Cross-border malaria control for internally displaced persons: observational results from a pilot programme in eastern Burma/Myanmar

Approaches to increase access to community-based infectious disease control for ethnically, racially, and religiously marginalised populations: a scoping review

Marginalised populations often have reduced access to infectious disease prevention interventions, and as a result of this and other socioeconomic factors, these populations are at a higher risk of disease. Here, we reviewed the literature of community-based interventions delivered at the individual level across multiple diseases, and focused on how to increase access to infectious disease interventions for ethnically, racially, and religiously marginalised populations. Most of the included studies only focused on a single disease and used quantitative descriptive methods. We noted the lack of research, especially in low-income and middle-income countries. Common themes on the adaptations made included the importance of trust, descriptions of how the community was engaged at a deep level, and highlighting the importance of where interventions were delivered. We conclude that there is a need for more implementation research on this topic. Understanding how to increase access is crucial for achieving universal health coverage, which is also important from a global health security perspective, especially in an era when large-scale epidemics and pandemics are becoming more common.

Vector control for malaria prevention during humanitarian emergencies: a systematic review and meta-analysis

BACKGROUND

Humanitarian emergencies can lead to population displacement, food insecurity, severe health system disruptions, and malaria epidemics among individuals who are immunologically naive. We aimed to assess the impact of different vector control interventions on malaria disease burden during humanitarian emergencies.

METHODS

In this systematic review and meta-analysis, we searched ten electronic databases and two clinical trial registries from database inception to Oct 19, 2020, with no restrictions on language or study design. We also searched grey literature from 59 stakeholders. Studies were eligible if the population was affected by a humanitarian emergency in a malaria endemic region. We included studies assessing any vector control intervention and in which the primary outcome of interest was malaria infection risk. Reviewers (LAM, JF-A, KC, BP, and LP) independently extracted information from eligible studies, without masking of author or publication, into a database. We did random-effects meta-analyses to calculate pooled risk ratios (RRs) for randomised controlled trials, odds ratios (ORs) for dichotomous outcomes, and incidence rate ratios (IRR) for clinical malaria in non-randomised studies. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO, CRD42020214961.

FINDINGS

Of 12 475 studies screened, 22 studies were eligible for inclusion in our meta-analysis. All studies were conducted between Sept 1, 1989, and Dec 31, 2018, in chronic emergencies, with 616 611 participants from nine countries, evaluating seven different vector control interventions. Insecticide-treated nets significantly decreased Plasmodium falciparum incidence (RR 0·55 [95% CI 0·37-0·79]; high certainty) and Plasmodium vivax incidence (RR 0·69 [0·51-0·94]; high certainty). Evidence for an effect of indoor residual spraying on P falciparum (IRR 0·57 [95% CI 0·53-0·61]) and P vivax (IRR 0·51 [0·49-0·52]) incidence was of very low certainty. Topical repellents were associated with reductions in malaria infection (RR 0·58 [0·35-0·97]; moderate certainty). Moderate-to-high certainty evidence for an effect of insecticide-treated chaddars (equivalent to shawls or blankets) and insecticide-treated cattle on malaria outcomes was evident in some emergency settings. There was very low certainty evidence for the effect of insecticide-treated clothing.

INTERPRETATION

Study findings strengthen and support WHO policy recommendations to deploy insecticide-treated nets during chronic humanitarian emergencies. There is an urgent need to evaluate and adopt novel interventions for malaria control in the acute phase of humanitarian emergencies.

FUNDING

WHO Global Malaria Programme.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

BACKGROUND

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

METHODS

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

RESULTS

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

CONCLUSIONS

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Self-reported diseases and their associated risk factors among camp-dwelling conflict-affected internally displaced populations in Nigeria

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI = 79.5-82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR = 1.53;CI = 1.19-1.96), overcrowding (aOR = 1.07;CI = 1.00-1.36), long-term conditions (aOR = 2.72;CI = 1.88-3.94), outdoor defecation (aOR = 2.37;CI = 1.14-4.94) and presence of disease-causing vectors (aOR = 3.71;CI = 1.60-8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

Vector control for malaria prevention during humanitarian emergencies: protocol for a systematic review and meta-analysis

INTRODUCTION

Humanitarian emergencies, of either natural or anthropogenic origins, are equivalent to major disasters, which can lead to population displacement, food insecurity and health system disruptions. Almost two-thirds of people affected by humanitarian emergencies inhabit malaria endemic regions, particularly the WHO African Region, which currently accounts for 93% and 94% of malaria cases and deaths, respectively. As of late 2020, the United Nations Refugee Agency estimates that there are globally 79.5 million forcibly displaced people, including 45.7 million internally displaced people, 26 million refugees, 4.2 million asylum-seekers and 3.6 million Venezuelans displaced abroad.

METHODS AND ANALYSES

A systematic review and meta-analysis will be conducted to evaluate the impact of different vector control interventions on malaria disease burden during humanitarian emergencies. Published and grey literatures will be systematically retrieved from 10 electronic databases and 3 clinical trials registries. A systematic approach to screening, reviewing and data extraction will be applied based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Two review authors will independently assess full-text copies of potentially relevant articles based on inclusion criteria. Included studies will be assessed for risk of bias according to Cochrane and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Eligible studies with reported or measurable risk ratios or ORs with 95% CIs will be included in a meta-analysis. Subgroup analyses, including per study design, emergency phase and primary mode of intervention, may be performed if substantial heterogeneity is encountered.

ETHICS AND DISSEMINATION

Ethical approval is not required by the London School of Hygiene and Tropical Medicine to perform secondary analyses of existing anonymous data. Study findings will be disseminated via open-access publications in peer-reviewed journals, presentations to stakeholders and international policy makers, and will contribute to the latest WHO guidelines for malaria control during humanitarian emergencies.

PROSPERO REGISTRATION NUMBER

CRD42020214961.

The health beliefs, dengue knowledge and control behaviors among internally displaced persons versus local residents in Kachin Special Region II, Myanmar

Dengue fever (DF) is one of main public health problems along the China-Myanmar border, however, data about DF is still lacking in Kachin Special Region II (KSR2), Myanmar. To understand health beliefs in general, and knowledge and treatment-seeking and prevention behaviors related to DF among the neglected population, the study was carried out by using a combination of quantitative household questionnaire surveys (HHSs) and qualitative semi-structured in-depth interviews (SDIs). The HHS questionnaire was administered to a total of 258 household heads. The 215 (83.3%) HHS respondents believed in Christianity and Catholicism. However, the 141 (54.7%,) of the total respondents thought that people with evil practices might be punished by diseases. More respondents believed that too rainy weather and water were more related to disease in the internally displaced person (IDP) camp than the local community (P<0.01). Most of the HHS respondents had sound knowledge of dengue symptoms, causes, vectors, transmission and prevention. The 257 (99.6%) HHS respondents reported that their families went to the public health facilities first to seek treatment. The 210 (84.1%) respondents reported that they turned containers upside down within five days. The key informants (n = 18) identified that the appropriate knowledge and behaviors were attributable to formal school education and specific health education campaign during the outbreak response in 2017, and that Kachin people enjoy conversing with each other, neighbors talked about the dengue information they received. The study results indicated that Kachin people have a good knowledge and behaviors of dengue control. The actual situation of dengue is still not clear due to lacking data of laboratory test. In the context of resources shortage, more international assistance is still needed to promote local dengue control and prevention efforts.

The conflict between the Kachin Independence Army and the Myanmar government armed forces has lasted for more than eight years in the Kachin State (since 9^th June 2011). Control of vector-borne diseases is especially important in emergency settings of tropical regions. In 2017, a dengue outbreak occurred and then was successfully controlled in Kachin Special Region (KSR2), Myanmar. To understand further preparedness at the community level for future possible re-emergence of DF, one IDP camp and a local community were sampled to investigate people’s health beliefs in general, knowledge and treatment-seeking and prevention behaviors related to dengue control from August to December, the local dengue transmission season in 2018. This study found that the IDPs and local Kachin residents have sound knowledge about dengue, treatment-seeking and prevention behaviors; an inconsistency exists between their religious and health beliefs due to pressure from various diseases and health problems. The community members perceived DF as a serious and life-threatening disease; however, the local health authority did not think dengue was a priority health problem. The actual situation of dengue is still not clear due to lacking laboratory test and surveillance data. In the emergency context, dengue may still be a local health threat and dengue control is particularly important. The local capacity for dengue laboratory testing and control and prevention activities should be promoted urgently. This should get more international attention and assistance.

Delivering infectious disease interventions to women and children in conflict settings: a systematic reviefw

BACKGROUND

Conflict has played a role in the large-scale deterioration of health systems in low-income and middle-income countries (LMICs) and increased risk of infections and outbreaks. This systematic review aimed to synthesise the literature on mechanisms of delivery for a range of infectious disease-related interventions provided to conflict-affected women, children and adolescents.

METHODS

We searched Medline, Embase, CINAHL and PsychINFO databases for literature published in English from January 1990 to March 2018. Eligible publications reported on conflict-affected neonates, children, adolescents or women in LMICs who received an infectious disease intervention. We extracted and synthesised information on delivery characteristics, including delivery site and personnel involved, as well as barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data.

RESULTS

A majority of the 194 eligible publications reported on intervention delivery in sub-Saharan Africa. Vaccines for measles and polio were the most commonly reported interventions, followed by malaria treatment. Over two-thirds of reported interventions were delivered in camp settings for displaced families. The use of clinics as a delivery site was reported across all intervention types, but outreach and community-based delivery were also reported for many interventions. Key barriers to service delivery included restricted access to target populations; conversely, adopting social mobilisation strategies and collaborating with community figures were reported as facilitating intervention delivery. Few publications reported on intervention coverage, mostly reporting variable coverage for vaccines, and fewer reported on intervention effectiveness, mostly for malaria treatment regimens.

CONCLUSIONS

Despite an increased focus on health outcomes in humanitarian crises, our review highlights important gaps in the literature on intervention delivery among specific subpopulations and geographies. This indicates a need for more rigorous research and reporting on effective strategies for delivering infectious disease interventions in different conflict contexts.

PROSPERO REGISTRATION NUMBER

CRD42019125221.

Essential healthcare services provided to conflict-affected internally displaced populations in low and middle-income countries: A systematic review

Background: Conflict and violent crises have resulted in over 40 million of internally displaced persons (IDPs). Most affected regions lack access to basic health resources and generally rely on humanitarian support. The objective of this review was to appraise primary health service interventions among conflict-induced internally displaced populations in low and middle income countries between 2000 and 2019. Methods: A systematic review of literature in the following databases: Embase, MEDLINE, PsyArticles, PsycINFO, Scopus, Web of Science, LILAC and CAB Articles, was performed to identify interventions implemented in conflict IDP settings. Results: Initial searches yielded 4578 papers and 30 studies met the inclusion criteria. Descriptivesynthesis analysis was used, and the final selections were assessed using a customized CriticalAppraisal Skills Programme (CASP) checklist. Included papers were from Sub-Saharan Africa, South Asia and the Middle East regions. Most studies were on prevention interventions, especially water treatment and maternal health. Treatment interventions mostly focused on onmalaria and mental health. Only one food and nutrition study with outcome data was identified, indicating limitations in IDP health-related intervention publications. Reported interventions were conducted between one week to five years, and the study qualities were moderate. The most effective interventions were integrated programmes and common challenges were weakstudy methodology and data reporting. Conclusion: Regardless of the intervention types and durations, the services offered were beneficial to the IDPs. More intervention evidence are, however required as shown in gaps around food and nutrition, health education and disease surveillance.

Estimating malaria disease burden in the Asia-Pacific

Background: The Asia-Pacific aims to eliminate malaria by 2030. Many of the 22 endemic countries have earlier targets. To track progress towards elimination and predict timelines and funding required it is essential to have an accurate picture of the true burden of malaria over time. Estimating this is a major challenge with most countries having incomplete data on numbers of cases and wide variation between health system access and performance. Regular estimates are published by the World Health Organization (WHO), but these are not split by species, can have a wide range of uncertainty, change over time and are not available for every year. Methods: For the Asia Pacific Leaders Malaria Alliance, the burden of malaria for the 22 malaria-endemic countries in the Asia-Pacific from 2000 to 2015 was estimated by combining data submitted by countries to WHO with a systematic review to estimate the proportion of cases recorded. Due to a lack of suitable data, it was only possible to apply this method to 2013-2015. A simplified method was then derived to estimate the annual burden of falciparum and vivax malaria as inputs to a mathematical model to predict the cost of elimination, which is described elsewhere. Results: The total number of estimated cases was around double the number of confirmed cases reported in the Asia Pacific with a broad range of uncertainty around these estimates due primarily to sparsity of data with which to estimate proportions of cases reported. The ranges of estimated burdens were mostly like those published for countries by WHO, with some exceptions. Conclusions: The accuracy and precision of malaria burden estimates could be greatly improved by having more regular large surveys on access to healthcare in malaria-endemic areas and making subnational data on malaria incidence and reporting completeness publicly available.

Human population movement and behavioural patterns in malaria hotspots on the Thai-Myanmar border: implications for malaria elimination

BACKGROUND

Malaria is heterogeneously distributed across landscapes. Human population movement (HPM) could link sub-regions with varying levels of transmission, leading to the persistence of disease even in very low transmission settings. Malaria along the Thai-Myanmar border has been decreasing, but remains heterogeneous. This study aimed to measure HPM, associated predictors of travel, and HPM correlates of self-reported malaria among people living within malaria hotspots.

METHODS

526 individuals from 279 households in two malaria hotspot areas were included in a prospective observational study. A baseline cross-sectional study was conducted at the beginning, recording both individual- and household-level characteristics. Individual movement and travel patterns were repeatedly observed over one dry season month (March) and one wet season month (May). Descriptive statistics, random effects logistic regressions, and logistic regressions were used to describe and determine associations between HPM patterns, individual-, household-factors, and self-reported malaria.

RESULTS

Trips were more common in the dry season. Malaria risk was related to the number of days doing outdoor activities in the dry season, especially trips to Myanmar, to forest areas, and overnight trips. Trips to visit forest areas were more common among participants aged 20-39, males, individuals with low income, low education, and especially among individuals with forest-related occupations. Overnight trips were more common among males, and individual with forest-related occupations. Forty-five participants reported having confirmed malaria infection within the last year. The main place of malaria blood examination and treatment was malaria post and malaria clinic, with participants usually waiting for 2-3 days from onset fever to seeking diagnosis. Individuals using bed nets, living in houses with elevated floors, and houses that received indoor residual spraying in the last year were less likely to report malaria infection.

CONCLUSION

An understanding of HPM and concurrent malaria dynamics is important for consideration of targeted public health interventions. Furthermore, diagnosis and treatment centres must be capable of quickly diagnosing and treating infections regardless of HPM. Coverage of diagnosis and treatment centres should be broad, maintained in areas bordering malaria hotspots, and available to all febrile individuals.

Bayesian spatiotemporal analysis of malaria infection along an international border: Hlaingbwe Township in Myanmar and Tha-Song-Yang District in Thailand

BACKGROUND

One challenge in moving towards malaria elimination is cross-border malaria infection. The implemented measures to prevent and control malaria re-introduction across the demarcation line between two countries require intensive analyses and interpretation of data from both sides, particularly in border areas, to make correct and timely decisions. Reliable maps of projected malaria distribution can help to direct intervention strategies. In this study, a Bayesian spatiotemporal analytic model was proposed for analysing and generating aggregated malaria risk maps based on the exceedance probability of malaria infection in the township-district adjacent to the border between Myanmar and Thailand. Data of individual malaria cases in Hlaingbwe Township and Tha-Song-Yang District during 2016 were extracted from routine malaria surveillance databases. Bayesian zero-inflated Poisson model was developed to identify spatial and temporal distributions and associations between malaria infections and risk factors. Maps of the descriptive statistics and posterior distribution of predicted malaria infections were also developed.

RESULTS

A similar seasonal pattern of malaria was observed in both Hlaingbwe Township and Tha-Song-Yang District during the rainy season. The analytic model indicated more cases of malaria among males and individuals aged ≥ 15 years. Mapping of aggregated risk revealed consistently high or low probabilities of malaria infection in certain village tracts or villages in interior parts of each country, with higher probability in village tracts/villages adjacent to the border in places where it could easily be crossed; some border locations with high mountains or dense forests appeared to have fewer malaria cases. The probability of becoming a hotspot cluster varied among village tracts/villages over the year, and some had close to no cases all year.

CONCLUSIONS

The analytic model developed in this study could be used for assessing the probability of hotspot cluster, which would be beneficial for setting priorities and timely preventive actions in such hotspot cluster areas. This approach might help to accelerate reaching the common goal of malaria elimination in the two countries.

Microgeographic Heterogeneity of Border Malaria During Elimination Phase, Yunnan Province, China, 2011-2013

Malaria was concentrated in a few townships along the China–Myanmar border.

To identify township-level high-risk foci of malaria transmission in Yunnan Province, China, along the international border, we retrospectively reviewed data collected in hospitals and clinics of 58 townships in 4 counties during 2011–2013. We analyzed spatiotemporal distribution, especially hot spots of confirmed malaria, using geographic information systems and Getis-Ord G_i*(d) cluster analysis. Malaria incidence, transmission seasonality, and Plasmodium vivax:P. falciparum ratio remained almost unchanged from 2011 to 2013, but heterogeneity in distribution increased. The number of townships with confirmed malaria decreased significantly during the 3 years; incidence became increasingly concentrated within a few townships. High-/low-incidence clusters of P. falciparum shifted in location and size every year, whereas the locations of high-incidence P. vivax townships remained unchanged. All high-incidence clusters were located along the China–Myanmar border. Because of increasing heterogeneity in malaria distribution, microgeographic analysis of malaria transmission hot spots provided useful information for designing targeted malaria intervention during the elimination phase.

Using Respondent Driven Sampling to Identify Malaria Risks and Occupational Networks among Migrant Workers in Ranong, Thailand

Background

Ranong Province in southern Thailand is one of the primary entry points for migrants entering Thailand from Myanmar, and borders Kawthaung Township in Myanmar where artemisinin resistance in malaria parasites has been detected. Areas of high population movement could increase the risk of spread of artemisinin resistance in this region and beyond.

Methods

A respondent-driven sampling (RDS) methodology was used to compare migrant populations coming from Myanmar in urban (Site 1) vs. rural (Site 2) settings in Ranong, Thailand. The RDS methodology collected information on knowledge, attitudes, and practices for malaria, travel and occupational histories, as well as social network size and structure. Individuals enrolled were screened for malaria by microscopy, Real Time-PCR, and serology.

Results

A total of 619 participants were recruited in Ranong City and 623 participants in Kraburi, a rural sub-district. By PCR, a total of 14 (1.1%) samples were positive (2 P. falciparum in Site 1; 10 P. vivax, 1 Pf, and 1 P. malariae in Site 2). PCR analysis demonstrated an overall weighted prevalence of 0.5% (95% CI, 0–1.3%) in the urban site and 1.0% (95% CI, 0.5–1.7%) in the rural site for all parasite species. PCR positivity did not correlate with serological positivity; however, as expected there was a strong association between antibody prevalence and both age and exposure. Access to long-lasting insecticidal treated nets remains low despite relatively high reported traditional net use among these populations.

Conclusions

The low malaria prevalence, relatively smaller networks among migrants in rural settings, and limited frequency of travel to and from other areas of malaria transmission in Myanmar, suggest that the risk for the spread of artemisinin resistance from this area may be limited in these networks currently but may have implications for regional malaria elimination efforts.

Lessons on malaria control in the ethnic minority regions in Northern Myanmar along the China border, 2007-2014

BACKGROUND

For many countries where malaria is endemic, the burden of malaria is high in border regions. In ethnic minority areas along the Myanmar-China border, residents have poor access to medical care for diagnosis and treatment, and there have been many malaria outbreaks in such areas. Since 2007, with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), a malaria control project was introduced to reduce the malaria burden in several ethnic minority regions.

METHODS

A malaria control network was established during the period from 2007 to 2014. Multiple malaria interventions, including diagnosis, treatment, distribution of LLINs and health education, were conducted to improve the accessibility and quality of malaria control services for local residents. Annual cross-sectional surveys were conducted to evaluate intervention coverage and indicators of malaria transmission.

RESULTS

In ethnic minority regions where a malaria control network was established, both the annual malaria incidence (19.1 per thousand per year, in 2009; 8.7, in 2014) and malaria prevalence (13.6 % in 2008; 0.43 % in 2014) decreased dramatically during the past 5-6 years. A total of 851 393 febrile patients were detected, 202 598 malaria cases (including confirmed cases and suspected cases) were treated, and 759 574 LLINs were delivered to populations at risk. Of households in 2012, 73.9 % had at least one ITNs/LLINs (vs. 28.3 %, in 2008), and 50.7 % of children less than 5 years and 50.3 % of pregnant women slept under LLINs the night prior to their visit. Additionally, malaria knowledge was improved in 68.4 % of residents.

CONCLUSION

There has been great success in improving malaria control in these regions from 2007 to 2014. Malaria burdens have decreased, especially in KOK and WA. The continued maintenance of sustainable malaria control networks in these regions may be a long-term process, due to regional conflicts and the lack of funds, technology, and health workers. Furthermore, information and scientific support from the international community should be offered to these ethnic minority regions to uphold recent achievements.

Impact of interventions on malaria in internally displaced persons along the China-Myanmar border: 2011-2014

BACKGROUND

Internally displaced persons (IDP) represent vulnerable populations whose public health conditions merit special attention. In the China-Myanmar border area, human movement and resettlements of IDP can influence malaria transmission. Comparison of disease incidence and vector densities between IDP camps and surrounding local villages allows for better understanding of current epidemiology and to evaluate the effectiveness of interventions in the region.

METHODS

Malaria and vector surveillance was conducted in three IDP camps and three local villages neighbouring the camps along the China-Myanmar border in Myanmar. Clinical malaria cases were collected from seven hospitals/clinics from April 2011 to December 2014. Malaria vector population dynamics were monitored using CDC light traps. The use of malaria preventive measures and information on aid agencies and their activities was obtained through questionnaire surveys.

RESULTS

Malaria was confirmed in 1832 patients. Of these cases, 85.4 % were Plasmodium vivax and 11.4 % were Plasmodium falciparum malaria. Annual malaria incidence rates were 38.8 and 127.0 cases/1000 person year in IDP camps and local villages, respectively. Older children of 5-14 years had the highest incidence rate in the camps regardless of gender, while male adults had significantly higher incidence rates than females in local villages and females child-bearing age had significantly lower risk to malaria in IDP camps compare to local villages. Seasonal malaria outbreaks were observed both in the IDP camps and in the local villages from May to August 2013. The proportion of P. vivax remained unchanged in local villages but increased by approximately tenfold in IDP camps from 2011 to 2014. Anopheles vector density was tenfold higher in local villages compared to IDP camps (2.0:0.2 females/trap/night). Over 99 % of households in both communities owned bed nets. While long-lasting insecticidal nets accounted for 61 % of nets used in IDPs, nearly all residents of local villages owned regular nets without insecticide-impregnation. There were more active aid agencies in the camps than in local villages.

CONCLUSION

Malaria in IDP camps was significantly lower than the surrounding villages through effective control management. The observation of P. vivax outbreaks in the study area highlights the need for increased control efforts. Expansion of malaria intervention strategies in IDP camps to local surrounding villages is critical to malaria control in the border area.

Shifting from control to elimination: analysis of malaria epidemiological characteristics in Tengchong County around China-Myanmar border, 2005-2014

BACKGROUND

Tengchong County experienced a decreasing malaria prevalence period in 2005-2014 but the factors contributing to the trend are unclear. Herein, the malaria epidemiological data in years of 2005-2014 were collected and analysed, in order to provide evidence for subsequent effective strategic planning of malaria elimination that may be referenced by other counties with the similar elimination programmes along the China-Myanmar border.

METHODS

A retrospective study was conducted to explore malaria-endemic characteristics in years 2005-2014 in Tengchong County. All individual cases from a web-based reporting system were reviewed and analysed. Local infections and imported cases were obtained from an annual reporting system.

RESULTS

In total, 8321 confirmed malaria cases were recorded in this period, and 91.5% of them were reported during 2005-2010. Plasmodium vivax was the major species (n = 5867, 70.5%). Most cases (92.9%) were found in males, mainly in the age group 30-34 years. Only five deaths resulting from Plasmodium falciparum were reported, of which three occurred in 2005. The cases were mainly reported in the townships of Wuhe (18.5%), Mangbang (12.8%) and Gudong (9.3%). In addition, 147 local malaria (1.8%) and 8174 imported malaria (98.2%) were observed during 2005-2014. However, the proportion of imported malaria was more than 95% all the time and no local transmission has been observed since 2013. Moreover, Myanmar was the main imported source, with 716 cases (94.6%, 716/757) from Myanmar in 2011-2014.

CONCLUSIONS

Tengchong County has made achievements in controlling malaria, with incidence at historically its lowest level. However, imported malaria has increased and poses a great threat to malaria elimination. To achieve the elimination goal and prevent the re-introduction of malaria, surveillance systems need to be well planned and managed to ensure timely case detection and prompt response targeted to the mobile and migrate population at elimination stage.

Malaria ecology along the Thailand-Myanmar border

Background

Malaria in Southeast Asia frequently clusters along international borders. For example, while most of Thailand is malaria free, the border region shared with Myanmar continues to have endemic malaria. This spatial pattern is the result of complex interactions between landscape, humans, mosquito vectors, and malaria parasites. An understanding of these complex ecological and socio-cultural interactions is important for designing and implementing malaria elimination efforts in the region. This article offers an ecological perspective on the malaria situation along the Thailand–Myanmar border.

Discussion

This border region is long (2000 km), mountainous, and the environment ranges from thick forests to growing urban settlements and wet-rice fields. It is also a biologically diverse region. All five species of malaria known to naturally infect humans are present. At least three mosquito vector species complexes, with widely varying behavioural characteristics, exist in the area. The region is also a hub for ethnic diversity, being home to over ten different ethnolinguistic groups, several of which have been engaged in conflict with the Myanmar government now for over half a century. Given the biological and ethnic diversity, as well as the complex socio-political context, malaria control and elimination in the region is challenging.

Conclusion

Despite these complexities, multipronged approaches including collaborations with multiple local organizations, quick access to diagnosis and treatment, prevention of mosquito bites, radical cure of parasites, and mass drug administration appear to be drastically decreasing Plasmodium falciparum infections. Such approaches remain crucial as the region moves toward elimination of P. falciparum and potentially Plasmodium vivax.

Cross-border malaria: a major obstacle for malaria elimination

Movement of malaria across international borders poses a major obstacle to achieving malaria elimination in the 34 countries that have committed to this goal. In border areas, malaria prevalence is often higher than in other areas due to lower access to health services, treatment-seeking behaviour of marginalized populations that typically inhabit border areas, difficulties in deploying prevention programmes to hard-to-reach communities, often in difficult terrain, and constant movement of people across porous national boundaries. Malaria elimination in border areas will be challenging and key to addressing the challenges is strengthening of surveillance activities for rapid identification of any importation or reintroduction of malaria. This could involve taking advantage of technological advances, such as spatial decision support systems, which can be deployed to assist programme managers to carry out preventive and reactive measures, and mobile phone technology, which can be used to capture the movement of people in the border areas and likely sources of malaria importation. Additionally, joint collaboration in the prevention and control of cross-border malaria by neighbouring countries, and reinforcement of early diagnosis and prompt treatment are ways forward in addressing the problem of cross-border malaria.

Cost-effectiveness analysis of malaria rapid diagnostic test incentive schemes for informal private healthcare providers in Myanmar

BACKGROUND

The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options.

METHODS

A decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs.

RESULTS

ICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control.

Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar

Background

Myanmar has struggled through decades of internal conflict, which has negatively impacted the country’s health outcomes. Recent government changes have brought hope and reduced conflict. The ethnic minority groups have suffered the brunt of the health consequences and reside in regions that lack health infrastructure, resources, and providers. Due to the chronic lack of healthcare providers within conflict areas, health workers (HWs) have been trained in an effort to fill the void. Research has shown that these non-physician clinicians positively impact health outcomes in developing countries. These HWs are supported by community-based organizations in collaboration with foreign non-governmental organizations. Started in 2000, the trauma training course was developed to meet the educational needs of these HWs.

Methods

Essential procedures for HWs in conflict zones were identified, and teaching methods were adapted to develop models that were simple, reproducible, cost effective, and able to facilitate effective learning within the limitations of these challenging environments. This paper presents simulation models developed to teach trauma injury evaluation and management in resource-limited settings to HWs.

Results

Material and construction of the models described include breathing, chest, cricothyroidotomy, circulation, wound repair, fracture/dislocation, splinting, fasciotomy/amputation, and an animal model. In 2013, a pre/post test and post-training evaluation were completed, which demonstrated an increase in understanding of the material and satisfaction with the training.

Conclusions

The simulation models described engage the HWs in clinical skills practice specific to injury management, which builds upon the HWs existing knowledge and facilitates an increased understanding of life-saving procedures. Through observation of the HW performance and HW feedback, these simulation models have increased the understanding of trauma management. Limitations include lack of a graduated learning system for the HWs, logistics, and time constraints. Despite the barriers faced, we feel that this is a necessary program that has reduced morbidity and mortality due to traumatic injury in the geographic areas that the HWs serve. With the changing political environment in Myanmar and the development of peace agreements between the government and the ethnic minority groups, these HWs can be integrated into Myanmar’s evolving health system.

Malaria baseline survey in four special regions of northern Myanmar near China: a cross-sectional study

BACKGROUND

Epidemiological data in the border area of the northern Myanmar near China are either of little accuracy or sparse of information, due to the poor public health system in these areas, and malaria cases may be severely underestimated. This study aimed to investigate malaria prevalence and health facilities for malaria services, and to provide the baseline information for malaria control in these areas.

METHODS

A cluster, randomized, cross-sectional survey was conducted in four special regions of northern Myanmar, near China: 5,585 people were selected for a malaria prevalence survey and 1,618 households were selected for a mosquito net-owning survey. Meanwhile, a total of 97 health facilities were surveyed on their malaria services. The data were analysed and descriptive statistics were used.

RESULTS

A total of 761 people were found positive through microscopy test, including 290 people for Plasmodium falciparum, 460 for Plasmodium vivax, two for Plasmodium malariae, and nine for mixed infection. The average prevalence of malaria infection was 13.6% (95% CI: 12.7-14.6%). There were significant differences of prevalence of malaria infection among the different regions (P < 0.01); 38.1% (95% CI: 28.3-48.0%) of health facilities had malaria microscope examination service, and 35.1% (95% CI: 25.4-44.7%) of these had malaria treatment services, 23.7% (95% CI: 15.1-32.3%) had malaria outreach services. 28.3% (95% CI: 26.1-30.6%) of households owned one or more long-lasting insecticidal bed nets (LLINs).

CONCLUSION

The prevalence of malaria infection was high in the four special regions of northern Myanmar, near China. Malaria services in health facilities in these areas were weak. ITNs/LLINs owning rate was also low. The cross-border cooperation mechanism should be further strengthened to share the epidemical data about malaria, support technical assistance, and conduct joint malaria control or elimination activities.

Discourse on malaria elimination: where do forcibly displaced persons fit in these discussions?

Background

Individuals forcibly displaced are some of the poorest people in the world, living in areas where infrastructure and services are at a bare minimum. Out of a total of 10,549,686 refugees protected and assisted by the United Nations High Commissioner for Refugees globally, 6,917,496 (65.6%) live in areas where malaria is transmitted. Historically, national malaria control programmes have excluded displaced populations.

Results

The current discourse on malaria elimination rarely includes discussion of forcibly displaced persons who reside within malaria-eliminating countries. Of the 100 malaria-endemic countries, 64 are controlling malaria and 36 are in some stage of elimination. Of these, 30 malaria-controlling countries and 13 countries in some phase of elimination host displaced populations of ≥50,000, even though 13 of the 36 (36.1%) malaria-elimination countries host displaced populations of ≥50,000 people.

Discussion

Now is the time for the malaria community to incorporate forcibly displaced populations residing within malarious areas into malaria control activities. Beneficiaries, whether they are internally displaced persons or refugees, should be viewed as partners in the delivery of malaria interventions and not simply as recipients.

Conclusion

Until equitable and sustainable malaria control includes everyone residing in an endemic area, the goal of malaria elimination will not be met.

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.

Malaria in the Greater Mekong Subregion: heterogeneity and complexity

The Greater Mekong Subregion (GMS), comprised of six countries including Cambodia, China's Yunnan Province, Lao PDR, Myanmar (Burma), Thailand and Vietnam, is one of the most threatening foci of malaria. Since the initiation of the WHO's Mekong Malaria Program a decade ago, malaria situation in the GMS has greatly improved, reflected in the continuous decline in annual malaria incidence and deaths. However, as many nations are moving towards malaria elimination, the GMS nations still face great challenges. Malaria epidemiology in this region exhibits enormous geographical heterogeneity with Myanmar and Cambodia remaining high-burden countries. Within each country, malaria distribution is also patchy, exemplified by 'border malaria' and 'forest malaria' with high transmission occurring along international borders and in forests or forest fringes, respectively. 'Border malaria' is extremely difficult to monitor, and frequent malaria introductions by migratory human populations constitute a major threat to neighboring, malaria-eliminating countries. Therefore, coordination between neighboring countries is essential for malaria elimination from the entire region. In addition to these operational difficulties, malaria control in the GMS also encounters several technological challenges. Contemporary malaria control measures rely heavily on effective chemotherapy and insecticide control of vector mosquitoes. However, the spread of multidrug resistance and potential emergence of artemisinin resistance in Plasmodium falciparum make resistance management a high priority in the GMS. This situation is further worsened by the circulation of counterfeit and substandard artemisinin-related drugs. In most endemic areas of the GMS, P. falciparum and Plasmodium vivax coexist, and in recent malaria control history, P. vivax has demonstrated remarkable resilience to control measures. Deployment of the only registered drug (primaquine) for the radical cure of vivax malaria is severely undermined due to high prevalence of glucose-6-phosphate dehydrogenase deficiency in target human populations. In the GMS, the dramatically different ecologies, diverse vector systems, and insecticide resistance render traditional mosquito control less efficient. Here we attempt to review the changing malaria epidemiology in the GMS, analyze the vector systems and patterns of malaria transmission, and identify the major challenges the malaria control community faces on its way to malaria elimination.

International emergency medicine: a review of the literature from 2009

As the specialty of emergency medicine evolves in countries around the world, and as interest in international emergency medicine (IEM) grows within the United States, the IEM Literature Review Group recognizes an ongoing need for a high-quality, consolidated, and easily accessible evidence base of literature. The IEM Literature Review Group produces an annual publication that strives to provide readers with access to the highest quality and most relevant IEM research from the previous year. This publication represents our fifth annual review, covering the top 24 IEM research articles published in 2009. Articles were selected for the review according to explicit, predetermined criteria that emphasize both methodologic quality and impact of the research. It is our hope that this annual review acts as a forum for disseminating best practices, while also stimulating further research in the field of IEM.