Southeast Asian Studies, Vol. , No. , March  

Water, Livelihood and Health in Attapeu Province in Lao PDR

M>9DG>@6L6 Yutaka  ), M>9DG>@6L6 Kaoru  ), Bounphenh S6C<HDBH68@  )Traykhouane P=DJI6K6C  ), Kampheng C=DBA6H6@  ), W6I6C67: Toru  )Nanthasane V6CC6KDC<  ), H67: Shigehisa  ), N6@6IHJ Masami )KDH6@6 Yasuyuki ), Kongsap A@@=6KDC< ), Boungnong BDJE=6 )Michel SIGD7:A) and N6@6BJG6 Satoshi )Abstract
This paper presents the results of an investigation on water-borne infectious disease
conducted among the people of Attapeu province from   to  . Regardless of the lastcholera epidemic in Attapeu province, Lao PDR in the year  , the local peoples’
awareness of cholera was remarkably low, as demonstrated by the knowledge survey on
diarrheal diseases performed in the province in  . In the case study material, derived
from continuous field observations on malaria among permanent residents in relocatedvillages in Sanxay district from   to  , the infection rate among febrile cases was ashigh as  in the early resettlement period, while it was proved that the rate fell later to ῌ. Judging from the environmental condition of this settlement area, this paper
makes clear the persistent threat of malaria. Furthermore, among the villagers, hookworm
infection was highly prevalent. However, liver fluke infections were scarce and noascariasis was found from parasitic stool examination in  . Water quality analysis of
the water sources resulted in remarkably safe water from tube wells from   to  .
Keywords: Laos, Attapeu, relocation, ethnic minority, cholera, malaria, intestinal parasite.

   Suzuka University of Medical Science, Mie, Japan   School of Medicine, Mie University, Mie, Japan Department of Provincial Health Services, Attapeu, Lao PDR
 Centre for Laboratory and Epidemiology, Vientiane, Lao PDR
 College of Engineering, Drexel University, Philadelphia, PA USA
 College of Nursing, Ministry of Health, Champasack, Lao PDR School of Medicine, Fukuoka University, Fukuoka, Japan ῌ    Research Institute, International Medical Centre of Japan, Tokyo, Japan
Corresponding author’s e-mail: (Nakamura Satoshi) snakamurari.imcj.go.jp
  Research Institute for Humanity and Nature, Kyoto, Japan  National Institute of Public Health, Vientiane, Lao PDR
 French Institute for Tropical Medicine, Vientiane, Lao PDR
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M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDRI

IntroductionIῌῌ Water-borne and Food-borne Infections in Lao PDR
Lao PDR accomplished rapid economic development in the past two decades after the
Chinthanakaan mai policy of , with accompanying improvements of the healthcondition of the people [Nakamura and Iwasa : ]. However, water-borne andfood-borne diseases, including severe diarrheal diseases such as cholera, dysentery andintestinal parasitic infections are still the most common threatening people in Lao PDR.
According to government statistics, the major causes of death in  (  pairs of
population) were malaria ( ), ARI (Acute Respiratory Infections including pneumonia)
caused by bacterial and/or viral pathogens ( ) and diarrhea, including dysentery ( ),meningitis () and tuberculosis (), among others [Disease Statistics  : iii]. These

trends show no change in the year  [United Nations Country Team  : ῌ].
Hence, the water-borne infections like diarrhea and malaria are the most common causesof death. Water-borne disease is an illness caused by direct contact with water or aquatic
vectors, containing causative microbes. In particular, water-borne disease is functionallycommon to food-borne infectious disease, for the causative microbe is taken orally.
Infective diarrhea, for example, which is focused on food-borne viral, bacterial and/or
protozoan agents, is seldom studied in Lao PDR and as such, research on food-borne
diarrhea and food hygiene/sanitation has only just started in Laos [Agriculture andRural Development Department & Rural Development & Natural Resources East Asia
and Pacific Region : ῌ]. Also, not many studies have been performed on bacterial
diarrhea agents through field surveys in this country. However, some hospital-based orlimited local diarrhea survey results are available. As a typical example of pathogen
research in this country, there is the case report of the epidemic of cholera in ῌ
[Midorikawa et al. :  ῌ  ] and a review of a severe diarrhea and cholera epidemicin ῌ [Nakamura and Iwasa : ῌ ]. As for the causes of these epidemics,
only Vibrio cholerae O Ogawa strains have been reported till the present [Midorikawa etal. :  ῌ  ; Phantouamath et al. :  ῌ]. Common bacterial diarrhea agents
identified are enteropathogenic E. coli, Shigella spp., V. parahaemolyticus, Campylobacter
spp. and Salmonella Thyphi in Vientiane Capital [Yamashiro et al. :  ῌ;Phethsouvanh et al. : ῌ; Phethsouvanh et al. :  ῌ ]. Other infective
diarrhea microbes related to parasitic helminthes such as roundworms, hookworms,
tapeworms and liver flukes have been widely identified in the country [Phommasack et
al. : ῌ]. Some minor protozoan diarrhea agents such as Entamoeba spp. andGiardia intestinalis [Phetsouvanh et al. : ῌ], as well as Cryptosporidium spp. andCyclospora sp. have also been detected in Vientiane Capital [Takemasa et al.  : ῌ;Kimura et al.  :  ῌ ]. Regarding diarrheal virus identification, only Rotavirus in479῔῕῎῏῎ῒῑ ῐΐῐ ῐ ΐVientiane, [Yamashiro et al. ῍῕῕῔: ῎῍῕ῑῌ῎῍῕῕; Phethsouvanh et al. ῍῕῕῕: ῏῍῕ῌ῏῎῏; Phantouamath et al. ῎ῌῌῐ: ῎ῌ῏ῌ῎ῌῐ] and Norovirus in Champasack [Watanabe et al. ῎ῌῌῒ] have beenreported. Hepatitis A and E viruses have also been reported in Vientiane Capital [Bounlu
et al. ῍῕῕῔: ΐ῍ΐῌΐ῎῍]. Moreover, others like Leptospira spp. [Suzuki et al. ῍῕῕ΐ: ῐ῏ῒῌῐ῏ΐ; Laras
et al. ῎ῌῌ῎: ῎ΐ῔ῌ῎῔ῒ; Kawaguchi et al. ῎ῌῌ῔: ῕ῑΐῌ῕ῒ῍] and Schistosoma mekongi are known
important water-borne microbes in Lao PDR [Matsuda and Kirinoki ῎ῌῌῑ: ῍ῐ῏ῌ῍ῑῒ;
Nakamura ῎ῌῌΐ: ῎῍ΐῌ῎῎ΐ].

In addition to these studies, in the Mekong watershed in

Indo-China the research on the infection risk analysis of water supply systems [Watanabe
et al. ῎ῌῌῒ: ῍῔ῌ῎῍] and the model study on local water risk analysis using GIS [Miura et al.

῎ῌῌΐ: ῒ῍῍ῌῒ῍ῒ] has proved to be useful.
The water-borne factor is also related to mosquito-borne infections like malaria anddengue fever, because the vectors originated from a water environment. Therefore as
mentioned above, malarial death is common in Laos even today and remote rural
populations living in or near forests or hilly areas alongside streams are at a particularlyhigh risk [United Nations Country Team. ῎ῌῌΐ: ῎῕].
Iῌ῎ῌ Background of Diseases, Control and Prevention
The key background factors of such outbreaks of infectious diseases are malnutrition,
especially among children, and insufficient clean water supply. Although many cases ofmalnutrition are observed in rural areas, the actual conditions of specific areas are notreadily grasped, except in the case of a few in-depth studies [Kachondham and Dhanamitta ῍῕῕῎.: ΐ῕ῌ῔ΐ; Boupha et al. ῎ῌῌ῏: ῍ῌῒΐ; Miyoshi et al. ῎ῌῌῑ: ῔῔ΐῌ῔῕ῌ]. On the other hand,
it is commonly understood that maintenance of a clean water supply or sewer treatment
is indispensable in controlling water-borne infections. As in Japan, jurisdiction over thewater supply system of Lao PDR is divided between the Ministry of Public Works andTransport (MPWT) and the Ministry of Health (MOH). The former is responsible mainly
for supplying drinking water through a piped water system in urban areas, and the latterfor constructing tube-wells in rural areas. The Water and Water Resources Law wasenacted in ῍῕῕ῒ to ensure the maintenance of water quality. The drinking water quality
standard in the health sector was enacted as law within the government in ῎ῌῌῑ, which
required that E. coli is not detected in drinking water [Anonymous ῎ῌῌῑ: ΐ ]. However,
the efficacy of this microbiological standard is questionable, as access to safe water inrural areas was found to be only ῏ῑ῍ in research on national health knowledge andattitudes towards drinking water [Steering Committee for Census of Population andHousing ῎ῌῌῑ: ῍῍῔ῌ῍῍῕], and is not always reliable in the capital city either [Nakamura

῎ῌῌῒ: ῏ΐῌῐ῍].
In ῍῕ΐ῔ to ῍῕῔ῌ, the Lao government carried out a campaign for the “three hygienes”(sam sa-at), promoting awareness of water, foods, and clothes in the prevention ofwater-food-borne infections among rural people [Boupa and Dalaloy ῍῕῕ΐ: ῍῕]. This is acore idea of Primary Health Care (PHC) which will be mentioned later. The government
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finally specified the responsibilities for the nation’s health in the Constitution enacted in῍῔῔῎, and further enacted the Hygiene, Prevention and Health Promotion Law in ῎ῌῌ῍, andthe Law on Health Care in ῎ῌῌῑ. As for national food hygiene, the Law on Food wasenacted in ῎ῌῌῐ, and related regulations on bottled drinking water standards werebrought into force by the Ministry of Health in ῎ῌῌῑ. These laws are currently available
to view on the internet website of the Embassy of Japan in the Lao PDR.
As such in Lao PDR, the implementation of health policies has been guided by afive-year health plan whereby the control policy corresponding to diseases in urban areas
is hospital-based treatment. In rural areas, these policies are implemented by the PHC
system together with primary medical treatment administered by Village Health Volunteers (VHV) and a public health campaign to prevent diseases [Anonymous ῎ῌῌῌ: ῏ΐ῍ῐ῏].
The definition of PHC is that it “encompasses primary care, disease prevention, healthpromotion, population health (similar to public health), and community development
within a holistic framework, with the aim of providing essential community-focusedhealth care” [Shoultz and Hatcher ῍῔῔ΐ: ῎῏῍῎ῒ]. In Lao PDR, the government defined apublic access range to PHC, which implies the least accessibility of the rural people tohealth facilities such as a dispensary at the village. This zoning is overlapped with khet
or koumban (village cluster), which will be mentioned later.
On the other hand, these infections are closely related to poverty and the Poverty
Reduction Strategy Paper (PRSP), supported by the IMF-World Bank, lays out anapproach to improving health conditions through economic stimulus. In this strategy,
the government specified ΐ῎ poor districts ῍ including the ῐΐ poorest ones ῌ as a priority
poverty reduction area. In addition to this, the National Growth and Poverty Eradication
Strategy (NGPES) program included provisions for promoting health [Government of
Lao PDR ῎ῌῌῐ]. In this strategy, agricultural and forestry, education, health, and transportation infrastructure are stated as priority sectors. The basic policies, priority issues,and projects aimed at eradicating poverty by the year ῎ῌ῍ῌ are also described. NGPES isregarded as the core of the poverty reduction policy in the ῒ th National Socio-Economic
Development Plan (NSEDP: ῎ῌῌῒ῍῍ῌ), which was approved by the government in ῎ῌῌῒ. It
is also specified that the koumban should provide health care and PHC in mountainous
resettlement areas that are home to ethnic minority groups [Evrard and Goudineau ῎ῌῌῐ:῔ῐῑ῍῔ῐῒ]. Moreover, water sanitation is a health sector priority in the strategy.
I῍῏ῌ Resettlement and Health of Mountain Ethnic Minorities
Although the economy of Laos is developing quickly and living conditions and thelivelihood of the people are also improving, the situation of the public health services in
the mountainous poverty area mentioned is still not sufficiently improved. In manycases, health problems, such as increased mortality rates due to diarrhea, malaria, or
intestinal parasites have been reported as an element of the process of resettling mountain ethnic minorities in Laos. Some important surveys were carried out to investigate481ῒΐῌ῍ῌῐ῏ ῐΐ῎ ῐ ῑthe general background and the food situation in these resettlement schemes [Ducourtieux ῎ῌῌῐ: ῎ΐῌ῏ῌ]. According to Goudineau’s report on resettlement in the ῍῕῕ῌs, therelocation policy was originally based on the national policy to eliminate production ofopium by ethnic minorities and to increase the convenience and effectiveness of minority
groups’ access to public services. The justification for resettlement was then changed toenvironmental protection, and more specifically the prohibition of swidden agriculture[Goudineau ῍῕῕ΐ. Vol. ῍ : ῎῕ῌ῏ῒ]. Even after the year ῎ῌῌῌ, reports also told about the caseof the Akha, for example, in the northern part of the country, where the incidence of
vector-borne fever and other infectious diseases had increased at their new villages.
[Lyttleton et al. ῎ῌῌῐ: ῒ῎ῌῒῒ; Gonzales et al. ῎ῌῌῑ: ῏῏]. In the results of investigations in ῍῎villages sampled from Luang Phabang, Saravane and Attapeu provinces, the majordiseases were diarrhea and malaria. The studies showed that these diseases were still athreat to the people in the area [Sanogo and Vikan ῎ῌῌῒ: ῍ῐῌ῍ῑ]. Furthermore, according
to the Participatory Poverty Assessment (PPA) report of the UNDP, dysentery andmalaria are still the major health issues in the villages surveyed for the previous PPA in῎ῌῌῌ [Chamberlain ῎ῌῌΐ: ῑῐ, ῒῐ].

II Objectives
In ῎ῌῌ῏ we started a health development study in collaboration with the Lao National
Institute of Public Health, Ministry of Health to assess the risk of diseases in rural areasof the country. Before this, we had been investigating the situation of food-water-borne
diseases in an area of Vientiane Capital where cholera had once occurred in ῍῕῕῕
[Nakamura and Marui ῎ῌῌῌ].
Regarding cholera, in the southern provinces, although the causative vibrios were
not fully identified, an immunization program with a Vietnamese oral vaccine wasconducted for the first time in Laos in some limited areas in Sekong and Attapeu
provinces during ῍῕῕ῑῌ῕ῒ [Nakamura and Iwasa ῎ῌῌ῔: ῎ῐ῎]. Following this, however, ῕῏῎cases of another outbreak of cholera occurred in ῎ῌῌῌ in all the districts of Attapeu
province except Sanxay [Songsomsack and The Secretary’s Team ῎ῌῌῌ: ῎ ]. Therefore,
we decided to investigate water-borne diseases in the province, where health careconditions are quite different from urban areas like Vientiane.
Our study aims to support the provincial health administration activities technicallythrough improving recognition of, and ways of coping with, water-borne diseases among
the local residents after an epidemic. Furthermore, support is provided through longterm observational studies to analyse health conditions related to water supply andwater quality, including parasitic infections in the relocation area of Sanxay district,Attapeu province (Fig. ῍ ), where the cholera vaccine had been administrated. The people
moved from a hilly environment to the present lowland environment several years ago
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M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDR

Fig. ῌ Relocation for Forming Focal Sites in Sanxay District in Attapeu
Note: Modification of the local administration map, ῎ῌῌ῍and supposed to experience health risk at the initial stage of resettlement. Hence, we
selected an investigation site in which both the infections and poverty overlap as an area.
Most data in previous reports was obtained by cross-sectional investigation in thenorthern part of the country, and there is little sustained field research on infectious
diseases in the southern part of the country. The results of continued investigation onmalaria and water-borne diseases in Attapeu province are presented in this article.

III MethodsIIIῌ῍ῌ Study Area
Attapeu province, the southernmost province in Lao PDR, has five districts: Samarkhixay, Sanamxay, Sanxay, Saysetha and Puvong, comprised of ῎ῌῒ villages with a total
population of ΐ῍῕῎ῐΐ (῎ῌῌῌ). According to the latest national census, the estimated crude
death rate of the province was one of the highest (῍῏῔῎ per ῍῕ῌῌῌ persons), comparable to
Oudomxay (῍῏῔ΐ) and Sekong (῍῏῔῏) provinces [Steering Committee for Census of Population and Housing ῎ῌῌῐ: ῍ῌῑῌ῍῍῍]. Several villages in the province (excluding Saysetha
district) were selected for administering of a diarrhea knowledge survey.
Ban Pak Pae (Pak Pae village) in Sanxay district (Fig. ῍ ) was selected as the site fora case study. The village was relocated in ῎ῌῌ῍ from its original mountain slope location
to the present village site. The villagers are all from the Alak ethnic minority, numbering483ΐ῔῍῎῍ῑῐ῏ ῒ people and  households residingin  houses in . The known age
group structure is shown in Fig. .
Their ancestors originated in Sekong
About ῌ of the people

province.

were given oral cholera vaccines
during ῌ [Nakamura et al.  : ῌ]. Their mean annual income
was 



kip, with a range of ῌ   kip.
The largest change in livelihoods
was the shift from upland swidden
cultivation

to unfamiliar lowland

paddy cultivation. In the paddy fields
developed around the new village,

Fig. ῌ

Sanxay District, Attapeu Province in there is an increased risk of mosquito
populations which transmit malaria and/or Japanese encephalitis. On the positive side,
the benefits of their new lifestyle include enhanced education for their children andincreased access to medical services. However, villagers have to pay expenses associatedwith medical treatment. Therefore, people find themselves selling valuable livestock to
obtain cash for medical service payments. Moreover, some comparatively rich peoplebought hand-tractors for paddy cultivation, but faced problems in purchasing fuel to run
their new machinery.

The village was merged with two neighboring villages andrenamed Ban Phuxay (total population ca. ) after  . However, in this paper, we willcontinue to use the original name.
Health personnel, such as health volunteers, and health kits have been available in
the expanded village since  . Pak Pae villagers utilize two water sources for drinking
water and daily use water. One is the Pa river water located  m near of the village, andthe other is two shared tube-wells with hand pumps managed by villagers in the village.
These wells were both  m in depth and were installed by AusAID in . Villagers did
not own private water sources like wells or ponds. The district hospital is located about
km southeast of the village. Nutritional status measured by BMI among  adultvillagers sampled in Ban Phuxay indicated that almost half of the people are underweight ( ῌ), while no cases of obesity were observed (unpublished observation in 
and ). The daily meals in this area consist of steamed rice and fermented fish sauce
only.

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IV Study MethodsIVῌῌ Diarrhea Awareness and Practices among Residents of Attapeu ProvinceThis investigation was conducted through an interview survey of households using aquestionnaire in  villages from four districts: Sanxay, Sanamxay, Samarkhyxay andPhouvong, in February and March in .

These villages include:  villages of

Dapokmam, Hindam, Hindan, Somboun, Souksavong, Then, Vanaxay in Sanxay district, villages named Bok, Caoomphoy, Tatphyla, Hatuhao, Khang, Lanhum, Monang, Sapouan, Saysy, Smongtay, Somsanouk, Somsaypay, Thasengchanh in Sanamxay district, villages of Isok, Khang, Samarkhy, Sekhamane, Somsanouk, Somsouk, Tha, Thahin,
That, Xaysomboune in Samarkhy Xay district, the capital area of the province, and 
villages of Lagnaoneumay, Naxeuak, Phomseat, Vangngong, and Vangnhay in Phouvong
district. The population of these villages ranged between  and  . The structured
questionnaire included items such as diarrhea episodes of the past four weeks; knowledgeof common names of different diarrhea, dysentery, and cholera diseases; knowledge of
how to cope with diseases using medicines or medicinal plants; consulting traditional
healers; seeking local medicinal plants; and actual prescription knowledge of the medicinal plants (See Appendix).
IVῌῌ Household Health Survey in Pak Pae Village
Questionnaire surveys were conducted at Pak Pea resettlement village in  and in (See Appendix). For the household head or housewife, we asked through a structured
questionnaire about occupation, animal husbandry, annual income, water sources andutilization, type of toilet used, ownership of electric goods and mosquito nets, annual
illness episodes (especially febrile and diarrheal episodes) and their management in thelast two years up to December . These investigations were performed after full
informed and voluntary consent was obtained.

In  , a questionnaire survey on

diarrhea and on fever/ malaria was conducted.
IVῌῌ Water Quality Analysis in the Village
Water quality, specifically bacterial contamination of water sources, was measured withthe test-paper method [Midoriawa and Itokawa  :  ῌ ; Furusawa et al.  : ῌ ].
The paper was immediately submerged into the water sample (Sun Chemical Co. Ltd.),
and the E. coli colonies were numbered at ῍ after  hours. This count was theindicator of bacterial contamination, where no E. coli per  ml of water was thecriterion for safe drinking water, as defined in the Lao standards [Anonymous : ].
The survey was conducted yearly from  to  .
Microbial water analysis of the Pa river water was conducted in December ,485῔῕῎῏῎ῒῑ ῐΐῐ ῐ ΐlooking for contamination of Entamoeba spp. Vibrio cholerae, and norovirus. Forty litersof the sample water from the river was ῍ : ῐῌῌ concentrated using activated Diethylaminoethyl cellulose (DEAE) particle adsorption to detect the objective DNA sequences ofpathogens using Polymerase chain reaction (PCR) method [Troll et al. ῍῕῕ΐ; Phetsouvanh
et al. ῎ῌῌ῔; Yano et al. ῍῕῕῏: ῎῕ῑῌ῎῕῔].

V Observation of Parasitic Infections in the VillageVῌ῍ῌ Malaria
When we visited the village in December ῎ῌῌ῏ there were many cases and fatalities froman unknown febrile disease suspected to be a malarial infection. Study of malarial
infection rates and the number of malarial patients was started from December ῎ῌῌῐ. The
study was conducted yearly during the dry season, until March ῎ῌῌ῔. Malaria parasites
were examined with Giemsa stain of blood smears [Midorikawa and Hapue ῍῕῕ΐ: ῏῍ῌ῏ῑ],
PCR method [Arai et al. ῍῕῕ῐ: ῒ῍ΐῌῒ῎ῒ], and OptiMAL-IT(DiaMed)kits using ῍ῌ ml of bloodcollected from the finger tip. Samples were collected by medical officers. Only thosepatients who agreed to be diagnosed were involved in the study. The number of villagers
participating was ῎ΐ people in ῎ῌῌῐ, ῑ῕ in ῎ῌῌῑ, ῒ῏ in ῎ῌῌῒ and ῐΐ in ῎ῌῌ῔.
Vῌ῎ῌ Intestinal Parasitic Infection
In December ῎ῌῌῒ, a total of ῍῎ῌ plastic bags were distributed to people who had remained
at Pak Pea village. Stool examination using a routine formalin-detergent technique[Waikagul et al. ῍῕῕ΐ: ῑῌ῍῍] was also used to collect enteric parasites and eggs. For thestool sample collection, we distributed plastic bags to the people under the full given
conditions of informed consent. Analysis of the samples was performed at a laboratory
at the provincial hospital.

VI ResultsVIῌ῍ῌ Diarrhea Awareness and Practices
The results of the questionnaire survey are shown in Table ῍. Among ῒῌ people interviewed, there was ῍ case of diarrhea in the past ῐ weeks. Although all the interviewees
knew about common diarrhea and dysentery, with the exception of Xaysomboune and
Sekhamane in Samarkhy Xay, all of them did not know the name of cholera and its
characteristics. On the other hand, ῔ῌ῍ of the residents knew some medicinal herbs to be
used in case of dysentery or common diarrhea. The most commonly cited medicinal plant
was Guava (Psidium guajava Linne). Of them, ΐῌ῍ used the plants as herbal tea (Fig. ῏A). Consulting a traditional healer at the time of diarrhea was rare, only occurring in ῐ
cases (ΐ῍).
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M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDR
Table ῌKnowledge of Diarrhea Diseases and Treatment Using Medicinal Plants in Attapeu,
Lao PDR
Knowledge on (῎)
Medicinal Plants Usage on (῎)
Sampled Sampled
Village
HH
Diarrhea Dysentery Cholera Diarrhea Dysentery Cholera

District
Phouvong
Samarkhy Xay
Sanamxay
Sanxay





















*
 



Total











Note: *N῍ ,








 


**
***

῏










῏

**N῍ , ***N῍ , N῍ Aῌ Guava as Medicinal Tea
Fig. ῍

Bῌ A Plant (Azadirachta indica) for
Malaria Treatment

Medicinal Plants for Prevention of Diarrhea and Malaria Treatment

VIῌῌ Household Health Survey at Pak Pae Village in 2003
Among the  households cooperating in the survey (῎), the main drinking water
sources were well water ( cases) and river water ( case), as shown in Table . The
practice of boiling water for drinking took place in  cases (  ῎), and there was toilet
ownership in  cases ( ῎), while most of the people defecated on the ground in theforest.

All the houses had tin roofs and walls made of bamboo. Personal property

included a radio in  cases but no television set. Mosquito net ownership was found in cases (῎). Animal husbandry included  buffaloes,  pigs,  chickens, and 
ducks in . With regard to eating habits and food supply, the people traditionally took
meals twice daily, once each in the morning and the evening. Rice was the staple food,obtained from individual paddy fields. There was no rice surplus. Additional cultivationof maize was evidenced before the relocation. Cash income was made by the gatheringand selling of rattan from the forest: a bunch of  pieces of small-diameter, about  kg
in weight, could be sold for  to  US dollars in Vientiane. The actual selling price totraders at the village was   Kip per bunch. One man also earned wages by fishing,which was conducted on week-long trips.
487ΐ῔῍῎῍ῑῐTable ῌ῏ ῒResults of Household Interview Survey on Selected Items at Pak Pae Village, Sanxay
District, Attapeu in Item Interviewed

Number






 






 *

Population
House
FamilyNumber of the house head/wife interviewed
Occupation: farmer
Mean annual income (Kip)
Animal husbandry: Buffaloes (population)
Animal husbandry: Pigs (population)
Animal husbandry: Chicken (population)
Animal husbandry: Ducks (population)
Drinking water source: Tube well
Drinking water source: The Pa river
Drinking water practice: drinking water after boiling
Drinking water practice: drinking raw water
Ownership of toilet
Ownership of radio
Ownership of television
Ownership of mosquito net
Number of smoking habit (population)
Awareness of drug abuse







Note: * In some cases some did drink raw water or river water but boiled the water before
drinking
Table ῍

Disease Episodes from Interviews at Pak Pae Village
in  Years from  to 

Disease







Malaria/Fever
Diarrhea
DysenteryHelminthes
ARI
Measles
Others () ( )
() ()
()
 ( )
 ()

 ()
 ()
()
 ( )
 ()

 ( )

 ( )
 ( )
NA
NA
NA
NA
NA

Note: NA: not asked
Number in parenthesis is total case of episodeThe disease episodes reported during the year  were as follows (Table ): fever
was experienced in  households (ῌ) accounting for a total of  cases, of which only
three were referred to the district hospital, and at least  case was consulted by healthpersonnel. In the same year,

cases of measles were observed from  households( ῌ). Diarrhea was experienced in  households ( ῌ); among  cases, one consulted health personnel. The households experiencing dysentery totaled( ῌ), with

only one case out of an estimated  consulting a health worker. The known helminthes
488

M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDR

infection was  households (῍), which included  cases. There were at least  casesof ARI in  households ( ῍). Others reported problems included injury, where only household was concerned.
For the following year , the reported cases were as follows: households experiencing cases of fever (suspected to be malarial) numbered  (῍).

Four out of an

estimated  cases were referred to the district hospital and at least one case consulted ahealth worker.

There were( ῍) households experiencing diarrhea and among

these,  cases consulted a health worker;
and  among( ῍) households experienced dysentery,

estimated cases consulted a health worker, whereas only one household

was aware of helminthes infection, with  cases in the family. There were  cases of
ARI from the same household ( ῍);  households including

cases reported injury,

two of which were referred to the district hospital. In the year  , about  (῍) of theinterviewees experienced diarrhea and the total cases of diarrhea including the village
members was  cases.
VIῌῌ Microbial Contamination of the Drinking Water Sources
No E. coli contamination was confirmed at the two shared tube-wells with hand pumps
managed in the village in the annual surveys administered since December . Before
the resettlement, the people were using river water boiled at the mountainside village.
People used to drink tea from guava leaves and medicinal wood tip for diarrhea prevention. However, they usually drank unboiled water in the fields at that time. The Pa riverwater contained   coliform bacteria per  ml, indicating that the water was notsuitable for drinking.

However, no norovirus or Entoamoeba species was detected,

although the river might contain non-O non- Vibrio cholerae related strains whichhave a common DNA sequence with V. cholerae O, which was confirmed by the PCR.
VIῌ . Infectious Diseases in the Resettlement VillageVIῌ ῌῌ Fever and Malaria
In December  , interviews and blood collection were performed by  village healthvolunteers to detect malarial infections in  households. The age range of the sample
was ῌ . The number of unknown febrile episodes among interviewees and among
their family members was  ( ῍) and  cases, respectively. At least two malaria cases
were detected on site by microscopy. However,  out of  persons (  ῍) were infectedwith Plasmodium falciparum, later confirmed by PCR.

In , only one falciparum

malaria case among  displaced people was confirmed ( ῍) with a rapid test kit. In, a total of  displaced people were examined for malaria by rapid test;

cases ( ῍)

had falciparum malaria or mixed infection from P. falciparum plus P. vivax (vivax
malaria). These cases were all in children under  years old. Among the cases, threewere severe cases sent to the district hospital immediately. Another one was an adultvivax malaria case. In  ,  falciparum malaria cases ( ῍) among

consulting cases489῔῕῎῏῎ῒῑ ῐ  ΐFig. ῌ

Malaria Infection per Year from   to 
Village, Sanxay, Attapeu

at Pak Pae

were confirmed. The decreasing incidence tendency of malaria is shown in Fig. .
VIῌῌῌ Intestinal Parasites
A total of  samples were recovered. Within the sample,  samples contained somesputa or blank.

Therefore,  out of the households’ stool samples (῍) wererecovered. As for the results,  hookworm infections,  Trichuris trichiura infections,and  liver fluke (Opisthorchis viverrini) infections were confirmed (Table  ).

The

averages of the number of eggs in each  g (EPG) were ,  and , respectively. In
terms of age distribution,  ῍ of the infections were in children aged  years or less.
However, this finding was influenced by the age structure bias of the sample (Table  ).
Moreover, although  ῍, of cases had heavy infection, especially for hookworm and T.
trichiura, there was no gender difference in case repartition.
Table ῌConcerning protozoan

Results of Intestinal Parasite Infections at Pak Pae
Village in Sanxay, Attapeu in  

Egg of Parasite*

Case

Per cent Rate

Mean EPG**

Hookworm
Trichuris trichiura
Opisthorchis viverrini.






 


 
 
 

Note: * Modified Formalin-detergent method [Waikagul et al.
]** Egg per  g490

M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDR
Table ῌParasitic Infections by Age-group at Pak Pae Village
in 
῍

ῌ

 ῍

Total

 ( )No parasite
Hw
HwῌT







 ( )
 ()HwῌTῌothersHwῌothers





*







Total



( )
( )
()

Note: Hw: Hookworm, T: Trichuris trichiura* A case of Giardia intestinalis infection and an Entamoeba sp. infection case were included.

infection, a Entamoeba sp. case and a Giardia intestinalis case were confirmed, both inadult males.

VII Discussion
It is surprising that, according to our results on awareness of diarrheal diseases, the local
people were apparently not aware of cholera. This is despite the fact that provincial
health staff had provided health education for prevention of cholera during every
diarrhea epidemic in the region since  [Songsomsack and the secretary’s team : ]. A report of the cholera education team told that they provided interventions at villages ( ῎) in the

districts from  to  (Report of cholera education in

Attapeu province ῌ) when the last cholera outbreak occurred in the region. The
report also revealed that an insufficient budget for local government resulted in both
short time and low motivation among the work team as well as a lack of the relevant
education materials. Furthermore, the same report pointed out that few participants
were attending the intervention sessions because of their work in the rice fields. In 
and afterwards, the Lao government stopped using the term “cholera,” in order to protect
the country’s trade profits on trade except for the  epidemic [Nakamura and Iwasa

: ].
In relation to water safety among the studied village population, most people prefer
to use the safe (pathogenic bacteria-free) tube well water, and only one case reported
drinking non-boiled river water. It is not clear why tube well water was not used in thelatter case. The river water PCR revealed that it might contain a V. cholerae O  related
strain [Nakatsu et al. ]; this means that the water source will bear a risk of vibrio
infection [Phetsouvanh et al. ]. Although most of the villagers were using clean well
water for drinking, there were many diarrhea episodes annually. It should be noted thatthe causes were chronic malnutrition among the people, food contamination due to491ΐ῔῍῎῍ῑῐ ῐΐ῏ ῐ ῒunclean food handling, or polluted teacups and/or cookware usage, among others.
We do not have comprehensive data on malaria infection from ῎ῌῌ῎ῌῌ῏ after the Alakpeople relocated from the mountain area to the plain area. However, in Sanxay district,the rate of malaria infection is comparatively high within the province [Phetsouvanh etal. ῎ῌῌῐ: ῑῐΐῌῑῑ῍].

However, we observed a large number of fever cases.

It can be

estimated that the remarkable spread of malaria began among these people immediately
after migration and persisted until ῎ῌῌῐ. At the beginning of these malaria outbreaks,
people could not cope with the disease. Instead of using medicine for malaria such as
chloroquine or quinine, people in Pak Pae village tried to collect and use grass and herbal
teas that were not effective at that time. The use of traditional treatments can besummarized as: ( ῍ ) The villagers thought that those grass and herbal tea were effective
for malarial parasites. ( ῎ ) They had no idea of anti-malarial medicines such as chloroquine. ( ῏ ) In fact, even if they had the knowledge, medicines such as chloroquine andquinine were too expensive for them to buy. The medicinal herbs that they used as amalaria treatment were sold on the Attapeu market in ῎ῌῌῐ disappeared from the market
after ῎ῌῌῑ (Fig. ῏ B). This means that migrating people in Pak Pae village had learned
better methods and used effective anti-malarial medicine. For the prevention of malaria,
the focal site including Pak Pae village is located along with Pa River, which flows
throughout the dry season.

This means that the malaria vectors can breed there

year-round. As an example, the malaria infection rate in Pier Keo village (La Ve ethnic
group), located ΐ km from Pak Pae, was as high as ῐῌῌ, and the vector mosquito has
been identified as Anopheles dirus [Sidavon et al. ῎ῌῌῐ: ῏ῌ῕ῌ῏῍ῑ]. Recently, it has beenshown that ordinary mosquito nets do not prevent malarial infection, because eventhough the distribution of nets has been completed, people are still being bitten bymosquitoes [Vythilingam et al. ῎ῌῌῑ: ῔῏῏ῌ῔῏῕]. Moreover, it is pointed out that their housestructure is not what can fully prevent invasion of mosquitoes either.

In addition,

concerning falciparum malaria, although drug resistance is a little lower in the southernpart as compared with northern Laos, the genotype variation analysis showed thatchloroquine-resistant mutagenicity was about ῍ῌῌῌ in Attapeu and the adjacent provinces of Sekong and Champasack, thus a combination of medicine other than chloroquine
is needed for medical treatment in the near-future [Mayxay et al. ῎ῌῌΐ: ῏ῒῌῐ῏]. For thesereasons, the risk of malaria infection from the vectors in this area is considered high, evenin the future. Hence, systematic and immediate countermeasures, such as easier access totherapeutic facilities, and the improvement of housing are essential.
NGPES specifies that intestinal parasitic infections may still be a threat to people inrelocated communities [Government of Lao PDR ῎ῌῌῐ: ῔῕].

The sample size in ourinvestigations at Pak Pae village was small, and thus sufficient conclusions cannot be
drawn. However, the rate and intensity of hookworm infection was demonstrated to bevery high. Interestingly, no Ascaris lumbricoides infection case was found despite the factthat it is very common in both urban and rural settings in Laos [Phathammavong et al.
492

M>9DG>@6L6 Y. et al. : Water, Livelihood and Health in Attapeu Province in Lao PDR

῎ῌῌΐ: ῒ῔῕ῌῒ῕ῐ; Erlanger et al. ῎ῌῌ῔: ῎῎῏ῌ῎ῐ῎]; the liver fluke infection rate was also very low.
This may be explained by the fact that the people’s resettlement time from the mountains
to lowlands was short and eating habits did not change. There are still significant
differences with lowland diets; for example, relocated uplanders do not eat raw foods,
such as fish.

VIII Conclusions
Our continuous and cross-sectional studies in the resettlement village clearly demonstrate that febrile diseases, especially malaria, are still a threat to the people, and control
measures are needed in the area. If the conditions of one’s living environment change, thekind of infections acquired will change and countermeasures towards them must change
as well. Migration into areas where the health service system is not well developed raises
the risk of infectious disease, as shown in the research site. There should be a simultaneous effort to increase government-led countermeasures and awareness-raising. Thesepublic health measures will have a high impact on local peoples’ nutrition conditions,which is a critical part of poverty eradication, and thus should be coordinated closelywith these socio-economic development strategies locally.
The cases of diseases demonstrated in this study are similar to those previously
performed in Lao PDR. [Ducourtieux ῎ῌῌῐ: ῎ΐῌ῏ῌ; Gonzales et al. ῎ῌῌῑ: ῏῏; Sanogo andVikan ῎ῌῌῒ: ῍ῐῌ῍ῑ; Lyttleton et al. ῎ῌῌῐ: ῒ῎ῌῒῒ], and are closely related to agricultural
subsistence problems. In particular, people’s nutrition status is the most important factor
for the prevention of communicable diseases. Although technical guidance, particularly
in connection with rice production, is not described in the NGPES, it is thought that astable supply of rice and its surplus are especially important for health promotion in thearea. Hence, further investigation should be performed, with special emphasis on anemia
and nutritional status, and put in relation to communicable diseases including intestinal
parasitic infections. A major implication of this study is that the local government
should continue to grasp disease structure to increase health care services, and especiallyin the resettlement areas, it is necessary to consider the public health service program
corresponding to inevitable change of the living environment.

Acknowledgements
We thank the technical staff and directors of both Sanxay district hospital and the provincial
hospital of Attapeu and Dr. Boupha Thongmalayvong of the National Institute of Public Health forsample collection and technical help of the surveys. Thanks are due to Professor Tatsuo Omura of
Tohoku University, Professors Tomoya Akimichi and Kazuhiko Moji of the Research Institute for
Humanity and Nature, Dr. Phengta Vongphrachanh of the National Centre for Laboratory andEpidemiology, and Dr. Kinjiro Miyakawa, former Professor of Kagawa University, for their support.
We also wish to thank Dr. Nathan Badenoch for providing information on resettlement. The study493ῒΐῌ῍ῌῐ῏ ῐΐ῎ ῐ ῑwas supported in part by grant in aid under the Ministry of Education, Culture, Sports, Science andTechnology (MEXT) in Japan (No. ῍ΐῑ῕ῌῑ῏ῌ), by the Research Institute for Humanity and Nature,
MEXT in the project entitled “A Trans-Disciplinary Study on the Regional Eco-History in Tropical
Monsoon Asia: ῍῕ῐῑ῍῎ῌῌῑ,” and by MEXT in the project entitled “Sustainable Co-existence of
Humans, Nature and The Earth” under Research Revolution ῎ῌῌ῎.

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497ΐ῔῍῎῍ῑῐ ῐΐ῏ ῐ ῒAppendix
Questionnaire items for diarrhea survey in Attapeu province, February-March, ῍ῌῌῐ῍ ῌ Name of village, district, and date of interview;῎ ῌ Total population, and number of households;
῏ ῌ Name of interviewee, age and sex;ῐ ῌ Have knowledge on: common diarrhea, dysentery, cholera;ῑ ῌ Know some plant remedies for: common diarrhea, dysentery, cholera;ῒ ῌ If positive response to ῑ: self treatment with plants for diarrhea; usages with help of medicine
man; knows where to collect medicinal plants; know how to prepare plant remedies;ΐ ῌ Diarrhea episode in the preceding ῐ weeks;
Baseline data survey items on Ban Pak Pae, Sanxay district, Attapeu province, December, ῍ῌῌ῎῍ ῌ Village: , House number: , Answered by: , Name of enumerator: , Date of interview: ,῎ ῌ Household information: Number, Name, Sex, Age Relation, Occupation, Schooling, Place ofliving;῏ ῌ Animal husbandry: Number of: Oxen Cow, Buffalo, Pig, Goat, Sheep, Chicken, Duck, Goose, other;ῐ ῌ Household income in the last year (Kip): Regular income/Salary, Wage labor, Selling crop,
Selling animal, Remittance, other, Total income;ῑ ῌ Loans;ῒ ῌ Water resource; Availability, drinking practice, utilization purposes, taste, and volume: Tube
well, Dug well, Tap water, Fountain, River, Pond, Weir, Rain water, Tank, Bottled, other;ΐ ῌ Ownership of the wells;῔ ῌ Toilet: No toilet, Outside on ground, River/Canal, Bore hole/Pit, Latrine with water, Flush toilet,
other;
῕ ῌ Housing: Traditional style house made of: Bamboo wall, Wood, Bamboo and wood wall, Woodand cement/block; completely block build house;
῍ῌῌ Possessions: Radio, Television, Refrigerator, Tape-recorder, Bicycle, Motorbike, Thak-Thak,
Jambo, Tuk-Tuk, Automobile;῍῍ῌ Disposition of daily wastes/garbage: Fixed place, Routine collection, Scatter around the house,
other;῍῎ῌ Disease and consultation: Number of disease cases in your family if you aware at present year(῎ῌῌ῏) and in the last year (῎ῌῌ῎). And with whom she/he consulted the case.; Disease: Common
cold/ARI, TB, Malaria/fever, Diarrhea, Dysentery, Helminthes, Tetanus, Dengue, Polio, Measles,
Diabetes, Cancer, Animal bite, Accidental Wound, other῍῏ῌ Usage of bed net; Smoking habit: Information awareness on drug abuse.
Questionnaire items for diarrhea and fever/malaria survey at Pak Pae village, Sanxay district,Attapeu province in December ῍ῌῌ῏῍ ῌ Date of interview, Name of surveyor, Interviewee: name, age, sex, Number of the household;῎ ῌ Experience of the cholera vaccine during ῍῕῕ῑῌ῕ῒ;῏ ῌ Interviewee’s episode on severe diarrhea and/or abdominal pain in the year;ῐ ῌ The family members’ episode on severe diarrhea and/or abdominal pain in the year;ῑ ῌ If replied to ῐ, check the number of people with the episode;ῒ ῌ Interviewee’s episode on fever and/or malaria in the year;ΐ ῌ The family members’ episode on fever and/or malaria in the year;῔ ῌ If replied to ΐ, check the number of people with the episode.

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