Understanding malaria treatment-seeking preferences within the public sector amongst mobile/migrant workers in a malaria elimination scenario: a mixed-methods study

Plasmodium vivax populations in the western Greater Mekong Subregion evaluated using a genetic barcode

An improved understanding of the Plasmodium vivax populations in the Great Mekong Subregion (GMS) is needed to monitor the progress of malaria elimination. This study aimed to use a P. vivax single nucleotide polymorphism (SNP) barcode to evaluate the population dynamics and explore the gene flow among P. vivax parasite populations in the western GMS (China, Myanmar and Thailand). A total of 315 P. vivax patient samples collected in 2011 and 2018 from four regions of the western GMS were genotyped for 42 SNPs using the high-throughput MassARRAY SNP genotyping technology. Population genetic analysis was conducted to estimate the genetic diversity, effective population size, and population structure among the P. vivax populations. Overall, 291 samples were successfully genotyped at 39 SNPs. A significant difference was observed in the proportion of polyclonal infections among the five P. vivax populations (P = 0.0012, Pearson Chi-square test, χ2 = 18.1), with western Myanmar having the highest proportion (96.2%, 50/52) in 2018. Likewise, the average complexity of infection was also highest in western Myanmar (1.31) and lowest in northeast Myanmar (1.01) in 2018. The older samples from western China in 2011 had the highest pairwise nucleotide diversity (π, 0.388 ± 0.046), expected heterozygosity (He, 0.363 ± 0.02), and the largest effective population size. In comparison, in the neighboring northeast Myanmar, the more recent samples in 2018 showed the lowest values (π, 0.224 ± 0.036; He, 0.220 ± 0.026). Furthermore, the 2018 northeast Myanmar parasites showed high and moderate genetic differentiation from other populations with FST values of 0.162-0.252, whereas genetic differentiation among other populations was relatively low (FST ≤ 0.059). Principal component analysis, phylogeny, and STRUCTURE analysis showed that the P. vivax population in northeast Myanmar in 2018 substantially diverged from other populations. Although the 42 SNP barcode is a valuable tool for tracking parasite origins of worldwide parasite populations, a more extended barcode with additional SNPs is needed to distinguish the more related parasite populations in the western GMS.

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.

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.

Environmental Factors Linked to Reporting of Active Malaria Foci in Thailand

Thailand has made substantial progress towards malaria elimination, with 46 of the country’s 77 provinces declared malaria-free as part of the subnational verification program. Nonetheless, these areas remain vulnerable to the reintroduction of malaria parasites and the reestablishment of indigenous transmission. As such, prevention of reestablishment (POR) planning is of increasing concern to ensure timely response to increasing cases. A thorough understanding of both the risk of parasite importation and receptivity for transmission is essential for successful POR planning. Routine geolocated case- and foci-level epidemiological and case-level demographic data were extracted from Thailand’s national malaria information system for all active foci from October 2012 to September 2020. A spatial analysis examined environmental and climate factors associated with the remaining active foci. A logistic regression model collated surveillance data with remote sensing data to investigate associations with the probability of having reported an indigenous case within the previous year. Active foci are highly concentrated along international borders, particularly Thailand’s western border with Myanmar. Although there is heterogeneity in the habitats surrounding active foci, land covered by tropical forest and plantation was significantly higher for active foci than other foci. The regression results showed that tropical forest, plantations, forest disturbance, distance from international borders, historical foci classification, percentage of males, and percentage of short-term residents were associated with the high probability of reporting indigenous cases. These results confirm that Thailand’s emphasis on border areas and forest-going populations is well placed. The results suggest that environmental factors alone are not driving malaria transmission in Thailand; rather, other factors, including demographics and behaviors that intersect with exophagic vectors, may also be contributors. However, these factors are syndemic, so human activities in areas covered by tropical forests and plantations may result in malaria importation and, potentially, local transmission, in foci that had previously been cleared. These factors should be addressed in POR planning.

A comparison of malaria prevention behaviours, care-seeking practices and barriers between malaria at-risk worksite migrant workers and villagers in Northern Shan State, Myanmar-a mixed method study

Background

Migrant populations are at an increased risk of exposure to malaria due to their nature of work and seasonal migration. This study aimed to compare malaria prevention behaviours and care-seeking practices among worksite migrant workers and villagers in the malaria-at-risk areas of Eastern Myanmar close to the China border.

Methods

A mixed method study was conducted in March 2019. The malaria-at-risk worksites in the four targeted townships, and villages located the nearest to these worksites were approached. Key stakeholders, such as worksite managers and village leaders, were interviewed.

Results

A total of 23 worksites, which employed 880 migrants and 447 locals, and 20 villages, which were homes for 621 migrants and 9731 locals, were successfully interviewed. Regarding malaria prevention behaviours, sleeping under a bed net was common among both worksites (74%) and villages (85%). In contrast, insecticide-treated nets/long-lasting insecticidal nets (ITN/LLIN) usage was much lower in the worksites than in the villages (39% vs 80%). Regarding care-seeking practices for febrile illness, self-medication was a popular choice for both worksite workers and villagers owing to the easy availability of western medicine. Moreover, local-belief-driven traditional practices were more common among villagers. For occasions in which fever was not relieved, both would seek health care from rural health centres, private clinics, or public hospitals. As for barriers, villagers mostly cited language barriers, which often lead to misunderstanding between health providers and them. In contrast, most of the worksites cited logistics issues as they were in remote areas with devastated road conditions and the routes to formal health facilities were not secure due to frequent armed conflicts.

Conclusion

This study demonstrated that site-workers and villagers had different malaria prevention behaviours and care-seeking practices even though they resided in the same geographic area. Hence, it is important to recognize such differences for more effective intervention approaches.

Genetic polymorphisms in genes associated with drug resistance in Plasmodium vivax parasites from northeastern Myanmar

Background

Anti-malarial drug resistance is still a major threat to malaria elimination in the Great Mekong Sub-region. Plasmodium vivax parasites resistant to anti-malarial drugs are now found in Myanmar. Molecular surveillance on drug resistance genes in P. vivax parasites from northeastern Myanmar was aimed at estimating the underlying drug resistance in this region.

Methods

Blood samples from patients with vivax malaria were collected from Laiza city in northeastern Myanmar in 2020. Drug resistance genes including Pvcrt-o, Pvmdr1, Pvdhfr and Pvdhps were amplified and sequenced. Genetic polymorphisms and haplotypes were analysed to evaluate the prevalence of mutant alleles associated with drug resistance.

Results

A total of 149 blood samples from P. vivax patients were collected. The prevalence of Pvmdr1 mutations at codons 958 and 1076 was 100.0% and 52.0%, respectively, whereas no single nucleotide polymorphism was present at codon 976. The proportions of single and double mutant types were 48.0% and 52.0%, respectively. A K10 “AAG” insertion in the Pvcrt-o gene was not detected. Mutations in Pvdhfr at codons 57, 58, 61, 99 and 117 were detected in 29.9%, 54.3%, 27.6%, 44.9% and 55.1% of the samples, respectively. Wild type was predominant (46.3%), followed by quadruple and double mutant haplotypes. Of three types of tandem repeat variations of Pvdhfr, Type B, with three copies of GGDN repeats, was the most common. Pvdhps mutations were only detected at codons 383 and 553 and the wild type Pvdhps was dominant (78.0%). Eleven haplotypes were identified when combining the mutations of Pvdhfr and Pvdhps, among which the predominant one was the wild type (33.9%), followed by double mutant alleles S58R/S117N /WT (24.6%).

Conclusions

This study demonstrated resistant P. vivax phenotypes exists in northeastern Myanmar. Continued surveillance of drug resistance markers is needed to update treatment guidelines in this region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04084-y.

The use of respondent‑driven sampling to assess febrile illness treatment-seeking behaviours among forest-goers in Cambodia and Vietnam

Background

Countries in the Greater Mekong sub-region (GMS) aim to eliminate all forms of malaria by 2030. In Cambodia and Vietnam, forest-goers are at an increased risk of malaria. Universal access to prompt diagnosis and treatment is a core malaria intervention. This can only be achieved by understanding the healthcare-seeking behaviour among the most vulnerable groups and eliminating barriers to prompt and effective treatment. This study aimed to explore healthcare-seeking behaviours for febrile illness among populations at risk for malaria in Cambodia and Vietnam.

Methods

In 2019, researchers from Population Services International (PSI) conducted a population-based survey of forest-goers in Cambodia and Vietnam using respondent-driven sampling (RDS) In Cambodia two operational districts, Oral and Phnom Srouch in Kampong Speu Province were included in the study. In Vietnam, communes located within 15 km of the forest edge in Binh Phuoc and Gia Lai Provinces were selected. Adults who had spent at least one night per week or four nights per month in the forest over the previous three months were eligible for the study.

Results

Some 75% of forest-goers in Cambodia and 65% in Vietnam sought treatment for illness outside the home. In Cambodia, 39% sought treatment from the private sector, 32% from community health workers, and 24% from public health facilities. In Vietnam, 62% sought care from community facilities, 29.3% from the private sector, and 6.9% went to a public facility. Among forest-goers who sought care, 33% in Cambodia and 52% in Vietnam did so within 24 h.

Conclusions

This study is consistent with others that show that early diagnosis and treatment of malaria remains an obstacle to malaria elimination. This study also demonstrates that there are gaps in timeliness of care seeking among forest-goers. The findings from this study around provider preference and delays in treatment-seeking can be used to strengthen the design and targeting of malaria interventions and social and behaviour change strategies to accelerate malaria elimination in Cambodia and Vietnam.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04001-9.

Access to malaria prevention and control interventions among seasonal migrant workers: A multi-region formative assessment in Ethiopia

BACKGROUND

Mobile or seasonal migrant workers are at increased risk for acquiring malaria infections and can be the primary source of malaria reintroduction into receptive areas. The aim of this formative assessment was to describe access to malaria prevention and control interventions among seasonal migrant or mobile workers in seven regional states of Ethiopia.

METHODS

A cross-sectional formative assessment was conducted using a qualitative and quantitative mixed-method design, between October 2015 and October 2016. Quantitative data were collected from organizations that employ seasonal migrant workers and were analyzed using Microsoft Excel and ArcGIS 10.8 (Geo-spatial data). Qualitative data were collected using in-depth interview from 23 key informants (7 seasonal migrant workers, and 16 experts and managers of development projects who had hired seasonal migrant workers), which were recorded, transcribed, translated, coded, and thematically analyzed.

RESULTS

There were 1,017,888 seasonal migrant workers employed in different developmental organizations including large-scale crop cultivating farms, sugar cane plantations, horticulture, road and house construction work, and gold mining and panning. Seasonal migrant workers' housing facilities were poorly structured and overcrowded (30 people living per 64 square meter room) limiting the use of indoor residual spraying (IRS), and forcing seasonal migrant workers not to use long lasting insecticidal treated nets (LLINs). Seasonal migrant workers are engaged in nighttime activities when employment includes watering farmlands, harvesting sesame, and transporting sugar cane from the field to factories. Despite such high-risk living conditions, access and utilization of preventive and curative services by the seasonal workers were limited. Informal migrant worker employment systems by development organizations and inadequate technical and financial support coupled with poor supply chain management limited the planning and delivery of malaria prevention and treatment strategies targeting seasonal migrant workers.

CONCLUSIONS

Seasonal migrant workers in seven regions of Ethiopia were at substantial risk of acquiring malaria. Existing malaria prevention, control and management interventions were inadequate. This will contribute to the resurgence of outbreaks of malaria in areas where transmission has been lowered. A coordinated action is needed among all stakeholders to identify the size of seasonal migrant workers and develop and implement a comprehensive strategy to address their healthcare needs.

Low practice of malaria prevention among migrants and seasonal farmworkers in Metema and west Armacheho districts, Northwest Ethiopia

BACKGROUND

More than hundreds and thousands of migrants and seasonal farm workers move from the highlands (relatively low malaria endemicity areas) to the lowlands (higher malaria endemicity areas) for the development of the corridor of the Amhara region during planting, weeding, and harvesting seasons in each year. Seasonal migrant workers are at high risk of malaria infection. Therefore, evidence of their knowledge level and practice in the prevention of malaria during their stay would be important.

OBJECTIVE

The aims of this study was to assess the knowledge and practice of malaria prevention and associated factors among migrants and seasonal farm workers in Northwest Ethiopia.

METHOD

A cross-sectional study was conducted from October to November, 2018 in Metema and West Armacheho districts, northwest Ethiopia. A sample of about 950 migrants and seasonal farm workers were included using two stages of cluster sampling technique. Interview administered structured questionnaire was used. Both bi-variable and multivariable binary logistic regressions were applied to identify predictors of malaria prevention.

RESULT

The overall good knowledge of malaria (those participants who scored more than 60% of correct response for knowledge related questions) was 50.2% with 95% CI (47.0-53.0) and the overall good practice of malaria (those participants who practiced more than 60% for practice related questions) was 27.2% with 95% CI (244.3-29.9). Age (AOR = 0.51(95%CI; 0.33-0.80)), level of education (AOR = 0.55(95%CI; 0.32-0.94)), using mass media as a source of information (AOR = 2.25(95%CI; 1.52-3.32)) and length of stay at the farming site (AOR = 0.59(95%CI; 0.44-0.79)) were significantly associated with knowledge of malaria prevention. Knowledge (AOR = 6.62(95%CI; 4.46-9.83)), attitude (AOR = 2.17(95%CI1.40-3.37), use of mass media (AOR = 1.64(95%CI; 1.30-2.60)) and the length of stay (AOR = 1.93(95%CI; 1.35-2.77)) in the farming area were significantly associated with practice of malaria prevention.

CONCLUSION

The practice of malaria prevention among migrant and seasonal farm workers was low. The programmers and implementers should design tailored malaria intervention programs and strategies for these hard to reach population.

From control to elimination: a spatial-temporal analysis of malaria along the China-Myanmar border

Background

Malaria cases have declined significantly along the China-Myanmar border in the past 10 years and this region is going through a process from control to elimination. The aim of this study is to investigate the epidemiology of malaria along the border, will identify challenges in the progress from control to elimination.

Methods

National reported malaria cases from China and Myanmar, along with the data of 18 Chinese border counties and 23 townships in Myanmar were obtained from a web-based diseases information reporting system in China and the national malaria control program of Myanmar, respectively. Epidemiological data was analyzed, including the number of reported cases, annual parasite index and proportion of vivax infection. Spatial mapping of the annual parasite index (API) at county or township level in 2014 and 2018 was performed by ArcGIS. The relationship of malaria endemicity on both sides of the border was evaluated by regression analysis.

Results

The number of reported malaria cases and API declined in the border counties or townships. In 2014, 392 malaria cases were reported from 18 Chinese border counties, including 8.4% indigenous cases and 91.6% imported cases, while the highest API (0.11) was occurred in Yingjiang County. There have been no indigenous cases reported since 2017, but 164 imported cases were reported in 2018 and 97.6% were imported from Myanmar. The average API in 2014 in 23 Myanmar townships was significantly greater than that of 18 Chinese counties (P < 0.01). However, the API decreased significantly in Myanmar side from 2014 to 2018 (P < 0.01). The number of townships with an API between 0 and 1 increased to 15 in 2018, compared to only five in 2014, while still four townships had API > 10. Plasmodium vivax was the predominant species along the border. The number of reported malaria cases and the proportion of vivax infection in the 18 Chinese counties were strongly correlated with those of the 23 Myanmar townships (P < 0.05).

Conclusions

Malaria elimination is approaching along the China-Myanmar border. However, in order to achieve the malaria elimination in this region and prevent the re-establishment of malaria in China after elimination, continued political, financial and scientific commitment is required.

Do we need to go further to train healthcare providers in the targeted regions for malaria elimination in Myanmar? A mixed-methods study

Background

The National Malaria Control Programme (NMCP) in Myanmar trained health staff at the township level starting in mid-2016 in order to achieve the Plasmodium falciparum malaria elimination target by 2020. This study aimed to evaluate the knowledge and perception of Basic Health Staff (BHS) and Vector-borne Diseases Control (VBDC) teams exposed to a short training course on malaria elimination in six targeted townships which included two conflict-affected townships between 2016 and 2017.

Methods

This was a cross-sectional mixed-methods study using quantitative and qualitative data extracted from one survey database conducted between October 2018 and March 2019. Modified Poisson regression analysis was performed to ascertain the determinants of low knowledge scores after the training programme.

Results

Altogether, 544 trained frontline health workers involved in malaria elimination at the time of the survey were recruited and 56% (302/544) were stationed at sub-Rural Health Centers. More than half of the respondents had correct knowledge of malaria case categories although relapse and recrudescent cases (39% and 37% respectively) were less well known. Over two-thirds of respondents could mention those eligible for malaria testing. Less than 30% knew the foci classification. The overall knowledge scores ranged from 10 to 31. The significant predictors of low level of knowledge [the cut-off point was set at the median value of 21 (IQR 12-30)] in multivariate analysis were the younger age group (18-29 years) and health staff who had attended malaria elimination training in 2017, [(APR = 1.6, 95% CI 1.2-2.2)]; and (APR = 1.5, 95%CI 1.2-1.8)]. Qualitative data from 10 key informants identified perceived challenges in conflict-affected areas as well as in areas of high population mobility with further implications for case surveillance. In addition, the low level of education of community members was noted as one of the barriers that hampered public readiness in the elimination scenario.

Conclusion

A significant impact on knowledge improvement after the training programme was not visible especially for correct notification of malaria cases and treatment according to National Malaria Elimination Guidelines. Regular monitoring and continuing guidance by the higher level management is critical to support the field staff.

Challenges in early phase of implementing the 1-3-7 surveillance and response approach in malaria elimination setting: A field study from Myanmar

Background

The National Plan for Malaria Elimination (NPME) in Myanmar (2016–2030) aims to eliminate indigenous Plasmodium falciparum malaria in six states/regions of low endemicity by 2020 and countrywide by 2030. To achieve this goal, in 2016 the National Malaria Control Program (NMCP) implemented the “1-3-7” surveillance and response strategy. This study aims to identify the barriers to successful implementation of the NPME which emerged during the early phase of the “1-3-7” approach deployment.

Methods

A mixed-methods study was conducted with basic health staff (BHS) and Vector Born Disease Control Program (VBDC) staff between 2017 and 2018 in six townships of six states/regions targeted for sub-national elimination by 2020. A self-administered questionnaire, designed to assess the knowledge required to implement the “1-3-7” approach, was completed by 544 respondents. Bivariate analysis was performed for quantitative findings and thematic analysis was conducted for qualitative findings using Atals.ti software.

Results

Although 83% of participants reported performing the key activities in the “1-3-7” surveillance and response approach, less than half could report performing those activities within 3 days and 7 days (40 and 43%, respectively). Low proportion of BHS correctly identified six categories of malaria cases and three types of foci (22 and 26%, respectively). In contrast, nearly 80% of respondents correctly named three types of case detection methods. Most cited challenges included ‘low community knowledge on health’ (43%), ‘inadequate supplies’ (22%), and ‘transportation difficulty’ (21%). Qualitative data identified poor knowledge of key surveillance activities, delays in reporting, and differences in reporting systems as the primary challenges. The dominant perceived barrier to success was inability to control the influx of migrant workers into target jurisdictions especially in hard-to-reach areas. Interviews with township medical officers and the NMCP team leaders further highlighted the necessity of refresher training for every step in the “1-3-7” surveillance and response approach.

Conclusions

The performance of the “1-3-7” surveillance and response approach in Myanmar delivers promising results. However, numerous challenges are likely to slow down malaria elimination progress in accordance with the NPME. Multi-stakeholder engagement and health system readiness is critical for malaria elimination at the sub-national level.

Utilization of insecticide-treated bed nets and care-seeking for fever and its associated socio-demographic and geographical factors among under-five children in different regions: evidence from the Myanmar Demographic and Health Survey, 2015-2016

Background

Malaria is one of the top-five contributors to under-5 deaths in Myanmar. Use of insecticide-treated nets (ITN) and receiving early appropriate care in case of fever are the core interventions to prevent malaria and its complications and thereby deaths. This study aimed to assess among the under-five children, (a) utilization of ITNs and its associated factors, (b) care-seeking behaviour among their caregivers and its associated factors and uptake of malaria testing among those with fever in the last 2 weeks.

Methods

This was a cross sectional study using secondary analysis of Myanmar Demographic and Health Survey (MDHS) conducted in 2015–2016. Multivariable logistic regression was used to explore the factors associated with non-utilization of ITNs and not seeking care for fever. Effect sizes have been presented using odds ratios with 95% confidence intervals. Data analysis was done using svyset command in STATA to account for the multi-stage sampling design of the survey.

Results

Of 4597 alive under-five children, 80.5% did not sleep under an ITN last night. The factors significantly associated with non-utilization of ITNs were residing in malaria elimination regions (aOR = 2.0, 1.3–3.2), urban residence (aOR = 1.8, 1.2–2.9), staying in delta region (aOR = 8.7, 4.7–12.2), hilly region (aOR = 3.0, 2.0–4.6, and having highest wealth quintile (aOR = 1.8, 1.1–3.0). Around 16% had fever in the last 2 weeks, of whom 66.7% sought care for fever and 3% got tested for malaria. Nearly half (50.9%) of the caregivers sought care from a government health facility, followed by private hospital/doctor (27.8%), shop (8.0%), village health worker (4.4%) and pharmacy (3.1%). The factors associated with not seeking care for fever were residing in specific geographical locations (hilly, delta and central plains compared to coastal region) and having lowest wealth quintile (aOR = 2.3, 1.1–5.7).

Conclusions

This study highlighted that ownership and utilization of ITNs was very poor among under-5children. Care-seeking behaviour of the caregivers of under-5 children in case of fever was dismal with two-thirds not seeking care. The programme should seriously consider addressing these barriers if Myanmar is to achieve zero malaria deaths by 2030.

Quality of Malaria Treatment Provided under 'Better Health Together' Project in Ethnic Communities of Myanmar: How Are We Performing?

Malaria accounted for 18% of all deaths in the ethnic communities of Myanmar. In this cross-sectional study, we assessed the extent of and factors associated with receipt of quality malaria treatment services provided by integrated community malaria volunteer (ICMV) under six ethnic health organisations. Data of people with malaria diagnosed by rapid diagnostic tests during 2017–2018 were extracted from the ICMV registers. Documentation of prescribing a complete course of drugs was used to assess quality. Of 2881 people with malaria, village-based ICMV diagnosed and treated 2279 (79%) people. Overall, 2726 (95%) people received correct drugs in the correct dose and adequate duration appropriate to malaria species, age and pregnancy status while 1285 (45%) people received ‘correct and timely (within 24 h of fever)’ treatment. Children under five years, those with severe malaria, mixed infection and falciparum malaria were less likely to receive the correct treatment. When compared to health posts, village-based ICMVs and mobile teams performed better in providing correct treatment and mobile teams in providing ‘correct and timely’ treatment. This calls for ensuring the early presentation of people to health workers within 24 h of undifferentiated fever through health promotion initiatives. Future studies should assess adherence to medication and clinical improvement.

Challenges and the Path Forward on Malaria Elimination Intervention: A Systematic Review

BACKGROUND

This systematic review was conducted to highlights key challenges, and outlines important next steps to maximize the potential to contribute to the broader malaria elimination interventions.

METHODS

This systematic review on malaria elimination intervention and challenges was undertaken searching six databases, between 1995 and 2018. Inclusion and exclusion criteria were set. The references were collated and categorized according to type of study, intervention, population, and health outcome. Articles selection based on title and abstract, retrieval of full text and additions of articles from reference lists and recommendations from experts. Disagreement in data extraction was solved by consultation of third reviewer.

RESULTS

Overall, 4039 records were examined related to malaria elimination that initially identified by our designated electronic databases search. Overall, 35 studies contained 14 experimental studies (40%) and 21 analytic observational studies (60%) met the inclusion criteria for this review. Studies used a wide variety of malaria elimination interventions. Types of interventions either elimination-focused interventions or general interventions on educational, prevention and treatment of malaria are included. This review pointed out the variety of challenges for eliminate malaria among low and high endemic countries.

CONCLUSION

Malaria elimination is facilitated by strong health systems, determined leadership, appropriate incentivization, an effective surveillance system, and regional collaborations. We have identified areas for elimination-specific interventions deserve more attention in the conduct and reporting.

Emerging neglected helminthiasis and determinants of multiple helminth infections in flood-prone township in Myanmar

BACKGROUND

Myanmar has similar agro-based ecology and environmental risks as others in the Greater Mekong sub-region leading to the broad array of helminthic infections. Basic health staff (BHS) from the public sector forms a key stakeholder group in deworming interventions. The study aimed to ascertain the prevalence and determinants of multiple species helminth infections to promote township-level integrated interventions.

METHODS

A cross-sectional implementation research study in 2017 covered randomly selected 240 households in four villages of Shwegyin Township. Trained interviewers administered the pre-tested structured questionnaire to either the household head or the assigned person concerning their knowledge, perceptions, practices, food habits, and deworming experience. Concomitantly, the research team collected a single stool sample from each of 698 participants (age range of 8 months to 87 years) from 93% (224/240) of eligible households and examined by Kato-Katz smear microscopy. Eventually, 16 BHS joined the interactive dialogue session based on research evidence and knowledge translated for further validation.

RESULTS

The estimated prevalence of at least one helminth infection was 24% [168/698; 95% CI 21.0-27.0]. Apart from the soil-transmitted helminths (14%), zoonotic helminths especially Taenia spp. (0.7%) and Schistosoma spp. (3%) were detected. Almost half of the seasonally mobile gold panning workers (12/25; 48%) and 46% of pre-school-age children had helminth infections. Community risk groups at riverside villages had significantly higher multiple species helminth infection than those from inland villages (AOR = 10.9; 95% CI 4.9-24.2). Gold panning workers had higher infection rates than other categories (AOR = 2.5; 95% CI 0.6-9.5) but not significant. In flood-prone areas, householders failed to follow the guidelines to construct/re-construct specific type of sanitary latrines and challenges remained in disseminating health messages for community engagement. The innovative ideas recapitulated by BHS included the integration of health talks during the sessions for small agricultural loans and to harness advocacy with water, sanitation, and hygiene interventions.

CONCLUSIONS

The emerging evidence of neglected zoonotic helminths required attention to introduce the periodic mopping-up and the "selective deworming plan" for vulnerable groups to cover the missed targets. Further multidisciplinary research to confirm the intermediate hosts and vectors of zoonotic helminths in the environment is essential for surveillance and response.

Challenges for the diagnosis and treatment of malaria in low transmission settings in San Lorenzo, Esmeraldas, Ecuador

BACKGROUND

Ecuador is on the verge of eliminating malaria according to the World Health Organization criteria. Nevertheless, active transmission foci still persist in the country, and these represent an important challenge for achieving the objectives set out. Diagnosis and treatment are a mainstay in the control and elimination of this disease. This study aimed to explore the barriers hindering the implementation of malaria diagnosis and treatment strategies in a focus of active transmission in the San Lorenzo canton, Ecuador.

METHODS

Using a convergent mixed methods design during 2017, the researchers assessed the physical and human resources of the services network at the primary level of care along with the quality assurance activities, patient access to healthcare services and perceptions regarding the care provided to patients with malaria.

RESULTS

The programme's administrative transition from the National Service of Vector-borne Diseases to the Ministry of Public Health is perceived from the interviewed participants to have weakened the diagnosis network established in recent years. A mean of 6.4 ± 0.88 months was found for anti-malarial medication shortage at the primary level of care. Likewise, there was high healthcare staff turnover (permanence, Me = 7 months; IQR = 5-16) and a deficit of general knowledge on the disease among the entirety of healthcare staff, as only 29% of physicians were aware of the correct first-line treatment for malaria by Plasmodium falciparum and Plasmodium vivax. It was evidenced that 95.7% of patients were hospitalized to receive anti-malarial treatment. Both patients and healthcare staff considered the area to be difficult to reach due to its geography and the presence of groups outside the law. They also identified the lack of personnel and microscopy posts in this border area as the main barrier.

CONCLUSION

The network of diagnostic services for malaria is weak in San Lorenzo, and socio-economic, political and historical factors hinder the implementation of the universal malaria elimination strategy based on diagnosis and treatment.

Low uptake of malaria testing within 24 h of fever despite appropriate health-seeking among migrants in Myanmar: a mixed-methods study

Background

There is limited information on uptake of malaria testing among migrants who are a ‘high-risk’ population for malaria. This was an explanatory mixed-methods study. The quantitative component (a cross sectional analytical study-nation-wide migrant malaria survey in 2016) assessed the knowledge; health-seeking; and testing within 24 h of fever and its associated factors. The qualitative component (descriptive design) explored the perspectives of migrants and health care providers [including village health volunteers (VHV)] into the barriers and suggested solutions to increase testing within 24 h. Quantitative data analysis was weighted for the three-stage sampling design of the survey. Qualitative data analysis involved manual descriptive thematic analysis.

Results

A total of 3230 households were included in the survey. The mean knowledge score (maximum score 11) for malaria was 5.2 (0.95 CI 5.1, 5.3). The source of information about malaria was 80% from public health facility staff and 21% from VHV. Among 11 193 household members, 964 (8.6%) had fever in last 3 months. Health-seeking was appropriate for fever in 76% (0.95 CI 73, 79); however, only 7% (0.95 CI 5, 9) first visited a VHV while 19% (0.95 CI 16, 22) had self-medication. Of 964, 220 (23%, 0.95 CI 20, 26) underwent malaria blood testing within 24 h. Stable migrants, high knowledge score and appropriate health-seeking were associated with testing within 24 h. Qualitative findings showed that low testing within 24 h despite appropriate health-seeking was due to lack of awareness among migrants regarding diagnosis services offered by VHV, delayed health-seeking at public health facilities and not all cases of fever being tested by VHV and health staff. Providing appropriate behaviour change communication for migrants related to malaria, provider’s acceptance for malaria testing for all fever cases and mobile peer volunteer under supervision were suggested to overcome above barriers.

Conclusions

Providers were not testing all migrant patients with fever for malaria. Low uptake within 24 h was also due to poor utilization of services offered by VHV. The programme should seriously consider addressing these barriers and implementing the recommendations if Myanmar is to eliminate malaria by 2030.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2546-4) contains supplementary material, which is available to authorized users.