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Tabernero P, Swamidoss I, Mayxay M, Khanthavong M, Phonlavong C, Vilayhong C, Sichanh C, Sengaloundeth S, Green MD, Newton PN. A random survey of the prevalence of falsified and substandard antibiotics in the Lao PDR. J Antimicrob Chemother 2022; 77:1770-1778. [PMID: 35137095 PMCID: PMC7614350 DOI: 10.1093/jac/dkab435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In 2012, a stratified random survey, using mystery shoppers, was conducted to investigate the availability and quality of antibiotics sold to patients in the private sector in five southern provinces of the Lao People's Democratic Republic (Laos). METHODS A total of 147 outlets were sampled in 10 districts. The active pharmaceutical ingredient (API) content measurements for 909 samples, including nine APIs (amoxicillin, ampicillin, ceftriaxone, ciprofloxacin, doxycycline, ofloxacin, sulfamethoxazole, tetracycline and trimethoprim), were determined using HPLC. RESULTS All the analysed samples contained the stated API and we found no evidence for falsification. All except one sample had all the units tested with %API values between 75% and 125% of the content stated on the label. However, we identified the presence of substandard antibiotics: 19.6% (201/1025) of samples had their units outside the 90%-110% content of the label claim and 18.3% (188/1025) of the samples had units outside the International Pharmacopoeia/United States Pharmacopoeia assay (percentage of label claim) specifications. Trimethoprim had a high number of samples [51.6% (64)] with units below the limit range, followed by ceftriaxone [42.9% (3)] and sulfamethoxazole [34.7% (43)]. Doxycycline, ofloxacin and ciprofloxacin had the highest number of samples with high API content: 43.7% (38), 14.7% (10) and 11.8% (2), respectively. Significant differences in %API were found between stated countries of manufacture and stated manufacturers. CONCLUSIONS With the global threat of antimicrobial resistance on patient outcomes, greater understanding of the role of poor-quality antibiotics is needed. Substandard antibiotics will have reduced therapeutic efficacy, impacting public health and control of bacterial infections.
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Affiliation(s)
- Patricia Tabernero
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Public Health Unit, Faculty of Medicine, University of Alcalá, Alcalá de Henares, Spain
| | - Isabel Swamidoss
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuf?eld Department of Medicine, Churchill Hospital, University of Oxford, Oxford, UK
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao PDR
| | | | - Chindaphone Phonlavong
- Bureau of Food and Drug Inspection (BFDI), Ministry of Health, Government of the Lao PDR, Vientiane, Lao PDR
| | - Chanthala Vilayhong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Chanvilay Sichanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Sivong Sengaloundeth
- Food and Drug Department (FDD), Ministry of Health, Government of the Lao PDR, Vientiane, Lao PDR
| | - Michael D. Green
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuf?eld Department of Medicine, Churchill Hospital, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory, Nuf?eld Department of Medicine, Churchill Hospital, University of Oxford, Oxford, UK
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Zambrzycki SC, Caillet C, Vickers S, Bouza M, Donndelinger DV, Geben LC, Bernier MC, Newton PN, Fernández FM. Laboratory evaluation of twelve portable devices for medicine quality screening. PLoS Negl Trop Dis 2021; 15:e0009360. [PMID: 34591844 PMCID: PMC8483346 DOI: 10.1371/journal.pntd.0009360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Post-market surveillance is a key regulatory function to prevent substandard and falsified (SF) medicines from being consumed by patients. Field deployable technologies offer the potential for rapid objective screening for SF medicines. METHODS AND FINDINGS We evaluated twelve devices: three near infrared spectrometers (MicroPHAZIR RX, NIR-S-G1, Neospectra 2.5), two Raman spectrometers (Progeny, TruScan RM), one mid-infrared spectrometer (4500a), one disposable colorimetric assay (Paper Analytical Devices, PAD), one disposable immunoassay (Rapid Diagnostic Test, RDT), one portable liquid chromatograph (C-Vue), one microfluidic system (PharmaChk), one mass spectrometer (QDa), and one thin layer chromatography kit (GPHF-Minilab). Each device was tested with a series of field collected medicines (FCM) along with simulated medicines (SIM) formulated in a laboratory. The FCM and SIM ranged from samples with good quality active pharmaceutical ingredient (API) concentrations, reduced concentrations of API (80% and 50% of the API), no API, and the wrong API. All the devices had high sensitivities (91.5 to 100.0%) detecting medicines with no API or the wrong API. However, the sensitivities of each device towards samples with 50% and 80% API varied greatly, from 0% to 100%. The infrared and Raman spectrometers had variable sensitivities for detecting samples with 50% and 80% API (from 5.6% to 50.0%). The devices with the ability to quantitate API (C-Vue, PharmaChk, QDa) had sensitivities ranging from 91.7% to 100% to detect all poor quality samples. The specificity was lower for the quantitative C-Vue, PharmaChk, & QDa (50.0% to 91.7%) than for all the other devices in this study (95.5% to 100%). CONCLUSIONS The twelve devices evaluated could detect medicines with the wrong or none of the APIs, consistent with falsified medicines, with high accuracy. However, API quantitation to detect formulations similar to those commonly found in substandards proved more difficult, requiring further technological innovation.
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Affiliation(s)
- Stephen C. Zambrzycki
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Celine Caillet
- Lao-Oxford-Mahosot Hospital-Wellcome Trust-Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO) & WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Serena Vickers
- Lao-Oxford-Mahosot Hospital-Wellcome Trust-Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO) & WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Marcos Bouza
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - David V. Donndelinger
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Laura C. Geben
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Matthew C. Bernier
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust-Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO) & WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Facundo M. Fernández
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
- * E-mail:
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Caillet C, Vickers S, Zambrzycki S, Fernández FM, Vidhamaly V, Boutsamay K, Boupha P, Peerawaranun P, Mukaka M, Newton PN. A comparative field evaluation of six medicine quality screening devices in Laos. PLoS Negl Trop Dis 2021; 15:e0009674. [PMID: 34591852 PMCID: PMC8483322 DOI: 10.1371/journal.pntd.0009674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Medicine quality screening devices hold great promise for post-market surveillance (PMS). However, there is little independent evidence on their field utility and usability to inform policy decisions. This pilot study in the Lao PDR tested six devices' utility and usability in detecting substandard and falsified (SF) medicines. METHODOLOGY/PRINCIPAL FINDINGS Observational time and motion studies of the inspections by 16 Lao medicine inspectors of 1) the stock of an Evaluation Pharmacy (EP), constructed to resemble a Lao pharmacy, and 2) a sample set of medicines (SSM); were conducted without and with six devices: four handheld spectrometers (two near infrared: MicroPHAZIR RX, NIR-S-G1 & two Raman: Progeny, Truscan RM); one portable mid-infrared spectrometer (4500a), and single-use paper analytical devices (PAD). User experiences were documented by interviews and focus group discussions. Significantly more samples were wrongly categorised as pass/fail with the PAD compared to the other devices in EP inspections (p<0.05). The numbers of samples wrongly classified in EP inspections were significantly lower than in initial visual inspections without devices for 3/6 devices (NIR-S-G1, MicroPHAZIR RX, 4500a). The NIR-S-G1 had the fastest testing time per sample (median 93.5 sec, p<0.001). The time spent on EP visual inspection was significantly shorter when using a device than for inspections without devices, except with the 4500a, risking missing visual clues of samples being SF. The main user errors were the selection of wrong spectrometer reference libraries and wrong user interpretation of PAD results. Limitations included repeated inspections of the EP by the same inspectors with different devices and the small sample size of SF medicines. CONCLUSIONS/SIGNIFICANCE This pilot study suggests policy makers wishing to implement portable screening devices in PMS should be aware that overconfidence in devices may cause harm by reducing inspectors' investment in visual inspection. It also provides insight into the advantages/limitations of diverse screening devices in the hands of end-users.
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Affiliation(s)
- Céline Caillet
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Serena Vickers
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Stephen Zambrzycki
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Facundo M. Fernández
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Vayouly Vidhamaly
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Kem Boutsamay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Phonepasith Boupha
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Robertson SG, Hehonah NT, Mayaune RD, Glass BD. Prevalence of Substandard Amoxicillin Oral Dosage Forms in the National Capital District of Papua New Guinea. Am J Trop Med Hyg 2021; 105:238-244. [PMID: 33999844 PMCID: PMC8274755 DOI: 10.4269/ajtmh.20-1570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/25/2021] [Indexed: 11/07/2022] Open
Abstract
Antibiotics are commonly reported as being substandard or falsified in low- to middle-income countries, having potential to contribute to the development of antimicrobial resistance and drug-resistant infections. Amoxicillin, used to treat a number of infections and listed by the WHO as an essential medicine, presented as a good drug candidate for this study. We aimed to measure the prevalence of substandard and falsified amoxicillin oral products (tablets, capsules, and suspensions) in the National Capital District of Papua New Guinea (PNG). These oral products were surveyed in 2018 and 2019 from retail pharmacies, private and public health facilities, and the Area Medical Store, representing more than 90% of licensed medicine outlets. The product packaging was visually inspected, and the samples were analyzed for amoxicillin content using a validated high-performance liquid chromatography method. Although no falsified products were identified, 15% of the 190 products analyzed contained substandard amounts of amoxicillin. Quality varied with the dosage form (P = 0.002), with capsules exhibiting the lowest incidence of substandard content (4% in 2019) and tablets collected in 2018 experiencing the highest failure rate (50%). Suspension (40%) quality was compromised by failure to achieve homogeneity on reconstitution. A higher incidence of substandard content (P = 0.002) was associated with one major retail group. Routine testing of medicines by resource-poor countries is often unachievable, leading to the circulation of poor quality drugs, which is a global public health concern. Our study highlighted that substandard amoxicillin oral products are indeed prevalent in the NCD of PNG.
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Affiliation(s)
- Sherryl G. Robertson
- Pharmacy, College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Naomi T. Hehonah
- Division of Basic Medical Sciences, Pharmacology, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Rose D. Mayaune
- Division of Basic Medical Sciences, Pharmacology, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Beverley D. Glass
- Pharmacy, College of Medicine and Dentistry, James Cook University, Townsville, Australia
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Tabernero P, Swamidoss I, Mayxay M, Khanthavong M, Phonlavong C, Vilayhong C, Yeuchaixiong S, Sichanh C, Sengaloundeth S, Green MD, Newton PN. A random survey of the prevalence of falsified and substandard antibiotics in the Lao PDR. J Antimicrob Chemother 2020; 74:2417-2425. [PMID: 31049576 PMCID: PMC6640311 DOI: 10.1093/jac/dkz164] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/18/2019] [Accepted: 03/24/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Patricia Tabernero
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.,Public Health Unit, Faculty of Medicine, University of Alcalá, Alcalá de Henares, Spain
| | - Isabel Swamidoss
- U.S. Centers for Disease Control and Prevention (CDC), Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.,Centre for Tropical Medicine & Global Health, Nuffield Research Building, Churchill Hospital, University of Oxford, Oxford, UK.,Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao PDR
| | | | - Chindaphone Phonlavong
- Bureau of Food and Drug Inspection (BFDI), Ministry of Health, Government of the Lao PDR, Vientiane, Lao PDR
| | - Chanthala Vilayhong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Sengchanh Yeuchaixiong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Chanvilay Sichanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
| | - Sivong Sengaloundeth
- Food and Drug Department (FDD), Ministry of Health, Government of the Lao PDR, Vientiane, Lao PDR
| | - Michael D Green
- U.S. Centers for Disease Control and Prevention (CDC), Division of Parasitic Diseases and Malaria, Atlanta, GA, USA
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.,WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine & Global Health, Nuffield Research Building, Churchill Hospital, University of Oxford, Oxford, UK.,Infectious Diseases Data Observatory, Nuffield Research Building, Churchill Hospital, University of Oxford, Oxford, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Sunpuwan M, Punpuing S, Jaruruengpaisan W, Kinsman J, Wertheim H. What is in the drug packet?: access and use of non-prescribed poly-pharmaceutical packs (Yaa Chud) in the community in Thailand. BMC Public Health 2019; 19:971. [PMID: 31331304 PMCID: PMC6647088 DOI: 10.1186/s12889-019-7300-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 'Yaa Chud' is a non-prescribed poly-pharmaceutical pack containing several types of drugs, including antibiotics and steroids, which can be purchased over the counter in Thailand for self-medication. Although it is illegal, it is still available at some community outlets. This study aimed to understand access to and use of Yaa Chud at the community level in order to raise awareness on its usage and to provide policy recommendations to address the problem. METHODS This study employed qualitative methods, including in-depth interviews with 18 drug suppliers and 16 community members, and six focus group discussions. It included inventories from 17 drug suppliers. Data were collected in selected communities of the Kanchanaburi Demographic Surveillance System, located in the western region of Thailand.Thematic analysis was based upon the Health Services Utilization Model and conducted using the Open Code qualitative software program. RESULTS Overcrowding, long waiting times, and a perceived unwelcoming environment at public health-care service outlets were identified as factors that drive people into the private sector, where loose regulation of drug laws facilitates access and use of Yaa Chud. Migrants and older people were most likely to seek and use Yaa Chud, especially for mild illness. Availability, easy access through a user's network, low cost, and perceived effectiveness were identified as factors that enable access and use of Yaa Chud. CONCLUSIONS Though illegal in Thailand, Yaa Chud is likely to remain available for self-medication by community members, due to the persisting demand by the elderly and migrant workers. There is an urgent need to replace these mixed medications with better choices. Safer Yaa Chud may be a preferred, first-line health-care option, which could help reduce congestion in the formal health-care setting. At the same time, enforcement of regulatory compliance needs to be continued in order to stop the supply of unsafe Yaa Chud.
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Affiliation(s)
- Malee Sunpuwan
- Institute for Population and Social Research, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Sureeporn Punpuing
- Institute for Population and Social Research, Mahidol University, Salaya, Nakhon Pathom, Thailand.
| | - Wipaporn Jaruruengpaisan
- Institute for Population and Social Research, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - John Kinsman
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Heiman Wertheim
- Oxford University Clinical Research Unit, Hanoi, Vietnam
- The Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Microbiology and the Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, Netherlands
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