Poor quality medicines have been described as a global pandemic that threatens the lives of millions of people. The problem is much more severe in poor-resource countries where pharmaceutical legislation and regulation are limited. Poor quality medicines are divided into three categories: substandard, degraded and falsified and the countermeasures vary according to each category. The use of poor quality medicine leads from minimal to severe complications (including death) for the individuals but also harms the community. Furthermore, they lead to a loss of confidence of the patients in essential medicines, in manufacturers and in health system and they increase the work burden for health workers, customs and police. To detect them, different techniques have been developed, each with advantages and limits. This article describes these aspects of poor quality medicines and also presents the factors that contribute to the existence and spread of poor quality medicines. A section of the article is devoted to the issue of poor quality medicine in Laos.

This is a policy brief article on the prediction of Covid-19 outbreak and its prevention and control for the possible second wave in the Lao PDR. Compartmental dynamic modeling was created to reflect the natural history of Covid-19. This included susceptible, symptomatic and asymptomatic states and recovery or death. The simulation was done for one year and with two scenarios: 1) high transmission level (R0=5.2) and 2) mid -transmission level (R0=2.0). The model output showed that the size of the outbreak depended on the transmission level, and could reach to 85% of the Lao population with high transmission scenario. However, disease burden was predicted to be smaller with the interventions. Among these, voluntary home quarantine was found to be the most effective, but the predication reverses in the mid-level transmission scenario. Social distancing is much more effective. If there are imported COVID-19 cases, a new wave could occur in two weeks to 2 months, depending on the size of pandemic and efficacy of the rest of interventions. Mid-level lockdown would result in new epidemic starting by July 2020, but the number of infected people would be less if travel bans and social distancing are maintaining. Only high-level lockdown would be able to stop community transmission in the country.

Background and Rational: WHO reported that 735,000 people suffering from chronic disease due to pesticide use. However, no study has been conducted to assess this health burden in the Lao PDR. Therefore, no appropriate strategy was implemented even though pesticide is widely used in Lao PDR. Objective: To study the health impact amongst farmers utilizing pesticides for agriculture in Vientiane Capital. Methodology: The cross-sectional study was conducted in farmers using pesticides. The total number included in the study was 247 people in Hadsayfong and Xaythany Districts. The data were collected from April to June 2017. The data were analysed using Stata version xx. Multiple logistic regression was used to assess the relationship between the health impact and pesticide use. Result: We found that farmers are less educated and used pesticides incorrectly. The proportion of people having small and moderate symptoms were 56.3% and 43.7%, respectively. The factors associated with having symptoms were larger household size (Adjusted Odd Ratio =1.9; 95%CI= 1.0-3.6; P-value = 0.02), using pesticide longer than 3 hours each occasion (AOR=4.8; 95%CI= 2.6-8.9; P-value < 0.001), and using pesticide more than 8 times per month (AOR=0.5; 95%CI= 0.2-1; P-value = 0.01). Significant factors associated with not having symptoms included using materials to stir pesticide (AOR=0.5; 95%CI= 0.2-1; P-value=0.002) and wearing masks during pesticide spraying (AOR=0.4; 95%CI= 0.2-0.7; P-value=0.004). Conclusion and recommendation The study found that the knowledge of farmers towards pesticide’s side effects was mostly low with incorrect use. Without any appropriate education, farmers risk of suffering from chronic diseases such as cancer and dermatological diseases.

Background and Rational: In Lao PDR, relapse of metamphetamine use following discharge from rehabilitation center is unacceptably high (~50%). Good preparedness and IEC provision to the rehabilitated addicts before discharge from the rehabilitation center is likely to be vital to prevent relapse. Effective IEC would probably help to reduce the rate of relapse. Methodology: This was an open cluster-randomized-controlled trial to assess the newly developed IEC package among metamphetamine users. The intervention group received new IEC package (education message + brochure + telephone contact number + follow-up) while the conventional advice was given to control group. The study participants were followed up for 6 months by telephone (at 1, 3, 6 months). The primary endpoint was the relapse rate. Result: One hundred and eighty-one addicts were enrolled in the trial (93 in intervention and 88 in control groups). Ninety-six subjects were male. The overall mean (SD) age of the participants was 26.5 (6.1) years and the overall median (range) duration of drug use was 5 (0.5 – 26) years and these figures were not significantly different between the groups (P=0.50 and P=0.97), respectively). The proportion of the participants who were lost to follow-up was 8%. Sixty percents of the study subjects completed 6-months follow up and this was not statistically different between the groups (P=0.93). The overall percentage of relapse was 39% (65/166) [36% (31/85) in intervention and 42% (34/81) in control groups, P=0.38). The median (range) duration of relapse was 30 (1 – 160) days and this was not significantly different between the groups (P=0.38). In a multiple logistic regression model, contact with drug users following discharge from the rehabilitation center was significantly associated with relapse [AOR = 73, 95%CI = 39 – 405, P<0.001] while having a permanent job following discharge was a protective factor for relapse [AOR = 0.03 (0.004 – 0.27), P=0.002]. Conclusion The relapse rate of metamphetamine use was lower in the group with new IEC package than in control group but this was not statistically significant. Further study with a larger scale is strongly recommended

Background and Rational: Improving quality of services is one of the main strategies of the Ministry of Health to strengthen health care services, aiming to provide better care. The Emergency Ward (ER) of Mahosot Hospital provides services to patients 24 hours a day. Since the work there is very busy, some complaints were arisen from the nurses regarding the workload, insufficient staffing levels, and staffs did not have time for families. In addition, three nurses asked to change their jobs and 6 ask to move to another ward. We, therefore, conducted this study to assess job satisfaction of the nurses and obstacles in regards to their work and management. Methodology: A descriptive cross-sectional study was conducted from 19-25 February 2018. Thirty-three nurses working in ER were interviewed using pre-designed and pre-tested questionnaire comprising 4 parts. Data analysis was done using SPSS. Result: The mean age of the respondents was 34.3 years, 85% were female and 73% were married. Nearly half of them did not have children. Thirty-nine percent of them have worked for 6-10 years with 73% having a nursing degree. The majority of them are satisfied with their current work (90.9 %) and 79% of them said that they had a great job with appreciation from their colleagues. More than half had the appropriate opportunity for short-course training and support from the head of department. Observing their practice, we found that they had clean nursing uniform (66.7%), showed appropriate behaviors (54.5%), friendly service (54.5%) and had good relationships with their colleagues (63.6%). Regarding the obstacles and solution, they reported that some problems need to be solved including those related to human resource (90.9%), relationships with other nurses (21.2%), head nurses (9%), doctors (27.16%), nature of workplace and environment (63%), facility and management (27%), equipment and medicine availability (72.7%), remuneration (51.5%) and others (30%). Conclusion The job satisfaction level of the nurses at ER of Mahosot Hospital is high but there remain some concerns related to work safety, working environment, equipment and salary. Therefore, it is vital that these problems should be solved urgently in order to strengthen quality of health care service.

Background and Rational: Open trades in Lao PDR leads to many imported goods. Lacking capacity with international standards for inspecting and validating the imported goods at border check point would harm consumers. Methodology: A descriptive study was conducted to assess the opinions and practice towards the staff of food and drug administration at 16 check points in Lao PDR using self-administered questionnaire from March to June 2015. Result: The detection and validation were done based on food categories, which included raw food, canned food and other prepared food. There are 5 steps of validation: 1) checking documents at the checking point; 2) checking food; 3) seizing food; 4) releasing food and 5) reporting. The staff reported that documents should include name of food, label, certificate of food quality, certificate of laboratory sample analysis, certificate of importation permission, invoice and packaging list. Meanwhile, checking food includes the random selection of product for screening tests, particularly raw food. The suspected contaminated food will be verified at the main laboratory. Then, the suspected contaminated food was seized until the result of the laboratory are available. The foods from those who had the history of contaminated food importation should be randomly tested. The contaminated foods were recorded as blacklisted in order to facilitate next importation in detecting and validating the quality of food. Any update regulations should inform to the importers. The food and drug administrators at checkpoints had a good practice based on Lao regulations. However, some materials need to be improved. The detection form needs to be separated according to the food categories. They need more test kits, random detection guidelines, guidelines for laboratory tests, guidelines for detecting high-risk contaminated food, tools and materials of inspection. Moreover, there is a need of short and long-term training on using detection tool kits, random selection and reporting system. Conclusion There are different methods of inspection of imported food at checking point of Lao PDR. The international checking point had better quality than the other one.

Introduction: Neonatal sepsis is a major cause of morbidity and mortality among newborns. Sepsis accounts for 30-50% of all neonatal deaths in developing countries. C-reactive protein (CRP) has been used to predict neonatal sepsis with high sensitivity and specificity. Currently, blood culture is the gold standard for neonatal sepsis diagnosis, but it takes at least 48 hours to 7 days and not all cases have positive culture in neonatal infection. Objective: To assess the performance of C-reactive protein for predicting neonatal sepsis. Methodology: A prospective and retrospective descriptive study in neonates aged up to 28 days old presenting with symptoms and signs of sepsis and maternal high-risk factor of neonatal sepsis at Pediatric Intensive Care Unit of Mahosot Hospital. C-reactive protein rapid test was considered positive if the test level was ≥6mg/L. Blood culture was used as reference test. Result: Among 725 neonates recruited in the study, 3.9% blood cultures were positive. Among these, 21.4% were Staphylococcus aureus, 14.3% Escherichia coli and 10.7% Klebsiella pneumoniae. Sensitivity, Specificity, Positive and Negative predictive values of CRP in predicting neonatal sepsis were 71.42%, 70.15%, 8.77% and 98.3% respectively. Conclusion C-reactive protein rapid test could not predict neonatal sepsis very well, but might enable to rule out non-sepsis patients because of its high negative predictive value. This is clinically useful for treatment follow-up and antibiotic use.

Background and Rational: Fever is a common illness in children. Fever accounts for about 30% of all chief complaints in children presenting at emergency ward of the Childrens’ Hospital, Vientiane. Objective: To compare the efficacy of fever management using rectal paracetamol plus tepid sponge (Group 1) versus rectal paracetamol plus fever cooling sheet (Group 2) in children aged 2 months to 5 years. Methodology: We conducted a randomized controlled trial at the emergency ward of the national Children Hospital, Vientiane Capital, Lao PDR. Fever was defined as axillary temperature of ≤38.5°C. The study was from 1st June to 1st September 2018. The doses of paracetamol used were 80 mg, 125 mg and 250 mg for children weighed 3-<6 kg, 6-10 kg and >10-<15 kg, respectively. Consent ethics Result: One hundred children enrolled in the study, 50 children in Group 1 and 50 in Group 2. The most common febrile illness in our study was the common cold. There was no significant difference of proportion of common colds in both groups (45.8% vs 39.2% in Group 1 and Group 2, respectively). The average temperature prior to treatment was 38.69°C and 38.78 °C for Group 1 and Group 2, respectively. After 15 minutes of the treatment, the temperature reduced to 38.43°C and 38.67°C, reduced to 38.13°C and 38.55°C in 30 minutes and to 37.62°C and 38.41°C in 60 minutes later for Group 1 and Group 2, respectively. The temperature at 60 minutes after the treatment was significantly lower in Group 1 (p=0.021). The proportion of children with normal temperature ( ≥37.5°C) was significantly higher Group 2 than Group 1 (18.7% vs 0%, respectively; p=0.01). The side effect of the treatment (irritation) in 60 minutes later was significantly higher in Group 2 as compared to Group 1 (76.9% vs 23.1%, p=0.006). Conclusion Rectal paracetamol plus tepid sponge was more efficacious than rectal paracetamol plus fever cooling sheet in lowering the temperature in children. Therefore, tepid sponge should be highly recommended to avoid the side effects derived from fever cooling sheet.

Introduction: Diarrhea is the most common disease of children particularly in those under 5 years old. In Lao PDR, diarrhea is responsible for 12% of all childhood deaths and the disease is increasing. Therefore, there is a need to study optimal disease management in Lao patients Methodology: A retrospective study was carried out by reviewing medical records of patients admitted at the Pediatric Infectious Ward, Mahosot Hospital, Vientiane Capital from 01/01/2017 to 31/06/2018. We included those diagnosed with acute diarrhea aged 15 years old or younger. Finding: Three hundred and seventy children with diarrhea were included in the analyses, with a higher proportion of males than females [230 (62.2%), 140 (37.6%)] with a ratio of 1.6:1. Mean (SD) age of the patients was 2.1±2.33 years old. The most common age group was those < 2 years old with 247 cases (66.8%), followed by the age group of 2-5 years old [92 cases (24.9%)], 5-10 years old [25 cases (6.8%)] and 10-15 years old [6 cases (1.6%)]. The management in patients without clinically-evident dehydration was ORS in 161 (98.7%), IV fluid in 115 (71.5%) and antibotics in 12 (7.4%). For patients with moderate dehydration, the management consisted of giving ORS in 370 (100%), IV fluid in 198 (96%) and antibotics in one (0.5%). One patient with severe dehydration was given ORS and IV fluid. Conclusion High proportion of diarrhea found in children under 5 years old. Management in patients without clinical dehydration were rehydration with ORS and IV fluid because patients refused to drink ORS.

Background: Laos has a high prevalence of hepatitis B infection, at about 8% of the population. Hepatocellular carcinoma (HCC) caused by this virus could be significantly reduced by the primary prevention and early treatment of patients with chronic hepatitis B. Objective: To describe the levels of viral load in patients with chronic Hepatitis B before and after antiretroviral (ARV) treatment in Lao PDR. Methodology: A retrospective descriptive study was conducted by reviewing the laboratory records of 135 patients with chronic hepatitis B registered from January 2010 to August 2013 at the Christrophe Merieux Infectiology Centre, Vientiane Capital, Lao PDR. Hepatitis B viral load (VL) was determined by PCR before and after treatment initiation among this population. Pearson chi-square and Wilcoxon tests were used to compare the proportions and geometric mean. Result: Among 135 hepatitis B patients, most (88%) of the patients were from referral hospitals in Vientiane Capital. 65% were male, and 55% were given ARV without VL testing. Among these, Cycloferon (an immunomodulator) was the commonly used (57%), which is not yet recommended by the Asian Pacific Association for the Study of the Liver Guidelines (APASL). The VLs of patients treated with ARV and Immunomodulator were significantly reduced from the baseline after 4 months. Patients treated with ARV alone had significantly lower geometric mean VL [IC 95%] 4 months after treatment initiation than those treated with Immunomodulator (3.53 [2.81-4.2] versus 4.14 [2.99-5.29]; p<0.001), and those treated with a combination of ARV and Immunomodulator (Geometric mean of VL: 3.53 [2.81-4.2] versus 4.82[3.8-5.8]; p=0.035). Our study found that there was no significant difference in VL between Immunomodulator and ARV+ Immunomodulator (4.14 [3-5.2] versus 4.82 [3.8-5.8]; p=0.371). Conclusion ARV and Immunomodulator treatment is effective in reducing HBV VL, but ARV works more effectively than when used in combination with Immunomodulator and for Immunomodulator alone. There is an urgent need of developing Lao consensus hepatitis B treatment guidelines and good clinical practice implementation.