Jamal Hisham Hashim

Health and health-care systems in southeast Asia: diversity and transitions.

Summary Southeast Asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. These factors have not only contributed to the disparate health status of the regions diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. Rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. While novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. New challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. Juxtaposed between the emerging giant economies of China and India, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. In this first paper in the Lancet Series on health in southeast Asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health.

Health risk assessment of inorganic arsenic intake of Cambodia residents through groundwater drinking pathway.

In order to compare the magnitudes and health impacts of arsenic and other toxic trace elements in well water, groundwater and hair samples were collected from three areas with different arsenic exposure scenarios in the Mekong River basin of Cambodia. Ampil commune in Kampong Cham province was selected as an uncontaminated area, Khsarch Andaet commune in Kratie province was selected as a moderately contaminated area, and Kampong Kong commune in Kandal Province was selected as an extremely contaminated area. Results of ICP-MS analyses of the groundwater samples revealed that As, Mn, Fe and Ba concentrations were significantly different among the three study areas (Kruskal-Wallis test, p < 0.0001). Out of 46 observed wells in the Kandal province study area, 100% detected As > 50 μg L(-1) and Fe > 300 μg L(-1); 52.17% had Mn > 400 μg L(-1) and 73.91% found Ba > 700 μg L(-1). In the Kratie province study area (n = 12), 25% of wells showed elevated arsenic levels above 10 μg L(-1) and 25% had Mn > 400 μg L(-1), whereas samples from Kampong Cham province study area (n = 18) were relatively clean, with As < 10 μg L(-1). A health risk assessment model derived from the USEPA was applied to calculate individual risks resulting from drinking groundwater. Computational results indicated that residents from Kandal Province study area (n = 297) confronted significantly higher non-carcinogenic and carcinogenic risks than those in Kratie (n = 89) and Kampong Cham (n = 184) province study areas (Kruskal-Wallis test, p < 0.0001). 98.65% of respondents from the Kandal province study area were at risk for the potential non-cancer effect and an average cancer risk index was found to be 5 in 1000 exposure. The calculations also indicated that, in the Kratie province study area, 13.48% of respondents were affected by non-cancer health risks and 33.71% were threatened by cancer, whereas none of respondents in the Kampong Cham province study area appeared to have non-carcinogenic effect. Positively significant correlations of the arsenic content in scalp hair (As(h)) with both arsenic levels in groundwater (As(w)) (r(s) (304) = 0.757, p < 0.0001) and individual average daily doses (ADD) of arsenic (r(s) (304) = 0.763, p < 0.0001) undoubtedly indicated that arsenic accumulation in the bodies of Cambodia residents in the Mekong River basin was mainly through a groundwater drinking pathway. To the best of our knowledge, this is the first comprehensive report comparing individual health risk assessments of arsenic exposure through a groundwater drinking pathway to enriched arsenic levels from groundwater in the Mekong River basin, Cambodia. This study indicates that elevated arsenic concentrations in groundwater may lead to thousands of cases of arsenicosis in the near future if mitigating actions are not taken.

Daily intake and human risk assessment of organochlorine pesticides (OCPs) based on Cambodian market basket data

To assess organochlorine pesticide (OCP) contaminations and its possible adverse health impacts, different food samples were collected from three areas of Cambodia, one of the poorest countries in the world. The ∑OCP concentrations in Kampong Cham, Kratie and Kandal provinces ranged from 1.28 to 188 (median 3.11), 1.06 to 25.1 (5.59) and 2.20 to 103 (20.6) ng g(-1), respectively. The dichlorodiphenyltrichloroethanes (DDTs) were the predominant OCPs and accounted for 62.2% (median) among all foodstuffs. Congener profile analyses suggested that there were new input sources of DDTs and hexachlorocyclohexanes (HCHs) in Cambodia, particularly in Kandal province. The estimated daily intake of OCPs (330 ng kg(-1)day(-1)) for residents in Kandal province ranked No. 1 among the 13 compared countries or regions. On the basis of 95th percentile concentrations, the carcinogenic hazard ratios (HRs) of most investigated individual OCPs in vegetable and fish in Cambodia exceeding unity. Particularly for α-HCH in vegetable, the 95th HR was as high as 186. The data revealed that there is a great cancer risk for the local residents with life time consumption of OCP contaminated vegetable and fish. To our knowledge, this the first study to evaluate the daily intakes of OCPs in Cambodia.

Fungal DNA, allergens, mycotoxins and associations with asthmatic symptoms among pupils in schools from Johor Bahru, Malaysia

To cite this article: Cai G‐H, Hashim JH, Hashim Z, Ali F, Bloom E, Larsson L, Lampa E, Norbäck D. Fungal DNA, allergens, mycotoxins and associations with asthmatic symptoms among pupils in schools from Johor Bahru, Malaysia. Pediatr Allergy Immunol 2011; 22: 290–297.

Toxic effect of gestational exposure to nonylphenol on F1 male rats

OBJECTIVE The purpose of this study was to examine whether gestational exposure to major environmental endocrine-disrupting chemicals, nonylphenol (NP), would lead to nerve behavioral and learning and memory capacity alterations in the male offspring of rats, and reproductive development alterations in the male offspring of rats. METHODS Dams were gavaged with NP at a dose level of 50 mg/kg/day, 100 mg/kg/day or 200 mg/kg/day daily from gestational day 9 to 15, and at a dose level of 40 mg/kg/day, 80 mg/kg/day or 200 mg/kg/day daily from gestational day 14 to 19 (transplacental exposures). RESULTS Exposure to 200 mg/kg/day NP produced a significant decrease in learning and memory functions in offspring rats (P<0.05) in Morris water maze task, as demonstrated by the increased escape latency and number of error. In Step-down Avoidance Test, offspring rats exposed to NP spent more reaction time (RT) and presented lower latency to first step-down than the control offspring (P<0.01). In utero exposure to 80 and 200 mg/kg/day NP produced a significant decrease in the number of live pups per litter and ratio of anogenital distance to body length on PND 0 (P<0.05), and also testes and prostate weight, activities of ALP, plasma testosterone concentration, cauda epididymis sperm counts, daily sperm production et al. respectively on PND 90 (P<0.05). Histopathological examination of the brain biopsy illustrates that exposure to NP at high dose induces the presence of abnormal distribution of spermatozoa showed in lumina of the seminiferous tubules, and absence of spermatogenesis and spermiogenesis. CONCLUSION Gestational exposure to nonylphenol might induce neurotoxic and reproductive toxic effects on F1 male rats.

Chapter one: exposure measurements

Determining human exposure to suspended particulate concentrations requires measurements that quantify different particle properties in microenvironments where people live, work, and play. Particle mass, size, and chemical composition are important exposure variables, and these are typically measured with time-integrated samples on filters that are later submitted to laboratory analyses. This requires substantial sample handling, quality assurance, and data reduction. Newer technologies are being developed that allow in-situ, time-resolved measurements for mass, carbon, sulfate, nitrate, particle size, and other variables. These are large measurement systems that are more suitable for fixed monitoring sites than for personal applications. Human exposure studies need to be designed to accomplish specific objectives rather than to serve too many purposes. Resources need to be divided among study design, field sampling, laboratory analysis, quality assurance, data management, and data analysis phases. Many exposure projects allocated too little to the non-measurement activities.

Non-occupational exposure of Malay women in Kuala Lumpur, Malaysia, to cadmium and lead

Abstract Peripheral blood and 24-h total food duplicate samples were obtained from 49 adult Malay women in Kuala Lumpur, Malaysia, in July, 1995. Samples of boiled and uncooked (raw) rice were also collected from the subjects. The blood samples, homogenates of each food duplicates and rice samples (both cooked and raw) were digested by heating in the presence of mineral acids, and the digests were subjected to analysis for cadmium (Cd) and lead (Pb) with a system composed of a fully automated liquid sampler, a graphiie furnace atomic absorption spectrometer and a data processor. The geometric mean metal concentrations in blood were 0.71 ng Cd per ml and 45.6 ng Pb per ml, and the dietary metal intakes were 7.31 μg Cd per day and 10.1 μg Pb per day. The metal intake via rice accounted for 53% and 13% of total dietary intake of cadmium and lead, respectively. When the absorption from the air and foods was compared, the cadmium burden came almost exclusively from foods, whereas the lead burden came both from air (44%) and foods (56%).

Dietary Exposure and Risk Assessment of Mercury via Total Diet Study in Cambodia

To assess the daily intakes of total mercury (THg) and methylmercury (MeHg) and the possible adverse health impacts, different food groups including fish, meat, vegetable and rice were collected from three areas in Cambodia. The concentrations of THg and MeHg ranged from 0.16 to 171 ng g(-1) and not detected (ND) to 82.3 ng g(-1) wet weight (ww), respectively. The concentrations of THg and MeHg in fish were approximately three to four orders of magnitude greater than that in fruit and vegetable. Fish had the highest contribution to the total daily intakes of THg and MeHg. The estimated daily intake (EDI) of THg for the general population in Kampong Cham, Kratie and Kandal was 0.24, 1.38 and 0.22 μg kg(-1) bw d(-1), and 0.11, 0.45 and 0.06 μg kg(-1) bw d(-1) for MeHg, respectively. The dietary daily intakes of MeHg in Kratie and Kampong Cham were greater than the reference dose (RfD) imposed by The United States Environmental Protection Agency (USEPA) and in Kratie was also exceed the provisional tolerable weekly intake (PTWI) imposed by World Health Organization (WHO). To our knowledge, this the first study to evaluate the daily intakes of THg and MeHg in Cambodia.

Asthma, Airway Symptoms and Rhinitis in Office Workers in Malaysia: Associations with House Dust Mite (HDM) Allergy, Cat Allergy and Levels of House Dust Mite Allergens in Office Dust

A prevalence study was conducted among office workers in Malaysia (N= 695). The aim of this study was to examine associations between asthma, airway symptoms, rhinitis and house dust mites (HDM) and cat allergy and HDM levels in office dust. Medical data was collected by a questionnaire. Skin prick tests were performed for HDM allergens (Dermatophagoides pteronyssinus, Dermatophagoides farinae) and cat allergen Felis domesticus. Indoor temperature and relative air humidity (RH) were measured in the offices and vacuumed dust samples were analyzed for HDM allergens. The prevalence of D. pteronyssinus, D. farinae and cat allergy were 50.3%, 49.0% and 25.5% respectively. Totally 9.6% had doctor-diagnosed asthma, 15.5% had current wheeze and 53.0% had current rhinitis. The Der p 1 (from D. pteronyssinus) and Der f 1 (from D. farinae) allergens levels in dust were 556 ng/g and 658 ng/g respectively. Statistical analysis was conducted by multilevel logistic regression, adjusting for age, gender, current smoking, HDM or cat allergy, home dampness and recent indoor painting at home. Office workers with HDM allergy had more wheeze (p= 0.035), any airway symptoms (p= 0.032), doctor-diagnosed asthma (p= 0.005), current asthma (p= 0.007), current rhinitis (p= 0.021) and rhinoconjuctivitis (p< 0.001). Cat allergy was associated with wheeze (p= 0.021), wheeze when not having a cold (p= 0.033), any airway symptoms (p= 0.034), doctor-diagnosed asthma (p= 0.010), current asthma (p= 0.020) and nasal allergy medication (p= 0.042). Der f 1 level in dust was associated with daytime breathlessness (p= 0.033) especially among those with HDM allergy. Der f 1 levels were correlated with indoor temperature (p< 0.001) and inversely correlated with RH (p< 0.001). In conclusion, HDM and cat allergies were common and independently associated with asthma, airway symptoms and rhinitis. Der f 1 allergen can be a risk factor for daytime breathlessness.

Rhinitis, Ocular, Throat and Dermal Symptoms, Headache and Tiredness among Students in Schools from Johor Bahru, Malaysia: Associations with Fungal DNA and Mycotoxins in Classroom Dust.

There are few studies on rhinitis and sick building syndrome (SBS) among students in tropical countries. We studied associations between levels of five fungal DNA sequences, two mycotoxins (sterigmatocystin and verrucarol) and cat allergen (Fel d 1) levels in schools and rhinitis and other weekly SBS symptoms in the students. Fungal DNA was measured by quantitative PCR and cat allergen by ELISA. Pupils (N = 462) from eight randomly selected schools in Johor Bahru, Malaysia participated (96%). Dust samples were collected by cotton swabs and Petri dishes exposed for one week. None of the schools had a mechanical ventilation system, but all classrooms had openable windows that were kept open during lectures and indoor CO2 levels were low (mean 492 ppm; range 380–690 ppm). Weekly nasal symptoms (rhinitis) (18.8%), ocular (11.6%), throat (11.1%), dermal symptoms, headache (20.6%) and tiredness (22.1%) were common. Total fungal DNA in swab samples was associated with rhinitis (p = 0.02), ocular symptoms (p = 0.009) and tiredness (p = 0.001). There were positive associations between Aspergillus versicolor DNA in Petri dish samples, ocular symptoms (p = 0.02) and tiredness (p = 0.001). The level of the mycotoxin verrucarol (produced by Stachybotrys chartarum) in swab samples was positively associated with tiredness (p = 0.04). Streptomyces DNA in swab samples (p = 0.03) and Petri dish samples (p = 0.03) were negatively associated with tiredness. In conclusion, total fungal contamination, measured as total fungal DNA) in the classrooms, Aspergillus versicolor and verrucarol can be risk factors for rhinitis and SBS symptoms among students in the tropical country Malaysia.