Up to 8% of deaths of Cambodians under the age of five are due to diarrhea. This percentage increases significantly when deaths due to premature births, birth asphyxia, and other peripartum deaths are excluded from totals (Conseil Sante 2016). While the burden of disease (BOD) in adults in the Greater Mekong Subregion (GMS) countries has shifted to noncommunicable diseases, the BOD in children is still predominantly comprised of diarrheal diseases. In most cases, Cambodians are more vulnerable than other GMS countries due to the rate of poverty, percent of the rural population, etc. The incidence of acute diarrhea in Cambodia, however, is considered quite high across all socio-economic groups, ranging from 11% among the wealthiest and 18% among the least wealthy quintiles of the population, indicating that determinants of diarrheal disease extend beyond poverty.

Diarrheal diseases occur primarily through the consumption of contaminated water or food. In the case of Cambodia, the etiological agents responsible for most cases of diarrhea are unknown. This is especially true for diseases outside of reportable infectious diseases and waterborne diseases, such as cholera. Likewise, comprehensive data regarding etiological agents responsible for (what are traditionally considered) foodborne diseases are still scarce in Cambodia. This being stated, officially recognized foodborne disease outbreaks have occurred throughout the country (Inrasothythep 2019). These are usually large outbreaks with associated fatalities. In these instances, the Cambodian government has been able to identify the causes of disease. For example, from 2014-2019, Cambodia officially reported 135 foodborne disease outbreaks, resulting in 5,825 individual cases and 81 deaths (Mekong Institute 2019). Recent high-profile, larger-scale outbreaks have involved methanol poisoning (homemade rice wine; Anon. 2016), parasitic infections (pork; Kunthear 2017), noodles (Bacillus and/or Staphylococcus; Kimsean et al. 2016), a 2015 outbreak at a large conference affecting 800 attendees (herbicide poisoning and/or poor hygiene; Dara 2015, Sotheary et al. 2015), a 2017 outbreak at a school affecting 200 individuals (contaminated rice; Suy 2017), and a 2018 disease outbreak involving pesticide-contaminated water that resulted in at least 120 cases and 10 deaths.

It is important to note that these data represent only confirmed cases. More accurate estimations of the true incidence of foodborne disease usually come from modeling. Such modeling studies are not available for Cambodia, but conditions in the country would indicate that, as in other countries, the number of foodborne disease outbreaks and individual cases is likely several orders of magnitude higher than what is reported due to limits in surveillance, diagnostics, and epidemiology. For reference, Laos, Myanmar, and Vietnam reported 949, 6,864, and 5,664 incidents of “food poisoning,” respectively, for 2016 alone (Sante 2016). Troeger et al. (2018) recently reported that the disease burden of diarrhea in Cambodia as 5 determined by disability-adjusted life years, which combines mortality and morbidity, is much higher than that estimated by the Global Burden of Disease.

There is a clear lack of data on etiological agents for acute diarrheal diseases. There are less data concerning chronic exposure to foodborne pathogens and foodborne illness that may not result in hospitalization. Malnutrition and associated effects such as stunting are significant challenges in Cambodia, and it is currently unclear how foodborne disease contributes to these challenges (e.g., gastric dysfunction, impaired absorption of macro and micronutrients, etc.). When unresolved, these types of foodborne illnesses also contribute significantly to the diarrhea-associated BOD. Taken together, these observations highlight a need to close major data gaps, follow informed policies, link food sector stakeholders, and enhance food safety communication throughout the country. The following is a landscape review of food safety efforts in Cambodia with the aim of describing the current status of food safety governance, surveillance, research, partnerships, and opportunities.