Coinfection and circulation of chikungunya virus and dengue virus in pediatric patients in Myanmar, 2019.

Myanmar is an endemic country for arboviruses, and outbreaks occur frequently. A cross-sectional analytical study was conducted during the peak season of the chikungunya virus (CHIKV) outbreak in 2019. A total of 201 patients with acute febrile illness who were admitted to the 550-bedded Mandalay Children Hospital in Myanmar were enrolled in the study, and virus isolation, serological tests, and molecular tests for the dengue virus (DENV) and CHIKV were performed for all samples. Out of 201 patients, 71 (35.3%) were only DENV-infected, 30 (14.9%) were only CHIKV-infected and 59 (29.4%) were coinfected with DENV and CHIKV. The viremia levels of the DENV- and CHIKV- mono-infected groups were significantly higher than those of the group coinfected with DENV and CHIKV. Genotype I of DENV-1, genotypes I and III of DENV-3, genotype I of DENV-4 and the East/Central/South African genotype of CHIKV were co-circulating during the study period. Two novel epistatic mutations of CHIKV (E1:K211E and E2:V264A) were noted. This study highlighted that there were many coinfection cases during the outbreak and that the co-circulation of both viruses in DENV-endemic regions warrants effective monitoring of these emerging pathogens via comprehensive surveillance to facilitate the implementation of effective control measures.

Exposure to diverse sarbecoviruses indicates frequent zoonotic spillover in human communities interacting with wildlife.

BACKGROUND: Sarbecoviruses are a subgenus of Coronaviridae that mostly infect bats with known potential to infect humans (SARS-CoV and SARS-CoV-2). Populations in Southeast Asia, where these viruses are most likely to emerge, have been undersurveyed to date. METHODS: We surveyed communities engaged in extractive industries and bat guano harvesting from rural areas in Myanmar. Participants were screened for exposure to sarbecoviruses, and their interactions with wildlife were evaluated to determine the factors associated with exposure to sarbecoviruses. RESULTS: Of 693 people screened between July 2017 and February 2020, 12.1% were seropositive for sarbecoviruses. Individuals were significantly more likely to have been exposed to sarbecoviruses if their main livelihood involved working in extractive industries (logging, hunting, or harvesting of forest products; odds ratio [OR] = 2.71, P = 0.019) or had been hunting/slaughtering bats (OR = 6.09, P = 0.020). Exposure to a range of bat and pangolin sarbecoviruses was identified. CONCLUSION: Exposure to diverse sarbecoviruses among high-risk human communities provides epidemiologic and immunologic evidence that zoonotic spillover is occurring. These findings inform risk mitigation efforts needed to decrease disease transmission at the bat-human interface, as well as future surveillance efforts warranted to monitor isolated populations for viruses with pandemic potential.

Molecular Profiles of Multiple Antimalarial Drug Resistance Markers in Plasmodium falciparum and Plasmodium vivax in the Mandalay Region, Myanmar.

Emergence and spreading of antimalarial drug resistant malaria parasites are great hurdles to combating malaria. Although approaches to investigate antimalarial drug resistance status in Myanmar malaria parasites have been made, more expanded studies are necessary to understand the nationwide aspect of antimalarial drug resistance. In the present study, molecular epidemiological analysis for antimalarial drug resistance genes in Plasmodium falciparum and P. vivax from the Mandalay region of Myanmar was performed. Blood samples were collected from patients infected with P. falciparum and P. vivax in four townships around the Mandalay region, Myanmar in 2015. Partial regions flanking major mutations in 11 antimalarial drug resistance genes, including seven genes (pfdhfr, pfdhps, pfmdr-1, pfcrt, pfk13, pfubp-1, and pfcytb) of P. falciparum and four genes (pvdhfr, pvdhps, pvmdr-1, and pvk12) of P. vivax were amplified, sequenced, and overall mutation patterns in these genes were analyzed. Substantial levels of mutations conferring antimalarial drug resistance were detected in both P. falciparum and P. vivax isolated in Mandalay region of Myanmar. Mutations associated with sulfadoxine-pyrimethamine resistance were found in pfdhfr, pfdhps, pvdhfr, and pvdhps of Myanmar P. falciparum and P. vivax with very high frequencies up to 90%. High or moderate levels of mutations were detected in genes such as pfmdr-1, pfcrt, and pvmdr-1 associated with chloroquine resistance. Meanwhile, low frequency mutations or none were found in pfk13, pfubp-1, pfcytb, and pvk12 of the parasites. Overall molecular profiles for antimalarial drug resistance genes in malaria parasites in the Mandalay region suggest that parasite populations in the region have substantial levels of mutations conferring antimalarial drug resistance. Continuous monitoring of mutations linked with antimalarial drug resistance is necessary to provide useful information for policymakers to plan for proper antimalarial drug regimens to control and eliminate malaria in the country.

Temporal Changes in the Genetic Diversity of Plasmodium vivax Merozoite Surface Protein-1 in Myanmar.

Despite a significant decline in the incidence of malaria in Myanmar recently, malaria is still an important public health concern in the country. Although Plasmodium falciparum is associated with the highest incidence of malaria in Myanmar, the proportion of P. vivax cases has shown a gradual increase in recent years. The genetic diversity of P. vivax merozoite surface protein-1 block 5-6 (pvmsp-1 ICB 5-6) in the P. vivax population of Myanmar was analyzed to obtain a comprehensive insight into its genetic heterogeneity and evolutionary history. High levels of genetic diversity of pvmsp-1 ICB 5-6 were identified in the P. vivax isolates collected from Myanmar between 2013 and 2015. Thirty-nine distinct haplotypes of pvmsp-1 ICB 5-6 (13 for Sal I type, 20 for recombinant type, and 6 for Belem type) were found at the amino acid level. Comparative analyses of the genetic diversity of pvmsp-1 ICB 5-6 sequences in the recent (2013-2015) and the past (2004) P. vivax populations in Myanmar revealed genetic expansion of the pvmsp-1 ICB 5-6 in recent years, albeit with a declined incidence. The recent increase in the genetic heterogeneity of Myanmar pvmsp-1 ICB 5-6 is attributed to a combination of factors, including accumulated mutations and recombination. These results suggest that the size of the P. vivax population in Myanmar is sufficient to enable the generation and maintenance of genetic diversity, warranting continuous molecular surveillance of genetic variation in Myanmar P. vivax.

Surge of severe acute respiratory syndrome coronavirus 2 infections linked to single introduction of a virus strain in Myanmar, 2020.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a major health concern globally. Genomic epidemiology is an important tool to assess the pandemic of coronavirus disease 2019 (COVID-19). Several mutations have been reported by genome analysis of the SARS-CoV-2. In the present study, we investigated the mutational and phylogenetic analysis of 30 whole-genome sequences for the virus's genomic characteristics in the specimens collected in the early phase of the pandemic (March-June, 2020) and the sudden surge of local transmission (August-September, 2020). The four samples in the early phase of infection were B.6 lineage and located within a clade of the samples collected at the same time in Singapore and Malaysia, while five returnees by rescue flights showed the lineage B. 1.36.1 (three from India), B.1.1 (one from India) and B.1.80 (one from China). However, there was no evidence of local spread from these returnees. Further, all 19 whole-genome sequences collected in the sudden surge of local transmission showed lineage B.1.36. The surge of the second wave on SARS-CoV-2 infection was linked to the single-introduction of a variant (B.1.36) that may result from the strict restriction of international travel and containment efforts. These genomic data provides the useful information to disease control and prevention strategy.

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.

Genetic polymorphism of merozoite surface protein-3 in Myanmar Plasmodium falciparum field isolates.

BACKGROUND: Plasmodium falciparum merozoite surface protein-3 (PfMSP-3) is a target of naturally acquired immunity against P. falciparum infection and is a promising vaccine candidate because of its critical role in the erythrocyte invasion of the parasite. Understanding the genetic diversity of pfmsp-3 is important for recognizing genetic nature and evolutionary aspect of the gene in the natural P. falciparum population and for designing an effective vaccine based on the antigen. METHODS: Blood samples collected from P. falciparum-infected patients in Naung Cho and Pyin Oo Lwin, Myanmar, in 2015 were used in this study. The pfmsp-3 was amplified by polymerase chain reaction, cloned, and sequenced. Genetic polymorphism and natural selection of Myanmar pfmsp-3 were analysed using the programs DNASTAR, MEGA6, and DnaSP 5.10.00. Genetic diversity and natural selection of the global pfmsp-3 were also comparatively analysed. RESULTS: Myanmar pfmsp-3 displayed 2 different alleles, 3D7 and K1. The 3D7 allelic type was predominant in the population, but genetic polymorphism was less diverse than for the K1 allelic type. Polymorphic characters in both allelic types were caused by amino acid substitutions, insertions, and deletions. Amino acid substitutions were mainly occurred at the alanine heptad repeat domains, whereas most insertions and deletions were found at the glutamate rich domain. Overall patterns of amino acid polymorphisms detected in Myanmar pfmsp-3 were similar in the global pfmsp-3 population, but novel amino acid changes were observed in Myanmar pfmsp-3 with low frequencies. Complicated patterns of natural selection and recombination events were predicted in the global pfmsp-3, which may act as major driving forces to maintain and generate genetic diversity of the global pfmsp-3 population. CONCLUSION: Global pfmsp-3 revealed genetic polymorphisms, suggesting that the functional and structural consequences of the polymorphisms should be considered in designing a vaccine based on PfMSP-3. Further examination of genetic diversity of pfmsp-3 in the global P. falciparum population is necessary to gain in-depth insight for the population structure and evolutionary aspect of global pfmsp-3.

On the road to Mandalay: contribution to the Microhyla Tschudi, 1838 (Amphibia: Anura: Microhylidae) fauna of Myanmar with description of two new species.

We present a morphological and molecular assessment of the Microhyla fauna of Myanmar based on new collections from central (Magway Division) and northern (Kachin State) parts of the country. In total, six species of Microhyla are documented, including M. berdmorei, M. heymonsi, M. butleri, M. mukhlesuri and two new species described from the semi-arid savanna-like plains of the middle part of the Irrawaddy (Ayeyarwady) River Valley. We used a 2 481 bp long 12S rRNA-16S rRNA fragment of mtDNA to hypothesize genealogical relationships within Microhyla. We applied an integrative taxonomic approach combining molecular, morphological, and acoustic lines of evidence to evaluate the taxonomic status of Myanmar Microhyla. We demonstrated that the newly discovered populations of Microhyla sp. from the Magway Division represent two yet undescribed species. These two new sympatric species are assigned to the M. achatina species group, with both adapted to the seasonally dry environments of the Irrawaddy Valley. Microhyla fodiens sp. nov. is a stout-bodied species with a remarkably enlarged shovel-like outer metatarsal tubercle used for burrowing and is highly divergent from other known congeners (P-distance≥8.8%). Microhyla irrawaddy sp. nov. is a small-bodied slender frog reconstructed as a sister species to M. kodial from southern India (P-distance=5.3%); however, it clearly differs from the latter both in external morphology and advertisement call parameters. Microhyla mukhlesuri is reported from Myanmar for the first time. We further discuss the morphological diagnostics and biogeography of Microhyla species recorded in Myanmar.

A new species of Crocodile Newt, genus Tylototriton (Amphibia, Caudata, Salamandridae) from the mountains of Kachin State, northern Myanmar.

We describe a new species of the genus Tylototriton from Ingyin Taung Mt., Mohnyin Township, Kachin State, Myanmar, based on morphological and molecular evidence. The new species is assigned to the subgenus Tylototriton s. str. and is clearly distinct from all known congeners by the following characters: medium body size; thin, long tail, lacking lateral grooves; rough skin; truncate snout; wide, protruding supratemporal bony ridges on head, beginning at anterior corner of orbit; weak, almost indistinct sagittal ridge; long, thin limbs, broadly overlapping when adpressed along body; distinct, wide, non-segmented vertebral ridge; 13 or 14 rib nodules; brown to dark-brown background coloration with dull orange-brown to yellowish-brown markings on labial regions, parotoids, rib nodules, whole limbs, vent, and ventral tail ridge. We also briefly discuss biogeography and species diversity of the genus Tylototriton in Myanmar.

Surgical hip dislocation for treatment of cam femoroacetabular impingement.

BACKGROUND: Cam femoroacetabular impingement is caused by a misshapen femoral head with a reduced head neck offset, commonly in the anterolateral quadrant. Friction in flexion, adduction and internal rotation causes limitation of the hip movements and pain progressively leading to labral and chondral damage and osteoarthritis. Surgical hip dislocation described by Ganz permits full exposure of the hip without damaging its blood supply. An osteochondroplasty removes the bump at the femoral head neck junction to recreate the offset for impingement free movement. MATERIALS AND METHODS: Sixteen patients underwent surgery with surgical hip dislocation for the treatment of cam femoroacetabular impingement by open osteochondroplasty over last 6 years. Eight patients suffered from sequelae of avascular necrosis (AVN). Three had a painful dysplastic hip. Two had sequelae of Perthes disease. Three had combined cam and pincer impingement caused by retroversion of acetabulum. All patients were operated by the trochanteric flip osteotomy with attachments of gluteus medius and vastus lateralis, dissection was between the piriformis and gluteus minimus preserving the external rotators. Z-shaped capsular incision and dislocation of the hip was done in external rotation. Three cases also had subtrochanteric osteotomy. Two cases of AVN also had an intraarticular femoral head reshaping osteotomy. RESULTS: Goals of treatment were achieved in all patients. No AVN was detected after a 6 month followup. There were no trochanteric nonunions. Hip range of motion improved in all and Harris hip score improved significantly in 15 of 16 cases. Mean alpha angle reduced from 86.13° (range 66°-108°) to 46.35° (range 39°-58°). CONCLUSION: Cam femoroacetabular Impingement causing pain and limitation of hip movements was treated by open osteochondroplasty after surgical hip dislocation. This reduced pain, improved hip motion and gave good to excellent results in the short term.

Confirmation of elevated arsenic levels in groundwater of Myanmar.

Millions of villagers across South and Southeast Asia are exposed to toxic levels of arsenic (As) by drinking well water. In order to confirm the field-kit results that Myanmar is also affected, a total of 55 wells were tested in the field in January 2013 and sampled for laboratory analysis across seven villages spanning a range of As contamination in the lower Ayeyarwady basin. Elevated concentrations of As (50-630 µg/L) were measured in wells up to 60 m deep and associated with high levels of Fe (up to 21 mg/L) and low concentrations of SO4 (<0.05 mg/L). Concentrations of As <10 µg/L were measured in some shallow (<30 m) grey sands and in both shallow and deep orange sands. These results indicate that the main mechanism of As release to groundwater in Myanmar is the reductive dissolution of Fe oxyhydroxides, as in the neighboring Bengal, Mekong, and Red River basins. Concentrations of As in groundwater of Myanmar are therefore unlikely to change rapidly over time and switching to existing low-As wells is a viable way of reducing exposure in the short term. However, only 17 of the 55 well owners interviewed correctly recalled the status of their well despite extensive testing in the region. A renewed effort is thus needed to test existing wells and new wells that continue to be installed and to communicate the health risks of exposure to As for infants, children, and adults.

Hunting for a living: wildlife trade, rural livelihoods and declining wildlife in the Hkakaborazi National Park, north Myanmar.

Hunting is a threat to wildlife within the Hkakaborazi National Park in north Myanmar. We used questionnaire surveys to obtain data on variables such as commonly targeted species, prices of traded wildlife, reasons for hunting and the relative importance of livelihood sources. We examine (a) the significance of hunting and trade for livelihoods and explore (b) the impacts of hunting on targeted species. Ninety per cent of trade records (n = 803) was constituted by seven species commonly targeted by hunters (serow, red goral, muntjac, bear, Assamese macaque, black musk deer and takin). Commercially valuable species previously targeted by hunters (tiger, otter, pangolin) appear to be completely absent from current harvest records and potentially in decline. Although farming is the predominant occupation, hunting (driven by trade) represents a significantly higher source of income than other livelihood activities. Management recommendations include increased investment in enforcement, education and outreach, small livestock development, improved crop productivity, demarcation of no-take areas for wildlife and biological monitoring of targeted species.

Hunting, livelihoods and declining wildlife in the Hponkanrazi Wildlife Sanctuary, North Myanmar.

The Hponkanrazi Wildlife Sanctuary, North Myanmar and three contiguous protected areas, comprise some of the largest expanses of natural forest remaining in the region. Demand for wildlife products has resulted in unsustainable exploitation of commercially valuable species resulting in local extirpation of vulnerable species. Camera trap, track and sign, and questionnaire-based surveys were used to examine (a) wildlife species targeted by hunters, (b) the importance of wild meat for household consumption, and (c) the significance of hunting as a livelihood activity for resident villages. Certain commercially valuable species highly preferred by hunters were either completely absent from hunt records (tiger, musk deer and otter) or infrequently obtained during actual hunts (bear, pangolin). Species obtained by hunters were commonly occurring species such as muntjacs with low commercial value and not highly preferred by hunters. Fifty eight percent of respondents (n = 84) indicated trade, 27% listed subsistence use and 14% listed human-wildlife conflict as the main reason for hunting (n = 84). Average amount of wild meat consumed per month is not significantly higher during the hunting season compared to the planting season (paired t-test, P > 0.05). Throughout the year, the average amount of fish consumed per month was higher than livestock or wild meat (Friedman test, P < 0.0001). Hunting is driven largely by trade and wild meat, while not a critical source of food for a large number of families could potentially be an important, indirect source of access to food for hunting families. Findings and trends from this study are potentially useful in helping design effective conservation strategies to address globally prevalent problems of declining wildlife populations and dependent human communities. The study provides recommendations to reduce illegal hunting and protect vulnerable species by strengthening park management through enforcement, increasing the opportunity costs of poaching, establishing no-take zones and research to determine the economic significance of hunting for livelihoods.

Plasmodium vivax resistance to chloroquine in Dawei, southern Myanmar.

OBJECTIVE: To assess the efficacy of chloroquine in the treatment of Plasmodium vivax malaria in in Dawei District, southern Myanmar. METHODS: Enrolled patients at Sonsinphya clinic >6 months of age were assessed clinically and parasitologically every week for 28 days. To differentiate new infections from recrudescence, we genotyped pre- and post-treatment parasitaemia. Blood chloroquine was measured to confirm resistant strains. RESULTS: Between December 2002 and April 2003, 2661 patients were screened, of whom 252 were included and 235 analysed. Thirty-four per cent (95% CI: 28.1-40.6) of patients had recurrent parasitaemia and were considered treatment failures. 59.4% of these recurrences were with a different parasite strain. Two (0.8%) patients with recurrences on day 14 had chloroquine concentrations above the threshold of 100 ng/ml and were considered infected with chloroquine resistant parasites. 21% of failures occurred during the first 3 weeks of follow-up: early recurrence and median levels of blood chloroquine comparable to those of controls suggested P. vivax resistance. CONCLUSIONS: Plasmodium vivax resistance to chloroquine seems to be emerging in Dawei, near the Thai-Burmese border. While chloroquine remains the first-line drug for P. vivax infections in this area of Myanmar, regular monitoring is needed to detect further development of parasite resistance.