Peripheral neuropathy induced by drinking water contaminated with low-dose arsenic in Myanmar

BACKGROUND@#More than 140 million people drink arsenic-contaminated groundwater. It is unknown how much arsenic exposure is necessary to cause neurological impairment. Here, we evaluate the relationship between neurological impairments and the arsenic concentration in drinking water (ACDW).@*PARTICIPANTS AND METHODS@#A cross-sectional study design was employed. We performed medical examinations of 1867 residents in seven villages in the Thabaung township in Myanmar. Medical examinations consisted of interviews regarding subjective neurological symptoms and objective neurological examinations of sensory disturbances. For subjective neurological symptoms, we ascertained the presence or absence of defects in smell, vision, taste, and hearing; the feeling of weakness; and chronic numbness or pain. For objective sensory disturbances, we examined defects in pain sensation, vibration sensation, and two-point discrimination. We analyzed the relationship between the subjective symptoms, objective sensory disturbances, and ACDW.@*RESULTS@#Residents with ACDW ≥ 10 parts per billion (ppb) had experienced a "feeling of weakness" and "chronic numbness or pain" significantly more often than those with ACDW  50 ppb). These data suggest a threshold for the occurrence of peripheral neuropathy due to arsenic exposure, and indicate that the arsenic concentration in drinking water should be less than 10 ppb to ensure human health.

Sentinel surveillance for rotavirus in children <5 years of age admitted for Diarrheal illness to Yangon Children's Hospital, Myanmar, 2009-2014.

BACKGROUND: Rotavirus is the leading cause of severe acute gastroenteritis (AGE) in children <5 years of age in Myanmar. The purpose of this analysis is to report from the sentinel surveillance system for rotavirus gastroenteritis (RVGE), which collects information on the epidemiology and circulating genotypes to assess the disease burden and support vaccine introduction in Myanmar. METHODS: Prospective, active surveillance for RVGE-associated hospitalizations was conducted during 2009 -2014 at Yangon Children's Hospital. Stool samples collected from children <5 years of age admitted for AGE were screened for rotavirus antigen by ELISA (ProSpecT™ Rotavirus, OXOID-UK). G and P genotyping was performed by reverse transcription polymerase chain reaction. RESULTS: Overall, 1860/3724 (49.9%) of stool samples tested positive for rotavirus, ranging from 42-56% of hospitalized AGE cases each year. RVGE was predominant in the 6-11 months age group 889/1860 (47.8%) as compared with 12-23 months 633/1860 (34.0%), 0-5 months 226/1860 (12.2 %) and 24-59 months 112/1860 (6.0%). RVGE occurred in a seasonal cycle with peak occurrence in the cold and dry months (November to February), accounting for 65.3% (1151/1763) among enrolled AGE cases. Vomiting (84.1% Vs 67.9%; P < .01), fever (84.5% Vs 75.6%; P < .01) and dehydration (78% Vs 69%; P < .01) were more frequently observed in RVGE than non-RVGE. Genotyping revealed that G1P[8] was predominant from January to June 2009, G12P[8] was predominant throughout 2009-2012 which was replaced in 2012-2013 by G2P[4] and changed again to G1P[8] in 2013-2014 and G9P[8] in late 2014. CONCLUSIONS: Rotavirus is accounting for approximately half of AGE-associated hospitalizations among children <5 years of age in Myanmar. There is immense diversity of rotavirus strains similar to that reported previously for other countries in the region. Information gained from this surveillance system highlights consideration of rotavirus vaccine introduction into this target population.

Current Status of Standard Diagnostics and Treatment for Malaria, Tuberculosis, and Hepatitis in Myanmar

Malaria, tuberculosis, and hepatitis are common and notorious infectious diseases in Myanmar. Despite intensive efforts to control these diseases, their prevalence remains high. For malaria, which is a vector-borne disease, a remarkable success in the reduction of new cases has been achieved. However, the annual number of tuberculosis cases has increased over the last few decades, and the prevalence of chronic viral hepatitis infection has been high in Myanmar and other nearby countries. Early detection and prompt treatment are crucial to control these diseases. We have devoted our research efforts to understanding the status of these infectious diseases and working towards their eventual elimination for the last four years with the support of the Korea International Cooperation Agency. In the modern era, an infection that develops in one geographical area can spread globally because national borders do not effectively limit disease transmission. Our efforts to understand the status of infectious diseases in Myanmar will benefit not only Myanmar but also neighboring countries such as Korea.

Comparison of microscopy and PCR for the detection of human Plasmodium species and Plasmodium knowlesi in southern Myanmar

Objectives To determine the distribution of Plasmodium (P) species including Plasmodium knowlesi and to compare the specificity and sensitivity of microscopy with nested PCR in malaria diagnosis. Methods The study was conducted in Kawthaung, southern Myanmar. Ninety clinically suspected malaria patients were screened for malaria by Giemsa stained microscopy and confirmed by nested PCR. Results Among the participants, 57 (63.3%) were positive and 33 (36.7%) were negative by microscopy. Of positive samples, 39 (68.4%) were Plasmodium falciparum, 17 (29.8%) Plasmodium vivax and 1 (1.8%) Plasmodium malariae, whereas 59-amplified by PCR were 40 (67.8%), 18 (30.5%) and 1 (1.7%) respectively. PCR amplified 2 microscopy negative samples. Two samples of P. falciparum detected by microscopy were amplified as P. vivax and vice versa. All samples were negative for Plasmodium ovale, P. knowlesi and mixed infections. Microscopy had a very good measure of agreement (κ = 0.95) compared to nested PCR. Sensitivity and specificity of microscopy for diagnosis of P. falciparum were 92.5% (95% CI: 79.6–98.4) and 96.0% (95% CI: 86.3–99.5) respectively, whereas for P. vivax were 83.3% (95% CI: 58.6–96.4) and 97.2% (95% CI: 90.3–99.7). Conclusions P. knowlesi was not detected by both microscopy and PCR. Giemsa stained microscopy can still be applied as primary method for malaria diagnosis and is considered as gold standard. As to the lower sensitivity of microscopy for vivax malaria, those with previous history of malaria and relapse cases should be diagnosed by RDT or PCR combined with microscopy. Inaccuracy of species diagnosis highlighted the requirement of training and refresher courses for microscopists.

Effective High-Throughput Blood Pooling Strategy before DNA Extraction for Detection of Malaria in Low-Transmission Settings

In the era of (pre) elimination setting, the prevalence of malaria has been decreasing in most of the previously endemic areas. Therefore, effective cost- and time-saving validated pooling strategy is needed for detection of malaria in low transmission settings. In this study, optimal pooling numbers and lowest detection limit were assessed using known density samples prepared systematically, followed by genomic DNA extraction and nested PCR. Pooling strategy that composed of 10 samples in 1 pool, 20 µl in 1 sample, was optimal, and the parasite density as low as 2 p/µl for both falciparum and vivax infection was enough for detection of malaria. This pooling method showed effectiveness for handling of a huge number of samples in low transmission settings (<9% positive rate). The results indicated that pooling of the blood samples before DNA extraction followed by usual nested PCR is useful and effective for detection of malaria in screening of hidden cases in low-transmission settings.

Promoting antenatal care services for early detection of pre-eclampsia

A prospective, quasi-experimental study was carried out in 2009 at urban health centres (UHCs)of five townships of Mandalay, Myanmar, to improve the skill of midwives (MWs) in diagnosis andreferral of pre-eclampsia (PE) from UHC to the Central Women’s Hospital (CWH) and to enhancethe supervision of midwives by lady health visitors (LHVs). The intervention was training on qualityantenatal care focusing on PE using an updated training manual. Altogether, 75 health care providers(MWs & LHVs) participated. In this study, data were extracted from patient registers and monthlyreports of UHCs and CWH. Interviewers were trained regarding the conduct of semi-structuredquestionnaires to elicit knowledge and to use checklists in observation of skills in screening ofPE, measuring blood pressure and urine protein (dipstick test). A guide for LHVs was also usedto obtain data, and data was collected six months prior to and after the intervention. Significantimprovements from baseline to endline survey occurred in the knowledge (p<0.001) and skill levels(p<0.001) including skills for screening, measuring blood pressure and urine protein. At CWH, therewas an increase in referred cases of PE after the intervention, from 1.25% to 2.56% (p<0.001). Inconclusion, this study highlights the early detection of pre-eclampsia by widespread use of qualityantenatal care, education and training of health-care providers to improve their performance andincrease human resources for health care, in order to enable women in our society to have healthypregnancies and healthy babies.

Scenario of the twins with suspected congenital rubella syndrome (CRS) in Yangon, Myanmar

Rubella is a common cause of childhood rash and fever. Congenital rubella syndrome (CRS) can lead to deafness, heart disease, cataracts, and a variety of other permanent manifestations. In order to identify the disease burden of rubella infection, CRS surveillance among infants in Yangon was conducted for two consecutive years from December 2000 to December 2002, as a WHO-funded study. Among the 13 participating hospitals, the Special Care Baby Unit of the Central Women‘s Hospital in Yangon reported 17 infants with suspected CRS. Interestingly, three sets of twins with suspected CRS were reported. One ml of blood was collected from each infant after obtaining informed consent, then tested for the presence of rubella antibody (Immunoglobulin M and G) by the ELISA method, and for the presence of rubella viral RNA by the RT-PCR method. Furthermore, nucleotide sequencing and genotype identification of samples from two cases with positive rubella RNA were performed. All 3 sets of twins were IgM negative. However, rubella RNA was detected by RT-PCR in twin 1A who showed no obvious clinical signs, and in twin 2B who had patent ductus arteriosus, splenomegaly and hepatomegaly. Nucleotide sequences of PCR positive cases revealed genotype Ia sequences. Twin 2B was identified as having deafness of the left ear on audiometry assessment conducted at 5 years and 4 months of age. Both twins of twin set-2 were IgG positive at age 12 days, but turned out to be negative by the age of 9 months. Both twins of twin set-3 presented with splenomegaly and died before 2 months of age, probably due to other infections. Our findings revealed the different scenario of twins with suspected CRS. It is expected to serve as a valuable addition to the medical literature as there were very few reports on twins with CRS.