Progress towards malaria elimination in the Greater Mekong Subregion: perspectives from the World Health Organization.

Malaria remains a global health challenge, disproportionately affecting vulnerable communities. Despite substantial progress, the emergence of anti-malarial drug resistance poses a constant threat. The Greater Mekong Subregion (GMS), which includes Cambodia, China's Yunnan province, Lao People's Democratic Republic, Myanmar, Thailand, and Viet Nam has been the epicentre for the emergence of resistance to successive generations of anti-malarial therapies. From the perspective of the World Health Organization (WHO), this article considers the collaborative efforts in the GMS, to contain Plasmodium falciparum artemisinin partial resistance and multi-drug resistance and to advance malaria elimination. The emergence of artemisinin partial resistance in the GMS necessitated urgent action and regional collaboration resulting in the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030), advocating for accelerated malaria elimination interventions tailored to country needs, co-ordinated and supported by the WHO Mekong malaria elimination programme. The strategy has delivered substantial reductions in malaria across all GMS countries, with a 77% reduction in malaria cases and a 97% reduction in malaria deaths across the GMS between 2012 and 2022. Notably, China was certified malaria-free by WHO in 2021. Countries' ownership and accountability have been pivotal, with each GMS country outlining its priorities in strategic and annual work plans. The development of strong networks for anti-malarial drug resistance surveillance and epidemiological surveillance was essential. Harmonization of policies and guidelines enhanced collaboration, ensuring that activities were driven by evidence. Challenges persist, particularly in Myanmar, where security concerns have limited recent progress, though an intensification and acceleration plan aims to regain momentum. Barriers to implementation can slow progress and continuing innovation is needed. Accessing mobile and migrant populations is key to addressing remaining transmission foci, requiring effective cross-border collaboration. In conclusion, the GMS has made significant progress towards malaria elimination, particularly in the east where several countries are close to P. falciparum elimination. New and persisting challenges require sustained efforts and continued close collaboration. The GMS countries have repeatedly risen to every obstacle presented, and now is the time to re-double efforts and achieve the 2030 goal of malaria elimination for the region.

Antibiotic Use in Broiler Poultry Farms in Kathmandu Valley of Nepal: Which Antibiotics and Why?

Inappropriate antibiotic use in food-producing animals is associated with the emergence and spread of antibiotic resistance. In industrial broiler poultry farms in three districts of Kathmandu valley, Nepal, we assessed antibiotic use prevalence, and their classes, types, and quantities. A cross-sectional questionnaire study involving field visits to large poultry farms (flock size ≥ 3000) of the Kathmandu, Bhaktapur, and Lalitpur districts was conducted. Of 30 farms (total flock size 104,200; range 3000-6000), prevalence of antibiotic use was 90% (95% CI: 73-98%). Six (22%) farms used antibiotics as prophylaxis, while 21 (78%) used it for therapeutics. Seven antibiotics from six classes (including quinolones, macrolides, and polymyxins) were used. The most commonly used antibiotics were tylosin (47%), colistin (47%), and dual therapies with neomycin and doxycycline (33%). A total of 50,000 grams of antibiotics (total weight including active and inactive ingredients) were used (0.5 grams/chicken/45 days of flock life) with eight (26%) farms using more than two antibiotics. No farms had records on clinical indications for prophylaxis or treatment. No post-mortem records of sick birds were available. Prevalence of antibiotic use in broiler farms of Kathmandu valley is high and includes "highest priority critically important antibiotics" for human use, with direct implications on public health.

Decreasing Trends in Antibiotic Consumption in Public Hospitals from 2014 to 2017 Following the Decentralization of Drug Procurement in Myanmar.

(1) Background: In 2014, drug procurement for public hospitals in Myanmar was decentralized to a pull system. This might lead to increasing trends in the consumption of broad-spectrum and last-resort antibiotics. For fiscal years 2014-2017, we assessed annual antibiotic consumption trends and patterns in total defined daily doses (DDDs). (2) Methods: We followed World Health Organization (WHO) methodology for surveillance of antimicrobial consumption based on hospital antibiotic procurement records (as a proxy). (3) Results: In 32% of all public hospitals where data were retrieved, total antibiotic consumption reduced by 19% between 2014 (7,122,852 DDD) and 2017 (5,794,904 DDD). Consumption per 1000 inhabitants per day (<200 bed hospitals) also reduced from 0.6 to 0.3. Over 60% of procurement was for beta-lactam antibiotics and quinolones; quinolones decreased over time. Consumption of first-line antibiotics increased (42% in 2014 to 54% in 2017), whereas broad-spectrum antibiotics decreased (46% in 2014 to 38% in 2017). Linezolid was the only last-resort antibiotic procured. There was a progressive reduction in per capita government current health expenditure from approximately 9.2 US$ in 2014 to 8.3 US$ in 2017. (4) Conclusions: Antibiotic consumption decreased over time in public hospitals. This first study provides a baseline for developing an antibiotic consumption surveillance system in Myanmar.

Efficacy and Safety of Pyronaridine-Artesunate for the Treatment of Uncomplicated Plasmodium falciparum and Plasmodium vivax Malaria in Myanmar.

Four single-arm, prospective, clinical studies of pyronaridine-artesunate efficacy in uncomplicated Plasmodium falciparum or Plasmodium vivax malaria were conducted in Myanmar between 2017 and 2019. Eligible subjects were aged at least 6 years, with microscopically confirmed P. falciparum (n = 196) or P. vivax mono-infection (n = 206). Patients received pyronaridine-artesunate once daily for 3 days with follow-up until day 42 for P. falciparum or day 28 for P. vivax. For the primary efficacy analysis, adequate clinical and parasitological response (ACPR) in the per-protocol population at day 42 for P. falciparum malaria was 100% (88/88; 95% CI: 95.9, 100) in northern Myanmar (Kachin State and northern Shan State), and 100% (101/101; 95% CI: 96.4, 100) in southern Myanmar (Tanintharyi Region and Kayin State). Plasmodium falciparum day-3 parasite clearance was observed for 96.9% (190/196) of patients. Mutations in the P. falciparum Kelch propeller domain (K13) were detected in 39.0% (69/177) of isolates: F446I (14.7% [26/177]), R561H (13.0% [23/177]), C580Y (10.2% [18/177]), and P574L (1.1% [2/177]). For P. vivax, the day-28 ACPR was 100% (104/104; 95% CI: 96.5, 100) in northern Myanmar and 100% (97/97; 95% CI: 96.3, 100) in southern Myanmar. Across both P. vivax studies, 100% (206/206) of patients had day-3 parasite clearance. There were no adverse events. Pyronaridine-artesunate had excellent efficacy in Myanmar against P. falciparum and P. vivax and was well tolerated. This study supports the inclusion of pyronaridine-artesunate in national malaria treatment guidelines for Myanmar.

Multi-sectoral Approach to Non-Communicable Diseases Control: Easier Said than Done.

The burden of non-communicable diseases is growing and countries are committed to combat this and achieve the sustainable development goals and targets. Non-communicable diseases are complex conditions attributed by multiple behavioural risk factors and without understanding the whole ecosystem of such diseases, it is difficult to determine the global goals and targets for them and to take action to address them. Countries are trying to take the multi-sectoral approach in addressing the non-communicable diseases and often encounter challenges in operationalizing the approach. Therefore, it is essential to nuance the multi-sectoral approach to non-communicable diseases in order to better inform application to achieving the sustainable development goals for which multisectoral approach is imperative. Keywords: multi-sectoral; non-communicable diseases; risk factors; sustainable development goals.

Correction to: How are the village health volunteers delivering malaria testing and treatment services and what are the challenges they are facing? A mixed methods study in Myanmar.

[This corrects the article DOI: 10.1186/s41182-018-0110-0.].

How are the village health volunteers deliver malaria testing and treatment services and what are the challenges they are facing? A mixed methods study in Myanmar.

BACKGROUND: Village health volunteers (VHVs) play a key role in delivering community-based malaria care especially in the hard-to-reach areas in Myanmar. It is necessary to assess their performance and understand the challenges encountered by them for effective community management of malaria. This mixed methods study was conducted to (i) understand the cascade of malaria services (testing, diagnosis, referral, and treatment of malaria) provided by the VHVs under the National Malaria Control Programme (NMCP) in Myanmar in 2016 and compare with other health care providers and (ii) explore the challenges in the delivery of malaria services by VHVs. METHODS: A sequential mixed methods study was designed with a quantitative followed by a descriptive qualitative component. The quantitative study was a cohort design involving analysis of secondary data available from NMCP database whereas the qualitative part involved 16 focus group discussions (eight each with community and VHVs) and 14 key informant interviews with program stakeholders in four selected townships. RESULTS: Among 444,268 cases of undifferentiated fever identified by VHVs in 2016, 444,190 were tested using a rapid diagnostic test. Among those tested, 20,375 (4.6%) cases of malaria were diagnosed, of whom 16,910 (83.0%) received appropriate treatment, with 7323 (35.9%) receiving treatment within 24 h. Of all malaria cases, 296 (1.5%) were complicated, of whom 79 (26.7%) were referred to the higher facility. More than two thirds of all cases were falciparum malaria (13,970, 68.6%) followed by vivax (5619, 27.6%). Primaquine was given to 83.6% of all cases. VHVs managed 34.0% of all undifferentiated fever cases, 35.9% of all malaria cases, and identified 38.0% of all Plasmodium falciparum cases reported under NMCP. The key barriers identified are work-related (challenges in reporting, referral, management of malaria especially primaquine therapy, and lack of community support) and logistics related (challenges in transportation, financial constraints, time and shortage of drugs, and test kits). On the other hand, they also enjoy good community support and acceptance in most areas. CONCLUSION: VHVs play an important role in malaria care in Myanmar, especially in the hard-to-reach areas. More programmatic support is needed in terms of logistics, transportation allowance, and supervision to improve their performance.

Are village health volunteers as good as basic health staffs in providing malaria care? A country wide analysis from Myanmar, 2015.

BACKGROUND: Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar. METHODS: This was a retrospective cohort study using record review of routinely collected programme data available in electronic format. All patients with undifferentiated fever screened and diagnosed for malaria in January-December 2015 by VHV and BHS under National Malaria Control Programme in Myanmar were included in the study. Unadjusted and adjusted prevalence ratios (aPR) were calculated to assess the effect of VHV/BHS on receipt of treatment by patients. RESULTS: Of 978,735 undifferentiated fever patients screened in 2015, 11.0% of patients were found malaria positive and the malaria positivity in VHV and BHS group were 11.1 and 10.9% respectively. Access to malaria care: higher proportion of children aged 5-14 years (21.8% vs 17.3%) and females (43.7% vs 41.8%) with fever were screened for malaria by VHV compared to BHS. However, the same for children aged < 5 years was 2.2% lower in VHV group compared to BHS. Quality of malaria care: the proportion of malaria cases that received treatment was 96.6 and 94.9; treatment initiation within 24 h of fever was 44.7 and 34.1; and, complete treatment delivery was 80.9 and 88.2, respectively, in VHV and BHS groups. After adjustment for potential confounders, patients with malaria provided care by VHV had 1.02 times higher chance of receiving treatment compared to BHS [aPR (95% confidence interval) 1.017 (1.015, 1.020)]. CONCLUSIONS: The VHV were more accessible to children and women than BHS in providing malaria screening services. The malaria treatment services provided by VHV was as good as BHS. Further qualitative research to explore and address the challenges on initiation and delivering complete treatment by VHV including inventory assessment and cost-effectiveness studies on integration of VHV in routine health system are needed.

"Alert-Audit-Act": assessment of surveillance and response strategy for malaria elimination in three low-endemic settings of Myanmar in 2016.

BACKGROUND: Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and response strategy similar to "1-3-7" Chinese strategy to achieve sub-national elimination in six low-endemic region/states of the country. Among these, Yangon, Bago-East, and Mon region/states have implemented this malaria surveillance and response strategy with modification in 2016. The current study was conducted to assess the case notification, investigation, classification, and response strategy (NICR) in these three states. METHODS: This was a retrospective cohort study using routine program data of all patients with malaria diagnosed and reported under the National Malaria Control Programme in 2016 from the above three states. As per the program, all malaria cases need to be notified within 1 day and investigated within 3 days of diagnosis and response to control (active case detection and control) should be taken for all indigenous malaria cases within 7 days of diagnosis. RESULTS: A total of 959 malaria cases were diagnosed from the study area in 2016. Of these, the case NICR details were available only for 312 (32.5%) malaria cases. Of 312 cases, the case notification, investigation, and classification were carried out within 3 days of malaria diagnosis in 95.5% cases (298/312). Of 208 indigenous malaria cases (66.7%, 208/312), response to control was taken in 96.6% (201/208) within 7 days of diagnosis. CONCLUSION: The timeline at each stage of the strategy namely case notification, investigation, classification, and response to control was followed, and response action was taken in nearly all indigenous malaria cases for the available case information. Strengthening of health information and monitoring system is needed to avoid missing information. Future research on feasibility of mobile/tablet-based surveillance system and providing response to all cases including imported malaria can be further studied.

Status of Tuberculosis services in Indian Prisons.

INTRODUCTION: Prisons are known to be a high risk environment for tuberculosis (TB) due to overcrowding, low levels of nutrition, poor infection control and lack of accessible healthcare services. India has nearly 1400 prisons housing 0.37 million inmates. However, information on, availability of diagnostic and treatment services for TB in the prison settings is limited. This study examined the availability of TB services in prisons of India. Simultaneously, prison inmates were screened for tuberculosis. METHOD: The study was conducted in 157 prisons across 300 districts between July-December 2013. Information on services available and practices followed for screening, diagnosis and treatment of TB was collected. Additionally, the inmates and prison staff were sensitised on TB using interpersonal communication materials. The inmates were screened for cough ≥2 weeks as a symptom of TB. Those identified as presumptive TB patients (PTBP) were linked with free diagnostic and treatment services. RESULTS: Diagnostic and treatment services for TB were available in 18% and 54% of the prisons respectively. Only half of the prisons screened inmates for TB on entry, while nearly 60% practised periodic screening of inmates. District level prisons (OR, 6.0; 95% CI, 1.6-22.1), prisons with more than 500 inmates (OR, 52; 95% CI, 1.4-19.2), and prisons practising periodic screening of inmates (OR, 2.7; 95% CI, 1.0-7.2) were more likely to diagnose TB cases. 19% of the inmates screened had symptoms of TB (cough ≥2 weeks) and 8% of the PTBP were diagnosed with TB on smear microscopy. CONCLUSION: The TB screening, diagnostic and treatment services are sub-optimal in prisons in India and need to be strengthened urgently.

Serial survey shows community intervention may contribute to increase in knowledge of Tuberculosis in 30 districts of India.

BACKGROUND: Correct knowledge about Tuberculosis (TB) is essential for appropriate healthcare seeking behaviour and to accessing diagnosis and treatment services timely. There are several factors influencing knowledge about TB. The present study was conducted to assess the change in community knowledge of Tuberculosis (TB) and its association with respondent's socio-demographic characteristics in two serial knowledge-attitude-practice surveys. METHODS: Community level interventions including community meetings with youth groups, village health committees and self-help groups and through mass media activities were undertaken to create awareness and knowledge about TB and service availability. Increase in knowledge on TB and its association with respondent's socio-demographic characteristics was assessed by two serial KAP surveys in 2010-2011 (baseline) and 2012-2013 (midline) in 30 districts of India. Correct knowledge of TB was assessed by using lead questions and scores were assigned. The composite score was dichotomized into two groups (score 0-6, poor TB knowledge and score 7-13, good TB knowledge). RESULTS: In baseline and midline survey, 4562 and 4808 individuals were interviewed. The correct knowledge about TB; cough ≥2 weeks, transmission through air, 6-8 months treatment duration, and free treatment increased by 7 % (p-value <0.05), 11 % (p-value <0.05), 2 % (p-value <0.05), and 8 % (p-value <0.05) in midline compared to baseline, respectively. The knowledge on sputum smear test for diagnosis of TB was 66 % in both surveys while knowledge on availability of free treatment and that TB is curable disease decreased by 5 % and 2 % in midline (p-0.001), compared to baseline, respectively. The mean score for correct knowledge about TB increased from 60 % in baseline to 71 % in midline which is a 11 % increase (p-value <0.001). The misconception regarding on transmission of TB by- sharing of food and clothes and handshake persisted in midline. Respondents residing in northern (OR, 2.2, 95 % CI, 1.7-2.6) and western districts (OR, 3.4, 95 % CI, 2.7-4.1) of India and age groups- 25-34 years (OR, 1.3; 95 % CI, 1.1-1.6) and 45-44 years (OR, 1.4; 95 % CI, 1.1-1.7)- were independently associated with good TB knowledge. CONCLUSIONS: The knowledge about TB has increased over a period of 2 years and this may be attributable to the community intervention in 30 districts of India. The study offers valuable lesson for designing TB related awareness programmes in India and in other high burden countries.

Light Emitting Diode Fluorescence Microscopy increased the detection of smear-positives during follow-up of Tuberculosis patients in India: program implications.

BACKGROUND: In India, since July 2012, at designated Microscopy Centers (DMCs) in 200 medical colleges, sputum smear examination for tuberculosis bacilli changed from Ziehl Neelsen (ZN) method to auramine based Light Emitting Diode Fluorescent Microscopy (LED-FM) method. We assessed the additional yield of smear positives among patients undergoing follow-up sputum examination during TB treatment before and after deploying LED-FM. METHODS: This was a before and after comparison study in eight conveniently selected medical college DMCs across North India. We extracted data from TB laboratory registers on number of TB patients examined for follow-up and their smear microscopy results including the grades by ZN (before; July-December 2011) and LED-FM (after; July-December 2012) and compared them. RESULTS: Altogether, 2868 TB patients were examined by LED-FM and 2740 were examined by ZN during follow-up. LED-FM increased the proportion of follow-up smear positives from 5.0 % (n = 136) to 7.4 % (n = 213) with an additional yield of 77 follow-up smear-positives-with the highest increase in smears graded scanty (2.6 vs 1.2 %) (p value <0.05). CONCLUSIONS: Since all smear positives during follow-up are considered 'presumptive multidrug resistant (MDR)-TB patients' in India, introduction of LED-FM would result in additional number of patients eligible for MDR-TB testing, which would have otherwise been missed by ZN.

Co-existence of beta-lactamases in clinical isolates of Escherichia coli from Kathmandu, Nepal.

BACKGROUND: The trend of extended-spectrum beta-lactamases producing Escherichia coli (ESBL-EC) is increasing in Nepal. Limited studies have been reported investigating ESBL types and carbapenemases in E. coli. METHODS: A cross sectional study was conducted between June 2012 to January 2013 in Kathmandu Medical College and Teaching Hospital, Nepal. Non-repetitive clinical samples from out-patient department (OPD) and Intensive Care Units (ICU) were processed for bacteriological culture and identification of E. coli. Antibiotic susceptibility test, screening and phenotypic confirmation for ESBLs and carbapenemases and PCR (blaCTX-M, blaSHV and blaTEM-type ESBLs, blaVIM, blaIMP and blaNDM-1-type carbapenemases, and class 1 integron element integrase gene) were performed. Clones were resolved by PCR-Randomly Amplified Polymorphic DNA. RESULTS: Out of 332 non-repetitive clinical specimens processed for culture and identification 160 (48.2%) were culture positive. Of which, 93 (58.1%) were E. coli. Of these, 24 (25.8%) were phenotypically confirmed as ESBL-EC and 3 (12.50%) of 24 ESBL-EC were carbapenemase producers. blaCTX-M-type ESBL was most common (23, 95.8%) followed by blaTEM (7, 29.2%) and blaSHV (3, 12.5%). blaVIM, blaIMP and blaNDM-1 were present in 3, 2 and 2 ESBL-EC, respectively. Class 1 integron element was present in 18 (75.0%) ESBL-EC. Nine isolates possessed more than one type of beta-lactamases. Interestingly, all carbapenemase producers were isolated form ICU and co-existence of blaCTX-M, blaSHV, blaTEM, blaIMP, blaVIM and blaNDM-1 beta-lactamases was documented in one ESBL-EC (EC104). All most all isolates had different RAPD patterns. CONCLUSIONS: For the first time in Nepal, high prevalence of blaCTX-M-type ESBL and co-existence of ESBLs and carbapenemases has been described. Continuous monitoring and surveillance and proper infection control and prevention practices will limit the further spread of these super-bugs within this hospital and beyond.

LED-fluorescence microscopy for diagnosis of pulmonary tuberculosis under programmatic conditions in India.

BACKGROUND: Light-emitting diode fluorescence microscopy (LED-FM) has been shown to be more sensitive than conventional bright field microscopy using Ziehl-Neelsen (ZN) stain in detecting sputum smear positive tuberculosis in controlled laboratory conditions. In 2012, Auramine O staining based LED-FM replaced conventional ZN microscopy in 200 designated microscopy centres (DMC) of medical colleges operating in collaboration with India's Revised National Tuberculosis Control Programme. We aimed to assess the impact of introduction of LED-FM services on sputum smear positive case detection under program conditions. METHODS: This was a before and after comparison study. In 15 randomly selected medical college DMCs, all presumptive TB patients who underwent sputum smear examination in the years 2011 (before LED-FM) and 2012 (after LED-FM) were compared. An additional 15 comparable DMCs that implemented conventional ZN sputum smear microscopy were also selected for comparison between 2011 and 2012. RESULTS: The proportion of presumptive TB patients (PTP)found sputum smear positive increased by 30%- from 13.6% (3432/25159) in 2011 to 17.8% (4706/26426) in 2012 (P value <0.01) in the sites that implemented LED-FM microscopy, whereas in DMCs where the ZN staining procedure is followed the proportion of sputum smear positive had remained unchanged (13.0%versus 12.6%;P value0.31). CONCLUSION: Use of LED-FM significantly increased the proportion of smear positive cases among presumptive TB patients under routine program conditions in high workload laboratories. The study provides operational evidence needed to scale-up the use of LED-FM in similar settings in India and beyond.

Neonatal sepsis as a major cause of morbidity in a tertiary center in Kathmandu.

INTRODUCTION: Neonatal sepsis causes high morbidity and mortality of newborns. The study aims to study the predictors and clinical, haematological and bacteriological factors of neonatal sepsis. METHODS: A descriptive cross sectional study was conducted in a Neonatal Intensive Care Unit (NICU) of Paropakar Maternity and Women's Hospital in Kathmandu between October and December 2011. Demographic, obstetrics, clinical and microbiological data were studied for 300 neonates. RESULTS: The NICU prevalence rate of sepsis was 37.12%. Early onset neonatal sepsis was common (91.39%) (P=0.000). Cesarean section (OR 1.95, 95% CI 1.15-3.31), apgar score<4 at 1 min (P=0.00) and <7 at 5 min of birth (P=0.00) predicted sepsis. Neonates with sepsis were more likely to present with hypothermia (OR 1.180, 95% CI 0.080-17.214), pustules (OR 2.188, 95% CI 0.110-43.465), dehydration (OR 3.040, 95% CI 0.170-54.361), diminished movement (OR 3.082, 95% CI 0.433-21.950) and bulging fontanels (OR 16.464, 95% CI 0.007-41495.430). Coagulase negative Staphylococcus spp. (CoNS) (21, 41.17%) was most common pathogen of neonatal sepsis. Variable antibiotic resistance patterns of isolates with emergence of meropenem resistance in Pseudomonas spp. and methicillin resistance in CoNS and S. aurues were noted. Mortality due to sepsis was highest (15, 8.06%) among total mortalities (21, 11.29%). CONCLUSIONS: Delivery via cesarian section, apgar score<4 at 1 min, and <7 at 5 min predicted sepsis. Morbidity and mortality of neonatal sepsis was common in this setting and early maternal and neonatal interventions are required to address this issue.

High prevalence of bla(OXA)-23 in oligoclonal carbapenem-resistant Acinetobacter baumannii from Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Acinetobacter baumannii has emerged in health care settings as a pandrug-resistant pathogen. Carbapenems are ineffective for treatment of this pathogen. Here we explored the molecular epidemiology and mechanism of carbapenem resistance in clinical isolates of carbapenem-resistant A. baumannii (CRAB). Antibiotic susceptibility by disk diffusion test was performed using imipenem and meropenem disk on 200 different clinical CRAB isolates. All isolates were resistant and gave inhibition zones of both antibiotic disks < or = 13 mm. Polymerase chain reaction (PCR) was carried out on 37 randomly selected isolates to amplify the common carbapenem hydrolyzing beta-lactamase genes (bla(OXA23)-like, bla(OXA-24/40)-like, bla(OXA-58), bla(IMP), and bla(VLM)). Clones were resolved by PCR-randomly amplified polymorphic DNA (PCR-RAPD) and plasmid profiling. PCR amplification and DNA sequencing revealed the existence of bla(OXA-23) downstream of the insertion element, ISAba1, in all 37 isolates tested. This segment was present in the carbapenem-resistant genomic resistant island AbaR4. These isolates were resolved into three RAPD types (Type I, 20 isolates; Type II, 16 isolates; and type III, 1 isolate) and 10 plasmid profiles. The CRAB isolates investigated here were oligoclonal and carbapenem resistance was conferred by the presence of bla(OXA-23). The presence of this beta-lactamase gene in many clonal isolates indicated its wide spread.