AHC/COMRUs ground-breaking research on melioidosis: a retrospective analysis
Turner et al. BMC Infectious Diseases (2016) A retrospective analysis of melioidosis in Cambodian Children 2009-2013, BMC Infection Diseases, 16:688, DOI 10.1186/s12879-016-2034-9.
Melioidiosis is an important but frequently under-recognised cause of morbidity and mortality in Southeast Asia and elsewhere in the tropics. Melioidosis is an infectious disease cause by Burkholderia pseudomallei bacteria which is found in soil and water. It causes a broad range of infection, ranging from minor skin or soft tissue infection to pneumonia and bacteraemia, and is attributed to many fatal cases of sepsis at AHC. The source of infection is often thought to be ingestion or aspiration of contaminated water sources with doctors at our Satellite Clinic finding its presence in cases of near-drownings, for example.
Data on the epidemiology of paediatric melioidosis in Cambodia are extremely limited. In July 2016, AHC/COMRU carried out an analysis of culture-positive melioidosis cases presenting at AHC between 1st January 2009 and 31st December 2013. Research findings were presented at the 8th World Melioidosis Congress (WMC) 2016 in the Philippines (on 7-10 August) and published in BMC Infectious Diseases.
The research found that the median commune level incidence was estimated to be 28-35 cases per 100,000 children. Most cases presented during the wet season, May to October (see fig 1). The median age at presentation was 5.7 years (with an age range from 8 days–15.9 years). Three quarters (131/173) of the children had localised infection, most commonly skin/soft tissue infection (60 cases) or suppurative parotitis (51 cases). There were 39 children with B. pseudomallei bacteraemia: 29 (74.4%) of these had clinical and/or radiological evidence of pneumonia. Overall mortality was 16.8% (29/173) with mortality in sepsis cases of 71.8% (28/39), even in cases of early treatment.
Figure 1 Seasonality (trend) of meliodosis case presentation at AHC 2009-2013
1 One hundred seventy-three evaluable cases were identified, presenting from eight provinces
Figure 2 Incidence of melioidosis per 100,000 children aged <15 years in Siem Reap province (2009-2013)
This study is the most comprehensive description of paediatric melioidosis in Cambodia to date. Along with the limited adult data from Phnom Penh, this AHC/COMRU data and analysis on the prevalence and high mortality associated with melioidosis in Cambodian children highlights the wide geographic distribution of cases within the country.
The findings of this research are feeding into further AHC/COMRU research, and AHC’s clinical and educational activities. For instance, this highlights an urgent need for greater awareness amongst healthcare professionals in Cambodia and other countries where melioidosis is known or suspected to be endemic. Community based awareness programmes – such as the AHC’s Child HELP programme – can support this through improving understanding disease risk factors and reducing time to presentation at hospital, and in turn may improve mortality.
Consistent availability of ceftazidime and meropenem for empiric treatment of suspected melioidosis is also critical: currently this may be sub-optimal in Cambodia as a result of cost. For AHC, the cost of a 1 gram vial of ceftazidime is US$4.20, compared with US$1.05 for a 1 gram vial of ceftriaxone. To put these costs in context, the GDP (gross domestic product) per capita for Cambodia was US$735 in 2009, rising to US$1020 in 2013. AHC is therefore grateful to have the support of donors such as the Ptarmingan Foundation, who provide us with support on antibiotic supplies.
2 The Child HELP village programme provides a holistic approach to improving the overall health and nutrition status of vulnerable children living in rural areas in Cambodia. The programme will not only provide information and knowledge to community members but will also achieve long term impact by building the capacity of key health players within the community and engaging them in the implementation of health and nutrition programmes.