Steatotic liver disease among lean and non-lean individuals in Southern Lao PDR: a cross-sectional study of risk factors

BACKGROUND

Steatotic liver disease (SLD) prevalence is rising worldwide, linked to insulin resistance and obesity. SLD prevalence can surpass 10% even among those with normal weight. In Lao People's Democratic Republic (Lao PDR), where Opisthorchis viverrini (OV) trematode infection and type 2 diabetes mellitus (T2DM) are common, infection related liver morbidity such as cholangiocarcinoma (CCA) is high, but data on SLD prevalence is lacking. The objective of this study was to estimate the prevalence and explore determinants of SLD in rural southern Lao PDR for lean and non-lean populations.

METHOD

A cross-sectional community-based study assessed SLD prevalence using abdominal ultrasonography (US). Factors investigated for association with SLD were identified by interview, serological tests (Hepatitis B surface antigen (HBsAg); lipids and HbA1c), anthropometrical measurements, and parasitological assessments (OV infection). Uni- and multivariable logistic regression analyses with SLD as endpoint were conducted separately for lean (body mass index (BMI) <23.0 kg/m2) and non-lean (BMI ≥ 23.0 kg/m2) participants.

RESULT

2,826 participants were included. SLD prevalence was 27.1% (95% confidence interval (95% CI) 24.0%-30.4%), higher among non-lean (39.8%) than lean individuals (17.4%). Lean individuals with OV infection had a statistically significant association with lower odds of SLD (adjusted odds ratio (aOR) 0.49, 95% CI 0.33 - 0.73). T2DM showed a significant positive association with SLD in both lean (aOR 3.58, 95% CI 2.28 - 5.63) and non-lean individuals (aOR 3.31, 95% CI 2.31 - 4.74) while dyslipidemia was significantly associated only in the non-lean group (aOR 1.83, 95% CI 1.09 - 3.07). Females participants exhibited elevated odds of SLD in both lean (aOR 1.43, 95% CI 1.02 - 2.01) and non-lean SLD (aOR 1.50, 95% CI 1.12 - 2.01).

CONCLUSION

SLD prevalence is notably high among Laotian adults in rural areas, particularly in females and in non-lean individuals. Lean individuals with OV infection exhibited lower SLD prevalence. SLD was more prevalent in individuals with T2DM, independent of BMI. SLD adds to the burden of infection-related liver morbidity in Lao PDR.

Intestinal helminth infections and associated risk factors among adults in the Lao People's Democratic Republic

BACKGROUND

Helminthiases are highly endemic in Southeast Asia, including the Lao People's Democratic Republic (Lao PDR). This study aimed to assess the current intestinal helminth infections and the associated risk factors among adults across the Lao PDR.

METHODS

A cross-sectional survey was conducted in 165 villages across 17 provinces and the Vientiane Capital, Lao PDR. A multi-stage sampling method was employed to select the adult study participants (≥ 18 years). Data collection included (1) interview of the study participants, (2) physical measurements, and (3) a five gram of stool sample from each study participant was collected and preserved in 10% formalin solution for intestinal helminth detection using formalin-ether concentration technique (FECT). Descriptive analysis was used to describe the socio-demographic characteristics of study participants and the prevalence of intestinal helminth infections. Logistic regressions were applied to test the association between intestinal helminth infection and individual risk factors. A P-value below 0.05 was considered statistically significant.

RESULTS

A total of 2800 study participants were enrolled. Their average age was 46.0 years; 57.8% were female. Overall, 30.9%, 8.6% and 1.5% of study participants were infected with one, two, or three different intestinal helminth species, respectively. Among the study participants 21.6% were infected with hookworm, 18.8% with Opisthorchis viverrini-like (Ov-like) infection, 4.8% with Strongyloides stercoralis, 2.3% with Ascaris lumbricoides, 1.5% with Trichuris trichiura, and 3.3% with Taenia spp. Ov-like infection was of high prevalence in the southern (28.8%) and central (21.3%) provinces, while hookworm (26.3%), A. lumbricoides (7.3%), T. trichiura (3.1%), and Taenia spp. (4.2%) were prevalent in the northern provinces. Risk analysis showed that men were more likely to be infected with hookworm [adjusted odds ratio (aOR) = 1.2, P = 0.019]. The Lao-Tai ethnic group had a 5.2-times (P < 0.001) higher chance of having Ov-like infection than the minorities. Possession of toilet facility at home was associated with reduced odds for Ov-like (aOR = 0.4, P < 0.001) and hookworm (aOR = 0.6, P < 0.001) infections.

CONCLUSIONS

Our study provides a nationwide update of the intestinal helminth prevalence among adults in Lao PDR. To the best of our knowledge, this is the first Lao nationwide survey on intestinal helminth infections and risk factors in adults. It provides crucial information for national control programs for intestinal helminth infections in Lao PDR.

Seroprevalence of measles and rubella antibodies in vaccinated and unvaccinated infants in the Lao People's Democratic Republic

BACKGROUND

Even though measles vaccination was introduced in the Lao PDR in 1984, coverage rates remain consistently low and outbreaks continue to occur frequently. This study was performed to investigate the seroprevalence of measles and rubella antibodies in vaccinated and unvaccinated children from Central Lao PDR.

METHODS

Antibody titres of 1090 children aged 8-29 months who were vaccinated at different levels of the health care system were assessed by ELISA. Bivariate and multivariable analyses were performed to identify factors affecting seropositivity against measles and rubella.

RESULTS

Among the vaccinated children, 67.5% in Vientiane Province and 76.4% in Bolikhamxay Province were double positive/borderline for measles and rubella IgG. A high proportion of unvaccinated children at both study sites (24.4% and 38.4%) were positive/borderline for measles and/or rubella. Time since vaccination <180 days, more than two siblings, and a mother who is a farmer/labourer were negatively associated with seropositivity.

CONCLUSIONS

A high prevalence of measles and rubella antibodies was found in unvaccinated children, indicating widespread circulation of both viruses and underreporting of cases. The high proportion of vaccinated children still susceptible to measles suggests problems with vaccine immunogenicity, emphasizing the need for regular evaluations of vaccine efficacy and management.

Timeliness of immunisation with the pentavalent vaccine at different levels of the health care system in the Lao People's Democratic Republic: A cross-sectional study

Background

The timely administration of vaccines is considered to be important for both individual and herd immunity. In this study, we investigated the timeliness of the diphtheria-tetanus-whole cell pertussis-hepatitis B-Haemophilus influenzae type b (pentavalent) vaccine, scheduled at 6, 10 and 14 weeks of age in the Lao People’s Democratic Republic. We also investigated factors associated with delayed immunization.

Methods

1162 children aged 8–28 months who had received the full course of the pentavalent vaccine at different levels of the health care system were enrolled. Vaccination dates documented in hospital records and/or immunisation cards were recorded. Age at vaccination and time intervals between doses were calculated. Predictors for timely completion with the pentavalent vaccine at 24 weeks were assessed by bivariate and multivariable analyses.

Results

Several discrepancies in dates between vaccination documents were observed. In general, vaccination with the pentavalent vaccine was found to be delayed, especially in health care settings below the provincial hospital level. Compared to the central hospital level, less participants who were vaccinated at the district/health center level received the third dose by 16 (48% at the central hospital level vs. 7.1% at the district and 12.4% at the health center level) and 24 weeks of age (94.4% at the central hospital level vs 64.6% at the district-outreach and 57.4% at the health center level) respectively. In logistic regression analyses, lower education level of the mother as well as vaccination by outreach service, were independently associated with delayed completion of vaccination.

Conclusion

We observed a general delay of vaccination, especially at lower ranked facilities, which correlated with indicators of poor access to health services. This highlights the need for further improving health equity in rural areas. Age-appropriate vaccination should become a quality indicator for the national immunization programme. In addition, we recommend further training of the health care staff regarding the importance of reliable documentation of dates.

Seroprotection at Different Levels of the Healthcare System After Routine Vaccination With Diphtheria-Tetanus-Pertussis whole cell-Hepatitis B-Haemophilus influenzae Type B in Lao People's Democratic Republic

Background

The Lao People’s Democratic Republic continues to sustain a considerable burden of vaccine-preventable diseases because of incomplete vaccine coverage and weak vaccine responses. We have assessed seroconversion after routine vaccination with the pentavalent vaccine to capture weaknesses of vaccine management at the different levels of the healthcare system.

Methods

A total of 1151 children (aged 8–28 months) with 3 documented doses of the pentavalent vaccine delivered at central hospitals in Vientiane and the provincial hospital, 3 district hospitals, and 10 health centers in Bolikhamxay province were enrolled. Sociodemographic information was collected with a standardized questionnaire. Serum samples were analyzed for antibodies against vaccine components, and bivariate and multivariable analyses were performed to identify risk factors for low vaccine responses.

Results

Seroprotection rates at the provincial, district, and health center level were as high as in central hospitals, but seroprotection rates in areas covered by remote health centers were significantly lower. Protective levels also rapidly decreased with age at sampling. Seroprotection rates in Bolikhamxay against the different components reached 70%–77% and were up to 20% higher than in previous studies in the same region; 18.8% more children received the hepatitis B vaccine birth dose and the hepatitis B virus infection rate was 4 times lower.

Conclusions

Vaccine immunogenicity has dramatically improved in a central province, likely due to training and investment in the cold chain. Nevertheless, there remains a need to focus on the “last mile” in remote areas were most children are vaccinated through outreach activities.

Cross-reaction of POC-CCA urine test for detection of Schistosoma mekongi in Lao PDR: a cross-sectional study

BACKGROUND

The point-of-care circulating cathodic antigen (POC-CCA) test is increasingly used as a rapid diagnostic method for Schistosoma mansoni infection. The test has good sensitivity, although false positive results have been reported among pregnant women and patients with urine infections and hematuria. We validated the POC-CCA test's ability to diagnose Schistosoma mekongi infection in Lao People's Democratic Republic (Lao PDR), where S. mekongi is endemic. Of particular interest was the test's specificity and possible cross-reactivity with other helminth infections.

METHODS

We conducted a cross-sectional study of children and adults in the provinces of Champasack (Schistosoma mekongi and Opisthorchis viverrini endemic), Savannakhet (O. viverrini endemic) and Luang Prabang (soil-transmitted helminths endemic) between October 2018 and April 2019. POC-CCA and urine dipstick tests were administered to all study participants, while an additional pregnancy test was offered to women. Two stool samples were collected from participants and examined with a Kato-Katz test (two smears per stool). Logistic regression was used to associate potential confounding factors (predictors) with POC-CCA test results (outcome).

RESULTS

In S. mekongi-endemic Champasack, 11.5% (n = 366) and 0.5% (n = 2) of study participants had positive POC-CCA and Kato-Katz test results, respectively. Only one of the two Kato-Katz positive patients was also POC-CCA positive. In Champasack and Luang Prabang, where S. mekongi is not endemic, the POC-CCA test yielded (presumably) false positive results for 6.0% (n = 22) and 2.5% (n = 9) of study participants, respectively, while all of the Kato-Katz tests were negative. POC-CCA positive test results were significantly associated with O. viverrini infection (1.69, 95% confidence interval (CI): 1.02-2.77, P = 0.042), increased leukocytes (adjusted Odds Ratio (aOR) = 1.58, 95% CI: 1.15-2.17, P = 0.005) and hematuria (aOR = 1.50, 95% CI: 1.07-2.10, P = 0.019) if the observed trace was counted as a positive test result. Two pregnant women from Champasack province had POC-CCA positive tests.

CONCLUSIONS

We observed a cross-reaction between the POC-CCA test and O. viverrini infection. To some extent, we can confirm previous observations asserting that POC-CCA provides false positive results among patients with urinary tract infections and hematuria. In S. mekongi-endemic areas, POC-CCA can be applied cautiously for surveillance purposes, keeping in mind the considerable risk of false positive results and its unknown sensitivity.

Febrile illness in Asia: gaps in epidemiology, diagnosis and management for informing health policy

BACKGROUND

Increasing evidence is becoming available on the aetiology and management of fevers in Asia; the importance of these fevers has increased with the decline in the incidence of malaria.

AIMS

To conduct a narrative review of the epidemiology and management of fevers in South and South-East Asia and to highlight gaps in our knowledge that impair evidence-based health policy decisions.

SOURCES

A narrative review of papers published since 2012 on developments in fever epidemiology, diagnosis and treatment in South and South-East Asia. The papers that the authors felt were pivotal, from their personal perspectives, are discussed.

CONTENT

We identified 100 studies. Among the 30 studies (30%)-including both children and adults-that investigated three or more pathogens, the most frequently reported fever aetiology was dengue (reported by 15, 50%), followed by leptospirosis (eight, 27%), scrub typhus (seven, 23%) and Salmonella serovar Typhi (six, 20%). Among four studies investigating three or more pathogens in children, dengue and Staphylococcus aureus were the most frequent, followed by non-typhoidal Salmonella spp, Streptococcus pneumoniae, Salmonella serovar Typhi, and Orientia tsutsugamushi. Increased awareness is needed that rickettsial pathogens are common but do not respond to cephalosporins, and that alternative therapies, such as tetracyclines, are required.

IMPLICATIONS

Many key gaps remain, and consensus guidelines for study design are needed to aid comparative understanding of the epidemiology of fevers. More investment in developing accurate and affordable diagnostic tests for rural Asia and independent evaluation of those already on the market are needed. Treatment algorithms, including simple biomarker assays, appropriate for empirical therapy of fevers in different areas of rural Asia should be a major aim of fever research. Enhanced antimicrobial resistance (AMR) surveillance and openly accessible databases of geography-specific AMR data would inform policy on empirical and specific therapy. More investment in innovative strategies facilitating infectious disease surveillance in remote rural communities would be an important component of poverty reduction and improving public health.