Serological diagnoses for infectious diseases such as those based on disease¬specific IgM antibody detection often confuse clinicians and therefore make treatment decisions difficult. This is due to the relatively long persistence of IgM in the blood circulation following exposure to the organism or nonspecific polyclonal activation of memory cells. We report a Lao patient diagnosed as having scrub typhus on admission based on detection of IgM to Orientia tsutsugamushi and initially treated with Doxycycline. The patient became afebrile but had severe pulmonary involvement. The blood culture was subsequently positive for Leptospira spp. which is the cause of leptospirosis. The admission blood sample of the patient was negative for Orientia tsutsugamushi, Rickettsia typhi, and Rickettsia spp. DNA targets, by PCR, suggesting that the patient did not have scrub typhus, murine typhus or Spotted Fever. After one week of IV ceftriaxone treatment, the patient improved and was discharged well. The positive IgM to scrub typhus detected on admission was probably due to previous exposure to O. tsutusgamushi, and scrub typhus was not the cause of her presenting illness. Fortunately, Doxycycline, given to the patient for scrub typhus treatment, is also effective for leptospirosis preventing death. However, the patient required intravenous ceftriaxone (which would not have been effective for scrub typhus) when she developed severe disease. This patient’s illness is a reminder that clinicians should be cautious about serological diagnosis. At present, laboratory diagnosis of leptospirosis remains a big challenge for the clinicians because the existing gold standard test such as Microscopic Agglutination Test (MAT) and culture are labour intensive, expensive and seldom available. Until the development of the simple, rapid, and more reliable tests, the empirical treatment of patients with suspected leptospirosis with doxycycline, penicillins or ceftriaxone are strategies to reduce severe complications and death although it should be born in mind that penicillins and ceftriaxone will not be effective against rickettsial organisms.

Rational and Background: Advertisements are forms of communication used to encourage or persuade an audience to continue or to take some new action, usually to purchase. Product and service adverts on Lao television have significantly increased recently. However, very little is known about the frequency of health- related adverts on Lao television and whether they are containing Lao appropriate public health messages. Study of the frequency and potential impact of health-related adverts might help us to better understand the situation and contribute to solving health-related problems of Lao people. Methodology: This was a descriptive study to describe the adverts on Lao television during three months (February – April 2011). All Lao television adverts broadcasted during three months were tape-recorded and information was extracted on a pre-designed form. All adverts were analyzed and classified as health-related and non health-related. The time of adverts was also calculated. Data were entered into excel sheet and analyzed using STATA 10.0. Results: During three months, 34 adverts were observed on all three Lao television channels. Of these, 28 (82%) were health-related and 6 (18%) were not. Of 28 health-related adverts, 10 (36%) were classified as good for Lao public health, 3 (11%) were considered as dangerous to health, and 15 (53%) were of uncertain classification. All three adverts regarded as ‘bad’ to health were advertising beverages containing alcohol or caffeine. The average advert durations were 1.5 minutes and 1 minute for those advertising alcohol- and caffeine- containing beverage. Over three months, 3,702 spots of these three adverts were on air with an average total exposure time of 82.5 hours, which was longer than those considered as ‘good’ for health (2,068 spots over 32.9 hours). Some products were exaggeratedly advertized which might mislead the audience and negatively affect their health. Conclusion: More than 80% of all Lao TV adverts were health-related, but 2/3 were classified as potentially harmful to health. The frequency and total duration of health-related adverts, which were considered to be harmful to health, were higher and longer, respectively, when compared to those considered to be good for health. This study suggests that Lao people are exposed to adverts that are contrary to the interests of Lao public health. Strict measures to ensure that advertisements are accurate and do not mislead people, persuading them to buy things that are not in the interests of Lao public health, are required.

Rational and Background: Epidemiological surveillance by Khammouane Provincial Health Centers has been inadequate with incomplete and untimely data collection, and insufficient information dissemination. However, difficulties and gaps in the surveillance system have not been identified. Study of the administrative factors and processes affecting performance of epidemiological surveillance by health center workers would help to identify problems and therefore identify appropriate solutions. Methodology: This was a descriptive, cross-sectional study involving two groups: (1) 143 health workers from 74 health centers who were interviewed using a questionnaire and (2) 9 heads of epidemiology teams from 9 districts of Khammouane Provinces, Lao PDR who were interviewed in-depth. Results: Fifty-nine percent of the respondents were female with mean (SD) age of 35.6 (8.5) years. The mean (SD) years of working in epidemiology was 4.1 (4.2) years. The overall mean (SD) score of performance in epidemiological surveillance by the health center workers was 3.30/5 (0.94). The mean (SD) score of administrative factors affecting the performance in epidemiological surveillance was 2.68/5 (0.80). Previous training in epidemiology and educational level were positively correlated with epidemiology surveillance performance (r=0.25, P<0.05) and (r=0.27, P<0.05). Manpower, material, and budget were related with work performance (r=0.54, P<0.01), (r=0.34, P<0.01), and (r=0.22, P<0.01), respectively. In a multivariate analysis, planning (P<0.01), organization (P<0.01), and staff training (P<0.01) were independently correlated with the epidemiological surveillance performance. Conclusion: The level of the performance of epidemiological surveillance by Khammouan Health Center staff was moderately satisfactory. Regular monitoring of the work performance by the Provincial and District Health is required to identify problems and solutions. At least 1-2 workshops on epidemiological surveillance should be organized in order to enhance knowledge and understanding of disease surveillance by the health center staff aimed at improving their work performance.

Rationale and Background: Diarrhea remains an important cause of morbidity and mortality among Lao children, particularly those aged < 5 years. Child caretakers’ behaviors on the prevention of diarrhea are key determinants affecting child morbidity and mortality. Study of factors associated with caretakers’ behavior on diarrhea prevention is therefore needed to identify correct and appropriate solutions in the community. Methodology: This was cross-sectional research to identify factors associated with child caretakers’ behavior on diarrhea prevention among children aged 0 - 5 years in rural Champasack Province, Lao PDR. The study population was caretakers of children aged 0 – 5 years who lived together in the same household (n = 280). The study was performed between June 2010 – June 2011 using predesigned and pretested questionnaire. Results: Eighty-one percent of respondents were females with a mean (SD) age of 32.4 (10.2) years and 50% of them were rice farmers. Sixty-five percent of the caretakers had high level (score 24 – 30) of perceived risk of getting diarrhea with a mean (SD) score of 24.7/30 (3.26). The mean (SD) score of disease severity perception of the respondents was 26.03/30 (2.47) and 82.5% of them had high level of perception. Eighty percent of those interviewed perceived benefits of following advice about diarrhea prevention behaviors at high level, about half perceived obstacles in following advice in diarrhea prevention behaviors at high level (52.14%) and 60.71% had a high level of diarrhea prevention behaviors. In a multiple linear regression analysis, factors associated with caretakers’ behaviors on prevention of diarrhea were educational attainment (no education) (Mean diff = -0.156; 95%CI = -1.487 to -0.327; P-value < 0.001), perceived severity of diarrhea (Mean diff = 0.328; 95%CI = 0.160 to 0.361; P-value < 0.001), and perceived benefits of following advice in diarrhea prevention behaviors (Mean diff = 0.2763; 95%CI = 0.255 to 0.500; P-value < 0.001). Conclusion: Despite a high level of child caretakers perception of risk of getting diarrhea, disease severity, and benefit of following advice in diarrhea prevention behavior, there remains a need to provide health education on hygiene and sanitation to prevent diarrhea among children, aimed at reducing morbidity and mortality among Lao children which is still high at the moment.

Severe P. falciparum malaria kills people, particularly African children ~ 200,000 per year. Quinine and quinidine infusions were the only antimalarial drugs available to treat severe malaria until recently. The rediscovery of artemisinins in 1972 and subsequent synthesis of artemether and artesunate have provided highly effective alternatives to quinine. Results from meta¬analysis demonstrated that artemether significantly reduced mortality in adult patients with severe malaria from Southeast Asia. Pharmacokinetic studies suggest that the oil¬soluble artemether, which can be given intramuscularly but not intravenously, is poorly and slowly absorbed from the injection site while the water¬soluble artesunate is absorbed rapidly and reliably. The SEAQUAMAT study comparing intravenous artesunate vs quinine among adults and children in 4 Asian countries and demonstrated a significant absolute reduction of mortality of 34.7% (95%CI = 18.5 – 47.6%). A subsequent study (AQUAMAT study) conducted in African children with severe malaria in 9 countries confirmed the excellent efficacy of artesunate with a significant relative reduction of death of 22.5% (95%CI = 8.1 – 36.9%). A large meta¬analysis with more than 7,000 patients also confirmed that artesunate significantly reduced mortality in Africa of 22.5% and that in Asia of 38.6%. Patients treated with quinine had significantly higher incidence of hypoglycemia when compared to those who received artesunate. If these studies had been conducted 20 years earlier, perhaps 4 million patients with severe malaria would not have died particularly African children. Parenteral artesunate should replace quinine everywhere in the world as the first line treatment of severe falciparum malaria. Such a change in policy would save an estimated 200,000 live of children with severe malaria each year. With support from the Global Fund for the fight against AIDS, Tuberculosis and Malaria (GFATM), Laos changed the national policy of severe malaria treatment to artesunate as first line in 2006.

Beriberi (vitamin B1 or thiamin deficiency) is neglected health problem that probably remains as a significant cause of mortality among infants in Asia. There has been very little research in the last 4 decades. Although there are few data from Laos, the clinical experience of Lao pediatricians, along with some data from Mahosot Hospital in Vientiane, suggests that beriberi is probably an important cause of infant mortality, which is currently very high in Laos. Diagnosis of infantile beriberi can be clinically if signs are evident. However, a significant number of infants may have clinical unapparent vitamin B1 deficiency, complicating their illness, which is impossible to diagnose unless biochemical assays are performed. Unapparent vitamin B1 deficiency may complicate the illness of infants presenting with other diseases and supplementary treatment with vitamin B1 could potentially improve their outcome and reduce infant mortality. Two recently published papers by the Wellcome Trust – Mahosot Hospital – Oxford Tropical Medicine Research Collaboration suggested that approximately 13% of Lao sick infants admitted with diarrhea, pneumonia and sepsis (without clinical evidence of beriberi) at the Pediatric Wards, Mahosot Hospital, Vientiane had evidence of biochemical vitamin B1 deficiency particularly among those aged > 2 months. Infants with biochemical vitamin B1 deficiency had higher mortality than those who were not B1 deficient. The study also demonstrated that the activation coefficient (α), which has been used to diagnose vitamin B1 among adults living in non¬rice eating societies, cannot be reliably used for the diagnosis of vitamin B1 deficiency in infants, that basal ETK < 0.59 micromoles/min/gHb is a better biochemical marker of infantile beriberi, and that detection of the cardiac dysfunction marker troponin T may be useful indicator of infantile beriberi. The implication of the findings in these two papers were that (i) since clinical unapparent vitamin B1 deficiency is common among Lao sick infants, co¬treatment with vitamin B1 may reduce disease severity and mortality, (ii) since basal ETK is more accurate than activation coefficient (α) in the diagnosis of infantile beriberi, basal ETK should be used for the diagnosis of vitamin B1 deficiency among infants, and (iii) since troponin T may be useful in the diagnosis of infantile beriberi and as this assay is now available as a bedside test these should be evaluated as accessible markers.

Melioidosis is recognized with increasing frequency in the Lao PDR, and is probably far more common than is currently appreciated. Recommendations for the antibiotic treatment of melioidosis are based on good evidence from a series of large clinical trials conducted mainly in northeast Thailand over the past 25 years. This review summarizes that evidence and considers it in a Lao context. Treatment is usually divided into 2 phases: in the first, or acute phase, parenteral drugs are given for at least 10 days with the aim of preventing death from overwhelming sepsis; in the second, or eradication phase, oral drugs are given, usually to complete a total of 20 weeks, with the aim of preventing relapse. Within these broad generalisations, specific treatment for individual patients needs to be tailored according to clinical manifestations and response, and there remain many unanswered questions. Some patients with very mild infections can probably be cured by oral agents alone. In the Lao PDR, ceftazidime is used for the acute phase, with co-amoxiclav as second line therapy. Co¬trimoxazole plus doxycycline is preferred for the eradication phase, with the alternative of co¬amoxiclav. It is likely that clinical trial evidence will soon support the use of co¬trimoxazole alone. In all cases, the best available supportive care is needed, along with drainage of abscesses whenever possible. Treatment for melioidosis is extremely expensive, but the relative costs have reduced over the past decade. Unfortunately there is no likelihood of any new or cheaper options becoming available in the immediate future.

Rational and Background: University of Health Sciences (UHS) is a unique health institution in Laos that trains medical doctors. Annually more than 150 new medical doctors graduate from this institution but only some of them are recruited in the government health sector and a small number of them continue their higher medical education. Post¬graduate education has increasingly been established and developed at the UHS but very little is known about the expectation and awareness on post¬graduate medical training of the final year medical students. Understanding this issue may help health policy makers to develop strategic plans for medical doctor training appropriately and realistically. Additionally, attitude and suggestion of medical students on the current training program would also be important and essential to improve the curriculum. Methodology: This was a descriptive study to explore the expectation and awareness of the final year medical students on post-graduate medical training at the UHS including their attitude and suggestion towards the current medical training using face¬ to ¬face interview technique with application of pre-designed and pre¬tested questionnaire. Results: Of the 208 final year medical students in the academic year 2010, 186 (89.4%) were interviewed. The proportion of the students with expectation to continue their post¬graduate medical training was 53% (98/186) while the remainder wished to work following their graduation. The percentage of students who wished to continue their training was not significantly different between those who came from provinces [60/120 (50%)] and those who lived in Vientiane Capital [38/66 (58%)], P = 0.32 but this figure was statistically lower among those who had previously worked as health workers compared to those who had not [4/20 (20%) vs 94/166 (57%), P = 0.006]. Only 64.5% of all respondents knew that there is post¬graduate medical training at the UHS. Residency (90%) and family medicine (85%) training programs were the most common post¬graduate medical education of which they were aware but only 21% them correctly understand about residency training program and 16.6% about family medicine program. The training programmes that respondents most commonly stated that they would like to study were OBGY (21%) and Internal Medicine (21%). Among 81 interviewees (43.5%) who expected to work following their graduation, 68 (84%) intended to work for the government sector particularly in the public hospital (75%) for the reason that they wanted to help patients (53%). Only 7.5% of all respondents mentioned that the existing undergraduate training program was good and did not require further improvement while the remainder strongly suggested that the curriculum need to be revised with the emphasis on more practice in the laboratory and hospital. Conclusion: Approximately half of the last-year medical students (academic year 2010) expected to work in clinical practice while the rest wished to continue their further training. But their understanding of the post¬graduate training programs was very low. Most of these students suggested that the existing undergraduate training program be revised with the emphasis on more practice in the laboratory and hospital.

Rational and Background: Diarrhea remains an important cause of morbidity and mortality among children under five (U5) in Laos. Complications of paediatric diarrhea are not uncommonly found among the children admitted to hospitals. Incorrect home¬care practice of children with diarrhea by their guardians may be an important factor contributing to such complications. Methodology: A cross¬sectional, descriptive study was carried out at three central hospitals of Vientiane Capital (Mahosot, Mother and Child, and Setthathirat) between January and February 2010 with objectives to (1) determine the frequency of diarrhea complications among U5 children, (2) describe home care behavior of diarrhea by care¬givers, and (3) correlate such behavior with complications. Results: During the study period 3,722 U5¬children presented or were admitted to the three hospitals. Of these 880 (24%) had diarrhea. Of all children with diarrhea, 262 children and their guardians were studied. All children had been treated before presenting to the study hospitals [home¬care by guardians (52%), treated in public hospitals (34%) and in private clinic (14%)]. One hundred and seventy¬one children (65%) had at least one complication at presentation including dehydration (48.5%), malnutrition (27%) and abdominal distension (12%) with one intussusception (0.4%). Treatments given to the children before presenting to the hospitals were ORS (83%), antibiotics (46%), anti¬diarrheals (25%), herbal medicines (8.5%), and antiemetics (5%). Ninety percent of the guardians had correct knowledge of diarrhea definition and on how to prepare ORS but only 32% and 27% of the guardians increased quantity of daily fluid and food, respectively, to their children during diarrhea. The mean (95%CI) years of schooling of the guardians whose children had complications at presentation were significantly lower than those whose children did not have complications [8.5 (8.1 – 8.9) vs 9.2 (8.2 – 9.6), P = 0.04]. Children who received anti¬diarrheals and antibiotics before presentation were 5 and 3 times, respectively, likely to have complications when compared to those who did not [OR = 4.9, 95%CI = 2.2¬10.9; P < 0.001 and OR = 3.4, 95%CI = 1.9 – 5.9; P < 0.001; respectively]. Children treated with anti-diarrheals and antibiotics prior to presentation were 26 and 5 times, respectively likely to have abdominal distension compared to those without treatment [OR = 26.1, 95%CI = 9.4-72.4; P < 0.001 and OR = 4.8, 95%CI = 2.0¬11.7; P < 0.001; respectively]. Children who were given normal quantity of fluid by the guardians during diarrhea were 1.5 times likely to be dehydrated when compared to those who received increased quantity of fluids [OR = 1.6, 95%CI = 1.1¬2.2; P = 0.002]. Conclusion: Half of Lao U5¬children with diarrhea admitted or presented at central hospitals in Vientiane Capital had been treated by their caregivers and 2/3 of them had at least one complication. These complications were significantly associated with incorrect home¬care practice by the guardians especially treatments with anti¬diarrheals and antibiotics.

Staphylococcus aureus is a common and often serious human pathogen accounting for about a fifth of all cases of bacteraemia with an associated mortality of up to 50%. This review summarizes the aspects of S. aureus bacteraemia that are relevant in a Lao context, including the antibiotic susceptibility patterns seen at Mahosot Hospital, Vientiane over the past 11 years and provides guidance and rationale for clinical management. In the Lao PDR it is the third commonest cause of bacteraemia and the leading cause of skin and soft-tissue infection. Mahosot Hospital has seen almost 200 cases and antibiotic susceptibility testing shows that a significant proportion of isolates are tetracycline and erythromycin resistant. Methicillin-resistance remains very rare, though this is unlikely to continue. Key risk factors for S. aureus disease in financially-poor settings include surgical procedures and previous antibiotic exposure. The identification and removal or drainage of a focus of infection is a key part of the management strategy. Transthoracic echocardiography (TTE) is advised for all patients, where this technique is accessible, and consideration should be given to repeating this test or performing a transoesophageal echocardiogram for patients with a negative TTE, but with a high index of suspicion for infective endocarditis. Treatment with a !-lactam antibiotic (preferably cloxacillin), for 2 weeks in uncomplicated disease and 4 to 6 weeks in complicated disease, is essential to provide cure and prevent relapse. An oral switch may be required, though this should take place only if the patient has been afebrile for 48 hours and has no ongoing complications requiring intervention. Copyright: ∀ 2012 Elliot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.