A System Dynamics Model of Caries Preventive Interventions in Thailand's School-Aged Population.

PURPOSE: To compare the long-term effects of the Ministry of Public Health's (MOPH) caries preventive interventions for 6- to 12-year-olds (supervised toothbrushing [STB], dental sealant, and combined STB+sealant) to the base case (no intervention) using the System Dynamics Model. MATERIALS AND METHODS: The System Dynamics Model was used to evaluate the intervention scenarios of supervised toothbrushing (STB), sealant, and combined STB+sealant with the base-case scenario. The effectiveness data for the model's interventions were obtained from systematic reviews and meta-analyses. RESULTS: The model determined that the caries-free population increased by 36.2%, 25.5%, and 14.5%, while the caries-affected population decreased by 8.1%, 5.5%, and 3.1% in the combined STB+sealant, sealant, and supervised toothbrushing scenarios compared to the base case at 15 years of age. CONCLUSION: Combined STB+sealant is the most efficacious intervention among those administered to children between the ages of 6 and 12 with permanent teeth. In addition, the System Dynamics Model could be helpful in comparing interventions or policies to determine the optimal intervention for a given population.

Clinical use of mood stabilizers beyond treatment for bipolar disorder: The REAP-MS study.

OBJECTIVE: Mood stabilizers are psychotropic drugs mainly used to treat bipolar disorder in the acute phase or for maintenance therapy to prevent relapse. In clinical practice, mood stabilizers are commonly prescribed for conditions other than bipolar disorder. This study investigated the distribution of mood stabilizer prescriptions for different psychiatric diagnoses and studied differences in the drugs, dosage, and plasma concentration in 10 Asian countries including Taiwan, South Korea, Malaysia, China, Thailand, India, Pakistan, Singapore, Indonesia, and Myanmar. METHODS: Patients prescribed mood stabilizers (lithium, carbamazepine, valproic acid, or lamotrigine) for a psychiatric condition other than bipolar disorder (codes F31.0-F31.9 in the International Classification of Diseases, 10th Edition, Clinical Modification) were recruited through convenience sampling. A website-based data entry system was used for data collection. RESULTS: In total, 1557 psychiatric patients were enrolled. Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20-F29, 55.8 %) was the most common diagnosis, followed by non-bipolar mood disorders (F30, F31- F39, 25.3 %), organic mental disorder (F00-F09, 8.8 %), mental retardation (F70-F79, 5.8 %) and anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (F40-F48, 4.4 %). The most frequently targeted symptoms (>20 %) were irritability (48 %), impulsivity (32.4 %), aggression (29.2 %), anger (20.8 %), and psychosis (24.1 %). Valproic acid was the most frequently used medication. CONCLUSIONS: Clinicians typically prescribe mood stabilizers as empirically supported treatment to manage mood symptoms in patients with diagnoses other than bipolar disorders, though there is on official indication for these disorders. The costs and benefits of this add-on symptomatic treatment warrant further investigation.

Prescription Patterns for Bipolar Disorder in Asian Countries: Findings from Research on Asian Prescription Pattern-Bipolar Disorder.

OBJECTIVE: Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries. The rates of polypharmacy and psychotropic drug load were also analyzed. METHODS: The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥ 2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method. RESULTS: Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1,619 (80.8%) patients received mood stabilizers, 1,644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40. Results varied widely between countries. CONCLUSION: Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥ 80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment.

Oral Health System in Myanmar: A Review.

OBJECTIVES: The study aims at reviewing Myanmar's current situation to consider an improved oral health system and at promoting the oral health status of the Myanmar population. MATERIALS AND METHODS: This review was conducted using the World Health Organization's (WHO's) six building blocks of the health system: oral health-care service delivery, dental workforce, oral health information system, essential medicine, health financing, and leadership and governance. The review was established on scientific articles and documents and information from reliable government and nongovernment organizations' websites. RESULTS: According to the National Oral Health Survey (2016-2017), the prevalence rate of untreated caries in six-year-old Myanmar children (84.1%), and in the 35-44 and 65-74 age group (above 40%) is high, which reflects a low utilization of oral health-care services. The dentist to population ratio is approximately 1:16,000: There are around 5,000 dentists and 400 trained dental nurses in Myanmar, and only about 1,000 dentists serve in government sectors. The inequalities in dental health care are compounded by a limited dental workforce and inequality of dentists between the public and private sectors in Myanmar. In the last National Health Plan (NHP, 2006-2011), the Myanmar government's funding for required dental equipment and materials in each dental unit (around 5726 USD) has been considered inadequate. The current expenditure is not transparent. The other challenges are an insufficient supply of dental materials and instruments to all public dental sectors and a lack of oral health-care infrastructure. CONCLUSIONS: Such findings suggest a pressing need to address the effective oral health-care system and decree the specific goals for the Myanmar population's oral health.

Mental health of adolescents in Myanmar: A systematic review of prevalence, determinants and interventions.

Adolescence is a developmental phase where mental disorders typically manifest and where platforms for response (including schools and health services) change rapidly. However, data to inform public mental health responses are limited, including in countries like Myanmar which has a large adolescent population and where mental health has been identified as a priority of policy. In this paper we sought to systematically review the peer-reviewed and grey literature to determine (i) the prevalence of mental disorder among adolescents in Myanmar, (ii) determinants of mental disorder and (iii) interventions that have been implemented and evaluated. Nine publications met inclusion criteria (7 peer-reviewed and 2 grey literature) that included 7 publications reporting prevalence, 6 reporting correlates and one an intervention. The available data from the 2016 Global School-based Health Survey highlight that depression (27.2%) and suicidal ideation (9.4%) are prevalent in Myanmar, and these rates are substantially higher than regional averages. The limited available data on correlates identified violence and bullying, alcohol and substance use, and home, family and community security and cohesion as being closely related to mental health for adolescents. Only one study focussed on interventions and this found mindfulness meditation training to be an effective approach for young people whose parents were affected by HIV. These findings underscore the need to address adolescent mental health in Myanmar, but also to invest in better data collection efforts.

Source Apportionment of Coarse Particulate Matter (PM10) in Yangon, Myanmar.

The Republic of the Union of Myanmar is one of many developing countries facing concerns about particulate matter (PM). Previously, a preliminary study of PM2.5 in 2018 suggested that the main source of PM in Yangon, the former capital, was vehicle emissions. However, this suggestion was not supported by any chemical composition data. In this study, to fill that gap, we quantitatively determined source contributions to coarse particulate matter (PM10) in Yangon, Myanmar. PM10 samples were collected in Yangon from May 2017 to April 2018 and chemically analyzed to determine composition. Chemical composition data for these samples were then used in the Chemical Mass Balance (CMB) model to identify the major sources of particulate matter in this area. The results indicate that PM10 composition varies seasonally according to both meteorological factors (e.g., precipitation and temperature) and human activities (e.g., firewood and yard waste burning). The major sources of PM in Yangon annually were dust, secondary inorganic aerosols (SIA), and secondary organic aerosols (SOA), while contributions from biomass burning were more important during the winter months.

Do we need to go further to train healthcare providers in the targeted regions for malaria elimination in Myanmar? A mixed-methods study.

BACKGROUND: The National Malaria Control Programme (NMCP) in Myanmar trained health staff at the township level starting in mid-2016 in order to achieve the Plasmodium falciparum malaria elimination target by 2020. This study aimed to evaluate the knowledge and perception of Basic Health Staff (BHS) and Vector-borne Diseases Control (VBDC) teams exposed to a short training course on malaria elimination in six targeted townships which included two conflict-affected townships between 2016 and 2017. METHODS: This was a cross-sectional mixed-methods study using quantitative and qualitative data extracted from one survey database conducted between October 2018 and March 2019. Modified Poisson regression analysis was performed to ascertain the determinants of low knowledge scores after the training programme. RESULTS: Altogether, 544 trained frontline health workers involved in malaria elimination at the time of the survey were recruited and 56% (302/544) were stationed at sub-Rural Health Centers. More than half of the respondents had correct knowledge of malaria case categories although relapse and recrudescent cases (39% and 37% respectively) were less well known. Over two-thirds of respondents could mention those eligible for malaria testing. Less than 30% knew the foci classification. The overall knowledge scores ranged from 10 to 31. The significant predictors of low level of knowledge [the cut-off point was set at the median value of 21 (IQR 12-30)] in multivariate analysis were the younger age group (18-29 years) and health staff who had attended malaria elimination training in 2017, [(APR = 1.6, 95% CI 1.2-2.2)]; and (APR = 1.5, 95%CI 1.2-1.8)]. Qualitative data from 10 key informants identified perceived challenges in conflict-affected areas as well as in areas of high population mobility with further implications for case surveillance. In addition, the low level of education of community members was noted as one of the barriers that hampered public readiness in the elimination scenario. CONCLUSION: A significant impact on knowledge improvement after the training programme was not visible especially for correct notification of malaria cases and treatment according to National Malaria Elimination Guidelines. Regular monitoring and continuing guidance by the higher level management is critical to support the field staff.

The burden of Japanese encephalitis, the catch-up vaccination campaign, and health service providers' perceptions in Myanmar: 2012-2017.

BACKGROUND: Myanmar is endemic for Japanese encephalitis (JE) and has experienced several outbreaks in recent years. The vector-borne disease control (VBDC) program has collected hospital-based surveillance data since 1974. There is an urgent need to collate, analyze, and interpret the most recent information. The study aimed to describe (i) hospital-based JE cases and deaths between 2012 and 2017, (ii) a catch-up vaccination campaign in children in 2017, and (iii) health service provider perceptions about JE in one township in 2018. METHODS: This was a cross-sectional study of cases, deaths, and catch-up childhood vaccinations using secondary data from program records and a survey database of health service provider perceptions. RESULTS: Between 2012 and 2017, there were 872 JE cases and 79 deaths with a case fatality rate of 91 per 1000; 2016 was the year with most cases and deaths. Most cases (n = 324) and deaths (n = 37) occurred in children aged 5-9 years. Large case numbers were reported in delta and lowland regions (n = 550) and during the wet season (n = 580). The highest case fatality rates were observed in the hills and coastal regions (120 and 112 per 1000, respectively). Nationwide coverage of the catch-up JE vaccination campaign among 13.7 million eligible children was 92%, with coverage lower in the hills and coastal regions (84%) compared with delta and lowland regions and plains (94%). More vaccinations (65%) occurred through school-based campaigns with the remainder (35%) vaccinated through community-based campaigns. Structured interviews in one township showed that service providers (n = 47) had good perceptions about various aspects of JE, although perceived benefits of specific vector control measures were poor: spraying/fumigation (38%), garbage removal (36%), larvicide use (36%), and drainage of standing/stagnant water (32%). CONCLUSION: The catch-up vaccination campaign was a successful response to high JE case numbers and deaths in children. However, ongoing surveillance for JE needs to continue and be strengthened to ensure comprehensive reporting of all cases, more knowledge is needed on disability in JE survivors, and all attempts must be made to ensure high percentage coverage of vaccination through routine and catch-up campaigns.

Evaluation of the cross-neutralization capacity of Thai green pit viper antivenom against venom of Myanmar green pit viper.

Green pit viper (Trimeresurus sp.) bite occurred throughout Myanmar, but there is no specific antivenom produced in the country for related envenomation. Instead, Myanmar Russell's viper antivenom (Anti-MRV) was often misused because of prolonged clotting time was observed from both species. Thai green pit viper antivenom (Anti-TGPV) raised against Trimeresurus albolabris was found to be effective against venoms of more than ten Trimeresurus sp. from Thailand, Malaysia and Indonesia. The present study compared the neutralization capacities of Anti-TGPV and Anti-MRV towards the venom from T. erythrurus from Myanmar. Anti-TGPV was more efficacious than Anti-MRV in cross-neutralizing the lethal and haemorrhagic activities of the venom by a potency of a least 1.4 times higher. Although Anti-TGPV effectively cross-neutralized the coagulation activity of the venom, Anti-MRV failed to do so. Immunodiffusion and immunoblot experiments showed that Anti-TGPV cross-reacted with more protein components of the venom than Anti-MRV. In conclusion, Anti-TGPV is a better choice for patients bitten by Myanmar green pit viper, but further clinical investigation is required. The current findings highlight the development of a specific antivenom against Myanmar green pit viper venom.

The prevalence of mental distress and the association with education: a cross-sectional study of 18-49-year-old citizens of Yangon Region, Myanmar.

BACKGROUND: Poor mental health is an important contributor to the global burden of disease. Mental health problems are often neglected in communities, and are scarcely studied in developing countries, including Myanmar. This study estimates the prevalence of mental distress by socio-demographic and health related factors, and the association between education and mental distress. As far as the authors are aware, this is the first population-based study in Myanmar estimating the prevalence of mental distress. METHODS: Between October and November 2016, a cross sectional study was conducted using a multi-stage sampling design with face-to-face interviews using the Hopkins Symptom Checklist (HSCL-10) for mental distress (symptoms of depression and anxiety). The multivariable analysis strategy was based on Directed Acyclic Graphs (DAGs), to identify confounders, mediators and colliders. Pearson's chi-square was used for testing differences between proportions and multiple linear regression analysis was applied to explore the association between education (years at school) and mental distress (HSCL score). RESULTS: A random sample of 2391 (99.6% response) men and women aged 18-49 years participated in the study. The prevalence of mental distress was 18.0% (95% confidence interval (CI): 14.7-21.9), being higher among women (21.2%; 95% (CI): 16.6-26.6) than men (14.9%; 95% (CI): 11.4-19.2). Older-age, being separated or divorced and having a higher number of children were associated with increased mental distress. In linear regression analyses, adjusted for confounders (age, marital status and income), there was a significant negative association between years at school and mental distress among women and older men (> 30 years), but not among the youngest men. CONCLUSIONS: The prevalence of mental distress is high, and there is an association between HSCL-10 score and education. Due to the scarcity of mental health services in Myanmar, the findings indicate a need for a mental health policy to handle the burden of mental health problems in Yangon, a burden which is probably high within the country.

Utilization of insecticide-treated bed nets and care-seeking for fever and its associated socio-demographic and geographical factors among under-five children in different regions: evidence from the Myanmar Demographic and Health Survey, 2015-2016.

BACKGROUND: Malaria is one of the top-five contributors to under-5 deaths in Myanmar. Use of insecticide-treated nets (ITN) and receiving early appropriate care in case of fever are the core interventions to prevent malaria and its complications and thereby deaths. This study aimed to assess among the under-five children, (a) utilization of ITNs and its associated factors, (b) care-seeking behaviour among their caregivers and its associated factors and uptake of malaria testing among those with fever in the last 2 weeks. METHODS: This was a cross sectional study using secondary analysis of Myanmar Demographic and Health Survey (MDHS) conducted in 2015-2016. Multivariable logistic regression was used to explore the factors associated with non-utilization of ITNs and not seeking care for fever. Effect sizes have been presented using odds ratios with 95% confidence intervals. Data analysis was done using svyset command in STATA to account for the multi-stage sampling design of the survey. RESULTS: Of 4597 alive under-five children, 80.5% did not sleep under an ITN last night. The factors significantly associated with non-utilization of ITNs were residing in malaria elimination regions (aOR = 2.0, 1.3-3.2), urban residence (aOR = 1.8, 1.2-2.9), staying in delta region (aOR = 8.7, 4.7-12.2), hilly region (aOR = 3.0, 2.0-4.6, and having highest wealth quintile (aOR = 1.8, 1.1-3.0). Around 16% had fever in the last 2 weeks, of whom 66.7% sought care for fever and 3% got tested for malaria. Nearly half (50.9%) of the caregivers sought care from a government health facility, followed by private hospital/doctor (27.8%), shop (8.0%), village health worker (4.4%) and pharmacy (3.1%). The factors associated with not seeking care for fever were residing in specific geographical locations (hilly, delta and central plains compared to coastal region) and having lowest wealth quintile (aOR = 2.3, 1.1-5.7). CONCLUSIONS: This study highlighted that ownership and utilization of ITNs was very poor among under-5children. Care-seeking behaviour of the caregivers of under-5 children in case of fever was dismal with two-thirds not seeking care. The programme should seriously consider addressing these barriers if Myanmar is to achieve zero malaria deaths by 2030.

Emerging neglected helminthiasis and determinants of multiple helminth infections in flood-prone township in Myanmar.

BACKGROUND: Myanmar has similar agro-based ecology and environmental risks as others in the Greater Mekong sub-region leading to the broad array of helminthic infections. Basic health staff (BHS) from the public sector forms a key stakeholder group in deworming interventions. The study aimed to ascertain the prevalence and determinants of multiple species helminth infections to promote township-level integrated interventions. METHODS: A cross-sectional implementation research study in 2017 covered randomly selected 240 households in four villages of Shwegyin Township. Trained interviewers administered the pre-tested structured questionnaire to either the household head or the assigned person concerning their knowledge, perceptions, practices, food habits, and deworming experience. Concomitantly, the research team collected a single stool sample from each of 698 participants (age range of 8 months to 87 years) from 93% (224/240) of eligible households and examined by Kato-Katz smear microscopy. Eventually, 16 BHS joined the interactive dialogue session based on research evidence and knowledge translated for further validation. RESULTS: The estimated prevalence of at least one helminth infection was 24% [168/698; 95% CI 21.0-27.0]. Apart from the soil-transmitted helminths (14%), zoonotic helminths especially Taenia spp. (0.7%) and Schistosoma spp. (3%) were detected. Almost half of the seasonally mobile gold panning workers (12/25; 48%) and 46% of pre-school-age children had helminth infections. Community risk groups at riverside villages had significantly higher multiple species helminth infection than those from inland villages (AOR = 10.9; 95% CI 4.9-24.2). Gold panning workers had higher infection rates than other categories (AOR = 2.5; 95% CI 0.6-9.5) but not significant. In flood-prone areas, householders failed to follow the guidelines to construct/re-construct specific type of sanitary latrines and challenges remained in disseminating health messages for community engagement. The innovative ideas recapitulated by BHS included the integration of health talks during the sessions for small agricultural loans and to harness advocacy with water, sanitation, and hygiene interventions. CONCLUSIONS: The emerging evidence of neglected zoonotic helminths required attention to introduce the periodic mopping-up and the "selective deworming plan" for vulnerable groups to cover the missed targets. Further multidisciplinary research to confirm the intermediate hosts and vectors of zoonotic helminths in the environment is essential for surveillance and response.

Child and adolescent psychiatry in the Far East: A 5-year follow up on the Consortium on Academic Child and Adolescent Psychiatry in the Far East (CACAP-FE) study.

AIM: Data pertaining to child and adolescent psychiatry (CAP) training systems are limited as extant research has mostly been derived from one-time data collection. This 5-year follow-up survey collects updated information on CAP training systems in the Far East, allowing for the tracking of system changes over the past 5 years. METHODS: Data were obtained from 18 countries, or functionally self-governing areas, in the Far East, 17 of which were also included in the original study. An online questionnaire was completed by leading CAP professionals in each country. Questions were expanded in the present study to capture the contents of CAP training. RESULTS: When compared to data from the original study, there has been progress in CAP training systems in the last 5 years. Specifically, there has been an increase in the number of countries with CAP training programs and national guidelines for the training. In addition, the number of CAP departments/divisions affiliated with academic institutions/universities has increased. Findings from 12 of 18 countries in the present study provide data on clinical contents. All informants of the present study reported the need for more child and adolescent psychiatrists and allied professionals. CONCLUSION: Despite progress in CAP training systems over the last 5 years, the need for more professionals in child and adolescent mental health care in all the relevant areas in this region have yet to be adequately addressed. Continued national efforts and international collaborations are imperative to developing and sustaining new CAP training systems while facilitating improvements in existing programs.

Access to primaquine in the last mile: challenges at the service delivery points in pre-elimination era, Myanmar.

BACKGROUND: Alongside monitoring of the disease burden, the successful move towards malaria elimination relies on the readiness of the health care delivery system. However, there is a lack of evidence in the gap of existing National Guidelines and access to low dose primaquine in real practice under varying degrees of antimalarial resistance in the pre-elimination phase in Myanmar. Therefore, this study addressed the essential information from the service delivery points (SDPs) of public and private sectors on the availability and the use of primaquine in both supply and demand side. Concomitantly, the study aimed to underscore challenges in health system infrastructure to promote the sustained flow in rolling out primaquine in line with National Guidelines for malaria elimination. METHODS: A cross-sectional study conducted from September 2017 to February 2018 included six townships of three states/regions. The team used an observation checklist for documenting primaquine supplies at SDPs. Semi-structured interviews, key informant, and in-depth interviews focused both public and private sectors including staff from the Vector-Borne Diseases Control (VBDC) teams in each state/region and rural health centers (n = 25), those from the non-governmental organizations (NGOs), general practitioners and drug sellers (n = 11), and recently infected malaria patients (n = 11). Triangulation of quantitative and qualitative data provided meaningful interpretations. RESULTS: Public sector staff reported an adequate stock of primaquine, but it was unavailable at the general practitioners' clinics without any connection to NGOs and also at the unlicensed drug shops. Health care providers of the public sector experienced challenges in poor compliance of malaria patients to primaquine treatment in conjunction with an artemisinin-based combination therapy, loss-to-follow-ups especially in conflict areas, and delays in timely substitution of new batches of primaquine. Respondents from the private sector demanded for the refresher training course on updated antimalarial treatment guidelines. CONCLUSION: Monitoring compliance and safety of primaquine treatment was found as a barrier especially among mobile migrant workers and those who were in conflict areas. An alternative strategy by the NMCP could enable to prevent the underutilization of primaquine in vivax malaria to reach the malaria elimination targets.

Household ownership and utilization of insecticide-treated nets under the Regional Artemisinin Resistance Initiative in Myanmar.

BACKGROUND: Malaria is a major public health problem in Myanmar with reported artemisinin resistance. Myanmar promotes the use of insecticide-treated nets (ITNs) through the free delivery of long-lasting insecticide nets (LLINs) with target coverage of at least 80% in moderate and high-risk areas by 2014. Migrant people are at greater risk of malaria. They have significant barriers to health care services for febrile illness and malaria. Thus, a community-based survey was conducted among the migrant population to assess the ownership and utilization of bed nets (ITN/LLINs) for malaria. METHODS: The study analyzed secondary data from a community-based malaria survey conducted in 2014 among migrant population in 30 randomly selected townships out of 52 Regional Artemisinin Resistance Initiative (RAI) townships. In each township, five migrant sites were randomly selected (total of 150 migrant sites). A total of 3933 households (approximately 125 households from each township) were selected. RESULTS: Of 3923 households assessed, 97% had access to at least one bed net (any type), but only half had access to ITN/LLINs. Only 24% of households had adequate ITN/LLIN access (at least one ITN/LLIN per two persons). In terms of household utilization, 94.3% slept under a bed net (any type) the previous night. Only 43.4% slept under an ITN/LLIN. ITN/LLIN utilization in children under 5 years and pregnant women (high-malaria risk groups) was 45.3 and 46.6%, respectively. Of all nets, 31.3% had holes or had already undergone repairs. In terms of insecticide treatment status, 52.9% of bed nets were untreated and 35.9% of ITNs had not been treated with insecticide for more than a year. CONCLUSION: This study highlights poor access and high utilization of ITN/LLINs among migrant population, particularly among children and pregnant women. It highlights the need for improving bed net coverage and access to ITN/LLINs through bed net distributions and/or social marketing with the focus on migrant population and targeting of households with children and pregnant women.

Rapid progress towards elimination of lymphatic filariasis in endemic regions of Myanmar as a result of 16 years of anti-filarial activities (2001-2016).

BACKGROUND: As Myanmar progresses towards lymphatic filariasis (LF) elimination, it is important to know how well the anti-filarial activities have performed. The present study was conducted to study the implementation of the key anti-filarial activities and their impact on key indicators of LF transmission. METHODS: A secondary analysis of aggregate program data on the anti-filarial activities was conducted in four endemic state/regions of Myanmar receiving at least six mass drug administration (MDA) rounds during 2001-2016. RESULTS: MDA coverage has been expanded to cover all the endemic implementation units (IUs), i.e., 45 by 2015 and 6 IUs out of them have already stopped MDA. The reported coverage of MDA ranges from 87 to 100% whereas surveyed coverage ranges from 78 to 100% among the eligible population. The prevalence of microfilaria has significantly declined especially in Magway from 4.7 to 0.2% and Sagaing region from 7.9 to 1.3% during 2001-2016. Around 2.5% of estimated cases of hydrocele were reported to the program during 2009-2014. CONCLUSION: Myanmar has achieved significant success in interrupting LF transmission through several MDA rounds with high coverage. However, morbidity reporting and management, being in its initial phase requires an active surveillance system for identifying and managing people with LF-associated morbidities under the program.

Assessment of household ownership of bed nets in areas with and without artemisinin resistance containment measures in Myanmar.

BACKGROUND: Myanmar lies in the Greater Mekong Subregion where there is artemisinin-resistant Plasmodium falciparum malaria. As the artemisinin compound is the pillar of effective antimalarial therapies, containing the spread of artemisinin resistance is a national and global priority. The use of insecticide-treated bed nets/long-lasting insecticidal nets (ITNs/LLINs) is the key intervention for ensuring the reduction of malaria transmission and the spread of resistant strains, and for eventually eliminating malaria. This study aimed at assessing household ownership of, access to, and utilization of bed nets in areas of Myanmar with and without artemisinin resistance containment measures. METHODS: Secondary data from a nationwide community-based malaria survey conducted by the National Malaria Control Program in 2014 were analyzed. Based on evidence of artemisinin resistance, Myanmar was divided into tiers 1, 2, and 3: townships in tiers 1 and 2 were aggregated as the Myanmar Artemisinin Resistance Containment (MARC) areas and were compared with tier 3 townships, which were defined as non-MARC areas. The chi-square test was used to compare groups, and the level of significance was set at P ≤ 0.05. RESULTS: Of the 6328 households assessed, 97.2% in both MARC and non-MARC areas had at least one bed net (any type), but only 63% of households had ITNs/LLINs. Only 44% of households in MARC areas and 24% in non-MARC areas had adequate numbers of ITNs/LLINs (one ITN/LLIN per two persons, P <  0.001). Nearly 44% of household members had access to ITNs/LLINs. Regarding the utilization of ITNs/LLINs, 45% of household members used them in MARC areas and 36% used them in non-MARC areas (P <  0.001, desired target = 100%). Utilization of ITNs/LLINs among children aged below five years and pregnant women (high malaria risk groups) was low, at 44% and 42%, respectively. CONCLUSIONS: This study highlights the nationwide shortfalls in the ownership of, access to, and utilization of ITNs/LLINs in Myanmar, which is of particular concern in terms of containing the spread of artemisinin resistance. It highlights the need for priority attention to be paid and mobilization of resources in order to improve bed net coverage and utilization through bed net distribution and/or social marketing, information dissemination, and awareness-raising.

Awareness of malaria and treatment-seeking behaviour among persons with acute undifferentiated fever in the endemic regions of Myanmar.

BACKGROUND: Myanmar has a high burden of malaria with two-third of the population at risk of malaria. One of the basic elements of the Roll Back Malaria Initiative to fight against malaria is early diagnosis and treatment within 24 h of fever. Public awareness about malaria is a key factor in malaria prevention and control and in improving treatment-seeking behaviour. METHODS: A large community-based survey was carried out in 27 townships of malaria endemic regions in Myanmar in 2015 which reported on the knowledge, behaviour and practices around malaria in the general population. We used the data already collected in this survey to assess (i) general public awareness of malaria and (ii) treatment-seeking behaviour and associated factors among persons with acute undifferentiated fever. RESULTS: A total of 6597 respondents from 6625 households were interviewed (response rate of 99.5%). About 85% of the respondents were aware that mosquito bite was the mode of transmission of malaria and 90% mentioned that malaria was preventable. However, only 16% of the respondents knew about anti-malaria drug resistance. There were certain misconceptions about the transmission of malaria such as dirty water, same blood group, sharing shelter, sleeping/eating together and poor hygiene. Health facility staff were the most common source of information about malaria (80%). Nearly one-fourth (23%) of the respondents with fever resorted to self-medication. Around 28% of the respondents with fever underwent blood testing, less than half of whom (44%) were tested within 24 h. Elderly age group, females, those with poor knowledge about malaria and those residing in non-Regional Artemisinin Resistance Initiative townships were associated with poor treatment-seeking behaviour in case of fever. CONCLUSION: Although there is fair knowledge on mosquito bite as a mode of transmission and prevention of malaria, there are some misconceptions about transmission of malaria. Those having poor knowledge about malaria have poor treatment-seeking behaviour. A considerable number of respondents seek care from informal care providers and seek care late. Thus, there is a need to promote awareness about the role of early diagnosis and appropriate treatment and address misconceptions about transmission of malaria.

The burden of dengue, source reduction measures, and serotype patterns in Myanmar, 2011 to 2015-R2.

BACKGROUND: Myanmar is currently classified as a high burden dengue country in the Asian Pacific region. The Myanmar vector-borne diseases control (VBDC) program has collected data on dengue and source reduction measures since 1970, and there is a pressing need to collate, analyze, and interpret this information. The aim of this study was to describe the burden of hospital-based dengue disease, dengue control measures, and serotype patterns in Myanmar between 2011 and 2015. METHODS: This was a cross-sectional study using annual records from the Dengue Fever/Dengue Hemorrhagic Fever Prevention and Control Project in Myanmar. RESULTS: Between 2011 and 2015, there were a total of 89,832 cases and 393 deaths in hospitals, with 97% of cases being in children. In 2013 and 2015, there was an increased number of cases, respectively at 21,942 and 42,913, while during the other 3 years, numbers ranged from 4738 to 13,806. The distribution of dengue deaths each year mirrored the distribution of cases. Most cases (84%) occurred in the wet season and 54% occurred in the delta/lowlands. Case fatality rate (CFR) was highest in 2014 at 7 per 1000 dengue cases, while in the other years, it ranged from 3 to 5 per 1000 cases. High CFR per 1000 were also observed in infants < 1 year (CFR = 8), adults ≥ 15 years (CFR = 7), those with disease severity grade IV (CFR = 17), and those residing in hilly regions (CFR = 9). Implementation and coverage of dengue source reduction measures, including larval control, space spraying, and health education, all increased between 2012 and 2015, although there was low coverage of these interventions in households and schools and for water containers. In the 2013 outbreak, dengue virus serotype 1 predominated, while in the 2015 outbreak, serotypes 1, 2, and 4 were those mainly in circulation. CONCLUSION: Dengue is a serious public health disease burden in Myanmar. More attention is needed to improve monitoring, recording, and reporting of cases, deaths, and vector control activities, and more investment is needed for programmatic research.