SEACTN

30 May 2025

In the remote corners of Chattogram Division in Bangladesh, a simple fever can be a death sentence. Limited access to care, delays in seeking help, and widespread self-medication are factors putting rural communities at risk. A new qualitative study dives deep into the challenges of managing acute febrile illness in these areas, drawing insights from interviews with local and international stakeholders.

The research reveals a fragile healthcare system strained by referral barriers, under-resourced emergency care, and reliance on community health workers who often lack the tools and training to respond to febrile illness beyond malaria. In the health centres, undiagnosed fevers are often treated with guesswork and unnecessary antibiotics, which fuels antimicrobial resistance.

This study makes the case for a more integrated approach – one that strengthens triage and referral systems, empowers frontline health workers with diagnostic tools and digital innovations, and removes the financial and logistical barriers that prevent timely care. As infectious disease patterns are shifting and rural health needs are evolving, we need to rethink how febrile illness in these communities is managed. Text: Marco Liverani

COMRU

4 June 2025

In May 2025, circus performances were used to educate Cambodian youth on the correct use of antibiotics. Misuse of antibiotics is a major driver of bacterial antimicrobial resistance (AMR) worldwide. The wide availability of antibiotics over the counter in Cambodia and linguistic issues make it difficult for younger Cambodians to understand when antibiotic use is appropriate.

Involving circus arts, storytelling and social media, the performances aimed to improve Cambodian youth’s awareness of the problem of AMR and its causes. Funded by a bursary from MORU Bioethics, the project is related to MORU’s ongoing research on AMR in Cambodia and complemented SEACTN’s Electronic clinical Decision support for management of Acute fever (EDAM) cluster-randomised trial in Battambang, which completed data collection in January 2025. The performances were part of a package of educational activities developed by MORU and the Cambodia-Oxford Medical Research Unit (COMRU) who teamed up with the Cambodian Ministry of Health (MoH), Action for Health Development (AHEAD), and Phare, the Cambodian Circus to educate Cambodian school children and youth groups on the correct use of antibiotics.

Delivered in Battambang on 19-20 May and Siem Reap on 22-23 May, the circus performances were extremely well received by a total audience of >1,200. Subsequent social media posts have been viewed >360,000 times to date. Next steps are to complete an educational video based on the circus performance and work with Cambodia MoH colleagues to integrate this into national AMR awareness activities.  – Text: Paul Turner.

In May 2024, following many months of preparations, the first patients were enrolled in the Electronic clinical Decision support for Acute fever Management (EDAM) cluster randomised trial in Battambang province, Cambodia.

The EDAM trial aims to assess the impact of an electronic decision support tool (the EDAM app) on antibiotic prescribing rates among patients presenting with acute febrile illness (AFI) to primary care centres in Battambang. The EDAM app, co-created with local clinicians, guides healthcare workers through various steps in order to help guide clinical assessment of AFI and suggest appropriate clinical management. In the trial, half of the 30 participating health centres were randomised to use the EDAM app in clinical care, whilst the other half will serve as a comparison group.

Coordinated on the ground by MORU’s research partner, Action for Health and Development (AHEAD, led by executive director Dr Moul Vanna) and field research team (led by Dr Abhijit Mishra and Phal Chanpheakdey), the EDAM trial has enrolled more than 1,000 patients since the end of May. The MORU and AHEAD staff have been working closely with the Provincial Health Department (PHD) and Operational District (OD) Directors to provide support and guidance to the healthcare workers partaking in the trial, focussing particularly on how healthcare workers can optimally integrate using the EDAM app during the busiest clinic hours.

With a recruitment target of 4,560 participants, the EDAM trial will continue to enrol patients throughout the rainy season over the next few months.

On 2 and 3 May, the Provincial Health Department in Battambang, Cambodia, hosted a “Train the Trainer” workshop in collaboration with Mahidol Oxford Tropical Medicine Research Unit (MORU) and Action for Health Development (AHEAD) to prepare for the upcoming launch of the Electronic clinical Decision support for Acute fever Management (EDAM) study.

The EDAM study is a cluster-randomised clinical trial that will evaluate the impact of an electronic clinical decision support algorithm (eCDSA) – incorporating pulse oximetry and a rapid C-reactive protein (CRP) test – on antibiotic prescribing rates in primary care. The EDAM algorithm is housed within a user-friendly app and has been co-created with local clinicians. Thirty healthcare centres across three districts will be randomised into the intervention or control arm.

During the workshop on 2 and 3 May, the EDAM study protocol and procedures were presented to senior members of the Provincial Health Department (PHD) and Operation District (OD) Directors, after which a fruitful discussion followed to ensure the optimal planning of the study for the local context in Battambang. Workshop participants also had the chance to test the EDAM app, the structure and content of which has been honed over the past 5 months by Dr Marco Liverani with input from both MORU clinical researchers and Cambodian doctors. Despite 42-degree heat and intermittent air-conditioning, all participants were very engaged and provided invaluable suggestions for improving the study!

The MORU-AHEAD team in Cambodia will continue to work closely with PHD and the OD Directors to plan the main training session on 16 and 17 May 2024 for 90 healthcare workers who will carry out EDAM study procedures. We expect the first participant to be enrolled in the study on 20 May 2024.

The data collection for the SEACTN household health survey across Bangladesh, Cambodia, and Chiang Rai (Thailand) is completed. This survey utilized questionnaire interview, physical examinations, and blood tests to evaluate the prevalence of a wide range of non-communicable and communicable diseases in these rural communities. The findings will inform evidence-based healthcare prioritization.

Read article at BMJ

Using data collected in the SEACTN Rural Febrile Illness project, Christopher Chew and colleagues evaluate the cost-effectiveness of a multiplex rapid diagnostic test able to diagnose enteric fever and dengue, coupled with CRP measurement to guide antibiotic prescribing for respiratory tract infections, in rural Cambodian and Bangladeshi primary care settings.

Read article at ScienceDirect

We have surpassed 7,000 enrolled participants in Work Package B! Thanks to everyone involved for reaching this milestone.

The BRAC Health Program research team has recently wrapped up both WPA and HHS data collection activities in Bangladesh, having recruited over 19000 participants for WPA and 1800 participants for HHS from SEACTN villages in Bandarban and Cox’s Bazar. Having also completed Stakeholder Analysis and being the only site to have implemented all five major components under this initial phase of SEACTN studies, it has been a tremendous achievement for the research staff.

“We have worked diligently in partnership with our friends at MORU in order to establish a capable team of research physicians, clinical staff, interviewers and data managers, which will not only contribute to the ongoing success of SEACTN, but will help answer key questions regarding health priorities in the region and establish local scientific leadership and expertise for future studies on health research in Bangladesh,” said Dr Akramul Islam, Senior Director of BRAC and the local Principal Investigator for SEACTN in Bangladesh.

“We are eagerly looking forward to learning what the data reveals, so that we may work more effectively with our government partners and local stakeholders in order to improve the quality of health among rural populations in Bangladesh,” said Dr Shayla Islam, Associate Director of BRAC and Co-investigator for SEACTN.

The activities of the field research team was also audited during multiple visits by visiting teams from MORU, which greatly added to overall quality of work and towards the development of professional capacity within local staff.

The next challenge for the team is to ship all the biological samples collected and send them to MORU central laboratory for analysis and results dissemination. Very exciting times indeed!

– Text and pictures courtesy of Dr. Aninda Sen.