Distance matters: barriers to antenatal care and safe childbirth in a migrant population on the Thailand-Myanmar border from 2007 to 2015, a pregnancy cohort study

BACKGROUND

Antenatal care and skilled childbirth services are important interventions to improve maternal health and lower the risk of poor pregnancy outcomes and mortality. A growing body of literature has shown that geographic distance to clinics can be a disincentive towards seeking care during pregnancy. On the Thailand-Myanmar border antenatal clinics serving migrant populations have found high rates of loss to follow-up of 17.4%, but decades of civil conflict have made the underlying factors difficult to investigate. Here we perform a comprehensive study examining the geographic, demographic, and health-related factors contributing to loss to follow-up.

METHODS

Using patient records we conducted a spatial and epidemiological analysis looking for predictors of loss to follow-up and pregnancy outcomes between 2007 and 2015. We used multivariable negative binomial regressions to assess for associations between distance travelled to the clinic and birth outcomes (loss to follow-up, pregnancy complications, and time of first presentation for antenatal care.) RESULTS: We found distance travelled to clinic strongly predicts loss to follow-up, miscarriage, malaria infections in pregnancy, and presentation for antenatal care after the first trimester. People lost to follow-up travelled 50% farther than people who had a normal singleton childbirth (a ratio of distances (DR) 1.5; 95% confidence interval (CI): 1.4 - 1.5). People with pregnancies complicated by miscarriage travelled 20% farther than those who did not have miscarriages (DR: 1.2; CI 1.1-1.3), and those with Plasmodium falciparum malaria in pregnancy travelled 60% farther than those without P. falciparum (DR: 1.6; CI: 1.6 - 1.8). People who delayed antenatal care until the third trimester travelled 50% farther compared to people who attended in the first trimester (DR: 1.5; CI: 1.4 - 1.5).

CONCLUSIONS

This analysis provides the first evidence of the complex impact of geography on access to antenatal services and pregnancy outcomes in the rural, remote, and politically complex Thailand-Myanmar border region. These findings can be used to help guide evidence-based interventions to increase uptake of maternal healthcare both in the Thailand-Myanmar region and in other rural, remote, and politically complicated environments.

Association between biological sex and insecticide-treated net use among household members in ethnic minority and internally displaced populations in eastern Myanmar

Malaria prevalence in Myanmar is highest among remote and ethnic minority populations living near forest fringes along the country’s international borders. Insecticide-treated nets (ITNs) are a key intervention used to prevent malaria transmission, but insufficient ITN availability and low use can hinder effectiveness. This study assessed age and sex disparities in ITN possession, access, and use among household members of ethnic minority and internally displaced populations in eastern Myanmar. Cross-sectional data from the 2013 Eastern Burma Retrospective Mortality Survey were used to describe prevalence of ITN possession, access, and use. The association between a household member’s biological sex and their ITN use was assessed using multilevel log binomial regression. Age and household ITN supply were tested as potential effect modifiers. Of 37927 household members, 89.8% (95% CI: 89.5, 90.1) of people lived in households with at least one ITN. Approximately half belonged to households with sufficient ITN supply and used an ITN. Pregnant women and children under five had the highest proportion of ITN use regardless of sufficient household ITN status. Female adults aged 15 to 49 years old (Risk ratio or RR: 1.4, 95% CI: 1.29, 1.52) were more likely to use ITNs. This relationship did not differ by sufficient household ITN status. The findings suggest that among ethnic minority populations in areas where ITN use is indicated, many households do not have adequate ITN supply, and many individuals are not using ITNs. Children under five and pregnant women appear to be prioritized for ITN use and overall, women are slightly more likely to use ITNs than men. This study’s findings can support efforts ensuring that all household members belonging to ethnic minority and displaced populations in Eastern Myanmar benefit from sufficient ITN access and use for malaria prevention.

Attitudes Towards Family Planning among Bhutanese, Burmese, and Iraqi Refugee Women: A Qualitative Study

The number of foreign-born people living in the United States continues to increase yearly. Foreign-born women in the United States, a group that includes both refugees and immigrants, continue to have higher birth rates when compared to their US-born counterparts. This study examines the cultural and socioeconomic factors influencing family planning choices of resettled refugee women living in the United States. Thirty-two Bhutanese, Burmese, and Iraqi women living in Philadelphia participated in interviews and focus groups. A grounded theory approach was used for analysis. Three overarching themes were identified: knowledge acquisition and experiential learning with trans-border migration and resettlement, changes in gender roles and family relations, and provider relationships and provision of care. Findings from the study show that a stable environment results in increased opportunities and personal freedoms, a sense of empowerment, and the desire for family planning. Women want to discuss options, but healthcare providers must begin the conversation. As health care providers in Hawai'i, a state with about 18% of residents being foreign-born, what can be learned from the Philadelphia refugee experience and family planning?

The potential impact of COVID-19 in refugee camps in Bangladesh and beyond: A modeling study

BACKGROUND

COVID-19 could have even more dire consequences in refugees camps than in general populations. Bangladesh has confirmed COVID-19 cases and hosts almost 1 million Rohingya refugees from Myanmar, with 600,000 concentrated in the Kutupalong-Balukhali Expansion Site (mean age, 21 years; standard deviation [SD], 18 years; 52% female). Projections of the potential COVID-19 burden, epidemic speed, and healthcare needs in such settings are critical for preparedness planning.

METHODS AND FINDINGS

To explore the potential impact of the introduction of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Kutupalong-Balukhali Expansion Site, we used a stochastic Susceptible Exposed Infectious Recovered (SEIR) transmission model with parameters derived from emerging literature and age as the primary determinant of infection severity. We considered three scenarios with different assumptions about the transmission potential of SARS-CoV-2. From the simulated infections, we estimated hospitalizations, deaths, and healthcare needs expected, age-adjusted for the Kutupalong-Balukhali Expansion Site age distribution. Our findings suggest that a large-scale outbreak is likely after a single introduction of the virus into the camp, with 61%-92% of simulations leading to at least 1,000 people infected across scenarios. On average, in the first 30 days of the outbreak, we expect 18 (95% prediction interval [PI], 2-65), 54 (95% PI, 3-223), and 370 (95% PI, 4-1,850) people infected in the low, moderate, and high transmission scenarios, respectively. These reach 421,500 (95% PI, 376,300-463,500), 546,800 (95% PI, 499,300-567,000), and 589,800 (95% PI, 578,800-595,600) people infected in 12 months, respectively. Hospitalization needs exceeded the existing hospitalization capacity of 340 beds after 55-136 days, between the low and high transmission scenarios. We estimate 2,040 (95% PI, 1,660-2,500), 2,650 (95% PI, 2,030-3,380), and 2,880 (95% PI, 2,090-3,830) deaths in the low, moderate, and high transmission scenarios, respectively. Due to limited data at the time of analyses, we assumed that age was the primary determinant of infection severity and hospitalization. We expect that comorbidities, limited hospitalization, and intensive care capacity may increase this risk; thus, we may be underestimating the potential burden.

CONCLUSIONS

Our findings suggest that a COVID-19 epidemic in a refugee settlement may have profound consequences, requiring large increases in healthcare capacity and infrastructure that may exceed what is currently feasible in these settings. Detailed and realistic planning for the worst case in Kutupalong-Balukhali and all refugee camps worldwide must begin now. Plans should consider novel and radical strategies to reduce infectious contacts and fill health worker gaps while recognizing that refugees may not have access to national health systems.

Malnutrition trends in Rohingya children aged 6-59 months residing in informal settlements in Cox's Bazar District, Bangladesh: An analysis of cross-sectional, population-representative surveys

BACKGROUND

More than 700,000 ethnic Rohingya have crossed the border from Rakhine State, Myanmar to Cox's Bazar District, Bangladesh, following escalated violence by Myanmar security forces. The majority of these displaced Rohingya settled in informal sites on previously forested land, in areas without basic infrastructure or access to services.

METHODS AND FINDINGS

Three cross-sectional population-representative cluster surveys were conducted, including all informal settlements of Rohingya refugees in the Ukhia and Teknaf Upazilas of Cox's Bazar District. The first survey was conducted during the acute phase of the humanitarian response (October-November 2017), and the second and third surveys were conducted 6 (April-May 2018) and 12 (October-November 2018) months later. Anthropometric indices (weight, height, mid-upper arm circumference [MUAC], oedema) and haemoglobin (Hb) were measured in children aged 6-59 months following standard procedures. Final samples for survey rounds 1, 2, and 3 (R1, R2, and R3) included 1,113, 628, and 683 children, respectively, of which approximately half were male (50.7%-53.5% per round) and a third were 6-23 months of age (32.4%-33.3% per round). Prevalence of global acute malnutrition (GAM) as assessed by weight for height in R2 (12.1%, 95% CI: 9.6-15.1) and R3 (11.0%, 95% CI: 8.4-14.2) represent a significant decline from the observed prevalence in R1 (19.4%, 95% CI: 16.8-22.3) (p < 0.001 for both comparisons). Overall, the prevalence of anaemia significantly declined (p < 0.001) between the first 2 rounds (47.9%, 95% CI: 44.1-51.7 and 32.3%, 95% CI: 27.8-37.1, respectively); prevalence increased significantly (p = 0.04) to 39.8% (95% CI, 34.1-45.4) during R3 but remained below R1 levels. Reported receipt of both fortified blended foods (12.8%) and micronutrient powders (10.3%) were low during R1 but increased significantly (p < 0.001 for both) within the first 6 months to 49.8% and 29.9%, respectively. Although findings demonstrate improvement in anthropometric indicators during a period in which nutrition programme coverage increased, causation cannot be determined from the cross-sectional design.

CONCLUSIONS

These data document significant improvements in both acute and micronutrient malnutrition among Rohingya children in makeshift settlements. These declines coincide with a scaleup of services aimed at prevention and treatment of malnutrition. Ongoing activities to improve access to nutritional services may facilitate further reductions in malnutrition levels to sustained below-crisis levels.

Burden of eye disease and demand for care in the Bangladesh Rohingya displaced population and host community: A cohort study

BACKGROUND

There is a growing awareness that addressing chronic as well as acute health conditions may contribute importantly to the well-being of displaced populations, but eye care service has generally not been prioritized in crisis situations. We describe a replicable model of eye care provision as delivered by Orbis International and local partners to the Rohingya and host population in Cox's Bazar, Bangladesh, and characterize the burden of vision impairment and demand for sight-restoring services in this setting.

METHODS AND FINDINGS

Orbis International and local secondary facility Cox's Bazar Baitush Sharaf Hospital (CBBSH) provide eye care support to the Rohingya population and the host community of all ages in Cox's Bazar, Bangladesh, with fixed vision screening locations established in Camps 4 and 11 of the Kutupalong refugee settlement. Structured outreach targets these camps and four surrounding local subdistricts, with referrals made as needed for refraction (glasses measurement) and cataract surgery to CBBSH. Between February 2018 and March 2019, 48,105 displaced Rohingya (70.3%, among whom 71.6% were children and 46.5% women) and 20,357 local residents (29.7%, 88.5% children, 54.4% women) underwent vision screening. Displaced Rohingya sought services from a total of 12 surrounding camps, within which coverage was 17.3%, including 43.3% (27,027/62,424) of children aged 5-11 years and 60.0% (5,315/8,857) of adults ≥ 60 years old. The prevalence of blindness (presenting acuity < 3/60) among Rohingya patients exceeded that among local residents by 3- to 6-fold in each 10-year age group between 18 and 59 years (P < 0.001 comparing vision between the two groups in this age range), and the prevalence of cataract requiring surgery was also higher in Rohingya patients (18-29 years: 4.67% versus 1.80%, P = 0.0019; 30-39: 7.61% versus 2.39%, P < 0.001; and 40-49 years: 7.91% versus 3.77%, P = 0.0014). A limitation of the study is lack of data on population prevalence of eye disease.

CONCLUSIONS

The burden of untreated eye disease is very high among the Rohingya, particularly those in their peak working years who could contribute most to the resiliency of their community. Demand for eye care service is also great among children and adults in this population with many competing healthcare priorities. Research is needed, building on strong evidence of benefit in settled populations, to explore the specific impact of vision care on the well-being of displaced populations.

Assessment of immunity to polio among Rohingya children in Cox's Bazar, Bangladesh, 2018: A cross-sectional survey

BACKGROUND

We performed a cross-sectional survey in April-May 2018 among Rohingya in Cox's Bazar, Bangladesh, to assess polio immunity and inform vaccination strategies.

METHODS AND FINDINGS

Rohingya children aged 1-6 years (younger group) and 7-14 years (older group) were selected using multi-stage cluster sampling in makeshift settlements and simple random sampling in Nayapara registered camp. Surveyors asked parents/caregivers if the child received any oral poliovirus vaccine (OPV) in Myanmar and, for younger children, if the child received vaccine in any of the 5 campaigns delivering bivalent OPV (serotypes 1 and 3) conducted during September 2017-April 2018 in Cox's Bazar. Dried blood spot (DBS) specimens were tested for neutralizing antibodies to poliovirus types 1, 2, and 3 in 580 younger and 297 older children. Titers ≥ 1:8 were considered protective. Among 632 children (335 aged 1-6 years, 297 aged 7-14 years) enrolled in the study in makeshift settlements, 51% were male and 89% had arrived after August 9, 2017. Among 245 children (all aged 1-6 years) enrolled in the study in Nayapara, 54% were male and 10% had arrived after August 9, 2017. Among younger children, 74% in makeshift settlements and 92% in Nayapara received >3 bivalent OPV doses in campaigns. Type 1 seroprevalence was 85% (95% CI 80%-89%) among younger children and 91% (95% CI 86%-95%) among older children in makeshift settlements, and 92% (88%-95%) among younger children in Nayapara. Type 2 seroprevalence was lower among younger children than older children in makeshift settlements (74% [95% CI 68%-79%] versus 97% [95% CI 94%-99%], p < 0.001), and was 69% (95% CI 63%-74%) among younger children in Nayapara. Type 3 seroprevalence was below 75% for both age groups and areas. The limitations of this study are unknown routine immunization history and poor retention of vaccination cards.

CONCLUSIONS

Younger Rohingya children had immunity gaps to all 3 polio serotypes and should be targeted by future campaigns and catch-up routine immunization. DBS collection can enhance the reliability of assessments of outbreak risk and vaccination strategy impact in emergency settings.

Molecular surveillance of Pfcrt and k13 propeller polymorphisms of imported Plasmodium falciparum cases to Zhejiang Province, China between 2016 and 2018

BACKGROUND

Resistance to anti-malarial drugs hinders malaria elimination. Monitoring the molecular markers of drug resistance helps improve malaria treatment policies. This study aimed to assess the distribution of molecular markers of imported Plasmodium falciparum infections.

METHODS

In total, 485 P. falciparum cases imported from Africa, Southeast Asia, and Oceania into Zhejiang province, China, from 2016 to 2018 were investigated. Most were imported from Africa, and only a few cases originated in Asia and Oceania. Blood samples were collected from each patient. Plasmodium falciparum chloroquine resistance transporter (Pfcrt) at residues 72-76 and Kelch13-propeller (k13) were determined by nested PCR and DNA sequence.

RESULTS

Wild-type Pfcrt at residues 72-76 was predominant (72.61%), but mutant and mixed alleles were also detected, of which CVIET (22.72%) was the most common. Mutant Pfcrt haplotypes were more frequent in patients from West Africa (26.92%), North Africa (25%), and Central Africa (21.93%). The number of cases of P. falciparum infections was small in Southeast Asia and Oceania, and these cases involved Pfcrt mutant type. For the k13 propeller gene, 26 samples presented 19 different point mutations, including eight nonsynonymous mutations (P441S, D464E, K503E, R561H, A578S, R622I, V650F, N694K). In addition, R561H, one of the validated SNPs in k13, was detected in one patient from Myanmar and one patient from Rwanda. A578S, although common in Africa, was found in only one patient from Cameroon. R622I was detected in one sample from Mozambique and one sample from Somalia. The genetic diversity of k13 was low in most regions of Africa and purifying selection was suggested by Tajima's D test.

CONCLUSIONS

The frequency and spatial distributions of Pfcrt and k13 mutations associated with drug resistance were determined. Wild-type Pfcrt was dominant in Africa. Among k13 mutations correlated with delayed parasite clearance, only the R561H mutation was found in one case from Rwanda in Africa. Both Pfcrt and k13 mutations were detected in patients from Southeast Asia and Oceania. These findings provide insights into the molecular epidemiological profile of drug resistance markers in the study region.

Challenges in health-care service use among Burmese refugees: A grounded theory approach

The timely use of health-care services is essential to achieve the best health outcomes. We explore barriers to health-care access among refugees from Burma through interviews with key community informants who serve their community as interpreters, health-care professionals, paraprofessionals, and/or representatives. The interviews with a convenience sampling of 11 leaders from Burmese and Karen ethnic communities revealed three stages of health-care use (i.e., before, during, and after doctor's appointments), in which their community members encounter difficulties in accessing health-care services. Using grounded theory analysis approach, specific difficulties and cultural considerations for each stage were emerged. This study suggests that training programs for health-care providers on refugee populations' needs, cultural expectations, attitudes, and health behaviors may ease the process for refugees during each of these three stages. Interpreters as cultural brokers have an important role in facilitating cross-cultural communications not only before and during the appointment but also after doctor's visits, such as in the pharmacy and labs.

Violence and mortality in the Northern Rakhine State of Myanmar, 2017: results of a quantitative survey of surviving community leaders in Bangladesh

BACKGROUND

In August, 2017, Myanmar security forces initiated a widespread response against the Rohingya ethnic minority in Northern Rakhine State, displacing thousands of people to Bangladesh. This attack was purportedly in response to attacks committed by the Arakan Rohingya Salvation Army, a non-state insurgent group, on Myanmar police, Border Guard Police, and military posts, killing 12 security personnel on Aug 25, 2017. This study aimed to capture the experiences of the population from all Rohingya hamlets in the Northern Rakhine State who have been displaced to Bangladesh.

METHODS

A quantitative survey was done among Rohingya leaders displaced to refugee camps in Bangladesh. Community leaders from 590 Rohingya hamlets and eight urban wards provided hamlet-level data on the extent, nature, and perpetrators of the violence in Northern Rakhine State in August, 2017, and the resulting morbidity and mortality.

RESULTS

From May 28 to July 25, 2018, 462 (77%) of 604 hamlet leaders reported that the primary reason they and their community members fled was because of violence in their hamlet or in a neighbouring hamlet. 568 (94%) respondents reported that they had experienced destruction in their hamlets, including burning or destruction of fields or farms, homes, and mosques; 531 (89%) of 599 respondents reported violence in their hamlets before flight and 373 (64%) of 586 reported violence against civilians in flight. The main perpetrators of violence included but were not limited to Border Guard Police, Myanmar military, and Rakhine extremists. Of the 531 respondents who reported violence in their hamlets, 408 (77%) reported that military forces used helicopters, 372 (70%) reported military vehicles, and 113 (21%) reported tanks in these assaults on civilian communities. We estimate that 7803 Rohingya died from violent and non-violent causes associated with the August, 2017, attacks and subsequent displacement.

INTERPRETATION

In 2017, the Rohingya ethnic minority population of Northern Rakhine State were the targets of a campaign of widespread and systematic violence, including violence by state forces.

FUNDING

An anonymous grant to Physicians for Human Rights.

"Sleeping in a boundary" constructing the meaning of health in a refugee camp

Sociopolitical discourses surrounding refugee migration and resettlement are characterized by divisiveness, assumptions, and fear. When these discussions are grounded in the narratives of women refugees a deeper understanding of issues impacting health, family, and resilience emerges. We examine how 26 Karen women living in camps along the Thai-Burma border construct meaning around health, in relation to livelihoods. Through directed content analysis, themes emerged: precursors to achieving health, health and livelihoods, and position and agency. Women identified barriers and facilitators to health, identified a dynamic relationship between health and livelihoods, and described their position and agency in the systems they navigate.

Knowledge of potential risk of blood-borne viral infections and tattooing practice among adults in Mandalay Region, Myanmar

Introduction

Tattooing especially gains popularity among both men and women in adulthood from the wide range of socioeconomic groups and is noted as a risk taking behaviour in adults. Especially when tattooing does not perform to the highest standards, it can potentially be the hazardous practice. Myanmar has a paucity of evidence-based information on the estimated prevalence of tattoos and awareness of potential disease transmission from tattooing under insanitary conditions as well as the infection risk. The present research was undertaken to help identify the self-reported prevalence of tattooing among adults (18–35 years) and their knowledge of transmission risk of blood-borne infections and its determinants.

Methods

A community-based cross-sectional study focused on residents aged 18–35 years was carried out in two urban and two rural areas in Mandalay district, Mandalay Region during 2015. Trained interviewers used a pre-tested structured questionnaire for face-to-face interviews with one eligible participant per selected household (n = 401). Bivariate analysis and multivariable analysis using binary logistic regression were done to ascertain the relevant explanatory variables.

Results

The overall self-reported prevalence of tattooing was 19.5% (78/401) (95% CI = 16–24). Nearly 80% of participants (318/401) knew at least one blood-borne viral infection that could be transmitted from tattooing. The persons who had high formal education, manual laborers and those who lived with their families were significantly more likely to cite at least one blood-borne viral infection. Their perceived possibility to remove tattoo independently influenced the practice of tattooing (aOR = 1.91, 95% CI = 1.06–3.45; p = 0.03) compared with participants who reported no perceived possibility. Tattooing was more common in male (aOR = 13.07, 95% CI = 6.25–27.33; p<0.001) compared to female which was independently significant.

Conclusions

This study ascertained the tattoo prevalence as two in ten adults of working age especially among male in central part of Myanmar in the context of lack of registration system for tattoo parlours and the issuance of safety guidelines. Findings have suggested the target groups and risk factors to be included in future health promotion programs. Future research directions should focus on perspectives of tattooists to create and sustain the sanitary practices to reduce the chance of transmission of blood-borne viral infections.

Hepatitis A and B among newly arrived refugees: Vaccinate all, or test first for immunity?

AIM

When screening newly arrived refugees, physicians must decide whether to vaccinate against hepatitis A and B at first encounter, thereby minimising missed opportunity, or to test for immunity and vaccinate only the susceptible, minimising unnecessary intervention. Better knowledge of hepatitis A and B immunity in refugee populations from different parts of the world is needed.

METHOD

Overseas and domestic medical records of refugees from Africa, Asia, and the Middle East who entered Marion County (Indiana) between 1 September 2016 and 31 December 2017 were reviewed.

RESULTS

Of 1191 refugees, 1163 and 1153 were tested for immunity to hepatitis A and B respectively. Among <19 year-olds, immunity to hepatitis A ranged from 52.1% to 79.6%, and immunity to hepatitis B ranged from 75.5% to 87.6%. Among ≥19 year-olds, immunity to hepatitis A was greater than 90% for each of the three regions, whereas immunity to hepatitis B ranged from 19.3% to 94.4%. 96% of refugees in the subset of Burmese ≥19 years old were immune to hepatitis B. Of individuals immune to hepatitis B, immunity was due to vaccination in 94.1% of <19 year-olds and 57.4% of ≥19 year-olds. 10% of refugees with at least three documented doses of hepatitis B vaccine were negative for hepatitis B surface antibody. 34.1% of uninfected refugees with no documented doses of hepatitis B vaccination were positive for hepatitis B surface antibody.

CONCLUSION

It is reasonable to begin hepatitis A vaccination of <19 year-olds in this refugee population at first encounter but to test first for hepatitis A susceptibility before vaccinating those ≥19 years old. Similarly delaying hepatitis B vaccination might be appropriate only for a subset of Burmese adults.

Real time PCR detection of common CYP2D6 genetic variants and its application in a Karen population study

BACKGROUND

Plasmodium vivax malaria is characterized by relapses arising from the hypnozoite stages in the liver. The only currently registered drug for radical treatment to prevent relapse is primaquine. Primaquine, a prodrug, requires metabolism through the liver cytochrome CYP2D6 isoenzyme to its active metabolite. Mutations in the CYP2D6 gene may thus affect primaquine efficacy. A SNPs genotyping technique was developed to characterize the CYP2D6 genetic variants and tested this in the patients with Plasmodium vivax infection collected in a Karen population on the Thailand-Myanmar border, where P. vivax malaria is endemic.

METHODS

Direct sequencing of PCR-reamplified products (DSP) was used to uncover exonic CYP2D6 sequence variations. Subsequently, an allele-specific oligonucleotide probe real-time SNPs genotyping (ASO) assay was developed for rapid detection of the four clinically relevant CYP2D6 variants occurring in this population. These two in-house developed assays were used to genotype CYP2D6 mutations in blood samples obtained from 70 Karen adults.

RESULTS

Results showed a high degree of concordance between the DSP and ASO methods. Six CYP2D6 point mutations were identified within the Karen population: C100T, C1039T, G1661C, G1846A, C2850T and G4180C, at frequencies of 0.43, 0.43, 0.76, 0.02, 0.32 and 0.76, respectively. The CYP2D6*2, *4, *5, *10 and *36 allelic frequencies were 0.33, 0.02, 0.03, 0.40 and 0.01, respectively. Alleles conferring an intermediate CYP2D6 metabolizer phenotype comprised 46% of the total number of alleles.

CONCLUSION

The newly developed ASO assay is a reliable and rapid tool for large-scale CYP2D6 genotyping. The high frequency of the CYP2D6*10 allele in the Karen population warrants further assessment of its association with the radical curative efficacy of primaquine.

Population pharmacokinetics of mefloquine given as a 3-day artesunate-mefloquine in patients with acute uncomplicated Plasmodium falciparum malaria in a multidrug-resistant area along the Thai-Myanmar border

BACKGROUND

Low mefloquine exposure has been shown to contribute to treatment failure in patients with uncomplicated falciparum malaria following a 3-day artesunate-mefloquine combination. The present study aimed to develop a population pharmacokinetic model for mefloquine based on whole blood concentration-time profiles of this target population for further dose optimization.

METHODS

A total of 129 Burmese patients aged above 15 years who presented with typical symptoms of malaria and had a blood smear positive for Plasmodium falciparum were included in the study. All were treated with the standard 3-day combination regimen of artesunate and mefloquine consisting of mefloquine for 2 days and artesunate for 3 days. Blood samples were collected before and at different time points after drug administration from different sub-groups of patients. Mefloquine concentrations were quantified in whole blood using high-performance liquid chromatography. A non-linear mixed-effect modelling approach was applied for population pharmacokinetic analysis using the NONMEM v7.3 software. Covariates investigated (body weight, gender, admission parasitaemia, and molecular markers of mefloquine resistance) were investigated in a step-wise manner using the SCM functionality in Perl-Speaks-NONMEM.

RESULTS

Population pharmacokinetic analysis of mefloquine was performed in all patients with a total of 653 samples. Whole blood mefloquine concentration-time profiles were described by a two-compartment disposition model. Of the covariates investigated, none was found to have a significant impact on the pharmacokinetics of mefloquine. Significant differences in maximum concentration (Cmax) and elimination half-life (t1/2) were found in patients who had treatment failure (36 cases) compared to patients with successful treatment (107 cases).

CONCLUSION

The study successfully describes the pharmacokinetics of mefloquine following a 2-day treatment of mefloquine as a part of a 3-day artesunate-mefloquine in patients with uncomplicated falciparum malaria from Thailand. A model has been developed which adequately describes the pharmacokinetics of mefloquine. More extensive clinical studies including both adults and children are needed to fully characterize the pharmacokinetics of mefloquine.

"Because if we talk about health issues first, it is easier to talk about human trafficking"; findings from a mixed methods study on health needs and service provision among migrant and trafficked fishermen in the Mekong

BACKGROUND

Human trafficking in the fishing industry or "sea slavery" in the Greater Mekong Subregion is reported to involve some of the most extreme forms of exploitation and abuse. A largely unregulated sector, commercial fishing boats operate in international waters far from shore and outside of national jurisdiction, where workers are commonly subjected to life-threatening risks. Yet, research on the health needs of trafficked fishermen is sparse. This paper describes abuses, occupational hazards, physical and mental health and post-trafficking well-being among a systematic consecutive sample of 275 trafficked fishermen using post-trafficking services in Thailand and Cambodia. These findings are complemented by qualitative interview data collected with 20 key informants working with fishermen or on issues related to their welfare in Thailand.

RESULTS

Men and boys trafficked for fishing (aged 12-55) were mainly from Cambodia (n = 217) and Myanmar (n = 55). Common physical health problems included dizzy spells (30.2%), exhaustion (29.5%), headaches (28.4%) and memory problems (24.0%). Nearly one-third (29.1%) reported pain in three or more areas of their body and one-quarter (26.9%) reported being in "poor" health. Physical health symptoms were strongly associated with: severe violence; injuries; engagement in long-haul fishing; immigration detention or symptoms of mental health disorders. Survivors were exposed to multiple work hazards and were perceived as disposable when disabled by illness or injuries. Employers struggled to apply internationally recommended Personal Protective Equipment (PPE) practices in Thailand. Non-governmental organizations (NGOs) encountered challenges when trying to obtain healthcare for uninsured fishermen. Challenges included fee payment, service provision in native languages and officials siding with employers in disputes over treatment costs and accident compensation. Survivors' post-trafficking concerns included: money problems (75.9%); guilt and shame (33.5%); physical health (33.5%) and mental health (15.3%).

CONCLUSION

Fishermen in this region are exposed to very serious risks to their health and safety, and their illnesses and injuries often go untreated. Men who enter the fishing industry in Thailand, especially migrant workers, require safe working conditions and targeted protections from human trafficking. Survivors of the crime of sea slavery must be provided with the compensation they deserve and the care they need, especially psychological support.

Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh

This survey study assesses the health and nutritional status of Rohingya children aged 6 to 59 months in the Kutupalong refugee camp in Bangladesh.

Feasibility of Implementation of a Parenting Intervention with Karen Refugees Resettled from Burma

Parents and children exposed to war and relocation have high rates of negative relational and mental health outcomes. This study tested the feasibility of implementing an adapted evidence-based parenting intervention for contexts of trauma and relocation stress. Eleven Karen refugee caregivers from Burma participated in the intervention. Participants and a focal child completed ethnographic interviews as well as structured assessments at baseline and follow-up. Caregivers reported changes in their teaching, directions, emotional regulation, discipline, and child compliance. Children reported changes in these areas and in positive parent involvement. Caregivers reported higher mental health distress immediately after the intervention, potentially due to increased awareness. Researchers made personalized referrals for counseling services as needed. Children reported a decrease in mental health symptoms.

Migrant tuberculosis patient needs and health system response along the Thailand-Myanmar border

This article aims to identify how the health system in Tak province, Thailand has responded to migrants' barriers to tuberculosis (TB) treatment. Our qualitatively driven multi-methods project utilized focus group discussions, key informant interviews, and a survey of community health volunteers to collect data in 2014 from multiple perspectives. Migrants identified legal status and transportation difficulties as the primary barriers to seeking TB treatment. Lack of financial resources and difficulties locating appropriate and affordable health services in other Thai provinces or across the border in Myanmar further contributed to migrants' challenges. TB care providers responded to barriers to treatment by bringing care out into the community, enhancing patient mobility, providing supportive services, and reaching out to potential patients. Interventions to improve migrant access and adherence to TB treatment necessarily extend outside of the health system and require significant resources to expand equitable access to treatment. Although this research is specific to the Thailand-Myanmar border, we anticipate that the findings will contribute to broader conversations around the inputs that are necessary to address disparities and inequities. Our study suggests that migrants need to be provided with resources that help stabilize their financial situation and overcome difficulties associated with their legal status in order to access and continue TB treatment.

Co-inheritance of glucose-6-phosphate dehydrogenase deficiency mutations and hemoglobin E in a Kachin population in a malaria-endemic region of Southeast Asia

Glucose-6-phosphate dehydrogenase (G6PD) deficiency and hemoglobin E (HbE, β26 Glu-Lys) are two common red cell disorders in Southeast Asia. G6PD deficiency produces hemolytic anemia, which can be triggered by certain drugs or infections. HbE is asymptomatic or is manifested as microcytic, minimally hemolytic anemia. The association between G6PD deficiency and HbE is little understood. This study aimed to investigate G6PD deficiency and HbE in a Kachin ethnic group in the China-Myanmar border area. G6PD enzyme activity was measured using a quantitative G6PD assay, G6PD variants genotyped by the SNaPshot assay, and an HbE gene mutation identified by an amplification refractory mutation system and subsequently confirmed by using a reverse dot blot hybridization assay from 100 unrelated individuals in the study area. G6PD enzyme activity ranged from 0.4 to 24.7 U/g Hb, and six males had severe G6PD deficiency (<0.12-1.2 U/g Hb), while six males and 12 females had mild G6PD deficiency (>1.2-4.5 U/g Hb). Among the 24 G6PD-deficient subjects, 22 (92%) had the Mahidol 487G>A mutation (12 male hemizygotes, one female homozygote, and nine female heterozygotes), while the G6PD genotypes in two female subjects were unknown. HbE was identified in 39 subjects (20 males and 19 females), including 15 HbEE (seven males and eight females) and 24 HbAE (13 males and 11 females). Twenty-three subjects co-inherited both G6PD deficiency and HbE (22 with HbAE and one with HbEE). Whereas mean Hb levels were not significantly different between the HbA and HbE groups, G6PD-deficient males had significantly lower Hb levels than G6PD-normal males (P < 0.05, t-test). However, it is noteworthy that two G6PD-deficient hemizygous males with HbAE were severely anemic with Hb levels below 50 g/L. This study revealed high prevalence of co-inheritance of G6PD deficiency with HbAE in the Kachin ethnicity, and a potential interaction of the G6PD Mahidol 487G>A and HbAE in males leading to severe anemia. The presence of 6% males with severe G6PD deficiency raised a major concern in the use of primaquine for radical cure of vivax malaria.

The impact of a family skills training intervention among Burmese migrant families in Thailand: A randomized controlled trial

Objective

To conduct a randomized controlled trial assessing the impact of a family-based intervention delivered to Burmese migrant families displaced in Thailand on parenting and family functioning.

Participants and procedures

Participants included 479 Burmese migrant families from 20 communities in Thailand. Families, including 513 caregivers and 479 children aged 7 to 15 years, were randomized to treatment and waitlist control groups. The treatment group received a 12-session family-based intervention delivered to groups of families by lay facilitators. Adapted standardized and locally derived measures were administered before and after the intervention to assess parent-child relationship quality, discipline practices, and family functioning.

Results

Compared with controls, intervention families demonstrated improved quality of parent-child interactions on scales of parental warmth and affection (Effect size (ES) = 0.25 caregivers; 0.26 children, both p < 0.05) and negative relationship quality (ES = -0.37, p < 0.001 caregivers; -0.22 children, p < 0.05). Both children and caregivers also reported an effect on relationship quality based on a locally derived measure (ES = 0.40 caregivers, p < .001; 0.43 children, p < .05). Family functioning was improved, including family cohesion (ES = 0.46 caregivers; 0.36 children; both p < 0.001) and decreased negative interactions (ES = -0.30 caregivers, p < 0.01; -0.24 children, p < 0.05). Family communication also improved according to children only (ES = 0.29, p < 0.01). Caregivers, but not children, reported decreased harsh discipline (ES = -0.39, p < 0.001), and no effects were observed on use of positive discipline strategies. Treatment attendance was high, with participants attending a mean of 9.7 out of 12 sessions.

Conclusion

The intervention increased protective aspects of family well-being for migrant children and caregivers in a middle-income country. The strongest effects were on parent-child relationship quality and family functioning, while results were mixed on changes in discipline practices. Results suggest that a behavioral family-based approach implemented by lay providers in community settings is a promising intervention approach for strengthening families in highly stressed contexts.

Trial registration

Clinicaltrials.gov: NCT01668992

Maternal and neonatal service usage and determinants in fragile and conflict-affected situations: a systematic review of Asia and the Middle-East

BACKGROUND

Fragile and conflict-affected situations (FCS) in Asia and the Middle-East contribute significantly to global maternal and neonatal deaths. This systematic review explored maternal and neonatal health (MNH) services usage and determinants in FCS in Asia and the Middle-East to inform policy on health service provision in these challenging settings.

METHODS

This systematic review was conducted using a standardised protocol. Pubmed, Embase, Web of Science, and selected development agency websites were searched for studies meeting inclusion criteria. Studies were assessed for methodological quality using an adapted evaluation tool. Qualitative and quantitative data were synthesized and pooled odds ratios generated for meta-analysis of service-usage determinants.

RESULTS

Of 18 eligible peer-reviewed studies, eight were from Nepal, four from Afghanistan, and two each from Iraq, Yemen, and the Palestinian Territories. Fragile situations provide limited evidence on emergency obstetric care, postnatal care, and newborn services. Usage of MNH services was low in all FCS, irrespective of economic growth level. Demand-side determinants of service-usage were transportation, female education, autonomy, health awareness, and ability-to-pay. Supply-side determinants included service availability and quality, existence of community health-workers, costs, and informal payments in health facilities. Evidence is particularly sparse on MNH in acute crises, and remains limited in fragile situations generally.

CONCLUSIONS

Findings emphasize that poor MNH status in FCS is a leading contributor to the burden of maternal and neonatal ill-health in Asia and the Middle-East. Essential services for skilled birth attendance and emergency obstetric, newborn, and postnatal care require improvement in FCS. FCS require additional resources and policy attention to address the barriers to appropriate MNH care. Authors discuss the 'targeted policy approach for vulnerable groups' as a means of addressing MNH service usage inequities.

A Survey of Practice and Knowledge of Refugee and Migrant Pregnant Mothers Surrounding Neonatal Jaundice on the Thailand-Myanmar Border

BACKGROUND

In populations with a high prevalence of glucose-6-phosphate dehydrogenase deficiency, practices that can induce haemolysis need to be identified to raise awareness of preventable risks. The aim of this survey was to determine the proportion of prospective mothers using haemolytic agents and their knowledge and practice surrounding neonatal jaundice.

METHODS

Pregnant mothers were invited to participate in a cross-sectional survey conducted at Shoklo Malaria Research Unit on the Thailand-Myanmar border.

RESULTS

From 12 April 2015 to 12 June 2015, 522 pregnant women completed the survey. Mothball use in the household was reported by 41.4% (216 of 522) of prospective mothers and menthol containing products on baby skin by 46.7% (244 of 522).

CONCLUSION

Just over 40% of the households reported use of naphthalene-containing mothballs. Future health promotion activities that focus on reducing naphthalene mothball and menthol-containing products use have the potential to reduce rates of severe neonatal jaundice in this population.

"The Pain of Exile": What Social Workers Need to Know about Burmese Refugees

Refugees from Burma have comprised the largest group of refugees resettling in the United States over the past decade, with nearly 90,000 people, and 19 percent of the total refugee population. However, very little literature exists that describes the cultural context and displacement experiences of this population. This article addresses that gap in the literature by examining historical, social, political, and cultural dimensions relevant to social work practice with Burmese refugees. Practice with Burmese refugees should be informed by knowledge of refugee policy, refugee resettlement, and social services delivery systems; the Burmese historical and political context; the community's specific strengths, needs, and cultural diversity; and human rights and social justice issues. Strong community partnerships between social workers and indigenous community leaders, between resettlement agencies and ethnic community-based organizations, and between different Burmese refugee groups are important to meeting short- and long-term social services needs and fostering successful adaptation and community integration.

EXPLORING HEALTHCARE PERSPECTIVES OF BURMESE CHIN REFUGEES

The objective of this study was to understand the Burmese Chin refugees' experiences with and perspectives on the United States healthcare system. Using a mixed-methods study design, a survey was distributed and focus groups were conducted. Thirty-seven surveys were completed. Five major themes emerged from the focus group discussions: time, language barriers, relationships with healthcare providers, traditional medicine, and adolescents'roles in their community. Refugee healthcare perspectives give health providers insights on how to work towards providing culturally appropriate care.

PULMONARY TB AMONG MYANMAR MIGRANTS IN SAMUT SAKHON PROVINCE, THAILAND: A. PROBLEM OR NOT FOR THE TB CONTROL PROGRAM?

Most transnational migrant workers in Thailand are from Myanmar, a country with a high tuberculosis prevalence. We investigated the prevalence of suspected pulmonary tuberculosis (TB) among Myanmar migrants in communities of Mueang District, Samut Sakhon Province, Thailand. Symptom screening for those with a productive cough of more than 2 weeks was conducted by face-to-face home interviews with 4,874 participants aged at least 15 years. Most subjects (75%) were aged 15-34 years (75%), 52% were male and 60% were married. Subjects typically lived with fellow nationals in crowded, poorly ventilated apartments or row houses. Ten subjects had suspected TB, giving a prevalence rate of 0.2%. Ninety-seven percent were working in Thailand legally but 80% had no health insurance. None had sought community health services; all preferred self-medication and private clinics due to stigma associated with TB, medication costs and health center waiting times. Providing information about health insurance and introducing TB prevention and control in this group should be considered. Further studies are needed to develop a TB control program and communicable disease surveillance among migrant communities, in Thailand.

Smoking, alcohol consumption and betal-quid chewing among young adult Myanmar laborers in Thailand

Health-risk behaviors among young adults are a serious public health problem. This cross sectional study aimed to estimate the prevalence of single and concurrent multiple health-risk behaviors: smoking tobacco, consuming alcohol, and chewing betel quid among young adult Myanmar laborers in Mae Sot District, Tak Province, Thailand. Three hundred Myanmar laborers, aged 18-24 years, were interviewed using a structured questionnaire. About 33.6% reported no risk behaviors, 24.7% had one, and 41.7% had two or three risk behaviors. Multinomial logistic regression analysis showed six variables were significantly associated with health-risk behaviors: male gender, high/moderate custom/traditional influences, friends who smoked/consumed alcohol/chewed betel quid, and exposure to betel-quid chewing by other family members.

Mental health status among Burmese adolescent students living in boarding houses in Thailand: a cross-sectional study

BACKGROUND

In Tak province of Thailand, a number of adolescent students who migrated from Burma have resided in the boarding houses of migrant schools. This study investigated mental health status and its relationship with perceived social support among such students.

METHODS

This cross-sectional study surveyed 428 students, aged 12-18 years, who lived in boarding houses. The Hopkins Symptom Checklist (HSCL)-37 A, Stressful Life Events (SLE) and Reactions of Adolescents to Traumatic Stress (RATS) questionnaires were used to assess participants' mental health status and experience of traumatic events. The Medical Outcome Study (MOS) Social Support Survey Scale was used to measure their perceived level of social support. Descriptive analysis was conducted to examine the distribution of sociodemographic characteristics, trauma experiences, and mental health status. Further, multivariate linear regression analysis was used to examine the association between such characteristics and participants' mental health status.

RESULTS

In total, 771 students were invited to participate in the study and 428 students chose to take part. Of these students, 304 completed the questionnaire. A large proportion (62.8%) indicated that both of their parents lived in Myanmar, while only 11.8% answered that both of their parents lived in Thailand. The mean total number of traumatic events experienced was 5.7 (standard deviation [SD] 2.9), mean total score on the HSCL-37A was 63.1 (SD 11.4), and mean total score on the RATS was 41.4 (SD 9.9). Multivariate linear regression analysis revealed that higher number of traumatic events was associated with more mental health problems.

CONCLUSIONS

Many students residing in boarding houses suffered from poor mental health in Thailand's Tak province. The number of traumatic experiences reported was higher than expected. Furthermore, these traumatic experiences were associated with poorer mental health status. Rather than making a generalized assumption on the mental health status of migrants or refugees, more detailed observation is necessary to elucidate the unique nature and vulnerabilities of this mobile population.

Thai health education program for improving TB migrant's compliance

OBJECTIVE

Investigate the effectiveness of health education programs by using the PRECEDE-PROCEED Model to improve non-Thai migrant TB patient's compliance during treatment.

MATERIAL AND METHOD

This quasi-intervention study was conducted in three targeted hospitals, between August 2009 and December 2010. The study sample consisted of 100 cases, 50 cases who registered in Samutsakorn Province served as the intervention group and 50 cases who registered in Samutprakarn Province served as the control group.

RESULTS

At the end of the health education intervention, the intervention group showedsignificantly improved health-behavior scores in nine domains-health promotion, health education, predisposing, reinforcing, enabling factors, behavior and lifestyle, environment, and health status, which were also significantly higher than the control group (p < 0.001). The percentage of patients achieving successful treatment outcomes was 76% in the intervention group and 62% in the control group.

CONCLUSION

The tuberculosis treatment and care program, and the associated health education interventions enabled migrants to complete the treatment regimen and achieve treatment success. It could also help TB staff develop an appropriate program and clear understanding of TB control among migrants. It is recommended that this type of information and health education program be used in other hospitals and healthcare settings providing TB services for migrants throughout the nation.

Are you ready for the betel nut?

As Texas becomes more diverse in its urban populations, dentists should educate themselves on their diverse patient base, including its cultures and cultural habits. The betel nut is chewed by more than 10% of the world's population and the oral care of these patients present many unique challenges. Other cultural beliefs can represent years of ideas passed on from one generation to another and need to be respected. Education is an excellent way of changing harmful cultural habits.

Health and healing: traditional medicine and the Karen experience

OBJECTIVE

To examine the beliefs, attitudes and health-seeking behavior surrounding the use of traditional medicine among the Karen (refugees from Burma).

METHODS

Three focus groups and two key-informant interviews were conducted with the Karen along with observations by researchers.

RESULTS

The Karen continue to use elements of their traditional healthcare system after resettling in the U.S. Accessibility and perceived efficacy of treatments influence their health-seeking behavior. The participants discussed beliefs about health and healing, spirituality, and their experience as refugees. Implications for improving the quality of healthcare for the Karen and recommendations for further research are discussed.

The impact of a national program to eliminate lymphatic filariasis in selected Myanmar immigrant communities in Bangkok and Ranong Province, Thailand

Some immigrants from Myanmar to Thailand have brought Wuchereria bancrofti infections with them, causing a community health problem for Thai citizens. The seroprevalence of bancroftian filariasis was detected in 438 and 512 Myanmar immigrants residing in Bangkok and Ranong Provinces, respectively, along with 81 Thai citizens living in Bangkok. The immunochromatograpy card test was positive in 5 Myanmar immigrants living in Bangkok and 1 living in Ranong for a prevalence of 0.63%. Antifilarial IgG4 antibodies were found in 21 Myanmar immigrants living in Bangkok and 14 living in Ranong for a prevalence of 3.68%. None of the samples from Thai citizens were positive with either test. These prevalence rates are lower than those observed between 2001 and 2005. The Thai mass drug administration program to eliminate lymphatic filariasis among Myanmar immigrants appears to be a successful public health strategy.

Tuberculosis treatment in a refugee and migrant population: 20 years of experience on the Thai-Burmese border

SETTING

Although tuberculosis (TB) is a curable disease, it remains a major global health problem and an important cause of morbidity and mortality among vulnerable populations, including refugees and migrants.

OBJECTIVE

To describe results and experiences over 20 years at a TB programme in refugee camps on the Thai-Burmese border in Tak Province, Thailand, and to identify risk factors associated with adverse outcomes (e.g., default, failure, death).

DESIGN

Retrospective review of routine records of 2425 patients admitted for TB treatment in the Mae La TB programme between May 1987 and December 2005.

RESULTS

TB cases notified among refugees decreased over 20 years. Among patients treated with a first-, second- or third-line regimen, 77.5% had a successful outcome, 13.5% defaulted, 7.6% died and 1.3% failed treatment. Multivariate analysis for new cases showed higher likelihood of adverse outcomes for patients who were Burmese migrants or Thai villagers, male, aged >15 years or with smear-negative pulmonary TB.

CONCLUSION

These findings suggest that treatment outcomes depend on the programme's capacity to respond to specific patients' constraints. High-risk groups, such as migrant populations, need a patient-centred approach, and specific, innovative strategies have to be developed based on the needs of the most vulnerable and marginalised populations.

Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project

BACKGROUND

Access to essential maternal and reproductive health care is poor throughout Burma, but is particularly lacking among internally displaced communities in the eastern border regions. In such settings, innovative strategies for accessing vulnerable populations and delivering basic public health interventions are urgently needed.

METHODS

Four ethnic health organizations from the Shan, Mon, Karen, and Karenni regions collaborated on a pilot project between 2005 and 2008 to examine the feasibility of an innovative three-tiered network of community-based providers for delivery of maternal health interventions in the complex emergency setting of eastern Burma. Two-stage cluster-sampling surveys among ever-married women of reproductive age (15-45 y) conducted before and after program implementation enabled evaluation of changes in coverage of essential antenatal care interventions, attendance at birth by those trained to manage complications, postnatal care, and family planning services.

RESULTS

Among 2,889 and 2,442 women of reproductive age in 2006 and 2008, respectively, population characteristics (age, marital status, ethnic distribution, literacy) were similar. Compared to baseline, women whose most recent pregnancy occurred during the implementation period were substantially more likely to receive antenatal care (71.8% versus 39.3%, prevalence rate ratio [PRR] = 1.83 [95% confidence interval (CI) 1.64-2.04]) and specific interventions such as urine testing (42.4% versus 15.7%, PRR = 2.69 [95% CI 2.69-3.54]), malaria screening (55.9% versus 21.9%, PRR = 2.88 [95% CI 2.15-3.85]), and deworming (58.2% versus 4.1%, PRR = 14.18 [95% CI 10.76-18.71]. Postnatal care visits within 7 d doubled. Use of modern methods to avoid pregnancy increased from 23.9% to 45.0% (PRR = 1.88 [95% CI 1.63-2.17]), and unmet need for contraception was reduced from 61.7% to 40.5%, a relative reduction of 35% (95% CI 28%-40%). Attendance at birth by those trained to deliver elements of emergency obstetric care increased almost 10-fold, from 5.1% to 48.7% (PRR = 9.55 [95% CI 7.21-12.64]).

CONCLUSIONS

Coverage of maternal health interventions and higher-level care at birth was substantially higher during the project period. The MOM Project's focus on task-shifting, capacity building, and empowerment at the community level might serve as a model approach for similarly constrained settings.

[Study on the longevity related mitochondrial genome variation in Bama elderly population in Guangxi province]

OBJECTIVE

To investigate the human mitochondrial DNA (mtDNA) variations associated with longevity in Bama elderly population from Guangxi.

METHODS

Mitochondrial genome of 20 individuals over 96 years of age was sequenced, and seven target single nucleotide polymorphism (SNPs) were observed by comparing with the standard rCRS sequence, and two were tested by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in a larger population including 208 individuals of 90-113 years old, and 586 unrelated control individuals from Guangxi.

RESULTS

The 4824G frequency of the mtDNA4824A/G locus increased with age both in the long-lived elderly and in controls. And it was significantly higher in controls than that in long-lived population (P<0.05).

CONCLUSION

The mtDNA4824 A/G is not only an age-related locus, its mutation is also negatively correlated with longevity.

Caring for the Karen. A newly arrived refugee group

Since 2004, Minnesota has seen an influx of refugees from Burma. Many of these newcomers came from the Karen state and spent time in refugee camps in Thailand before resettling in the United States. To better understand the health needs of this population, the authors of this article conducted chart reviews at a St. Paul family medicine clinic that serves a number of Karen refugees and reviewed formal data from the Minnesota Department of Health's Refugee Health Program. Here, they briefly describe this community, the cultural issues that could affect health care providers' ability to care for Karen patients, and the health concerns of these refugees.

Prevalence and risk factors of low back pain among Thai and Myanmar migrant seafood processing factory workers in Samut Sakorn Province, Thailand

This study assessed the prevalence of low back pain (LBP) and investigated risk factors for LBP among seafood processing factory workers in Thailand including migrant workers. The subjects were Thai and Myanmar workers in the typical seafood processing factory. A cross-sectional study was carried out with a self-administered questionnaire. Prevalence of LBP, general characteristics, life style, and working condition were investigated. The associations between LBP and risk factors were estimated by multiple logistic regression models. Of 254 workers, 165 completed the questionnaire. Half of these workers were Thai, the others were from Myanmar. The point prevalence of LBP was 28.5%. Risk factors for LBP were age over 40 yr, poor health status, history of back injury, twisting posture at work, and slipping on wet floors. The results suggest that health promotion should focus on working conditions rather than individual life style in order to prevent LBP. Furthermore, greater attention to other risk factors such as history of back injury and perception of health status after regular health check up, especially in older age groups may be needed.

Screening practices for infectious diseases among Burmese refugees in Australia

Increasing numbers of refugees from Burma (Myanmar) are resettling in Western countries. We performed a retrospective study of 156 Burmese refugees at an Australian teaching hospital. Of those tested, Helicobacter pylori infection affected 80%, latent tuberculosis 70%, vitamin D deficiency 37%, and strongyloidiasis 26%. Treating these diseases can prevent long-term illness.