A comparison of chronic pain prevalence in Japan, Thailand, and myanmar

BACKGROUND

Pain has been regarded as important in the improvement of quality of life (QOL). In the advanced countries of Europe and the North America, a number of large-scale epidemiological surveys on pain, particularly chronic pain, have thus been performed in general populations. However, few epidemiological surveys of chronic pain have been reported from developing countries, and no surveys appear to have examined chronic pain in the least developed countries.

OBJECTIVES

To compare the incidence of chronic pain in Asian countries, using Japan as an advanced country, Thailand as a developing country, and Myanmar as one of the least developed countries.

STUDY DESIGN

Cross-sectional study in 4 hospitals.

SETTING

A university hospital and a general hospital in Japan, a university hospital in Thailand, and a general hospital in Myanmar.

METHODS

Patients were 1,000 nursing staff working in Japan, 448 nursing staff working in Thailand, and 405 nursing staff working in Myanmar. The survey was performed by requesting all nursing staff to anonymously answer the questionnaire. Data were used to calculate chronic pain prevalence, pain site, presence or absence of consultation with doctors, methods of handling pain other than consultation with doctors, and whether pain was controlled for each country. The results were then compared between countries.

RESULTS

The prevalence of chronic pain in Myanmar was 5.9%, which was significantly lower (P < 0.01) than in Japan (17.5%) or Thailand (19.9%). The most frequent pain sites were the lower back, head, and shoulders in Japan, and the shoulders, ankle, upper back, and head in Thailand, whereas in Myanmar, no clear certain tendencies were observed. The most frequent method for handling pain other than consultation with doctors was over-the-counter drugs in Japan, massage in Thailand, and relaxation therapy (meditation) in Myanmar.

LIMITATIONS

Limitations of this study were the cross-sectional design study, the small number of hospitals included, the limitation of patients to nursing staff, and the omission from the questionnaire of questions regarding body height and weight, working situation, family background, trauma history, sports activity history, smoking history, psychological/character tests, QOL, and pain levels of patients.

CONCLUSION

The prevalence of chronic pain was significantly lower in Myanmar than in Japan or Thailand. With regard to the site and treatment of chronic pain, no clear tendencies were observed between countries, suggesting that frequency and the character of chronic pain differ from country to country around the world.

Oral health status and oral hygiene habits among children aged 12-13 years in Yangon, Myanmar

We conducted a cross sectional study among children aged 12-13 years in Yongon, Myanmar to assess the oral health status and oral hygiene habits. The studied 220 students were from two high schools, one urban and the other rural. We conducted an oral health examination following WHO criteria and used a self-administrated questionnaire. The prevalence rate of dental caries among the study population was 53.2%. The mean number of decayed, missing and filled teeth (DMFT) was 1.7 +/- 2.1 teeth per person (decayed, 1.5 +/- 1.9); missing 0.0 +/- 0.2; filled, 0.1 +/- 0.4). Multivariate analysis revealed significant risk factors for dental caries were: the geographical location of the school (adjusted OR=2.24; 95% CI: 1.01-4.94), occupational status of the father (adjusted OR=2.83; 95% CI: 1.05-7.62) and the child's attitude about dental caries (adjusted OR=2.35; 95% CI: 1.18-4.67). Knowledge and oral hygiene habits were not associated with dental caries. The results of this study suggest the need to change from restoration orientated dentistry to dental public health care services, to reduce of the high level of dental caries in this age group.

The Anopheles community and the role of Anopheles minimus on malaria transmission on the China-Myanmar border

BACKGROUND

Malaria around the China-Myanmar border is a serious health problem in the countries of South-East Asia. An. minimus is a principle malaria vector with a wide geographic distribution in this area. Malaria is endemic along the boundary between Yunnan province in China and the Kachin State of Myanmar where the local Anopheles community (species composition) and the malaria transmission vectors have never been clarified.

METHODS

Adult Anopheles specimens were collected using CDC light traps in four villages along the border of China and Myanmar from May 2012 to April 2013. Morphological and molecular identification of mosquito adults confirmed the species of Anopheles. Blood-meal identification using the female abdomens was conducted using multiplex PCR. For sporozoite detection in An. minimus, sets of 10 female salivary glands were pooled and identified with SSU rDNA using nested PCR. Monthly abundance of An. minimus populations during the year was documented. The diversity of Anopheles and the role of An. minimus on malaria transmission in this border area were analyzed.

RESULTS

4,833 adult mosquitoes in the genus Anopheles were collected and morphologically identified to species or species complex. The Anopheles community is comprised of 13 species, and 78.83% of our total specimens belonged to An. minimus s.l., followed by An. maculatus (5.55%) and the An. culicifacies complex (4.03%). The quantity of trapped An. minimus in the rainy season of malaria transmission was greater than during the non-malarial dry season, and a peak was found in May 2012. An. minimus fed on the blood of four animals: humans (79.8%), cattle (10.6%), pigs (5.8%) and dogs (3.8%). 1,500 females of An. minimus were pooled into 150 samples and tested for sporozoites: only 1 pooled sample was found to have sporozoites of Plasmodium vivax.

CONCLUSION

Anopheles is abundant with An. minimus being the dominant species and having a high human blood index along the China-Myanmar border. The sporozoites in An. minimus were determined to be Plasmodium vivax with a 0.07-0.7% infection rate.

Dengue outbreak in an Indo-Myanmar boarder area: epidemiological aspects and risk factors

During October 2007, a large outbreak of suspected dengue fever (DF) was reported in Moreh township, Manipur: the first widespread outbreak in Northeast India. A cross sectional study was carried out in Moreh. The information on outbreak was collected and then described in time, place and person characteristics to arrive at aetiological hypotheses. Two hundred and eighty two serum samples were collected. Ninety one samples were reported positive for acute infection with dengue virus. Co-circulation of all the four dengue virus serotypes (1-4) and concurrent infection of 2 & 3, 1 & 3, and 1 & 4 serotypes was found. Predominant clinical features of the patients were fever (100%), headache (39%), vomiting (9.8%) and joint pain (4.16%). Haemorrhagic manifestation was recorded in one patient who subsequently died. Entomological surveys revealed profuse breeding of Aedes mosquitoes in all the affected municipal wards with high HI (37.5-71.43%), CI (53.84-86.95%) and BI (80-208.33%). Presence of IgM antibody, co-circulation of all the serotypes and concurrent infection with more than one serotype in the same individual confirmed the outbreak due to dengue virus infection. Preventive and control measures undertaken following the epidemiological investigation helped in controlling the outbreak.

Neonatal intensive care in a Karen refugee camp: a 4 year descriptive study

Background

A third of all deaths in children aged <5 years occur in the neonatal period. Neonatal intensive care is often considered too complex and expensive to be implemented in resource poor settings. Consequently the reductions that have been made in infant mortality in the poorest countries have not been made in the neonatal period. This manuscript describes the activities surrounding the introduction of special care baby unit (SCBU) in a refugee setting and the resulting population impact.

Methods

A SCBU was developed in Maela refugee camp on the Thailand-Myanmar border. This unit comprised of a dedicated area, basic equipment, drugs and staff training. Training was built around neonatal guidelines, comprising six clinical steps: recognition, resuscitation, examination, supportive medical care, specialised medical care, and counselling of parents with sick newborns.

Results

From January 2008 until December 2011, 952 infants were admitted to SCBU. The main admission diagnoses were early onset neonatal sepsis, jaundice and prematurity. Early prematurity (<34 weeks) carried the highest risk of mortality (OR 9.5, 95% CI 5.4–16.5, p<0.001). There was a significant decrease in mortality from 19.3% (2008) to 4.8% (2011) among the infants admitted for prematurity (p=0.03). The neonatal mortality in Maela camp as a whole declined by 51% from 21.8 to 10.7 deaths per 1000 live births over the corresponding period (p=0.04). Staff expressed more confidence in their ability to take care of neonates and there was a more positive attitude towards premature infants.

Conclusion

Neonatal mortality can be reduced in a resource poor setting by introduction of a simple low cost unit specialising in care of sick neonates and run by local health workers following adequate training. Training in recognition and provision of simple interventions at a high standard can increase staff confidence and reduce fatalistic attitudes towards premature neonates.

Border malaria associated with multidrug resistance on Thailand-Myanmar and Thailand-Cambodia borders: transmission dynamic, vulnerability, and surveillance

This systematic review elaborates the concepts and impacts of border malaria, particularly on the emergence and spread of Plasmodium falciparum and Plasmodium vivax multidrug resistance (MDR) malaria on Thailand-Myanmar and Thailand-Cambodia borders. Border malaria encompasses any complex epidemiological settings of forest-related and forest fringe-related malaria, both regularly occurring in certain transmission areas and manifesting a trend of increased incidence in transmission prone areas along these borders, as the result of interconnections of human settlements and movement activities, cross-border population migrations, ecological changes, vector population dynamics, and multidrug resistance. For regional and global perspectives, this review analyzes and synthesizes the rationales pertaining to transmission dynamics and the vulnerabilities of border malaria that constrain surveillance and control of the world's most MDR falciparum and vivax malaria on these chaotic borders.

Reaching men who have sex with men in Myanmar: population characteristics, risk and preventive behavior, exposure to health programs

To estimate risk behavior and HIV program reach among men who have sex with men (MSM) in Myanmar, we conducted cross-sectional surveys in four cities (Yangon, Mandalay, Pathein, Monywa) using respondent-driven sampling (RDS). Prevention response indicators across the cities ranged from 56 to 70 % testing for HIV and receiving results last year, 89-100 % identifying ways of preventing transmission, 50-95 % rejecting misconceptions about HIV, and 82-94 % using a condom at last anal sex. MSM in smaller cities had similar or higher use of programs compared those in larger cities. MSM classified as Ah Chawk Ma (broadly feminine gender presentation) reported having more sex partners, less consistent condom use, and more frequent history of sexually transmitted infections compared to those described as Tha Ngwe (broadly masculine gender presentation). Our behavioral survey data help advocate for appropriate services and form a baseline to gauge future impact of the HIV response for this marginalized population.

[An outbreak of imported dengue fever from Myanmar to the border of China, with its viral molecular epidemiological features]

OBJECTIVE

To understand the epidemiologic characteristics of dengue fever, imported from Myanmar to the border of Yunnan province, China. Viral molecular epidemiologic features were also studied.

METHODS

Questionnaires were used on each diagnosed, suspected dengue fever, case or unknown cases with fever when coming from Myanmar entering the port and hospitals in Ruili city of Yunnan province. Serum samples of these patients were collected to detect IgM antibody against dengue virus and RT-PCR assay. Homology and phylogenetic tree based on the whole nucleotide sequence of PrM-C and NS5 gene of dengue virus were further analyzed.

RESULTS

A total of 103 sera were collected from patients at acute stage in Ruili city in July to November 2008. Among them, 49 cases were confirmed for dengue fever according to IgM and nucleic acid testings. Except one, other 48 cases were all imported into Ruili, from Myanmar. Of those, 18 patients were residents from Mujie city of Myanmar and hospitalized in Ruili and the rest 30 patients were Chinese citizens who had finished business and returned from Myanmar. Two isolates of serum samples from the imported cases were identified and both homology and phylogenetic analysis were performed, using the nucleotide sequences of PrM and NS5 genes. They were divided into dengue type 1 (RLB61) and dengue type 3 (RLC31) and were closer to the dengue virus strains isolated from Southeast Asia countries.

CONCLUSION

It is confirmed that an epidemic of dengue fever which was imported from Myanmar to Ruili city of Yunnan province, China. Evidence also showed that both type I and III epidemic strains of dengue virus did exist in Mujie city of Myanmar in 2008.

Sexually transmitted infections among male highway coach drivers in Myanmar

A cross sectional descriptive study was conducted from February 2008 to December 2009 at the largest Highway Terminal, Yangon, Myanmar to determine the prevalence of curable STIs (syphilis, gonorrhea, chlamydial infections, and trichomoniasis), to find out the associated factors for STIs, and to determine the antibiotic susceptibility pattern of gonococcal infection among highway drivers. Urine and blood specimens were collected from 601 male highway coach drivers after an interview about their behavior. Standard laboratory tests were carried out to detect STIs. Multivariate analysis was used to ascertain potential risk factors for STIs. The prevalence rates of syphilis, gonorrhea, chlamydial infections, and trichomoniasis were 4.8, 4.3, 5.7, and 9.8%, respectively. One hundred and two (17.0%) were infected with at least one of the tested four STIs, and 34 (5.7%) had STI co-infections (2STIs). Those who had multiple sexual contacts were likely to be infected with at least one STI, and those who had a history of inconsistent condom use within past two weeks and multiple sexual contacts were more likely to have STI co-infections (p < 0.05). Antimicrobial susceptibility of 21 Neisseria gonorrhoeae isolates showed that 85.7% were susceptible to azithromycin, 80.9% to spectinomycin, 66.7% to cefixime, 61.9% to ceftriaxone, and 38.1% to ciprofloxacin. The high prevalence of STIs in this study and the decreased susceptibility of Neisseria gonorrhoeae to cephalosporin and fluoroquinolone highlighted the role of periodic screening in early diagnosis and effective treatment of STIs among high-risk populations.

Reduced susceptibility of Plasmodium falciparum to artesunate in southern Myanmar

Background

Plasmodium falciparum resistance to artemisinins, the first line treatment for malaria worldwide, has been reported in western Cambodia. Resistance is characterized by significantly delayed clearance of parasites following artemisinin treatment. Artemisinin resistance has not previously been reported in Myanmar, which has the highest falciparum malaria burden among Southeast Asian countries.

Methods

A non-randomized, single-arm, open-label clinical trial of artesunate monotherapy (4 mg/kg daily for seven days) was conducted in adults with acute blood-smear positive P. falciparum malaria in Kawthaung, southern Myanmar. Parasite density was measured every 12 hours until two consecutive negative smears were obtained. Participants were followed weekly at the study clinic for three additional weeks. Co-primary endpoints included parasite clearance time (the time required for complete clearance of initial parasitemia), parasite clearance half-life (the time required for parasitemia to decrease by 50% based on the linear portion of the parasite clearance slope), and detectable parasitemia 72 hours after commencement of artesunate treatment. Drug pharmacokinetics were measured to rule out delayed clearance due to suboptimal drug levels.

Results

The median (range) parasite clearance half-life and time were 4.8 (2.1–9.7) and 60 (24–96) hours, respectively. The frequency distributions of parasite clearance half-life and time were bimodal, with very slow parasite clearance characteristic of the slowest-clearing Cambodian parasites (half-life longer than 6.2 hours) in approximately 1/3 of infections. Fourteen of 52 participants (26.9%) had a measurable parasitemia 72 hours after initiating artesunate treatment. Parasite clearance was not associated with drug pharmacokinetics.

Conclusions

A subset of P. falciparum infections in southern Myanmar displayed markedly delayed clearance following artemisinin treatment, suggesting either emergence of artemisinin resistance in southern Myanmar or spread to this location from its site of origin in western Cambodia. Resistance containment efforts are underway in Myanmar.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12610000896077

High rates of pneumonia in children under two years of age in a South East Asian refugee population

BACKGROUND

There are an estimated 150 million episodes of childhood pneumonia per year, with 11-20 million hospital admissions and 1.575 million deaths. Refugee children are particularly vulnerable, with poorly defined pneumonia epidemiology.

METHODS

We followed a birth cohort of 955 refugee infants, born over a one-year period, until two years of age. Clinical and radiographic pneumonia were diagnosed according to WHO criteria. Detailed characteristics were collected to determine risk factors for clinical, radiological and multiple episodes of pneumonia. Investigations were taken during a pneumonia episode to help determine or to infer an aetiological diagnosis.

FINDINGS

The incidence of clinical pneumonia was 0.73 (95% CI 0.70-0.75) episodes per child year (/CY) and of radiological primary endpoint pneumonia (PEP) was 0.22/CY (95% CI 0.20-0.24). The incidence of pneumonia without severe signs was 0.50/CY (95% CI 0.48-0.53), severe pneumonia 0.15/CY (95% CI 0.13-0.17) and very severe pneumonia 0.06/CY (0.05-0.07). Virus was detected, from a nasopharyngeal aspirate, in 61.3% of episodes. A reduced volume of living space per person (IRR 0.99, 95% CI 0.99-1.0, p = 0.003) and young maternal age (IRR 1.59, 95% CI 1.12-2.27, p = 0.01) were risk factors for developing pneumonia. The risk of a child having >1 episode of pneumonia was increased by having a shorter distance to the next house (IRR 0.86, 95% CI 0.74-1.00, p = 0.04). Infants were at risk of having an episode of PEP if there was a shorter distance from stove to bed (IRR 0.89, 95% CI 0.80-0.99, p = 0.03). Raised CRP and neutrophil values were associated with PEP.

CONCLUSIONS

There was a high incidence of pneumonia in young children in this SE Asian refugee population. Viral infections were important, however CXR and non-specific marker findings suggested that bacteria may be involved in up to a third of cases.

Plasmodium falciparum populations from northeastern Myanmar display high levels of genetic diversity at multiple antigenic loci

Levels of genetic diversity of the malaria parasites and multiclonal infections are correlated with transmission intensity. In order to monitor the effect of strengthened malaria control efforts in recent years at the China-Myanmar border area, we followed the temporal dynamics of genetic diversity of three polymorphic antigenic markers msp1, msp2, and glurp in the Plasmodium falciparum populations. Despite reduced malaria prevalence in the region, parasite populations exhibited high levels of genetic diversity. Genotyping 258 clinical samples collected in four years detected a total of 22 PCR size alleles. Multiclonal infections were detected in 45.7% of the patient samples, giving a minimum multiplicity of infection of 1.41. The majority of alleles experienced significant temporal fluctuations through the years. Haplotype diversity based on the three-locus genotypes ranged from the lowest in 2009 at 0.33 to the highest in 2010 at 0.80. Sequencing of msp1 fragments from 36 random samples of five allele size groups detected 13 different sequences, revealing an additional layer of genetic complexity. This study suggests that despite reduced prevalence of malaria infections in this region, the parasite population size and transmission intensity remained high enough to allow effective genetic recombination of the parasites and continued maintenance of genetic diversity.

Malaria burden and artemisinin resistance in the mobile and migrant population on the Thai-Myanmar border, 1999-2011: an observational study

BACKGROUND

The Shoklo Malaria Research Unit has been working on the Thai-Myanmar border for 25 y providing early diagnosis and treatment (EDT) of malaria. Transmission of Plasmodium falciparum has declined, but resistance to artesunate has emerged. We expanded malaria activities through EDT and evaluated the impact over a 12-y period.

METHODS AND FINDINGS

Between 1 October 1999 and 30 September 2011, the Shoklo Malaria Research Unit increased the number of cross-border (Myanmar side) health facilities from two to 11 and recorded the number of malaria consultations. Changes in malaria incidence were estimated from a cohort of pregnant women, and prevalence from cross-sectional surveys. In vivo and in vitro antimalarial drug efficacy were monitored. Over this period, the number of malaria cases detected increased initially, but then declined rapidly. In children under 5 y, the percentage of consultations due to malaria declined from 78% (95% CI 76-80) (1,048/1,344 consultations) to 7% (95% CI 6.2-7.1) (767/11,542 consultations), p<0.001. The ratio of P. falciparum/P. vivax declined from 1.4 (95% CI 1.3-1.4) to 0.7 (95% CI 0.7-0.8). The case fatality rate was low (39/75,126; 0.05% [95% CI 0.04-0.07]). The incidence of malaria declined from 1.1 to 0.1 episodes per pregnant women-year. The cumulative proportion of P. falciparum decreased significantly from 24.3% (95% CI 21.0-28.0) (143/588 pregnant women) to 3.4% (95% CI 2.8-4.3) (76/2,207 pregnant women), p<0.001. The in vivo efficacy of mefloquine-artesunate declined steadily, with a sharp drop in 2011 (day-42 PCR-adjusted cure rate 42% [95% CI 20-62]). The proportion of patients still slide positive for malaria at day 3 rose from 0% in 2000 to reach 28% (95% CI 13-45) (8/29 patients) in 2011.

CONCLUSIONS

Despite the emergence of resistance to artesunate in P. falciparum, the strategy of EDT with artemisinin-based combination treatments has been associated with a reduction in malaria in the migrant population living on the Thai-Myanmar border. Although limited by its observational nature, this study provides useful data on malaria burden in a strategically crucial geographical area. Alternative fixed combination treatments are needed urgently to replace the failing first-line regimen of mefloquine and artesunate. Please see later in the article for the Editors' Summary.

A high burden of respiratory syncytial virus associated pneumonia in children less than two years of age in a South East Asian refugee population

Background

Pneumonia is a major cause of childhood mortality and morbidity approximately 1.6 million deaths and 150 million episodes occur annually in children <5 years. Respiratory syncytial virus (RSV) may be responsible for up to 25% of cases and 12% of deaths making it an important potential vaccine target, although data from South East Asia is scarce.

Methods

We followed a birth cohort of Burmese refugee children, born over a one year period, for two years. Pneumonia episodes were diagnosed using WHO criteria. A chest radiograph, nasopharyngeal aspirate and non-specific markers of infection were taken during each episode.

Results

The incidence of RSV-associated pneumonia was 0.24 (95% CI 0.22–0.26) episodes per child year. All children with pneumonia received antibiotic treatment, following WHO guidelines. The highest incidence was in the 2–12 month age group. The commonest diagnosis in a child with RSV-associated pneumonia was non-severe pneumonia (239/362∶66.0%), however the incidence of RSV-associated severe or very severe pneumonia was 0.08 (95% CI 0.01–0.10) episodes per child year. Birth in the wet season increased the risk of severe disease in children who had their first episode of RSV-associated pneumonia aged 2–11 months (OR 28.7, 95% CI 6.6–125.0, p<0.001). RSV episodes were highly seasonal being responsible for 80.0% of all the pneumonia episodes occurring each October and November over the study period.

Conclusions

There was a high incidence of RSV associated pneumonia in this refugee population. Interventions to prevent RSV infection have the potential to reduce the incidence of clinically diagnosed pneumonia and hence unnecessary antibiotic usage in this population.

Molecular surveillance for drug-resistant Plasmodium falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a systematic review of resistance studies

BACKGROUND

Confirmation of artemisinin-delayed parasite clearance in Plasmodium falciparum along the Thai-Myanmar border has inspired a global response to contain and monitor drug resistance to avert the disastrous consequences of a potential spread to Africa. However, resistance data from Myanmar are sparse, particularly from high-risk areas where limited health services and decades of displacement create conditions for resistance to spread. Subclinical infections may represent an important reservoir for resistance genes that confer a fitness disadvantage relative to wild-type alleles. This study estimates the prevalence of resistance genotypes in three previously unstudied remote populations in Myanmar and tests the a priori hypothesis that resistance gene prevalence would be higher among isolates collected from subclinical infections than isolates collected from febrile clinical patients. A systematic review of resistance studies is provided for context.

METHODS

Community health workers in Karen and Kachin States and an area spanning the Indo-Myanmar border collected dried blood spots from 988 febrile clinical patients and 4,591 villagers with subclinical infection participating in routine prevalence surveys. Samples positive for P. falciparum 18 s ribosomal RNA by real-time PCR were genotyped for P. falciparum multidrug resistance protein (pfmdr1) copy number and the pfcrt K76T polymorphism using multiplex real-time PCR.

RESULTS

Pfmdr1 copy number increase and the pfcrt K76 polymorphism were determined for 173 and 269 isolates, respectively. Mean pfmdr1 copy number was 1.2 (range: 0.7 to 3.7). Pfmdr1 copy number increase was present in 17.5%, 9.6% and 11.1% of isolates from Karen and Kachin States and the Indo-Myanmar border, respectively. Pfmdr1 amplification was more prevalent in subclinical isolates (20.3%) than clinical isolates (6.4%, odds ratio 3.7, 95% confidence interval 1.1 - 12.5). Pfcrt K76T prevalence ranged from 90-100%.

CONCLUSIONS

Community health workers can contribute to molecular surveillance of drug resistance in remote areas of Myanmar. Marginal and displaced populations under-represented among previous resistance investigations can and should be included in resistance surveillance efforts, particularly once genetic markers of artemisinin-delayed parasite clearance are identified. Subclinical infections may contribute to the epidemiology of drug resistance, but determination of gene amplification from desiccated filter samples requires further validation when DNA concentration is low.

Thyroid malignancy among goitrous thyroid lesions: a review of hospital-based studies in Malaysia and Myanmar

Endemic goitre is a major concern in many parts of the world, including Southeast Asia. Goitrous thyroid lesion is postulated as a precursor lesion to thyroid cancer (TC). This paper reviews the prevalence rates and characteristics of TC among cases of goitrous thyroid-swelling in different parts of Malaysia and Myanmar. Recorded data from hospital-based retrospective studies of thyroid cases, whose study periods ranged from three to 11 years, were analysed. These included research findings from the author's publications as well as other published review articles of retrospective analyses. The incidence of TC varies among gender, age, race/ethnicity and histological type. There appears to be a higher rate of occurrence among females aged 21-60 years. Papillary thyroid carcinoma is the more common histological type compared to follicular cancer. This review also presents a descriptive analysis and discussion on studies conducted in other countries. Further exploration is warranted in order to uncover the possible risk factors for the rising incidence of TC.

Characteristics and malaria prevalence of migrant populations in malaria-endemic areas along the Thai-Cambodian border

The rise of artemisinin resistant Plasmodium falciparum along the Thai-Cambodian border is an urgent public health threat. We conducted an employer-based survey of migrant workers in two provinces in Thailand along the Thai-Cambodian border to explore socio-economic conditions, bednet ownership, and parasite prevalence among migrant workers. Five thousand three hundred seventy-one migrant workers were enrolled in this study; 56.9% were male. Cambodians comprised 69.0%, migrants from Myanmar comprised 20.7% and Mon and Laotian comprised 10.3%. Short term (< 6 months) Cambodian migrants, primarily located in Chanthaburi Province, typically work in orchards or on cassava farms. The majority did not speak Thai and bednet ownership was low. The only cases of malaria, all P. vivax, were found in Chanthaburi. Migrants in Trat Province were primarily long-term residents (> 6 months) from Cambodia and Myanmar and were engaged in rubber tapping, fisheries and domestic work. Bednet ownership and oral Thai fluency were higher, though Thai literacy remained low. Migrants from Myanmar had higher mother tongue literacy than migrants from Cambodia. The low oral Thai fluency and literacy rates suggest a Behavior Change Communication (BCC) package for Cambodian migrants should be developed in the Cambodian language. The low parasite prevalence and absence of P. falciparum in this study are encouraging signs in the fight against artemisinin resistance in eastern Thailand.

Microcytic anaemia predominates in adolescent school girls in the delta region of Myanmar

OBJECTIVE

Anaemia is one of major nutritional problems in Myanmar affecting all age groups. However, there is lack of recent information and a study was conducted to acquire information on the current status of anaemia among adolescent schoolgirls in Nyaung Done township, Ayeyarwady division where an intervention study was planned.

SUBJECTS AND METHODS

A cross-sectional survey was conducted on 1269 subjects to obtain complete blood count, anthropometry and socioeconomic characteristics were obtained by questionnaire. Using red cell indices, we applied Bessman's, and Green and King's index classification to differentiate the types of anaemia. Electrophoresis was also done on a subsample (n=228).

RESULTS

Stunting was 21.2% and wasting was 10.7% respectively. Prevalence of anaemia was 59.1% and was mainly microcytic. Green and King's index showed 35.8% were iron deficient. Electrophoresis revealed 36 cases of Hb E haemoglobinopathy in the subsample.

CONCLUSION

Anaemia is still a major nutrition problem in Myanmar. The reasons for this high prevalence should be explored and properly addressed. The study highlights the need for a comprehensive and large scale survey for the anaemia control programme in Myanmar.

Oral health status and behaviours of children in Myanmar - a pilot study in four villages in rural areas

PURPOSE

To describe the tooth status, periodontal status, oral hygiene and snacking habits of children in four villages in northeastern Myanmar.

MATERIALS AND METHODS

This was a cross-sectional study using a convenient sampling protocol. All children ages 5 and 12 years from four villages were examined by an experienced epidemiologist, and the status of their primary and permanent dentition, respectively, was reported using the diagnostic criteria recommended by the World Health Organisation. A parental questionnaire survey was performed to study the children's habits.

RESULTS

A total of 95 5-year-old and 80 12-year-old children were examined. It was found that 94% and 39% of the 5- and 12-year-old children, respectively, had never brushed their teeth. Few children had snacking habits. Most of the children - 75% of the 5-year-olds and 85% of the 12-year-olds - had no caries experience. The mean dmft score of the 5-year-olds was 0.9, while the mean DMFT score of the 12-year-olds was 0.2. Signs of moderate to severe gingivitis were found in 42% of the 5-year-olds, and 40% of the 12-year-olds had dental calculus.

CONCLUSIONS

The prevalence and severity of dental caries among the children in the four villages in northeastern Myanmar was low. Their oral hygiene habits and periodontal conditions were not satisfactory and need to be improved.

The Burmese medic: an international physician assistant analogue

Although there have been recent democratic reforms in Myanmar (formerly known as Burma), for nearly 60 years there has been a consistent history of human rights violations as part of a civil war waged by the Myanmar military, known as the Tatmadaw. Approximately 3,500 villages have been destroyed by the Tatmadaw during the half-century of civil war. Oppression against minority groups, including the Karen, Karenni, Kachin, Mon, Shan, Chin, and Muslims has adversely affected the health outcomes of these vulnerable populations. Since the mid 1990s, medics have been providing care for the ethnic minorities who were displaced from their homes by the civil war and who live in the jungles of eastern Burma as well as in the refugee camps and towns in the border areas of Thailand. This article will look at how these medics are providing care similar to that provided by physician assistants in the United States.

[An investigation on malaria vectors in western part of China-Myanmar border]

OBJECTIVE

To reveal the distribution and composition of malaria-transmitting vectors on the western part of China-Myanmar border.

METHODS

An entomological survey of malaria vectors was carried out in six villages of Yingjiang County and Xidong County on China-Myanmar border between August and September, 2008. Mosquitoes in human dwellings and cattle sheds were collected by overnight trapping with ovitrap light. The mosquitoes were firstly identified morphologically, and then Anopheles minimus A and C, An. aconitus, and An. jeyporiensis were identified by using multiplex PCR. Some mosquitoes were selected to extract the total genomic DNA, and detect sporozoites by nested PCR.

RESULTS

A total of 4571 mosquitoes were captured with 54.32% (2483/4571) of anopheline mosquitoes. There was significant difference in Anopheles species composition in human dwellings and cattle sheda The main species in human dwellings were An. kochi, An. minimus, and An. sinensis, while the principal species in cattle sheds consist of An. kochi (223), An. annularis (184), An. vagus (131), and An jeyporiensis (129). Furthermore, the composition in human dwellings of villages with and without cattle was significantly different. An. minimus (260) and An. kochi (49) werethe most important species in villages with cattle, whereas An. kochi (481) and An. sinensis (124) were the key species in villages without cattle. A total of 1075 mosquitoes were examined for sporozoites and 9 mosquitoes were found to be infected. Only three species, Le. An. minimus (7/408), An aconiaus (1/125) and An. pseudowillmori (1/101) were infected with malaria parasite. All sporozoites were identified as Plasmodium falcipoarum by sequencing, the target fragment was 204 bp.

CONCLUSION

The species composition of mosquitoes is complex in the study sites on the western part of China-Myanmar border, and An. minimus is the major malaria vector. Additionally, An. aconitus and An.pseudowillmori are also confirmed as potential malaria vector in this area.

Seroprevalence of hepatitis A among Thai population residing near Myanmar border

hen compared with Thailand, the seroprevalence of hepatitis A virus (HAV) is extremely high among its neighbouring countries. To investigate the seroprevalence of HAV among the Thai people residing in the border area between Thailand and Myanmar, 308 residents in Umphang, Maesod district, Tak, were recruited. Sera were tested for HAV IgG antibodies by enzyme-linked immunosorbent assay. The overall seroprevalence among the Thai people residing in the border area of Thailand was significantly higher than that among the general Thai population (71% vs 27% respectively, p < 0.05). As asymptomatic or mild HAV infection typically occurs in children, the Thai people residing in the border area may receive little benefit from universal HAV vaccination. Lower protective antibodies against HAV, along with the exclusion of HAV vaccine from the Expanded Programme on Immunization, potentially increase the susceptibility to HAV among the general Thai population and may lead to more future outbreaks if HAV is introduced from the border areas. The findings suggest that HAV vaccines should be recommended to travellers before their journey to the border between Thailand and Myanmar where HAV is endemic.

Case-control study of ectopic pregnancies in Myanmar: infectious etiological factors

We studied the role of infections in ectopic pregnancy and the different methods of detecting Chlamydia trachomatis infection using serology, cervical and tubal PCR assays, by using a hospital-based, case-control study conducted between November 2007 and September 2009. The sample size was 339 with 113 cases and 226 controls. The cases were women admitted for the management of ectopic pregnancy while the controls were women admitted for spontaneous miscarriage. Both cases and controls were tested for syphilis and chlamydial infection by serology. In addition, cervical samples from controls and both cervical and tubal samples from cases were examined for the presence of chlamydia and gonococcal DNA. Sociodemographic data and past histories were collected using set Proforma. Independent variables for multivariate analysis included previous history of spontaneous abortion, ectopic pregnancy, symptoms of sexully transmitted infections (STI), and use of contraception. Women with a previous history of ectopic pregnancy (adjusted OR 28.3; 95% CI 5.8-138.8; p = 0.01) and a past history of having had symptoms of STI (adjusted OR 11.06; 95% CI 5.45-22.44; p = 0.0005) were significantly more likely to have an ectopic pregnancy than those without such a history. Syphilis serology was positive in 13.3% of ectopic pregnancy cases compared to only 3.5% of controls (crude OR 0.24; 95% CI -0.10-0.58; p = 0.001). From cervical swabs, chlamydia DNA was detected significantly more frequently in cases than controls (8.0% vs 2.2%; crude OR 0.261; 95% CI -0.09-0.80, p = 0.012) but gonorrhea DNA detection rates were not significantly different (3.5% vs 0.9%, crude OR 0.24; 95% CI -0.04-1.35; p = 0.1). Chlamydia was positive in cases only as diagnosed tubal samples for PCR in 17 (15.0%), cervical samples for PCR in 9 (8.0%) and IgM ELISA in 6 (5.3%). Among the three STI tested for in this study, C. trachomatis was the most frequently associated with ectopic pregnancy and was more frequently diagnosed by PCR on tubal samples than PCR on cervical samples or chlamydia IgM serology.

Comparison of HIV-, HBV-, HCV- and co-infection prevalence between Chinese and Burmese intravenous drug users of the China-Myanmar border region

Background

Co-infection with HIV and HCV and/or HBV is highly prevalent in intravenous drug users (IDUs). Because of the proximity to the “Golden Triangle”, HIV prevalence among the IDUs is very high in the China-Myanmar border region. However, there are few studies about co-infection with HIV and HCV and/or HBV, especially in the region that belongs to Myanmar.

Methods

721 IDUs, including 403 Chinese and 318 Burmese, were investigated for their HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) serological status. Statistical analysis was performed to evaluate the differences of the epidemic situation between the Chinese IDUs and the Burmese IDUs.

Results

Among the Chinese IDUs and the Burmese IDUs, HCV infection was the most prevalent (69.0% vs 48.1%, P<0.001), followed by HBV (51.6% vs 43.1%, P<0.05) and HIV (33.7% vs 27.0%, P>0.05). Besides, there were more HIV-HBV co-infected IDUs (20.1% vs 11.3%, P<0.005), and HIV-HCV co-infected IDUs (31.8% vs 23.9%, P<0.05) in China than in Myanmar, as well as HIV-HBV-HCV triple infection (19.1% vs 10.4%, P<0.005).

Conclusion

Co-infection with HIV and HCV and/or HBV is highly prevalent among the IDUs in the China-Myanmar border region. The HIV epidemic appears to be in a downward trend, compared with previous reports. However, all infections were more prevalent among the Chinese IDUs than among the Burmese.

[Investigation on an outbreak of measles caused by new virus (d11 genotype) imported from Myanmar]

OBJECTIVE

To study the relevant factors on an measles outbreak caused by imported new virus (d11 genotype) from Myanmar and to develop effective strategies and measures.

METHODS

On-site investigation on the outbreak was carried out.

RESULTS

There were four townships (66%) in Menglian county reported 15 cases of measles, with 7 cases aged 6 months to 5 years old, 2 cases with the history of measles vaccination (MV). Another 8 cases were 21 to 49 year-olds but their histories on immunization were unclear. 14 of the measles cases with Myanmar citizenship came to China for treatment. They were aged 10 months to 13 years old, with only one case had ever received MV vaccination. For all the 29 cases, except for one case who did not adopt the sample case of Myanmar, the remaining 28 patients were positive for measles IgM antibodies. 6 cases of measles virus RNA were detected in the amplified sequence which showed genotype d11, and was considered Myanmar imported wild virus. 184 people received the MV inoculation, with a rate of 61.96% and the serum samples showed a measles IgG antibody positive rate of 87.50%. Manner MV emergency vaccination was carried out timely in that county so the measles outbreak was effectively controlled.

CONCLUSION

Imported measles cases from foreign countries might lead to epidemic, indicating the difficulty and challenge in the elimination of measles in our province. Emergent vaccination of MV could interrupt the transmission of the disease. Our experience showed that MV was effective in the prevention of d11 genotypes measles infection in the area.

Complex Interactions between soil-transmitted helminths and malaria in pregnant women on the Thai-Burmese border

BACKGROUND

Deworming is recommended by the WHO in girls and pregnant and lactating women to reduce anaemia in areas where hookworm and anaemia are common. There is conflicting evidence on the harm and the benefits of intestinal geohelminth infections on the incidence and severity of malaria, and consequently on the risks and benefits of deworming in malaria affected populations. We examined the association between geohelminths and malaria in pregnancy on the Thai-Burmese border.

METHODOLOGY

Routine antenatal care (ANC) included active detection of malaria (weekly blood smear) and anaemia (second weekly haematocrit) and systematic reporting of birth outcomes. In 1996 stool samples were collected in cross sectional surveys from women attending the ANCs. This was repeated in 2007 when malaria incidence had reduced considerably. The relationship between geohelminth infection and the progress and outcome of pregnancy was assessed.

PRINCIPAL FINDINGS

Stool sample examination (339 in 1996, 490 in 2007) detected a high prevalence of geohelminths 70% (578/829), including hookworm (42.8% (355)), A. lumbricoides (34.4% (285)) and T.trichuria (31.4% (250)) alone or in combination. A lower proportion of women (829) had mild (21.8% (181)) or severe (0.2% (2)) anaemia, or malaria 22.4% (186) (P.vivax monoinfection 53.3% (101/186)). A. lumbricoides infection was associated with a significantly decreased risk of malaria (any species) (AOR: 0.43, 95% CI: 0.23-0.84) and P.vivax malaria (AOR: 0.29, 95% CI: 0.11-0.79) whereas hookworm infection was associated with an increased risk of malaria (any species) (AOR: 1.66, 95% CI: 1.06-2.60) and anaemia (AOR: 2.41, 95% CI: 1.18-4.93). Hookworm was also associated with low birth weight (AOR: 1.81, 95% CI: 1.02-3.23).

CONCLUSION/SIGNIFICANCE

A. lumbricoides and hookworm appear to have contrary associations with malaria in pregnancy.

A prospective evaluation of diagnostic methodologies for the acute diagnosis of dengue virus infection on the Thailand-Myanmar border

Clinically useful diagnostic tests of dengue virus infection are lacking. We prospectively evaluated the performance of real-time reverse transcriptase (rRT)-PCR, NS-1 antigen and IgM antibody tests to confirm dengue virus infection in acute blood specimens from 162 patients presenting with undifferentiated febrile illness compatible with dengue infection. rRT-PCR was the most sensitive test (89%) and potentially could be used as a single test for confirmation of dengue infection. NS-1 antigen and IgM antibody were not sufficiently sensitive to be used as a single confirmatory test with sensitivities of 54% and 17% respectively. The specificities of rRT-PCR, NS-1 antigen and IgM antibody tests were 96%, 100% and 88% respectively. Combining NS-1 and rRT-PCR or the combination of all three tests resulted in the highest sensitivity (93%) but specificities dropped to 96% and 83% respectively. We conclude that at least the combination of two tests, either agent detection (rRT-PCR) or antigen detection (NS-1) plus IgM antibody detection should be used for laboratory confirmation of dengue infection.

[Genotyping of Plasmodium vivax in China-myanmar border by circumsporozoite protein]

By using a series of type-specific primers for Plasmodium vivax circumsporozoite protein (CSP) gene and nested PCR, genotyping was conducted for the specimens of Plasmodium vivax isolated from China-Myanmar border. In 174 isolates of P. vivax, four genotypes, namely, tropical zone family strain, temperate zone family strain, genotype-mixed infection and PV-II type, were identified each accounting for 54.6%, 35.6%, 6.9%, and 2.9%, respectively. The tropical zone family strain was dominant in the border area. There was no significant difference on the P.v CSP genotype constitution between Laza isolate of Myanmar and Tengchong isolate of Yunnan, China.

Self-efficacy, self-care behaviors and glycemic control among type-2 diabetes patients attending two private clinics in Yangon, Myanmar

This cross-sectional study aimed to estimate the prevalence of glycemic control and its associated factors among type-2 diabetes patients attending two private clinics in Yangon, Myanmar. Two hundred sixty-six diabetes patients attending two private diabetes clinics in Yangon during February and March, 2009 were included in the study. The participants completed a structured questionnaire. HbA(1c) was used as the index for glycemic control. The prevalence of successful glycemic control (HbA(1c) < or =7%) was 27.1%. The median HbA(1c) value was 7.8%. About 62.0% of patients had high self-efficacy levels, and 30.8% had good self-care behavior. Multiple logistic regression analysis revealed four variables associated with glycemic control: age > or =60 years (OR 2.46, 95% CI 1.17-5.21), taking one oral hypoglycemic agent (OHA) (OR 2.56, 95% CI 1.26-5.19), being overweight (OR 2.01, 95% CI 1.02-3.95) and having a high self-efficacy level (OR 5.29, 95% CI 2.20-12.75). Interventions to increase diabetic patient self-efficacy levels and self-care behavior, especially related to diet and exercise, are needed to reduce poor glycemic control.

[Status of enterovirus infection and molecular identification among healthy children at the areas bordering Myanmar, in Yunnan province, China]

OBJECTIVE

To explore the enterovirus infection status among healthy children under 15 years old in the border areas of Yunnan province that connecting Myanmar.

METHODS

A total of 319 stool samples were collected from healthy children in the 10 entrance ports. Enterovirus was isolated from these stool samples and then poliovirus and adenovirus were serotyped by neutralization test using specific anti-sera. All the non-polio enteroviruses (NPEVs) were identified by partial sequencing of VP1 gene.

RESULTS

All 53 enterovirus were isolated from 319 stool samples and 16.6% of them carried the virus. 23 polio virus (PVs) and 30 NPEVs were isolated with rates of carrying the virus were 7.2% and 9.4% respectively. 4 adenovirus were also isolated with a rate as 1.25%. 1 isolate could not be amplified by any Pan-enterovirus primers or by RT-PCR so was not able to be sequenced. The results of NPEVs sequencing showed that:1 isolate (3.3%) was classified into 1 serotype of HEV-A while 20 isolates (66.7%) were classified into 11 serotypes of HEV-B and 8 isolates (26.7%) were classified into 3 serotypes of HEV-C. However, we could not isolate any viruses that belong to HEV-D. nt. Result from the aa identify calculation showed that the nt and aa identification between isolates and corresponding standard strains were more than 75% and 85% respectively. The findings were similar to the international standards.

CONCLUSION

Our results showed that the rate of carrying the enterovirus especially poliovirus in some areas of Yunnan province that bordering Myanmar was higher than that of rate through the routine acute flaccid paralysis detection system. Of the enterovirus isolated, HEV-B group appeared the predominant with the wide spread of enterovirus serotype. Some newer enterovirus were also detected such as EV73 (2 strains), EV75 (1 strain), EV80 (1 strain) and EV96 (4 strains).

[Serological detection of malaria for people entering China from 19 ports of entry covering 8 border prefectures of Yunnan]

OBJECTIVE

To evaluate malaria situation in areas of Yunnan Province bordering with Myanmar, Laos and Vietnam.

METHODS

Blood samples on filter paper were collected from the entry people in March to December of 2007 involving 19 national and provincial ports of entry. Indirect fluorescent antibody test (IFAT) was carried out by using the blood samples collected before June 30 as the first half year and after July 1 as the second half year. Analysis was made on the relationship of IFAT positive rate and GMRT to malaria incidence in the province reported by the China information system for disease control and prevention.

RESULTS

IFAT positive rate in the first half year (5.6%) was 20.9% higher than that of second half year (4.4%) (chi2=12.95%, P<0.05). There was a positive correlation between IFAT positive rate and the number of malaria cases reported in 2007 from the 8 bordering prefectures (r=0.8124, P<.05). The highest IFAT positive rate was found in Dehong (8.7%), Baoshan (7.1%), and Lingcang (65%). Among the 19 entry ports, the highest IFAT positive rate was found in 5 entry ports: Lvliang, Laying, Jiegao, Houqiao, and Qingshuihe, all in China-Myanmar border. The IFAT positive rate in the Chinese entry people increased with their days of staying outside the border. Among the entry people, the highest antibody positive rate was from those of Myanmar nationality (11.7%) followed by those from Yunnan (3.7%).

CONCLUSION

To certain extent, higher malaria incidence outside the border impacts that of Yunnan Province.

Migrants and malaria risk factors: a study of the Thai-Myanmar border

The objective of this study was to investigate factors influencing self-reported malaria among migrants living along the Thai-Myanmar border. Songkaria Village, with 1600 inhabitants and 290 households in Sangkhla Buri District, Kanchanaburi Province, was selected for the study due to its intense malaria transmission. One hundred twenty-five households were randomly selected. Household members were interviewed about the history of malaria, socioeconomic status and knowledge and practices in regard to malaria using a structured questionnaire. Of the respondents, 10%, 42%, and 48% belonged to the Thai, Mon, and Karen ethnic groups, respectively. About 40 % of Thai and Karen migrants and almost 30% of Mon migrants reported having suffered from malaria at least once. Multivariate analysis focused on migrants. The results identified three independent factors for previous malaria: a high risk occupation, ie working primarily in the forest [odds ratio (OR), 3.55; 95% confidence interval 1.3-10.0], ability to read Thai [OR, 4.13 (1.5-11.7)], and correct knowledge about malaria symptoms [OR, 5.18 (1.1-23.5)]. Working conditions among migrants played a major role in acquiring malaria. They could not afford to apply additional preventive measures, such as using a mosquito net or repellent to be used while working. The concept of enhancing the environment for migrants to enable them to protect themselves against malaria needs to be examined. Ways and means of improving the economic conditions of migrants should be considered to minimize exposure to the vector.

Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai-Burmese border

OBJECTIVES

Ultrasound examination of the fetus is a powerful tool for assessing gestational age and detecting obstetric problems but is rarely available in developing countries. The aim of this study was to assess the intraobserver and interobserver agreement of fetal biometry by locally trained health workers in a refugee camp on the Thai-Burmese border.

METHODS

One expatriate doctor and four local health workers participated in the study, which included examinations performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks' gestation, and who had undergone an early dating ultrasound scan, attending the antenatal clinic in Maela refugee camp. At each examination, two examiners independently measured biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), with one of the examiners obtaining duplicate measurements of each parameter. Intraobserver measurement error was assessed using the intraclass correlation coefficient (ICC) and interobserver error was assessed by the Bland and Altman 95% limits of agreement method.

RESULTS

A total of 4188 ultrasound measurements (12 per woman) were obtained in 349 pregnancies at a median gestational age of 27 (range, 16-40) weeks in 2008. The ICC for BPD, HC, AC and FL was greater than 0.99 for all four trainees and the doctor (range, 0.996-0.998). For gestational ages between 18 and 24 weeks, interobserver 95% limits of agreement corresponding to differences in estimated gestational age of less than +/- 1 week were calculated for BPD, HC, AC and FL. Measurements by local health workers showed high levels of agreement with those of the expatriate doctor.

CONCLUSIONS

Locally trained health workers working in a well organized unit with ongoing quality control can obtain accurate fetal biometry measurements for gestational age estimation. This experience suggests that training of local health workers in developing countries is possible and could allow effective use of obstetric ultrasound imaging.

Cyclone Nargis in Myanmar: lessons for public health preparedness for cyclones

Recent natural disasters such as the 2004 tsunami, 2008 Sichuan earthquake, and the 2008 Myanmar cyclone have killed more than 100,000 people each. Mortality and morbidity associated with natural disasters are a growing concern, especially because extreme climate events are likely to get increasingly frequent. The authors comment on Cyclone Nargis, claiming an extraordinarily high death toll during its devastating track through the Irrawaddy delta in Myanmar on May 2, 2008 and analyze how and why its mortality pattern differs from other typical postdisaster situations. Underlying factors and preconditions are described and the specificity of the Myanmese context is presented. This leads to lessons how excess mortality can be reduced in future high-ranked cyclones, whose recurrence in this region will only be a matter of time.

Drug-resistant tuberculosis in Yangon, Myanmar

The extent of drug resistant tuberculosis (TB) in the capital city of Myanmar, Yangon has not yet been reported. This study aimed to determine the proportion and pattern of drug resistance to first-line anti-TB drugs, among Mycobacterium tuberculosis complex isolates from sputum smear positive TB patients who attended National TB Programme Yangon centres in April-August and October-December 2002. Drug susceptibility was determined by the Mycobacteria Growth Indicator Tube manual system (Becton Dickinson, MD, USA). Of the 567 patients, sputum specimens from 447 (79%) had a positive culture. Of these, 357 isolates (80%) had a susceptibility test result. Isolates from 76 of 259 (29.3%) new patients and from 45 of 98 (45.9%) previously treated patients were resistant to at least 1 of the anti-TB drugs. Resistance to isoniazid (INH) (22.0% vs 40.8%: new vs previously treated patients) and to > or =2 drugs (17.8% vs 29.6%: new vs previously treated patients) was common. Multidrug- resistant TB (MDR-TB) among new and previously treated patients was 4.2% and 18.4%, respectively. INH-resistant (adjusted OR: 2.0, 95% CI 1.1-3.6) and MDR-TB (adjusted OR: 3.4, 95% CI 1.4-8.3) cases were more likely to have taken anti-TB drugs > or =1 month previously. Collectively, prevalence of MDR-TB and TB resistance to > or =2 drugs are not rare in Yangon.

Identification of Entamoeba histolytica and Entamoeba dispar by PCR assay of fecal specimens obtained from Thai/Myanmar border region

Due to the indistinguishable morphology between Entamoeba histolytica (pathogenic) and Entamoeba dispar (non pathogenic), PCR-based assays were conducted. Based on microscopy, suspected Entamoeba cells were detected in 30 out of 455 fecal samples obtained from individuals residing at Thai/Myanmar border region. The target genes for PCR amplification included genes encoding small subunit rRNA (SSU-rRNA), chitinase and serine rich Entamoeba protein. PCR primers derived from SSU-rRNA gene amplified both E. histolytica and E. dispar genes producing an amplicon of 1,080 bp, and detected 3 out of 30 samples. PCR primers derived from chitinase gene of E. histolytica generating amplicons of 500 and 1,260 bp, samples were positive in 12 out of 30 samples. Due the large difference of gene encoding serine rich protein between E. histolytica and E. dispar, two specific sets of primers were designed. SREH-primer set, specific for E. histolytica, generated amplicons of 550 and 700 bp and detected 22 out of 30 samples. SED-primer set, specific to E. dispar, produced an amplicon of 550 bp, and together with a nested primer pair generating an amplicon of 477 bp, detected 16 out of 30 samples. Thus, detection of single and mixed infections of the two Entamoeba species could be effectively achieved directly from DNA extracted from feces without the need to culture the parasites.

High frequency of genetic diversity of Plasmodium vivax field isolates in Myanmar

Malaria is one of the most serious problems threatening human health in Myanmar. Although the morbidity and mortality rates due to malaria have been gradually declining, Myanmar still contributes to a large proportion of malarial death in the South-East Asia region. However, little is known about the nature and extent of genetic diversity of the malarial parasites circulating in Myanmar. In this study, we investigated the overall infection status of Plasmodium and the population diversity of Plasmodium vivax by analyzing three genetic markers, circumsporozoite protein (CSP), merozoite surface protein-1 (MSP-1), and merozoite surface protein-3 (MSP-3alpha), of P. vivax field isolates collected from infected individuals. In 349 blood samples collected from the individuals who exhibited clinical symptoms associated with malaria, 63.0% showed a positive result for malaria (220/349). P. vivax was detected in 58.2% (128/220) and Plasmodium falciparum was detected in 29.1% (64/220). Mixed infections with both parasites were detected in 12.7% (28/220). The 116 blood samples in which single infection of P. vivax was confirmed were selected and subjected to further genetic analysis. Genotyping of the CSP gene of P. vivax showed that VK210 type (98.3%, 114/116) is predominant in Myanmar, but a significant level of mixed infections of VK210 and VK247 types (24.1%, 28/116) was also identified. Sequence analyses of MSP-1 and MSP-3alpha genes revealed a large number of distinguishable alleles: 12 for MSP-1 and 25 for MSP-3alpha. These results collectively suggest that the P. vivax population in Myanmar is highly diverse and multiple clonal infections are prevalent in the country.

Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma

BACKGROUND

Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.

METHODS AND FINDINGS

Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15-45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or > or = 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates < or = 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95-2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21-25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23-15.8) times higher among those forcibly displaced.

CONCLUSIONS

Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.

Accessing maternal health services in eastern Burma

Macaya Douoguih discusses a retrospective household survey that characterized the relationships between access to care, health status, and human rights violations in eastern Burma.

Characterization of "Yaa Chud" Medicine on the Thailand-Myanmar border: selecting for drug-resistant malaria and threatening public health

Multidrug-resistant Plasmodium falciparum malaria is a severe public health problem on the Thailand-Myanmar border. Many villagers buy packets of 4-5 mixed medicines ("yaa chud") from shops without medical assessment as their first-line malaria treatment. In 2000-2001 a local researcher purchased 50 yaa chud from 44 shops around Mae Sot, Thailand and Myawaddy, Myanmar (Burma), for his wife who was said to be pregnant with fever and drowsiness. The tablets/capsules were provisionally identified by appearance and active ingredients determined in a subset by using mass and atomic spectrometry. The most frequently detected active ingredients were acetaminophen (22%), chlorpheniramine (13.4%), chloroquine (12.6%), tetracycline/doxycycline (11.4%), and quinine (5.1%). Only seven bags contained potentially curative medicine for malaria. A total of 82% of the bags contained medicines contraindicated in pregnancy. Inappropriate, ineffective antimalarial drugs on the Thailand-Myanmar border are likely to increase malaria morbidity, mortality and health costs and engender the emergence and spread of antimalarial drug resistance.

Risk behaviors for HIV/AIDS among youth in rural area of Myanmar

In some areas of Myanmar up to 1.8 percent of young people aged 15-24 are living with HIV. This study was to describe risk behaviors on HIV/AIDS among youth in rural area of Myanmar. Multistage random sampling was used. A sample of 210 youths aged 15-24 were interviewed. Majority of respondents (70%) were in low level of HIV/AIDS risk behavior. Among those who had sex experiences (30%), more than half had sex before marriage, only 15.9% of them always use condom and 27% of them have had more than one partner. Age, marital status, occupation, monthly income and level of knowledge were found to be significantly associated with level of risk behaviors. Education programs on HIV prevention should be conducted extensively among youths as community based program and also in schools to reinforce health promoting behaviors.

An outbreak of cholera among migrants living in a Thai-Myanmar border area

OBJECTIVE

To study epidemiologic characteristics of a cholera outbreak involving mainly Myanmar migrants living in overcrowded conditions with poor sanitation in a Thai-Myanmar border district, in 2007.

MATERIAL AND METHOD

Both passive and active case surveillances were carried out in Mae Sot District, Tak Province since the beginning of the outbreak. Samples of various types of drinking and non-drinking water from the infected areas, communal waters, and some selected foods were analyzed for the presence of cholera contamination. A case-control study was conducted to determine the vehicle of cholera transmission among Myanmar migrants in one municipal community with a cluster of 72 cholera cases. Preventive and control measures were primarily carried out by trained migrant health volunteers and workers.

RESULTS

Between May and October 2007, 477 cholera cases of biotype El Tor, serotype Inaba, were identified in the district. The majority of them (93.1%) were detected by active case surveillance in the communities. None died in this outbreak. Most (84.9%) were Myanmar migrants and the remainder were local Thai residents. The infection rates of cholera were significantly greater in communities with known passive cases than in those with no such cases. Three samples of seafood illegally imported from Myanmar were positive for cholera of the same biotype and serotype. Fifteen of 324 (4.6%) food handlers in the district were found to carry V. cholerae O1. A case-control study in one municipal community revealed a significant association between infection and frequently having food purchased from one infected food handler.

CONCLUSION

Active case finding and implementation of control measures by the assistance of trained migrant health volunteers and workers might reduce the morbidity and mortality in this population.

A pilot study of dental caries status in relation to knowledge, attitudes and practices in oral health in Myanmar

This study was to determine the dental caries prevalence among the Myanmar population, and to investigate the correlations between oral clinical indices and knowledge, attitudes and practices (KAP) on oral health. Subjects were randomly selected from 140,000 people residing in the Kyauktan township in a cross-sectional community-based study. The present analysis was confined to 739 subjects (353 males and 386 females) aged 12, 35-44 and 65-74 years, who were divided into two specified groups based on urban or rural location. KAP on oral health data and social demographic information were collected, while dental caries status was assessed by DMFT. The mean number of decayed teeth (DT) in rural areas was higher than that in urban areas, while the mean number of filled teeth (FT) in rural areas was lower than that in urban areas. Mean knowledge and attitude scores for correct answers were also significantly higher for the urban than the rural subjects. There were statistically significant correlations between the correct/incorrect responses to knowledge and attitude questionnaires on oral health and the mean number of DMFT. KAP pertaining to oral health of Myanmar population, especially those of rural subjects, might not be satisfactory and related to threaten their dental caries status.