Prevalence and genetic diversity of simian malaria in wild macaque populations across Thailand: Implications for human health

Over the past year, P. falciparum infections have declined in Thailand, yet nonhuman primate malaria infections have correspondingly increased, including Plasmodium knowlesi and P. cynomolgi. Nevertheless, little is known about simian malaria in its natural macaque hosts, Macaca mulatta and Macaca fascicularis. This study aims to address several research questions, including the prevalence and distribution of simian malaria in these two Thai wild macaque species, variations in infection between different macaque species and between M. fascicularis subspecies, and the genetic composition of these pathogens. Blood samples were collected from 82 M. mulatta and 690 M. fascicularis across 15 locations in Thailand, as well as two locations in Vietnam and Myanmar. We employed quantitative real-time PCR targeting the Plasmodium genus-specific 18S ribosomal RNA (rRNA) gene to detect malaria infection, with a limit of detection set at 1,215.98 parasites per mL. We genotyped eight microsatellite markers, and the P. cynomolgi dihydrofolate reductase gene (DHFR) was sequenced (N = 29). In total, 100 of 772 samples (13 %) tested positive for malaria, including 45 (13 %) for P. cynomolgi, 37 (13 %) for P. inui, 16 (5 %) for P. coatneyi, and 2 (0.25 %) for Hepatocystis sp. in Saraburi, central and Ranong, southern Thailand. Notably, simian malaria infection was observed exclusively in M. fascicularis and not in M. mulatta (P = 0.0002). Particularly, P. cynomolgi was detected in 21.7 % (45/207) of M. f. fascicularis living in Wat Tham Phrapothisat, Saraburi Province. The infection with simian malaria was statistically different between M. fascicularis and M. mulatta (P = 0.0002) but not within M. fascicularis subspecies (P = 0.78). A haplotype network analysis revealed that P. cynomolgi shares a lineage with reference strains obtained from macaques. No mutation in the predicted binding pocket of PcyDHFR to pyrimethamine was observed. This study reveals a significant prevalence of simian malaria infection in M. fascicularis. The clonal genotypes of P. cynomolgi suggest in-reservoir breeding. These findings raise concerns about the potential spread of nonhuman primate malaria to humans and underscore the need for preventive measures.

Health literacy and high blood pressure among Myanmar migrant workers in Northeastern Thailand

Hypertension, related to serious consequences unless diagnosed and treated, is a global concern, also affecting migrant workers. Due to the high prevalence of hypertension among migrant workers in Thailand, the influences of health literacy and other factors on blood pressure were needed to explore among Myanmar migrant workers in Northeastern Thailand. Hence, this study aimed to identify the prevalence of high blood pressure (HBP), its association with health literacy and other factors among Myanmar migrant workers in Northeastern Thailand. A cross-sectional analytical study was conducted in Northeastern Thailand. A multistage sampling procedure was applied. Data was gathered through interviews utilizing validated and reliable structured questionnaire. Descriptive statistics and inferential statistics with multiple logistic regression were used. Among 406 participants, about 60% were male and about 70% of them were married. The prevalence of overall HBP was 63.3% (95% CI: 58.49-67.86), 52% in females and 71.86% in males. Participants with limited health literacy were 79% more likely to have HBP than those with excellent and adequate health literacy (AOR = 1.79, 95% CI: 1.13-2.84). Other factors substantially linked with having HBP were being male gender (AOR = 4.68, 95% CI: 2.81-7.78), being overweight (AOR = 2.23, 95% CI: 1.18-4.23), being obese (AOR = 5.69, 95% CI: 2.96-10.96), not having health insurance (AOR = 2.01, 95% CI: 1.11-3.66), staying in Thailand for more than 48 months (AOR = 2.4, 95% CI: 1.48-3.9), and having family history of hypertension (AOR = 2.07, 95% CI: 1.28-3.35). In conclusion, more than half of Myanmar migrant workers had HBP. Factors associated with HBP were limited health literacy, male gender, overnutrition, lack of health insurance, longer duration of stay in Thailand and having family history of hypertension. Therefore, there is a need for a multifaceted strategy to prevent hypertension and its consequences by promoting health literacy as well as by enhancing good behavioural practice among this community.

Comparison of perinatal outcome and mode of birth of twin and singleton pregnancies in migrant and refugee populations on the Thai Myanmar border: A population cohort

BACKGROUND

In low- and middle-income countries twin births have a high risk of complications partly due to barriers to accessing hospital care. This study compares pregnancy outcomes, maternal and neonatal morbidity and mortality of twin to singleton pregnancy in refugee and migrant clinics on the Thai Myanmar border.

METHODS

A retrospective review of medical records of all singleton and twin pregnancies delivered or followed at antenatal clinics of the Shoklo Malaria Research Unit from 1986 to 2020, with a known outcome and estimated gestational age. Logistic regression was done to compare the odds of maternal and neonatal outcomes between twin and singleton pregnancies.

RESULTS

Between 1986 and 2020 this unstable and migratory population had a recorded outcome of pregnancy of 28 weeks or more for 597 twin births and 59,005 singleton births. Twinning rate was low and stable (<9 per 1,000) over 30 years. Three-quarters (446/597) of the twin pregnancies and 96% (56,626/59,005) of singletons birthed vaginally. During pregnancy, a significantly higher proportion of twin pregnancies compared to singleton had pre-eclampsia (7.0% versus 1.7%), gestational hypertension (9.9% versus 3.9%) and eclampsia (1.0% versus 0.2%). The stillbirth rate of twin 1 and twin 2 was higher compared to singletons: twin 1 25 per 1,000 (15/595), twin 2 64 per 1,000 (38/595) and singletons 12 per 1,000 (680/58,781). The estimated odds ratio (95% confidence interval (CI)) for stillbirth of twin 1 and twin 2 compared to singletons was 2.2 (95% CI 1.3-3.6) and 5.8 (95% CI 4.1-8.1); and maternal death 2.0 (0.95-11.4), respectively, As expected most perinatal deaths were 28 to <32 week gestation.

CONCLUSION

In this fragile setting where access to hospital care is difficult, three in four twins birthed vaginally. Twin pregnancies have a higher maternal morbidity and perinatal mortality, especially the second twin, compared to singleton pregnancies.

Detection of enterovirus D68 among children with severe acute respiratory infection in Myanmar

BACKGROUND

Enterovirus D68 (EV-D68) is an important reemerging pathogen that causes severe acute respiratory infection and acute flaccid paralysis, mainly in children. Since 2014, EV-D68 outbreaks have been reported in the United States, Europe, and east Asia; however, no outbreaks have been reported in southeast Asian countries, including Myanmar, during the previous 10 years.

METHODS

EV-D68 was detected in nasopharyngeal swabs from children with acute lower respiratory infections in Myanmar. The samples were previously collected from children aged 1 month to 12 years who had been admitted to the Yankin Children Hospital in Yangon, Myanmar, between May 2017 and January 2019. EV-D68 was detected with a newly developed EV-D68-specific real-time PCR assay. The clade was identified by using a phylogenetic tree created with the Bayesian Markov chain Monte Carlo method.

RESULTS

During the study period, nasopharyngeal samples were collected from 570 patients. EV-D68 was detected in 42 samples (7.4 %)-11 samples from 2017 to 31 samples from 2018. The phylogenetic tree revealed that all strains belonged to clade B3, which has been the dominant clade worldwide since 2014. We estimate that ancestors of currently circulating genotypes emerged during the period 1980-2004.

CONCLUSIONS

To our knowledge, this is the first report of EV-D68 detection in children with acute lower respiratory infections in Yangon, Myanmar, in 2017-2018. Detection and detailed virologic analyses of EV-D68 in southeast Asia is an important aspect of worldwide surveillance and will likely be useful in better understanding the worldwide epidemiologic profile of EV-D68 infection.

Socioeconomic inequalities in skilled attendance at birth and caesarean section rates in Myanmar 2015-2016: a cross-sectional study

OBJECTIVES

This study aims to assess inequalities in skilled birth attendance and utilisation of caesarean section (CS) in Myanmar.

STUDY DESIGN

Cross-sectional study design.

SETTING AND POPULATION

We used secondary data from the Myanmar Demographic and Health Survey (2015-2016). Our outcome measures of skilled birth attendance and utilisation of CS were taken from the most recent birth of interviewed women. Absolute and relative inequalities across several sociodemographic characteristics were assessed and evaluated by calculating rate differences, rate ratio and concentration indexes.

RESULTS

More than one-third (36%, 95% CI 32.5% to 39.4%) of women gave birth without a skilled birth attendant present at their most recent birth. 40.7% (95% CI 37.8% to 43.7%) gave birth in healthcare facilities, and the CS rate was 19.7% (95% CI 17.9% to 21.8%) for their most recent birth. The highest proportion of birth without a skilled provider was found in the hilly regions and rural residents, poorest and less educated women, and those with less than four antenatal care visits. Inequalities in birth without a skilled provider were observed across regions, place of residence, wealth quintile, education level and number of antenatal care taken. The highest rate of CS was found among plain regions and urban residents, richest women, more than secondary education, those with more than four antenatal care visits and in private health facilities. Inequalities in CS utilisation were observed across place of residence, wealth quintiles, education level, number of antenatal care taken and type of health facilities.

CONCLUSION

This study provides evidence regarding inequalities in maternal health service utilisation in Myanmar. Increasing maternal health service availability and accessibility, promoting quality of care and health education campaigns to increase maternal health services utilisation are recommended.

Association between Internet use and depressive symptoms among older adults in two regions of Myanmar: a cross-sectional study

BACKGROUND

Internet use has both positive and negative effects on mental health. However, few studies have examined the association between internet use and mental health among older adults in developing countries. This study aimed to investigate the association between Internet use and depressive symptoms among older adults in two regions of Myanmar.

METHODS

Data based on a visit to 1,200 older adults in urban and rural Myanmar were obtained through stratified random sampling using the cross-sectional baseline survey of the longitudinal study titled "Healthy and Active Aging in Myanmar." Our analysis included 1,186 participants. The dependent variable was depressive symptoms, and the 15-item version of the Geriatric Depression Scale (GDS) was used as a continuous variable; the higher the score, the more likely a person was to be depressed. Internet use (one of the questions about household property ownership) was used as an independent variable. After confirming the absence of multicollinearity, we adjusted for age, gender, educational background, activities of daily living, residential area, and frequency of meeting friends, and stratified by subjective economic status (above or below average). We also examined the interaction between internet use and subjective economic status. A linear regression analysis was performed.

RESULTS

Among the 1,186 participants included in the analysis (women: 59.5%; median age: 68 years old), 202 (17.0%) were Internet users (95% Confidential Interval [CI]: 0.15, 0.19), and they had significantly lower GDS scores than the participants who did not use the Internet (B: -1.59, 95% CI: -2.04, -1.13).GDS showed a negative association with Internet use even in the multivariate analysis (B: -0.95, 95% CI: -1.41, -0.50). However, the interaction term for GDS between Internet use and subjective economic status was not significantly associated (B: 0.43, 95% CI: -1.11, 1.98).

CONCLUSIONS

Internet use and depressive symptoms were associated especially among the older adults. However, there were no significant interaction between Internet use and subjective economic status for GDS.

Self-reported oral health-related quality of life and caries experiences of 5-year-old children in Mandalay, Myanmar

BACKGROUND

This study aimed to examine the impact of dental caries and other potential socio-demographic factors on the oral health-related quality of life (OHRQoL) of preschool children from Myanmar. This was done using the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5) as reported by both the children and their parents.

METHODS

A structured questionnaire was conducted to collect demographic information about the children and their caregivers, as well as socioeconomic data. The OHRQoL was assessed by interviewing the children and their parents using the Myanmar versions of SOHO-5c and SOHO-5p, respectively. Caries experience was assessed by two calibrated examiners and recorded using the dmft index. The Poisson regression model was adopted to investigate the association between OHRQoL and dental caries including socioeconomic factors.

RESULTS

A total of 454 pairs participated in the study. Among them, 64% of children and 70% of parents reported a negative impact on OHRQoL (with SOHO-5c and SOHO-5p scores exceeding 0). The mean score (SD) of the child self-report and parental version of the SOHO-5 was 1.86 (2.27) and 2.65 (3.13), respectively. Difficulties in eating and sleeping were the most commonly reported by both children and parents. The overall prevalence of dental caries was 87% (mean dmft score:5.59, SD:4.65). The final multivariate-adjusted model revealed that children with higher caries experiences were more likely to have lower OHRQoL for both child self-report (RR 4.38, 95% CI 3.16-6.14, p < 0.001) and parental report (RR 6.07, 95% CI 4.38-8.41, p < 0.001), respectively. A lower family income had a negative impact on the children's OHRQoL in child self-report (RR 1.59, 95% CI 1.26-2.04, p < 0.001) and parental report (RR 1.46, 95% CI 1.19-1.78, p < 0.001).

CONCLUSION

Two-thirds of the study children and their parents perceived the negative impact on children's OHRQoL. Higher caries experience and lower family income were associated with poorer OHRQoL of 5-year-old Myanmar children.

Prevalence and social determinants of depression: A cross-sectional survey of Myanmar migrant workers in Chiang Mai, Northern Thailand

BACKGROUND

Depression is a common mental disorder and the sixth leading cause of disability in Thailand. Chiang Mai has historically been a city of attraction for labour migration for Shan migrants from the adjacent Southern Shan State of Myanmar. Currently, only infectious diseases are screened during the pre-employment period. Prevention and early detection of noncommunicable diseases can improve a healthy workforce and reduce the healthcare burden on the host country. Therefore, we aimed to determine the prevalence of depression and associated factors.

METHODS

A cross-sectional survey was done among Myanmar migrant adults legally working in Chiang Mai, Thailand.

RESULTS

The final analysis included 360 participants and the prevalence of depression was 14.4%. Being female, duration of stay in Thailand of more than 10 years, co-residence with co-workers, and marginalisation pattern of acculturation were significant associated factors affecting depression in a multivariate regression analysis model.

CONCLUSION

Although the culture and dialect were not different between the host and country of origin, Myanmar migrant workers of Shan ethnicity suffered from depression. Our findings highlighted the importance of social determinants beyond common predictors of depression among migrants and the need for public health measures to promote migrants' integration into the host culture.

Can phone surveys be representative in low- and middle-income countries? An application to Myanmar

For decades, in-person data collection has been the standard modality for nationally and sub-nationally representative socio-economic survey data in low- and middle-income countries. As the COVID-19 pandemic rendered in-person surveys impossible and unethical, the urgent need for rapid monitoring necessitated researchers and statistical agencies to turn to phone surveys. However, apart from pandemic-related factors, a variety of other reasons can render large segments of a population inaccessible for in-person surveys, including political instability, climatic shocks, and remoteness. Such circumstances currently prevail in Myanmar, a country facing civil conflict and political instability since the February 2021 military takeover. Moreover, Myanmar routinely experiences extreme weather events and is characterized by numerous inaccessible and remote regions due to its mountainous geography. We describe a novel approach to sample design and statistical weighting that has been successfully applied in Myanmar to obtain nationally and sub-nationally representative phone survey data. We use quota sampling and entropy weighting to obtain a better geographical distribution compared to recent in-person survey efforts, including reaching respondents in areas of active conflict. Moreover, we minimize biases towards certain household and respondent characteristics that are usually present in phone surveys, for example towards well-educated or wealthy households, or towards men or household heads as respondents. Finally, due to the rapidly changing political and economic situation in Myanmar in 2022, the need for frequent and swift monitoring was critical. We carried out our phone survey over four quarters in 2022, interviewing more than 12,000 respondents in less than three months each survey. A survey of this scale and pace, though generally of much shorter duration than in-person interviews, could only be possible on the phone. Our study proves the feasibility of collecting nationally and sub nationally representative phone survey data using a non-representative sample frame, which is critical for rapid monitoring in any volatile economy.

Contraceptive method switching and discontinuation during the COVID-19 pandemic in Myanmar: findings from a longitudinal cohort study

The objective of this paper was to document contraceptive dynamics and associated correlates of contraceptive method switching and discontinuation in Myanmar during the COVID-19 pandemic. We conducted a secondary analysis of panel data collected between August 2020 and March 2021 among married women of reproductive age of households registered for a strategic purchasing project in Yangon. Statistical analysis included descriptive statistics, bivariate tests of association and adjusted log-Poisson models with generalised estimating equations to examine relative risks and 95% confidence intervals. Among the study sample, 28% of women reported method switching and 20% method discontinuation at least once during the study period. Difficulties accessing resupply/removal/insertion of contraception due to COVID-19 and method type at baseline were identified as correlates of method switching and discontinuation. Women who reported difficulty obtaining their method due to COVID-19 had an increased risk of method switching (RRadj: 1.85, 95%CI: 1.27, 2.71). Women who reported injectables as their initial contraceptive method at baseline had an increased risk of method switching (RRadj:1.71, 95%CI: 1.06, 2.76) and method discontinuation (RRadj: 2.16, 95%CI: 1.16, 4.02) compared to non-injectable users. As Myanmar evaluates its public health response to COVID-19, the country should consider innovative service delivery models that allow women to have sustained access to their method of choice during a health emergency. (211).

Dental caries in the Myanmar population: Findings from the first national oral health survey in 2016-2017

OBJECTIVES

This study aimed to investigate the dental caries status of indicator age groups as mentioned in the WHO pathfinder methodology, compare caries experiences among those age groups according to gender and geographical location, and assess the association between dental caries and related risk factors in primary and permanent dentition.

METHODS

A sample of 5928 participants aged 6, 12, 15-18, 35-44 and 60-74 years were recruited from 21 selected townships in the first Myanmar national oral health survey. Clinical oral examinations and questionnaire-based surveys were conducted from December 2016 to January 2017.

RESULTS

The prevalence of dental caries in primary teeth was 85.3% with a mean dmft of 5.7 at age 6 years. The prevalence of dental caries in permanent teeth and mean DMFT were 36.5% and 0.8 at 12 years, 43.8% and 1.1 at 15-18 years, 64.7% and 3.0 at 35-44 years, and 93.6% and 11.5 at 60-74 years. Missing teeth were higher in 60-74-year-olds, with 27 participants being fully edentulous. There were significant differences in caries experiences between males and females aged 15-18, 35-44 and 60-74 years. In the adjusted logistic regression, consumption of sweets or candies three times or more a day showed significantly higher risks of dental caries in primary teeth. Age, gender, consumption of sweets or candies and consumption of sweet drinks were associated factors for dental caries in permanent teeth.

CONCLUSION

The findings from the first national oral health survey indicate that caries in primary teeth is an important oral health problem for Myanmar children. Tooth loss was also found to be a concern in the aging population. National oral health policies and strategies need to be developed to promote awareness and understanding of oral health, in particular the role of risk factors such as sugary foods and drinks in tooth decay in children and adults.

Safely managed sanitation practice and childhood stunting among under five years old children in Myanmar

In 2020, 149 million children under the age of five were estimated to be stunted globally. Around half of deaths among children under 5 years of age are related to under-nutrition. Objective of this study is to determine the association between safely managed sanitation and childhood stunting among under-five years old children in Myanmar. This cross-sectional analytical study was conducted in 16 townships across three regions and five states in Myanmar. Multiple logistic regressions analysis was performed to determine the associations. This study found that 327 (27.09%) under-five children were stunted among a total of 1207 children in Myanmar. Children with unsafely managed sanitation were 2.88 times more likely to be stunting compared with children who access to safely managed sanitation services (AOR = 2.88, 95% CI: 2.16 to 3.85; p-value <0.01). Other associated factors for childhood stunting were needs 1-15 minutes for water collection (AOR = 2.07, 95% CI: 1.46 to 2.94; p-value <0.01), 15-60 minutes for water collection times (AOR = 1.55, 95% CI: 1.08 to 2.23; p-value 0.02), improper waste water disposal (AOR = 1.99, 95% CI: 1.47 to 2.70; p-value <0.01), boys children (AOR = 4.49, 95% CI: 3.30 to 6.12; p-value <0.01), did not take vitamin A supplements(AOR = 1.64, 95% CI: 1.22 to 2.20; p-value <0.01), mothers height shorter than 153.4cm (AOR = 1.94, 95% CI: 1.45 to 2.58; p-value <0.01), and the lower minimal diet diversity (AOR = 1.47, 95% CI: 1.08 to 2.01; p-value 0.02). More access to safely managed sanitation facilities, technical sharing for proper waste water disposal, promoting household water supply system, health promotion for children's diet eating pattern, and regular support for Vitamin A supplementation are critical to reduce childhood stunting among children under the age of five in Myanmar.

A systematic review of neglected tropical diseases (NTDs) in Myanmar

BACKGROUND

Neglected tropical diseases (NTDs) affect most impoverished communities in developing countries, like Myanmar in Southeast Asia. NTDs have been understudied and underreported in Myanmar.

METHODS

A systematic review of published and grey literature (1900-2023) on neglected tropical diseases (NTDs) in Myanmar was conducted. The literature search included five international databases: PubMed, EMBASE, Ovid Global Health, and Web of Science Core Collection and one national database: the Myanmar Central Biomedical Library (locally published papers and grey literature). The selection criteria included articles with all types of study designs of current or previous infections conducted in humans, that reported NTDs, recognised by WHO, US CDC, and listed in PLoS NTDs. We included melioidosis and rickettsioses which we consider also meet the definition of an NTD.

RESULTS

A total of 5941 records were retrieved and screened, of which, 672 (11%) met the selection criteria and were included in this review. Of the included articles, 449 (65%) were published after 2000 and 369 (55%) were from two regions (Yangon and Mandalay) of Myanmar. Of the included articles, 238 (35%) reported bacterial NTDs, 212 (32%) viral NTDs, 153 (23%) helminth NTDs, 25 (4%) protozoal NTDs and 39 (6%) reported more than one aetiology. Based on reported frequency in descending order, the bacterial NTDs were leprosy, Escherichia coli enteritis, salmonellosis, cholera, shigellosis, melioidosis, leptospirosis and rickettsioses; the viral NTDs were dengue, chikungunya and Japanese encephalitis virus (JEV) infection; the protozoal NTDs were amoebiasis, giardiasis and leishmaniasis, and the helminth NTDs were ascariasis, trichuriasis, hookworm disease, filariasis and strongyloidiasis.

CONCLUSION

This review summarises NTDs reported in Myanmar over the past 100 years. The findings suggest that most NTDs are likely to be under reported, especially from the majority of the country which is far from academic centres. Research capacity building together with strengthening of laboratory systems would lead to better understanding of the true burden of NTDs in Myanmar.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42018092627.

Successful elimination of falciparum malaria following the introduction of community-based health workers in Eastern Myanmar: A retrospective analysis

BACKGROUND

Myanmar has a large majority of all malaria in the Greater Mekong Subregion. In the past decade, substantial progress was made in malaria control. The residual burden of malaria is in remote areas where currently recommended malaria elimination approaches are generally not feasible. In such hard-to-reach communities in Mon state, East Myanmar, Medical Action Myanmar introduced community health workers (CHWs) to deliver early diagnosis and treatment for malaria. We conducted a retrospective analysis to assess the impact of this intervention.

METHODS AND FINDINGS

This retrospective analysis involved data collected routinely from a CHW programme in Mon state conducted between 2011 and 2018. A network of 172 CHWs serving a population of 236,340 was deployed. These CHWs carried out 260,201 malaria rapid diagnostic tests (RDTs) to investigate patients with acute febrile illness. The median blood examination rate was 1.33%; interquartile range (IQR) (0.38 to 3.48%); 95% CI [1.28%, 1.36%] per month. The changes in malaria incidence and prevalence in patients presenting with fever were assessed using negative binomial regression mixed effects models fitted to the observed data. The incidence of Plasmodium falciparum malaria (including mixed infections) declined by 70%; 95% CI [65%, 75%]; p < 0.001 for each year of CHW operation. The incidence of P. vivax malaria declined by 56%; 95% CI [50%, 62%]; p < 0.001 per year. Malaria RDT positivity rates for P. falciparum and P. vivax declined by 69%; 95% CI [62%, 75%]; p < 0.001 and 53%; 95% CI [47%, 59%]; p < 0.001 per year, respectively. Between 2017 and 2018, only 1 imported P. falciparum case was detected in 54,961 RDTs. The main limitations of the study are use of retrospective data with possible unidentified confounders and uncharacterised population movement.

CONCLUSIONS

The introduction of CHWs providing community-based malaria diagnosis and treatment and basic health care services in remote communities in Mon state was associated with a substantial reduction in malaria. Within 6 years, P. falciparum was eliminated and the incidence of P. vivax fell markedly.

Treatment-seeking behaviours of malaria patients versus non-malaria febrile patients along China-Myanmar border

BACKGROUND

Appropriate malaria treatment-seeking behaviour (TSB) is critical for timely detecting malaria, prompt treatment, and prevention of onward transmission of the disease in a community. This study aimed to compare treatment-seeking behaviours between malaria patients and non-malaria febrile patients, and to analyse the factors associated with appropriate TSB along the China-Myanmar border.

METHODS

A cross-sectional study was carried out to investigate the appropriate TSB of microscopy-confirmed malaria patients versus non-malaria febrile (NMF) patients. An unconditional logistic regression analysis (LRA) was used to identify factors associated with appropriate TSB.

RESULTS

Among 223 malaria patients and 446 NMF patients, 129 (57.8%) of the malaria patients versus 163 (36.5%) of the NMF patients firstly sought treatment in health facilities without laboratory testing for malaria (P < 0.0001). A total of 85(38.1%) of the malaria patients versus 278 (62.3%) of the NMF patients had appropriate TSB, namely, seeking treatment in health facilities with laboratory testing for malaria within 48 h (P < 0.0001). Multivariate LRA identified that the malaria patients with Chinese nationality had less appropriate TSB compared to those with other nationalities (adjusted odds ratio [AOR]: 0.21, 95% confidence interval CI 0.07-0.68, P = 0.0097), and malaria patients residing in urban areas had more appropriate TSB compared to those living in rural areas (AOR: 2.16, 95%CI 1.06-4.39, P = 0.0337).

CONCLUSIONS

TSB was not appropriate in malaria patients. Chinese citizenship and rural residence were two independent factors associated with inappropriate malaria TSB. It is urgently necessary to improve appropriate malaria TSB through effective campaigns of information, education, and communication for malaria control in Myanmar and preventing reestablishment of malaria transmission in Yunnan, China.

Interventions for promoting patients' adherence to 14-day primaquine treatment in a highly malaria-endemic township in Myanmar: a qualitative study among key stakeholders

BACKGROUND

Plasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients' commitment to PQ treatment in a highly malaria-endemic township in Myanmar.

METHODS

A qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis.

RESULTS

Responsible individuals from different levels of the Myanmar National Malaria Control Programme participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community's malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted.

CONCLUSION

In rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

The assessment of geriatric malnutrition, geriatric depression and associated co-morbidities among forcibly displaced Myanmar nationals in Bangladesh

OBJECTIVE

To assess the nutritional status and depression of the elderly forcibly displaced Myanmar nationals (FDMN) in Bangladesh and determine the associated factors of geriatric depression (GD).

DESIGN

This was a community-based, cross-sectional study among elderly FDMN. The Mini Nutritional Assessment Short-Form (MNA@-SF) and Geriatric Depression Scale Short-Form (GDS-15 SF) were used to determine malnutrition and GD, respectively.

SETTING

The study was conducted between November 2021 and March 2022 in Kutupalong Refugee Camp, Cox's Bazar, Bangladesh.

PARTICIPANTS

The study participants were elderly FDMN aged ≥ 60 years (n 430).

RESULTS

The mean age and BMI were 71·7(±7·8) years and 21·94(±2·6) kg/m2, respectively. There was a high prevalence of self-reported diabetes mellitus (32·1 %), hypertension (26·7 %), hypotension (20 %), skin diseases (28·4 %) and chronic obstructive pulmonary disease (16·5 %). The prevalence of malnutrition was 25·3 %, and another 29·1 % were at risk. The prevalence of GD was 57·9 %, and co-occurrences of GD and malnutrition were seen in 17·5 % of participants. GD was significantly higher among elderly people with malnutrition (adjusted OR, AOR = 1·71, 95 % CI: 1·01, 2·89). FDMN aged ≥ 80 years were at higher risk of GD (AOR = 1·84, 95 % CI: 1·01, 3·37), and having fewer than five members in the household was an independent predictor of GD. Diabetes mellitus (AOR = 1·95, 95 % CI: 1·24, 3·08) and hypotension (AOR = 2·17, 95 % CI: 1·25, 2·78) were also significantly associated with an increased risk of GD.

CONCLUSION

A high prevalence of GD and malnutrition was observed among elderly FDMN in Bangladesh. The agencies working in Cox's Bazar should focus on geriatric malnutrition and GD for the improvement of the health situation of FDMN in Bangladesh.

'Forest malaria' in Myanmar? Tracking transmission landscapes in a diversity of environments

BACKGROUND

In the Greater Mekong Subregion, case-control studies and national-level analyses have shown an association between malaria transmission and forest activities. The term 'forest malaria' hides the diversity of ecosystems in the GMS, which likely do not share a uniform malaria risk. To reach malaria elimination goals, it is crucial to document accurately (both spatially and temporally) the influence of environmental factors on malaria to improve resource allocation and policy planning within given areas. The aim of this ecological study is to characterize the association between malaria dynamics and detailed ecological environments determined at village level over a period of several years in Kayin State, Myanmar.

METHODS

We characterized malaria incidence profiles at village scale based on intra- and inter-annual variations in amplitude, seasonality, and trend over 4 years (2016-2020). Environment was described independently of village localization by overlaying a 2-km hexagonal grid over the region. Specifically, hierarchical classification on principal components, using remote sensing data of high spatial resolution, was used to assign a landscape and a climate type to each grid cell. We used conditional inference trees and random forests to study the association between the malaria incidence profile of each village, climate and landscape. Finally, we constructed eco-epidemiological zones to stratify and map malaria risk in the region by summarizing incidence and environment association information.

RESULTS

We identified a high diversity of landscapes (n = 19) corresponding to a gradient from pristine to highly anthropogenically modified landscapes. Within this diversity of landscapes, only three were associated with malaria-affected profiles. These landscapes were composed of a mosaic of dense and sparse forest fragmented by small agricultural patches. A single climate with moderate rainfall and a temperature range suitable for mosquito presence was also associated with malaria-affected profiles. Based on these environmental associations, we identified three eco-epidemiological zones marked by later persistence of Plasmodium falciparum, high Plasmodium vivax incidence after 2018, or a seasonality pattern in the rainy season.

CONCLUSIONS

The term forest malaria covers a multitude of contexts of malaria persistence, dynamics and populations at risk. Intervention planning and surveillance could benefit from consideration of the diversity of landscapes to focus on those specifically associated with malaria transmission.

Severe Falciparum and Vivax Malaria on the Thailand-Myanmar Border: A Review of 1503 Cases

BACKGROUND

The northwestern border of Thailand is an area of low seasonal malaria transmission. Until recent successful malaria elimination activities, malaria was a major cause of disease and death. Historically the incidences of symptomatic Plasmodium falciparum and Plasmodium vivax malaria were approximately similar.

METHODS

All malaria cases managed in the Shoklo Malaria Research Unit along the Thailand-Myanmar border between 2000 and 2016 were reviewed.

RESULTS

There were 80 841 consultations for symptomatic P. vivax and 94 467 for symptomatic P. falciparum malaria. Overall, 4844 (5.1%) patients with P. falciparum malaria were admitted to field hospitals, of whom 66 died, compared with 278 (0.34%) with P. vivax malaria, of whom 4 died (3 had diagnoses of sepsis, so the contribution of malaria to their fatal outcomes is uncertain). Applying the 2015 World Health Organization severe malaria criteria, 68 of 80 841 P. vivax admissions (0.08%) and 1482 of 94 467 P. falciparum admissions (1.6%) were classified as severe. Overall, patients with P. falciparum malaria were 15 (95% confidence interval, 13.2-16.8) times more likely than those with P. vivax malaria to require hospital admission, 19 (14.6-23.8) times more likely to develop severe malaria, and ≥14 (5.1-38.7) times more likely to die.

CONCLUSIONS

In this area, both P. falciparum and P. vivax infections were important causes of hospitalization, but life-threatening P. vivax illness was rare.

Prevalence of Soil-Transmitted Helminths at Baseline and after Albendazole Treatment in the School-Age Children of Forcibly Displaced Myanmar Nationals in Bangladesh

The forcibly displaced Myanmar nationals (FDMNs) known as Rohingya refugees are the largest group of stateless individuals globally. According to the emergencies humanitarian actors at the United Nations Office for the Coordination of Humanitarian Affairs, the worldwide refugee crisis involving FDMNs is intensifying at the fastest rate in history. Growing public health demands are being exacerbated by current difficulties in addressing poor access to health services, severe food shortages, and a lack of adequate housing. Infectious diseases constitute a major public health emergency in this vulnerable population. A study was carried out in FDMN children to investigate common soil-transmitted helminth (STH) infection at the time of enrollment and prospectively followed-up to 12 months after 2 doses albendazole treatment. At baseline, the prevalence of STH infection with at least one species was found to be 91.7% and 87.3% for Kato-Katz (KK) and quantitative polymerase chain reaction (qPCR) methods, respectively. Similarly, for follow-up children, the overall infection rate was 95.3% and 91.5%, respectively. Trichuris trichiura was the most predominant STH infection by both KK (baseline 87%, follow-up 89.1%) and qPCR (baseline 77.5%, follow-up 82.9%). The overall prevalence of stunting in the children was 37.8% at baseline and rose to 51.3% at 12 months. Alpha-1 antitrypsin (r = 0.13, P = 0.01) and myeloperoxidase (r = 0.12, P = 0.01) levels showed a positive correlation with Aascaris lumbricoides egg count per gram at baseline. An in-depth investigation is urgently needed to identify the underlying protective measures and the root cause of STH infections to improve the health of FDMN children.

Maternal Factors in Relation to Early Childhood Caries Among Preschool Children in Myanmar

A cross-sectional study was conducted among 3- to 5-year-old preschool children in Yangon City in 2016-2017 to investigate the association between their caries experience and maternal factors. Children's oral examination and questionnaire surveys to their mothers were conducted. Children's caries prevalence was 82.9% with mean dmft of 6.4 ± 4.9. Mean oral health knowledge score of their mothers was 8.5 ± 2.8. Mother's educational level and oral health knowledge were significant predictors of childhood caries. Third- or later-born children were twice more likely to have dental caries than first-born children (P = .022). Mother's regular dental check-up resulted in significantly lower odds ratios for caries development in her child. Children's caries experience was high and mother's oral health knowledge regarding the importance of primary teeth was unsatisfactory. It is, therefore, necessary to improve awareness and attentiveness for prevention of childhood caries among parents and guardians in Myanmar.

Genomic characterization of cocirculating Corynebacterium diphtheriae and non-diphtheritic Corynebacterium species among forcibly displaced Myanmar nationals, 2017-2019

Respiratory diphtheria is a serious infection caused by toxigenic Corynebacterium diphtheriae, and disease transmission mainly occurs through respiratory droplets. Between 2017 and 2019, a large diphtheria outbreak among forcibly displaced Myanmar nationals densely settled in Bangladesh was investigated. Here we utilized whole-genome sequencing (WGS) to characterize recovered isolates of C. diphtheriae and two co-circulating non-diphtheritic Corynebacterium (NDC) species - C. pseudodiphtheriticum and C. propinquum. C. diphtheriae isolates recovered from all 53 positive cases in this study were identified as toxigenic biovar mitis, exhibiting intermediate resistance to penicillin, and formed four phylogenetic clusters circulating among multiple refugee camps. Additional sequenced isolates collected from two patients showed co-colonization with non-toxigenic C. diphtheriae biovar gravis, one of which exhibited decreased susceptibility to the first-line antibiotics and harboured a novel 23-kb multidrug resistance plasmid. Results of phylogenetic reconstruction and virulence-related gene contents of the recovered NDC isolates indicated they were likely commensal organisms, though 80.4 %(45/56) were not susceptible to erythromycin, and most showed high minimum inhibition concentrations against azithromycin. These results demonstrate the high resolution with which WGS can aid molecular investigation of diphtheria outbreaks, through the quantification of bacterial genetic relatedness, as well as the detection of virulence factors and antibiotic resistance markers among case isolates.

Socioeconomic, behavioral, and psychological factors related to oral health in Myanmar: A cross-sectional study

OBJECTIVES

This study aims to evaluate the effects of socioeconomic, behavioral, and psychological factors on oral health status and oral health-related quality of life in Myanmar adults.

METHODS

Data were from a convenience sample of Myanmar adults who are from a township health center in Yangon city. Face-to-face interviews using a paper-based questionnaire in the Myanmar language and clinical oral examinations were performed at the health center. Mann-Whitney U test and linear regressions were used to assess the association of socio-demographic, behavioral, and psychological variables with oral health outcomes.

RESULTS

In socio-demographic variables, significant associations were observed in individual income with periodontal pocket and OHIP-14, and history of COVID-19 infection with OHIP-14. However, there were no associations between behavioral factors and oral health outcomes. After adjustment for sex, age, educational level, and individual income, the depression subscale was statistically significant with the number of present teeth, decayed teeth, decayed, missing, and filled teeth, and OHIP-14. The anxiety subscale remained significant with periodontal pocket, but no stress subscale was associated with oral health outcomes.

CONCLUSION

The experiences of oral health status were high, and the oral health-related quality of life was unfavorable in Myanmar adults. A large proportion of them suffers from psychological distress. Additionally, individuals with lower income and who experienced a history of COVID-19 infection were susceptible to poor oral health-related quality of life. Psychological distress indicates a higher risk for oral health problems in Myanmar adults.

Lifestyle Risk Behaviours and Nutritional Status Associated with Mental Health Problems among Myanmar Adolescents: Secondary Analysis of a Nationwide 2016 School Survey

Engaging in unhealthy lifestyles may be considered a risk factor for mental health problems, but there is limited evidence. This study aimed to identify the relationship between unhealthy lifestyles and mental health problems among Myanmar school-going adolescents. Global School Based Student Health Survey (GSHS) data from 2838 school-going adolescents from Myanmar were analysed. Bivariable and multivariable logistic regression analyses were applied. After adjusting for confounding variables, adolescents who were seated for more than three hours per day had higher odds of loneliness, anxiety-induced sleep disturbance, suicide ideation, and suicide attempts compared to others. Moreover, students who ate fruit less than one time per day were more likely to experience anxiety-induced sleep disturbance and suicidal ideation. Being a current drinker was significantly associated with suicidal ideation and attempt. Obese students were more likely to feel lonely compared to normal weight students. Our study indicates there is a strong association between unhealthy lifestyle behaviours and mental health problems among school adolescents in Myanmar.

Determinants of correct knowledge on tuberculosis transmission and self-reported tuberculosis prevalence among general population aged 15-49 years in Myanmar

INTRODUCTION

Myanmar has been identified as one of the tuberculosis (TB) high-burden countries and having an understanding of TB transmission is vital for personal infection prevention as well as preventing transmission to others. This study aimed to identify the determinants of correct knowledge on TB transmission and self-reported TB prevalence among general population in Myanmar.

METHODS

This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015-16. The determinants of correct knowledge on TB transmission mode and self-reported prevalence of TB were assessed using multivariable logistic regression models. Weighted estimates were provided in all analyses to account for the multistage sampling design used in the survey.

RESULTS

Among the respondents, less than half (44.6%, 95% CI: 43.9, 45.4) had the overall correct knowledge about TB transmission and misconceptions. Older age group, female gender, those with higher education and higher socioeconomic status, and exposed to mass media at least once a week, residents from the delta and lowland region or plain areas were more likely to have correct knowledge about TB transmission. The overall prevalence rate of self-reported TB was 2.6% (95%CI: 2.4, 2.9) and the prevalence was higher among older age group and males.

CONCLUSION

Our study highlights the need for targeted efforts to improve awareness and understanding of TB transmission among general population in Myanmar. The study suggests the implementation of appropriate, innovative, and comprehensive targeted TB education and communication strategies.

Burden of Chikungunya Virus Infection during an Outbreak in Myanmar

Chikungunya virus (CHIKV) infection is a re-emerging arboviral disease with no approved vaccine, although numerous options are in development. Before vaccine implementation, disease burden, affected age group, and hospitalization rate information should be documented. In 2019, a sizeable outbreak of the East Central South African genotype of CHIKV occurred in Myanmar, and during this period, a cross-sectional study was conducted in two regions, Mandalay and Yangon, to examine the molecular and seropositivity rate of the CHIKV infection. The participants (1124) included dengue-suspected pediatric patients, blood donors, and healthy volunteers, who were assessed using molecular assays (quantitative real-time RT-PCR), serological tests (anti-CHIKV IgM capture and IgG indirect enzyme-linked immunosorbent assays), and neutralization tests. The tests confirmed the following positivity rates: 11.3% (127/1124) for the molecular assay, 12.4% (139/1124) for the anti-CHIKV IgM Ab, 44.5% (500/1124) for the anti-CHIKV IgG Ab, and 46.3% (520/1124) for the CHIKV neutralizing Ab. The highest rate for the molecular test occurred with the dengue-suspected pediatric patients. The seroprevalence rate through natural infection was higher in the healthy volunteers and blood donors than that in the pediatric patients. The results of this study will help stakeholders determine the criteria for choosing appropriate recipients when a CHIKV vaccine is introduced in Myanmar.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017)

OBJECTIVE

The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar.

DESIGN

Repeated cross-sectional surveys in three states of Myanmar.

SETTING

Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta).

PARTICIPANTS

From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations.

RESULTS

Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting.

CONCLUSIONS

Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Standard- and large-sized eggs of Trichuris trichiura in the feces of schoolchildren in the Yangon Region, Myanmar: Morphological and molecular analyses

Standard- and large-sized eggs of Trichuris trichiura were found in the feces of schoolchildren in Yangon, Myanmar during epidemiological surveys and mass deworming with albendazole in 2017-2019. The standard-sized eggs were identified as those of T. trichiura, but it was necessary to exclude the possibility of the large-sized eggs belonging to Trichuris vulpis, a dog whipworm. We conducted morphological and molecular studies to determine the species of the 2 types of Trichuris eggs. Individual eggs of both sizes were isolated from Kato-Katz fecal smears (n=20) and mechanically destroyed using a 23G injection needle. Nuclear DNA was extracted, and the 18S rRNA region was sequenced in 15 standard-sized eggs and 15 large-sized eggs. The average size of standard-sized eggs (T. trichiura) was 55.2×26.1 μm (range: 51.7-57.6×21.3-28.0 μm; n=97), whereas the size of large-sized eggs was 69.3×32.0 μm (range: 65.1-76.4×30.1-34.5 μm; n=20), slightly smaller than the known size of T. vulpis. Regarding standard-sized eggs, the 18S rRNA nucleotide sequences exhibited 100% homology with T. trichiura deposited in GenBank and 88.6-90.5% homology with T. vulpis. Regarding large-sized eggs, the nucleotide sequences showed 99.8-100% homology with T. trichiura in GenBank and 89.6-90.7% homology with T. vulpis. Both standard- and large-sized eggs of Trichuris spp. found in Myanmar schoolchildren during 2017-2019 were morphologically and molecularly confirmed to belong to T. trichiura. The conversion of eggs from smaller to large sizes might be due to anthelmintic treatments with albendazole.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study

BACKGROUND

The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known.

METHODS

We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition.

RESULTS

Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU.

CONCLUSIONS

Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Coinfection and circulation of chikungunya virus and dengue virus in pediatric patients in Myanmar, 2019

Myanmar is an endemic country for arboviruses, and outbreaks occur frequently. A cross-sectional analytical study was conducted during the peak season of the chikungunya virus (CHIKV) outbreak in 2019. A total of 201 patients with acute febrile illness who were admitted to the 550-bedded Mandalay Children Hospital in Myanmar were enrolled in the study, and virus isolation, serological tests, and molecular tests for the dengue virus (DENV) and CHIKV were performed for all samples. Out of 201 patients, 71 (35.3%) were only DENV-infected, 30 (14.9%) were only CHIKV-infected and 59 (29.4%) were coinfected with DENV and CHIKV. The viremia levels of the DENV- and CHIKV- mono-infected groups were significantly higher than those of the group coinfected with DENV and CHIKV. Genotype I of DENV-1, genotypes I and III of DENV-3, genotype I of DENV-4 and the East/Central/South African genotype of CHIKV were co-circulating during the study period. Two novel epistatic mutations of CHIKV (E1:K211E and E2:V264A) were noted. This study highlighted that there were many coinfection cases during the outbreak and that the co-circulation of both viruses in DENV-endemic regions warrants effective monitoring of these emerging pathogens via comprehensive surveillance to facilitate the implementation of effective control measures.

The COVID-19 third wave in Myanmar following the military coup

Background: COVID-19 seriously hit Myanmar between June and August 2021, a few months after the military coup, though the first and second waves in 2020 were managed effectively by the government. People in Myanmar experienced serious consequences of the COVID-19 pandemic precipitated by the disorganized health system under the military junta. This study aimed to analyse the situation of COVID-19 occurrence and death proportions during its third wave in Myanmar. Methods: An online survey was conducted using a Google form. People with the symptoms of COVID-19 and those who died from COVID-19 between June and August 2021 were eligible to participate. The Google form was extracted into an Excel datasheet and analysed using Stata v16.1. Results: Among the 29,171 participants, 76.7% were over 30 years old and 56.4% were female. A majority of participants were from highly populated regions: Yangon (17,220; 59%) (Business capital), Mandalay (3,740; 12.8%) and Sagaing (1,546; 5.3%). Participants sought health care from telegram/other online services (34%), home care by health care providers (22%), private clinics (13%) and public hospitals run under the military junta (5%). Overall, 15% of participants died, of which, 72% occurred at home and 17% at public hospitals. Significantly higher proportions of deaths were seen among participants over 60 years than other age groups and males (p<0.001). Death proportions at different weeks from June to August 2021 ranged from 12.4% to 17.3%, much higher than the military junta's reports. Overall, 25% of participants received oxygen therapy. Conclusions: Death proportions in different weeks were consistently over 12%. The majority of participants received tele/online and home treatment services. Most deaths occurred at home. Findings indicated the high COVID-19 case fatality rates with limited access to public hospital care during the third wave. The data from this study suggest that the outcomes were adversely impacted by the military coup.

The Association between Betel Quid Chewing and Metabolic Syndrome Among Urban Adults in Mandalay District of Myanmar

Background

As the prevalence of metabolic syndrome, obesity and diabetes increase worldwide, the need to identify modifiable lifestyle risk factors also increases, especially those that may be relatively unique to a specific population. To explore a possible association between betel quid chewing and metabolic syndrome, a community-based cross-sectional study was conducted.

Methodology

Three hundred ninety-one (391) adults were interviewed and the following parameters were measured: triglycerides, HDL-cholesterol, glucose, waist circumference, body mass index and blood pressure. Multiple logistic regression was used to determine the association between betel quid chewing and metabolic syndrome while controlling for confounders.

Results

The prevalence of metabolic syndrome was similar in chewers and non-chewers, 50% and 49%, respectively. After controlling for other factors, development of metabolic syndrome was positively associated with number of betel quids chewed per day, age greater than 40 years, and a positive family history of hypertension and diabetes. Regarding the duration of betel chewing, when analyzed by sex, the risk was doubled in men compared to non-chewers (OR 2.15; 95% CI = 1.21, 3.84). As a result, a man chewing more than 10 pieces (OR 2.49; 95% CI = 1.36, 4.57) of betel quids per day for more than 10 years had a two-fold increased chance of developing the metabolic syndrome.

Conclusions

Frequency and duration of betel quid chewing may represent a behavioral lifestyle target for approaches to reduce the incidence of metabolic syndrome.

Nutritional and dietary diversity status of under-5 children and adolescent girls among forcibly displaced Myanmar nationals living in Bhasan Char relocation camp, Bangladesh: a cross-sectional survey

OBJECTIVE

To generate baseline evidence regarding the nutritional and dietary diversity status of under-5 children and adolescent girls among forcibly displaced Myanmar nationals (FDMN) relocated to Bhasan Char relocation camp of Bangladesh.

DESIGN

Cross-sectional survey.

SETTING

Bhasan Char relocation camp, Bangladesh, 7 November 2021-12 November 2021.

PARTICIPANTS

299 under-5 children (both male and female) and 248 adolescent girls (11-17 years) were surveyed.

OUTCOME MEASURES

Anthropometric indices and nutritional status of the study participants.

RESULTS

Nearly 17% of the adolescent girls were suffering from severe thinness/thinness, while 5% were overweight/obese. Severe thinness was more prevalent (2% vs 3.9%) in older adolescents (15-17 years) than their younger counterparts (11-14 years). The prevalence of severe stunting and stunting in adolescents were 14% (95% CI 11.21 to 16.87%) and 29% (95% CI 25.93 to 31.59%), respectively. One-third of the surveyed under-5 children were severely (8.50% (95% CI 5.60 to 11.33%)) or moderately (23.08% (95% CI 20.24 to 25.90%)) stunted, 27% were either severely (4.43% (95% CI 1.60 to 7.27%)) or moderately (22.98% (95% CI 20.15 to 25.81%)) underweight and 12% were severely (1.21% (95% CI 0.00 to 4.04%)) or moderately (10.88% (95% CI 8.05 to 13.72%)) wasted. The prevalence of moderate and severe acute malnutrition in children was low. Surveyed adolescents took a mean of 3.10 (SD 1.03) of nine food groups and 25% (95% CI 22.97 to 28.64%) of under-5 children took minimum diversified diet. The survey respondents mostly consumed carbohydrate-based poorly diversified diets. Nutritional status of the participants did not show any statistically significant association to the dietary diversity status.

CONCLUSION

A significant number of surveyed under-5 children and adolescent girls of relocated FDMN living in Bhasan Char of Bangladesh were suffering from thinness, stunting, underweight and wasting. Dietary diversity was poor among the surveyed population.

Whole-Genome Analysis of Influenza A(H3N2) and B/Victoria Viruses Detected in Myanmar during the COVID-19 Pandemic in 2021

An influenza circulation was observed in Myanmar between October and November in 2021. Patients with symptoms of influenza-like illness were screened using rapid diagnostic test (RDT) kits, and 147/414 (35.5%) upper respiratory tract specimens presented positive results. All RDT-positive samples were screened by a commercial multiplex real-time polymerase chain reaction (RT-PCR) assay, and 30 samples positive for influenza A(H3N2) or B underwent further typing/subtyping for cycle threshold (Ct) value determination based on cycling probe RT-PCR. The majority of subtyped samples (n = 13) were influenza A(H3N2), while only three were B/Victoria. Clinical samples with low Ct values obtained by RT-PCR were used for whole-genome sequencing via next-generation sequencing technology. All collected viruses were distinct from the Southern Hemisphere vaccine strains of the corresponding season but matched with vaccines of the following season. Influenza A(H3N2) strains from Myanmar belonged to clade 2a.3 and shared the highest genetic proximity with Bahraini strains. B/Victoria viruses belonged to clade V1A.3a.2 and were genetically similar to Bangladeshi strains. This study highlights the importance of performing influenza virus surveillance with genetic characterization of the influenza virus in Myanmar, to contribute to global influenza surveillance during the COVID-19 pandemic.

Evaluation of Simplified HCV Diagnostics in HIV/HCV Co-Infected Patients in Myanmar

To evaluate a decentralised testing model and simplified treatment protocol of hepatitis C virus (HCV) infection to facilitate treatment scale-up in Myanmar, this prospective, observational study recruited HIV-HCV co-infected outpatients receiving sofosbuvir/daclatasvir in Yangon, Myanmar. The study examined the outcomes and factors associated with a sustained virological response (SVR). A decentralised "hub-and-spoke" testing model was evaluated where fingerstick capillary specimens were transported by taxi and processed centrally. The performance of the Xpert HCV VL Fingerstick Assay in detecting HCV RNA was compared to the local standard of care ( plasma HCV RNA collected by venepuncture). Between January 2019 and February 2020, 162 HCV RNA-positive individuals were identified; 154/162 (95%) initiated treatment, and 128/154 (84%) returned for their SVR12 visit. A SVR was achieved in 119/154 (77%) participants in the intent-to-treat population and 119/128 (93%) participants in the modified-intent-to-treat population. Individuals receiving an antiretroviral therapy were more likely to achieve a SVR (with an odds ratio (OR) of 7.16, 95% CI 1.03-49.50), while those with cirrhosis were less likely (OR: 0.26, 95% CI 0.07-0.88). The sensitivity of the Xpert HCV VL Fingerstick Assay was 99.4% (95% CI 96.7-100.0), and the specificity was 99.2% (95% CI 95.9-99.9). A simplified treatment protocol using a hub-and-spoke testing model of fingerstick capillary specimens can achieve an SVR rate in LMIC comparable to well-resourced high-income settings.

Associations between socioeconomic status and adherence to hypertension treatment among older adults in urban and rural areas in Myanmar: a cross-sectional study using baseline data from the JAGES in Myanmar prospective cohort study

OBJECTIVES

This study aims to investigate whether there is a differential association between socioeconomic status (SES) and adherence to hypertension medication among older adults in rural and urban areas in Myanmar and assess what type of SES is associated with a difference.

DESIGN

Cross-sectional study using baseline data from the Japan Gerontological Evaluation Study in Myanmar prospective cohort study. A multistage random sampling method was applied in each region.

SETTING

An urban and a rural area in Myanmar.

PARTICIPANTS

A total of 1200 older adults over 60 years old in Myanmar were randomly selected in 2018 (600 each from rural and urban areas). Of them, 573 had hypertension and were eligible for the analysis (urban: 317, rural: 256).

OUTCOME

Adherence to hypertension medication (yes/no) is the outcome of interest. Three types of SES (wealth, education and current employment status) were the independent variables.

RESULTS

We found that 21.5% of urban residents and 48.4% of rural residents were non-adherent in the study population. Poisson regression modelling stratified by area was performed to estimate the prevalence ratios (PRs) of not following treatment instructions. Demographic information and complications of hypertension were adjusted for in all models as possible confounders. In terms of SES, middle level of wealth compared with low level was significantly associated with poor adherence (PR 2.68, 95% CI 1.28 to 5.59) in the urban area, but education and employment status did not show similar associations. Lower education compared with middle/high school or higher was significantly associated with poor adherence in the rural area (no school: PR 3.22, 1.37-7.58; monastic: 3.42, 1.16-5.07; primary school: 2.41, 1.18-4.95), but wealth and income did not show similar associations.

CONCLUSIONS

SES and adherence to hypertension medication were differently associated among older adults in rural and urban areas in Myanmar. To ensure healthcare access to hypertension treatment for every citizen, the differential association between SES and adherence in urban/rural areas needs to be recognised.

Mother's Dietary Diversity and Underweight among Under-five Rural Children in Three Major Agro-climatic Zones, Myanmar

Background

Children's growth is essential to nutritional status and population health. In 2015, 18.9% of under-five children in Myanmar were underweight, and only 25% of 6-23-month-old children had the minimum dietary diversity (MDD).

Objectives

We conducted this study to assess the association between mother's dietary diversity score (DDS) and underweight among under-five children.

Materials and Methods

This study analyzed data from the "Livelihood and Food Security Survey," a cross-sectional study conducted in 2016 in rural areas in Chin State, Magway, and Ayeyarwady regions. It included 2029 under-five children and used underweight as an outcome variable. We calculated DDSs for mothers of under-five children using the MDD-women methodology. The prevalence of underweight and MDD were estimated. A multivariable binary logistic regression analysis estimated odds ratios and 95% confidence intervals (CIs).

Results

The overall prevalence of underweight was 26.3% (95% CI: 23.4, 29.3), and that of the mother with a MDD score was 29.2% (95% CI: 26.0, 32.8). Multivariable binary logistic regression analysis showed that the prevalence of underweight in children was higher if maternal MDD was not met (adjusted odds ratio = 1.41; 95% CI: 1.05, 1.89).

Conclusions

The children's age, types of toilets, and region were independent predictors of being underweight. Underweight among under-five children and diverse food consumption among their mothers are critical public health challenges in rural Myanmar that require urgent action. Nutrition education for rural communities should focus on feeding children with locally available diverse foods.

Prevalence and Subtype Distribution of Blastocystis Isolated from School-Aged Children in the Thai-Myanmar Border, Ratchaburi Province, Thailand

Blastocystis is one of the most common enteric protozoa that inhabits the intestinal tract of humans and different animals. Moreover, it has a worldwide geographic distribution. Its main mode of transmission is via the fecal-oral route. At present, 26 subtypes are widely distributed across both humans and animals. The current study aimed to determine the prevalence and subtype distribution of Blastocystis among school-aged children living on the Thai-Myanmar border, Ratchaburi province, Thailand. In total, 508 samples were collected from children at six schools. The prevalence of Blastocystis infection was amplified and sequenced in the 600 bp barcode region of the small-subunit ribosomal RNA (SSU rRNA). The overall prevalence of Blastocystis infection was 3.35% (17/508). ST3 (11/17) was the most predominant subtype, followed by ST1 (5/17) and ST2 (1/17). A phylogenetic tree was constructed based on the Tamura92+G+I model using the maximum-likelihood algorithm. Surprisingly, all sequences of the ST3-positive samples were closely correlated with the cattle-derived sequence. Meanwhile, all sequences of the Blastocystis ST1-positive samples were closely correlated with the human-derived sequence. Nevertheless, further studies should be conducted to validate the zoonotic transmission of Blastocystis. Based on our findings, personal hygiene and sanitation should be improved to promote better health in children in this area.

The public health response to an outbreak of border-spill malaria along China-Myanmar border

INTRODUCTION

Malaria importation can be caused by cross-border movement either of both people and anopheline mosquitoes. However, there still lacks robust evidence of imported malaria caused by Plasmodium spp. infected anopheles along international border areas (border-spill malaria). The objectives of this study were to confirm whether an outbreak of Plasmodium vivax malaria is border-spill malaria and assess the effects of China's public health response along China-Myanmar border.

METHODS

Epidemiological, parasitological and entomological investigations were conducted to investigate the outbreak of border-spill malaria. Meanwhile, comprehensive interventions were carried out to prevent further transmission and reintroduction of malaria.

RESULTS

Rapid diagnostic testing, microscopy and polymerase chain reaction were performed and the infections were confirmed as P. vivax. A total of 22 (9.21%) of 239 workers contracted P. vivax during the outbreak. Multivariate logistic regression analysis identified that the distance of worker shelters in China within 300 meters to the internally displaced person (IDP) camps in Myanmar was a risk factors associated with malaria infection (adjusted odds ratio 7.5920; 95% confidence interval, 2.6079-22.1013; P = 0.0002). After comprehensive interventions, malaria transmission was successfully interpreted and prevented at the project site till the completion of project on 14 January 2020, and recurrence of P. vivax malaria was not detected by the end of 2020.

CONCLUSION

This study provided robust evidence of border-spill malaria along China-Myanmar border. Malaria parasite reservoir and distance travelled by female anopheline mosquitoes are two determinants for border-spill malaria. The public health response to the outbreak indicates that the malaria surveillance and response system works well in preventing reintroduction of malaria. However, prevention of border-spill malaria is still a major challenge in the Yunnan border area, China.

Sylvatic Transmission of Chikungunya Virus among Nonhuman Primates in Myanmar

Nonhuman primates living in proximity to humans increase risks for sylvatic arbovirus transmission. We collected serum samples from nonhuman primates in Hlawga National Park near Yangon, Myanmar, and detected antibodies against chikungunya (33%) and Japanese encephalitis (4%) viruses. Buffer zones between primate and human communities might reduce cross-species arbovirus transmission.

Epidemiologic and genomic investigations of an unusual increase in Salmonella enterica serovar Paratyphi A infection among travelers returning from Myanmar in 2015

OBJECTIVES

An unusual increase in Salmonella enterica serovar Paratyphi A infection rate in Japanese travelers returning from Myanmar was observed in 2015.

METHODS

We analyzed epidemiologic data of returned travelers with enteric fever from 2005-2019. We also analyzed 193 Salmonella Paratyphi A isolates, including 121 isolates with published genomes.

RESULTS

Annual notification trends showed a rapid increase in Salmonella Paratyphi A infection in travelers returning from Myanmar in 2015: 2-4 cases/100,000 travelers in 2012-2014 and 13 cases/100,000 travelers in 2015 (P <0.001). The genomic analyses revealed that 11 Myanmar-related isolates in 2015 formed a tight cluster in clade 3 with a single nucleotide variant (SNV) distance of 0-11 (primarily 0-7), yielding a wider SNV range than outbreak-associated isolates from Cambodia in 2013 (0-6 SNVs) or China in 2010 (0-5 SNVs). Although all Cambodia-related isolates in 2013 harbored the wild-type gyrA sequence, all Myanmar-related isolates in 2015 had a single, identical mutation (Ser83Phe) in the gyrA gene.

CONCLUSION

The epidemiologic and molecular investigations suggested an increase in the infection rate with genetically closely related Salmonella Paratyphi A in travelers returning from Myanmar in 2015. Careful monitoring of the infection in Myanmar as an endemic country is warranted, considering the resumption of cross-border travel during the COVID-19 pandemic.

Seroprevalence of SARS-CoV-2 antibodies among Forcibly Displaced Myanmar Nationals in Cox's Bazar, Bangladesh 2020: a population-based cross-sectional study

OBJECTIVES

The study aimed to determine the seroprevalence, the fraction of asymptomatic infections, and risk factors of SARS-CoV-2 infections among the Forcibly Displaced Myanmar Nationals (FDMNs).

DESIGN

It was a population-based two-stage cross-sectional study at the level of households.

SETTING

The study was conducted in December 2020 among household members of the FDMN population living in the 34 camps of Ukhia and Teknaf Upazila of Cox's Bazar district in Bangladesh.

PARTICIPANTS

Among 860 697 FDMNs residing in 187 517 households, 3446 were recruited for the study. One individual aged 1 year or older was randomly selected from each targeted household.

PRIMARY AND SECONDARY OUTCOME MEASURES

Blood samples from respondents were tested for total antibodies for SARS-CoV-2 using Wantai ELISA kits, and later positive samples were validated by Kantaro kits.

RESULTS

More than half (55.3%) of the respondents were females, aged 23 median (IQR 14-35) years and more than half (58.4%) had no formal education. Overall, 2090 of 3446 study participants tested positive for SARS-CoV-2 antibody. The weighted and test adjusted seroprevalence (95% CI) was 48.3% (45.3% to 51.4%), which did not differ by the sexes. Children (aged 1-17 years) had a significantly lower seroprevalence 38.6% (95% CI 33.8% to 43.4%) compared with adults (58.1%, 95% CI 55.2% to 61.1%). Almost half (45.7%, 95% CI 41.9% to 49.5%) of seropositive individuals reported no relevant symptoms since March 2020. Antibody seroprevalence was higher in those with any comorbidity (57.8%, 95% CI 50.4% to 64.5%) than those without (47.2%, 95% CI 43.9% to 50.4%). Multivariate logistic regression analysis of all subjects identified increasing age and education as risk factors for seropositivity. In children (≤17 years), only age was significantly associated with the infection.

CONCLUSIONS

In December 2020, about half of the FDMNs had antibodies against SARS-CoV-2, including those who reported no history of symptoms. Periodic serosurveys are necessary to recommend appropriate public health measures to limit transmission.

'I Doubt Myself and Am Losing Everything I Have since COVID Came'-A Case Study of Mental Health and Coping Strategies among Undocumented Myanmar Migrant Workers in Thailand

Migrant populations have always been vulnerable to a high burden of social exclusion, mental disorders, physical illnesses, and economic crises. The current COVID-19 pandemic has further created a frantic plight among them, particularly for undocumented migrant workers in the global south. We have conducted a mixed method study among the undocumented Myanmar migrant workers (UMMWs) in Thailand to explore how the COVID-19 disruption has impacted their mental health and what coping strategies they have adopted. Following the onset of COVID-19 and the recent coup d'état in Myanmar, our current study is the first attempt to understand the mental health status and predicament of this neglected migrant group. A total of 398 UMMWs were included in the online survey, of which 23 participated in qualitative interviews. The major mental health issues reported by the study participants were depression, generalized anxiety disorder, frustration, stress, and panic disorders, while loss of employment, worries about the pandemic, social stigma, lack of access to healthcare, lockdown, and fear of detention were the predominant contributing factors. In response, we identified two key coping mechanisms: coping at a personal level (listening to music, playing online game, praying, and self-motivation) and coping at a social level (chatting with family and friends and visiting religious institutions). These findings point to the importance of policy and intervention programs aimed at upholding mental health at such humanitarian conditions. Sustainable institutional mental health care support and social integration for the migrant workers, irrespective of their legal status, should be ensured.

Evolutionary Dynamics of Whole-Genome Influenza A/H3N2 Viruses Isolated in Myanmar from 2015 to 2019

This study aimed to analyze the genetic and evolutionary characteristics of the influenza A/H3N2 viruses circulating in Myanmar from 2015 to 2019. Whole genomes from 79 virus isolates were amplified using real-time polymerase chain reaction and successfully sequenced using the Illumina iSeq100 platforms. Eight individual phylogenetic trees were retrieved for each segment along with those of the World Health Organization (WHO)-recommended Southern Hemisphere vaccine strains for the respective years. Based on the WHO clades classification, the A/H3N2 strains in Myanmar from 2015 to 2019 collectively belonged to clade 3c.2. These strains were further defined based on hemagglutinin substitutions as follows: clade 3C.2a (n = 39), 3C.2a1 (n = 2), and 3C.2a1b (n = 38). Genetic analysis revealed that the Myanmar strains differed from the Southern Hemisphere vaccine strains each year, indicating that the vaccine strains did not match the circulating strains. The highest rates of nucleotide substitution were estimated for hemagglutinin (3.37 × 10^-3 substitutions/site/year) and neuraminidase (2.89 × 10^-3 substitutions/site/year). The lowest rate was for non-structural protein segments (4.19 × 10^-5 substitutions/site/year). The substantial genetic diversity that was revealed improved phylogenetic classification. This information will be particularly relevant for improving vaccine strain selection.

Outdoor residual spraying for malaria vector-control in Kayin (Karen) state, Myanmar: A cluster randomized controlled trial

Outdoor and early biting by mosquitoes challenge the efficacy of bed nets and indoor residual spraying against malaria in the Greater Mekong Subregion. The objective of this study was to assess the efficacy of outdoor residual spraying (ORS) for malaria vector-control in this region. A cluster randomized controlled trial was conducted between July 2018 and April 2019 in twelve villages in Karen (Kayin) state, Myanmar. Villages were randomly assigned to receive either a single round of ORS with a capsule suspension of lambda-cyhalothrin for two days in October or no intervention (six villages per group). The primary endpoint was the biting rate of malaria mosquitoes assessed with human-landing catch and cow-baited trap collection methods, and was analyzed with a Bayesian multi-level model. In the intervention villages, the proportion of households located within the sprayed area ranged between 42 and 100% and the application rate ranged between 63 and 559 g of active ingredient per hectare. At baseline, the median of Anopheles biting rate estimates in the twelve villages was 2 bites per person per night (inter-quartile range [IQR] 0–5, range 0–48) indoors, 6 bites per person per night (IQR 2–16, range 0–342) outdoors and 206 bites per cow per night (IQR 83–380, range 19–1149) in the cow-baited trap. In intention-to-treat analysis, it was estimated that ORS reduced biting rate by 72% (95% confidence interval [CI] 63–79) from Month 0 to Month 3 and by 79% (95% CI 62–88) from Month 4 to Month 6, considering control villages as the reference. In conclusion, ORS rapidly reduces the biting rates of malaria mosquitoes in a Southeast Asian setting where the vectors bite mostly outdoors and at a time when people are not protected by mosquito bed nets.

The use of corporal punishment against children in Myanmar: An analysis of data from the 2015-2016 Myanmar Demographic and Health Survey

BACKGROUND

The corporal punishment of children is a significant public health concern; corporal punishment also violates children's rights and may have negative impacts on children's long-term health.

OBJECTIVE

This study investigates the prevalence of corporal punishment of children in Myanmar and associated factors.

PARTICIPANT AND SETTING

This study is a secondary data analysis of the 2015-2016 Myanmar Demographic and Health Survey (MDHS). The study targeted 13,235 (weighted) children between 2 and 14 years old.

METHODS

Corporal punishment of children by caregivers was assessed using six questions that utilized UNICEF's child disciplinary module. Multiple logistic regression analyses were carried out to identify associated factors.

RESULTS

Nearly half of the children in the study (44.5 %; 95 % confidence interval (CI): 42.60, 46.50) were found to have been subjected to corporal punishment, and the most common form of corporal punishment was "spanking, hitting, or slapping the child on the bottom with a bare hand" (29.1 %; 95 % CI: 27.53, 30.80). Multivariable analyses revealed that a child's sex, age, education level, location of residence, and number of family members; the primary caregiver's sex and attitude toward corporal punishment; and the family's socio-economic status were all factors significantly associated with corporal punishment. The prevalence of corporal punishment of children in Myanmar was high, and many significant predictors were identified.

CONCLUSION

The implementation of child protection policies and the promotion of nonviolent parenting methods should be conducted immediately to community members. Community education should particularly focus on uneducated caregivers and families with low socioeconomic status.

Spread of Carbapenem-Resistant Klebsiella pneumoniae Clinical Isolates Producing NDM-Type Metallo-β-Lactamase in Myanmar

A total of 38 isolates of carbapenem-resistant Klebsiella pneumoniae harboring blaNDM were obtained during surveillance of 10 hospitals in Myanmar. Of these 38 isolates, 19 (50%) harbored genes encoding 16S rRNA methylases, such as armA or rmtB. The K. pneumoniae strains tested belonged to 17 sequence types (STs), including the high-risk clonal lineages ST101 and ST147. The ST101 and ST147 isolates carried IncFII plasmids harboring blaNDM-5 and IncFIB(pQil) plasmids harboring blaNDM-1, respectively. These results indicate that IncFII plasmids harboring blaNDM-5 and IncFIB(pQil) plasmids harboring blaNDM-1 have been spreading in K. pneumoniae ST101 and ST147 isolates, respectively, in Myanmar. IMPORTANCE The emergence of carbapenem-resistant K. pneumoniae has become a serious problem in medical settings worldwide. The present study demonstrated that carbapenem-resistant K. pneumoniae strains have been spreading in medical settings in Myanmar. In particular, plasmid genes encoding NDMs and 16S rRNA methylases have been spreading in K. pneumoniae high-risk clones.

Developing Molecular Surveillance Capacity for Asymptomatic and Drug-Resistant Malaria in a Resource-Limited Setting-Experiences and Lessons Learned

The COVID-19 pandemic has highlighted the important role molecular surveillance plays in public health. Such capacity however is either weak or nonexistent in many low-income countries. This article outlines a 2-year effort to establish two high-throughput molecular surveillance laboratories in Myanmar for tracking asymptomatic and drug resistant Plasmodium falciparum malaria. The lessons learned from this endeavor may prove useful for others seeking to establish similar molecular surveillance capacity in other resource-limited settings.