Embassy of the United States

About the Embassy

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Department of Health and Human Services
Centers for Disease Control and Prevention
Phnom Penh, Cambodia

CDC Personnel in Cambodia 

Carol A. Ciesielski, MD
Director
Phone: (855-23) 728-166
Fax: (855-23) 728-050

David B. Nelson
Associate Director for Operations
Phone: (855-23) 728-167
Fax: (855-23) 728-050
 
Joyce J. Neal, PhD, MPH
Epidemiologist
Phone: (855-23) 885-126
Fax: (855-23) 885-435
 
Paul Kitsutani, MD
Influenza Technical Advisor
Phone: (855-23) 885-126
Fax: (855-23) 885-435

Marie Downer
Laboratory Advisor
Phone: (855-23) 885-126
Fax: (855-23) 885-435

CDC Cambodia comprises two programs: 

• Global AIDS Program
• Influenza Program 

Global AIDS Program

The CDC Global AIDS Program (GAP) Cambodia office works with USAID and other partners to implement the President’s Emergency Plan for AIDS Relief (PEPFAR).  Launched in 2002, the CDC GAP Cambodia office now comprises 20 staff members: 6 Americans and 14 locally hired Cambodian nationals.

Overview

In Cambodia, CDC GAP collaborates with the Royal Government of Cambodia, international agencies, and other PEPFAR partners to support:

• Prevention of mother-to-child transmission (PMTCT)
• Blood safety
• Voluntary confidential counseling and testing (VCCT)
• Care and treatment
• Integration of tuberculosis (TB) and HIV programs
• Continuum-of-care network model
• Patient referral systems
• Laboratory infrastructure and quality assurance programs
• Surveillance, surveys, and monitoring and evaluation
• Strategic information management systems
• Capacity building
• Policy development

CDC GAP Cambodia provides technical expertise and financial support to help the Cambodian government develop scientifically sound and locally appropriate policies, strategies, guidelines, and best practices for HIV surveillance, prevention, control, and treatment.

General Demographic Information and Health Indicators for Cambodia

Cambodia is a country of 13.4 million people with 80% of the population living in rural areas [1].  In 2007, per capita gross domestic product was $597, ranked third lowest in Asia [2], and the World Bank estimated that 30% of the total population was living below the national poverty line [e-mail communication, October 2008].  Adult literacy rates are low—estimated in 2006 to be 86% among men and 67% among women [3].   

In 2006, the median age of the population in 2006 was 20 years [4], with 36% of the population younger than 15 years and 68% of the population younger than 30 years of age [5].  Life expectancy at birth was 59 years for men and 65 years for women [4]. 

Infant and child mortality rates are among the highest in Asia.  The 2005 Cambodian Demographic and Health Survey [6] found:

• Infant mortality was 66 per 1,000 live births
• Maternal mortality was 472 per 100,000 live births
• 44% of births were attended by skilled health personnel
• 22% of deliveries were in health facilities
• Under-5 mortality was 83 per 1,000 live births
• 36% of children younger than five years old were malnourished

HIV/AIDS

HIV prevalence in Cambodia is among the highest in Southeast Asia.  The Ministry of Health, National Center of HIV/AIDS, Dermatology, and STDs (NCHADS) estimated that 0.9% of Cambodian adults aged 15-49 years were living with HIV/AIDS in 2006 [7].  This represents a decline from a peak of 2.0% in 1998.  This decrease in the proportion of persons living with HIV is attributable to both the decline in numbers of new infections and the increasing numbers of deaths among persons who were infected in the early years of the epidemic.  Cambodia’s epidemic has been attributed primarily to heterosexual transmission among high risk groups, particularly female sex workers, their clients and sex partners, and sex partners of clients.  As Cambodia’s epidemic has matured, the proportion of women among persons living with HIV/AIDS has increased from 28% in 1992 [8] to 52% in 2006 [7].

Results [7] from Cambodia’s HIV Sentinel Surveys (HSS), most recently conducted in 22 of Cambodia’s 24 provinces and municipalities showed that from 1998 to 2006, HIV prevalence (the percent of persons living with HIV) declined from:

• 2.0 to 0.9 among all adults
• 2.1 to 1.1 among pregnant women
• 39.9 to 14.7 among brothel-based female sex workers

The survey also measured the proportion of HIV infections that were recently acquired and found that the estimated rate of new HIV infections (i.e., the HIV incidence rate) among pregnant women and female sex workers [9] also has declined compared with estimates for 1999, 2000, and 2002 (see figure). 

In 2006 an estimated:

• 0.07% of pregnant women in Cambodia were newly infected with HIV—i.e., annual HIV incidence rate of 70 per 100,000 pregnant women. 
• 1.7% of female sex workers in Cambodia were newly infected with HIV—i.e., 17 of every 1,000 female sex workers became infected in 2006.

Statistical projections [7] suggest that HIV incidence has declined markedly among Cambodia’s general adult population as well, from a peak in new infections of 28,000 in 1994 to 1,330 new infections in 2006.  In other words, from 1994 to 2006, Cambodia’s HIV incidence rate (new infections per 100,000 population) declined from 486 to 15.

Despite impressive declines in both HIV prevalence and incidence, HIV infection rates in Cambodia remain high compared with other countries in the region. Cambodia ranked second highest in HIV prevalence among all countries in South and Southeast Asia, according to the UNAIDS 2008 Report on the Global AIDS Epidemic [10].  Only Thailand, with an estimated adult HIV prevalence of 1.4% in 2007 ranked higher than Cambodia.
 
Although Cambodia has achieved remarkable success in lowering HIV prevalence and incidence, this is no time for complacency.  Prevention, control, and treatment efforts have to be maintained to sustain these hard fought gains against the HIV epidemic.

Tuberculosis

The burden of tuberculosis (TB) in Cambodia is extremely high.  Cambodia is included on the World Health Organization’s list of 22 high-burden countries which account for approximately 80% of all new TB cases arising each year [11].  In 2006, the estimated incidence of all forms of TB was 500 per 100,000 population, the highest rate of all 36 WHO Western Pacific Region countries, and second only to Timor-Leste among 47 Southeast Asia and Western Pacific Region countries [12].  Prevalence of TB (per 100,000) was 665, the ninth highest of 193 countries [11]. 

TB-HIV co-infection is of great concern.  TB is a leading cause of death among HIV-infected persons infected worldwide [13].  A national serologic survey conducted by the Cambodia Ministry of Health in 2007 found that 7.8% of patients with newly diagnosed TB were co-infected with HIV [14].  Mortality rates among HIV-infected TB patients are very high.  A study [15] conducted in Bangkok, Thailand found that HIV-infected TB patients who did not receive antiretroviral therapy (ART) were 20 times as likely to die compared with patients who had received ART.  Within 11 months of their TB diagnosis, 50% of patients who did not receive ART had died compared with less than 5% of patients who had received ART.  Patients who initiated ART after six months of TB diagnosis were 2.6 times as likely to die compared with those who initiated ART within 6 months of TB diagnosis.  Clearly, early identification and appropriate treatment of HIV among TB patients and TB among HIV patients is paramount in reducing mortality among TB-HIV co-infected patients.

Antiretroviral Therapy

Antiretroviral therapy (ART) and opportunistic infection prophylaxis first became available in Cambodia in 2001 but only at a few clinics in Phnom Penh, Takeo, and Siem Reap.  Since then, Cambodia has rapidly scaled up provision of ART to persons living with HIV/AIDS.  At the end of 2002 only 392 patients were receiving treatment.  The progress made since then has been remarkable: by July 2008, almost 27,000 of the 30,500 HIV-infected adults (88%) estimated to be in need of ART were receiving it [7, 16].
 
CDC’s Role

CDC GAP Cambodia’s strategic vision focuses on three areas:  HIV care and treatment, laboratory strengthening, and epidemiology and strategic information, while addressing the entire spectrum of the HIV epidemic.  CDC GAP-funded activities work at all levels to support policy development and build sustainable capacity required to effectively prevent, reduce, and monitor the impact of HIV/AIDS. 

CDC GAP Cambodia’s prevention strategies concentrate primarily on prevention of mother-to-child transmission (PMTCT), working to promote routine HIV testing among pregnant women and to improve linkages between PMTCT programs and antiretroviral (ARV) treatment services.  Such linkages are needed to ensure that treatment is available for HIV-positive mothers and that their HIV-exposed infants are enrolled in care and effectively followed.  CDC GAP Cambodia is working with Cambodia’s National Institute of Public Health and the Clinton Foundation to expand laboratory capacity for the early diagnosis of HIV among infants and with NCHADS and the National Maternal and Child Health Center to improve access to HIV testing and PMTCT services for all pregnant women.    

CDC GAP Cambodia supports the strengthening and expansion of high quality HIV testing services in the public sector, especially in rural and remote areas, and the establishment of sustainable quality assurance programs, patient referral systems, and home- and facility-based continuum of care services.  CDC GAP Cambodia is working with the Ministry of Health to promote Cambodia’s policy of provider-initiated testing and counseling to assure that pregnant women and patients with HIV-associated conditions (e.g., TB, STIs, infectious and dermatological diseases) are screened for HIV.  Essential to its strategy to reduce the impact of HIV/AIDS, CDC GAP places special attention on accurately diagnosing TB among HIV-infected persons, and is working to strengthen the diagnostic capacity of Cambodia’s TB laboratories and develop a region-specific, evidence-based algorithm for the diagnosis of TB among persons with HIV, as well as diagnostic algorithms to be used to select patients for isoniazid preventive therapy.  With Cambodia’s rapid scale-up of ART services, mechanisms to monitor the quality of services and assure that service quality is maintained at a high level need to be implemented.  CDC GAP Cambodia is working with National Center for HIV/AIDS, Dermatology, and STDs to develop quality assurance systems and to help ART clinics institute quality improvement activities.   

Currently, few clinical laboratories have sufficient skills and equipment to perform tests used to monitor patients receiving ARV treatment.  Therefore, strengthening laboratory infrastructure with an emphasis on quality assurance is one of the critical areas of the CDC GAP Cambodia program.  Additionally, the program offers technical assistance and guidance on systems strengthening and policy issues. 

CDC GAP Cambodia provides technical assistance and resources to expand and strengthen HIV and STI surveillance and other strategic information systems for monitoring the impact of the epidemic and evaluating the effectiveness of programs and Cambodia’s response to the epidemic.

In addition to providing support at the national level, CDC GAP Cambodia also provides the Ministry of Health with direct support for provincial level activities in Banteay Meanchey, Battambang, Pursat, and Pailin. 

CDC GAP Cambodia’s program is supported by CDC GAP headquarters, based in Atlanta, GA, and PEPFAR funds.  CDC GAP Cambodia is a proud partner in the unified U.S. government HIV response headed by the U.S. Office of the Global AIDS Coordinator.

Influenza Program

The CDC Influenza Program Office in Cambodia, established in 2006, comprises three staff members: an American director and two locally hired Cambodian nationals--a laboratorian and a budget analyst.

Avian/Pandemic Influenza Assistance Package to the Royal Government of Cambodia

Cambodia was one of the Southeast Asian countries hardest hit with the introduction of avian influenza virus H5N1-- first affecting the domestic poultry industry and subsequently infecting humans. This highly pathogenic H5N1 virus resulted in four human H5N1 cases in 2004, two cases in 2006, and one case in 2007; all seven infections have been fatal.  More than 21 confirmed highly pathogenic avian influenza outbreaks have occurred among birds (mostly chickens and ducks) in Cambodia since 2004.

In October 2005, Michael Leavitt, Department of Health and Human Services (DHHS) Secretary, toured Southeast Asia with senior US  public health officials to assess the situation and commit US assistance to countries hardest hit by the growing avian influenza epidemic.  This commitment to the Government of Cambodia was for financial, material, and technical support.

The overarching short and long term goals of this assistance include:

• Developing the overall public health capacity of the Ministry of Health to deal with potential pandemic influenza and other emerging infections.
• Contribute to the successful implementation of Cambodia’s National Influenza Pandemic Preparedness Plan.
• Assistance from CDC and other USG agencies will be guided by the

US pillars of the National Pandemic Flu Plan.  Three major pillars of this plan include:

1. Preparedness and Communication
2. Surveillance and Detection
3. Response and Containment

CDC assistance is broadly focused on:

• Increasing human capacity for surveillance and response to  pandemic influenza; 
• Strengthening and broadening surveillance infrastructure and networks;
• Ensuring biosecurity through laboratory infrastructure upgrades; and
• Building capacity of Cambodia to participate actively as a National Influenza Center (NIC) in the World Health Organization’s (WHO) network of Global Collaborating Centers for Pandemic Influenza.

CDC is focusing its direct assistance on the following pillars:

I.) Surveillance and Detection

1. Enhance laboratory capacity and infrastructure
2. Enhance surveillance and epidemiology capacity and infrastructure
3. Assist the Ministry of Health in establishing a laboratory system for detection and monitoring of influenza-like illness (ILI), sub-acute respiratory illness (SARI), and highly pathogenic avian influenza (HPAI)surveillance
4. Enhance epidemiologic  capacity for surveillance of and response to outbreaks of influenza and other emerging diseases, including suspect syndromes and clusters

II.) Response and Containment

1. Establish and support rapid response teams (RRT); refine training-of-trainers courses and standard operating procedures.
2. Establish and scale up infection control protocols within referral, provincial and district hospitals.
3. Develop clinical management standard operating procedures in referral hospitals.

Counterpart and Implementing Partners

The prime partner agency with which CDC works is the Cambodian Ministry of Health through the Cambodian Communicable Disease Control (CDC) Division and the National Institutes of Public Health (NIPH).

US CDC will work in support of the WHO Collaborating Centers for Pandemic Influenza and work within the guidelines of the International Health Regulations (IHR).

To implement this support, cooperative agreements between DHHS and US CDC provide:

• Direct government-to-government assistance – with Ministry of Health/National Institute of Public Health /Cambodian CDC (5-year duration)
• Indirect support and assistance to the Government of Cambodia through partner agencies as:
  - World Health Organization (WHO)
  -  Institute Pasteur, Paris
  -  CARE International 

References

1. National Institute of Statistics, General Population Census of Cambodia 2008.  Provisional Population Totals. 2008, Cambodian Ministry of Planning: Phnom Penh.
2. World Bank. Global Development Indicators Online.  2008  [cited 03 October 2008]; Available from: http://www.worldbank.org.
3. UNESCO Institute for Statistics. UIS Statistics in Brief  [cited 07 October 2008]; Available from: http://stats.uis.unesco.org.
4. World Health Organization. World Health Statistics Information System 2008.  2008  [cited 03 October 2008]; Available from: http://www.who.int/whosis/en/index.html
5. National Institute of Statistics Data User's Service Center, Cambodia Population Estimates and Projections, 1998-2020 (CD-ROM). 2004, Cambodian Ministry of Planning: Phnom Penh.
6. National Institute of Public Health, National Institute of Statistics, and and ORC Macro, Cambodia Demographic and Health Survey 2005. 2006, Cambodian National Institute of Public Health, National Institute of Statistics, and ORC Macro: Phnom Penh, Cambodia and Calverton, Maryland, USA.
7. National Center for HIV/AIDS, Dermatology, and and STDs, Report of a Consensus Workshop.  HIV Estimates and Projections for Cambodia, 2006-2012. 2007, Cambodian Ministry of Health: Phnom Penh.
8. National Center for HIV/AIDS, Dermatology, and and STDs, Asian Epidemic Model (unpublished data). 2007, Cambodian Ministry of Health: Phnom Penh.
9. National Center for HIV/AIDS, Dermatology, and and STDs, HIV Sentinel Surveillance 2006: Dissemination Workshop, Cambodian Ministry of Health: Phnom Penh.
10. Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic. 2008, UNAIDS: Geneva.
11. World Health Organization, Global tuberculosis control:  surveillance, planning, financing.  WHO report 2008. 2008, World Health Organization: Geneva.
12. World Health Organization, Global Tuberculosis Control in the Western Pacific Region:  2007 Report. 2007, World Health Organization , Western Pacific Region: Manila.
13. World Health Organization. 2007 Tuberculosis Facts.  2007  [cited 22 October 2008]; Available from: http://www.who.int/tb/publications/2007/factsheet_
    2007.pdf.
14. Ministry of Health, Tuberculosis Report 2007. 2007, Cambodian Ministry of Health: Phnom Penh.
15. Manosuthi W, et al., Survival rate and risk factors of mortality among HIV/tuberculosis-coinfected patients with and without antiretroviral therapy. J Acquir Immune Defic Syndr, 2006. 43: p. 42-46.
16. National Center for HIV/AIDS, Dermatology, and and STDs. NCHADS Data Management Unit 2008 2nd Quarterly Report on ART.  2008  [cited 07 October 2008]; Available from: http://www.nchads.org/DataMGT/q2%202008/art.pdf.