MALARIA: Emergence of artemisinin-resistant malaria on the western border of Thailand:

Aung Pyae Phyo MD a b, Standwell Nkhoma PhD c, Kasia Stepniewska PhD a d e, Elizabeth A Ashley MD a b d, Shalini Nair MSc c, Rose McGready MD a b d, Carit ler Moo b, Salma Al-Saai MSc c, Arjen M Dondorp MD a d, Khin Maung Lwin MD b, Pratap Singhasivanon MD a, Nicholas PJ Day FRCP a d, Nicholas J White FRS a d, Tim JC Anderson PhD c, Prof François Nosten MD a b d

Summary

Background

Artemisinin-resistant falciparum malaria has arisen in western Cambodia. A concerted international effort is underway to contain artemisinin-resistant Plasmodium falciparum, but containment strategies are dependent on whether resistance has emerged elsewhere. We aimed to establish whether artemisinin resistance has spread or emerged on the Thailand—Myanmar (Burma) border.

Methods

In malaria clinics located along the northwestern border of Thailand, we measured six hourly parasite counts in patients with uncomplicated hyperparasitaemic falciparum malaria (≥4% infected red blood cells) who had been given various oral artesunate-containing regimens since 2001. Parasite clearance half-lives were estimated and parasites were genotyped for 93 single nucleotide polymorphisms.

Findings

3202 patients were studied between 2001 and 2010. Parasite clearance half-lives lengthened from a geometric mean of 2·6 h (95% CI 2·5—2·7) in 2001, to 3·7 h (3·6—3·8) in 2010, compared with a mean of 5·5 h (5·2—5·9) in 119 patients in western Cambodia measured between 2007 and 2010. The proportion of slow-clearing infections (half-life ≥6·2 h) increased from 0·6% in 2001, to 20% in 2010, compared with 42% in western Cambodia between 2007 and 2010. Of 1583 infections genotyped, 148 multilocus parasite genotypes were identified, each of which infected between two and 13 patients. The proportion of variation in parasite clearance attributable to parasite genetics increased from 30% between 2001 and 2004, to 66% between 2007 and 2010.

Interpretation

Genetically determined artemisinin resistance in P falciparum emerged along the Thailand—Myanmar border at least 8 years ago and has since increased substantially. At this rate of increase, resistance will reach rates reported in western Cambodia in 2—6 years.

Funding

The Wellcome Trust and National Institutes of Health.

POVERTY: MYANMAR-THAILAND: Dying for lack of reproductive healthcare

BANGKOK, 10 February 2012 (IRIN)

 Photo: Contributor/IRIN
Disadvantaged at birth

Lack of access to reproductive health services in Myanmar has led to high rates of maternal deaths and unplanned pregnancies among the country's displaced, migrant and refugee populations, say health experts.
"There are huge unmet reproductive health needs for contraceptives, family planning, and access to skilled birth attendants," said Priya Manwell, the UN Population Fund's (UNFPA) humanitarian response coordinator for the Asia Pacific region.
Populations that are on the run or outside their home countries are often unable to gain access to reproductive healthcare, say health workers.
Without skilled birth attendants or contraception, complications from unsafe abortions and post-partum haemorrhage are common along the Thai-Burmese border, where there are more than 150,000 Burmese refugees, according to a new report by the international NGO, Ibis Reproductive Health.
"In Burma, the sad state of reproductive health... [bars] far too many, especially mobile populations, including migrants, refugees, and IDPs, from accessing appropriate, timely, and basic health services," Vit Suwanvanichkij, a research associate at the US-based Johns Hopkins Bloomberg School of Public Health, told IRIN.
Nationwide, only 37 percent of women gave birth with a trained birth attendant in 2007, according to the most recent government data reported to the World Health Organization (WHO).

Health displaced
Displaced people in Myanmar's east face "a health disaster", with a maternal mortality rate (MMR) of 721 deaths per 100,000 live births - three times the national average of 240, according to a 2010 NGO-collaborative report, Diagnosis Critical.
Some 10 percent of Myanmar's national MMR has been traced to unsafe abortions.
"A lack of safe, legal abortion creates conditions where women in both eastern Burma and Thailand are likely to either self-abort or engage untrained providers who may use methods likely to cause harm or even death," said Cari Siestra, co-author of Ibis Reproductive Health's recent report.
The lack of health infrastructure in eastern Myanmar has led to frequent reproductive complications from preventable illnesses, such as malaria, which is "the number-one killer of pregnant women", said Suwanvanichkij.
"Malnutrition, malaria, and repeat pregnancies without adequate birth spacing all impact [on] women's ability to carry pregnancies, even wanted ones, to term," added Sietstra.
Overall health challenges include a shortage of workers, investment and proper infrastructure, San San Myint, a national technical officer and reproductive health specialist at the WHO country office in Myanmar, told IRIN.
"Reproductive health coverage is [available in fewer than] 150 townships out of 325 townships. The main problem is funding and geographical barriers."

Camps
Reproductive health improves for refugees on the Thai side of the border, who have better access to trained providers, according to Sietstra.
But Thailand's estimated two million Burmese migrant workers, are often reluctant to seek medical assistance.
"Undocumented Burmese migrants are hesitant to access services because of their immigration status," said Jaime Calderon, the Southeast Asia regional health migration adviser at the International Organization for Migration office in Bangkok.
This is compounded by providers' discriminatory policies, language constraints and inability to pay, say health workers along the border.
"Put this awful constellation of vulnerabilities together and the result is that far too many women again are sickened, disabled, or die from preventable causes, such as complications of pregnancy and abortions," said Suwanvanichkij.
While Myanmar's recent political reforms have the potential to translate into better care if there is long-term investment in the health system, "we still need to address the immediate needs of people urgently", said Taweesap Sirapapasiri, UNFPA's programme officer for Thailand.
http://www.irinnews.org/report.aspx?reportID=94839

POVERTY:Back Pack Health Worker Team on Thai-Buma border

WORTHY OF SUPPORT
With fascinating slide show and video





Dr. Cynthia Maung,
Founder, Mae Tao Clinic and Chairperson, Back Pack Health Worker Team
When I was studying medicine at university in Burma, I undertook two clinical internships during 1980 – 1985, one at Mingaladone Military Hospital and the other at North Okkalar Civil Hospital. It was then that the problem for access to health care in Burma and in particular for the poor and rural populations first became apparent to me. At North Okkalar most of the patients came from the outskirts of the city and were poor; the hospital facilities were terribly inadequate and the staff overworked. There the staff struggled against many challenges, lack of medicine, lack of staff and also struggling to make ends meet for their own families. There were no preventive services and many patients arrived seriously ill. The differences between Okkalar and Mingaladone were striking in terms of the resources and who could access the services.
After I finished study, I was an intern at Moulmein Hospital, where the situation was very similar to North Okkalar, but so many of the patients had to travel 3 – 5 hours by bullock cart or boat to reach the facility. It became clear to me that for rural populations, preventive care was non existent and emergency services were not accessible. Government services were simply not accessible to all.
After I graduated, I went to work in the village of Eain Du in Karen State and there I realized the role of poor social and economic development on health as well as the affects of militarization. Young boys, called up for their “volunteer” work, to serve the army in building military camps or in carrying military supplies, returned to the village malnourished, injured and with untreated malaria. The fear of the military was pervasive, and villagers’ ability to work to raise enough for their own food and livelihood was severely impaired. The effect of militarization on the villagers was very clear.
The village was only 15 km from the State Hospital, but there was only public transport 2 times a day at night, or for emergencies, referral was really difficult. The hospital in Eain Du village had a 12 bed facility for a 20,000 – 25,000 population. During the 11 months that I stayed in Eain Du, a doctor was only available for 3 months. There was no medicine available. Nurses and midwives operated out of their houses, providing private medical services. Public services were barely provided. I soon knew that the Burmese health system had in fact collapsed.
When I fled to the border, we passed through the jungle, walking for 7 days. At that time I met with many villagers and internally displaced people who had never been able to access any government health care systems.
Since 1988, the health workers coming to the border have always been quick to identify and respond to the needs of the local villagers and internally displaced populations living along the border. Gradually mobile medical teams emerged and where possible, community health clinics were established. Most health work on the border started with medical services, but gradually expanded to public health, maternal and child services, school health programmes and basic trauma care. Through maternal and child health programmes and school health programmes, the community understanding of health issues and how to participate in their own health provision increased.
Each organization on the border was operating their own mobile medical teams, traveling for 3 – 6 months at a time. During 1996 and 1998, many ethnic areas fell under the control of the military regime; some clinics had to close down and the challenges in providing health care increased. In 1998, a series of meetings were held among different ethnic organizations and through these, the Back Pack Team model was developed. Through this effort, it was possible for standardization of service delivery and a great collaboration was initiated. Everyone involved was very proud of its establishment and it was so impressive that we were able to begin immediately with 38 teams in 1998.
Since the Back Pack Health Worker Team started 10 years ago, awareness of the health and human rights situation facing internally displaced people from Burma has increased and continues to grow.
http://www.backpackteam.org/

POVERTY: Burmese refugees in Thailand face ration cuts

 Photo: Brennon Jones/IRIN: Umpium refugee camp, one of nine along Thai-Myanmar border

BANGKOK, 24 January 2011 (IRIN) - Rising food prices may prompt the Thailand Burma Border Consortium (TBBC), an umbrella group of 12 humanitarian organizations working with more than 139,000 Burmese refugees in Thailand, to cut rice rations by up to 20 percent. Additional cuts will be made to salt, suger, oil and chili rations.
"Increased prices of food and [higher] exchange rates have made it more difficult to buy food," Sally Thompson, the TBBC's deputy executive director, told IRIN.
The ration for rice, a staple of the Burmese diet, will remain the same for vulnerable groups, including children under the age of five, pregnant and lactating women, and the ill. "Vulnerable people are still protected, and TBBC plans to conduct annual nutrition surveys to monitor the health situation," Thompson said.
According to the UN Refugee Agency (UNHCR), Thailand currently hosts 96,800 refugees from Myanmar who have been registered, and an estimated 53,000 who have not, and are living in nine government-run camps along the 1,400km Thai-Burmese border.
Burmese refugees in Thailand face ration cuts

http://www.irinnews.org/Report.aspx?Reportid=91705

MALARIA: The reality of using primaquine

Kathy Burgoine et al. Malaria Journal 2010, 9:376  Published: 27 December 2010

Background
Primaquine is currently the only medication used for radical cure of Plasmodium vivax infection. Unfortunately, its use is not without risk. Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency have an increased susceptibility to haemolysis when given primaquine. This potentially fatal clinical syndrome can be avoided if patients are tested for G6PD deficiency and adequately informed before being treated.

Case presentation
A 35-year old male presented to our clinic on the Thai-Burmese border with a history and clinical examination consistent with intravascular haemolysis. The patient had been prescribed primaquine and chloroquine four days earlier for a P. vivax infection. The medication instructions had not been given in a language understood by the patient and he had not been tested for G6PD deficiency. The patient was not only G6PD deficient but misunderstood the instructions and took all his primaquine tablets together. With appropriate treatment the patient recovered and was discharged home a week later.

Conclusions
Whilst primaquine remains the drug of choice to eradicate hypnozoites and control P. vivax transmission, the risks associated with its use must be minimized during its deployment. In areas where P. vivax exists, patients should be tested for G6PD deficiency and adequately informed before administration of primaquine.
http://www.malariajournal.com/content/9/1/376