The emergence and spread of drug resistance is a problem hindering malaria elimination in Southeast Asia. In this study, genetic variations in drug resistance markers of Plasmodium falciparum were determined in parasites from asymptomatic populations located in three geographically dispersed townships of Myanmar by PCR and sequencing. Mutations in dihydrofolate reductase (pfdhfr), dihydropteroate synthase (pfdhps), chloroquine resistance transporter (pfcrt), multidrug resistance protein 1 (pfmdr1), multidrug resistance-associated protein 1 (pfmrp1), and Kelch protein 13 (k13) were present in 92.3%, 97.6%, 84.0%, 98.8%, and 68.3% of the parasites, respectively. The pfcrt K76T, pfmdr1 N86Y, pfmdr1 I185K, and pfmrp1 I876V mutations were present in 82.7%, 2.5%, 87.5%, and 59.8% isolates, respectively. The most prevalent haplotypes for pfdhfr, pfdhps, pfcrt and pfmdr1 were 51I/59R/108N/164L, 436A/437G/540E/581A, 74I/75E/76T/220S/271E/326N/356T/371I, and 86N/130E/184Y/185K/1225V, respectively. In addition, 57 isolates had three different point mutations (K191T, F446I, and P574L) and three types of N-terminal insertions (N, NN, NNN) in the k13 gene. In total, 43 distinct haplotypes potentially associated with multidrug resistance were identified. These findings demonstrate a high prevalence of multidrug-resistant P. falciparum in asymptomatic infections from diverse townships in Myanmar, emphasizing the importance of targeting asymptomatic infections to prevent the spread of drug-resistant P. falciparum.

Background: Interventions to raise community awareness about malaria prevention and treatment have used various approaches with little evidence on their efficacy. This study aimed to determine the effectiveness of loudspeaker announcements regarding malaria care and prevention practices among people living in the malaria endemic villages of Banmauk Township, Sagaing Region, Myanmar.Methods: Four villages among the most malaria-burdened areas were randomly selected: two villages were assigned as the intervention group, and two as the control. Prior to the peak transmission season of malaria in June 2018, a baseline questionnaire was administered to 270 participants from randomly selected households in the control and intervention villages. The loudspeaker announcements broadcasted health messages on malaria care and prevention practices regularly at 7:00 pm every other day. The same questionnaire was administered at 6-month post intervention to both groups. Descriptive statistics, Chi-square, and the t-test were utilized to assess differences between and within groups.Results: Participants across the control and intervention groups showed similar socio-economic characteristics; the baseline knowledge, attitude and practice mean scores were not significantly different between the groups. Six months after the intervention, improvements in scores were observed atp-value < 0.001 in both groups, however; the increase was greater among the intervention group. The declining trend of malaria was also noticed during the study period. In addition, more than 75% of people expressed positive opinions of the intervention.Conclusions: The loudspeaker intervention was found to be feasible and effective, as shown by the significant improvement in scores related to prevention and care-seeking practices for malaria as well as reduced malaria morbidity. Expanding the intervention to a larger population in this endemic region and evaluating its long-term effectiveness are essential in addition to replicating this in other low-resource malaria endemic regions.

Purpose: Malaria still remains a significant public health problem in Myanmar and it has a complex epidemiology. Evidence-based community awareness raising interventions are also particularly needed. This cross-sectional study was organized to explore the basic characteristics associated with knowledge, attitude and practice (KAP) regarding malaria among people living in the most malaria-endemic villages of the Banmauk Township, Sagaing Region, Myanmar. The paper aims to discuss these issues.Design/methodology/approach: The Banmauk, one of the most malaria-endemic townships, was selected purposively in order to represent the survey results for people living in malaria hotspots. During the peak malaria season (July 2018), 250 household leaders were invited to be interviewed with structured questionnaires. In addition to descriptive data, the associations were determined byχ²-test and correlation.Findings: Overall KAP indicated considerably low percentages of good levels, especially in practice, only 21.6 percent showed good practice, 38.4 percent had good knowledge and 56.8 percent had good attitude. Age (p=0.022) and annual family income (p<0.001) were significantly associated with the knowledge level, whereas having fever attacks among family members in the last two weeks (p=0.023) showed statistical association with attitude at ap-value <0.05. Surprisingly, there were no associated variables with malaria practice. In addition, there were negative correlations between knowledge with attitude and knowledge with practice; however, the results were not significant.Originality/value: The overall KAP regarding malaria was at relatively poor levels among people living in malaria transmission areas. Therefore, new approaches to improve malaria KAP are promptly needed in this community.

The malaria burden of Myanmar still remains high within the Greater Mekong Subregion of Southeast Asia. An important indicator of progress towards malaria elimination is the prevalence of parasite infections in endemic populations. Information about malaria epidemiology is mostly derived from reports of confirmed acute malaria cases through passive case detection, whereas the prevalence of baseline subclinical malaria infections is much less known. In this study, cross-sectional surveys were conducted during the rainy season of 2017 in four townships (Bilin, Thabeikkyin, Banmauk and Paletwa) of Myanmar with divergent annual malaria incidences. A total of 1991 volunteers were recruited from local villages and Plasmodium subclinical infections were estimated by light microscopy (LM), rapid diagnostic tests (RDTs) and nested PCR. The nested PCR analysis was performed with a modified pooling strategy that was optimized based on an initial estimate the infection prevalence. The overall malaria infection prevalence based on all methods was 13.9% (277/1991) and it differed drastically among the townships, with Paletwa in the western border having the highest infection rate (22.9%) and Thabeikkyin in central Myanmar having the lowest (3.9%). As expected, nested PCR was the most sensitive and identified 226 (11.4%) individuals with parasite infections. Among the parasite species, Plasmodium vivax was the most prevalent in all locations, while Plasmodium falciparum also accounted for 32% of infections in the western township Paletwa. Two RDTs based on the detection of the hrp2 antigen detected a total of 103 P. falciparum infections, and the ultrasensitive RDT detected 20% more P. falciparum infections than the conventional RDT. In contrast, LM missed the majority of the subclinical infections and only identified 14 Plasmodium infections. Cross-sectional surveys identified considerable levels of asymptomatic Plasmodium infections in endemic populations of Myanmar with P. vivax becoming the predominant parasite species. Geographical heterogeneity of subclinical infections calls for active surveillance of parasite infections in endemic areas. The pooling scheme designed for nested PCR analysis offers a more practical strategy for large-scale epidemiological studies of parasite prevalence. Such information is important for decision-makers to put forward a more realistic action plan for malaria elimination.

Background: In the Greater Mekong sub-region, Plasmodium vivax has become the predominant species and imposes a major challenge for regional malaria elimination. This study aimed to investigate the variations in genes potentially related to drug resistance in P. vivax populations from the China–Myanmar border area. In addition, this study also wanted to determine whether divergence existed between parasite populations associated with asymptomatic and acute infections. Methods: A total of 66 P. vivax isolates were obtained from patients with acute malaria who attended clinics at the Laiza area, Kachin State, Myanmar in 2015. In addition, 102 P. vivax isolates associated with asymptomatic infections were identified by screening of volunteers without signs or symptoms from surrounding villages. Slide-positive samples were verified with nested PCR detecting the 18S rRNA gene. Multiclonal infections were further excluded by genotyping at msp-3α and msp-3β genes. Parasite DNA from 60 symptomatic cases and 81 asymptomatic infections was used to amplify and sequence genes potentially associated with drug resistance, including pvmdr1, pvcrt-o, pvdhfr, pvdhps, and pvk12. Results: The pvmdr1 Y976F and F1076L mutations were present in 3/113 (2.7%) and 97/113 (85.5%) P. vivax isolates, respectively. The K10 insertion in pvcrt-o gene was found in 28.2% of the parasites. Four mutations in the two antifolate resistance genes reached relatively high levels of prevalence: pvdhfr S58R (53.4%), S117N/T (50.8%), pvdhps A383G (75.0%), and A553G (36.3%). Haplotypes with wild-type pvmdr1 (976Y/997K/1076F) and quadruple mutations in pvdhfr (13I/57L/58R/61M/99H/117T/173I) were significantly more prevalent in symptomatic than asymptomatic infections, whereas the pvmdr1 mutant haplotype 976Y/997K/1076L was significantly more prevalent in asymptomatic than symptomatic infections. In addition, quadruple mutations at codons 57, 58, 61 and 117 of pvdhfr and double mutations at codons 383 and 553 of pvdhps were found both in asymptomatic and symptomatic infections with similar frequencies. No mutations were found in the pvk12 gene. Conclusions: Mutations in pvdhfr and pvdhps were prevalent in both symptomatic and asymptomatic P. vivax infections, suggestive of resistance to antifolate drugs. Asymptomatic carriers may act as a silent reservoir sustaining drug-resistant parasite transmission necessitating a rational strategy for malaria elimination in this region.

Background: While national malaria incidence has been declining in Myanmar, some subregions within the nation continue to have high burdens of malaria morbidity and mortality. This study assessed the malaria situation in one of these regions, Banmauk Township, located near the Myanmar-India border. Our goal was to provide a detailed description of the malaria epidemiology in this township and to provide some evidence-based recommendations to formulate a strategy for reaching the national malaria elimination plan. Banmauk consistently has one of the highest malaria burdens in Myanmar.Methods: With the implementation of strengthened malaria control and surveillance activities after the endorsement of a national malaria elimination plan in 2015, detailed incidence data were obtained for 2016–2018 for Banmauk Township. The data include patient demographics, parasite species, disease severity, and disease outcome. Data were analyzed to identify characteristics, trends, distribution, and risk factors.Results: During 2016–2018, 2,402 malaria cases were reported, withPlasmodium falciparumaccounting for 83.4% of infections. BothP. falciparumandP. vivaxwere transmitted more frequently during the rainy season (May–October). Despite intensified control, the annual parasite incidence rate (API) in 2017 (11.0) almost doubled that in 2016 (6.5). In total, 2.5% (59/2042) of the cases, of which 54P. falciparumand 5P. vivax, were complicated cases, resulting in 5 deaths. Malaria morbidity was high in children < 15 years and accounted for 33.4% of all cases and about 47% of the complicated cases. Older age groups and males living with poor transportation conditions were more likely to test positive especially in rainy and cold seasons. Despite the clear seasonality of malaria, severe cases were found among young children even more common in the dry season, when malaria incidence was low.Conclusions: Despite the declining trend, the malaria burden remained high in Banmauk Township. Our study also documented severe cases and deaths from both falciparum and vivax malaria.P. falciparumremained the predominant parasite species, demanding increased efforts to achieve the goal of elimination ofP. falciparumby 2025. AsP. falciparumcases decreased, the proportion of cases attributable toP. vivaxincreased. In order to eliminate malaria, it will likely be important to increasingly target this species as well.