothesized framework did not account: perceived risks/benefits, action knowledge, shared needs/benefits, and external accountability. Complex confirmatory factor analyses indicated that contextualized models fit the data better than hypothesized models for women and men. This study demonstrates that inductive, qualitative research allows community-derived factors to enhance existing tools for context-specific CE measurement. Additional research is needed to determine which CE factors transcend contexts and could, thus, form the foundation of a general CE measurement tool.

Continuing bonds and dreams following violent loss among Cambodian survivors of the Pol Pot era

In non-Western societies, two-way communication between the bereaved and deceased is important in distinguishing adaptive versus maladaptive continuing bonds (CBs). We examined CBs expressed in dreams among Cambodian survivors during the Pol Pot era. Participants completed measures addressing dreams of the deceased, complicated grief (CG), and post-traumatic stress disorder (PTSD) symptoms. Participants who reported distressing dreams were more likely to have witnessed violent deaths of loved ones during the Pol Pot era and reported more severe CG and PTSD symptoms relative to those reporting other types of dreams. Distressing visitation dreams were shown to mediate the effect of violent loss on CG but not on PTSD.

The evolution and genetic diversity of avian influenza A(H9N2) viruses in Cambodia, 2015 - 2016

Low pathogenic A(H9N2) subtype avian influenza viruses (AIVs) were originally detected in Cambodian poultry in 2013, and now circulate endemically. We sequenced and characterised 64 A(H9N2) AIVs detected in Cambodian poultry (chickens and ducks) from January 2015 to May 2016. All A(H9) viruses collected in 2015 and 2016 belonged to a new BJ/94-like h9-4.2.5 sub-lineage that emerged in the region during or after 2013, and was distinct to previously detected Cambodian viruses. Overall, there was a reduction of genetic diversity of H9N2 since 2013, however two genotypes were detected in circulation, P and V, with extensive reassortment between the viruses. Phylogenetic analysis showed a close relationship between A(H9N2) AIVs detected in Cambodian and Vietnamese poultry, highlighting cross-border trade/movement of live, domestic poultry between the countries. Wild birds may also play a role in A(H9N2) transmission in the region. Some genes of the Cambodian isolates frequently clustered with zoonotic A(H7N9), A(H9N2) and A(H10N8) viruses, suggesting a common ecology. Molecular analysis showed 100% of viruses contained the hemagglutinin (HA) Q226L substitution, which favours mammalian receptor type binding. All viruses were susceptible to the neuraminidase inhibitor antivirals; however, 41% contained the matrix (M2) S31N substitution associated with resistance to adamantanes. Overall, Cambodian A(H9N2) viruses possessed factors known to increase zoonotic potential, and therefore their evolution should be continually monitored.

Identification, Classification and Screening for γ-Amino-butyric Acid Production in Lactic Acid Bacteria from Cambodian Fermented Foods

Screening for various types of lactic acid bacteria (LAB) that form the biological agent γ-amino-butyric acid (GABA) is important to produce different kinds of GABA-containing fermented foods. So far, no GABA-producing LAB have been reported from Cambodian fermented foods. Most small-scale fermentations and even some industrial processes in this country still rely on indigenous LAB. The application of GABA-producing autochthonous starters would allow the production of Cambodian fermented foods with an additional nutritional value that meet the population's dietary habits and that are also more attractive for the international food market. Matrix-assisted laser desorption/ionizing time-of-flight mass spectrometry (MALDI-TOF MS) and partial 16S rDNA sequencing were used to identify 68 LAB isolates from Cambodian fermented foods. These isolates were classified and grouped with (GTG)5 rep-PCR, resulting in 50 strains. Subsequently, all strains were investigated for their ability to produce GABA by thin layer chromatography. GABA-positive strains were further analyzed by the GABase assay. Of the six GABA-positive LAB strains-one Lactobacillus futsaii, two Lactobacillus namurensis, and three Lactobacillus plantarum strains-two Lactobacillus plantarum strains produced high amounts of GABA (20.34 mM, 16.47 mM). These strains should be further investigated for their potential application as GABA-producing starter cultures in the food applications.

Patients' and healthcare providers' perspectives of diabetes management in Cambodia: a qualitative study

OBJECTIVE

This study aimed to explore the challenges encountered by patients and healthcare providers and opportunities for improvement in managing diabetes mellitus (DM) in a low- and middle-income country (LMIC) facing a rise in DM prevalence.

DESIGN

Qualitative cross-sectional study.

SETTING

Urban, semiurban, and rural areas in Cambodia.

PARTICIPANTS

Thirty health service providers and fifty-nine adult DM patients.

RESULTS

Most of the 59 DM patients reported having developed DM complications when they first sought treatment. The biggest challenges for the patients were geographical barriers, diet control, and shortage of medication supply. The healthcare staff expressed concerns about their limited knowledge and lack of confidence to treat diabetes, limited availability of diabetes care services, inadequate laboratory services, shortage of staff, poor patients' compliance, and insufficient medication supplies. Both healthcare staff and patients urged an expansion of diabetes services in Cambodia and prioritisation of diabetes care in a manner similar to communicable disease control programmes of the recent past.

CONCLUSIONS

Currently, the Cambodian healthcare system has very limited capacity to provide quality care for chronic diseases. As a consequence, many patients are either left untreated or have interrupted care due to several barriers including financial, geographical, and lack of knowledge and skills. A more comprehensive and multipronged approach is urgently needed to improve DM care, which would require a collaborative effort from government, external funding agencies, private sector, and communities.

Genetic and antigenic characterization of the first H7N7 low pathogenic avian influenza viruses isolated in Vietnam

During the annual surveillance of avian influenza viruses (AIVs) in Vietnam in 2018, three H7N7 AIV isolates were identified in domestic ducks in a single flock in Vinh Long province. The present study is the first documented report of H7N7 virus isolates in Vietnam and aimed to characterize these viruses, both genetically and antigenically. Deduced amino acid sequences for the hemagglutinins (HAs) indicated a low pathogenicity of these viruses in chickens. Phylogenetic analysis revealed that the H7 HA genes of these isolates were closely related to each other and belonged to the European-Asian sublineage, together with those of H7N3 viruses isolated from ducks in Cambodia during 2017. They were not genetically related to those of Chinese H7N9 or H7N1 viruses that were previously detected in Vietnam during 2012. Interestingly, the M genes of the two H7N7 virus isolates were phylogenetically classified into distinct groups, suggesting an ongoing reassortment event in domestic ducks because they were isolated from the same flock. These H7N7 viruses exhibited somewhat different antigenic characteristics compared with other representative H7 low pathogenic AIVs. Surprisingly, the antigenicity of Vietnamese H7N7 viruses is similar to Chinese H7N9 highly pathogenic AIV. The findings of this study suggest that H7N7 viruses may be undergoing reassortment and antigenic diversification in poultry flocks in Vietnam. The silent spread of Vietnamese H7N7 viruses in chickens may lead to acquire high pathogenicity in chickens although the zoonotic potential of the viruses seems to be low since these viruses retain typical avian-specific motifs in the receptor-binding site in the HA and there is no mutation related to mammalian adaptation in PB2 gene. Thus, these results highlight the need for continuous and intensive surveillance of avian influenza in Vietnam, targeting not only highly pathogenic AIVs but also low pathogenic viruses.

A Double-Blinded Cluster-Randomized Controlled Trial

BACKGROUND

Within Cambodia, micronutrient deficiencies continue to be prevalent in vulnerable groups, such as women and children. Fortification of staple foods such as rice could be a promising strategy for Cambodia to improve micronutrient status.

OBJECTIVE

Our objective was to investigate the impact of multiple-micronutrient fortified rice (MMFR), distributed through a World Food Program school-meals program (WFP-SMP) on serum zinc concentrations and folate status in a double-blind, cluster-randomized, placebo-controlled trial.

METHODS

Sixteen schools were randomly assigned to receive one of three different types of extruded-fortified rice (UltraRice Original (URO), UltraRice New (URN), or NutriRice) or unfortified rice (placebo) six days a week for six months. A total of 1950 schoolchildren (6-16 years old) participated in the study. Serum zinc (all groups) and folate (only in NutriRice and placebo group) concentrations were assessed from morning non-fasting antecubital blood samples and were measured at three time points (baseline and after three and six months).

RESULTS

After six months of intervention, serum zinc concentrations were significantly increased in all fortified rice group compared to placebo and baseline (0.98, 0.85 and 1.40 µmol/L for URO, URN and NutriRice, respectively) (interaction effect: p < 0.001 for all). Children in the intervention groups had a risk of zinc deficiencies of around one third (0.35, 039, and 0.28 for URO, URN, and NutriRice, respectively) compared to the placebo (p < 0.001 for all). The children receiving NutriRice had higher serum folate concentrations at endline compared to children receiving normal rice (+ 2.25 ng/mL, p = 0.007).

CONCLUSIONS

This study showed that the high prevalence of zinc and folate deficiency in Cambodia can be improved through the provision of MMFR. As rice is the staple diet for Cambodia, MMFR should be considered to be included in the school meal program and possibilities should be explored to introduce MMFR to the general population.

Implementation of guppy fish (Poecilia reticulata), and a novel larvicide (Pyriproxyfen) product (Sumilarv 2MR) for dengue control in Cambodia: A qualitative study of acceptability, sustainability and community engagement

BACKGROUND

In Cambodia dengue vector control activities are focused on larviciding with temephos and pyrethroid based adulticide sprays to which Aedes have been shown to be increasingly resistant. A cluster randomized trial assessed the impact of using biological control tools (guppy fish, pyriproxyfen (PPF), and Communication for Behavioral Impact (COMBI) activities in combination), which would be used in a value comparison to traditional chemical control tools. Given these new intervention methods, a qualitative assessment was designed in order to represent the quality of understanding, acceptance, and implementation by participants.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 103 participants in 12 Focus Group Discussions (FGDs) and nine In-Depth Interviews (IDIs) were included in the study. The majority of participants in intervention villages (50 out of 80) preferred guppy fish over other vector control methods due to ease of use and rearing, quick reproduction and propensity to eat larvae. A substantial number of participants (11 out of 40) in intervention villages with PPF favored it due to long-lasting effectiveness, lack of smell and easy maintenance. Participants showed high demand for both interventions and were willing to pay between 100-500 riel (0.03-0.13 USD). Nearly all participants perceived that the interventions resulted in a reduction in Aedes mosquitos (both adults and immatures) and dengue cases. The presence of larvae in the water despite the use of PPF was a source of concern for some participants, although this was overcome in some cases with proper health education through health volunteers. Interpersonal communication through health volunteers was the most favorite method of transmitting prevention messages.

CONCLUSIONS/SIGNIFICANCE

The community led COMBI strategy resulted in high acceptance and perceived effectiveness of the interventions in target villages. Health volunteers are an effective and accepted channel of communication to engage communities, disseminate information and promote behavioral change at the household and community level. If shown effective through corresponding entomological surveys, the interventions should be continued and further strengthened to ensure they are accessible, available and affordable.

Use of sterols and linear alkylbenzenes as molecular markers of sewage pollution in Southeast Asia

Southeast Asia has undergone rapid developments in terms of urbanization, economic and population growth. The progress in sewerage treatment infrastructure has not kept pace with such developments. The inadequacy and inefficiency of sewerage systems has prompted the release of untreated sewage into the aquatic environment of Southeast Asia causing many waterborne illnesses since surface water is utilized for recreational, agricultural and aquaculture purposes and, above all, as a source of water intake in Southeast Asia. This paper will review the current data on molecular markers of sewage pollution including sterols and linear alkylbenzenes (LABs) in Southeast Asian aquatic environment to clarify the state of sewage pollution and the competence of sewage treatment plants (STPs) in this area. Despite the importance of sewage pollution research in the region, the number of studies using molecular markers to trace the sources of sewage pollution is limited. So far, indicators of sewage pollution have been investigated in aquatic environments of Indonesia, Vietnam, Malaysia, the Philippines, Thailand, Cambodia and Brunei among Southeast Asian countries. The concentrations and diagnostic ratios of faecal sterols and LABs show the release of untreated and primary treated urban waste into water bodies of these countries. Further studies are required to fill the data gaps in Southeast Asia and come to a better understanding of the trends of sewage pollution in this part of the world. Graphical abstract.

Potential Use of Community-Based Rapid Diagnostic Tests for Febrile Illnesses: Formative Research in Peru and Cambodia

In 2012, the U.S. Defense Threat Reduction Agency Joint Science and Technology Office initiated a program to develop novel point-of-need diagnostic devices for surveillance of emerging infectious diseases including dengue, malaria, plague, and melioidosis. Prior to distribution of devices to observe their correct use among community members in Iquitos, Peru, and Phnom Penh, Cambodia, research was conducted to: 1) assess acceptability of use, including the motivation to use a rapid diagnostic test (RDT) before or instead of seeking care at a health facility, 2) explore comprehension of RDT use instructions, and 3) examine possible strategies for large scale RDT distribution and use at each site. In February 2014, 9 focus group discussions (FGD) with community members and 5 FGD with health professionals were conducted in Iquitos, and 9 FGD with community members and 9 in-depth interviews with health professionals in Phnom Penh. In both places, participants agreed to use the device themselves (involving finger prick) or could identify someone who could do so in their home or neighborhood. The main incentive to RDT use in both sites was the ability for device results to be used for care facilitation (post confirmatory tests), specifically reduced wait times to be seen or obtain a diagnosis. Comprehension of RDT use instructions was assessed in Iquitos by asking some participants to apply the device to research team members; after watching a short video, most steps were done correctly. In Phnom Penh, participants were asked to describe each step after reading the instructions; they struggled with comprehension. Health professionals’ main concerns in both sites were their community’s ability to accurately use the test, handle complicated instructions, and safety (i.e., disposal of lancets). Health system structure and ability to use home diagnostic devices varied in the two disease endemic sites, with substantial challenges in each, suggesting the need for different strategies for RDT large scale community use, and illustrating the value of formative research before deployment of novel technologies.

Development and use of devices to diagnose infectious diseases outside of health facilities (i.e., at home or in remote areas) continues to increase, providing new options for the follow up and treatment options of individuals, depending on the diseases. In this qualitative study, researchers in Iquitos, Peru, and Phnom Penh, Cambodia explored what local people thought about the possible availability of such a device to diagnose dengue and malaria in their own houses, and what would motivate them to use such a device instead of going directly to a health facility for the diagnosis. Participants reported being willing to use device on themselves and were motivated by the possibility that, by using this diagnostic device and taking the result to their health facility, they might be able to obtain quicker and more optimized attention at the health facility; for example, by obtaining a positive result to dengue or malaria on the rapid diagnostic device, they are aware they might still need confirmatory tests, but they would be able to reduce the wait time for obtaining a definitive diagnosis and starting treatment by a full day. Questions regarding accuracy of tests, complicated instructions and safety of using these devices in the community were brought up by participants—individuals living in the communities and local health professionals. Also, in this study, it was clear that if these devices were to be made available in Peru and Cambodia, different strategies for disseminating and using these in the communities would be needed to accommodate for different health infrastructure in both sites.

Factors Influencing Unintended Pregnancies amongst Adolescent Girls and Young Women in Cambodia

Background: Unintended pregnancies in Cambodian youth are a major reproductive health concern with detrimental personal and socioeconomic consequences. A social ecological model was used to identify sociodemographic factors potentially associated with unintended pregnancies, and an analysis of data from the 2014 Cambodian Demographic and Health Survey was used to determine associations. Methods: Weighted data were analysed using multiple logistic regression analyses for 3406 Cambodian sexually active single, in union or married females aged 15–29 years. Results: The prevalence of unintended pregnancy was 12.3%. Unintended pregnancy was significantly associated with younger age groups (15–24 years), multiparity, history of abortion, and current use of modern contraceptive methods. All women had an increased likelihood of unintended pregnancy when the husband alone or someone else in the household made decisions about their access to healthcare. Conclusion: The burden of unintended pregnancies is associated with young age, multiparity, history of abortions, unemployment, and low autonomy for accessing healthcare. Multi-pronged, holistic reproductive and sexual health program interventions are needed to increase literacy and accessibility to modern contraception and to raise awareness about women’s health and status in Cambodia.

Childhood conditions, pathways to entertainment work and current practices of female entertainment workers in Cambodia: Baseline findings from the Mobile Link trial

Background

Entertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.

Methods

Data used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.

Results

Most participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used a condom at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).

Conclusions

This information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety and respectful employment.

Access to prevention of mother-to-child transmission of HIV along HIV services cascade through integrated active case management in 15 operational districts in Cambodia

INTRODUCTION

Following the introduction of option B+ in 2013, and with the perspective of eliminating mother-to-child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow-up of all HIV-infected cases including pregnant women, and to ensure access to and use of the full prevention of mother-to-child transmission (PMTCT) service package by HIV-infected pregnant women and their HIV-exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia.

METHODS

We analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross-sectional) PMTCT indicators during the 2011 to 2013 period.

RESULTS

During the period 2014 to 2016, among 938 identified HIV-infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6-week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV-DNA PCR test respectively. Among the 396 HEI who received HIV-DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross-sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV-infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV-DNA PCR testing coverage among HEI (from 41.2% to 74.3%).

CONCLUSIONS

The implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.

Determinants of dihydroartemisinin-piperaquine treatment failure in Plasmodium falciparum malaria in Cambodia, Thailand, and Vietnam: a prospective clinical, pharmacological, and genetic study

BACKGROUND

The emergence and spread of resistance in Plasmodium falciparum malaria to artemisinin combination therapies in the Greater Mekong subregion poses a major threat to malaria control and elimination. The current study is part of a multi-country, open-label, randomised clinical trial (TRACII, 2015-18) evaluating the efficacy, safety, and tolerability of triple artemisinin combination therapies. A very high rate of treatment failure after treatment with dihydroartemisinin-piperaquine was observed in Thailand, Cambodia, and Vietnam. The immediate public health importance of our findings prompted us to report the efficacy data on dihydroartemisinin-piperaquine and its determinants ahead of the results of the overall trial, which will be published later this year.

METHODS

Patients aged between 2 and 65 years presenting with uncomplicated P falciparum or mixed species malaria at seven sites in Thailand, Cambodia, and Vietnam were randomly assigned to receive dihydroartemisinin-piperaquine with or without mefloquine, as part of the TRACII trial. The primary outcome was the PCR-corrected efficacy at day 42. Next-generation sequencing was used to assess the prevalence of molecular markers associated with artemisinin resistance (kelch13 mutations, in particular Cys580Tyr) and piperaquine resistance (plasmepsin-2 and plasmepsin-3 amplifications and crt mutations). This study is registered with ClinicalTrials.gov, number NCT02453308.

FINDINGS

Between Sept 28, 2015, and Jan 18, 2018, 539 patients with acute P falciparum malaria were screened for eligibility, 292 were enrolled, and 140 received dihydroartemisinin-piperaquine. The overall Kaplan-Meier estimate of PCR-corrected efficacy of dihydroartemisinin-piperaquine at day 42 was 50·0% (95% CI 41·1-58·3). PCR-corrected efficacies for individual sites were 12·7% (2·2-33·0) in northeastern Thailand, 38·2% (15·9-60·5) in western Cambodia, 73·4% (57·0-84·3) in Ratanakiri (northeastern Cambodia), and 47·1% (33·5-59·6) in Binh Phuoc (southwestern Vietnam). Treatment failure was associated independently with plasmepsin2/3 amplification status and four mutations in the crt gene (Thr93Ser, His97Tyr, Phe145Ile, and Ile218Phe). Compared with the results of our previous TRACI trial in 2011-13, the prevalence of molecular markers of artemisinin resistance (kelch13 Cys580Tyr mutations) and piperaquine resistance (plasmepsin2/3 amplifications and crt mutations) has increased substantially in the Greater Mekong subregion in the past decade.

INTERPRETATION

Dihydroartemisinin-piperaquine is not treating malaria effectively across the eastern Greater Mekong subregion. A highly drug-resistant P falciparum co-lineage is evolving, acquiring new resistance mechanisms, and spreading. Accelerated elimination of P falciparum malaria in this region is needed urgently, to prevent further spread and avoid a potential global health emergency.

FUNDING

UK Department for International Development, Wellcome Trust, Bill & Melinda Gates Foundation, Medical Research Council, and National Institutes of Health.

Dermatological Progression of a Probable Box Jellyfish Sting

This case report describes the typical features of the dermatological progression of a patient stung by a (probable) box jellyfish. The purpose is to guide clinicians and patients to an understanding of what to expect after such a sting using the clinical narrative and unique sequential photographs of the injury. With knowledgeable consultation from experienced physicians and meticulous care, this envenomation healed without the need for skin grafting.

Why are fewer women rising to the top? A life history gender analysis of Cambodia's health workforce

BACKGROUND

An adequate and qualified health workforce is critical for achieving Universal Health Coverage (UHC) and responding to the Sustainable Development Goals (SDGs). Frontline health workers who are mainly women, play important roles in responses to crisis. Despite women making up the vast majority of the health workforce, men occupy the majority of leadership positions. This study aims to understand the career progression of female health workers by exploring how gender norms influence women's upward career trajectories.

METHODS

A qualitative methodology deployed a life history approach was used to explore the perspectives and experiences of health workers in Battambang province, Cambodia. Twenty male and female health managers were purposively selected based five criteria: age 40 and above, starting their career during 1980s or 1990s, clinical skills, management roles and evidence of career progression. Themes and sub-themes were developed based on available data and informed by Tlaiss's (2013) social theory framework in order to understand how gender norms, roles and relations shape the career of women in the health industry.

RESULTS

The findings from life histories show that gender norms shape men's and women's career progression at different levels of society. At the macro level, social, cultural, political, and gender norms are favorably changing by allowing more women to enter medical education; however, leadership is bias towards men. At the meso organziational level, empowerment of women in the health sector has increased with the support of gender working groups and women's associations. At the micro individual level, female facility managers identified capacity and qualifications as important factors in helping women to obtain leadership positions.

CONCLUSION

While Cambodia has made progress, it still has far to go to achieve equality in leadership. Promoting gender equity in leadership within the health workforce requires a long vision and commitment along with collaboration among different stakeholders and across social structures. If more women are not able to obtain leadership roles, the goals of having an equitable health system, promoting UHC, and responding to the SDGs milestones by leaving no one behind will remain unattainable objectives.

Factors Influencing the Accessibility of Maternal Health Service in Cambodia

Despite worldwide efforts, maternal and child mortality remains a major health problem in many developing countries. Cambodia’s maternal mortality rate has decreased over recent years through government efforts and support from various international development cooperation agencies. The purpose of this study was to investigate the factors that affected the accessibility of Cambodia’s maternal healthcare services. Data from maternal health service surveys conducted in Battambang, Cambodia in 2012 and 2015 were compared and analyzed. Multiple regression analysis was conducted to identify factors related to the accessibility of integrated maternal healthcare service. The travel time to health centers was found to be related to distance from the health center (ß = 0.031, p < 0.001), travel time during the rainy season (ß = 0.166, p < 0.001), and travel cost (ß = 0.001, p < 0.001), with an explanatory power of 27% (R² = 0.274). Based on these findings, future research and policy should focus on improving accessibility to effective maternal and child healthcare services, to reduce maternal and child mortality. This study is intended to contribute to developing a multi-directional and integrated strategy for access to maternal health services in developing countries.

Selection of WHO-recommended essential medicines for non-communicable diseases on National Essential Medicines Lists

BACKGROUND

Non-communicable diseases (NCDs) are the leading cause of death worldwide. Inadequate and inequitable access to essential NCD medicines is a major concern, particularly in low- and middle-income countries. National Essential Medicines Lists (EMLs) are important policy tools that indicate which medicines are prioritized as essential within a country's health system. This study sought to analyze a wide range of national essential medicines lists (EMLs) for their inclusion of priority non communicable disease (NCD) interventions recommended by the World Health Organization (WHO).

METHODS

Three lists of WHO endorsed priority NCD interventions were included. A database with 137 national EMLs and the WHO EML was created from the WHO Repository and these EMLs were compared for listing of priority NCD interventions.

RESULTS

Across 137 countries with national EMLs, the median percentage of 20 Best Buys interventions listed was 90% (IQR 80-95) and 31 Package of essential noncommunicable disease interventions (PEN) interventions listed was 94% (IQR 90-97), of 9 HEARTS interventions was 100% (IQR 89-100), and of the 43 unique interventions across the three priority lists was 88% (IQR 84-93). Less than 80% of the 43 interventions were listed by 22 (16%) countries and less than half of the interventions were listed by 2 countries: Angola (35%) and Cambodia (23%). Interventions listed on the fewest number of national EMLs were: influenza vaccine, HPV vaccine, hepatitis B vaccine, cervical cancer chemotherapy, codeine, promethazine, senna, and oxygen.

CONCLUSION

Most NCD interventions have been prioritized in national policy in most cases. The majority of priority medicines for NCDs described within key WHO NCD technical packages are listed on nearly all national EMLs across 137 countries of all income levels. Most NCD interventions have been prioritized in national policy in most cases, but in some countries and for select interventions such as the HPV vaccine, prioritization may be reviewed.

The cost-effectiveness of the use of selective media for the diagnosis of melioidosis in different settings

Background

Melioidosis is a frequently fatal disease requiring specific treatment. The yield of Burkholderia pseudomallei from sites with a normal flora is increased by culture using selective, differential media such as Ashdown’s agar and selective broth. However, since melioidosis mainly affects people in resource-poor countries, the cost effectiveness of selective culture has been questioned. We therefore retrospectively evaluated this in two laboratories in southeast Asia.

Methodology/Principal findings

The results of all cultures in the microbiology laboratories of Mahosot Hospital, Vientiane, Laos and Angkor Hospital for Children, Siem Reap, Cambodia, in 2017 were reviewed. We identified patients with melioidosis who were only diagnosed as a result of culture of non-sterile sites and established the total number of such samples cultured using selective media and the associated costs in each laboratory. We then conducted a rudimentary cost-effectiveness analysis by determining the incremental cost-effectiveness ratio (ICER) per DALY averted and compared this against the 2017 GDP per capita in each country.

Overall, 29 patients in Vientiane and 9 in Siem Reap (20% and 16.9% of all culture-positive patients respectively) would not have been diagnosed without the use of selective media, the majority of whom (18 and 8 respectively) were diagnosed by throat swab culture. The cost per additional patient detected by selective culture was approximately $100 in Vientiane and $39 in Siem Reap. Despite the different patient populations (all ages in Vientiane vs. only children in Siem Reap) and testing strategies (all samples in Vientiane vs. based on clinical suspicion in Siem Reap), selective B. pseudomallei culture proved highly cost effective in both settings, with an ICER of ~$170 and ~$28 in Vientiane and Siem Reap, respectively.

Conclusions/Significance

Selective culture for B. pseudomallei should be considered by all laboratories in melioidosis-endemic areas. However, the appropriate strategy for implementation should be decided locally.

Melioidosis is a frequently fatal disease caused by a soil bacterium called Burkholderia pseudomallei, that is widespread in the rural tropics. Because staff are often not familiar with it and because it may be hidden if it is outgrown by other bacteria, special culture media can help laboratories diagnose the disease. However, this costs more money so it is not always done even in areas where the disease is known to be present. We have looked at the results of a year’s bacterial cultures in two different laboratories in southeast Asia to identify how many patients were only identified using these special culture techniques, how much it cost, and whether the investment was considered worthwhile in terms of the gain in healthy life years in these patients who might otherwise have died had the disease not been diagnosed. Even though the laboratories adopted very different strategies for using the special media and served very different populations, in both places the use of the special techniques was very cost effective in terms not just of lives saved, but on purely financial grounds when compared with the GDP of each country.

Thiamine dose response in human milk with supplementation among lactating women in Cambodia: study protocol for a double-blind, four-parallel arm randomised controlled trial

INTRODUCTION

Thiamine (vitamin B1) deficiency remains a concern in Cambodia where women with low thiamine intake produce thiamine-poor milk, putting their breastfed infants at risk of impaired cognitive development and potentially fatal infantile beriberi. Thiamine fortification of salt is a potentially low-cost, passive means of combating thiamine deficiency; however, both the dose of thiamine required to optimise milk thiamine concentrations as well as usual salt intake of lactating women are unknown.

METHODS AND ANALYSIS

In this community-based randomised controlled trial, 320 lactating women from Kampong Thom, Cambodia will be randomised to one of four groups to consume one capsule daily containing 0, 1.2, 2.4 or 10 mg thiamine as thiamine hydrochloride, between 2 and 24 weeks postnatal. The primary objective is to estimate the dose where additional maternal intake of thiamine no longer meaningfully increases infant thiamine diphosphate concentrations 24 weeks postnatally. At 2, 12 and 24 weeks, we will collect sociodemographic, nutrition and health information, a battery of cognitive assessments, maternal (2 and 24 weeks) and infant (24 weeks only) venous blood samples (biomarkers: ThDP and transketolase activity) and human milk samples (also at 4 weeks; biomarker: milk thiamine concentrations). All participants and their families will consume study-provided salt ad libitum throughout the trial, and we will measure salt disappearance each fortnight. Repeat weighed salt intakes and urinary sodium concentrations will be measured among a subset of 100 participants. Parameters of Emax dose-response curves will be estimated using non-linear least squares models with both 'intention to treat' and a secondary 'per-protocol' (capsule compliance ≥80%) analyses.

ETHICS AND DISSEMINATION

Ethical approval was obtained in Cambodia (National Ethics Committee for Health Research 112/250NECHR), Canada (Mount Saint Vincent University Research Ethics Board 2017-141) and the USA (University of Oregon Institutional Review Board 07052018.008). Results will be shared with participants' communities, as well as relevant government and scientific stakeholders via presentations, academic manuscripts and consultations.

TRIAL REGISTRATION NUMBER

NCT03616288.

Sex and age effects in past-year experiences of violence amongst adolescents in five countries

Purpose

To date, there has been insufficient focus on age and sex differences in studies of violence amongst adolescents and young adults in low- and middle-income countries. As adolescence is a formative period during which experiencing violence can have both short- and long-term consequences, we aim to investigate experiences of violence by age and sex across five countries.

Methods

Incidences of past-year violence victimization were estimated by sex across two-year age bands (13–24 years) using Violence Against Children Survey datasets from Cambodia, Haiti, Kenya, Malawi, and Tanzania. Analyses were conducted separately for each country. The presence of an association with age and each type of violence was identified using logistic regressions separately by sex. Sex was then added to the models as an interaction term and adjusted Wald tests were used to assess differences between males and females in age effects.

Results

Risk of physical violence by both an adult caregiver and a community member decreased with age for both sexes in all countries. In contrast, risk of IPV increased with age for both sexes in all countries. Although some countries displayed a steeper increase in risk of IPV and sexual violence with age for males, females face higher overall levels of risk for these forms of violence.

Conclusion

Findings highlight how adolescents’ and young adults’ risk of violence changes with age and type of violence. The analysis underscores the importance of collecting violence data disaggregated by age and sex to best inform policies and programming.

Implications and contributions

We analyzed five Violence Against Children Surveys (VACS) and found age effects for physical, sexual, and intimate partner violence for adolescents 13–24 years old. Age effects for sexual violence are stronger among females than males. Future policies targeting adolescents should consider how age and gender influence risk of violence.

Regulation of nursing professionals in Cambodia and Vietnam: a review of the evolution and key influences

BACKGROUND

In 2006, the countries of the Association of Southeast Asian Nations (ASEAN) signed the Mutual Recognition Arrangements (MRA) in relation to nursing services in the region. This agreement was part of a set of policies to promote the free flow of skilled labor among ASEAN members and required mutually acceptable professional regulatory frameworks. This paper presents a narrative review of the literature to (1) describe progress in the development of the regulatory framework for nursing professionals in Cambodia and Vietnam since 2000 and (2) identify key factors, including the MRA, that affect these processes.

METHODS

For document review, policy documents, laws, regulations, and published peer-reviewed and gray literature were reviewed. Data were triangulated and analyzed using a tool developed by adapting McCarthy et al.'s regulatory function framework and covering eight functions (legislation, accreditation of preservice education, competency assessment, registration and licensing system, tools and data flow of registration, scope of practice, continuing professional development, professional misconduct and disciplinary powers).

RESULTS

Cambodia and Vietnam have made remarkable progress in developing their regulatory frameworks for nursing. A number of key influences contributed to the development of nursing regulations, including the signing of the MRA in 2006 and the establishment of the Joint Coordinating Committee on Nursing (AJCCN) in 2007 as key milestones. Macroeconomic and political factors affecting the process were economic growth and an emerging private sector, social demand for quality care and professionalism, global attention to health workforce competencies, the role of development partners, and regular monitoring and mutual learning through AJCCN. A period of incubation enabled countries to develop consensus among stakeholders regarding regulatory arrangements; this trend accelerated after 2010 by bringing national regulatory schemes into conformity with the regional framework. Some similarities in the process (e.g., preservice education first, legislation later) and differences in key actors (e.g., professional councils and the capacity of nursing leaders) were observed in two countries.

CONCLUSION

Further development of the regulatory framework will require strong nursing leadership to sustain achievements and drive continued progress. The adapted tool to assess regulatory capacity works well and may be of value in assessing the development of regulations in the nursing profession.

Comparative Analysis of African and Asian Lineage-Derived Zika Virus Strains Reveals Differences in Activation of and Sensitivity to Antiviral Innate Immunity

In recent years, Asian lineage Zika virus (ZIKV) strains emerged to cause pandemic outbreaks associated with a high rate of congenital ZIKV syndrome (CZVS). The reasons for the enhanced spread and severe disease caused by newly emerging strains are not fully understood. Here we compared viral sequences, viral replication, and innate immune signaling induction of three different ZIKV strains derived from African and Asian lineages and West Nile virus, another flavivirus. We found pronounced differences in activation of innate immune signaling and inhibition of viral replication across ZIKV strains. The newly emerged Asian ZIKV strain Brazil Fortaleza 2015, which is associated with a higher rate of neurodevelopmental disorders like microcephaly, induced much weaker and delayed innate immune signaling in infected cells. However, superinfection studies to assess control of innate immune signaling induced by Sendai virus argue against an active block of IRF3 activation by the Brazilian strain of ZIKV and rather suggest an evasion of detection by host cell pattern recognition receptors. Compared to the Asian strain FSS13025 isolated in Cambodia, both ZIKV Uganda MR766 and ZIKV Brazil Fortaleza appear less sensitive to the interferon-induced antiviral response. ZIKV infection studies of cells lacking the different RIG-I-like receptors identified RIG-I as the major cytosolic pattern recognition receptor for detection of ZIKV.IMPORTANCE Zika Virus (ZIKV), discovered in 1947, is divided into African and Asian lineages. Pandemic outbreaks caused by currently emerging Asian lineage strains are accompanied by high rates of neurological disorders and exemplify the global health burden associated with this virus. Here we compared virological and innate immunological aspects of two ZIKV strains from the Asian lineage, an emerging Brazilian strain and a less-pathogenic Cambodian strain, and the prototypic African lineage ZIKV strain from Uganda. Compared to the replication of other ZIKV strains, the replication of ZIKV Brazil was less sensitive to the antiviral actions of interferon (IFN), while infection with this strain induced weaker and delayed innate immune responses in vitro Our data suggest that ZIKV Brazil directs a passive strategy of innate immune evasion that is reminiscent of a stealth virus. Such strain-specific properties likely contribute to differential pathogenesis and should be taken into consideration when choosing virus strains for future molecular studies.

Development and validation of a multiplexed-tandem qPCR tool for diagnostics of human soil-transmitted helminth infections

Soil-transmitted helminths (STH) are a major cause of morbidity in tropical developing countries with a global infection prevalence of more than one billion people and disease burden of around 3.4 million disability adjusted life years. Infection prevalence directly correlates to inadequate sanitation, impoverished conditions and limited access to public health systems. Underestimation of infection prevalence using traditional microscopy-based diagnostic techniques is common, specifically in populations with access to benzimidazole mass treatment programs and a predominance of low intensity infections. In this study, we developed a multiplexed-tandem qPCR (MT-PCR) tool to identify and quantify STH eggs in stool samples. We have assessed this assay by measuring infection prevalence and intensity in field samples of two cohorts of participants from Timor-Leste and Cambodia, which were collected as part of earlier epidemiological studies. MT-PCR diagnostic parameters were compared to a previously published multiplexed qPCR for STH detection. The MT-PCR assay agreed strongly with qPCR data and showed a diagnostic specificity of 99.60–100.00% (sensitivity of 83.33–100.00%) compared to qPCR and kappa agreement exceeding 0.85 in all tests. In addition, the MT-PCR has the added advantage of distinguishing Ancylostoma spp. species, namely Ancylostoma duodenale and Ancylostoma ceylanicum. This semi-automated platform uses a standardized, manufactured reagent kit, shows excellent run-to-run consistency/repeatability and supports high-throughput detection and quantitation at a moderate cost.

Soil-transmitted helminthiases are among the most prevalent and damaging neglected tropical diseases and have a significant global health impact. Accurate identification and quantitation of STH infection is a cornerstone of effective control. Direct observation and counting of eggs in faeces is the current gold-standard method for diagnosis of infection. This approach is time consuming and has poor sensitivity. As ongoing oral benzimidazole therapy across many endemic regions leads to a reduction in STH prevalence and intensity, these sensitivity limitations become an increasingly relevant issue, particularly with respect to monitoring treatment efficacy, identifying reductions in parasite transmission, and accurately quantifying infection burden in discrete populations in middle-income countries. PCR-based detection has long been proposed as an alternative approach to STH diagnosis and many protocols, including quantitative PCR-based methods, have been developed. However, these methods are largely bespoke and use non-standardized reagents that can greatly impact on the transferability and relative consistency of their performance. In the current study, we evaluate an automated, commercially-produced molecular diagnostic tool for validation of the major soil-transmitted helminths, including Ascaris lumbricoides, Trichuris trichiura, Necator americanus, Ancylostoma duodenale and Ancylostoma ceylanicum, and evaluate its performance in comparison to an established multiplexed qPCR using faecal samples from endemic settings.

Early Childhood Nutritional Implications of the Rise in Factory Employed Mothers in Rural Cambodia: A Qualitative Study

OBJECTIVES

Limited research has been conducted on the maternal and child health situation of garment factory workers in Cambodia. This qualitative study investigated the health-seeking behaviours for maternal and infant care of female garment factory workers in Kampong Tralach district, Cambodia.

METHODS

We conducted 54 in-depth interviews, six focus group discussions and observed two factories. Participants were pregnant women and mothers of infants who have worked in factories, young women currently working in factories, caregivers of children, village leaders, healthcare workers, and factory managers. Deductive and inductive thematic analysis was performed.

RESULTS

The women were accessing regular antenatal and facility-based delivery care. Most factory managers provided maternity leave, and some also provided leave for regular antenatal (ANC) visits. Women often returned to work 2 months post-delivery and this triggered the cessation of exclusive breastfeeding. Feeding was also compromised for the 6-12 months old children as carers, delayed the introduction of complementary feeds. Factories were equipped with childcare and breastfeeding spaces, however these were not used due to both feasibility issues and distrust of factory management. Instead, grandmothers were the preferred childcare providers.

CONCLUSIONS FOR PRACTICE

Current factory policies regarding ANC, maternity leave and childcare provisions are context insensitive to rural workers who live far from the workplace to avail themselves of mandated ANC leave or breastfeeding breaks. Our study suggest that the increasing number of young women working in garment factories is compromising the early nutrition of their children, with a reduction in exclusive breastfeeding and inadequate complementary feeding.

Slow growth of Burkholderia pseudomallei compared to other pathogens in an adapted blood culture system in Phnom Penh, Cambodia

PURPOSE

Burkholderia pseudomallei is a key pathogen causing bloodstream infections at Sihanouk Hospital Center of Hope, Phnom Penh, Cambodia. Here, visual instead of automated detection of growth of commercial blood culture bottles is done. The present study assessed the performance of this system.

METHODOLOGY

Blood culture sets, consisting of paired adult aerobic and anaerobic bottles (bioMérieux, FA FAN 259791 and FN FAN 252793) were incubated in a standard incubator for 7 days after reception. Each day, the bottle growth indicator was visually inspected for colour change indicating growth. Blind subculture was performed from the aerobic bottle at day 3.

RESULTS

From 2010 to 2015, 11  671 sets representing 10  389 suspected bloodstream infection episodes were documented. In 1058 (10.2  %) episodes, pathogens grew; they comprised Escherichia coli (31.7 %), Salmonella Paratyphi A (13.9 %), B. pseudomallei (8.5 %), Staphylococcus aureus (7.8 %) and Klebsiella pneumoniae (7.0 %). Blind subculture yielded 72 (4.1  %) pathogens, mostly (55/72, 76.4 %) B. pseudomallei. Cumulative proportions of growth at day 2 were as follows: E. coli: 85.0 %, Salmonella Paratyphi A: 85.0 %, K. pneumoniae: 76.3  % and S. aureus: 52.2  %; for B. pseudomallei, this was only 4.0  %, which increased to 70.1  % (70/99) at day 4 mainly by detection on blind subculture (55/99). Compared to the anaerobic bottles, aerobic bottles had a higher yield and a shorter time-to-detection, particularly for B. pseudomallei.

CONCLUSIONS

Visual inspection for growth of commercial blood culture bottles in a low-resource setting provided satisfactory yield and time-to-detection. However, B. pseudomallei grew slowly and was mainly detected by blind subculture. The aerobic bottle outperformed the anaerobic bottle.

Simultaneous-count models to estimate abundance from counts of unmarked individuals with imperfect detection

We developed a method to estimate population abundance from simultaneous counts of unmarked individuals over multiple sites. We considered that at each sampling occasion, individuals in a population could be detected at 1 of the survey sites or remain undetected and used either multinomial or binomial simultaneous-count models to estimate abundance, the latter being equivalent to an N-mixture model with one site. We tested model performance with simulations over a range of detection probabilities, population sizes, growth rates, number of years, sampling occasions, and sites. We then applied our method to 3 critically endangered vulture species in Cambodia to demonstrate the real-world applicability of the model and to provide the first abundance estimates for these species in Cambodia. Our new approach works best when existing methods are expected to perform poorly (i.e., few sites and large variation in abundance among sites) and if individuals may move among sites between sampling occasions. The approach performed better when there were >8 sampling occasions and net probability of detection was high (>0.5). We believe our approach will be useful in particular for simultaneous surveys at aggregation sites, such as roosts. The method complements existing approaches for estimating abundance of unmarked individuals and is the first method designed specifically for simultaneous counts.

Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal

Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.

Consumption and exchange in Early Modern Cambodia: NAA of brown-glaze stoneware from Longvek, 15th-17th centuries

An evaluation of the geochemical characteristics of 102 storage jar sherds by k₀-neutron activation analysis (k₀-NAA) from archaeological contexts in Cambodia and reference samples from stoneware production centres in Thailand provides a new perspective on regional and global trade in mainland Southeast Asia. Identification of seven geochemical groups enables distinctions between production centres, and articulation of their role in trade between northern and central Thailand, South China and Cambodia. Storage jars from Thailand and South China are known in archaeological contexts worldwide because of their durability and intrinsic functional and cultural values. Evidenced by a novel application of k₀-NAA, analogous stoneware sherds at Longvek connect the Cambodian capital to a global trading network. Additional proof of ceramics from an undocumented Cambodian kiln demonstrates the gradual and complex transition between the Angkorian past and the Early Modern period.

Perceptions of Sexual Infidelity in Rural Cambodia: A Qualitative Study of Adolescent Men

Sexual infidelity plays a significant role in the high rate of spousal transmission of HIV in Cambodia. The sexual beliefs and attitudes of a person begin in childhood and are developed through multiple chains in early adolescence, affecting his or her future sexual behavior and future incidence of HIV. A deeper understanding of the perspectives of adolescents regarding infidelity is critical to effective HIV prevention efforts during adulthood. Using a descriptive qualitative approach, this study explored the perceptions of male adolescents regarding male infidelity. Through the thematic analysis method, themes and subcategories were developed from the responses of 48 male high school students from three provinces. Majority of the participants ( n = 33) were found to have liberal attitudes not only toward male infidelity but also toward the high possibility of their own future infidelity ( n = 14). Almost 45% ( n = 21) of the participants explained that men would fulfill their sexual desires outside, such as in karaoke, when their wives are unable to have sex with them. Participants believed it annoying for men to disclose their extramarital activities to their wives. The study concluded that the participants hold accepting perceptions about infidelity; they are part of the HIV problem and must be part of the solution. Educators and counselors need to deliver age-appropriate, scientifically correct, and culturally relevant messages about sexual health and HIV prevention to growing adolescents.

Mapping vaccination coverage to explore the effects of delivery mechanisms and inform vaccination strategies

The success of vaccination programs depends largely on the mechanisms used in vaccine delivery. National immunization programs offer childhood vaccines through fixed and outreach services within the health system and often, additional supplementary immunization activities (SIAs) are undertaken to fill gaps and boost coverage. Here, we map predicted coverage at 1 × 1 km spatial resolution in five low- and middle-income countries to identify areas that are under-vaccinated via each delivery method using Demographic and Health Surveys data. We compare estimates of the coverage of the third dose of diphtheria-tetanus-pertussis-containing vaccine (DTP3), which is typically delivered through routine immunization (RI), with those of measles-containing vaccine (MCV) for which SIAs are also undertaken. We find that SIAs have boosted MCV coverage in some places, but not in others, particularly where RI had been deficient, as depicted by DTP coverage. The modelling approaches outlined here can help to guide geographical prioritization and strategy design.

Dual in-aquifer and near surface processes drive arsenic mobilization in Cambodian groundwaters

Millions of people globally, and particularly in South and Southeast Asia, face chronic exposure to arsenic from reducing groundwaters in which. Arsenic release to is widely attributed largely to reductive dissolution of arsenic-bearing iron minerals, driven by metal reducing bacteria using bioavailable organic matter as an electron donor. However, the nature of the organic matter implicated in arsenic mobilization, and the location within the subsurface where these processes occur, remains debated. In a high resolution study of a largely pristine, shallow aquifer in Kandal Province, Cambodia, we have used a complementary suite of geochemical tracers (including ¹⁴C, ³H, ³He, ⁴He, Ne, δ¹⁸O, δD, CFCs and SF₆) to study the evolution in arsenic-prone shallow reducing groundwaters along dominant flow paths. The observation of widespread apparent ³H-³He ages of <55years fundamentally challenges some previous models which concluded that groundwater residence times were on the order of hundreds of years. Surface-derived organic matter is transported to depths of >30m, and the relationships between age-related tracers and arsenic suggest that this surface-derived organic matter is likely to contribute to in-aquifer arsenic mobilization. A strong relationship between ³H-³He age and depth suggests the dominance of a vertical hydrological control with an overall vertical flow velocity of ~0.4±0.1m·yr^-1 across the field area. A calculated overall groundwater arsenic accumulation rate of ~0.08±0.03μM·yr^-1 is broadly comparable to previous estimates from other researchers for similar reducing aquifers in Bangladesh. Although apparent arsenic groundwater accumulation rates varied significantly with site (e.g. between sand versus clay dominated sequences), rates are generally highest near the surface, perhaps reflecting the proximity to the redox cline and/or depth-dependent characteristics of the OM pool, and confounded by localized processes such as continued in-aquifer mobilization, sorption/desorption, and methanogenesis.

Community engagement, social context and coverage of mass anti-malarial administration: Comparative findings from multi-site research in the Greater Mekong sub-Region

BACKGROUND

Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)-was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage.

METHODS AND FINDINGS

Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study's ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage.

CONCLUSIONS

The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.

Determinants of Undernutrition among Young Children Living in Soth Nikum District, Siem Reap, Cambodia

BACKGROUND

Child undernutrition is of public concern in Cambodia. An understanding of factors influencing child nutritional status is essential to design programs that will reduce undernutrition. Using the UNICEF conceptual framework of causes of malnutrition, our research investigates the relationship between nutritional status of children aged 6⁻23 months and its immediate and underlying determinants.

METHODS

Baseline data from a cluster-randomized controlled trial aiming to assess the impact of the promotion of optimal feeding practices combined or not with the provision of local foods among 360 children 6⁻23 months of age were used. Anthropometry and biochemical measurements were performed at baseline. Data on each determinant of undernutrition were collected through interviews and direct observations.

RESULTS

Our results show that the degree of satisfaction of proteins and zinc requirements as well as the access to improved water sources and sanitation were positively associated with length-for-age, while having a better health status and a higher degree of satisfaction of energy, protein, zinc, and iron requirements were associated to an improved weight-for-length. Only child health status was associated to ferritin.

CONCLUSION

Our results reiterate the importance of improving child diet and health status, but also the access to a healthy environment to ensure an optimal nutritional status.

De novo assembly of transcriptomes, mining, and development of novel EST-SSR markers in Curcuma alismatifolia (Zingiberaceae family) through Illumina sequencing

Curcuma alismatifolia widely used as an ornamental plant in Thailand and Cambodia. This species of herbaceous perennial from the Zingiberaceae family, includes cultivars with a wide range of colours and long postharvest life, and is used as an ornamental cut flower, as a potted plant, and in exterior landscapes. For further genetic improvement, however, little genomic information and no specific molecular markers are available. The present study used Illumina sequencing and de novo transcriptome assembly of two C. alismatifolia cvs, 'Chiang Mai Pink' and 'UB Snow 701', to develop simple sequence repeat markers for genetic diversity studies. After de novo assembly, 62,105 unigenes were generated and 48,813 (78.60%) showed significant similarities versus six functional protein databases. In addition, 9,351 expressed sequence tag-simple sequence repeats (EST-SSRs) were identified with a distribution frequency of 12.5% total unigenes. Out of 8,955 designed EST-SSR primers, 150 primers were selected for the development of potential molecular markers. Among these markers, 17 EST-SSR markers presented a moderate level of genetic diversity among three C. alismatifolia cultivars, one hybrid, three Curcuma, and two Zingiber species. Three different genetic groups within these species were revealed using EST-SSR markers, indicating that the markers developed in this study can be effectively applied to the population genetic analysis of Curcuma and Zingiber species. This report describes the first analysis of transcriptome data of an important ornamental ginger cultivars, also provides a valuable resource for gene discovery and marker development in the genus Curcuma.

Cambodia's health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility

BACKGROUND

From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia.

METHODS

This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility.

RESULTS

Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms.

CONCLUSION

The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.

Surveillance for Sri Lankan cassava mosaic virus (SLCMV) in Cambodia and Vietnam one year after its initial detection in a single plantation in 2015

Cassava mosaic disease, one of the ten most economically important crop viral diseases in the world, was first reported in Southeast Asia from a single plantation in Cambodia in 2015. To determine the presence and incidence of Sri Lankan cassava mosaic virus (SLCMV) one year after first detection, a total of 6,480 samples from 419 fields were systematically collected from cassava production areas across Cambodia (3,840 samples; 240 fields) and Vietnam (2,640samples; 179 fields) in the 2016 cropping season. Using PCR-based diagnostics, we identified 49 SLCMV-infected plants from nine fields, representing 2% of the total number of fields sampled. Infected fields were geographically restricted to two provinces of Eastern Cambodia, while no infection was detected from any of the other sampled sites in either country. Symptom expression patterns in infected plants suggested that SLCMV may have been transmitted both through infected planting materials, and by Bemisia tabaci, the known whitefly vector of SLCMV. In addition, 14% of virus infected plants did not express typical symptoms of cassava mosaic disease on their leaves, highlighting that molecular-based validation is needed to confirm the presence of SLCMV in the field. None of the owners of the SLCMV-infected fields indicated acquired planting materials from the plantation in Ratanakiri where SLCMV was first reported. The surveillance baseline data generated for both countries is discussed in light of future options to control and manage cassava mosaic disease.