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Programs

CNM co-ordinates four main national programmes; for the control of malaria, dengue haemorrhagic fever (DHF), filariasis and schistosomiasis and intestinal parasitic infections, respectively.

THE NATIONAL MALARIA CONTROL PROGRAM

The National Malaria Control Program is “a vertical programme led by the National Malaria Center (CNM) in Phnom Penh, but is decentralized administratively with responsibility for activities assigned to provincial and district health departments.”

Structure

The Malaria Control Programme has four Departments overseeing its implementation within the CNM: (1) Prevention and Health Education, (2) Diagnostics, (3) Treatment, and (4) Epidemiology and Operational Research.

Structure of the Malaria Control Program

Goal and Objectives

The overall goal of the malaria control program is to improve the health status of the people in Kingdom of Cambodia by contributing to the reduction of malaria morbidity & mortality.

The specific objectives are to reduce the malaria morbidity by 20% and malaria mortality by 30% by the year 2005 (compared to the baseline year 2000).

Strategies

Strengthening the institutional capacity of the national malaria control program at central as well as peripheral levels
Improving the malaria case management for all segments of the population
Improving preventive measures to protect the population groups at risk
Increasing the coverage and effectiveness of IEC for population residing in areas of risk.

Main Strategies for Malaria Control & Responsibilities

The following table summarizes the responsibilities of the institutions at different levels in implementing the identified strategies and activities.

Strategies and Responsibilities for Malaria Control in Cambodia

Adoption of the Strategic Approaches for different Risk Groups

Decentralized Responsibilities of the Provincial Health Departments for Malaria Control

Assessment of malaria situation in the province
Planning of all malaria control activities in the province
Organizing Training Courses for different personnel
Distribution & retreatment of IBNs
Assistance with social marketing of insecticide-treated hammock-nets
Distribution of dipsticks, microscopes, reagents, antimalarials, etc
IEC Material distribution & IEC campaigns
Collection of Health Information on Malaria
Participation in Operational Research Studies of CNM
Supervision of ODs/Referral hospitals/Health Centers
Participation in Border Malaria Meetings and Follow-up actions

THE NATIONAL DENGUE CONTROL PROGRAM

Introduction

The dengue control programme in Cambodia is under the organization of National Center of Malaria Control (CNM). However, it is not a vertical programme as such, its integrated to the existing structure of the Ministry of Health. The programme structure is composed of a National dengue fever control committee, a programme management team, and 4 sub-committees: Epidemiology, Entomology, Clinical Management, and Health Education as illustrated in the following diagram. Under the responsibility of the Director and Vice Director of the Malaria Center, and with the collaboration of the sub-committees, the role of the dengue fever programme management at the CNM is to coordinate all activities related to controlling dengue fever in Cambodia. The main responsibilities include the following:

Define dengue control strategies for each of the programme component, including – Epidemiology, Entomology, Clinical Management and Health Education,
Develop a comprehensive plan of action for emergency preparedness,
Implement, monitor and evaluate the control strategies,
Collect, compile and analyse epidemiological data,
Procure of insecticides, equipment and drugs supplies,
Conduct entomological assessment and monitoring on vector control, including bioassay and susceptibility tests,
Produce Health education and IEC productions, and Health Campaign Day,
Conduct operational field research on new and alternative vector control approaches,
Train of health personnel including private sectors on clinical, epidemiological and entomological aspects of DHF.

Programme Objectives:

The objectives of the national dengue control programme (NDCP) are:

To prevent childhood mortality due to DHF and DSS, by strengthening clinical management and seeking early hospitalization and treatment,
To reduce the morbidity of DF/DHF through preventive measures and create community awareness in source reduction of Aedes aegypti breeding sites.

National DHF Control Strategy

Diagnosis and Treatment of DHF: The diagnosis and treatment of DHF in the Kingdom of Cambodia is carried out following the protocol set out in the latest edition of specific Dengue treatment guidelines for the treatment of simple or severe forms of dengue fever. The guidelines are to be updated by the clinical subcommittee, which is also responsible for the organization and training of hospital and private practitioners.
Epidemiological Surveillance of DHF: As part of the Health Information System of the MOH, the National Malaria Center (CNM) established a nation-wide DHF surveillance system, that include case reporting and serological confirmation as well as the entomological surveillance.
Emergency Preparedness for outbreaks and epidemics: The National Malaria Center is responsible to co-ordinate the allocation of supplies to the Municipalities and Provincial Health Department. This includes larvicide and insecticides, spraying and other medical supplies and equipment, necessary to carry out a focal or extended outbreak control intervention. The CNM is also responsible for partner coordination and for allocation of funding required for the epidemic control. The Municipalities or Provincial Health Departments will organize the actual execution of epidemic control measures as far as possible.
Health Education, Community Awareness and Participation: The sub-committee of health education is responsible of organizing an integrated programme to enhance awareness of dengue, and to stimulate communities to take actions to eliminate the breeding sites. The health education subcommittee is also responsible for educate the public about the signs and symptoms of DF/DHF and the importance of early hospitalizations.
Evaluation and operation research: The CNM, the National Institute of Public Health/NAMRU, the Pasteur Institute and other national and international institutions are involved in the operational research required to monitor the effectiveness of the control measures and to follow-up and analysed all factors that could facilitate the prediction or early detection of future outbreak.

The involvement of external partners

WHO has been directly involved in providing managerial and technical support to the control of DHF in the Kingdom of Cambodia. WHO’s specific role has been to obtain technical expert advice and to support and help coordinate fund-raising. The most important organizations in terms of financial support to dengue control have been USAID, ECHO, and International Red Cross Federation. Several NGOs, such as the Cambodian Red Cross and MSF have been very active in supporting implementation of epidemic control. Following the 1998 nation-wide outbreak, USAID’s Bureau agreed to provide continued support to the NDCP, through WHO for US$150,000 per year for five years (1999-2003). The main identified areas of support include: the disease surveillance system, case management in both public and private health facilities and at the household level, health education messages and community involvement in dengue prevention measures, vector control activities and regional exchange to enhance capabilities of NDCP to implement dengue control intervention.

New Update: Dengue Prevention and Control in Cambodia

Contribution by DHF Control Programme, CNM

Despite the increase in some of the rural districts of Cambodia, a sustained massive nationwide outbreak of dengue fever (DF) and dengue haemorrhagic fever (DHF) as predicted this year has been prevented so far. Unlike previous years, the increased number of cases occurred from the month of April (327 cases) and peaked in June (1651 cases). The magnitude of increased cases during the month of May and June exceeded the mean of non –epidemic years (Figure 1). However the month of July contributed fewer cases, resulting in a decreasing epidemic curve.

Several focal outbreaks in rural districts of Banteay Meanchey, Siem Reap, Pursat, Rattanakiri and Preah Vihear that have taken place this year were paradoxical to previous epidemics. These focal points are areas of low population densities. Improved epidemiological surveillance was thought to be one possible explanation. The low immunity of the children in these rural areas also accelerated the transmission of DHF within a confined geographical area. Entomological investigations taken as part of the epidemic response revealed the wide spread of Aedes aegypti in rural districts of Cambodia. It is, however, evidenced that if focal space spraying using 1% K-Orthrin supported with selective abate larviciding and health education campaigns were used, the situation would be alleviated within a short period. It is also clear that the involvement of various NGOs in abate application and providing community education to supplement the limited resources of the Provincial Health Department is of vital importance in DHF control.

One the of spectacular and remarkable achievements of the dengue vector control events this year was the accomplishment of two application rounds of abate larviciding in the high risk areas. These vector control events were collaborated with the International Federation of Red Cross (IFRC), USAID and WHO and was possibly the world’s largest DHF campaign, which covered more than 3.5 million people and 2.5 million water jars in the 38 districts of high risk to DHF. The distribution areas were geographically condensed (carpet distribution) to limit the possibility of reinvasion of the vector. In order to ensure its effectiveness, the pre-emptive strike against Aedes aegypti larvae was done before the transmission season and in 3 month intervals. For maximum effect, each round of application was carried out within the shortest possible time frame of 14 days involving 1000 distributors nationwide. A total of 90 tons of abate 1% sand granules was consumed for each application round, with 36 gm per water jar of treatment.

The effectiveness of this carpet distribution of abate larviciding as a preventive measure was evaluated in collaboration with NAMRU-2. Randomized sampling of districts and households in treatment areas of Phnom Penh were chosen for both entomological and epidemiological assessment. The current ongoing assessment activity has so far suggested that Abate could prevent the risk of DHF epidemics by 3 fold. Entomological information following the treatment of abate larvicide shows a rapid decline of larval density. There was an inverse correlation between jars treated with Abate and Aedes aegypti container index. However, the mass effect on the adult Aedes aegypti is only apparent 3 weeks after the commencement of treatment. This information suggests that a time lapse of about three weeks is required to allow the Abate to take effect. Thus a good and timely coverage in all high risk areas will have to be ensured for the effectiveness.

In parallel with the mass Abate larviciding operation, the DHF control progamme has been taking the initiative to develop jar lids for community use. One innovation that is being investigated is the use of netting for the jar lid industrially treated with pyrethroid insecticide : deltamethrin. This novel initiative is based on the Aedes aegypti ovipositioin behaviour. Studies have been shown that gravid female Ae. aegypti deposit their eggs over many available breeding sites within a single gonotrophic cycle. During the process of searching and striking the breeding sites (water jars), the gravid females would have to make several contacts with the deltamethrin impregnated fabric. The possibility of killing infected adults and reducing or interrupting transmission arises if they contact and receive a lethal dose of insecticide when searching for multiple oviposition sites over the duration of 2-3 gonotrophic cycles.

Photograph 1 shows the Deltamethrin impregnated jar lid (85 cm²), the fabric material is polyethylene with 156 mesh per inch² and 100 denier. The rim is powder coated steel and the net weight is 800 gm.

The DHF control programme is currently carrying out the efficacy studies under field controlled conditions. The bioassay studies have so far indicated that the impregnated jar lids have a lethal effect after 12 weeks duration, regardless of the jar positions (indoor/outdoor). However, the mortality rate declines to below 60% if the fabric is persistently submerged in water. A parallel study on toxicity assessment of the water samples collected from jars covered with impregnated jar lids indicated no deltamethrin has been detected in the water samples. Excitingly, this finding also extends to water samples collected from jars where the treated fabric has been submerged over a 12 week duration (limit of reporting is 0.05 ppb). All the above studies favorably point towards using the industrially treated jar lids for Ae. aegypti control in water jars.

Following the imminent completion of the phase I laboratory studies of deltamethrin treated jar lids, phase II studies are being planned on a community level. A more vigorous entomological evaluation, which will include assessment of the impact on the life expectancy of the female Aedes aegypti and the possibility of breeding site deviation following the community use of jar lids, will be investigated.

NATIONAL SCHISTOSOMIASIS CONTROL PROGRAM

Introduction:

The program commenced in 1996 in collaboration with MSF, Swiss Tropical institute, WHO and SMHF.

Objective:

To reduce Schistosomiasis morbidity and mortality in the endemic areas in Kratie and Stung Treng Provinces.

Schistosomiasis Control Activities

1.Annual Mass Treatment Activities

• To the target population: 46739 persons in Kratie province and 32157 persons in Stung Treng province.

• On average 65 % of target population received a standard treatment: A single dose of Praziquantel 40mg/kg combined with Mebendazole 500mg.

2.Health Education Activities

• Health education through school children, pagoda, collaboration with other partner (NGOs). To improve the knowledge, attitude and practice of communities about schistosomiasis and Intestinal parasitic infection.

• Materials: Story books, Poster, Leaflets, Song, and Short story by local channel radio.

3.Sanitation activities

• Close collaboration with NGOs working in environmental health issues: pumps and latrines for the communities.

• The number of latrines and water wells has been improved, but the availability is still insufficient.

4.Training: Control Activities

• Health staff: To strengthen the knowledge and skills about the disease to the Health staff at hospital and Health Centre levels in Schistosomiasis endemic areas.

• Primary School teacher: To enable the teacher to conduct health education lessons related to schistosomiasis.

• Community representative: Educating them on their role in control activities.

5.Epidemiological Surveillance in Sentinel villages

• Four sentinel schools in Kratie province were selected for monitoring the prevalence and morbidity of infection. The objectives are:

-To evaluate the participation in the mass-treatment in the village population.

-To evaluate the impact of the annual mass-treatment on infection and morbidity.

6.Treatment of Severe schistosomiasis cases

• Severe cases are present: Hepatosplenomegaly with risks of bleeding from the oesophageal varices (chronic cases for which the treatment came late, considerable number known especially in Kratie province.

• Surgical intervention: to reduce blood pressure in the oesophageal vein is being organized at Calmette Hospital in Phnom Penh.

7.Integration and decentralization

Intervention:

combine schistosomiasis with helminth control activities (treatment).

close collaboration with Provincial Education Department (Deworming).

Collaboration with other community health programs

NGOs

Measles

THE NATIONAL HELMINTHIASIS CONTROL PROGRAM

Introduction

The National control programme commenced in 1997 as an integrated program with schistosomiasis control program.

Objectives

- To reduce the prevalence and intensity of soil-transmitted helminth infection to a low level

- To increase the knowledge and awareness of the causes of intestinal helminthes in school children.

Strategies

To establish and maintain a network for the treatment of helminthic infection and provision of health education in primary schools.
To provide mass-treatment with Mebendazole 500mg and health education every six months in the primary schools.
To develop a health education strategy and material by adapting the TOT in collaboration with all the partners.
To perform TOT workshop for the headmasters of primary schools and to perform supervision for the schools
To monitor the intervention and to evaluate the effectiveness of the treatment on infection and morbidity indicators.

THE NATIONAL FILARIASIS ELIMINATION PROGRAM

INTRODUCTION

The National Filariasis Elimination program commenced in 2000

Overall Goal of the program

To eliminate and eradicate Lymphatic Filariasis (LF) from Cambodia by the year 2015.

OBJECTIVES:

To precisely define the characteristics of LF infection in Cambodia in studying the magnitude of infection rate and filariasis species, and in defining the endemic areas.
To identify the target provinces and prepare for Mass Treatment in 2004.
To stop the LF transmission and enhance integration, partner co-ordination and collaboration from the year 2005 to 2009.

RATIONALE:

LF has been found in 8 provinces among patients who have been confirmed as clinical cases of lymphatic filariasis. These overt cases indicate that LF is a public health issue in Cambodia as the number of hidden cases will be far higher. It is now possible through simple and cost-effective interventions to eradicate the disease over a 15-year period.

Strategies

Night Blood Surveys and ICT surveys in provinces and districts considered at risk
Institution of treatment for all positive cases

Activities carried out in first half of 2001

The major activity during the reporting period has been the successful completion of Night Blood and ICT surveys on Lymphatic Filariasis in 3 provinces, Ratanakiri, Mondulkiri, and Preah Vihear.

Results from the Surveys:

Based on the results from the surveys, lymphatic filariasis has been found to be active in 2 provinces, Ratanakiri and Preah Vihear and inactive in Mondulkiri.