Key factors associated with malaria infection among patients seeking care through the public sector in endemic townships of Ayeyarwady Region, Myanmar.

BACKGROUND: Ayeyarwady Region in Myanmar has made significant progress towards malaria elimination, with cases decreasing from 12,312 in 2015 to 122 in 2019. As transmission declines, malaria becomes increasingly focalized both in geographic hotspots and among population groups sharing certain risk factors. Developing a thorough profile of high-risk activities associated with malaria infections is critical to ensure intervention approaches are evidence-based. METHODS: A test-negative study was conducted from September 2017 to May 2018 in Ngaputaw, Pathein and Thabaung townships in Ayeyarwady Region. Patients that presented to selected public facilities or community health volunteers with fever answered survey questions on demographic and behavioural risk factors, including exposure to malaria interventions, and were assigned to case and control groups based on the result of a malaria rapid diagnostic test. A random-effects logistic regression model adjusted for clustering at the facility level, as well as any variables along the causal pathway described by a directed acyclic graph, was used to determine odds ratios and association with malaria infections. RESULTS: A total of 119 cases and 1744 controls were recruited from 41 public facilities, with a mean age of 31.3 and 63.7% male. Higher risk groups were identified as males (aOR 1.8, 95% CI 1.2-2.9) and those with a worksite located within the forest (aOR 2.8, 95% CI 1.4-5.3), specifically working in the logging (aOR 2.7, 95% CI 1.5-4.6) and rubber plantation (aOR 3.0, 95% CI 1.4-6.8) industries. Additionally, links between forest travel and malaria were observed, with risk factors identified to be sleeping in the forest within the past month (aOR 2.6, 95% CI 1.1-6.3), and extended forest travel with durations from 3 to 14 days (aOR 8.6, 95% CI 3.5-21.4) or longer periods (aOR 8.4, 95% CI 3.2-21.6). CONCLUSION: Malaria transmission is highly focalized in Ayeyarwady, and results illustrate the need to target interventions to the most at-risk populations of working males and forest goers. It will become increasingly necessary to ensure full intervention coverage of at-risk populations active in forested areas as Myanmar moves closer to malaria elimination goals.

Factors associated with the decline of malaria in Myanmar's Ayeyarwady Region between 2013 and 2017.

The burden of malaria in Myanmar has declined rapidly in recent years; cases decreased from 333,871 in 2013 to 85,019 in 2017 (75% decrease). Decline of malaria in the Ayeyarwady Region of Myanmar reflects this trend with an 86% decrease in cases over this period. In this exploratory analysis, quantitative and qualitative information were assessed to explore potential factors responsible for the decline of malaria in Ayeyarwady. Data on malaria incidence, programmatic financing, surveillance, case management, vector control interventions, climate and ecological factors, and policies and guidelines spanning 2013 to 2017 were compiled. Poisson regression models that adjust for correlation were used to analyze the association between annual malaria case numbers with malaria intervention factors at the township level. Between 2013 and 2017, there was a decrease in mean township-level malaria incidence per 1000 from 3.03 (SD 4.59) to 0.34 (SD 0.79); this decline coincided with the implementation of the government's multi-pronged malaria elimination strategy, an increase of approximately 50.8 million USD in malaria funding nationally, and a period of deforestation in the region. Increased funding in Ayeyarwady was invested in interventions associated with the decline in caseload, and the important roles of surveillance and case management should be maintained while Myanmar works towards malaria elimination.

Notified dengue deaths in Myanmar (2017-18): profile and diagnosis delays.

Background: Complications in dengue usually occur between day four and day six after fever onset. Hence, early diagnosis and haematological monitoring are vital. Among all hospital reported dengue deaths in Myanmar in 2017-18, we assessed the i) patient profile, ii) proportion of patients who arrived with a dengue diagnosis at admission and iii) delays in diagnosis after fever onset. Methods: This was a descriptive study involving secondary data. For all the notified deaths, death investigation forms were not available in prescribed format and therefore, data were extracted from hospital case records.  Results: Of 304 deaths, 184 (60.5%) were female and 233 (76.6%) were less than 10 years old. Township level hospitals or below reported 36 deaths (11.8%) and the remaining deaths were from higher level facilities. Dengue was diagnosed before admission in 26 (8.5%) people and 169 (55.6%) were in shock at admission. Of 208 with date of fever onset recorded, the median diagnosis delay was four (interquartile range-IQR: 3, 5) days. Patient level delay (median three days) was a major contributor to the diagnosis delay. Conclusions: Most of the patients who died did not have a diagnosis of dengue before admission. This calls for an urgent review of health system preparedness in peripheral health facilities to suspect, diagnose, monitor, refer and treat dengue in children and patient level factors for better understanding of the reasons of delay. Timely filling of death investigation forms in a prescribed format and quarterly death reviews based on these is recommended.