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BACKGROUND: Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published. METHODS AND FINDINGS: Five community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was collected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (representing moderate or severe malnutrition) was 11.3% (8.0-14.7). A total of 250 deaths occurred during the year prior to the survey. Infant deaths accounted for 64 of these (IMR 94.2; 95% CI 66.5-133.5) and there were 94 child deaths (U5MR 141.9; 95% CI 94.8-189.0). 10.7% of households (95% CI 7.0-14.5) experienced at least one HRV in the past year, while four percent reported 2 or more HRVs. Household exposure to one or more HRVs was associated with moderate-severe malnutrition among children (14.9 vs. 6.8%; prevalence ratio 2.2, 95% CI 1.2-4.2). Household exposure to HRVs was associated with self-reported fair or poor health status among respondents (PR 1.3; 95% CI 1.1-1.5). CONCLUSION: This large survey of health and human rights demonstrates that two years after political transition, vulnerable populations of eastern Myanmar are less likely to experience human rights violations compared to previous surveys. However, access to health services remains constrained, and risk of disease and death remains higher than the country as a whole. Efforts to address these poor health indicators should prioritize support for populations that remain outside the scope of most formal government and donor programs.
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Trastornos de la Nutrición del Niño/epidemiología , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Estado de Salud , Derechos Humanos/psicología , Poblaciones Vulnerables/psicología , Adolescente , Adulto , Niño , Mortalidad del Niño , Trastornos de la Nutrición del Niño/mortalidad , Trastornos de la Nutrición del Niño/psicología , Preescolar , Composición Familiar , Femenino , Abastecimiento de Alimentos , Encuestas Epidemiológicas , Humanos , Lactante , Mortalidad Infantil , Mianmar/epidemiología , Estado Nutricional , Violencia/estadística & datos numéricosRESUMEN
BACKGROUND: Confirmation of artemisinin-delayed parasite clearance in Plasmodium falciparum along the Thai-Myanmar border has inspired a global response to contain and monitor drug resistance to avert the disastrous consequences of a potential spread to Africa. However, resistance data from Myanmar are sparse, particularly from high-risk areas where limited health services and decades of displacement create conditions for resistance to spread. Subclinical infections may represent an important reservoir for resistance genes that confer a fitness disadvantage relative to wild-type alleles. This study estimates the prevalence of resistance genotypes in three previously unstudied remote populations in Myanmar and tests the a priori hypothesis that resistance gene prevalence would be higher among isolates collected from subclinical infections than isolates collected from febrile clinical patients. A systematic review of resistance studies is provided for context. METHODS: Community health workers in Karen and Kachin States and an area spanning the Indo-Myanmar border collected dried blood spots from 988 febrile clinical patients and 4,591 villagers with subclinical infection participating in routine prevalence surveys. Samples positive for P. falciparum 18 s ribosomal RNA by real-time PCR were genotyped for P. falciparum multidrug resistance protein (pfmdr1) copy number and the pfcrt K76T polymorphism using multiplex real-time PCR. RESULTS: Pfmdr1 copy number increase and the pfcrt K76 polymorphism were determined for 173 and 269 isolates, respectively. Mean pfmdr1 copy number was 1.2 (range: 0.7 to 3.7). Pfmdr1 copy number increase was present in 17.5%, 9.6% and 11.1% of isolates from Karen and Kachin States and the Indo-Myanmar border, respectively. Pfmdr1 amplification was more prevalent in subclinical isolates (20.3%) than clinical isolates (6.4%, odds ratio 3.7, 95% confidence interval 1.1 - 12.5). Pfcrt K76T prevalence ranged from 90-100%. CONCLUSIONS: Community health workers can contribute to molecular surveillance of drug resistance in remote areas of Myanmar. Marginal and displaced populations under-represented among previous resistance investigations can and should be included in resistance surveillance efforts, particularly once genetic markers of artemisinin-delayed parasite clearance are identified. Subclinical infections may contribute to the epidemiology of drug resistance, but determination of gene amplification from desiccated filter samples requires further validation when DNA concentration is low.
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Antimaláricos/farmacología , Resistencia a Medicamentos , Malaria Falciparum/parasitología , Plasmodium falciparum/efectos de los fármacos , Plasmodium falciparum/genética , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Niño , Preescolar , ADN Protozoario/genética , Femenino , Variación Genética , Genotipo , Humanos , Lactante , Recién Nacido , Masculino , Proteínas de Transporte de Membrana/genética , Persona de Mediana Edad , Proteínas Asociadas a Resistencia a Múltiples Medicamentos/genética , Mianmar/epidemiología , Plasmodium falciparum/aislamiento & purificación , Reacción en Cadena de la Polimerasa , Proteínas Protozoarias/genética , Adulto JovenRESUMEN
BACKGROUND: Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable. OBJECTIVE: We reviewed the content, impact, risk-benefit, and feasibility of interventions for obstetric complications with high population attributable risk of intrapartum-related hypoxic injury, as well as human resource, skill development, and technological innovations to improve obstetric care quality and availability. RESULTS: Despite ecological associations of obstetric care with improved perinatal outcomes, there is limited evidence that intrapartum interventions reduce intrapartum-related neonatal mortality or morbidity. No interventions had high-quality evidence of impact on intrapartum-related outcomes in low-resource settings. While data from high-resource settings support planned cesarean for breech presentation and post-term induction, these interventions may be unavailable or less safe in low-resource settings and require risk-benefit assessment. Promising interventions include use of the partograph, symphysiotomy, amnioinfusion, therapeutic maneuvers for shoulder dystocia, improved management of intra-amniotic infections, and continuous labor support. Obstetric drills, checklists, and innovative low-cost devices could improve care quality. Task-shifting to alternative cadres may increase coverage of care. CONCLUSIONS: While intrapartum care aims to avert intrapartum-related hypoxic injury, rigorous evidence is lacking, especially in the settings where most deaths occur. Effective care at birth could save hundreds of thousands of lives a year, with investment in health infrastructure, personnel, and research--both for innovation and to improve implementation.
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Parto Obstétrico , Países en Desarrollo , Muerte Fetal/prevención & control , Complicaciones del Trabajo de Parto/prevención & control , Atención Prenatal/organización & administración , Femenino , Muerte Fetal/epidemiología , Humanos , Complicaciones del Trabajo de Parto/epidemiología , Embarazo , Factores SocioeconómicosRESUMEN
OBJECTIVES: To document the feasibility of a cross-border community based integrated malaria control programme implemented by internally displaced persons in eastern Burma/Myanmar. METHODS: This pilot study was conducted from February 2003 through January 2005 in seven villages of displaced ethnic Karen. Interventions comprised early diagnosis of Plasmodium falciparum and treatment with mefloquine and artesunate, distribution of long-lasting insecticide treated nets (LLITNs), and educational messages. The primary outcome measure was P. falciparum prevalence during bi-annual universal screenings with the Paracheck-Pf (Orchid Biomedical Systems, Goa, India) device. Secondary outcomes were P. falciparum incidence and process indicators related to net use and malaria knowledge, attitudes and practices (KAP). RESULTS: P. falciparum prevalence in original programme areas declined from 8.4% [95% confidence interval (CI) 8.3-8.6] at baseline to 1.1% (95% CI 1.1-1.2) in the final screening. Annual incidence in original areas declined from 232 to 70 cases/1000/year [incidence rate ratio 0.30 (95% CI 0.24-0.39)]. The proportion of household members sleeping under a LLITN improved from 0% to 89% and malaria KAP improved in all areas. CONCLUSIONS: Integrated malaria control organized and implemented by displaced persons is feasible in eastern Burma/Myanmar. The decline in P. falciparum prevalence and incidence suggest that it may be possible to reduce the burden of disease and the reservoir of malaria in eastern Burma/Myanmar, with implications for malaria control in the greater Mekong region.
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Antimaláricos/uso terapéutico , Malaria Falciparum/tratamiento farmacológico , Refugiados , Ropa de Cama y Ropa Blanca , Emigración e Inmigración , Estudios de Factibilidad , Femenino , Conocimientos, Actitudes y Práctica en Salud , Directrices para la Planificación en Salud , Humanos , Incidencia , Malaria Falciparum/diagnóstico , Malaria Falciparum/epidemiología , Masculino , Control de Mosquitos/métodos , Mianmar/epidemiología , Mianmar/etnología , Proyectos Piloto , PrevalenciaRESUMEN
INTRODUCTION: Access to governmental and international nongovernmental sources of health care within eastern Myanmar's conflict regions is virtually nonexistent. Historically, under these circumstances effective care for the victims of trauma, particularly landmine injuries, has been severely deficient. Recognizing this, community-based organizations (CBOs) providing health care in these regions sought to scale up the capacity of indigenous health workers to provide trauma care. CASE DESCRIPTION: The Trauma Management Program (TMP) was developed by CBOs in cooperation with a United States-based health care NGO. The goal of the TMP is to improve the capacity of local health workers to deliver effective trauma care. From 2000 to the present, international and local health care educators have conducted regular workshops to train indigenous health workers in the management of landmine injuries, penetrating and blunt trauma, shock, wound and infection care, and orthopedics. Health workers have been regularly resupplied with the surgical instruments, supplies and medications needed to provide the care learnt through TMP training workshops. DISCUSSION AND EVALUATION: Since 2000, approximately 300 health workers have received training through the TMP, as part of a CBO-run health system providing care for approximately 250,000 internally displaced persons (IDPs) and war-affected residents. Based on interviews with health workers, trauma registry inputs and photo/video documentation, protocols and procedures taught during training workshops have been implemented effectively in the field. Between June 2005 and June 2007, more than 200 patients were recorded in the trauma patient registry. The majority were victims of weapons-related trauma. CONCLUSION: This report illustrates a method to increase the capacity of indigenous health workers to manage traumatic injuries. These health workers are able to provide trauma care for otherwise inaccessible populations in remote and conflicted regions. The principles learnt during the implementation of the TMP might be applied in similar settings.
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BACKGROUND: Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services. METHODS AND FINDINGS: Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15-45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or > or = 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates < or = 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95-2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21-25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23-15.8) times higher among those forcibly displaced. CONCLUSIONS: Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.