Rabies in Myanmar: Prevalent, Preventable but not Prioritized

A systematic review of neglected tropical diseases (NTDs) in Myanmar

BACKGROUND

Neglected tropical diseases (NTDs) affect most impoverished communities in developing countries, like Myanmar in Southeast Asia. NTDs have been understudied and underreported in Myanmar.

METHODS

A systematic review of published and grey literature (1900-2023) on neglected tropical diseases (NTDs) in Myanmar was conducted. The literature search included five international databases: PubMed, EMBASE, Ovid Global Health, and Web of Science Core Collection and one national database: the Myanmar Central Biomedical Library (locally published papers and grey literature). The selection criteria included articles with all types of study designs of current or previous infections conducted in humans, that reported NTDs, recognised by WHO, US CDC, and listed in PLoS NTDs. We included melioidosis and rickettsioses which we consider also meet the definition of an NTD.

RESULTS

A total of 5941 records were retrieved and screened, of which, 672 (11%) met the selection criteria and were included in this review. Of the included articles, 449 (65%) were published after 2000 and 369 (55%) were from two regions (Yangon and Mandalay) of Myanmar. Of the included articles, 238 (35%) reported bacterial NTDs, 212 (32%) viral NTDs, 153 (23%) helminth NTDs, 25 (4%) protozoal NTDs and 39 (6%) reported more than one aetiology. Based on reported frequency in descending order, the bacterial NTDs were leprosy, Escherichia coli enteritis, salmonellosis, cholera, shigellosis, melioidosis, leptospirosis and rickettsioses; the viral NTDs were dengue, chikungunya and Japanese encephalitis virus (JEV) infection; the protozoal NTDs were amoebiasis, giardiasis and leishmaniasis, and the helminth NTDs were ascariasis, trichuriasis, hookworm disease, filariasis and strongyloidiasis.

CONCLUSION

This review summarises NTDs reported in Myanmar over the past 100 years. The findings suggest that most NTDs are likely to be under reported, especially from the majority of the country which is far from academic centres. Research capacity building together with strengthening of laboratory systems would lead to better understanding of the true burden of NTDs in Myanmar.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42018092627.

Incidence and mortality trends of neglected tropical diseases and malaria in China and ASEAN countries from 1990 to 2019 and its association with the socio-demographic index

BACKGROUND

People in China and the countries in the Association of Southeast Asian Nations (ASEAN) are affected by neglected tropical diseases and malaria (NTDM). In this study, we aimed to assess the current status and trends of NTDM burden from 1990 to 2019 in China and ASEAN countries, and also explore the association of NTDM burden with socio-demographic index (SDI).

METHODS

The data from the Global Burden of Diseases Study 2019 (GBD 2019) results were used. Absolute incidence and death number, and age-standardized incidence and mortality rate (ASIR and ASMR) of NTDM in China and ASEAN were extracted. The estimated annual percentage change (EAPC) and join-point regression in the rates quantified the trends. Nonlinear regression (second order polynomial) was used to explore the association between SDI and ASRs.

RESULTS

The ASIR of NTDM increased in China, Philippines, Singapore and Brunei, at a speed of an average 4.15% (95% CI 3.83-4.47%), 2.15% (1.68-2.63%), 1.03% (0.63-1.43%), and 0.88% (0.60-1.17%) per year. Uptrends of ASIR of NTDM in recent years were found in China (2014-2017, APC = 10.4%), Laos (2005-2013, APC = 3.9%), Malaysia (2010-2015, APC = 4.3%), Philippines (2015-2019, APC = 4.2%), Thailand (2015-2019, APC = 2.4%), and Vietnam (2014-2017, APC = 3.2%, all P < 0.05). Children < 5 had relatively low incidences but unexpectedly high mortality rates of NTDM in most ASEAN countries. Both incidence and mortality rates of NTDM were higher in older people. ASIR and ASMR of NTDM had a U-shaped association with SDI.

CONCLUSIONS

The burden of NTDM in China and ASEAN countries was still huge and affects vulnerable and impoverished populations' livelihoods, including children under the age of 5 and people aged 60 and older. Facing with the large burden and complex situation of NTDM in China and ASEAN countries, regional cooperating strategies are needed to reduce the burden of NTDM, so as to achieve the goal of elimination in the world.

The impact of decentralisation on health systems in fragile and post-conflict countries: a narrative synthesis of six case studies in the Indo-Pacific

A health system has three key stakeholders, the State-at national and subnational levels-the health service providers and the citizens. In most settings and especially in peacetime, these stakeholders are typically well-defined. In contrast, during conflict and crisis as well as during ceasefire and post-conflict peacebuilding, stakeholders in the health system are often more diverse and contested. Health systems in such settings tend to be more decentralised, de facto-often in addition to de jure decentralisation. Despite much debate on the potential benefits of decentralisation, assessing its impact on health system performance remains difficult and its effect is open to dispute in the literature. This narrative synthesis aims to support efforts to assess and make sense of how decentralisation impacts health system performance in fragile and post-conflict countries-by synthesising evidence on the impact of decentralisation on health system performance from six country case studies: Papua New Guinea, the Philippines, Indonesia, Pakistan, Myanmar and Nepal. The impact of decentralisation on health system performance is optimised when combining centralisation (e.g., the benefits of central coordination in improving efficiency) with decentralisation (e.g., the benefits of local decision making in improving equity and resilience). The findings may inform efforts to think through what to centralise or decentralise, the impacts of those choices, and how the impact may change over time as countries go through and emerge from conflict-and as they go through and recover from the Covid-19 pandemic and prepare for future pandemics.

Rabies in Southeast Asia: a systematic review of its incidence, risk factors and mortality

OBJECTIVE

Rabies is a neglected zoonotic disease that can infect all mammals, including humans. We aimed to summarise the current knowledge of the incidence, risk factors and mortality of rabies in Southeast Asia.

DESIGN

Systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

DATA SOURCES

Scopus, Web of Science and PubMed were searched from 1 January 2012 to 21 February 2023.

ELIGIBILITY CRITERIA

Original English language articles published between 2012 and 2023 were included.

DATA EXTRACTION AND SYNTHESIS

Nine independent reviewers extracted data and assessed the risk of bias. The quality appraisal of included articles was carried out using the Mixed Methods Appraisal Tool.

RESULTS

A total of eight articles were included in this analysis. In Vietnam, the incidence of rabies ranged from 1.7 to 117.2 per 100 000 population. The cumulative incidence in Sarawak was estimated at 1.7 per 100 000 population. In Indonesia, 104 human rabies cases were reported from 2008 to 2010, while in Thailand, a total of 46 rabies cases were reported in Thailand from 2010 to 2015. In the Philippines, the incidence of rabies ranged from 0.1 to 0.3 per 100 000 population. An increased risk of rabies virus infection was associated with a high population density, illiteracy, seasonal patterns and dog butchers. The case fatality rate was 100%.

CONCLUSION

This study included research from Southeast Asia, which may not represent rabies infection in other regions or continents. In addition, the role of publication bias should be acknowledged as grey literature was not included. The occurrence of rabies in Southeast Asia is due to the high number of unvaccinated stray and pet dogs, working hazards (dog butchers in Vietnam), the unavailability of the rabies vaccine in rural regions and misinformation about the significance of seeking treatment after dog bites.

PROSPERO REGISTRATION NUMBER

CRD42022311654.

Exploring rabies endemicity in Pakistan: Major constraints & possible solutions

Rabies, the oldest recorded viral zoonosis in the Indo-Pakistan subcontinent, is a neglected and lingering endemic disease in Pakistan. The review of online available rabies-related journals, papers and reports through platforms and electronic databases have provided the basis for a detailed analysis of the rabies situation in Pakistan. Only published materials related to various research areas of rabies in Pakistan were included and meaningful conclusions were developed to identify major constraints and generate an intellectual discussion on possible solutions. Results revealed 52 studies representing major issues concerning rabies prevention related to topics including, but not limited to: epidemiological investigations (40.38%), prophylactic measures (21.15%), population of wandering dogs (13.46%), public awareness and government interventions (17.30%) and diagnostic surveillance (7.69%). In order to minimize these problems and reduce the prevalence of dog bites or rabies in significant manners, the country direly needs to apply the following actions: a maintained supply of rabies prophylactic measures in public hospitals at subsidized rates, mass dog vaccination at regional levels, enforced responsible animal ownerships, implementing a systematic One Health approach, and diagnostic labs equipped with surveillance mechanisms established in coordination with the livestock and medical departments. This review, which presents up-to-date information on the risk factors and epidemiological features of rabies in Pakistan, provides useful information for scientists, policy makers, and administrative health officials wishing to understand how this deadly disease persists in the absence of effective control measures.

A Rapid Assessment of Health Literacy and Health Status of Rohingya Refugees Living in Cox's Bazar, Bangladesh Following the August 2017 Exodus from Myanmar: A Cross-Sectional Study

Background: A survey was conducted among Rohingya refugees to assess their overall health literacy and health status. Methods: A questionnaire was developed to conduct face to face interviews among Rohingya refugees in Cox’s Bazar, Bangladesh in November–December 2017. Families were selected using convenience sampling from four large refugee camps. Results: Primary respondents aged 10–90 (median 32) years, 56% male, representing 1634 families were interviewed and provided data of themselves and 6268 additional family members, 4163 (66.4%) of whom were children aged <18 years. Of all, only 736 (45%) primary respondents knew how to appropriately treat diarrhoea, 882 (54%) relied on unqualified village “doctors” for treatment, 547 (33.5%) reported a family member suffering injuries in the previous six months, with 8% (42/547) of injuries fatal. One hundred and ninety two (11.8%) primary respondents also reported deaths within their family in the preceding 12 months, with the majority (70% [134/192]) occurring in males, and 44% (85/192) of all deaths were claimed to be homicidal. Conclusion: This survey highlights overall poor health literacy, limited access to qualified health care, and a high rate of injuries and assaults among Rohingyas. However, these data come from an anecdotal survey that excluded some sensitive but important questions.

Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability

BACKGROUND AND AIM

There is little published research to examine the best approach to the management of Helicobacter pylori in Myanmar. This study aimed to determine the relative efficacy and tolerability of sequential eradication therapy compared to Myanmar's current recommendation of a concomitant four drug regimen.

METHODS

Patients were screened for H. pylori using monoclonal Stool Antigen Testing (SAT). Those testing positive were randomized 1:1 to receive receive Myanmar's first-line regimen of 14 days of concomitant rabeprazole, clarithromycin, amoxycillin and tinidazole (140 pills, cost US$23) or 10 days of sequential rabeprazole, clarithromycin, amoxycillin and tinidazole (60 pills, cost US$10). Adherence and adverse effects were recorded, and the efficacy of the regimens assessed with repeat SAT.

RESULTS

Of the 1011 patients screened for H. pylori infection, 313 (31%) tested positive. There was no statistical difference in the cure rates of the two regimens in either intention-to-treat: 128/157 (82%; 95% confidence interval (CI): 75-87%) receiving sequential therapy versus 123/156 (79%; 95% CI: 72-85%) receiving concomitant therapy (P = 0.55) or per-protocol analysis: 125/131 (95%; 95% CI: 90-98) receiving sequential therapy versus 121/130 (93%; 95% CI: 87-96) receiving concomitant therapy (P = 0.42). Side effects of therapy were reported in 54/157 (47%) patients taking sequential therapy compared with 62/156 (53%) taking concomitant therapy, but this difference did not reach statistical significance (P = 0.33).

CONCLUSIONS

In this high-burden, resource-poor setting, less expensive sequential therapy was as effective and as well tolerated as the currently recommended concomitant four drug regimen for eradication of H. pylori.

Descriptive assessment of rabies post-exposure prophylaxis procurement, distribution, monitoring, and reporting in four Asian countries: Bangladesh, Bhutan, Cambodia, and Sri Lanka, 2017-2018

BACKGROUND

There are approximately 35,000 human deaths from rabies in Asia annually. Rabies can be prevented through timely post-exposure prophylaxis (PEP) consisting of wound washing, rabies vaccine, and in some cases, rabies immunoglobulin (RIG). However, access to rabies PEP often remains limited to urban areas and is cost-prohibitive. There is little information on procurement, distribution, monitoring, and reporting of rabies PEP.

METHODS

We interviewed key informants in the public sector from various levels in Bangladesh, Bhutan, Cambodia, and Sri Lanka between March 2017 and May 2018 using a descriptive assessment tool to obtain information on procurement, distribution, monitoring, and reporting of rabies PEP. These four countries in Asia were chosen to showcase a range of rabies PEP systems. National rabies focal points were interviewed in each country and focal points helped identify additional key informants at lower levels.

RESULTS

A total of 22 key informants were interviewed at various levels (central level to health facility level) including national rabies focal points in each country. Each country has a unique system for managing rabies PEP procurement, distribution, monitoring, and reporting. There are varying levels of PEP access for those with potential rabies exposures. Rabies PEP is available in select health facilities throughout the country in Bangladesh, Bhutan, and Sri Lanka. In Cambodia, rabies PEP is limited to two urban centers. The availability of RIG in all four countries is limited. In these four countries, most aspects of the rabies PEP distribution system operate independently of systems for other vaccines. However, in Bhutan, rabies PEP and Expanded Programme on Immunization (EPI) vaccines share cold chain space in some locations at the lowest level. All countries have a monitoring system in place, but there is limited reporting of data, particularly to the central level.

CONCLUSION

Systems to procure, deliver, monitor, and report on rabies PEP are variable across countries. Sharing information on practices more widely among countries can help programs to increase access to this life-saving treatment.

The clinical characteristics of adults with rheumatic heart disease in Yangon, Myanmar: An observational study

BACKGROUND

Rheumatic heart disease (RHD) is a major cause of premature death in low and middle-income countries. The greatest barrier to RHD control is neglect of the disease in national health policies and a lack of prevalence data that might inform control efforts. Myanmar is making remarkable progress against many infectious diseases, but there are almost no data to define the clinical burden of RHD in the country. This prospective audit was performed in an adult medical ward of a tertiary-referral hospital in Yangon, to gain an insight into the prevalence of RHD in Myanmar.

PRINCIPAL FINDINGS

All patients admitted to the ward between May 1, 2016 and April 30, 2017 were eligible for enrolment. RHD was confirmed in 96 patients who were admitted on 134 occasions, representing 1.1% of the 12,172 adult medical admissions during the study period. This compared with 410 (3.4%) admissions with HIV and 14 (0.1%) with malaria. Patients with RHD had a median age of 44 years (interquartile range: 35-59); 70 (73%) were female. Only one patient had ever had surgery despite 79 (82%) meeting criteria for intervention; 54 (56%) patients were not receiving any regular clinician review. Prior to hospitalisation only 18 (19%) patients were receiving regular penicillin. Only 8 (19%) of the 42 women <50 years were using contraception. Of 49 patients who had been hospitalised previously, 22 (45%) were receiving no regular therapy. During the study three (3.1%) patients died, and 28 (29%) were lost to follow-up. Of the 65 (68%) alive and retained in care, 21 (32%) were still experiencing moderate-severe RHD-related symptoms at the study's end.

CONCLUSIONS

There is a significant and unmet clinical burden of RHD in Myanmar. A national RHD programme would improve patient care, reducing morbidity and mortality from this preventable disease.