Accurate prevalence data are essential for the elimination of lymphatic filariasis (LF) as a public health problem. Despite it bearing one of the highest burdens of disease globally, there remains limited reliable information on the current epidemiology of filariasis in mainland Southeast Asia. We conducted a systematic review and meta-analysis of available literature to assess the recent and current prevalence of infection and morbidity in the region. Fifty-seven journal articles and reports containing original prevalence data were identified, including over 512,010 participants. Data were summarised using percentage prevalence estimates and a subset combined using a random effects meta-analysis by country and year. Pooled estimates for microfilaraemia, immunochromatographic card positivity and combined morbidity were 2.64%, 4.48% and 1.34% respectively. Taking into account pooled country estimates, grey literature and the quality of available data, we conclude that Lao People's Democratic Republic (PDR), Myanmar and Northeast India demonstrate ongoing evidence of LF transmission that will require multiple further rounds of mass drug administration. Bangladesh, Malaysia, Thailand and Vietnam appear close to having eliminated LF, whilst Cambodia has already achieved elimination status. We estimate that the burden of morbidity is likely high in Thailand; moderate in Cambodia, Myanmar, and Northeast India; and low in Bangladesh. There was insufficient evidence to accurately estimate the disease burden in Lao PDR, Malaysia or Vietnam. The results of this study indicate that whilst considerable progress toward LF elimination has been made, there remains a significant filariasis burden in the region. The results of this study will assist policy makers to advocate and budget for future control programs.

Lymphatic filariasis is widely endemic in Myanmar. Despite the establishment of an elimination program in 2000, knowledge of the remaining burden of disease relies predominantly on programmatic information. To assist the program, we conducted an independent cross-sectional household cluster survey to determine the prevalence of filariasis infection, morbidity and mass-drug administration coverage in four townships of the Mandalay Region: Amarapura, Patheingyi, Tada-U and Wundwin. The survey included 1014 individuals from 430 randomly selected households in 24 villages. Household members one year and older were assessed for antigenaemia using immunochromatographic test cards and if positive, microfilaraemia by night-time thick blood smear. Participants 15 years and older were assessed for filariasis morbidity by ultrasound-assisted clinical examination. The overall prevalence of infection was 2.63% by antigenaemia (95% confidence interval (CI) 1.71–4.04%) and 1.03% by microfilaraemia (95%CI 0.59–1.47%). The prevalence of hydrocoele in adult males was 2.78% (95%CI 1.23–6.15%) and of lymphoedema in both genders was 0% (95%CI 0–0.45%). These results indicate the persistence of filarial infection and transmission despite six rounds of annual mass drug administration and highlight the need for further rounds as well as the implementation of morbidity management programs in the country. Lymphatic filariasis (LF) is a mosquito-transmitted worm infection that causes chronic and progressive swelling of the limbs (lymphoedema) and testis (hydrocoele). Over time this swelling results in significant disfigurement and disability for sufferers. In 2000, Myanmar commenced a National Program to Eliminate LF through the annual mass drug administration (MDA) of two de-worming medications: albendazole and diethylcarbamazine to all endemic districts. However there remains little reliable information on how well the elimination program is working, and how large the burden of disease is in the country. This study assessed the prevalence of LF and participation in the MDA program in 24 villages across four townships of Mandalay Region in central Myanmar. The study found ongoing filarial infection suggesting that the six rounds of MDA had not been sufficient to stop LF transmission in the area. It also identified a substantial burden of hydrocoele but no cases of lymphoedema. These results suggest that further rounds of effective MDA are required to halt LF transmission and highlight the urgent need for morbidity management programs in the country.

Background: Myanmar commenced a lymphatic filariasis (LF) elimination programme in 2000. Whilst the country has made considerable progress since then, a number of districts have demonstrated persistent transmission after many rounds of mass drug administration (MDA). The causes of unsuccessful MDA have been examined elsewhere; however, there remains little information on the factors that contribute in Myanmar. Methods: We conducted an analysis of factors associated with persistent infection, LF-related hydrocoele and MDA participation in an area with ongoing transmission in 2015. A cross-sectional household survey was undertaken in 24 villages across four townships of Mandalay Region. Participants were screened for circulating filarial antigen (CFA) using immunochromatographic tests and, if positive, for microfilaria by night-time thick blood slide. Individuals 15 year and older were assessed for filariasis morbidity (lymphoedema and, if male, hydrocoele) by ultrasound-assisted clinical examination. A pre-coded questionnaire was used to assess risk factors for LF and for non-participation (never taking MDA). Significant variables identified in univariate analyses were included in separate step-wise multivariate logistic regressions for each outcome. Results: After adjustment for covariates and survey design, being CFA positive was significantly associated with age [odds ratio (OR) 1.03, 95% CI 1.01–1.06), per year], male gender (OR 3.14, 1.27–7.76), elevation (OR 0.96, 0.94–0.99, per metre) and the density of people per household room (OR 1.59, 1.31–1.92). LF-related hydrocoele was associated with age (OR 1.06, 1.03–1.09, per year) and residing in Amarapura Township (OR 8.93, 1.37–58.32). Never taking MDA was associated with male gender [OR 6.89 (2.13–22.28)] and age, particularly in females, with a significant interaction term. Overall, compared to those aged 30–44 years, the proportion never taking MDA was higher in all age groups (OR highest in those < 5 years and > 60 years, ranging from 3.37 to 12.82). Never taking MDA was also associated with residing in Amarapura township (OR 2.48, 1.15–5.31), moving to one’s current village from another (OR 2.62, 1.12–6.11) and ever having declined medication (OR 11.82, 4.25–32.91). Decreased likelihood of never taking MDA was associated with a higher proportion of household members being present during the last MDA round (OR 0.16, 0.03–0.74) and the number visits by the MDA programme (OR 0.69, 0.48–1.00). Conclusions: These results contribute to the understanding of LF and MDA participation-related risk factors and will assist Myanmar to improve its elimination and morbidity management programmes. Graphical

The elimination of lymphatic filariasis (LF) is achieved through repeated mass drug administration (MDA) of anti-filarial medications, which interrupts transmission and prevents new infections. Accurate transmission assessments are critical to deciding when to stop MDA. Current methods for evaluating transmission may be insufficiently sensitive, resulting in post-MDA resurgence. We, therefore, evaluated potential diagnostic testing scenarios for post-MDA surveillance. Data were used from two surveys (a household cluster and a cohort) conducted in an area of Mandalay Region, Myanmar, with ongoing transmission following several rounds of MDA. First, age- and sex-adjusted seroprevalence were estimated for the area using the household survey. Next, three Bayesian networks were built from the combined datasets to compare antigens by immunochromatic testing (ICT) and/or Og4C3 enzyme-linked immunosorbent assay (ELISA) and antibody (Ab) detection methods (Wb123 or Bm14 Ab ELISA). The networks were checked for validity and then used to compare diagnostic testing scenarios. The adjusted prevalence from the household survey for antigen, Wb123 Ab and Bm14 Ab were 4.4% (95% CI 2.6–7.3%), 8.7% (5.96–12.5%) and 20.8% (16.0–26.6%), respectively. For the three networks, the True Skill Statistic and Area Under the Receiver Operating Characteristic Curve for antigen, Wb123 and Bm14 Ab were 0.79, 0.68 and 0.55; and 0.97, 0.92 and 0.80, respectively. In the Bayesian network analysis, a positive case was defined as testing positive to one or more infection markers. A missed result was therefore the probability of a positive case having a negative test result to an alternate marker. The probability of a positive case prior to any testing scenario was 17.4%, 16.8% and 26.6% for antigen, Wb123 Ab and Bm14 Ab, respectively. In the antigen-only testing scenario, the probability of a missed positive LF result was 5.2% for Wb123 and 15.6% for Bm14 Ab. The combination of antigen plus Bm14 Ab testing reduced the probability of missing a positive LF case as measured by Wb123 Ab to 0.88%. The combination of antigen plus Wb123 Ab was less successful and yielded an 11.5% probability of a missed positive result by Bm14 Ab testing. Across scenarios, there was a greater discordance between Bm14 and both antigen and Wb123 Ab in the 1–10 age group compared to older ages. These findings suggest that the addition of Bm14 Ab improves the sensitivity of LF testing for current or past infection. The combination of antigen plus Bm14 Ab should therefore be considered for inclusion in post-MDA surveillance to improve the sensitivity of transmission surveys and prevent the premature cessation of MDA.

Antimicrobial resistance increasingly impacts paediatric mortality, particularly in resource-constrained settings. We aimed to evaluate the susceptibility profiles of bacteria causing infections in children from the Western Pacific region. We conducted a systematic review and meta-analysis of bacteria responsible for common infections in children. We included studies published from January 2011 to December 2023 (PROSPERO CRD42021248722). Pooled susceptibilities were evaluated against empiric antibiotics recommended to treat common clinical syndromes. Fifty-one papers met inclusion criteria, incorporating 18,330 bacterial isolates. Of available published data, only six countries from the region were represented. Escherichia coli revealed a pooled susceptibility to ampicillin of 17% (95% CI 12-23%, n = 3292), gentamicin 63% (95% CI 59-67%, n = 3956), and third-generation cephalosporins 59% (95% CI 49-69%, n = 3585). Susceptibility of Klebsiella spp. to gentamicin was 71% (95% CI 61-80%, n = 2323), third-generation cephalosporins 35% (95% CI 22-49%, n = 2076), and carbapenems 89% (95% CI 78-97%, n = 2080). Pooled susceptibility of Staphylococcus aureus to flucloxacillin was 72% (95% CI 58-83%, n = 1666), and susceptibility of Streptococcus pneumoniae meningitis isolates to ampicillin was 26% (95% CI 11-44%, n = 375), and 63% (95% CI 40-84%, n = 246) to third-generation cephalosporins. The burden of antimicrobial resistance among bacteria responsible for common infections in children across the Western Pacific region is significant, and the currently recommended World Health Organization antibiotics to treat these infections may be inefficacious. Strategies to improve the availability of high-quality data to understand the burden of antimicrobial resistance in the region are necessary. The study was supported by an Australian GovernmentNational Health and Medical Research Council Investigator Grant. This research was funded in part by the Wellcome Trust [220211/Z/20/Z]. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

Background: Myanmar commenced a lymphatic filariasis (LF) elimination program in 2000. Whilst the country has made considerable progress since then, a number of districts have demonstrated persistent transmission after many rounds of mass drug administration (MDA). The causes of unsuccessful MDA have been examined elsewhere, however, there remains little information on the factors that contribute in Myanmar. Methods: We conducted an analysis of factors associated with persistent infection, LF-related hydrocoele and MDA participation in an area with ongoing transmission in 2015. A cross-sectional household survey was undertaken in 24 villages across four townships of Mandalay Region. Participants were screened for circulating filarial antigen (CFA) using immunochromatographic tests and if positive, for microfilaria by night-time thick blood slide. Individuals 15 year and older were assessed for filariasis morbidity (lymphoedema and if male, hydrocoele) by ultrasound-assisted clinical examination. A pre-coded questionnaire was used to assess risk factors for LF and for never-taking MDA. Significant variables identified in univariate analyses were included in separate step-wise multivariate logistic regressions for each outcome. Results: After adjustment for covariates and survey design, being CFA positive was significantly associated with age (odds ratio (OR) 1.03, 95% CI 1.01 – 1.06), per year), male gender (OR 3.11, 1.23 – 7.87), elevation (OR 0.97, 0.94 – 1.00, per metre) and the density of people per household room (OR 1.56, 1.26 – 1.93). LF-related hydrocoele was associated with age (OR 1.06, 1.02 – 1.09, per year) and residing in Amarapura Township (OR 8.56, 1.33 – 55.22). Never-taking MDA was associated with age (less than 15 years: OR 2.89, 1.11 – 7.51; greater than 60 years: OR 4.00, 1.53 – 10.48), male gender (OR 1.85, 1.05 – 3.25), residing in Amarapura township (OR 2.99, 1.39 – 6.43), moving to one’s current village from another (OR 2.84, 1.15 – 7.02) and ever having declined medication (OR 13.76, 4.79 – 39.58). Decreased likelihood of never taking MDA was associated with a higher proportion of household members being present during the last MDA round (OR 0.18, 0.04 – 0.96)).Conclusions: These results contribute to the understanding of LF and MDA participation related risk factors, and will assist Myanmar improve its elimination and morbidity management programs.