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Narayanasamy S, Dat VQ, Thanh NT, Ly VT, Chan JFW, Yuen KY, Ning C, Liang H, Li L, Chowdhary A, Youngchim S, Supparatpinyo K, Aung NM, Hanson J, Andrianopoulos A, Dougherty J, Govender NP, Denning DW, Chiller T, Thwaites G, van Doorn HR, Perfect J, Le T. A global call for talaromycosis to be recognised as a neglected tropical disease. Lancet Glob Health 2021; 9:e1618-e1622. [PMID: 34678201 PMCID: PMC10014038 DOI: 10.1016/s2214-109x(21)00350-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/13/2021] [Accepted: 07/22/2021] [Indexed: 02/05/2023]
Abstract
Talaromycosis (penicilliosis) is an invasive mycosis that is endemic in tropical and subtropical Asia. Talaromycosis primarily affects individuals with advanced HIV disease and other immunosuppressive conditions, and the disease disproportionally affects people in low-income and middle-income countries, particularly agricultural workers in rural areas during their most economically productive years. Approximately 17 300 talaromycosis cases and 4900 associated deaths occur annually. Talaromycosis is highly associated with the tropical monsoon season, when flooding and cyclones can exacerbate the poverty-inducing potential of the disease. Talaromycosis can present as localised or disseminated disease, the latter causing cutaneous lesions that are disfiguring and stigmatising. Despite up to a third of diagnosed cases resulting in death, talaromycosis has received little attention and investment from regional and global funders, policy makers, researchers, and industry. Diagnostic and treatment modalities remain extremely insufficient, however control of talaromycosis is feasible with known public health strategies. This Viewpoint is a global call for talaromycosis to be recognised as a neglected tropical disease to alleviate its impact on susceptible populations.
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Affiliation(s)
- Shanti Narayanasamy
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - Vu Quoc Dat
- Department of Medicine, Hanoi Medical University, Hanoi, Vietnam; Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Nguyen Tat Thanh
- Woolcock Institute of Medical Research, Ho Chi Minh City, Vietnam
| | - Vo Trieu Ly
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; Ward E, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jasper Fuk-Woo Chan
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, Li Ka Shing Faculty of Medicine, and Hainan Medical University-The University of Hong Kong Joint Laboratory of Tropical Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kwok-Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, Li Ka Shing Faculty of Medicine, and Hainan Medical University-The University of Hong Kong Joint Laboratory of Tropical Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Chuanyi Ning
- BSL-3 Lab Core and Guangxi Key Laboratory of AIDS Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Guangxi, China
| | - Hao Liang
- BSL-3 Lab Core and Guangxi Key Laboratory of AIDS Prevention and Treatment, Life Sciences Institute, Guangxi Medical University, Guangxi, China
| | - Linghua Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Sirida Youngchim
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Ne Myo Aung
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | - Josh Hanson
- Department of Medicine, University of Medicine 2, Yangon, Myanmar; The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Alex Andrianopoulos
- Molecular, Cellular, and Developmental Biology, School of Biosciences, University of Melbourne, Melbourne, VIC, Australia
| | - John Dougherty
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - Nelesh P Govender
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester, Manchester, UK; Global Action Fund for Fungal Infections, Geneva, Switzerland
| | - Tom Chiller
- Center for Disease Control and Prevention, Atlanta, GA, USA
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - John Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA; Oxford University Clinical Research Unit, Hanoi, Vietnam.
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Narayanasamy S, Dat VQ, Thanh NT, Ly VT, Chan JFW, Yuen KY, Ning C, Liang H, Li L, Chowdhary A, Youngchim S, Supparatpinyo K, Aung NM, Hanson J, Andrianopoulos A, Dougherty J, Govender NP, Denning DW, Chiller T, Thwaites G, van Doorn HR, Perfect J, Le T. A global call for talaromycosis to be recognised as a neglected tropical disease. The Lancet Global Health 2021; 9:e1618-e1622. [DOI: https:/doi.org/10.1016/s2214-109x(21)00350-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
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Nyein PP, Aung E, Aung NM, Kyi MM, Boyd M, Lin KS, Hanson J. The impact of gender and the social determinants of health on the clinical course of people living with HIV in Myanmar: an observational study. AIDS Res Ther 2021; 18:50. [PMID: 34372879 PMCID: PMC8350926 DOI: 10.1186/s12981-021-00364-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background There is a growing recognition of the impact of gender and the social determinants of health on the clinical course of people living with HIV (PLHIV). However, the relative contribution of these factors to clinical outcomes of PLHIV is incompletely defined in many countries. This study was performed to gain a greater understanding of the non-clinical determinants of prognosis of PLHIV in Myanmar. Methods Selected demographic, behavioural and socioeconomic characteristics of outpatients at two specialist HIV hospitals and one general hospital in Yangon, Myanmar were correlated with their subsequent clinical course; a poor outcome was defined as death, hospitalisation, loss to follow-up or a detectable viral load at 6 months of follow-up. Results 221 consecutive individuals with advanced HIV commencing anti-retroviral therapy (ART) were enrolled in the study; their median CD4 T-cell count was 92 (44–158) cells/mm3, 138 (62.4%) were male. Socioeconomic disadvantage was common: the median (interquartile range (IQR) monthly per-capita income in the cohort was US$48 (31–77); 153 (69.9%) had not completed high school. However, in a multivariate analysis that considered demographic, behavioural, clinical factors and social determinants of health, male gender was the only predictor of a poor outcome: odds ratio (95% confidence interval): 2.33 (1.26–4.32, p = 0.007). All eight of the deaths and hospitalisations in the cohort occurred in males (p = 0.03). Conclusions Men starting ART in Myanmar have a poorer prognosis than women. Expanded implementation of gender-specific management strategies is likely to be necessary to improve outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00364-w.
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Warrell CE, Phyo AP, Win MM, McLean ARD, Watthanaworawit W, Swe MMM, Soe K, Lin HN, Aung YY, Ko CK, Waing CZ, Linn KS, Aung YPW, Aung NM, Tun NN, Dance DAB, Smithuis FM, Ashley EA. Observational study of adult respiratory infections in primary care clinics in Myanmar: understanding the burden of melioidosis, tuberculosis and other infections not covered by empirical treatment regimes. Trans R Soc Trop Med Hyg 2021; 115:914-921. [PMID: 33681986 PMCID: PMC8326957 DOI: 10.1093/trstmh/trab024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 01/22/2021] [Accepted: 02/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Lower respiratory infections constitute a major disease burden worldwide. Treatment is usually empiric and targeted towards typical bacterial pathogens. Understanding the prevalence of pathogens not covered by empirical treatment is important to improve diagnostic and treatment algorithms. METHODS A prospective observational study in peri-urban communities of Yangon, Myanmar was conducted between July 2018 and April 2019. Sputum specimens of 299 adults presenting with fever and productive cough were tested for Mycobacterium tuberculosis (microscopy and GeneXpert MTB/RIF [Mycobacterium tuberculosis/resistance to rifampicin]) and Burkholderia pseudomallei (Active Melioidosis Detect Lateral Flow Assay and culture). Nasopharyngeal swabs underwent respiratory virus (influenza A, B, respiratory syncytial virus) polymerase chain reaction testing. RESULTS Among 299 patients, 32% (95% confidence interval [CI] 26 to 37) were diagnosed with tuberculosis (TB), including 9 rifampicin-resistant cases. TB patients presented with a longer duration of fever (median 14 d) and productive cough (median 30 d) than non-TB patients (median fever duration 6 d, cough 7 d). One case of melioidosis pneumonia was detected by rapid test and confirmed by culture. Respiratory viruses were detected in 16% (95% CI 12 to 21) of patients. CONCLUSIONS TB was very common in this population, suggesting that microscopy and GeneXpert MTB/RIF on all sputum samples should be routinely included in diagnostic algorithms for fever and cough. Melioidosis was uncommon in this population.
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Affiliation(s)
- Clare E Warrell
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Medical Action Myanmar, Yangon, Myanmar
| | | | - Mo Mo Win
- Department of Medical Research, Myanmar
| | - Alistair R D McLean
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Wanitda Watthanaworawit
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | | | - Kyaw Soe
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Htet Naing Lin
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Medical Action Myanmar, Yangon, Myanmar
| | | | | | | | | | | | - Ne Myo Aung
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Ni Ni Tun
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Medical Action Myanmar, Yangon, Myanmar
| | - David A B Dance
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank M Smithuis
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Medical Action Myanmar, Yangon, Myanmar
| | - Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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5
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Affiliation(s)
- Ne Myo Aung
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Phyo Pyae Nyein
- Department of Medicine, Specialist Hospital Mingaladon, Mingaladon Township, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Josh Hanson
- Director's Unit, Kirby Institute, University of New South Wales, Sydney, Australia
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Ashokan A, Hanson J, Aung NM, Kyi MM, Taylor SL, Choo JM, Flynn E, Mobegi F, Warner MS, Wesselingh SL, Boyd MA, Rogers GB. Investigating potential transmission of antimicrobial resistance in an open-plan hospital ward: a cross-sectional metagenomic study of resistome dispersion in a lower middle-income setting. Antimicrob Resist Infect Control 2021; 10:56. [PMID: 33736699 PMCID: PMC7977308 DOI: 10.1186/s13756-021-00915-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/26/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) represents a profound global health threat. Reducing AMR spread requires the identification of transmission pathways. The extent to which hospital wards represent a venue for substantial AMR transmission in low- and middle-income countries settings is poorly understood. METHODS Rectal swabs were obtained from adult male inpatients in a "Nightingale" model general medicine ward in Yangon, Myanmar. Resistome characteristics were characterised by metagenomic sequencing. AMR gene carriage was related to inter-patient distance (representing inter-patient interaction) using distance-based linear models. Clinical predictors of AMR patterns were identified through univariate and multivariate regression. RESULTS Resistome similarity showed a weak but significant positive correlation with inter-patient distance (r = 0.12, p = 0.04). Nineteen AMR determinants contributed significantly to this relationship, including those encoding β-lactamase activity (OXA-1, NDM-7; adjusted p < 0.003), trimethoprim resistance (dfrA14, adjusted p = 0.0495), and chloramphenicol resistance (catB3, adjusted p = 0.002). Clinical traits of co-located patients carrying specific AMR genes were not random. Specifically, AMR genes that contributed to distance-resistome relationships (OXA-1, catB3, dfrA14) mapped to tuberculosis patients, who were placed together according to ward policy. In contrast, patients with sepsis were not placed together, and carried AMR genes that were not spatially significant or consistent with shared antibiotic exposure. CONCLUSIONS AMR dispersion patterns primarily reflect the placement of particular patients by their condition, rather than AMR transmission. The proportion of AMR determinants that varied with inter-patient distance was limited, suggesting that nosocomial transmission is a relatively minor contributor to population-level carriage.
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Affiliation(s)
- Anushia Ashokan
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Josh Hanson
- Cairns Hospital, Cairns, QLD, Australia
- Insein General Hospital, Insein, Yangon, Myanmar
| | - Ne Myo Aung
- Insein General Hospital, Insein, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Mar Mar Kyi
- Insein General Hospital, Insein, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Steven L Taylor
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Jocelyn M Choo
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Erin Flynn
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Fredrick Mobegi
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Morgyn S Warner
- Faculty of Health and Medical Sciences, University of Adelaide, North Terrace, Adelaide, SA, Australia
- South Australia (SA) Pathology, Adelaide, SA, Australia
| | - Steve L Wesselingh
- South Australia Health and Medical Research Institute, Adelaide, SA, Australia
| | - Mark A Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Geraint B Rogers
- Microbiome and Host Health, South Australia Health and Medical Research Institute, Adelaide, SA, 5001, Australia.
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, SA, Australia.
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Mar Minn M, Aung NM, Kyaw DZ, Zaw TT, Chann PN, Khine HE, McLoughlin S, Kelleher AD, Tun NL, Oo TZC, Myint NPST, Law M, Mar Kyi M, Hanson J. The comparative ability of commonly used disease severity scores to predict death or a requirement for ICU care in patients hospitalised with possible sepsis in Yangon, Myanmar. Int J Infect Dis 2021; 104:543-550. [PMID: 33493689 DOI: 10.1016/j.ijid.2021.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To determine the comparative prognostic utility of commonly used disease prediction scores in adults with presumed community-acquired sepsis in a resource-limited tropical setting. METHODS This prospective, observational study was performed on the medical ward of a tertiary-referral hospital in Yangon, Myanmar. The ability of the National Early Warning Score 2 (NEWS2), quick NEWS (qNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, Universal Vital Assessment (UVA) and Sequential Organ Failure Assessment (SOFA) scores to predict a complicated inpatient course (death or requirement for intensive care unit (ICU) support) in patients with two or more systemic inflammatory response syndrome criteria was determined. RESULTS Among the 509 patients, 30 (6%) were HIV-seropositive. The most commonly confirmed diagnoses were tuberculosis (30/509, 5.9%) and measles (26/509, 5.1%). Overall, 75/509 (14.7%) died or required ICU support. All the scores except the qSOFA score, which was inferior, had a similar ability to predict a complicated inpatient course. CONCLUSIONS In this resource-limited tropical setting, disease severity scores calculated at presentation using only vital signs-such as the NEWS2 score-identified high-risk sepsis patient as well as the SOFA score, which is calculated at 24 h and which also requires laboratory data. Use of these simple clinical scores can be used to facilitate recognition of the high-risk patient and to optimise the use of finite resources.
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Affiliation(s)
- Mar Mar Minn
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - De Zin Kyaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Pyae Nyein Chann
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Hnin Ei Khine
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | | | | | - Ne Lin Tun
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thin Zar Cho Oo
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; The Kirby Institute, University of New South Wales, Sydney, Australia.
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Hanson J, Nyein PP, Aung NM, Kyi MM. Time for pragmatic, prospective clinical trials to determine the role of empirical antibacterial therapy in critically ill adults hospitalized with malaria. Int J Infect Dis 2020; 102:28-31. [PMID: 33017698 DOI: 10.1016/j.ijid.2020.09.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Children with severe falciparum malaria in malaria-endemic regions are predisposed to developing life-threatening bacterial co-infection. International guidelines therefore recommend empirical broad-spectrum antibacterial therapy in these children. Few studies have examined co-infection in adults, although it has been believed to be relatively rare; antibacterial therapy is therefore not routinely recommended in adults with falciparum malaria. DISCUSSION However, the fundamental pathophysiology of falciparum malaria in adults and children is the same; it is therefore unclear why adults would not also be predisposed to bacterial infection. Indeed, recent studies have identified bacteraemia in >10% of adults hospitalized with malaria. Some have suggested that these adults probably had bacterial sepsis, with the parasitaemia an incidental finding. However, it is usually impossible in resource-limited settings to determine-at presentation-whether critically ill, parasitaemic adults have severe malaria, bacterial sepsis, or both. Given the significant case-fatality rates of severe malaria and bacterial sepsis, the pragmatic initial approach would be to cover both possibilities. CONCLUSIONS Life-threatening bacterial co-infection may be more common in critically ill adults with malaria than previously believed. While further prospective data are awaited to confirm these findings, it might be more appropriate to provide empirical aantibacterial cover in these patients than current guidelines suggest.
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Affiliation(s)
- Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, Australia; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.
| | - Phyo Pyae Nyein
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Mingaladon Specialist Hospital, Mingaladon Township, Yangon, Myanmar
| | - Ne Myo Aung
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mar Mar Kyi
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; Insein General Hospital, Insein Township, Yangon, Myanmar
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Pa Pa Aung W, Myint NPST, Zaw TT, Cooper DA, Aung NM, Kyi MM, Lwin MM, Hanson J. The Influence of HIV Status on the Burden and Clinical Manifestations of Gastrointestinal Pathogens in Yangon, Myanmar. Am J Trop Med Hyg 2020; 102:884-888. [PMID: 32100684 DOI: 10.4269/ajtmh.19-0725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The impact of HIV infection on the burden of gastrointestinal pathogens in Myanmar is poorly defined. Stools of 103 HIV-infected and 105 HIV-uninfected adult outpatients at a tertiary referral hospital in Yangon were examined microscopically. Stool antigen tests for Helicobacter pylori infection were positive in 63/103 (61%) HIV-infected and 61/105 (58%) HIV-uninfected patients (P = 0.65). Soil-transmitted helminth infections were much less common, occurring in 9/103 (9%) HIV-infected and 13/103 (13%) HIV-uninfected patients (P = 0.50). One HIV-uninfected patient had Giardia duodenalis, but there were no cases of Strongyloides stercoralis, Entamoeba histolytica, Capillaria philippinensis, Isospora, Cyclospora, or Schistosoma infection in the entire cohort. Despite the high prevalence of H. pylori, only 1/208 (0.5%) had ever received eradication, compared with 159/208 (76%) who had ever been dewormed. Helicobacter pylori appears to be an underappreciated pathogen in Myanmar. Its strong association with gastric cancer and peptic ulcer disease necessitates a more aggressive approach to its management.
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Affiliation(s)
- Win Pa Pa Aung
- Department of Microbiology, University of Medicine 2, Yangon, Yangon, Myanmar
| | - Nan Phyu Sin Toe Myint
- Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Thet Tun Zaw
- Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar
| | - David A Cooper
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Ne Myo Aung
- Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Mya Mya Lwin
- Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar.,Department of Microbiology, University of Medicine 2, Yangon, Yangon, Myanmar
| | - Josh Hanson
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Yangon, Yangon, Myanmar
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Myint NPST, Zaw TT, Sain K, Waiyan S, Danta M, Cooper D, Aung NM, Kyi MM, Hanson J. Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability. J Gastroenterol Hepatol 2020; 35:617-623. [PMID: 31758571 DOI: 10.1111/jgh.14942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/12/2019] [Accepted: 11/19/2019] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Kyauk Sain
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Soe Waiyan
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington, Sydney, Australia.,Department of Gastroenterology, St Vincent's Hospital, Darlinghurst, Sydney, Australia
| | - David Cooper
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.,Kirby Institute, University of New South Wales, Kensington, Sydney, Australia
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar.,University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.,Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar.,Kirby Institute, University of New South Wales, Kensington, Sydney, Australia
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11
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Ye Lynn KL, Hanson J, Mon NCN, Yin KN, Nyein ML, Thant KZ, Kyi MM, Oo TZC, Aung NM. The clinical characteristics of patients with sepsis in a tertiary referral hospital in Yangon, Myanmar. Trans R Soc Trop Med Hyg 2020; 113:81-90. [PMID: 30412257 DOI: 10.1093/trstmh/try115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/31/2018] [Indexed: 01/08/2023] Open
Abstract
Background The clinical characteristics and course of patients hospitalised with sepsis in Myanmar and the responsible pathogens remain poorly defined. Methods We performed an observational study of adults admitted from the community to a tertiary referral hospital in Yangon with fever and dysfunction of at least two organ systems. Results The 120 patients had a median age of 47 y (interquartile range 28-63); 11 (9%) were human immunodeficiency virus positive. Limited laboratory support meant that a microbiological diagnosis was possible in only 35 (29%) patients, but 18 (13%) had pathogens in blood cultures, including 9 (50%) organisms that were multidrug resistant (4 Escherichia coli, 4 Pseudomonas aeruginosa, 1 Burkholderia pseudomallei). Tuberculosis was confirmed in six patients, with two being rifampicin resistant, and dengue infection was confirmed in five patients. Without access to comprehensive intensive care support, 34 (28%) patients died. An admission National Early Warning Score ≥7 (odds ratio [OR] 8.6 [95% confidence interval {CI} 2.6 to 28.2], p=0.001) and quick sequential (sepsis-related) organ failure assessment score ≥2 (OR 3.2 [95% CI 1.3 to 8.0], p=0.02) were helpful in predicting death. Conclusions Tropical pathogens are a common cause of sepsis in Myanmar. The frequent identification of multidrug-resistant organisms and limited diagnostic and intensive care support hinder patient care significantly. However, simple clinical assessment on admission has prognostic utility.
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Affiliation(s)
- Kyi Lai Ye Lynn
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Josh Hanson
- Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar.,Kirby Institute, Level 6, Wallace Wurth Building High Street, UNSW, Kensington, NSW, Australia
| | - Nan Cho Nwe Mon
- Department of Medical Research, Ministry of Health and Sports, Ziwaka Road, Dagon Township, Yangon, Myanmar
| | - Kyi Nyein Yin
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar
| | - Myo Lwin Nyein
- Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar.,Department of Medicine, North Okkalapa General Hospital, May Darwi Road, North Okkalapa Township, Yangon, Myanmar
| | - Kyaw Zin Thant
- Department of Medical Research, Ministry of Health and Sports, Ziwaka Road, Dagon Township, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Thin Zar Cho Oo
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Ne Myo Aung
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
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12
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Aung NM, Nyein PP, Htut TY, Htet ZW, Kyi TT, Anstey NM, Kyi MM, Hanson J. Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria. Am J Trop Med Hyg 2018; 99:688-696. [PMID: 30014826 DOI: 10.4269/ajtmh.18-0378] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
It has been believed that concomitant bacteremia is uncommon in adults hospitalized with falciparum malaria. Accordingly, the World Health Organization treatment guidelines presently only recommended additional antibacterial therapy in these patients if they have a clinical syndrome compatible with serious bacterial infection. Admission blood cultures were collected from 20 consecutive adults in Myanmar, hospitalized with a positive immunochromatographic test and blood film, suggesting a diagnosis of falciparum malaria; four (20%) had bacteremia with a clinically significant pathogen. These case series' data were pooled with a previously published multicenter study from Myanmar which had also collected blood cultures in adults hospitalized with a diagnosis of falciparum malaria. Among 87 patients in the two studies, 13 (15%) had clinically significant bacteremia on admission, with Gram-negative organisms in 10 (77%) and Staphylococcus aureus in the remaining three (23%). Bacteremic patients had more severe disease than non-bacteremic patients (median [interquartile range] respiratory coma acidosis malaria score 2 [1-4] versus 1 [1-2], P = 0.02) and were more likely to die (2/13 [15%] versus 1/74 [1%], P = 0.01). However, bacterial coinfection was suspected clinically in a minority of bacteremic patients (5/13 [38%] compared with 13/70 [19%] of non-bacteremic patients, P = 0.11). Concomitant bacteremia in adults diagnosed with falciparum malaria may be more common than previously believed and is difficult to identify clinically in resource-poor settings. Death is more common in these patients, suggesting that clinicians should have a lower threshold for commencing empirical antibacterial therapy in adults diagnosed with falciparum malaria in these locations than is presently recommended.
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Affiliation(s)
- Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | | | | | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia.,University of Medicine 2, Yangon, Myanmar
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13
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Myint NPST, Aung NM, Win MS, Htut TY, Ralph AP, Cooper DA, Nyein ML, Kyi MM, Hanson J. The clinical characteristics of adults with rheumatic heart disease in Yangon, Myanmar: An observational study. PLoS One 2018; 13:e0192880. [PMID: 29466408 PMCID: PMC5821331 DOI: 10.1371/journal.pone.0192880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nan Phyu Sin Toe Myint
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Ne Myo Aung
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Myint Soe Win
- Department of Cardiology, North Okkalapa General Hospital, Yangon, Myanmar
| | - Thu Ya Htut
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
| | - Anna P. Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - David A. Cooper
- Director’s Unit, Kirby Institute, University of New South Wales, Sydney, Australia
| | - Myo Lwin Nyein
- University of Medicine 2, Yangon, Myanmar
- Department of Cardiology, North Okkalapa General Hospital, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Yangon, Myanmar
- University of Medicine 2, Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, Yangon, Myanmar
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Director’s Unit, Kirby Institute, University of New South Wales, Sydney, Australia
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14
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Thit SS, Aung NM, Htet ZW, Boyd MA, Saw HA, Anstey NM, Kyi TT, Cooper DA, Kyi MM, Hanson J. The clinical utility of the urine-based lateral flow lipoarabinomannan assay in HIV-infected adults in Myanmar: an observational study. BMC Med 2017; 15:145. [PMID: 28774293 PMCID: PMC5543584 DOI: 10.1186/s12916-017-0888-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/06/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of the point-of-care lateral flow lipoarabinomannan (LF-LAM) test may expedite tuberculosis (TB) diagnosis in HIV-positive patients. However, the test's clinical utility is poorly defined outside sub-Saharan Africa. METHODS The study enrolled consecutive HIV-positive adults at a tertiary referral hospital in Yangon, Myanmar. On enrolment, patients had a LF-LAM test performed according to the manufacturer's instructions. Clinicians managing the patients were unaware of the LF-LAM result, which was correlated with the patient's clinical course over the ensuing 6 months. RESULTS The study enrolled 54 inpatients and 463 outpatients between July 1 and December 31, 2015. On enrolment, the patients' median (interquartile range) CD4 T-cell count was 270 (128-443) cells/mm3. The baseline LF-LAM test was positive in 201/517 (39%). TB was confirmed microbiologically during follow-up in 54/517 (10%), with rifampicin resistance present in 8/54 (15%). In the study's resource-limited setting, extrapulmonary testing for TB was not possible, but after 6 months, 97/201 (48%) with a positive LF-LAM test on enrolment had neither died, required hospitalisation, received a TB diagnosis or received empirical anti-TB therapy, suggesting a high rate of false-positive results. Of the 97 false-positive tests, 89 (92%) were grade 1 positive, suggesting poor test specificity using this cut-off. Only 21/517 (4%) patients were inpatients with TB symptoms and a CD4 T-cell count of < 100 cells/mm3. Five (24%) of these 21 died, three of whom had a positive LF-LAM test on enrolment. However, all three received anti-TB therapy before death - two after diagnosis with Xpert MTB/RIF testing, while the other received empirical treatment. It is unlikely that knowledge of the baseline LF-LAM result would have averted any of the study's other 11 deaths; eight had a negative test, and of the three patients with a positive test, two received anti-TB therapy before death, while one died from laboratory-confirmed cryptococcal meningitis. The test was no better than a simple, clinical history excluding TB during follow-up (negative predictive value (95% confidence interval): 94% (91-97) vs. 94% (91-96)). CONCLUSIONS The LF-LAM test had limited clinical utility in the management of HIV-positive patients in this Asian referral hospital setting.
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Affiliation(s)
- Swe Swe Thit
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | - Mark A Boyd
- University of Adelaide, Lyell McEwin Hospital, Adelaide, Australia.,The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Tint Tint Kyi
- Insein General Hospital, Yangon, Myanmar.,Department of Medical Care, Ministry of Health, Nay Pyi Taw, Myanmar
| | - David A Cooper
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, Yangon, Myanmar. .,The Kirby Institute, University of New South Wales, Sydney, Australia. .,Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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15
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Aung NM, Hanson J, Kyi TT, Htet ZW, Cooper DA, Boyd MA, Kyi MM, Saw HA. HIV care in Yangon, Myanmar; successes, challenges and implications for policy. AIDS Res Ther 2017; 14:10. [PMID: 28257647 PMCID: PMC5336692 DOI: 10.1186/s12981-017-0137-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/17/2017] [Indexed: 01/01/2023] Open
Abstract
Background Approximately 0.8% of adults aged 18–49 in Myanmar are seropositive for Human Immunodeficiency Virus (HIV). Identifying the demographic, epidemiological and clinical characteristics of people living with HIV (PLHIV) is essential to inform optimal management strategies in this resource-limited country. Methods To create a “snapshot” of the PLHIV seeking anti-retroviral therapy (ART) in Myanmar, data were collected from the registration cards of all patients who had been prescribed ART at two large referral hospitals in Yangon, prior to March 18, 2016. Results and discussion Anti-retroviral therapy had been prescribed to 2643 patients at the two hospitals. The patients’ median [interquartile range (IQR)] age was 37 (31–44) years; 1494 (57%) were male. At registration, injecting drug use was reported in 22 (0.8%), male-to-male sexual contact in eleven (0.4%) and female sex work in eleven (0.4%), suggesting that patients under-report these risk behaviours, that health care workers are uncomfortable enquiring about them or that the two hospitals are under-servicing these populations. All three explanations appear likely. Most patients were symptomatic at registration with 2027 (77%) presenting with WHO stage 3 or 4 disease. In the 2442 patients with a CD4+ T cell count recorded at registration, the median (IQR) count was 169 (59–328) cells/mm3. After a median (IQR) duration of 359 (185–540) days of ART, 151 (5.7%) patients had died, 111 (4.2%) patients had been lost to follow-up, while 2381 were alive on ART. Tuberculosis (TB) co-infection was common: 1083 (41%) were already on anti-TB treatment at registration, while a further 41 (1.7%) required anti-TB treatment during follow-up. Only 21 (0.8%) patients were prescribed isoniazid prophylaxis therapy (IPT); one of these was lost to follow-up, but none of the remaining 20 patients died or required anti-TB treatment during a median (IQR) follow-up of 275 (235–293) days. Conclusions People living with HIV in Yangon, Myanmar are generally presenting late in their disease course, increasing their risk of death, disease and transmitting the virus. A centralised model of ART prescription struggles to deliver care to the key affected populations. TB co-infection is very common in Myanmar, but despite the proven efficacy of IPT, it is frequently not prescribed.
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16
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Mu TT, Sein AA, Kyi TT, Min M, Aung NM, Anstey NM, Kyaw MP, Soe C, Kyi MM, Hanson J. Malaria incidence in Myanmar 2005-2014: steady but fragile progress towards elimination. Malar J 2016; 15:503. [PMID: 27756394 PMCID: PMC5069869 DOI: 10.1186/s12936-016-1567-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 10/07/2016] [Indexed: 01/20/2023] Open
Abstract
Background There has been an impressive recent reduction in the global incidence of malaria, but the development of artemisinin resistance in the Greater Mekong Region threatens this progress. Increasing artemisinin resistance is particularly important in Myanmar, as it is the country in the Greater Mekong Region with the greatest malaria burden. If malaria is to be eliminated in the region, it is essential to define the spatial and temporal epidemiology of the disease in Myanmar to inform control strategies optimally. Results Between the years 2005 and 2014 there was an 81.1 % decline in the reported annual incidence of malaria in Myanmar (1341.8 cases per 100,000 population to 253.3 cases per 100,000 population). In the same period, there was a 93.5 % decline in reported annual mortality from malaria (3.79 deaths per 100,000 population to 0.25 deaths per 100,000 population) and a 87.2 % decline in the proportion of hospitalizations due to malaria (7.8 to 1.0 %). Chin State had the highest reported malaria incidence and mortality at the end of the study period, although socio-economic and geographical factors appear a more likely explanation for this finding than artemisinin resistance. The reduced malaria burden coincided with significant upscaling of disease control measures by the national government with support from international partners. These programmes included the training and deployment of over 40,000 community health care workers, the coverage of over 60 % of the at-risk population with insecticide-treated bed nets and significant efforts to improve access to artemesinin-based combination treatment. Beyond these malaria-specific programmes, increased general investment in the health sector, changing population demographics and deforestation are also likely to have contributed to the decline in malaria incidence seen over this time. Conclusions There has been a dramatic fall in the burden of malaria in Myanmar since 2005. However, with the rise of artemisinin resistance, continued political, financial and scientific commitment is required if the ambitious goal of malaria elimination in the country is to be realized.
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Affiliation(s)
- Thet Thet Mu
- Department of Public Health, Ministry of Health, Nay Pyi Taw, Myanmar
| | - Aye Aye Sein
- Department of Public Health, Ministry of Health, Nay Pyi Taw, Myanmar
| | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health, Nay Pyi Taw, Myanmar
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar
| | | | | | | | - Chit Soe
- University of Medicine 1, Yangon, Myanmar
| | | | - Josh Hanson
- University of Medicine 2, Yangon, Myanmar. .,Menzies School of Health Research, Darwin, Australia. .,The Kirby Institute, Sydney, Australia.
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17
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Nyein PP, Aung NM, Kyi TT, Htet ZW, Anstey NM, Kyi MM, Hanson J. High Frequency of Clinically Significant Bacteremia in Adults Hospitalized With Falciparum Malaria. Open Forum Infect Dis 2016; 3:ofw028. [PMID: 26989752 PMCID: PMC4794945 DOI: 10.1093/ofid/ofw028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background. African children with severe falciparum malaria commonly have concomitant Gram-negative bacteremia, but co-infection has been thought to be relatively rare in adult malaria. Methods. Adults with a diagnosis of falciparum malaria hospitalized at 4 tertiary referral hospitals in Myanmar had blood cultures collected at admission. The frequency of concomitant bacteremia and the clinical characteristics of the patients, with and without bacteremia, were explored. Results. Of 67 adults hospitalized with falciparum malaria, 9 (13% [95% confidence interval, 5.3%-21.6%]) were also bacteremic on admission, 7 (78%) with Gram-negative enteric organisms (Escherichia coli [n = 3], typhoidal Salmonella species [n = 3], nontyphoidal Salmonella [n = 1]). Bacteremic adults had more severe disease (median Respiratory Coma Acidosis Malaria [RCAM] score 3; interquartile range [IQR], 1-4) than those without bacteremia (median RCAM score 1; IQR, 1-2) and had a higher frequency of acute kidney injury (50% vs 16%, P = .03). Although 35 (52%) were at high risk of death (RCAM score ≥2), all 67 patients in the study survived, 51 (76%) of whom received empirical antibiotics on admission. Conclusions. Bacteremia was relatively frequent in adults hospitalized with falciparum malaria in Myanmar. Like children in high transmission settings, bacteremic adults in this low transmission setting were sicker than nonbacteremic adults, and were often difficult to identify at presentation. Empirical antibiotics may also be appropriate in adults hospitalized with falciparum malaria in low transmission settings, until bacterial infection is excluded.
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Affiliation(s)
| | | | | | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
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18
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Aung NM, Kaung M, Kyi TT, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The Safety of a Conservative Fluid Replacement Strategy in Adults Hospitalised with Malaria. PLoS One 2015; 10:e0143062. [PMID: 26581060 PMCID: PMC4651424 DOI: 10.1371/journal.pone.0143062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 10/22/2015] [Indexed: 12/29/2022] Open
Abstract
Background A conservative approach to fluid resuscitation improves survival in children with severe malaria; however, this strategy has not been formally evaluated in adults with the disease. Methods Adults hospitalised with malaria at two tertiary referral hospitals in Myanmar received intravenous fluid replacement with isotonic saline, administered at a maintenance rate using a simple weight-based algorithm. Clinical and biochemical indices were followed sequentially. Results Of 61 adults enrolled, 34 (56%) had Plasmodium falciparum mono-infection, 17 (28%) Plasmodium vivax mono-infection and 10 (16%) mixed infection; 27 (44%) patients were at high risk of death (P. falciparum infection and RCAM score ≥ 2). In the first six hours of hospitalisation patients received a mean 1.7 ml/kg/hour (range: 1.3–2.2) of intravenous fluid and were able to drink a mean of 0.8 ml/kg/hour (range: 0–3). Intravenous fluid administration and oral intake were similar for the remainder of the first 48 hours of hospitalisation. All 61 patients survived to discharge. No patient developed Adult Respiratory Distress Syndrome, a requirement for renal replacement therapy or hypotension (mean arterial pressure < 60mmHg). Plasma lactate was elevated (> 2 mmol/L) on enrolment in 26 (43%) patients but had declined by 6 hours in 25 (96%) and was declining at 24 hours in the other patient. Plasma creatinine was elevated (> 120 μmol/L) on enrolment in 17 (28%) patients, but was normal or falling in 16 (94%) at 48 hours and declining in the other patient by 72 hours. There was no clinically meaningful increase in plasma lactate or creatinine in any patient with a normal value on enrolment. Patients receiving fluid replacement with the conservative fluid replacement algorithm were more likely to survive than historical controls in the same hospitals who had received fluid replacement guided by clinical judgement in the year prior to the study (p = 0.03), despite having more severe disease (p < 0.001). Conclusions A conservative fluid resuscitation strategy appears safe in adults hospitalised with malaria.
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Affiliation(s)
| | - Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar
| | | | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar
| | | | - Nicholas M. Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- * E-mail:
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19
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Kaung M, Kyi TT, Aung NM, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The prognostic utility of bedside assessment of adults hospitalized with malaria in Myanmar: a retrospective analysis. Malar J 2015; 14:63. [PMID: 25881290 PMCID: PMC4323221 DOI: 10.1186/s12936-015-0549-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/06/2015] [Indexed: 01/03/2023] Open
Abstract
Background Data collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient’s Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting. Methods A retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course. Results The recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum mono-infection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score <2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score <2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥2 (p < 0.0001). No patient with P. vivax mono-infection required supportive care during their hospitalization. Patients with an oxygen saturation ≤95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002). Conclusions Even outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.
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Affiliation(s)
- Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar.
| | | | - Ne Myo Aung
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar.
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar.
| | - Zaw Win Htet
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Mar Mar Kyi
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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