ORIGINAL ARTICLE

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

Utilizing three years of epidemiological data from medical

missions in Cambodia to shape the mobile medical clinic

formulary

Jeany Kim Jun
a
, Junia S Koo

b
, Amy Y Kang

c
, Deborah B Chien

d
, Albert Shim

e
, Dale

Knutson
f
, Eda M Kim

a
PharmD, MPH, BCACP, AAP, Assistant Professor of Clinical and Administrative Sciences, Keck Graduate Institute

School of Pharmacy, USA
b

PharmD, Staff Pharmacist, University of California Los Angeles Medical Center, California, USA
c
PharmD, Post-Graduate Year 1 Pharmacy Practice Resident, Department of Clinical Pharmacy, University of

California San Francisco School of Pharmacy, USA
d

PharmD, Per-Diem Pharmacist, Department of Pharmacy, Desert Valley Hospital, California, USA
e

MD, Family Medicine and Pediatrics Physician, Department of Internal Medicine and Pediatrics, Cedars Sinai

Medical Group, California, USA
f
MD, Pediatrician, Medical Missionary, Mission to the World, Cambodia

g
MD, Family Practice Physician at Mission to the World, USA

Abstract
Objective: The purpose of this project was to gather epidemiological data on

common diseases and medications dispensed during medical mission trips to

Cambodia to shape the mobile medical clinic formulary.

Methods: Data for patients seen during week-long mobile medical clinics was

collected in Cambodia during Septembers 2012 to 2014. Each patient’s gender, age,

weight, blood pressure, glucose, pertinent laboratory values, diagnoses, and

medications dispensed were collected. Blood pressure and glucose levels were

measured in patients 18 years and above. Data collected onto paper intake forms

were transferred onto spreadsheets without patient identifying information and

analyzed for aggregate means, common diseases, and most dispensed medications.

This project received institutional review board approval.

Results: A total of 1,015 patients were seen over three years. Women made up

61.4%, and the mean age was 41.8 years. The most common diagnosis was

gastrointestinal disorders (22.9%) that included gastroesophageal reflux disease and

intestinal parasites. Next, 20.1% of patients had hypertension (BP>140/90), 18.0%

had presbyopia, 15.4% had back and joint pain, followed by 8.8% with headache,

including migraines. Approximately 8.4% of patients had hyperglycemia (RPG >140

mg/dl). The top five medications dispensed were acetaminophen, omeprazole,

multivitamin, ibuprofen, and metformin. For hypertension, amlodipine and lisinopril

were dispensed.

14 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

Conclusion: Cambodia lacks systematic public health collection of epidemiological

data for prevalence of diseases. Hence, investigators collected and analyzed

information from week-long mobile medical clinics over three years. Proton-pump

inhibitors and H. pylori lab tests were recommended for gastrointestinal disorders.

Acetaminophen and ibuprofen were recommended for pain. Angiotensin-converting-

enzyme inhibitors and dihydropyridine calcium channel blockers were recommended

over diuretics since patients were already dehydrated. Metformin was recommended

for diabetes. Vitamins and supplements were recommended for malnourished

patients. Hemoglobin machines and urine test strips were suggested. This

information should help future teams decide what medications and laboratory tests

would be the most beneficial for use by medical teams in Cambodia.

Introduction
Cambodia is located in Southeast Asia with a

population of 14.4 million.
1
Approximately 80.5%

reside in rural areas with 1.3 million people living

in the capital city of Phnom Penh.
1

The life

expectancy at birth averages 61 to 64 years for men

and women, respectively.
2

Agriculture with rice

production is the country’s primary source of

revenue.
1
In addition, small-scale subsistence

agriculture serves as another source of revenue; this

includes raising fish and livestock.
1

Around the year 2000, following an era of war

and civil conflict, Cambodia entered a decade of

rapid economic growth, along with demographic

and epidemiological shifts.
3
Largely from increased

tourism and gains in the garment industry,

Cambodia’s gross domestic product grew at an

average annual rate of 7% in the following decade.
4

Additionally, the under-5 mortality rate per 1,000

live-births declined from 124 in 2000 to 54 in

2010.
4
Even so, Cambodia remains one of the

poorest and most underdeveloped countries in Asia,

where many are living on a wage of less than $1.20

United States Dollar (USD) per day.
4
About 6,400

deaths occur annually from lack of adequate

nutrition.
5

Malnutrition among the poor leads to

stunted growth (reduced height for age) in 40% of

the children and wasting (reduced weight for

height) in 11% of the children.
1

Despite the many improvements in the health

status in Cambodia, great disparities exist between

urban and rural areas, and across socioeconomic

groups. Rural areas rely heavily on rain for

drinking water during the dry season, and less

developed sanitation facilities contribute to

increased exposure to communicable diseases.
1

Acute respiratory infection, fever, and diarrhea are

common causes of childhood mortality. While

many of these conditions are treatable, in a largely

fee-based health care system, the cost of healthcare

often creates a barrier to those seeking treatment.

In addition to communicable diseases, motor-

vehicular accidents are a major cause of injury or

death in urban areas in the age group 20-39.
1
Non-

governmental organizations (NGOs), sponsored by

international nonprofit organizations, bridge the

access gap in healthcare through supporting and

serving NGOs led by nationals within Cambodia.
6

Objective
Mobile medical clinics provide intermittent

care in Cambodia to the underserved population.

However, in 2011, the lack of available

epidemiological data for prevalent diseases or

15 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

medications hampered the preparation of medical

teams to provide appropriate treatment for the

patients. In order for future medical teams to more

accurately secure medications and laboratory tests

needed, this project was undertaken. For the

purpose of this project, we gathered epidemio-

logical data on the most common diseases and

medications dispensed during medical mission

teams to Cambodia from 2012 to 2014 in order to

shape future mobile medical clinic formularies.

Methods
This study evaluated all patients seen during

three years of week-long mobile medical clinics

held in Septembers 2012, 2013, and 2014 in

Cambodia. Patients were seen and evaluated by a

multidisciplinary team of healthcare professionals

from the United States, including physicians,

pharmacy students, pharmacists, physical therapists,

and registered nurses, working alongside long-term

medical missionaries and Cambodian trained health

care providers.

Medical mission teams visited Phnom Penh,

as well as three rural villages in Kampot Province.

In 2012, the medical team spent four days in

NeaReay and two days in Phnom Penh, and saw a

total of 317 patients. In 2013, the team spent two

days in AngKjay, two days in NeaReay, and two

days in Phnom Penh and saw a total of 408 patients.

In 2014, the team spent one day in Prey Thom, a

very rural village without electricity, two days in

AngKjay, and two days in NeaReay and saw a total

of 290 patients.

Each patient’s gender, age, weight, blood

pressure, blood glucose, pertinent laboratory values,

diagnoses, and dispensed medications were

collected. Blood pressure and blood glucose levels

were measured in patients 18 years and older. Data

were collected onto paper intake forms and then

organized into a computerized spreadsheet, without

patient identifying information, and stored using a

secure web interface.

Descriptive statistics were computed for all

study variables. Means for adults 18 years and

above were reported. The numbers of medications

dispensed and common disease states were

identified. This study was approved by the Loma

Linda University Institutional Review Board.

Results

Demographics

A total of 1,015 patients were included in the

data analysis over three years. Women made up

61.4% (N=624), and the mean age was 41.8 years

with a range of 2 weeks to 87 years. Infants,

children, and teenagers, 0-17 years, included 15.5%

of the patients. Adults, 18-39 years, made up

25.7%, 40-59 years were 37.0%, and 60 years and

over included 21.8% of the sample. In patients 18

years and above (N=858), the mean weight and

height was 56.3 kilograms (kg) and 65.7 inches in

men, and 44.9 kg and 60.7 inches in women.

Average body mass index (BMI) was 21.5 and 21.0

kg/m
2
for men and women, respectively.

Common Diseases

Overall, gastrointestinal (GI) disorders,

including gastritis and gastroesophageal reflux

disease (GERD), Helicobacter pylori (H. pylori)

infection, dyspepsia, and intestinal parasites were

the most common disorders diagnosed in 22.9% of

patients of all ages. H. pylori laboratory testing was

not available in 2012 and resulted in 27 patients

receiving treatment without a laboratory diagnosis.

Investigators purchased H. pylori testing kits in

Cambodia for $1 USD each. In the subsequent year,

only three patients received treatment with a

laboratory-confirmed positive test. Seven patients

received H. pylori eradication treatment in 2014.

All patients received albendazole for possible

intestinal parasites. Refer to Figure 1 for the top ten

most common disorders.

16 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

Figure 1. Top 10 diagnoses in 2012, 2013, and 2014 combined (N=1015)

Note: Numbers within figures represent total number of patients with this diagnosis.

Hypertension, defined as a systolic blood

pressure of 140 mm Hg or above, or diastolic blood

pressure of 90 mm Hg or above,

was the second

most common diagnosis.
7
The prevalence of hyper-

tension among Cambodian adults aged 18 and over

was 20.1% and was similar among men (21.7%)

and women (19.7%). The prevalence of

hypertension increased with age, from 9.6% among

those aged 18-39, to 21.7% among those 40-59, to

43.9% among those 60 and over.

Blurry vision due to apparent presbyopia was

a common complaint from patients over 40 years

and made up 18% of the sample. A total of 183

pairs of reading glasses were given over three years.

More low-diopter readers (+1.00 to +2.00) were

dispensed (N=139) than high-diopter readers (+2.25

to +3.50) (N=44).

Back, knee, and joint pain, including

osteoarthritis, was the fourth most common

diagnosis at 15.4%. Most of the patients in the rural

villages were rice farmers and spent a bulk of their

time planting or harvesting rice. Furthermore, head

pain, including migraine and tension-type headache,

was fourth with 8.8%. Patients with complaints of

back and knee pain were referred to the physical

therapist (PT). One PT evaluated a total of 113

patients (71 patients in 2013 and 42 patients in

2014) with complaints of back and knee pain,

subsequently instructing them in proper exercises

and posture.

The overall prevalence of hyperglycemia,

defined as a random plasma glucose (RPG) of

greater or equal to 140 mg/dl, was 8.4% and was

slightly higher in men (9.6%) than women (7.6%).

The prevalence of hyperglycemia increased with

age, from 4.2% among those aged 18-39, to 11.0%

among those 40-59, and to 14.8% among those 60

and over. Severe hyperglycemia, defined as a RPG

of 200 mg/dl or greater, was found in 3.7% of the

patients with similar rates between men (3.5%) and

women (3.8%). The prevalence of severe hyper-

glycemia increased with age with 0.8% among 18-

Constipation

Allergic rhinitis

Vaginitis

Hyperglycemia (RPG≥140 mg/dl)

URI / viral URI / bronchitis

Headache / migraine / tension
HA

Pain (knee / back / joint, arthritis)

Blurry vision / Presbyopia

HTN (BP≥140/90mmHg)

GI Disorders

2012 2013 2014

22.9%

20.1%

18.0%

15.4%

8.8%

8.6%

8.4%

4.5%

4.1%

3.3%

GI: Gastrointestinal, HTN: Hypertension,
BP: Blood Pressure, HA: Headache,
URI: upper respiratory infection,
RPG: random plasma glucose

17 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

39 year olds, 4.8% among 40-59 year olds, and

5.4% in those 60 years and over. The average

glucose value for the 32 patients with severe

hyperglycemia was 355.0 mg/dl.

Common Medications

The top five medications dispensed were

acetaminophen, omeprazole, multivitamin, ibupro-

fen, and metformin. This paralleled the top diseases

to treat gastrointestinal disorders and pain. Since

most patients treated for hyperglycemia required the

maximum dose of metformin at 2000 mg/day, four

tablets of metformin 500 mg were required daily for

patients. Most patients with diabetes were given

120 tablets each. Hence, it became one of the top

five dispensed medications to treat 8.4% of the

patients. For hypertension, amlodipine and

lisinopril were dispensed the most but diuretics

were not used much. Most of the hypertension

medications were given once daily, and hence,

fewer tablets were dispensed. See Table 1 for a list

of the top 20 most dispensed drugs during the three

years.

Table 1. Top 20 medications dispensed during 2012-2014

Rank Medications 2012 2013 2014 Total # tabs

1 Paracetamol 500 mg (Acetaminophen) 3880 4095 4320 12295

2 Omeprazole 20mg 2606 3318 1170 7094

3 Multivitamins 1955 1172 2670 5797

4 Ibuprofen 200 or 400 mg 1721 1711 960 4392

5 Metformin 500 mg or 850 mg 685 1140 600 2425

6 Loratadine 10 mg 310 617 910 1837

7 Children's vitamin 0 600 1200 1800

8 Ferrous fumarate 200 mg or sulfate 325 mg 687 420 540 1647

9 Vitamin B12 510 460 300 1270

10 Amlodipine 5 or 10 mg 400 515 340 1255

11 Lisinopril 10 mg 375 601 210 1186

12 Calcium carbonate 500 mg 810 339 0 1149

13 Docusate sodium 100 mg 434 287 330 1051

14 Amoxicillin 250 or 500 mg 310 329 400 1039

15 Irbesartan 75 mg 0 0 990 990

16 Hydrochlorothiazide 25 mg 900 0 0 900

17 Aspirin 81 mg 490 270 30 790

18 Diphenhydramine 25 mg 267 85 270 622

19 Albendazole 400 mg 256 264 99 619

20 Atenolol 50 mg 540 0 30 570

Discussion
Epidemiological information guides overseas

medical mission medication needs. In 2011, no

epidemiological data existed in Cambodia on the

prevalence of diseases, especially in the rural areas.

The investigators collected and analyzed direct data

during week-long mobile medical clinics in the

Kampot Province of Cambodia from 2012 to 2014.

Public health epidemiological data regarding

Cambodia was published in September 2015 by the

World Bank and in 2014 by the World Health

Organization
4,8-10

that includes major causes of

death and burden of disease but does not indicate

prevalence rates by province. Gastrointestinal

complaints were the most common health problems.

Included in these complaints were intestinal

parasitic infections treated with albendazole 400

mg. Testing kits for H. pylori minimized antibiotics

and saved money. Each Cambodian H. pylori

antibody test cost $1 USD. This test detected

antibody presence, which enhanced clinical

18 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

judgment. For $5 USD, each H. pylori sequential

therapy eradication packet contained omeprazole 20

mg twice daily for ten days; amoxicillin 1000 mg

twice daily for the first five days; clarithromycin

500 mg twice daily for the next five days; and

metronidazole 500 mg twice daily for the next five

days. After utilizing H. pylori tests, the number of

packets given to patients was reduced from 27 in

2012 to 3 in 2013, and 7 in 2014, saving $75 in two

years. All the medications used in the H. pylori

packet were easily purchased in Cambodia.

A Cambodian survey completed in 2005

showed an unexpectedly high prevalence of

hypertension in the relatively poor rural

communities.

The prevalence of hypertension was

12% in a rural community (Siem Reap) and 25% in

a semi-urban community (Kampong Cham).
11

The

prevalence of hypertension in this study was in the

rang of that of the 2005 survey at 20.1% in Kampot

Province. For reference, the prevalence of HTN in

US adults was 29.1% in 2011-2012.
12

U.S. trained

physicians initially used the Seventh Report of the

Joint National Committee (JNC 7) guidelines which

recommended beginning patients with diuretics.
13

However, after viewing urinalysis results with high

specific gravity (above 1.030), the clinicians

recommended that diuretics not be used first line in

the treatment of hypertension. The clinicians,

including the pharmacist, recommended other

pharmacologic options, like lisinopril or enalapril,

an ACE inhibitor, and amlodipine, a dihydro-

pyridine calcium channel blocker. These medica-

tions were readily available in Cambodia for

patients to purchase at local pharmacies once they

ran out of medications received during the mobile

clinic visits and inexpensive at $0.02 per tablet for

lisinopril or enalapril 10 mg and $0.04 per tablet for

amlodipine 5 mg.
14

The 2005 survey also reported rates of

diabetes in the two provinces. The total prevalence

of diabetes was 5% at Siem Reap and 11% at

Kampong Cham, and the prevalence of impaired

glucose tolerance was 10% at Siem Reap and 15%

at Kampong Cham. Thus, total prevalence of

abnormal glucose tolerance was 15% at Siem Reap

and 26% at Kampong Cham.
11

However, in 2015,

the International Diabetes Federation reported that

the prevalence of diabetes in adults in Cambodia

aged 20-79 years was only 2.6%.
15

According to

this study, the prevalence of hyperglycemia, or

possibly impaired glucose tolerance, with glucose

values between 140 and 199 mg/dl was 6.2% with

higher rates in men (8.7%) than women (4.7%).

The prevalence of severe hyperglycemia with

glucose values 200 mg/dl and above, which likely

indicates diabetes, was 3.7%. Hence, the overall

prevalence of hyperglycemia and severe hyper-

glycemia was 8.4%. In terms of treatment,

metformin was the first-line option for diabetes,

after establishing baseline renal function through

urinalysis tests. Metformin was readily available

for purchase in Cambodian pharmacies by the

patient once they completed the medications

provided during the mobile medical clinic visits.

Although inexpensive, sulfonylureas were not

recommended due to the risk of hypoglycemia and

lack of glucose monitoring by patients. For patients

with severe hyperglycemia, insulin treatment was

not considered due to limited availability of

refrigeration in patients’ homes.

Analgesics, such as acetaminophen and

ibuprofen, treated back, neck, joint, and headache

pain. Based on the needs of the patient population,

preparing adequate supplies of these medications is

recommended. Interestingly, vaginitis was one of

the top ten diagnoses. Limited access to clean

water leading to poor hygiene may provide the basis

for vaginitis as a common complaint. Antifungal

treatments, like fluconazole or antifungal vaginal

creams, should be included in the formulary.

Loratadine was given for allergic symptoms and

mild respiratory complaints with a 10 to 30 day

supply. Diphenhydramine was used mostly to treat

insomnia with a 14 day supply.

According to the Demographic Health Survey

in Cambodia released in 2011, more than 4 in 10

women in Cambodia were anemic, although

moderate and severe anemia was relatively rare

19 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

(8%). In addition, more than half (55%) of

Cambodian children aged 6-59 months were

anemic.
16

Thus, adult multivitamins (ranked 3
rd

)

and children’s vitamins (ranked 7
th
), along with

other essential nutrients such as ferrous sulfate (8
th
),

vitamin B12 (9
th
), and calcium carbonate (12

th
),

were given in bulk to patients with poor nutritional

status. Prenatal vitamins for pregnant and

breastfeeding women were given in bulk for at least

three to six months to cover the duration of

pregnancy or lactation.

Reading glasses, available in low diopters,

helped older patients’ complaints of blurry vision.

Sunglasses were given to protect against cataracts

and pterygium. The investigators recommended the

H. pylori blood test kit, a hemoglobin machine to

test for anemia, and a glucometer. A simple

dipstick urinalysis to qualitatively measure urine

glucose, protein, leukocytes, and specific gravity

helped diagnose infections and understand kidney

function.

For chronic diseases such as hypertension and

diabetes, it was crucial that the medications selected

and started by the short-term mobile medical team

be readily available, and not be cost prohibitive for

patients to continue treatment once the patients ran

out of medications. Hence, mobile teams should

consider what medications are available locally

when deciding which medications to take with them

in the future to treat these diseases.

For sustainability of treatment for patients

seen at mobile medical clinics, the short-term

medical team was hosted by long-term medical

missionaries in partnership with the missionaries

located in the rural villages that were visited. After

the departure of the short-term team, the long-term

medical missionaries went back to these villages bi-

monthly to bring additional medications and

supplies, and provided follow-up care for those who

were identified as having a chronic illness such as

hypertension and diabetes. Although these results

are specific to the rural areas of Cambodia, some

aspects may be generalizable to some neighboring

South East Asian countries due to the similarities in

climate and rural living conditions with limited

access to clean water and electricity.

Limitations
The study faced several limitations during its

course. First, this was an observational study with

patient information gathered heavily from rural

areas, which may limit the generalizability of the

study. Second, this study mostly evaluated

prevalence at the time of the clinic visit and did not

provide information regarding diseases that may

have developed after the visit. Third, there was

limited availability of diagnostic testing devices

which may have limited the physicians’ ability to

make a definitive diagnosis. Furthermore, patients

typically had one blood pressure measurement,

whereas at least two are required for a definitive

diagnosis. Similarly, only one random blood

glucose measurement was done for most patients,

so it was difficult to accurately diagnose based on

one measurement. With that said, some strategies

to address these issues were to return to the same

villages bi-monthly to provide follow-up care for

those patients who had elevated blood pressures or

blood glucose values for a firm diagnosis.

Conclusion
Delivering cost-effective, high-quality health

care services in resource-poor settings remains an

enduring challenge. This challenge, however,

becomes more formidable for short-term medical

mission teams as they are faced not only with

limitations in language and culture, diagnostic tools,

and treatment options, but also with limitations with

respect to local epidemiological data, an

indispensable tool for pre-field preparation as well

as on-field diagnosis and treatment. The stakes are

high given the very poor access to healthcare

particularly in rural contexts, the generally high cost

of medical mission trips, the limitations of time, and

the unavoidable hard decisions the teams must

make with respect to what diagnostic tools and

medications they will take and which they will

20 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

leave behind. We submit this study not only as a

resource for those teams traveling to Cambodia but

also elsewhere, where attention to epidemiological

data promises to lead to a more thoughtful approach

to medical mission trips.

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Peer Reviewed

Competing Interests: None declared.

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http://dhsprogram.com/pubs/pdf/SR185/SR185.pdf/

23 Jun, Koo, Kang, Chien, Shim, Knutson, Kim

Mar 2017. Christian Journal for Global Health, 4(1): 13-23.

Correspondence: Jeany Kim Jun, Keck Graduate Institute School of Pharmacy, United States. jjun@kgi.edu

Cite this article as: Jun J K, Koo J S, Kang A Y, Chien D B, Shim A, Knutson D, Kim E M. Utilizing three years of

epidemiological data from medical missions in Cambodia to shape the mobile medical clinic formulary.

Christian Journal for Global Health. Mar 2017; 4(1): 13-23.

under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution,

and reproduction in any medium, provided the original author and source are properly cited. To view a

copy of the license, visit https://creativecommons.org/licenses/by/4.0/

www.cjgh.org

mailto:jjun@kgi.edu
https://creativecommons.org/licenses/by/4.0/