Imported malaria from land bordering countries in China: A challenge in preventing the reestablishment of malaria transmission.

OBJECTIVE: No indigenous malaria cases have been reported since 2017 in China, but a large number of imported cases are still reported every year, including those from the land bordering countries. To characterize their epidemiological profiles will provide evidence for the development of appropriate strategies to effectively address the challenges of border malaria in the post-elimination phase. METHODS: Individual-level data of imported malaria cases from the land bordering countries were collected from 2017 to 2021 in China via the web-based surveillance systems, and analyzed by SPSS, ArcGIS and WPS software, to explore their epidemiological profiles. RESULTS: A total of 1170 malaria cases imported into China from six of the fourteen land bordering countries were reported between 2017 and 2021 with a decline trend. Overall, cases were widely distributed in 31-97 counties from 11 to 21 provinces but mainly in Yunnan. Moreover, these imported cases were mainly infected with P. vivax (94.8%), and a total of 68 recurrent cases were reported in 6-14 counties from 4 to 8 provinces. In addition, nearly 57.1% of the total reported cases could seek healthcare within 2 days of getting sick, and 71.3% of the reported cases could be confirmed as malaria on the day they sought medical care. CONCLUSIONS: China still needs to attach great importance to the risk and challenge of the imported malaria from bordering countries particularly from Myanmar in preventing reestablishment of malaria transmission in the post-elimination phase. It is necessary not only to strengthen collaboration and cooperation with the bordering countries, but also coordinate multiple departments at home to improve malaria surveillance and response system and prevent the reestablishment of malaria transmission in China.

Bacterial and viral etiology of acute respiratory infection among the Forcibly Displaced Myanmar Nationals (FDMNs) in fragile settings in Cox's Bazar- a prospective case-control study.

The leading infectious cause of death in children worldwide is lower acute respiratory infection (LARI), particularly pneumonia. We enrolled a total of 538 acute respiratory infection (ARI) cases according to WHO criteria and age-sex matched 514 controls in the Forcibly Displaced Myanmar National (FDMN) refugee camps in Cox's Bazar, Bangladesh, between June 2018 and March 2020 to investigate the role of bacteria, viruses, and their co-infection patterns and observe Streptococcus pneumoniae (S. pneumoniae) serotype distribution. According to the etiological findings, children ≤5 years of age have a higher bacterial positivity (90%) and viral positivity (34%) in nasopharyngeal samples (NPS) compared to those >5 years of age, in both ARI cases as well as for the control group. Among the bacteria, S. pneumoniae was predominant in both cases and controls (85% and 88%). Adenovirus (ADV)(34), influenza virus A and B (IFV-A, B)(32,23), and respiratory syncytial virus (RSV)(26) were detected as the highest number among the viruses tested for the ARI cases. The total number of viruses was also found higher in ≤5 years of age group. Within this group, positive correlation was observed between bacteria and viruses but negative correlation was observed between bacteria. Both single and co-infection for viruses were found higher in the case group than the control group. However, co-infection was significantly high for Streptococcus aureus (S. aureus) and Haemophilus influenzae b (H. influenza b) (p<0.05). Additionally, semi-quantitative bacterial and viral load was found higher for the ARI cases over control considering Cycle threshold (Ct)≤30. Pathogen identification from blood specimens was higher by qRT-PCR than blood culture (16% vs 5%, p<0.05). In the S. pneumoniae serotype distribution, the predominant serotypes in ARI cases were 23F, 19A, 16F, 35B, 15A, 20 and 10F, while 11A, 10A, 34, 35A and 13 serotypes were predominant in the control group. Pathogen correlation analysis showed RSV positively correlated with human metapneumovirus (HMPV), S. aureus and H. influenza b while S. pneumoniae was negatively correlated with other pathogens in ≤5 years age group of ARI cases. However, in >5 years age group, S. aureus and H. influenza b were positively correlated with IFVs, and S. pneumoniae was positively correlated with HMPV and ADV. Logistic regression data for viruses suggested among the respondents in cases were about 4 times more likely to be RSV positive than the control. Serotype distribution showed 30% for PCV10 serotypes, 41% for PCV13 and 59% for other serotypes. Also, among the 40 serotypes of S. pneumoniae tested, the serotypes 22F, Sg24, 9V, 38, 8, and 1 showed strong positive correlation with viruses in the case group whereas in the control group, it was predominant for serotypes 14, 38, 17F and 39 ARI cases were prevalent mostly in monsoon, post-monsoon, and winter periods, and peaked in September and October. Overall these region-specific etiological data and findings, particularly for crisis settings representing the FDMNs in Cox's Bazar, Bangladesh, is crucial for disease management and disease prevention control as well as immunization strategies more generally in humanitarian crisis settings.

Evaluation of Simplified HCV Diagnostics in HIV/HCV Co-Infected Patients in Myanmar.

To evaluate a decentralised testing model and simplified treatment protocol of hepatitis C virus (HCV) infection to facilitate treatment scale-up in Myanmar, this prospective, observational study recruited HIV-HCV co-infected outpatients receiving sofosbuvir/daclatasvir in Yangon, Myanmar. The study examined the outcomes and factors associated with a sustained virological response (SVR). A decentralised "hub-and-spoke" testing model was evaluated where fingerstick capillary specimens were transported by taxi and processed centrally. The performance of the Xpert HCV VL Fingerstick Assay in detecting HCV RNA was compared to the local standard of care ( plasma HCV RNA collected by venepuncture). Between January 2019 and February 2020, 162 HCV RNA-positive individuals were identified; 154/162 (95%) initiated treatment, and 128/154 (84%) returned for their SVR12 visit. A SVR was achieved in 119/154 (77%) participants in the intent-to-treat population and 119/128 (93%) participants in the modified-intent-to-treat population. Individuals receiving an antiretroviral therapy were more likely to achieve a SVR (with an odds ratio (OR) of 7.16, 95% CI 1.03-49.50), while those with cirrhosis were less likely (OR: 0.26, 95% CI 0.07-0.88). The sensitivity of the Xpert HCV VL Fingerstick Assay was 99.4% (95% CI 96.7-100.0), and the specificity was 99.2% (95% CI 95.9-99.9). A simplified treatment protocol using a hub-and-spoke testing model of fingerstick capillary specimens can achieve an SVR rate in LMIC comparable to well-resourced high-income settings.

Community stressors and coping mechanisms in accessing the health system during a double crisis: a qualitative case study from Yangon Region, Myanmar.

BACKGROUND: Due to the COVID-19 pandemic and political crisis, Myanmar's health system has suspended routine services while struggling to respond to the pandemic. Many people who need continuous care, like pregnant women and people with chronic illnesses, have been facing challenges in seeking and receiving essential health services. This study explored community health seeking practices and coping mechanisms, including their views on health system stressors. METHODS: This was a cross-sectional qualitative study based on 12 in-depth-interviews with pregnant people and persons with pre-existing chronic health conditions in Yangon. Sampling was purposive, convenience-based and snowball sampling was also used. The 3-delays framework was used to understand how persons were interacting with and accessing health care services; community and health system stressors and coping mechanisms in relation to COVID-19 were also identified. RESULTS: Findings showed that Yangon region was the hardest hit with both the pandemic and political crisis and its health system was greatly affected. People were unable to access essential health services on time. The health facilities were not available to see patients, with serious shortages in human resources, medicines and equipment, resulting in interruption of essential routine services. The prices of medicines and consultation fees, and transportation costs, increased during this period. Limited options for accessing care were available due to travel restrictions and curfews. It became challenging to receive quality care because of unavailable public facilities and private hospitals being costly. Despite these challenges, the Myanmar people and health system have shown resilience. Cohesive and organized family support structures and extended and deep social networks played an important role in accessing health care. At times of emergency, people relied on community-based social organizations for transportation and accessing essential medicines. The health system also showed resilience through establishing new service provision options, such as teleconsultations, mobile clinics, and sharing medical advice through social media. CONCLUSIONS: This is the first study in Myanmar to explore peoples' perceptions on COVID-19, the health system and their healthcare experiences during political crisis. Although there is no easy way to cope with this dual hardship, the people and the health system, even in a fragile and shock-prone setting like Myanmar, stayed resilient by developing alternative pathways for seeking and providing health services.

A Prepandemic Nutrition-Sensitive Social Protection Program Has Sustained Benefits for Food Security and Diet Diversity in Myanmar during a Severe Economic Crisis.

BACKGROUND: One-third of preschool children in Myanmar were stunted in 2015-2016, and three-quarters of children 6-23 mo had inadequate diet diversity. In response, a large-scale nutrition-sensitive social protection program was implemented over 2016-2019. In 2020, however, Myanmar's economy was hit hard by the COVID-19 pandemic and harder still by a military takeover in 2021. OBJECTIVE: The objective of this study was to examine whether former beneficiaries of this program experienced better food security, food consumption, and diet diversity outcomes in the wake of major economic shocks. METHODS: In a previous cluster-randomized controlled trial conducted over 2016-2019, pregnant women and their children aged <2 y were randomly assigned to either: 1) CASH; 2) CASH + social and behavioral change communication (SBCC); or 3) a control group. Subsamples of these former participants were then resurveyed 10 times from June 2020 to December 2021 during Myanmar's protracted economic crisis. Randomized treatment exposure was used in a regression analysis to test for postprogram impacts on Food Insecurity Experience Scale indicators, household food consumption, and maternal and child diet diversity. We also examined the impacts on household income as a secondary outcome and potential impact pathway. RESULTS: Both intervention arms reported lower food insecurity, more frequent consumption of nutritious foods, and more diverse maternal and child diets compared with households in the control group. However, the improved dietary outcomes were larger for mothers and children exposed to CASH+SBCC compared with CASH, as was their monthly household income. CONCLUSIONS: The findings suggest that a program combining cash transfers with nutrition-related education can yield sustained benefits 1-2 y after the program was completed. This strengthens the evidence to support the expansion and scale-up of nutrition-sensitive social welfare programs to redress chronic malnutrition and enhance nutritional resilience in the face of a severe economic crisis.

Whole-Genome Analysis of Influenza A(H3N2) and B/Victoria Viruses Detected in Myanmar during the COVID-19 Pandemic in 2021.

An influenza circulation was observed in Myanmar between October and November in 2021. Patients with symptoms of influenza-like illness were screened using rapid diagnostic test (RDT) kits, and 147/414 (35.5%) upper respiratory tract specimens presented positive results. All RDT-positive samples were screened by a commercial multiplex real-time polymerase chain reaction (RT-PCR) assay, and 30 samples positive for influenza A(H3N2) or B underwent further typing/subtyping for cycle threshold (Ct) value determination based on cycling probe RT-PCR. The majority of subtyped samples (n = 13) were influenza A(H3N2), while only three were B/Victoria. Clinical samples with low Ct values obtained by RT-PCR were used for whole-genome sequencing via next-generation sequencing technology. All collected viruses were distinct from the Southern Hemisphere vaccine strains of the corresponding season but matched with vaccines of the following season. Influenza A(H3N2) strains from Myanmar belonged to clade 2a.3 and shared the highest genetic proximity with Bahraini strains. B/Victoria viruses belonged to clade V1A.3a.2 and were genetically similar to Bangladeshi strains. This study highlights the importance of performing influenza virus surveillance with genetic characterization of the influenza virus in Myanmar, to contribute to global influenza surveillance during the COVID-19 pandemic.

A four-generation family transmission chain of COVID-19 along the China-Myanmar border in October to November 2021.

Background: Foreign imported patients and within-household transmission have been the focus and difficulty of coronavirus disease 2019 (COVID-19) prevention and control, which has also posed challenges to border areas' management. However, household transmission caused by foreign imported cases has not been reported in China's border areas. This study aimed to reveal a clear family clustering transmission chain of COVID-19 caused by contact with Myanmar refugees along the China-Myanmar border during an outbreak in October to November 2021. Methods: During the outbreak, detailed epidemiological investigations were conducted on confirmed patients with COVID-19 and their close contacts in daily activities. Patients were immediately transported to a designated hospital for treatment and quarantine, and their close contacts were quarantined at designated sites. Regular nucleic acid testing and SARS-CoV-2 antibody testing were provided to them. Results: A clear four-generation family clustering transmission involving five patients with COVID-19 was found along the China-Myanmar border. The index case (Patient A) was infected by brief conversations with Myanmar refugees across border fences during work. His wife (Patient B) and 9-month-old daughter (Patient C) were second-generation cases infected by daily contact with him. His 2-year-old daughter (Patient D) was the third-generation case infected by her mother and sister during quarantine in the same room and then transmitted the virus to her grandmother (Patient E, the fourth-generation case) who looked after her after Patients B and C were diagnosed and transported to the hospital. The household secondary attack rate was 80.0%, the average latent period was 4 days, and the generation time was 3 days. Ten of 942 close contacts (1.1%) of this family had positive IgM antibody during the medical observation period. In total 73.9% (696/942) of them were positive for IgG antibody and 8.3% (58/696) had IgG levels over 20 S/CO (optical density of the sample/cut-off value of the reagent). Conclusion: This typical transmission chain indicated that it is essential to strengthen COVID-19 prevention and control in border areas, and explore more effective children care approaches in quarantine sites.

Trajectory of confirmed cases and deaths: fourth wave of COVID-19 epidemic in Myanmar.

The current coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has affected day-to-day life worldwide and presents an unprecedented challenge to public health. Many countries performed mitigation measures to contain the disease spread and break the exponential curve. Omicron had already become a dominant variant in Myanmar and then, the fourth wave of the COVID-19 epidemic started on 28th January 2022. Myanmar performed the main community mitigation measures such as strict quarantine for the people who came back from foreign countries, expansion of testing capacity, enforcement of non-pharmaceutical interventions, and improvement of COVID-19 vaccination coverage. Although decreasing the number of COVID-19 cases and deaths, Myanmar is facing the challenges such as human resource shortages in the health sector, community trust for vaccine safety, and inequitable vaccine demand. This communication intends to give insights on what should be considered as the proper mitigation measures to contain the disease spread through the community and as the challenges that occur in implementing public health and social measures.

Seroprevalence of SARS-CoV-2 antibodies among Forcibly Displaced Myanmar Nationals in Cox's Bazar, Bangladesh 2020: a population-based cross-sectional study.

OBJECTIVES: The study aimed to determine the seroprevalence, the fraction of asymptomatic infections, and risk factors of SARS-CoV-2 infections among the Forcibly Displaced Myanmar Nationals (FDMNs). DESIGN: It was a population-based two-stage cross-sectional study at the level of households. SETTING: The study was conducted in December 2020 among household members of the FDMN population living in the 34 camps of Ukhia and Teknaf Upazila of Cox's Bazar district in Bangladesh. PARTICIPANTS: Among 860 697 FDMNs residing in 187 517 households, 3446 were recruited for the study. One individual aged 1 year or older was randomly selected from each targeted household. PRIMARY AND SECONDARY OUTCOME MEASURES: Blood samples from respondents were tested for total antibodies for SARS-CoV-2 using Wantai ELISA kits, and later positive samples were validated by Kantaro kits. RESULTS: More than half (55.3%) of the respondents were females, aged 23 median (IQR 14-35) years and more than half (58.4%) had no formal education. Overall, 2090 of 3446 study participants tested positive for SARS-CoV-2 antibody. The weighted and test adjusted seroprevalence (95% CI) was 48.3% (45.3% to 51.4%), which did not differ by the sexes. Children (aged 1-17 years) had a significantly lower seroprevalence 38.6% (95% CI 33.8% to 43.4%) compared with adults (58.1%, 95% CI 55.2% to 61.1%). Almost half (45.7%, 95% CI 41.9% to 49.5%) of seropositive individuals reported no relevant symptoms since March 2020. Antibody seroprevalence was higher in those with any comorbidity (57.8%, 95% CI 50.4% to 64.5%) than those without (47.2%, 95% CI 43.9% to 50.4%). Multivariate logistic regression analysis of all subjects identified increasing age and education as risk factors for seropositivity. In children (≤17 years), only age was significantly associated with the infection. CONCLUSIONS: In December 2020, about half of the FDMNs had antibodies against SARS-CoV-2, including those who reported no history of symptoms. Periodic serosurveys are necessary to recommend appropriate public health measures to limit transmission.

'I Doubt Myself and Am Losing Everything I Have since COVID Came'-A Case Study of Mental Health and Coping Strategies among Undocumented Myanmar Migrant Workers in Thailand.

Migrant populations have always been vulnerable to a high burden of social exclusion, mental disorders, physical illnesses, and economic crises. The current COVID-19 pandemic has further created a frantic plight among them, particularly for undocumented migrant workers in the global south. We have conducted a mixed method study among the undocumented Myanmar migrant workers (UMMWs) in Thailand to explore how the COVID-19 disruption has impacted their mental health and what coping strategies they have adopted. Following the onset of COVID-19 and the recent coup d'état in Myanmar, our current study is the first attempt to understand the mental health status and predicament of this neglected migrant group. A total of 398 UMMWs were included in the online survey, of which 23 participated in qualitative interviews. The major mental health issues reported by the study participants were depression, generalized anxiety disorder, frustration, stress, and panic disorders, while loss of employment, worries about the pandemic, social stigma, lack of access to healthcare, lockdown, and fear of detention were the predominant contributing factors. In response, we identified two key coping mechanisms: coping at a personal level (listening to music, playing online game, praying, and self-motivation) and coping at a social level (chatting with family and friends and visiting religious institutions). These findings point to the importance of policy and intervention programs aimed at upholding mental health at such humanitarian conditions. Sustainable institutional mental health care support and social integration for the migrant workers, irrespective of their legal status, should be ensured.

COVID-19 Vaccine Acceptance and Its Determinants among Myanmar Migrant Workers in Southern Thailand.

Success in eradicating COVID-19 will rely on the rate of vaccination adoption worldwide. Vaccine acceptance among vulnerable groups is critical for preventing the spread of COVID-19 and decreasing unnecessary deaths. The purpose of this study was to report on the willingness to obtain COVID-19 immunization and the factors related to its acceptance among Myanmar migrant workers in southern Thailand. This cross-sectional study consisted of 301 samples collected between October and November 2021 and analyzed using multiple logistic regression. Thirty-nine percent of workers intended to receive the COVID-19 vaccine within a year. The following factors were associated with obtaining the COVID-19 vaccine: a high level of perception of COVID-19 (AOR = 5.43), income less than or equal to 10,000 baht/month (AOR = 6.98), financial status at a sufficient level (AOR = 7.79), wearing a face mask in the previous month almost all the time (AOR =4.26), maintaining 1-2 m of distance from anyone in the last month (AOR =2.51), and measuring temperature in the previous month (AOR = 5.24). High reluctance to accept the COVID-19 vaccine among Myanmar migrant workers can influence efforts to eliminate COVID-19. Collaboration with all stakeholders is critical to helping Myanmar workers understand COVID-19, social measures, and preventive beliefs to increase vaccine uptake.

How political engineering can make health a bridge to peace: lessons from a Primary Health Care Project in Myanmar's border areas.

This case study analyses a health project that focused on peacebuilding in addition to service provision, and the impacts of this dual focus in contested territories of Southeast Myanmar. The Swiss-funded Primary Health Care Project provided equal funds to both 'sides' in a decades-long conflict, and brought people together in ways designed to build trust. The case study demonstrates that health can play a valuable role in peace formation, if relationships are engineered in a politically sensitive way, at the right time. Whereas much of the literature on 'health as a bridge to peace' focuses on the apolitical in health, here the explicitly political approach and the deliberate adoption of neutrality as a tool for engaging with different parties were what enabled health to contribute to peace, using a political window of opportunity created by ceasefires and the beginnings of democratic transition in Myanmar. We argue that this approach was essential for health to contribute to bottom-up processes of peace formation-though the scope of the gains is necessarily limited. Crises like the COVID-19 pandemic and military coup in Myanmar can undermine the resilience and limit the impacts of such endeavours, yet there is reason to be hopeful about the small but significant contributions that can be made to peace through politically sensitive health projects.

The Lived Experience of COVID-19 Survivors During the Third Wave of the Pandemic and the Political Crisis in Myanmar: A Qualitative Study.

When the third wave of the COVID-19 epidemic broke out, the double burden of the pandemic and political instability meant that people in Myanmar did not have access to adequate hospital care. The aim of this study was to explore the lived experience of COVID-19 survivors in the community. A qualitative, descriptive, phenomenological approach was used, and participants were selected through purposive sampling. Fifteen individuals described their experiences using four themes and 17 categories. The main themes were the aggressive natures of the pandemic, suffering from the disease, receiving vital support for survival, and the hardships due to political pressure. The pandemic and subsequent waves of different variants should not be underestimated, and people's health should take priority over economic development and political crisis. Knowledge and practices of family members and society should be promoted by providing timely and comprehensive information regarding pandemic diseases.

Epidemiological and clinical characteristics of the largest COVID-19 outbreak along the China-Myanmar border in Ruili City, Yunnan Province, China.

Background: Imported COVID-19 patients posed great challenges to border areas' COVID-19 control. However, research was scarce to reveal epidemiological characteristics of COVID-19 in border areas. This study aimed to explore the detailed transmission chains, and reveal epidemiological and clinical characteristics of the largest COVID-19 outbreak caused by Delta variant of concern (VOC) occurred in the China-Myanmar border area. Methods: During the outbreak from July to September, 2021 in Ruili City, Yunnan Province, China, epidemiological investigation data and clinical-related data pertaining to confirmed COVID-19 patients were collected. Patients' contact history data and viral gene sequencing were used for inference of transmission chains. Sociodemographic and epidemiological characteristics, cycle threshold (Ct) value, and antibodies level were compared between patients who were vaccinated against COVID-19 or not. Results: A total of 117 COVID-19 patients were confirmed during the outbreak, among which 86 (73.5%) were breakthrough infections. These patients evenly split between Chinese and Myanmar people (50.4% vs. 49.6%). Most of these patients were mild (45.3%) or moderate (48.7%) infections with no death reported. Multi-source of infection led to 16 transmission chains with a maximum of 45 patients in one chain. Patients vaccinated against COVID-19 before infection had relatively higher antibodies (IgM and IgG) levels and more rapid response to infection than non-vaccinated patients (p < 0.05). Conclusion: Land border areas have greater risks of imported COVID-19 and more complicated epidemics. It should be cautious in formulating entry and exit requirements for border areas. The immune effect of COVID-19 vaccines and related mechanism should be further explored.

Public knowledge, practices, and awareness of antibiotics and antibiotic resistance in Myanmar: The first national mobile phone panel survey.

In 2017, the Myanmar National Action Plan for Containment of Antimicrobial Resistance (AMR) (2017-2022) was endorsed by the Ministry of Health and Sports, Myanmar; one of its objectives was to increase public awareness of AMR to accelerate appropriate antibiotic use. This survey aimed to assess the public knowledge, practices and awareness concerning antibiotics and AMR awareness among adults in Myanmar. We conducted a nationwide cross-sectional mobile phone panel survey in January and February 2020. Participants were randomly selected from the mobile phone panel in each of three groups stratified by gender, age group, and residential area urbanity; they were interviewed using a structured questionnaire. Collected data were weighted based on the population of each stratum from the latest national census and analyzed using descriptive and inferential statistics. Two thousand and forty-five adults from 12 regions and states participated in this survey. Overall, 89.5% of participants had heard about antibiotics; however, only 0.9% provided correct answers to all five questions about antibiotics, whereas 9.7% provided all incorrect answers. More than half of participants (58.5%) purchased antibiotics without a prescription, mainly from medical stores or pharmacies (87.9%); this was more frequent in age group (18-29 years) and those in rural areas (p = 0.004 and p < 0.001, respectively). Only 56.3% were aware of antibiotic resistance and received their information from medical professionals (46.3%), family members or friends (38.9%), or the media (26.1%). Less than half (42.4%) knew that antibiotics were used in farm animals. Most did not know that using antibiotics in farm animals could develop resistance (73.2%) and is banned for the purposes of growth stimulation (64.1%). This survey identifies considerable gaps in the knowledge, practices, and awareness about antibiotics among the general population in Myanmar. Continuous public education and awareness campaigns must be urgently conducted to fulfill these gaps, which would aid in promoting antibiotic stewardship, leading to combating AMR in Myanmar.

Surveillance to achieve malaria elimination in eastern Myanmar: a 7-year observational study.

BACKGROUND: The collection and utilization of surveillance data is essential in monitoring progress towards achieving malaria elimination, in the timely response to increases in malaria case numbers and in the assessment of programme functioning. This paper describes the surveillance activities used by the malaria elimination task force (METF) programme which operates in eastern Myanmar, and provides an analysis of data collected from weekly surveillance, case investigations, and monitoring and evaluation of programme performance. METHODS: This retrospective analysis was conducted using data collected from a network of 1250 malaria posts operational between 2014 and 2021. To investigate changes in data completeness, malaria post performance, malaria case numbers, and the demographic details of malaria cases, summary statistics were used to compare data collected over space and time. RESULTS: In the first 3 years of the METF programme, improvements in data transmission routes resulted in a 18.9% reduction in late reporting, allowing for near real-time analysis of data collected at the malaria posts. In 2020, travel restrictions were in place across Karen State in response to COVID-19, and from February 2021 the military coup in Myanmar resulted in widescale population displacement. However, over that period there has been no decline in malaria post attendance, and the majority of consultations continue to occur within 48 h of fever onset. Case investigations found that 43.8% of cases travelled away from their resident village in the 3 weeks prior to diagnosis and 36.3% reported never using a bed net whilst sleeping in their resident village, which increased to 72.2% when sleeping away from their resident village. Malaria post assessments performed in 82.3% of the METF malaria posts found malaria posts generally performed to a high standard. CONCLUSIONS: Surveillance data collected by the METF programme demonstrate that despite significant changes in the context in which the programme operates, malaria posts have remained accessible and continue to provide early diagnosis and treatment contributing to an 89.3% decrease in Plasmodium falciparum incidence between 2014 and 2021.