Brook, C.E., et al., 2024. Climate, demography, immunology, and virology combine to drive two decades of dengue virus dynamics in Cambodia. Proceeding of the National Academy of Science [Online], 121 (36). Available at: https://www.pnas.org/doi/10.1073/pnas.2318704121 [Accessed 5 December 2024].

Byaruhanga, T., et al., 2023. Arbovirus circulation, epidemiology and spatiotemporal distribution in Uganda. IJID Regions [Online], 6. 171-176. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10006739/#bib0001 [Accessed 5 December 2024].

Cambodia. Kingdom of Cambodia Ministry of Health, 2018. National Guideline for Clinical Management of Dengue [Online]. Cambodia: Kingdom of Cambodia Ministry of Health. Available at: https://niph.org.kh/niph/uploads/library/pdf/GL055_National_guideline_for_ClM_Dengue.pdf [Accessed 5 December 2024].

Cambodia: Health Equity Fund Brings Medical Care to the Poor, 2010. [YouTube]. The World Bank, 2010. Available at: https://www.youtube.com/watch?v=QwBvFyhro2I&t=2s [Accessed 5 December 2024].

Cambodia: Social Protection of Cambodia, 2024. Roadmap towards Universal health coverage in Cambodia [Online]. Cambodia: Social Protection of Cambodia.  Available at: https://nspc.gov.kh/Images/UHC%20Roadmap_ENGLISH%20_2024_08_27_08_32_42.pdf [Accessed 5 December 2024].

Data commons, 2023.  Cambodia statistics [Online]. Data Commons. Available at: https://datacommons.org/place/country/KHM?utm_medium=explore&mprop=lifeExpectancy&popt=Person&hl=en [Accessed 5 December 2024].

Doeurk, B., et al., 2024. Review of dengue vectors in Cambodia: distribution , bionomics, vector competence, control and insecticide resistance. Parasites and Vectors [Online], 17. Available at: https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-024-06481-5#:~:text=In%20Cambodia%2C%20dengue%20epidemics%20occur,30%2C%2032%2C%2033%5D  [Accessed 5 December 2024].

European Center for Disease Prevention and Control, 2024a. Dengue [Online].European Center for Disease Prevention and Control. Available at: https://www.ecdc.europa.eu/en/dengue [Accessed 5 December 2024].

European Centre for Disease Prevention and Control, 2024b. Chikungunya worldwide overview [Online]. European Centre for Disease Prevention and Control. Available at: https://www.ecdc.europa.eu/en/chikungunya-monthly [Accessed 5th December 2024].

France: Institut Pasteur, 2017. Better understand Arboviruses to control, diagnose and treat them  [Online]. France: Institut Pasteur. Available at: https://www.pasteur.fr/sites/default/files/ddgo/financement_interne/arbovirus_book_eng.pdf [Accessed 5 December 2024].

Global Forest Watch, 2024.  Cambodia [Online]. Global Forest Watch. Available at: https://www.globalforestwatch.org/dashboards/country/KHM/ [Accessed 5 December 2024].

IPS, 2024.  Cambodias population and urbanisation trends [Online]. IPS. Available at: https://ips-cambodia.com/cambodias-population-and-urbanisation-trends/ [Accessed 5 December 2024].

Kaiser, A.K., et al., 2019. Assesing Progress towards universdal health coverage in cambodia: Evidence using survey data from 2009-2019. Social Science & Medicine [Online], 321. Available at: https://www.sciencedirect.com/science/article/pii/S0277953623001491 [Accessed 5 December 2024].

Kektar, H., Herman, D.,  and Wang, P., 2019. Genetic Determinants of the re-emergence of arboviral diseases. Viruses [Online]. 11 (2). Available at: https://pubmed.ncbi.nlm.nih.gov/30759739/  [Accessed 5 December 2024].

Kobashi, Y., et al, 2020. Improving the Rural-Urban Balance in Cambodia’s Health Services. International Journal of Health Policy and Management [Online], 10 (6). 358-359. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9056147/ [Accessed 5 December 2024].

Kweka, E.J., Kimaro, E.E., and Munga, S., 2016. Effect of Deforestation and Land Use Changes on Mosquito Productivity and Development in Western Kenya Highlands: Implication for Malaria Risk. Frontiers in Public Health [Online], 4. Available via: https://pmc.ncbi.nlm.nih.gov/articles/PMC5080343/ [Accessed 5 December 2024].

• Cambodia National Social Protection Policy Framework 2016-2025 and Third Health Strategic Plan 2016-2020 have acted as the building blocks for many of their changes, such as expansions on their social equity-based pre-payment schemes that contribute to their universal health coverage advancements examples of this work can be seen in the video above (Kaiser et al., 2023). 

• Cambodia’s investments in its health sector over time have improved the service delivery capacity and innovations within this sector (Social Protection of Cambodia, 2024). These improvements can be evidenced below: 

Between 2014-2022, out of 1,000 live births, it was shown that:

• The infant mortality rate dropped from 28 deaths to 12.

• The newborn mortality rate dropped from 18 deaths to 8. 

• The under-five mortality rate dropped from 35 deaths to 16 (Social Protection of Cambodia, 2024). 

• From 2019, the hospital quality assessment score increased from 60.89% to 81.32% in 2022. 

• From 2019, the Health center quality assessment score increased from 64.34% in 2019 to 81.95% in 2022 (Social Protection of Cambodia, 2024). 

• The national Immunisation program currently provides 12 vaccines to children who are under the age of 1 to immunise them against diseases such as Pertussis, diphtheria, tuberculosis, polio, tetanus, rubella-measles, pneumococcal and hepatitis B (Social Protection of Cambodia, 2024). 

• The National Tuberculosis Control Program currently can have a 100% coverage of all health centres, hospital, and health post referrals of tuberculosis (Social Protection of Cambodia, 2024). 

• Between 2018, cases of malaria have dramatically decreased from 64,534 to 4,053 cases in 2022, this represents a 93.7% decrease in cases (Social Protection of Cambodia, 2024). These results seem especially valuable when comparing statistics to Mynamar, another southeast Asian country that recorded 127,797 cases of only P. vivax strain malaria in 2022. Although Myanmar’s population is just over four times the size of Cambodia, this increase of over 120,000 cases shows the impressive advancements that Cambodia has regarding its Malaria prevention (P.vivax information hub, 2024).

• When considering a global perspective, international standards in many medical facilities in Cambodia are not met. It is also recommended that individuals who visit Cambodia to travel should not use health care services for anything other than basic care or stabilisation and should instead seek medical care in Singapore or Bangkok (CDC, 2024a).

• Cambodia's population statistics show that in 2020, 61% of Cambodians were rural dwellers (Kaiser et al., 2023).

  
  

• In 2021, 63% of all dwellings In Cambodia were seen as agricultural dwellings, An example of their work is shown in the image above where people work in a row on a rice farm (Food and Agricultural Organization, 2021).

• 65.3% of Cambodia’s population can be found to be under the age of 30, critically speaking, this high proportion is very valuable to Cambodia’s economic progression as the young population plays a vital role regarding increases in the labour force (IPS, 2024). 

• Cambodia’s life expectancy in 2021 was expected to be 69.58 years; this is up from 58 in the year 2000 (Data Commons, 2023).

• Life expectancy for under-five and at birth children has been significantly improving since the year 2000 (World Bank Group, 2024). 

• Between 1996 and 2019, Cambodia could be seen to be one of the fastest-growing economies in the world, with tourism, real estate and construction being its primary drivers. After reaching lower-middle income status in 2015, Cambodia has now set its objective to become an upper middle-income country by 2030 and then higher income by 2050 (World Bank Group, 2024) 

• In the 2010s, Cambodia’s poverty rates declined at a rate of 1.6  percentage points on average a year; this was mostly due to a rise in labour earnings (especially regarding wages). The COVID-19 pandemic has since exacerbated poverty issues, causing the national poverty rate to slightly increase. However, poverty rates are expected to start declining again with projected economic recovery (World Bank Group, 2024). 

• Children born in Cambodia can be seen to be only 49% as productive once grown up as they could comparatively have been if they had better nutrition, health and education during their childhood (World Bank Group).

• Cambodia can also be observed to have seasonal monsoonal rains; these usually occur from June to November (CIA World Factbook, 2024).

• Out of countries situated in Southeast Asia, Cambodia can be seen to be one of the most religiously and ethnically homogenous with 95% of its population having a Khmer background and 95% identifying as Buddhist (CIA World Factbook, 2024).

• Currently, within Cambodia, Via international collaboration mediated by the UN, there are 265 programmatic interventions ongoing that are related to the 17 SDGs, these are split between localised, specific interventions and country-wide interventions (United Nations, 2024a).

Additionally, Cambodia has created their own Sustainable development goal (18) that considers the challenges of unexploded ordnance and landmines, there are three specific targets: 

1. to promote the quality of life of people living with disabilities due to mines and also introduce further rights for these people. 

2. to have casualty numbers reduced to lower than ten a year by the year 2030. 

3. To eradicate all identified mines and explosive remnants of war areas by 2030 (Open Development, 2015).  

• Statistics surrounding Multidimensional poverty have shown improvements with the fall of the population living in this category from 36.7% in 2014 to 16.6 % in 2022. However, it can still be seen to be a prominent health issue for Cambodia, with it generally affecting the population depending on variables such as gender, geographical location, and ethnicity (United Nations, 2024b).

• Cambodia can be seen to be one of the most vulnerable countries to climate change and its impacts. Due to the land makeup, Cambodia has very little capacity to adapt its landscape; This is worrying when its economy has such a large dependency on agriculture, which makes up 22 % of its GDP and 35.7 % of its employment (United Nations, 2024b). 

• Women and girls within Cambodia can be found to meet massive amounts of discrimination and inequalities as well as unequal gender norms, limited access to justice and gender-based violence (United Nations, 2024b).

• Non-communicable diseases management in Cambodia remains a challenge as the percentage of deaths caused by them increased from 64% to 68% from 2015 to 2019 (United Nations, 2024b). 

  
  

• The capacity for mental health treatment in Cambodia can be seen to be very low as there were only around 60 psychiatrists in the country as measured in 2018; Moreover, public hospitals can be found to not employ any social worker or psychologist positions, and in 2021 it was measured that only 0.7% of the adult population were receiving treatment for depression. Comparatively, in the UK, one in eight adults (12.1%) receive mental health treatment, with over half of these being related to depression (Mental Health Foundation, 2024; United Nations, 2024b). 

• arboviruses can be defined as a disease that is transmitted to humans mostly through a bite from an infected midge, mosquito, tick or sandfly, although in some cases, they can also be passed through organ transplantation, blood transfusions, breastfeeding, laboratory exposure or perinatal transmission; Most commonly they are passed via mosquito and as shown in the diagram above, have lots of inter-connected factors related to their re-emergence (CDC, 2024b).

• Globally, there are over 500 known arbovirus strains, with around 100 of these being harmful to humans and animals (Ali et al., 2023).

• Generally speaking, The Aedes mosquito can be found to be one of the main anthropoid vectors for diseases that are harmful to humans; within this, two subspecies the Aedes albopictus and Aedes Aegypti can both be understood as disease vectors, with Aedes Aegypti being the primary vector; However, the Aedes Albopictus subspecies can survive in colder non-tropical areas causing spread of diseases to colder climates than the tropical and sub-tropical conditions they historically have be found in (Whitehorn, 2015).

• Arboviruses must also be seen to be able to live within a vector, transmitted via a bite, and be able to multiply and cause disease in a human; often arboviruses can be found within birds and mammals after being bitten by an insect the disease is transmitted which is then transmitted again once an insect bites a human (WebMD, 2024).

• Due to the nature of how they are spread, arboviruses can be found most commonly in subtropical and tropical areas of the world, it’s believed that they have the potential to affect 3.9 billion people globally (Who, 2024a).

• A variety of symptoms can be caused by arbovirus infections; this is due to that arboviruses are made up of a range of different virus families (Institut Pasteur, 2017). 

• Although there are diagnostic tests available for arboviruses such as Zika virus, Chikungunya and Dengue Fever and vaccines for Dengue fever, Yellow fever, and Japanese encephalitis; There are still no specific treatments designed for arboviral diseases (Institut Pasteur, 2017). 

• As stated by WHO (2024a), in 2022, the Global Arbovirus Initiative was launched. It can be seen that the magnitude and frequency of arbovirus outbreaks are increasing, particularly regarding Aedes mosquitoes, outbreaks can be understood as being exacerbated by social, economic and ecologic factors; Some of the reasons for recent increases in cases can be understood as increased international travel, increasing mosquito populations, global climate change and vector competence (Kektar, Herman and Wang, 2019; WHO, 2024a).

• The global figure for arbovirus deaths sits at about 700,000 people annually (Byaruhanga et al., 2023). 

• Specific to Cambodia, there are a recorded 290 different species of mosquito, within this, 17 of them are considered to be effective vectors for arboviruses (Ali et al., 2023).

• Critically speaking, it would be too broad to cover all variants of arboviruses in this work. For this reason, The following four will be explored: Dengue fever, Zika and Chikungunya. These have been chosen due to factors such as their severity and prevalence on both a local and global level. 

8.1 Dengue Fever 

• Dengue fever is a viral infection spread through mosquitos and can be found in tropical and subtropical regions of the world, typically affecting semi-urban and urban areas. Regarding its actual symptoms, it can be seen to cause an influenza-like syndrome such as fever, headache and muscle or joint pain and can affect infants, children and adults; when considering infants and children it is also more likely to develop into more serious conditions such as dengue shock syndrome and haemorrhagic dengue, which can cause death (European Centre for diseases Prevention and Control, 2024a; Institut Pasteur, 2017).

• Dengue fever can be seen as one of the world’s most prominent arboviruses, with over 14  million cases this year and 10,000 deaths being reported (European Centre for Disease Prevention and Control, 2024a).   Additionally, Dengue fever’s regular epidemic pattern can be understood as occurring every 3 to 5 years; Historically bad years for dengue fever can be noted as 2007, 2012 and most recently, 2019 with over 90 million cases being reported and upwards of 20,000 deaths worldwide (Madewell, 2020); when critically considering these previous endemics and the patterns of occurrence it could be viewed that Cambodia is likely to have another outbreak in the imminent future (Brook et al, 2024). 

• Furthermore, 3.9 billion people in the world, across 129 countries can be seen to be at risk of contracting dengue fever (Doeurk et al., 2024). 

• It can be seen that annually, 500,000 cases of dengue fever can be understood as haemorrhagic dengue (Institut Pasteur, 2017). 

• When considering Cambodia, published statistics by the WHO (2024b) show that between January and November 2024, there were 16,327 cases and 42 deaths reported regarding dengue fever. 

• It can also be shown that Dengue outbreaks can occur in both urban or remote settings, with cases being reported in 22 of the 25 provinces within the country (Kingdom of Cambodia Ministry of Health, 2018).

• Although a vaccination exists for dengue fever, the rate of protection sits at 65% (Institut Pasteur, 2017). Critically, this means strategies to negate cases must be multi-faceted in their implementation and cannot just focus on prevention via vaccination. 

• Generally speaking, infected individuals are unlikely to show any symptoms of the Zika virus, if symptoms do occur, they are likely to be similar to those of dengue and chikungunya (Institut Pasteur, 2017). 

• As it develops, the Zika virus can lead to Guillain-Barré syndrome, which can cause limbs to become parlysed; When considering the transmission of the virus from mother to infant, foetal microcephaly can be caused, leading to serious developmental abnormalities in the brain of the infant (Institut Pasteur, 2017); critically speaking, for this reason, appropriate identification of Zika in the female population to limit intragenerational effects should be paramount to prevention strategies.

   

• Zika virus also currently has no vaccine or specific treatment option other than pain relief via the taking of analgesics (Institut Pasteur, 2017). 

• Globally, the Zika virus can currently be understood as having the majority of its recent cases in the Americas, with 27,000 cases (PAHO, 2024). However, when considering Dengue (3 million) and Chikungunya (324,000) cases, comparatively zika is not currently as endemic globally. 

• Critically speaking, the available figures on the Zika virus in Cambodia are under-reported publically. This is due to limited cases and information generally being supplied when there is a current outbreak (Travel Health Pro, 2024). 

• Factors that can be understood as facilitating the spread of arboviruses are as follows. Increases in international travel and trade, rapid urbanisation, climate change and mosquito adaptability (Ali, 2023).

• Climate change can exacerbate conditions in which mosquitos can breed, specifically in Cambodia, it can be understood that geographically they are massively impacted by climate change due to rainy seasons and the land makeup making them prone to flooding (United Nations, 2024); This, in turn, puts them at massive risk of exposure to arboviruses (Ali, 2023). 

  
  

• Geographical issues, notably the land use percentages of Cambodia show that in 2021 44.8% of the land was covered by forest (CIA World Factbook, 2024). Although this can be seen as substantial compared to the international average of 31.8%, identifying that their land coverage by forest in 1990 was 62.3% shows the impact that global deforestation trends have had on the geographical makeup of Cambodia (The Global Economy, 2021; World Bank Group, 2021). Furthermore, Global Forest Watch Statistics (2024) shows that from 2002 to 2023 there was a 1.44 Megahectar (Mha) loss of humid primary forest, representing a 34% overall decrease in humid primary forest within this same time scale for Cambodia. 

• These changes in the land makeup can be seen to exacerbate issues with Mosquito-borne diseases as the open land can be understood as being a suitable breeding habitat. Critically, this extended period of deforestation can also be associated with creating stable conditions for potential Arbovirus vectors to increase in population; Additionally, decreases in forest cover can also cause increases in the climate temperature which can shorten the developmental time for the aquatic stages of the development of a mosquito (Kweka, Kimaro and Munga, 2016). 

• When considering economic and demographic impacts, considering the IPS (2024) statistics stating that 65.3% of Cambodia’s workforce is under 30 is important; This is because generally speaking this young workforce could be seen as a great asset for economic growth; However when considering that Dengue fever vaccination only provides 65% protection from the disease it must be considered that the economic productivity of Cambodias youth is impacted by the health burden this virus creates (European Centre for Disease Prevention and Control; Institut Pasteur, 2017). 

• The preference for private healthcare in Cambodia (70% of the population) highlights the need for better health infrastructure and mitigates the impact on the population (Kaiser et al., 2023), this is because private healthcare can be seen to be unregulated and although public hospital quality scores increased from 60.89% to 81.32% between 2019 and 2022 further improvements are needed to improve efficiency which will decrease the usage of private services and increase effective local surveillance of Arboviruses (Kaiser et al, 2023; Social protection of Cambodia, 2024).

• Related to the last point, Cambodia's population can be seen to be split into a rural-urban divide, within this, the majority (60% or so) of their population are rural dwellers who are more susceptible to regional health inequalities; For this reason, advancements in sustaining health personnel as well as improving surveillance systems in the more rural areas should help to prevent spread of Arboviruses in these rural areas and, in turn, limit exposure of vector transmission from rural to urban (Kaiser et al, 2023; Kobashi et al, 2020; WHO,2022; Weaver 2013).

• when considering medical education it can also be shown that disparities can be caused in both academia and medical practice depending on an individual's geographical location (Kobashi et al, 2020). Often, universities in urban areas will have a more comprehensive educational experience and advanced medical equipment. Students from rural areas are less likely to be able to access these private faculties due to a lack of funds which, in turn, can lead to them having less developed healthcare skills and knowledge which will negatively affect health outcomes. For this reason, specific government sponsoring of rural health care students may help to rectify this issue. (Kobashi et al, 2020).

• To make the last point relevant specifically to arboviruses, one must understand that infant mortality is 3-fold higher in rural areas than in urban, critically this statistic is important as the infant and child age group is most at risk of death via Dengue fever, which currently is the most prevalent arbovirus in Cambodia (Institut Pasteur, 2017;  Kobashi et al, 2020).

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