The Safety of a Conservative Fluid Replacement Strategy in Adults Hospitalised with Malaria

BackgroundA 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.MethodsAdults 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.ResultsOf 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).ConclusionsA conservative fluid resuscitation strategy appears safe in adults hospitalised with malaria

The prognostic utility of bedside assessment of adults hospitalized with malaria in Myanmar: a retrospective analysis

BackgroundData 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.MethodsA 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.ResultsThe 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).ConclusionsEven 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

HIV care in Yangon, Myanmar; successes, challengesand implications for policy

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, inject-ing 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

The clinical characteristics of adults with rheumatic heart disease in Yangon, Myanmar: Anobservation a lstudy

BackgroundRheumaticheartdisease(RHD)is a majorcauseof prematuredeathin lowandmiddle-incomecountries.Thegreatestbarrierto RHDcontrolis neglectof thediseasein nationalhealthpoliciesanda lackof prevalencedatathatmightinformcontrolefforts.Myanmarismakingremarkableprogressagainstmanyinfectiousdiseases,buttherearealmostnodatato definetheclinicalburdenof RHDin thecountry.Thisprospective auditwasperformedinanadultmedicalwardof a tertiary-referralhospitalin Yangon,to gainaninsightintotheprevalenceof RHDin Myanmar.PrincipalfindingsAllpatientsadmittedto thewardbetweenMay1, 2016andApril30,2017wereeligibleforenrolment.RHDwasconfirmedin 96patientswhowereadmittedon134occasions,repre-senting1.1%of the12,172adultmedicaladmissionsduringthestudyperiod.Thiscom-paredwith410(3.4%)admissionswithHIVand14(0.1%)withmalaria.PatientswithRHDhada medianageof 44years(interquartilerange:35–59);70(73%)werefemale.Onlyonepatienthadeverhadsurgerydespite79(82%)meetingcriteriaforintervention;54(56%)patientswerenotreceivinganyregularclinicianreview.Priorto hospitalisationonly18(19%)patientswerereceivingregularpenicillin.Only8 (19%)of the42women<50yearswereusingcontraception.Of49patientswhohadbeenhospitalisedpreviously,22(45%)werereceivingnoregulartherapy.Duringthestudythree(3.1%)patientsdied,and28(29%)werelostto follow-up.Ofthe65(68%)aliveandretainedin care,21(32%)werestillexperiencingmoderate-severeRHD-relatedsymptomsat thestudy’send.ConclusionsThereis a significantandunmetclinicalburdenof RHDin Myanmar.A nationalRHDprogram-mewouldimprovepatientcare,reducingmorbidityandmortalityfromthispreventabledisease

Malaria incidence in Myanmar 2005–2014: steady but fragile progress towards elimination

Background: There has been an impressive recent reduction in the global incidence of malaria, but the develop-ment of artemisinin resistance in the Greater Mekong Region threatens this progress. Increasing artemisinin resist-ance 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 com-munity 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 deforesta-tion 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 realize

The clinical utility of the urine-basedlateral flow lipoarabinomannan assayin HIV-infected adults in Myanmar:an observational study

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. Onenrolment, patients had a LF-LAM test performed according to the manufacturer’s instructions. Clinicians managingthe patients were unaware of the LF-LAM result, which was correlated with the patient’s clinical course over theensuing 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 testwas positive in 201/517 (39%). TB was confirmed microbiologically during follow-up in 54/517 (10%), with rifampicinresistance 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. Only21/517 (4%) patients were inpatients with TB symptoms and a CD4 T-cell count of < 100 cells/mm3. Five (24%) of these21 died, three of whom had a positive LF-LAM test on enrolment. However, all three received anti-TB therapy beforedeath—two after diagnosis with Xpert MTB/RIF testing, while the other received empirical treatment. It is unlikely thatknowledge of the baseline LF-LAM result would have averted any of the study’s other 11 deaths; eight had a negativetest, and of the three patients with a positive test, two received anti-TB therapy before death, while one died fromlaboratory-confirmed cryptococcal meningitis. The test was no better than a simple, clinical history excluding TB duringfollow-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 Asianreferral hospital setting

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.

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

Malaria incidence in Myanmar 2005–2014: steady but fragile progress towards elimination

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