A mixed-methods evaluation of hepatitis B knowledge, attitudes, and practices among migrant women in Thailand.

BACKGROUND: Globally 90 % of transmission of Hepatitis B virus (HBV) is from mother-to child and occurs predominantly in resource limited countries where the prevalence of HBV is high. Transmission could be interrupted by timely vaccinations but coverage remains problematic in these areas. Low knowledge or awareness of HBV may play a part in low vaccination coverage. This study examines the provision of antenatal care counselling with a focus on HBV in two different regions of northern Thailand, Sarapee Hospital (SH), Chiang Mai, and Shoklo Malaria Research Unit (SMRU), Tak Province. METHODS: A mixed-methods sequential explanatory study design was used to evaluate antenatal services for migrants. Cross-sectional knowledge, attitude and practice (KAP) surveys were conducted immediately after counselling at first ANC contact, at 3-6 months after first ANC contact and at delivery. Surveys provided quantitative data, and qualitative methods included observations, focus group discussions (FGD) and in-depth interviews (IDI); analysed thematically to explore concepts of knowledge and understanding, attitude and practice of pregnant women and providers. RESULTS: Between September-2019 and May-2020, 757 women participated to KAP surveys, and 31 observations of counselling, 16 FGD and 9 IDI were conducted. KAP surveys showed in spite of low knowledge about HBV transmission, infection, or vaccination (correct response: SH 5.7 %, 9/157; SMRU 34.0 %, 204/600), most women (≥ 93 %, either site) understood they were screened for HBV and were willing to vaccinate infants for HBV. In explaining KAP survey results, qualitative analysis suggests counselling should: use the appropriate language; be tailored to the local health literacy level, provide only pertinent information, be repeated over the antenatal period; and attempt to ensure patient privacy (where possible). Programme effectiveness benefits from positive attitudes to screening and vaccinations and a high level of trust in the providers nevertheless participants provided good suggestions for improvements of the service. CONCLUSIONS: Limited knowledge of HBV among migrant women can be improved by counselling that emphasizes actionable knowledge such as vaccination schedule. Key improvements to the counselling process include training counsellors to conduct interactive counselling sessions in the woman's language, using appropriate visual aids and timely repetition over the course of the antenatal period.

A proposed method of grading malaria chemoprevention efficacy.

The efficacy and effectiveness of antimalarial drugs are threatened by increasing levels of resistance and therefore require continuous monitoring. Chemoprevention is increasingly deployed as a malaria control measure, but there are no generally accepted methods of assessment. We propose a simple method of grading the parasitological response to chemoprevention (focusing on seasonal malaria chemoprevention) that is based on pharmacometric assessment.

Quality of ultrasound biometry obtained by local health workers in a refugee camp on the Thai-Burmese border.

OBJECTIVE: In a refugee camp on the Thai-Burmese border, accurate dating of pregnancy relies on ultrasound measurements obtained by locally trained health workers. The aim of this study was to substantiate the accuracy of fetal biometry measurements performed by locally trained health workers by comparing derived reference equations with those published for Asian and European hospitals. METHODS: This prospective observational study included 1090 women who had a dating crown-rump length (CRL) scan and one study-appointed ultrasound biometry scan between 16 and 40 weeks of gestation. The average of two measurements of each of biparietal diameter, head circumference, abdominal circumference and femur length was used in a polynomial regression model for the mean and SD against gestational age (GA). The biometry equations obtained were compared with published equations of professional sonographers from Asian and European hospitals by evaluation of the SD and Z-scores of differences between models. RESULTS: Reference equations of biometric parameters were found to fit cubic polynomial models. The observed SD values, for any given GA, of fetal biometric measurements obtained by locally trained health workers were lower than those previously reported by centers with professional sonographers. For nearly the entire GA range considered, the mean values of the Asian and European equations for all four biometric measurements were within the 90% expected range (mean ± 1.645 SD) of our equations. CONCLUSION: Locally trained health workers in a refugee camp on the Thai-Burmese border can obtain measurements that are associated with low SD values and within the normal limits of published Asian and European equations. The fact that the SD values were lower than in other studies may be explained by the use of the average of two measurements, CRL dating or motivation of the locally trained sonographers.

Migration histories of multidrug-resistant tuberculosis patients from the Thailand-Myanmar border, 2012-2014.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) is a growing public health threat in South-East Asia. TB is typically a disease of poverty and can be spread by infectious humans who migrate from one region to another. DESIGN: We interviewed 20 MDR-TB patients on the Thailand-Myanmar border with regard to their migration histories. Migration origins and destinations were mapped. RESULTS: All but one participant had a history of migration, and maps of migration ranges revealed wide geographic dispersal. Most described living and work conditions that could contribute to the spread of drug-resistant TB, including numerous contacts and crowded living quarters. CONCLUSION: Our results show that at least some migrant workers in the region carry MDR-TB, and indicate that this subgroup of the population is important with regard to the transmission of MDR-TB throughout the region. Migrants in this region come into contact with high numbers of people and may be able to spread the disease across wide geographic ranges. Access to diagnosis and treatment and socio-economic development are at least as important as any TB control measures, meaning that innovative and bold approaches that extend across international borders are needed to address these problems.

Adverse effects of falciparum and vivax malaria and the safety of antimalarial treatment in early pregnancy: a population-based study.

BACKGROUND: The effects of malaria and its treatment in the first trimester of pregnancy remain an area of concern. We aimed to assess the outcome of malaria-exposed and malaria-unexposed first-trimester pregnancies of women from the Thai-Burmese border and compare outcomes after chloroquine-based, quinine-based, or artemisinin-based treatments. METHODS: We analysed all antenatal records of women in the first trimester of pregnancy attending Shoklo Malaria Research Unit antenatal clinics from May 12, 1986, to Oct 31, 2010. Women without malaria in pregnancy were compared with those who had a single episode of malaria in the first trimester. The association between malaria and miscarriage was estimated using multivariable logistic regression. FINDINGS: Of 48,426 pregnant women, 17,613 (36%) met the inclusion criteria: 16,668 (95%) had no malaria during the pregnancy and 945 (5%) had a single episode in the first trimester. The odds of miscarriage increased in women with asymptomatic malaria (adjusted odds ratio 2·70, 95% CI 2·04-3·59) and symptomatic malaria (3·99, 3·10-5·13), and were similar for Plasmodium falciparum and Plasmodium vivax. Other risk factors for miscarriage included smoking, maternal age, previous miscarriage, and non-malaria febrile illness. In women with malaria, additional risk factors for miscarriage included severe or hyperparasitaemic malaria (adjusted odds ratio 3·63, 95% CI 1·15-11·46) and parasitaemia (1·49, 1·25-1·78 for each ten-fold increase in parasitaemia). Higher gestational age at the time of infection was protective (adjusted odds ratio 0·86, 95% CI 0·81-0·91). The risk of miscarriage was similar for women treated with chloroquine (92 [26%] of 354), quinine (95 [27%) of 355), or artesunate (20 [31%] of 64; p=0·71). Adverse effects related to antimalarial treatment were not observed. INTERPRETATION: A single episode of falciparum or vivax malaria in the first trimester of pregnancy can cause miscarriage. No additional toxic effects associated with artesunate treatment occurred in early pregnancy. Prospective studies should now be done to assess the safety and efficacy of artemisinin combination treatments in early pregnancy.