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

Confirmation of Skywalker Hoolock Gibbon (Hoolock tianxing) in Myanmar extends known geographic range of an endangered primate

Characterizing genetically distinct populations of primates is important for protecting biodiversity and effectively allocating conservation resources. Skywalker gibbons (Hoolock tianxing) were first described in 2017, with the only confirmed population consisting of 150 individuals in Mt. Gaoligong, Yunnan Province, China. Based on river geography, the distribution of the skywalker gibbon has been hypothesized to extend into Myanmar between the N’Mai Kha and Ayeyarwaddy Rivers to the west, and the Salween River (named the Thanlwin River in Myanmar and Nujiang River in China) to the east. We conducted acoustic point-count sampling surveys, collected noninvasive samples for molecular mitochondrial cytochrome b gene identification, and took photographs for morphological identification at six sites in Kachin State and three sites in Shan State to determine the presence of skywalker gibbons in predicted suitable forest areas in Myanmar. We also conducted 50 semistructured interviews with members of communities surrounding gibbon range forests to understand potential threats. In Kachin State, we audio-recorded 23 gibbon groups with group densities ranging between 0.57 and 3.6 group/km2. In Shan State, we audio-recorded 21 gibbon groups with group densities ranging between 0.134 and 1.0 group/km2. Based on genetic data obtained from skin and saliva samples, the gibbons were identified as skywalker gibbons (99.54–100% identity). Although these findings increase the species’ known population size and confirmed distribution, skywalker gibbons in Myanmar are threatened by local habitat loss, degradation, and fragmentation. Most of the skywalker gibbon population in Myanmar exists outside protected areas. Therefore, the IUCN Red List status of the skywalker gibbon should remain as Endangered

Patients with MDR-TB on domiciliary care in programmatic settings in Myanmar: Effect of a support package on preventing early deaths

<div><p>Background</p><p>The community-based MDR-TB care (CBMDR-TBC) project was implemented in 2015 by The Union in collaboration with national TB programme (NTP) in 33 townships of upper Myanmar to improve treatment outcomes among patients with MDR-TB registered under NTP. They received community-based support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each project township had a project nurse exclusively for MDR-TB and a community volunteer who provided evening directly observed therapy (in addition to morning directly observed therapy by NTP).</p><p>Objectives</p><p>To determine the effect of CBMDR-TBC project on death and unfavourable outcomes during the intensive phase of MDR-TB treatment.</p><p>Methods</p><p>In this cohort study involving record review, all patients diagnosed with MDR-TB between January 2015 and June 2016 in project townships and initiated on treatment till 31 Dec 2016 were included. CBMDR-TBC status was categorized as “receiving support” if project initiation in patient’s township was before treatment initiation, “receiving partial support” if project initiation was after treatment initiation, and “not receiving support” if project initiation was after intensive phase treatment outcome declaration. Time to event analysis (censored on 10 April 2017) and cox regression was done.</p><p>Results</p><p>Of 261 patients initiated on treatment, death and unfavourable outcomes were accounted for 13% and 21% among “receiving support (n = 163)”, 3% and 24% among “receiving partial support (n = 75)” and 13% and 26% among “not receiving support (n = 23)” respectively. After adjusting for other potential confounders, the association between CBMDR-TBC and unfavourable outcomes was not statistically significant. However, when compared to “not receiving support”, those “receiving support” and “receiving partial support” had 20% [aHR (0.95 CI: 0.8 (0.2–3.1)] and 90% lower hazard [aHR (0.95 CI: 0.1 (0.02–0.9)] of death, respectively. This was intriguing. Implementation of CBMDR-TBC coincided with implementation of decentralized MDR-TB centers at district level. Hence, patients that would have generally not accessed MDR-TB treatment before decentralization also started receiving treatment and were also included under CBMDR-TBC “received support” group. These patients could possibly be expected to sicker at treatment initiation than patients in other CBMDR-TBC groups. This could be the possible reason for nullifying the effect of CBMDR-TBC in “receiving support” group and therefore similar survival was found when compared to “not receiving support”.</p><p>Conclusion</p><p>CBMDR-TBC may prevent early deaths and has a scope for expansion to other townships of Myanmar and implications for NTPs globally. However, future studies should consider including data on extent of sickness at treatment initiation and patient level support received under CBMDR-TBC.</p></div

Criteria to identify presumptive MDR-TB under programme setting who were referred to X-pert MTB/RIF testing facilities, Myanmar, 2015–16.

<p>Criteria to identify presumptive MDR-TB under programme setting who were referred to X-pert MTB/RIF testing facilities, Myanmar, 2015–16.</p

Death in intensive phase among patients with MDRTB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar (all patients and by CBMDR-TBC status).

<p>*under CBMDR_TBC after treatment initiation (“receiving partial support”); under CBMDR-TBC before treatment initiation (“receiving support”); Log rank test p value = 0.03 (unadjusted).</p

Care under community-based MDR-TB (CBMDR-TBC) project and end intensive phase treatment outcomes among patient with MDR-TB registered for treatment between January 2015 and June 2016 in 33 CBMDR-TBC project supported townships in Myanmar.

<p>Care under community-based MDR-TB (CBMDR-TBC) project and end intensive phase treatment outcomes among patient with MDR-TB registered for treatment between January 2015 and June 2016 in 33 CBMDR-TBC project supported townships in Myanmar.</p

Demographic characteristics of patients with MDRTB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.

<p>Demographic characteristics of patients with MDRTB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.</p

Risk factors for unfavorable treatment outcomes among patients with MDR-TB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.

<p>Risk factors for unfavorable treatment outcomes among patients with MDR-TB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.</p

Map of Myanmar showing 33 community-based MDR-TB care project (CBMDR-TBC) supported townships across four states/regions of Upper Myanmar, 2015–16.

<p>Map of Myanmar showing 33 community-based MDR-TB care project (CBMDR-TBC) supported townships across four states/regions of Upper Myanmar, 2015–16.</p

Serological evidence indicates widespread distribution of rickettsioses in Myanmar

Background Little research has been published on the prevalence of rickettsial infections in Myanmar. This study determined the seroprevalence of immunoglobulin G (IgG) antibodies to rickettsial species in different regions of Myanmar. Methods Seven hundred leftover blood samples from patients of all ages in primary care clinics and hospitals in seven regions of Myanmar were collected. Samples were screened for scrub typhus group (STG), typhus group (TG) and spotted fever group (SFG) IgG antibodies using enzyme-linked immunosorbent assays (ELISA). Immunofluorescence assays were performed for the same rickettsial groups to confirm seropositivity if ELISA optical density ≥0.5. Results Overall IgG seroprevalence was 19% [95% confidence interval (CI) 16–22%] for STG, 5% (95% CI 3–7%) for TG and 3% (95% CI: 2–5%) for SFG. The seroprevalence of STG was particularly high in northern and central Myanmar (59% and 19–33%, respectively). Increasing age was associated with higher odds of STG and TG seropositivity [per 10-year increase, adjusted odds ratio estimate 1.68 (p < 0.01) and 1.24 (p = 0.03), respectively]. Conclusion Rickettsial infections are widespread in Myanmar, with particularly high seroprevalence of STG IgG antibodies in central and northern regions. Healthcare workers should consider rickettsial infections as common causes of fever in Myanmar