Myanmar-Thailand Border Research Articles

Space-based optical imaging of blue corona discharges on a cumulonimbus cloud top

The ILAN-ES (Imaging of Lightning And Nocturnal Emissions from Space) experiment was conducted in April 2022 as part of the Axiom company AX-1 private mission to the International Space Station, in the framework of Rakia, an Israeli set of experiments selected for flight by the Ramon Foundation and the Israeli Space Agency. The mission objective was to record transient luminous events from the Cupola window in the ISS, based on preliminary thunderstorm forecasts uploaded to the crew 24–36 h in advance. A Nikon D6 camera with a 50 mm lens was used, in a video mode of 60 fps. During the 12-day mission, 82 different targets were identified for the ISS, of which 20 were imaged by the astronauts, yielding a total harvest >80 TLEs: sprites, Elves and BLUEs (blue corona discharges). We report here on opportune nadir observation of a thunderstorm that produced multiple blue events near the Myanmar-Thailand border on April 21st, 2022, at 21:30 UT. The storm produced many visible blue discharges of varying sizes and durations, in diameters ranging from hundreds of meters to a few km2. The emissions were mostly in blue, however the brightest events had also a conspicuous broadband red component. We used meteorological and ENTLN lightning data to establish the relationship between lightning type and the observable properties of the blue corona discharges.

Myanmar migrants living along the Thailand-Myanmar border: Experiences related to pandemic and migration decisions

ImportanceIn Myanmar, amid political and civil unrest, droves of Burmese are displaced to neighboring countries including Thailand. Since the COVID-19 pandemic, little is known about the available healthcare services and health and well-being among refugees and migrant workers within resettlement areas along the Myanmar-Thailand border. ObjectiveTo explore the unmet needs of migrants along the Thailand-Myanmar border during the COVID-19 pandemic and their reasons for leaving Myanmar. DesignA qualitative study that used focus groups with migrant schoolteachers and school masters was undertaken. An interpretative analysis approach was used to analyze the data from the focus group sessions. The study followed the COREQ (COnsolidated criteria for REporting Qualitative) checklist. SettingIn July 2022, community stakeholders from migrant schools located in the vicinity of Mae Sot, Thailand were referred to the study team. ParticipantsA purposive sample of 17 adult participants was recruited from 4 migrant schools. The participants were schoolteachers and schoolmasters who had traveled from Myanmar to Thailand 1 to 20 years ago. Main Outcome(s) and Measure(s)Thematic analysis was used to scrutinize qualitative data for the outcomes of health and well-being, barriers, and reasons for migration. ResultsThree main themes were identified: “issues related to the pandemic”, “teenage marriage and pregnancies” and "migration decisions". The issues related to the pandemic included behavior changes in children, a diminished quality of education, and barriers to receiving COVID-19 vaccines and accessing other health care. There were more dropouts due to teenage pregnancy/marriage during the shelter in place mandate. Migration decisions were affected by concerns over health, civil unrest, and military harassment. Conclusions and RelevanceThis study presented the difficulties experienced by Myanmar migrants currently living along the Thailand-Myanmar border. The reasons for leaving Myanmar included health and safety. Suspending education during the pandemic caused more school dropouts due to teenage pregnancy/marriage. Additionally, behavioral changes in children, a diminished quality of education, barriers to receiving COVID-19 vaccines and access to other health care services were reported. Future studies should focus on how migration stress and access to mental health care impact the migrant population.

Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border.

Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC). This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care. From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting. This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.

Impacts of biomass burning in Southeast Asia on aerosols over the low-latitude plateau in China: An analysis of a typical pollution event

From March to April, widespread forest fires and agro-residue burning frequently occur in Southeast Asia, which release large amounts of gas species and aerosols and impact air quality over the wide source and downwind regions. In this study, we investigated the impact of biomass burning (BB) over Southeast Asia on particulate matter concentrations and aerosol properties in downwind areas of the low-latitude plateau from 1 March to 30 April 2019, with a focus on a typical pollution event in Kunming (KM), the capital of Yunnan Province, by using a wide variety of observations from the Chenggong ground monitoring station in Yunnan University, an air quality network in China, satellite retrievals and ERA-5 reanalysis data and numerical simulation. A regional pollution event contributed by BB pollutants from Southeast Asia and the India-Myanmar trough occurred in Yunnan Province on 31 March to 1 April 2019, which was the only typical pollution event that pollution transmission ran through central Yunnan Province from south to north since 2013, when the Airborne Pollution Action Plan was unveiled by China government. The daily mean PM2.5, PM1, and black carbon concentrations increased by 73.3 μg m−3(78%), 70.5 μg m−3 (80%), and 7.7 μg m−3 (83%), respectively, and the scattering and absorbing coefficients increased by 471.6 Mm−1 and 63.5 Mm−1, respectively, at the Chenggong station. The southwest winds exceeding 2 km vertically thick appeared in front of the India-Myanmar trough over the fire regions, pushing BB plumes northward into Yunnan Province. The model results show that 59.5% of PM2.5 mass produced by BB in Yunnan Province was sourced from the Myanmar-Thailand border, and 29.3% was from western Myanmar at a lower altitude (<4.9 km), which indicated that BB in the Myanmar-Thailand border was the dominant contributor.

COVID lockdown and malaria incidence: A note from the tropical endemic area

Dear Editor, Malaria is an important mosquito-borne infection. The pathogenic Plasmodium parasite is the causative agent of malaria and it is presently seen at many tropical countries around the world. In tropical Asia, the disease is highly prevalent and there is an extremely high prevalence of drug-resistant malaria along Myanmar–Thailand border area.[1] Children are an important group affected by malaria.[1] At the border area, the school children are the main group that gets malaria and it can affect school performance, therefore, many school-based malaria control programs have been implemented.[2] Due to the present emerging COVID-19 crisis, the impact on malaria control is an interesting issue.[3] The interruption of the malaria control program during the COVID-19 pandemic is possible.[4] Here, the author would like to share the local data from the area that there is a co-endemicity between COVID-19 and malaria in Indochina. This area is the local rural province locating at Thailand–Myanmar border. The most updated data on June 2020 showed that there are already 9 COVID-19 cases and 265 malaria cases in this remote forestry area in 2020. All of the pediatric patients are school students and the primary presentation of all cases is high fever. In the country, COVID-19 started in January 2020 and the lockdown started in March 2020. The data on the incidence of COVID-19 and malaria in this area before and after the COVID-19 lockdown are presented in Table 1. Based on this data, the COVID-19 lockdown, that includes school closure, transportation blockage, and international border closure, can effectively reduce the incidence of COVID-19 in this malaria-endemic area. However, after the lockdown, the incidence of malaria significantly increases.Table 1: The incidence of COVID-19 and malariaIn fact, although the study area is a forestry area with high malaria prevalence, the problem of COVID-19 can still be seen. In fact, the rural forestry area does not guarantee for absence of COVID -19 cases and disease might be imported by outside.[5] The blockage of transportation and school closure seems to effectively control COVID-19. However, the lockdown does not have a positive control effect on malaria. Indeed, the difficulty in malaria control due to the COVID-19 lockdown is proposed and the present observation is good clinical evidence to support that hypothesis.[4] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Cross-sectional study of nutritional intake among patients undergoing tuberculosis treatment along the Myanmar–Thailand border

ObjectiveThis study summarises nutritional intake among patients with tuberculosis (TB) along the Myanmar–Thailand border according to the local diet.SettingTB clinic along the Myanmar–Thailand border.ParticipantsCross-sectional surveys of 24-hour food recall were...

Human movement patterns of farmers and forest workers from the Thailand-Myanmar border

Background: Human travel patterns play an important role in infectious disease epidemiology and ecology. Movement into geographic spaces with high transmission can lead to increased risk of acquiring infections. Pathogens can also be distributed across the landscape via human travel. Most fine scale studies of human travel patterns have been done in urban settings in wealthy nations. Research into human travel patterns in rural areas of low- and middle-income nations are useful for understanding the human components of epidemiological systems for malaria or other diseases of the rural poor. The goal of this research was to assess the feasibility of using GPS loggers to empirically measure human travel patterns in this setting, as well as to quantify differing travel patterns by age, gender, and seasonality. Methods: In this pilot study we recruited 50 rural villagers from along the Myanmar-Thailand border to carry GPS loggers for the duration of a year. The GPS loggers were programmed to take a time-stamped reading every 30 minutes. We calculated daily movement ranges and multi-day trips by age and gender. We incorporated remote sensing data to assess patterns of days and nights spent in forested or farm areas, also by age and gender. Results: Our study showed that it is feasible to use GPS devices to measure travel patterns, though we had difficulty recruiting women and management of the project was relatively intensive. We found that older adults traveled farther distances than younger adults and adult males spent more nights in farms or forests. Conclusion: The results of this study suggest that further work along these lines would be feasible in this region. Furthermore, the results from this study are useful for individual-based models of disease transmission and land use.

Short maternal stature and gestational weight gain among refugee and migrant women birthing appropriate for gestational age term newborns: a retrospective cohort on the Myanmar-Thailand border, 2004–2016

IntroductionTo examine the interactions between short maternal stature, body mass index (BMI) and gestational weight gain (GWG) among appropriate for gestational age (AGA) term newborns in a population of refugees...

Geno-Spatial Distribution of Mycobacterium Tuberculosis and Drug Resistance Profiles in Myanmar-Thai Border Area.

Worldwide, studies investigating the relationship between the lineage of Mycobacterium tuberculosis (MTB) across geographic areas has empowered the “End TB” program and understand transmission across national boundaries. Genomic diversity of MTB varies with geographical locations and ethnicity. Genomic diversity can also affect the emergence of drug resistance. In Myanmar, we still have limited genetic information about geographical, ethnicity, and drug resistance linkage to MTB genetic information. This study aimed to describe the geno-spatial distribution of MTB and drug resistance profiles in Myanmar–Thailand border areas. A cross-sectional study was conducted with a total of 109 sequenced isolates. The lineages of MTB and the potential associated socio-demographic, geographic and clinical factors were analyzed using Fisher’s exact tests. p value of statistically significance was set at < 0.05. We found that 67% of the isolates were lineage 1 (L1)/East-African-Indian (EAI) (n = 73), followed by lineage 2 (L2)/Beijing (n = 26), lineage 4 (L4)/European American (n = 6) and lineage 3 (L3)/Delhi/Central Asian (n = 4). “Gender”, “type of TB patient”, “sputum smear grading” and “streptomycin resistance” were significantly different with the lineages of MTB. Sublineages of L1, which had never been reported elsewhere in Myanmar, were detected in this study area. Moreover, both ethnicity and lineage of MTB significantly differed in distribution by patient location. Diversity of the lineage of MTB and detection of new sublineages suggested that this small area had been resided by a heterogeneous population group who actively transmitted the disease. This information on distribution of lineage of MTB can be linked in the future with those on the other side of the border to evaluate cross-border transmission.

The Reality and Dilemmas of Voluntary Repatriation: A Case Study of the Refugees in the Myanmar-Thailand Border Areas

The Reality and Dilemmas of Voluntary Repatriation: A Case Study of the Refugees in the Myanmar-Thailand Border Areas

"I can't read and don't understand": Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border.

Health literacy is increasingly recognized as an important determinant of health outcomes, but definition, measurement tools, and interventions are lacking. Conceptual frameworks must include both individual and health-systems domains which, in combination, determine an individual’s health literacy. Validated tools lack applicability in marginalized populations with very low educational levels, such as migrant worker communities on the Myanmar-Thailand border. We undertake a comprehensive health literacy assessment following a case study of a recent public health campaign promoting preconceptual folic acid uptake in this community. A mixed-methods design utilized quantitative analysis of the prevalence and predictors of low Health literacy, and focus group discussions to gather qualitative data from women about proposed and actual posters used in the campaign. Health literacy was measured with a locally developed tool that has been used in surveys of the population since 1995. Health literacy was low, with 194/525 (37.0%) of tested women demonstrating adequate health literacy, despite 63.1% (331/525) self-reporting being literate. Only one third of women had completed 4th grade or above and reported grade level attained in school was more predictive of health literacy than self-reported literacy. Focus group discussions revealed that low literacy, preconceived associations, and traditional health beliefs (individual domain) interacted with complex images, subtle concepts, and taboo images on posters (health-systems domain) to cause widespread misunderstandings of the visuals used in the campaign. The final poster still required explanation for clarity. Low health literacy is prevalent among pregnant women from this migrant community and barriers to communication are significant and complex. Public health posters need piloting prior to implementation as unanticipated misperceptions are common and difficult to overcome. Verbal communication remains a key method of messaging with individuals of low health literacy and educational system strengthening and audiovisual messaging are critical for improvement of health outcomes.

Maternal Hepatitis B Infection Burden, Comorbidity and Pregnancy Outcome in a Low-Income Population on the Myanmar-Thailand Border: A Retrospective Cohort Study.

Objectives Hepatitis B virus (HBV) was believed to have minimal impact on pregnancy outcomes apart from the risk of perinatal transmission. In more recent years, there have been reports of adverse associations, most consistently preterm birth (PTB), but this is in the context of high rates of caesarean section. The aim of this study was to explore the association of HBV on pregnancy outcomes in marginalized, low-income populations on the Myanmar-Thailand border. Methods HBsAg positive (+) point of care rapid detection tests results were confirmed by immunoassays. Women with a confirmed HBsAg status, HIV- and syphilis-negative at first antenatal care screening, singleton fetus and known pregnancy outcome (Aug-2012 to Dec-2016) were included. Logistic regression analysis was used to evaluate associations between HBV group (controls HBsAg negative, HBsAg+/HBeAg-, or HBsAg+/HBeAg+) and pregnancy outcome and comorbidity. Results Most women were tested, 15,046/15,114 (99.6%) for HBV. The inclusion criteria were not met for 4,089/15,046 (27.2%) women due mainly to unavailability of pregnancy outcome and nonconfirmation of HBsAg+. In evaluable women 687/11,025 (6.2%) were HBsAg+, with 476/11,025 (4.3%) HBsAg+/HBeAg- and 211/11,025 (1.9%) were HBsAg+/HBeAg+. The caesarean section rate was low at 522/8,963 (5.8%). No significant associations were observed between pregnancy comorbidities or adverse pregnancy outcomes and HBV status. Conclusions The results highlight the disease burden of HBV in women on the Myanmar-Thailand border and support original reports of a lack of significant associations with HBsAg+ irrespective of HBeAg status, for comorbidity, and pregnancy outcomes in deliveries supervised by skilled birth attendants.

Networks of Resilience: Legal Precarity and Transborder Citizenship among the Karen from Myanmar in Thailand

AbstractThis study probes the relationship between legal precarity and transborder citizenship through the case of the Karen from Myanmar in Thailand. Collected through ethnographic multi-sited fieldwork between 2012 and 2016, interconnected individual life stories evolving across the Myanmar-Thailand border allow the critical interrogation of the political and legal categories of ‘migrancy’, ‘refugeeness’, and ‘citizenship’, teasing out their blurry boundaries in migrants’ experience. Following the recent critical research in legal ethnography, this study demonstrates that legal precarity is not simply an antithesis to citizenship. The social and legal dimensions of citizenship may diverge, creating in-between areas of not-yet-full-citizenship with varying levels of heft (Macklin 2007). The article consists of three parts. First, it offers a theoretical framework to reconcile the Karen legal precarity (even de facto statelessness) and citizenship, even on both sides of the border (legally impossible). Second, it presents the three groups of Karen in Thailand, produced by the interaction of three major waves of Karen eastward migration and tightening Thai citizenship and migration regulations: Thai Karen, refugees, and migrant workers. All three face varying levels of legal precarity of temporary status without full citizenship. However, the last part demonstrates the intertwined nature of those groups. A grassroots transborder perspective reveals the resilience of the Karen networks when pooling together resources of the hubs established on Thai soil by the three waves. Even the most recent arrivals in Thailand use those resources to move from one precarious legal status to another and even to clandestinely obtain citizenship.

Evaluation of a treatment protocol for anaemia in pregnancy nested in routine antenatal care in a limited-resource setting

ABSTRACTBackground: Anaemia in pregnancy is typically due to iron deficiency (IDA) but remains a complex and pervasive problem, particularly in low resource settings. At clinics on the Myanmar–Thailand border, a protocol was developed to guide treatment by health workers in antenatal care (ANC).Objective: To evaluate the clinical use of a protocol to treat anaemia in pregnancy.Methods: The design was a descriptive retrospective analysis of antenatal data obtained during the use of a standard anaemia treatment protocol. Two consecutive haematocrits (HCT) <30% prompted a change from routine prophylaxis to treatment doses of haematinics. Endpoints were anaemia at delivery (most recent HCT before delivery <30%) and timeliness of treatment initiation. Women whose HCT failed to respond to the treatment were investigated.Results: From August 2007 to July 2012, a median [IQR] of five [4–11] HCT measurements per woman resulted in the treatment of anaemia in 20.7% (2,246/10,886) of pregnancies. Anaemia at delivery was present in 22.8% (511/2,246) of treated women and 1.4% (123/8,640) who remained on prophylaxis. Human error resulted in a failure to start treatment in 97 anaemic women (4.1%, denominator 2,343 (2,246 + 97)). Fluctuation of HCT around the cut-point of 30% was the major problem with the protocol accounting for half of the cases where treatment was delayed greater than 4 weeks. Delay in treatment was associated with a 1.5 fold higher odds of anaemia at delivery (95% CI 1.18, 1.97).Conclusion: There was high compliance to the protocol by the health workers. An important outcome of this evaluation was that the clinical definition of anaemia was changed to diminish missed opportunities for initiating treatment. Reduction of anaemia in pregnancy requires early ANC attendance, prompt treatment at the first HCT <30%, and support for health workers.

Ancylostoma ceylanicum Hookworm in Myanmar Refugees, Thailand, 2012-2015.

During 2012-2015, US-bound refugees living in Myanmar-Thailand border camps (n = 1,839) were surveyed for hookworm infection and treatment response by using quantitative PCR. Samples were collected at 3 time points: after each of 2 treatments with albendazole and after resettlement in the United States. Baseline prevalence of Necator americanus hookworm was 25.4%, Ancylostoma duodenale 0%, and Ancylostoma ceylanicum (a zoonosis) 5.4%. Compared with N. americanus prevalence, A. ceylanicum hookworm prevalence peaked in younger age groups, and blood eosinophil concentrations during A. ceylanicum infection were higher than those for N. americanus infection. Female sex was associated with a lower risk for either hookworm infection. Cure rates after 1 dose of albendazole were greater for A. ceylanicum (93.3%) than N. americanus (65.9%) hookworm (p<0.001). Lower N. americanus hookworm cure rates were unrelated to β-tubulin single-nucleotide polymorphisms at codons 200 or 167. A. ceylanicum hookworm infection might be more common in humans than previously recognized.

Beyond the Refugee-Migrant Binary? Refugee Camp Residency Along the Myanmar-Thailand Border

Processes of mixed migration beyond the reified “refugee-migrant binary” of migration studies are an empirical reality along the Myanmar-Thailand border. Utilizing a survey of 3874 mobile individuals from Myanmar in Thailand as a case study, this paper examines the impact of past experiences of migrants on the likelihood that any one of them will reside inside a refugee camp instead of outside of one in Thailand. A dataset is constructed that specifically intersects “refugee” communities with “labor migrant” communities in order to measure the importance of factors of socioeconomic, self-identity, past persecution, and social network considerations. Though indicators like religion, ethnicity, and the fear to return are salient in the likelihood of living inside a camp, family location is the strongest single predictor variable for whether or not an individual from Myanmar will inhabit a refugee camp. Future research may benefit by researching across migrant communities normally considered disparate.

‘Because the baby asks for it’: a mixed-methods study on local perceptions toward nutrition during pregnancy among marginalised migrant women along the Myanmar–Thailand border

ABSTRACTBackground: Under- and over-nutrition during pregnancy are known risk factors for pregnancy complications and adverse pregnancy and infant outcomes. Understanding perceptions around nutrition in pregnancy can create culturally appropriate interventions for improved health outcomes.Objective: A mixed-methods study was performed to explore local perceptions and practices of diet and physical activity in pregnancy in a marginalised population along the Myanmar–Thailand border.Methods: From April to July 2017, a cross-sectional survey and focus group discussions were conducted with pregnant women reporting to antenatal care; in-depth interviews were conducted with senior midwives at participating organisations along the Myanmar–Thailand border.Results: A total of 388 pregnant women were interviewed at two clinic sites along the Myanmar–Thailand border. A high proportion of women had limited knowledge of and poor dietary practices. Consuming a sweetened drink in the last 24 hours as well as being a non-teenage, multigravida woman was significantly associated with high body mass index (BMI) compared to normal BMI. Qualitative analysis combined focus group discussions (n = 66) and in-depth interviews (n = 4) summarising emergent themes: common foods eaten or avoided and rationale; benefits of nutrition; perceptions of overweight and weight gain during pregnancy; barriers to a healthy diet; and sources of diet information.Conclusions: There is limited awareness about healthy diets and lifestyle in these marginalised, migrant communities along the Myanmar–Thailand border. This study suggests that simple, culturally appropriate messaging should be provided to women and communities with low health literacy to generate awareness about healthy lifestyles and their effects on pregnancy outcomes as an important element of a broader strategy to address maternal nutrition in this population. However, more studies to determine the effectiveness of a broad range of interventions in low- and middle-income countries (LMIC) are needed, especially in marginalised migrant populations.

Scale up of a Plasmodium falciparum elimination program and surveillance system in Kayin State, Myanmar.

Background: Myanmar has one of the largest malaria burdens in the Greater Mekong Subregion (GMS). Throughout the GMS, Plasmodium falciparum parasites are increasingly resistant to artemisinin combination therapies. Given that there are no current alternative treatment therapies, one proposed solution to the threat of untreatable P. falciparum malaria is to eliminate the parasite from the region. Several small-scale elimination projects have been piloted in the GMS, including along the Myanmar-Thailand border. Following the success of the pilot elimination project along the Myanmar-Thailand border, there was a scale up to a broad area of Eastern Kayin State, Myanmar. Here we describe the establishment of the scale up elimination project in Easter Kayin State. Methods: The scale up relied on geographic reconnaissance and a geographic information system, community engagement, generalized access to community-based early diagnosis and treatment, near real-time epidemiological surveillance, cross sectional malaria prevalence surveys and targeted mass drug administration in villages with high prevalence of P. falciparum malaria. Molecular markers of drug resistance were also monitored in individuals with symptomatic and asymptomatic infections. Discussion: This protocol illustrates the establishment of an elimination project and operational research in a remote, rural area encompassing several armed groups, multiple political organizations and a near-absent health care infrastructure. The establishment of the project relied on a strong rapport with the target community, on-the-ground knowledge (through geographic surveys and community engagement), rapid decision making and an approach that was flexible enough to quickly adapt to a complex landscape. The elimination project is ongoing, now over three years in operation, and assessment of the impact of this operational research will follow. This project has relevance not only for other malaria elimination projects but also for operational research aimed at eliminating other diseases.

Scale up of a Plasmodium falciparum elimination program and surveillance system in Kayin State, Myanmar

Background: Myanmar has one of the largest malaria burdens in the Greater Mekong Subregion (GMS). Throughout the GMS, Plasmodium falciparum parasites are increasingly resistant to artemisinin combination therapies. Given that there are no current alternative treatment therapies, one proposed solution to the threat of untreatable P. falciparum malaria is to eliminate the parasite from the region. Several small-scale elimination projects have been piloted in the GMS, including along the Myanmar-Thailand border. Following the success of the pilot elimination project along the Myanmar-Thailand border, there was a scale up to a broad area of Eastern Kayin State, Myanmar. Here we describe the establishment of the scale up elimination project in Easter Kayin State. Methods: The scale up relied on geographic reconnaissance and a geographic information system, community engagement, generalized access to community-based early diagnosis and treatment, near real-time epidemiological surveillance, cross sectional malaria prevalence surveys and targeted mass drug administration in villages with high prevalence of P. falciparum malaria. Molecular markers of drug resistance were also monitored in individuals with symptomatic and asymptomatic infections. Discussion: This protocol illustrates the establishment of an elimination project and operational research in a remote, rural area encompassing several armed groups, multiple political organizations and a near-absent health care infrastructure. The establishment of the project relied on a strong rapport with the target community, on-the-ground knowledge (through geographic surveys and community engagement), rapid decision making and an approach that was flexible enough to quickly adapt to a complex landscape. The elimination project is ongoing, now over three years in operation, and assessment of the impact of this operational research will follow. This project has relevance not only for other malaria elimination projects but also for operational research aimed at eliminating other diseases.

Scale up of a Plasmodium falciparum elimination program and surveillance system in Kayin State, Myanmar

Background: Myanmar has one of the largest malaria burdens in Southeast Asia. Along the border with Thailand, Plasmodium falciparum parasites are increasingly showing reduced sensitivity to artemisinin combination therapies. Given that there are no current alternative treatment therapies, one proposed solution to the threat of untreatable P. falciparum malaria is to eliminate the parasite from the region. Several small-scale elimination projects have been piloted along the Myanmar-Thailand border. Following their success, this operational research aimed to scale up the elimination to a broad area of Eastern Kayin State, Myanmar. Methods: The project relied on geographic reconnaissance and a geographic information system, community engagement, generalized access to community-based early diagnosis and treatment, near real-time epidemiological surveillance, cross sectional malaria prevalence surveys and targeted mass drug administration in villages with high prevalence of P. falciparum malaria. Molecular markers of drug resistance were also monitored in individuals with symptomatic and asymptomatic infections. Discussion: This project illustrates the establishment of an elimination project and operational research in a remote, rural area encompassing several armed groups, multiple political organizations and a near-absent health care infrastructure. The establishment of the project relied on a strong rapport with the target community, on-the-ground knowledge (through geographic surveys and community engagement), rapid decision making and an approach that was flexible enough to quickly adapt to a complex landscape. The elimination project is ongoing, now over three years in operation, and assessment of the impact of this operational research will follow. This project has relevance not only for other malaria elimination projects but also for operational research aimed at eliminating other diseases.