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Cablegate: Cambodia: Worst Dengue Fever Outbreak Since 1998

DE RUEHPF #1755/01 2700850
P 270850Z SEP 06





E.O. 12958: N/A

1. Summary. Cambodia is in the midst of its worst dengue
outbreak since 1998, with 10,000 Cambodian children already
infected this year. Phnom Penh's SOS Clinic, a popular
choice among the expatriate community, reports 47 dengue
cases so far this year, in contrast to 45 during all of 2005.
The pattern of dengue infection in Cambodia is changing from
a peri-urban, cyclical disease to one which affects more
remote rural and core urban areas, and one which is affects
10,000 to 12,000 people per year. Although the fatality rate
has fallen over the past several years, 100-200 Cambodian
children die each year and low quality health care
necessitates medical travel to Bangkok for some expatriate
adults and children. End Summary.

10,000 Dengue Cases So Far This Year

2. About 10,000 Cambodian children have been infected with
dengue fever so far this year, compared to about 6,000
children in the same period last year, according to Dr. Ngan
Chantha, Director of the National Dengue Control Program. In
10 of Cambodia's 24 provinces, the incidence rate (defined as
new cases per 100,000 individuals) for the first 32 weeks of
2006 is more than double the rate for the same period in
2005. The incidence rate in Phnom Penh has risen even more
dramatically, from 35.6 cases per 100,000 in 2005 to 99.3
cases per 100,000 in 2006. At least 102 Cambodian children
have died from dengue infection this year. Some health
experts have speculated that the presence of a previously
uncommon strain of dengue has contributed to the outbreak as
fewer children have prior exposure to that strain.

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3. The largest reported dengue epidemic in Cambodia occurred
in 1998, with 16,216 dengue cases and 475 deaths reported.
This epidemic mainly affected Phnom Penh and Kandal province.
Although the annual number of reported dengue cases has
declined since 1998, the distribution of disease has spread
from mainly urban areas to rural areas. In the past, dengue
infections in Cambodia have been cyclical, with years with
fewer than 1,000 reported cases interspersed with years with
3,000 or more cases. Since 2001, however, there have been
approximately 10,000-12,000 cases reported each year,
resulting in 100-200 deaths per year. In contrast to rising
infection rates, the fatality rate has fallen from 2.9%
during the 1998 outbreak to 1.0% so far this year, which may
reflect better treatment, earlier diagnosis, and/or increased
immunity to circulating strains. Nonetheless, this fatality
rate is relatively high compared to other Southeast Asian

Expats Affected as Well

4. Brian Ritchie, director of the SOS Clinic, a private
clinic serving 1,200 patients per month, stated that the
clinic has confirmed 47 cases of dengue so far this year, in
comparison to 45 cases during all of 2005. (Comment: Given
that peak dengue season is from June to November, it is
significant that YTD cases for 2006 have already outpaced
cases for the entire calendar year 2005. End Comment.)
Despite having a patient base that is 35-40% Cambodian
nationals, Ritchie reported that all but 1 or 2 of this
year's dengue cases were among expatriates. Ritchie also
reported seeing an increase in urban exposure to dengue
starting in mid-2005, whereas in past years dengue exposure
among expatriates was often linked to peri-urban and rural
exposure. Several of these cases have been tied to stagnant
water at construction sites which are proliferating in Phnom
Penh's building boom.

5. Approximately 10 of this year's SOS clinic dengue cases
had to travel to Bangkok for medical treatment, either
because the patient's blood platelet count was falling
quickly and safe blood products are not available in
Cambodia, or because the patient was quite ill and needed
symptomatic care in a hospitalized setting not available in
Cambodia. (Note: One adult embassy family member was
medevaced to Bangkok in July for dengue treatment, including
a 7-day hospitalization. End Note.)

6. Dengue infection among adults is far more common in the
expatriate than the Cambodian population. The average age of
all dengue cases at the SOS clinic was 33 years, whereas
according to National Dengue Control Program statistics, just
1% of Cambodians infected with dengue are over the age of 15.
While Cambodian children have typically been exposed to
several of the four strains of dengue by the time they reach
adulthood, expatriates often come to Cambodia with no dengue
immunity, leaving them vulnerable to infection. Dr. Jim
Cousins of the SOS Clinic noted that dengue infections among

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adults are often more severe than those in children.

7. The three main international schools--Northbridge
International School of Cambodia, International School of
Phnom Penh, and the Lycee Rene Descartes--have all reported
dengue cases so far this school year among students and/or
staff. Several schools noted that cases seem to be down
slightly this year in their communities, though given their
relatively small size this may be just statistical variation.

Government Efforts to Battle Dengue

8. Cambodia has acknowledged the public health importance of
dengue fever and established a National Dengue Control
Program in 1996. Dengue control in Cambodia has shifted from
reactive outbreak response measures to a preventive approach.
Insecticidal spraying against adult mosquitoes which have
little or no impact on the larval population has been
reduced, and more sustainable methods of vector control have
been increasingly employed, including mass larviciding

9. At a recent meeting of the Technical Working Group for
Health, Dr. Chantha cited several factors hampering the
effective prevention of dengue, including poor sanitation,
lack of funding at a provincial level and lack of local
participation in preventive activities. In addition, efforts
to treat dengue are hampered by patients who are late to seek
medical care or resort to self-medication or folk remedies.

10. Comment: Despite its public health significance, dengue
prevention and control activities are under-funded and
neglected compared to other diseases with similar disease
burden and comparable impact on the health of the population.
This has resulted in the continued lack of awareness of the
risk of dengue among the general population and the adoption
of behaviors necessary to prevent infection from mosquitoes
that bite during the day. As most Cambodians lack confidence
in the underfunded and understaffed public health system,
many initially seek treatment from either poorly trained
private providers, further delaying life-saving diagnosis and
treatment. At the same time, expatriates--including embassy
staff and EFMs--face significant risks due to lack of prior
exposure to dengue and the limited health facilities that
even the best equipped clinics in Cambodia can offer. End

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