Surge of severe acute respiratory syndrome coronavirus 2 infections linked to single introduction of a virus strain in Myanmar, 2020

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a major health concern globally. Genomic epidemiology is an important tool to assess the pandemic of coronavirus disease 2019 (COVID-19). Several mutations have been reported by genome analysis of the SARS-CoV-2. In the present study, we investigated the mutational and phylogenetic analysis of 30 whole-genome sequences for the virus's genomic characteristics in the specimens collected in the early phase of the pandemic (March-June, 2020) and the sudden surge of local transmission (August-September, 2020). The four samples in the early phase of infection were B.6 lineage and located within a clade of the samples collected at the same time in Singapore and Malaysia, while five returnees by rescue flights showed the lineage B. 1.36.1 (three from India), B.1.1 (one from India) and B.1.80 (one from China). However, there was no evidence of local spread from these returnees. Further, all 19 whole-genome sequences collected in the sudden surge of local transmission showed lineage B.1.36. The surge of the second wave on SARS-CoV-2 infection was linked to the single-introduction of a variant (B.1.36) that may result from the strict restriction of international travel and containment efforts. These genomic data provides the useful information to disease control and prevention strategy.

Feasibility of Developing a Community-Based Cancer Registry in Kawa Township in Myanmar

PURPOSE

The objectives of this implementation research were to implement an innovative approach by basic health staff (BHS) using a cancer registry mobile application for continuous data reporting and to evaluate the process of establishing a community-based cancer registry.

METHODS

Eighty BHS in Kawa township, Bago region, were trained on the mobile application based on locally adapted CanReg5 software, common cancers and symptoms, and plans for implementation and monitoring. Required information of confirmed cancer cases was collected by the focal persons among local BHS using the application installed on their mobile devices and reported online to a database accessed by researchers. Two focus group discussions with BHS were conducted to identify challenges encountered during implementation and their suggested practical solutions.

RESULTS

A total of 74 confirmed cancer cases were registered during the 6-month implementation period. The most common cancers registered were breast cancer (20 cases), followed by GI cancers (18 cases) and lung cancers (9 cases). This finding was consistent with common cancers from regional hospital reports. Some data incompleteness was observed in topography, staging, and treatment information. In qualitative discussions, BHS reported technical difficulties in becoming familiar with morphologic codes, in saving registered cases in their phones, and in reading biopsy results and clinical notes. BHS approached family members mostly to obtain the hospital/laboratory records of patients with confirmed cases and some faced reluctance as family members did not want to inform the patients about their diagnosis. BHS could not register some cases when documents were not present, although they definitely knew the cases, including expired cases. The patient and/or caregiver expected financial or other support when they were registered. Once cancer is highly suspected or diagnosed, patients stop seeking proper care and turn to traditional healers. This is a result of the lack of knowledge about cancer. The cost of cancer health care is also a factor that influences whether treatment is sought.

CONCLUSION

A community-based cancer registry by BHS is feasible to a certain extent with some improvements. More community participation and proper referral to facilitate care are needed, as well as addressing technical difficulties.

The clinical characteristics of patients with sepsis in a tertiary referral hospital in Yangon, Myanmar

Background

The clinical characteristics and course of patients hospitalised with sepsis in Myanmar and the responsible pathogens remain poorly defined.

Methods

We performed an observational study of adults admitted from the community to a tertiary referral hospital in Yangon with fever and dysfunction of at least two organ systems.

Results

The 120 patients had a median age of 47 y (interquartile range 28-63); 11 (9%) were human immunodeficiency virus positive. Limited laboratory support meant that a microbiological diagnosis was possible in only 35 (29%) patients, but 18 (13%) had pathogens in blood cultures, including 9 (50%) organisms that were multidrug resistant (4 Escherichia coli, 4 Pseudomonas aeruginosa, 1 Burkholderia pseudomallei). Tuberculosis was confirmed in six patients, with two being rifampicin resistant, and dengue infection was confirmed in five patients. Without access to comprehensive intensive care support, 34 (28%) patients died. An admission National Early Warning Score ≥7 (odds ratio [OR] 8.6 [95% confidence interval {CI} 2.6 to 28.2], p=0.001) and quick sequential (sepsis-related) organ failure assessment score ≥2 (OR 3.2 [95% CI 1.3 to 8.0], p=0.02) were helpful in predicting death.

Conclusions

Tropical pathogens are a common cause of sepsis in Myanmar. The frequent identification of multidrug-resistant organisms and limited diagnostic and intensive care support hinder patient care significantly. However, simple clinical assessment on admission has prognostic utility.

Pilot Study on the Application of Telemedicine as a Tool for a Population-Based Cancer Registry in Hlegu Township, Yangon Region, Myanmar

Abstract 57

Purpose

The cancer burden is rising and threatens the social and economic development of low- and middle-income countries, including Myanmar, in the ASEAN region. A quality cancer registry plays a unique role in planning, the evaluation of cancer control program, treatment, and palliative care. To date, there is a paucity of studies in Myanmar that have focused on the implementation of a population-based cancer registry. In addition, the concept of telemedicine with the use of information technology applications as appropriate during implementation needs to be introduced. Such an approach may be beneficial to those working at the grassroots level for the overall improvement of the processes of community reporting, confirmation of diagnoses, effective referral for palliative care, and the establishment of cancer registries.

Methods

A pilot study was therefore carried out to formulate the strategic approach for establishing a population-based cancer registry in Hlegu Township in Northern Yangon District, Myanmar. First, the cancer data entry software was created and installed on mobile phones as an information technology tool to initialize telemedicine. Next, 15 health assistants in Hlegu Township were trained in the collection of data and the entry of basic information on patients with cancer, including name, age, gender, national ID, education, occupation, primary diagnosis, and the site of metastasis of confirmed cancer cases through mobile phone applications and reported to the cancer database unit at the Department of Medical Research.

Results

A total of 126 patients with cancer were registered in Hlegu Township from June 2016 to May 2017. The estimated prevalence of disease is 4.6 per 10,000 people. The most common age at cancer diagnosis was 46 to 65 years (73.58%). Female sex was 2.5 times predominant than male sex (72% v 27%). Among 91 registered female patients with cancer, the three most common cancers were breast (32.35%), cervix (16.17%) and uterine (15.17%). Eighty-five patients with cancer (67.46%) received their diagnosis in public hospitals. Overall, 59% of patients received combination treatment, 19% received surgery only, 16% were treated with traditional medicine, 3% were treated with radiotherapy only, and 3% were treated with chemotherapy only.

Conclusion

This study is a first step in applying the concept of telemedicine to the creation of a population-based cancer registry in a resource-limited setting. More concerted efforts are needed to move toward a well-established population-based cancer registry in Myanmar.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Chloroquine efficacy for Plasmodium vivax in Myanmar in populations with high genetic diversity and moderate parasite gene flow

BACKGROUND

Plasmodium vivax malaria remains a major public health burden in Myanmar. Resistance to chloroquine (CQ), the first-line treatment for P. vivax, has been reported in the country and has potential to undermine local control efforts.

METHODS

Patients over 6 years of age with uncomplicated P. vivax mono-infection were enrolled into clinical efficacy studies in Myawaddy in 2014 and Kawthoung in 2012. Study participants received a standard dose of CQ (25 mg/kg over 3 days) followed by weekly review until day 28. Pvmdr1 copy number (CN) and microsatellite diversity were assessed on samples from the patients enrolled in the clinical study and additional cross-sectional surveys undertaken in Myawaddy and Shwegyin in 2012.

RESULTS

A total of 85 patients were enrolled in the CQ clinical studies, 25 in Myawaddy and 60 in Kawthoung. One patient in Myawaddy (1.2%) had an early treatment failure and two patients (2.3%) in Kawthoung presented with late treatment failures on day 28. The day 28 efficacy was 92.0% (95% CI 71.6-97.9) in Myawaddy and 98.3% (95% CI 88.7-99.8) in Kawthoung. By day 2, 92.2% (23/25) in Myawaddy and 85.0% (51/60) in Kawthoung were aparasitaemic. Genotyping and pvmdr1 CN assessment was undertaken on 43, 52 and 46 clinical isolates from Myawaddy, Kawthoung and Shwegyin respectively. Pvmdr1 amplification was observed in 3.2% (1/31) of isolates in Myawaddy, 0% (0/49) in Kawthoung and 2.5% (1/40) in Shwegyin. Diversity was high in all sites (H _E 0.855-0.876), with low inter-population differentiation (F _ST 0.016-0.026, P < 0.05).

CONCLUSIONS

Treatment failures after chloroquine were observed following chloroquine monotherapy, with pvmdr1 amplification present in both Myawaddy and Shwegyin. The results emphasize the importance of ongoing P. vivax drug resistance surveillance in Myanmar, particularly given the potential connectivity between parasite population at different sites.

Genetic diversity of Plasmodium falciparum populations in southeast and western Myanmar

BACKGROUND

The genetic diversity of malaria parasites reflects the complexity and size of the parasite populations. This study was designed to explore the genetic diversity of Plasmodium falciparum populations collected from two southeastern areas (Shwekyin and Myawaddy bordering Thailand) and one western area (Kyauktaw bordering Bangladesh) of Myanmar.

METHODS

A total of 267 blood samples collected from patients with acute P. falciparum infections during 2009 and 2010 were used for genotyping at the merozoite surface protein 1 (Msp1), Msp2 and glutamate-rich protein (Glurp) loci.

RESULTS

One hundred and eighty four samples were successfully genotyped at three genes. The allelic distributions of the three genes were all significantly different among three areas. MAD20 and 3D7 were the most prevalent alleles in three areas for Msp1 and Msp2, respectively. The Glurp allele with a bin size of 700-750 bp was the most prevalent both in Shwekyin and Myawaddy, whereas two alleles with bin sizes of 800-850 bp and 900-1000 bp were the most prevalent in the western site Kyauktaw. Overall, 73.91% of samples contained multiclonal infections, resulting in a mean multiplicity of infection (MOI) of 1.94. Interestingly, the MOI level presented a rising trend with the order of Myawaddy, Kyauktaw and Shwekyin, which also paralleled with the increasing frequencies of Msp1 RO33 and Msp2 FC27 200-250 bp alleles. Msp1 and Msp2 genes displayed higher levels of diversity and higher MOI rates than Glurp. PCR revealed four samples (two from Shwekyin and two from Myawaddy) with mixed infections of P. falciparum and P. vivax.

CONCLUSIONS

This study genotyped parasite clinical samples from two southeast regions and one western state of Myanmar at the Msp1, Msp2 and Glurp loci, which revealed high levels of genetic diversity and mixed-strain infections of P. falciparum populations at these sites. The results indicated that malaria transmission intensity in these regions remained high and more strengthened control efforts are needed. The genotypic data provided baseline information for monitoring the impacts of malaria elimination efforts in the region.

Comparative study on Toxoplasma infection between Malaysian and Myanmar pregnant women

Background

Toxoplasma gondii, an obligate intracellular protozoan parasite, causes a disease called toxoplasmosis which can sometimes be acquired congenitally by a newborn from an infected mother. This study aimed to determine the seroprevalence of Toxoplasma infection and its associated risks among 219 and 215 pregnant women from Malaysia and Myanmar, respectively.

Methods

Anti-Toxoplasma IgG and IgM antibodies were screened by using standard commercial ELISA kits. The socio-demographic, obstetrics and risk factors associated with Toxoplasma infection data were compared between the two countries.

Results

The overall prevalence of Toxoplasma infection in Malaysian pregnant women (42.47%; 95% CI = 36.11-49.09) was significantly higher (p < 0.05) than Myanmar pregnant women (30.70%; 95% CI = 27.92-37.16). By univariate analysis, this study identified that age group, education, parity, awareness on toxoplasmosis and consumption of undercooked meat were significantly associated (p < 0.05) with Toxoplasma seropositive Malaysian pregnant women but none of these factors associated with Toxoplasma seropositive Myanmar pregnant women. In comparison using univariate analysis between the two countries, it was found that Toxoplasma seropositive Malaysian pregnant women was associated with aged 30 years and above, secondary or lower-secondary level of education, the third trimester of pregnancy, having one child or more, lacking awareness of toxoplasmosis, absence of bad obstetrics history, having no history of close contact with cats or soil, living on a farm and also consumption of undercooked meat, unpasterized milk or untreated water. Avidity measurement was used to confirm the stages of Toxoplasma infection in pregnant women who were positive for both IgG and IgM antibodies and found all were infected in the past.

Conclusion

From our study, Toxoplasma screening and its risk measurement in pregnant women is firmly recommended for monitoring purposes and assisting proper management, including diagnosis and treatment during antenatal period. Also, it is necessary to initiate preventive measures for Toxoplasma infection among reproductive-age women in general and seronegative pregnant women in particular. Avidity measurement should be incorporated in Toxoplasma routine screening, especially with the availability of a single serum sample to assist in the diagnosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-014-0564-9) contains supplementary material, which is available to authorized users.