Ownership and use of insecticide-treated nets in Myanmar: insights from a nationally representative demographic and health survey.

BACKGROUND: Malaria poses a substantial public health threat in Myanmar, indicating the need for rigorous efforts to achieve elimination of the disease nationwide by 2030. The use of insecticide-treated nets (ITNs) forms part of a pivotal strategy for preventing transmission. This study explored the ownership and use of ITNs in Myanmar and identified factors associated with non-use of ITNs. METHODS: Household datasets from the 2015-2016 Myanmar Demographic and Health Survey were utilised, which encompassed all household members except children under the age of five. Descriptive statistics and inferential tests, including simple and multiple logistics regression models and Pearson correlations, were employed for analysis. All analyses, taking the two-stage stratified cluster sampling design into account, used weighting factors and the "svyset" command in STATA. The ownership and use of bed nets were also visualised in QGIS maps. RESULTS: Among the 46,507 participants, 22.3% (95% CI 20.0%, 24.5%) had access to ITNs, with only 15.3% (95% CI 13.7, 17.1%) sleeping under an ITN the night before the survey. Factors associated with the non-use of ITNs included age category (15-34 years-aOR: 1.17, 95% CI 1.01, 1.30; 50+ years-aOR: 1.19, 95% CI 1.06, 1.33), location (delta or lowland-aOR: 5.39, 95% CI 3.94, 7.38; hills-aOR: 1.80, 95% CI 1.20, 2.71; plains-aOR: 3.89, 95% CI 2.51, 6.03), urban residency (aOR: 1.63, 95% CI 1.22, 2.17), and wealth quintile (third-aOR: 1.38, 95% CI 1.08, 1.75; fourth-aOR: 1.65, 95% CI 1.23, 2.23; fifth-aOR: 1.47, 95% CI 1.02, 2.13). A coherent distribution of the ownership and use of ITNs was seen across all states/regions, and a strong correlation existed between the ownership and use of ITNs (r: 0.9795, 95% CI 0.9377, 0.9933, alpha < 0.001). CONCLUSIONS: This study identified relatively low percentages of ITN ownership and use, indicating the need to increase the distribution of ITNs to achieve the target of at least one ITN per every two people. Strengthening the use of ITNs requires targeted health promotion interventions, especially among relatively affluent individuals residing in delta or lowland areas, hills, and plains.

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

BACKGROUND: Plasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients' commitment to PQ treatment in a highly malaria-endemic township in Myanmar. METHODS: A qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis. RESULTS: Responsible individuals from different levels of the Myanmar National Malaria Control Programme participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community's malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted. CONCLUSION: In rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

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

Background: Plasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients' commitment to PQ treatment in a highly malaria-endemic township in Myanmar. Methods: A qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis. Results: Responsible individuals from different levels of the Myanmar National Malaria Control Program participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community's malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted. Conclusion: In rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

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

INTRODUCTION: Myanmar has been identified as one of the tuberculosis (TB) high-burden countries and having an understanding of TB transmission is vital for personal infection prevention as well as preventing transmission to others. This study aimed to identify the determinants of correct knowledge on TB transmission and self-reported TB prevalence among general population in Myanmar. METHODS: This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015-16. The determinants of correct knowledge on TB transmission mode and self-reported prevalence of TB were assessed using multivariable logistic regression models. Weighted estimates were provided in all analyses to account for the multistage sampling design used in the survey. RESULTS: Among the respondents, less than half (44.6%, 95% CI: 43.9, 45.4) had the overall correct knowledge about TB transmission and misconceptions. Older age group, female gender, those with higher education and higher socioeconomic status, and exposed to mass media at least once a week, residents from the delta and lowland region or plain areas were more likely to have correct knowledge about TB transmission. The overall prevalence rate of self-reported TB was 2.6% (95%CI: 2.4, 2.9) and the prevalence was higher among older age group and males. CONCLUSION: Our study highlights the need for targeted efforts to improve awareness and understanding of TB transmission among general population in Myanmar. The study suggests the implementation of appropriate, innovative, and comprehensive targeted TB education and communication strategies.

Factors hindering coverage of targeted mass treatment with primaquine in a malarious township of northern Myanmar in 2019-2020.

Targeted mass primaquine treatment (TPT) might be an effective intervention to facilitate elimination of vivax malaria in Myanmar by 2030. In this study, we explored the factors hindering coverage of a TPT campaign conducted in a malarious township of northern Myanmar. From August 2019 to July 2020, a cross-sectional exploratory design including quantitative and qualitative data was conducted in five villages with high P. vivax prevalence following a TPT campaign. Among a targeted population of 2322; 1973 (85.0%) participated in the baseline mass blood survey (MBS) and only 52.0% of the total targeted population (1208, 91.9% of total eligible population) completed the TPT. G6PD deficiency was found among 13.5% of total MBS participants and those were excluded from TPT. Of 1315 eligible samples, farmers and gold miners, males, and those aged 15 to 45 years had higher percentages of non-participation in TPT. Qualitative findings showed that most of the non-participation groups were outside the villages during TPT because of time-sensitive agricultural and other occupational or education-related purposes. In addition to mitigating of some inclusion criteria (i.e. including young children or offering weekly PQ treatment to G6PD deficient individuals), strengthening community awareness and increasing engagement should be pursued to increase community participation.

Spatio-temporal trends of malaria incidence from 2011 to 2017 and environmental predictors of malaria transmission in Myanmar.

BACKGROUND: Myanmar bears the heaviest malaria burden in the Greater Mekong Subregion (GMS). This study assessed the spatio-temporal dynamics and environmental predictors of Plasmodium falciparum and Plasmodium vivax malaria in Myanmar. METHODS: Monthly reports of malaria cases at primary health centers during 2011-2017 were analyzed to describe malaria distribution across Myanmar at the township and state/region levels by spatial autocorrelation (Moran index) and spatio-temporal clustering. Negative binomial generalized additive models identified environmental predictors for falciparum and vivax malaria, respectively. RESULTS: From 2011 to 2017, there was an apparent reduction in malaria incidence in Myanmar. Malaria incidence peaked in June each year. There were significant spatial autocorrelation and clustering with extreme spatial heterogeneity in malaria cases and test positivity across the nation (P < 0.05). Areas with higher malaria incidence were concentrated along international borders. Primary clusters of P. falciparum persisted in western townships, while clusters of P. vivax shifted geographically over the study period. The primary cluster was detected from January 2011 to December 2013 and covered two states (Sagaing and Kachin). Annual malaria incidence was highest in townships with a mean elevation of 500‒600 m and a high variance in elevation (states with both high and low elevation). There was an apparent linear relationship between the mean normalized difference vegetative index and annual P. falciparum incidence (P < 0.05). CONCLUSION: The decreasing trends reflect the significant achievement of malaria control efforts in Myanmar. Prioritizing the allocation of resources to high-risk areas identified in this study can achieve effective disease control.

Malaria Preventive Practices among People Residing in Different Malaria-Endemic Settings in a Township of Myanmar: A Mixed-Methods Study.

Different villages in a township or an area exhibit different malaria endemicities. This study aimed to investigate malaria preventive practices among people residing in different villages with stratified malaria endemicity in a township in Myanmar. Quantitative data were collected using standardized questionnaires by conducting face-to-face interviews, and qualitative data were obtained through in-depth interviews using a guideline. Quantitative data were analyzed using descriptive statistics and logistic regression models, whereas thematic analysis was used to visualize qualitative data. A total of 360 respondents with similar characteristics participated in the quantitative study. Knowledge regarding malaria and the availability of health information exhibited insignificant differences. Malaria preventive practices were considerably poor among people from moderate- and high-endemic villages (p < 0.05). Adult male farmers or gold miners with low annual family incomes reported poor preventive practices in both moderate- and high-endemic groups. People could not practice some malaria preventive measures because of a lack of resources, e.g., a lack of mosquito repellents. To eliminate the disparities of preventive practices in different malaria-endemic settings, heath-awareness-raising activities should be increased, especially in moderate- and high-endemic villages.

Utilization of insecticide-treated bed nets among pregnant women in Myanmar-analysis of the 2015-2016 Demographic and Health Survey.

BACKGROUND: Due to the effectiveness of insecticide-treated nets (ITNs), most malaria-endemic countries resort to free distributions in the population with particular attention to pregnant women, a more vulnerable group. However, the mere issuance of ITNs does not usually translate to proper utilization. This study aimed to examine the utilization of ITNs and its associated factors among pregnant women in Myanmar. METHODS: The data analyzed in this cross-sectional study were extracted from available survey datasets of the 2015-16 Myanmar Demographic Health Survey. The secondary data were presented using a chart, descriptive statistics and inferential statistics including simple and multiple logistic regression models. All analyses were performed using STATA, Version 15. A p-value <0.05 was considered statistically significant. RESULTS: Of 466 currently pregnant women, the majority (96%) possessed bed nets for sleeping. Among them, 15.9% slept without a bed net the night before the survey, while 65.7% slept with untreated nets. Only about 1 in 5 (18.4%) slept under ITNs. In the multivariate logistic regression analysis, pregnant women residing in delta and lowland regions [adjusted odds ratio (aOR) = 7.70, 95% confidence interval (CI): 3.62, 16.38], plains (aOR = 7.09, 95%CI: 3.09, 16.25) or hilly areas (aOR = 4.26, 95%CI: 1.91, 9.52) were more likely to report non-utilization of ITNs than those residing in coastal regions. CONCLUSION: Relatively poor ITN utilization was observed among pregnant women in Myanmar. Health promotion activities for ITN utilization should be implemented especially for pregnant women residing in the delta, lowland, plain and hilly regions. Other social-behavioral factors including perceived susceptibility to malaria, knowledge of ITNs, and attitude towards ITN that might favor the non-utilization of ITNs need to be further explored.

Evaluation of the effectiveness and cost effectiveness of a Community-delivered Integrated Malaria Elimination (CIME) model in Myanmar: protocol for an open stepped-wedge cluster-randomised controlled trial.

INTRODUCTION: In the Greater Mekong Subregion, community health workers, known as malaria volunteers, have played a key role in reducing malaria in the control phase, providing essential malaria services in areas with limited formal healthcare. However, the motivation and social role of malaria volunteers, and testing rates, have declined with decreasing malaria burden and reorientation of malaria programmes from control to elimination. Provision of additional interventions for common health concerns could help sustain the effectiveness of volunteers and maintain malaria testing rates required for malaria elimination accreditation by the WHO. METHODS AND ANALYSIS: The Community-delivered Integrated Malaria Elimination (CIME) volunteer model, integrating interventions for malaria, dengue, tuberculosis, childhood diarrhoea and malaria Rapid Diagnostic Test (RDT)-negative fever, was developed based on global evidence and extensive stakeholder consultations. An open stepped-wedge cluster-randomised controlled trial, randomised at the volunteer level, will be conducted over 6 months to evaluate the effectiveness of the CIME model in Myanmar. One hundred and forty Integrated Community Malaria Volunteers (ICMVs, current model of care) providing malaria services in 140 villages will be retrained as CIME volunteers (intervention). These 140 ICMVs/villages will be grouped into 10 blocks of 14 villages, with blocks transitioned from control (ICMV) to intervention states (CIME), fortnightly, in random order, following a 1-week training and transition period. The primary outcome of the trial is blood examination rate determined by the number of malaria RDTs performed weekly. Difference in rates will be estimated across village intervention and control states using a generalised linear mixed modelling analytical approach with maximum likelihood estimation. ETHICS AND DISSEMINATION: The study was approved by Institutional Review Board, Myanmar Department of Medical Research (Ethics/DMR/2020/111) and Alfred Hospital Ethics Review Committee, Australia (241/20). Findings will be disseminated in peer-review journals, conferences and regional, national and local stakeholder meetings. TRIAL REGISTRATION NUMBER: NCT04695886.

Performance of Malaria Volunteers regarding Malaria Control Activities in Southeastern Myanmar: A Study in the Areas under Coverage of an Ethnic Health Organization.

Malaria volunteers (MVs) play an essential role in resolving malaria problems by delivering greater access to diagnosis and treatment services, mainly for the underserved community residing in hard-to-reach rural areas. The Karen Department of Health and Welfare (KDHW) has implemented community-based malaria control activities among the ethnic minorities in southeastern Myanmar by promoting the roles of MVs. This study aimed to explore the factors influencing the performance of MVs regarding malaria control activities in the area. From July to August 2019, a cross-sectional study was conducted in 12 townships of southeastern Myanmar under the umbrella of the KDHW malaria project. A total of 140 MVs were employed as study participants. Data were collected through face-to-face interviews using a structured questionnaire. For data analyses, descriptive statistics, chi-squared tests, and logistics regression models were applied. More than half of the MVs perceived a good level of performance on malaria control activities. A higher level of performance has been observed among the MVs who had another job (AOR: 1.9, 95% CI: 1.2-3.9), those experienced in health-related fields (AOR: 1.9, 95% CI: 1.4-4.9), who received good community support (AOR: 2.1, 95% CI: 1.3-10.9), who were volunteers beyond three years (AOR: 4.0, 95% CI: 2.8-9.2), and whose family income totaled over 500,000 MMK (AOR: 2.8, 95% CI: 1.6-4.2). The results mentioned the characteristics which should be prioritized in recruiting MVs. MV network and their workforce need to be nurtured by encouraging community support. For performance sustainability, attractive incentive schemes or a salary should be subsidized in support of their livelihoods.

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.