Developments in immunization planning in Cambodia--rethinking the culture and organization of national program planning

INTRODUCTION: As part of its health system reconstruction following decades of civil war, Cambodia undertook a program of health sector reform in 1996 to expand coverage of essential health services to the population of 14 million, 80% of whom are resident in over 13 000 rural villages. During this reform period, one of the major national health programs, the National Immunization Program (NIP), adapted its planning system to accommodate changes in social and health sector structure. Aims: The aims of this article are to review changes made in the approach to national immunization planning and to illustrate how these adaptations can help identify future challenges and opportunities for further improving immunization coverage in Cambodia. Sources of information for the study include immunization plans and data from international and national sources, as well as data from the national health information system. Findings of review: Management and service delivery reforms undertaken by the NIP include (1) strengthening links between immunization, health sector and international health planning; (2) development of immunization program multiyear and financial sustainability plans; (3) strengthening of national program decision making structures and processes; (4) widening of decentralized stakeholder participation in health planning; and (5) implementation of service level micro-planning. Outcomes: These management reforms have been associated with significant improvement in public health program performance and outcomes during this period (2003-2006). There has been an increase in vaccination coverage for children under the age of one year, over a five-year period (increase of 29% for fully immunized child at one year of age), with no significant differences in vaccination rates between urban and rural areas, and a sharp decrease in the incidence of vaccine preventable diseases. CONCLUSION: The NIP is now well positioned to take on additional challenges in coming years associated with expanding international partnerships, the continued development of civil society, further health system decentralization, and the requirement to further improve coverage in support of global and regional disease elimination goals. However, as costs continue to rise, planners in the future will need to emphasize the economic and public health benefits of immunization programs in order to sustain increasing levels of national and international investment.     

A cost–effectiveness analysis of Japanese encephalitis vaccine in Cambodia

This study aimed to evaluate the cost and effectiveness of introducing a live, attenuated vaccine (SA 14-14-2) against Japanese encephalitis (JE) into the immunization program. The study demonstrated that SA 14-14-2 immunization is cost–effective in controlling JE in Cambodia compared to no vaccination. Averting one disability-adjusted life year, from a societal perspective, through the introduction of SA 14-14-2 through routine immunization, or a combination of routine immunization plus a campaign targeting children 1–5 or 1–10 years of age, costs US$22, US$34 and US$53, respectively. Sensitivity analyses confirmed that there was a high probability of SA 14-14-2 immunization being cost–effective under conditions of uncertainty.     

The epidemiology of HIV-associated tuberculosis in rural Cambodia.

SETTING: Banteay Meanchey Province, Cambodia. OBJECTIVE: The World Health Organization recommends human immunodeficiency virus (HIV) testing for all tuberculosis (TB) patients and TB screening for all HIV-infected persons in countries with a TB-HIV syndemic. We sought to determine whether evidence supports implementing these recommendations in South-East Asia. DESIGN: We conducted a cross-sectional survey and retrospective cohort study of patients newly diagnosed with HIV or TB from October 2003 to February 2005 to identify risk factors for HIV infection and TB, and for death during TB treatment. RESULTS: HIV infection was diagnosed in 216/574 (38%) TB patients. TB disease was found in 124/450 (24%) HIV-infected persons. No sub-groups of patients had a low risk of HIV infection or TB. Of 180 TB patients with HIV infection and a recorded treatment outcome, 49 (27%) died compared to 17/357 (5%) without HIV infection (relative risk [RR] 5.2, 95% confidence interval [CI] 3.1-8.7). HIV-infected TB patients with smear-negative pulmonary disease died less frequently than those with smear-positive pulmonary disease (RR 0.39, 95%CI 0.16-0.93). CONCLUSIONS: No sub-groups of patients had low risk for HIV infection or TB, and mortality among HIV-infected TB patients was high. These data justify using the WHO global TB-HIV recommendations in South-East Asia. Urgent interventions are needed to reduce the high mortality rate in HIV-infected TB patients.     

Epidemiology and burden of disease from Japanese encephalitis in Cambodia: results from two years of sentinel surveillance

Objectives  To describe the results from two years of Japanese encephalitis (JE) sentinel surveillance in Cambodia.
Methods  Sentinel site surveillance for JE in children aged 15 years and under was implemented in Cambodia in mid-2006. It was integrated into the routine meningoencephalitis surveillance system. Six hospitals were selected as sentinel sites. Epidemiological information and diagnostic specimens were collected from each patient presenting with meningoencephalitis. Cerebrospinal fluid and sera were tested for presence of immunoglobulin M antibodies against JE and dengue viruses by an ELISA. Surveillance data from 2006 to 2008 were analysed.
Results  Of 586 patients presenting with meningoencephalitis, 110 (19%) were confirmed to have JE. The percentage of confirmed JE cases at individual sentinel sites ranged from 13% to 35% of all meningoencephalitis cases. Mean age was 6.2 years, with 95% of JE cases in children aged 12 years and under. Cases occurred year-round in both 12-month reporting periods.
Conclusions  JE is an important cause of meningoencephalitis in Cambodian children. As JE is a vaccine-preventable disease, an immunization programme could result in a considerable reduction in morbidity and mortality from JE among children in Cambodia.     

Human Infection with Avian Influenza A(H9N2) Virus,Cambodia, February 2021

In February 2021, routine sentinel surveillance for influenza-like illness in Cambodia detected a human avian influenza A(H9N2) virus infection. Investigations identified no recent H9N2 virus infections in 43 close contacts. One chicken sample from the infected child’s house was positive for H9N2 virus and genetically similar to the human virus.     

Improving immunization coverage through budgeted microplans and sub-national performance agreements: early experience from Cambodia

In recent years, Cambodia has demonstrated significant success in specific aspects of immunization with gains through campaign efforts in measles control and polio eradication. In contrast, routine immunization rates have failed to improve over the last five years. In response, the National Immunization Program of the Ministry of Health developed a coverage improvement planning (CIP) process. This paper describes the CIP process in Cambodia, including identified barriers to and strategies for improving coverage. Immunization coverage rose in 8 of 10 pilot districts in the year following the introduction of CIP in 2003. The mean increase in DPT3 coverage across pilot districts on an annual basis was 16%, which provides encouraging early evidence for the effectiveness of the intervention. Factors associated with success in coverage improvement included: (1) development of a needs-based micro-plan, (2) application of performance-based contracting between levels of management, (3) investment in social mobilization, (4) securing finance for health outreach programs and (5) strengthened monitoring systems. Lessons learned will guide program expansion to improve immunization coverage nationally.     

Imidazopyridine-Based Fatty Acid Synthase Inhibitors That Show Anti-HCV Activity and in Vivo Target Modulation

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柬埔寨农村地区HIV合并结核病的流行情况

地点：柬埔寨Banteay Meanchey省。目的：世界卫生组织建议在结核病和艾滋病双重感染流行的国家，对所有的结核病人进行艾滋病病毒（HIV）检测，并对所有HIV感染者和病人进行结核病筛查。本文探求在东南亚国家是否有证据支持这一建议的可行性。设计：本研究为横断面调查，对2003年10月2005年2月新诊断的艾滋病病毒感染者或结核病人进行回顾性的队列研究，以明确HIV感染和患结核病的危险因素，并确定抗结核治疗过程中的死亡情况。结果：574例结核病人中发现HIV感染者216例（38％），450例艾滋病病毒感染者和病人中诊断结核病病人124例（24％）。无任何组别的病人处于HIV感染或患结核病的低风险。180例艾滋病合并结核病且有抗结核治疗转归记录，其中49例（27％）死亡，而未感染HIV的357例结核病人中17例（5％）死亡（相对危险度5．2，95％可信区间为3．1—8．7）。感染HIV的涂阴肺结核病人的死亡率常常低于涂阳肺结核病人（相对危险度0．39，95％可信区间0．16—0．93）。结论：无任何组别的病人处于HIV感染或患结核病的低风险，感染HIV的结核病人的死亡率高。这些数据证明：在东南亚国家，应实施世界卫生组织的全球TB／HIV双重感染建议。有必要采取紧急干预措施，以降低艾滋病合并结核病病人的死亡率。     

The rationale for integrated childhood meningoencephalitis surveillance: a case study from Cambodia

Problem

Recent progress in vaccine availability and affordability has raised prospects for reducing death and disability from neurological infections in children. In many Asian countries, however, the epidemiology and public health burden of neurological diseases such as Japanese encephalitis and bacterial meningitis are poorly understood.

Approach

A sentinel surveillance system for Japanese encephalitis was developed and embedded within the routine meningoencephalitis syndromic surveillance system in Cambodia in 2006. The sentinel surveillance system was designed so surveillance and laboratory testing for other etiologies of neurological infection could be incorporated.

Local setting

The Communicable Disease Control department of the Ministry of Health in Cambodia worked with partners to establish the sentinel surveillance system.

Relevant changes

The sentinel surveillance system has provided important information on the disease burden of Japanese encephalitis in Cambodia and is now providing a platform for expansion to incorporate laboratory testing for other vaccine-preventable neurological infections in children.

Lessons learned

Sentinel surveillance systems, when linked to syndromic reporting systems, can characterize the epidemiology of meningoencephalitis and identify the proportion of hospital-based neurological infection in children that is vaccine preventable. Integrated systems enable consistency in data collection, analysis and information dissemination, and they enhance the capacity of public health managers to provide more credible and integrated information to policy-makers. This will assist decision-making about the potential role of immunization in reducing the incidence of childhood neurological infections.