Thai-Burmese Border Research Articles

Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai–Burmese border

ObjectivesUltrasound examination of the fetus is a powerful tool for assessing gestational age and detecting obstetric problems but is rarely available in developing countries. The aim of this study was to assess the intraobserver and interobserver agreement of fetal biometry by locally trained health workers in a refugee camp on the Thai–Burmese border.MethodsOne expatriate doctor and four local health workers participated in the study, which included examinations performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks' gestation, and who had undergone an early dating ultrasound scan, attending the antenatal clinic in Maela refugee camp. At each examination, two examiners independently measured biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), with one of the examiners obtaining duplicate measurements of each parameter. Intraobserver measurement error was assessed using the intraclass correlation coefficient (ICC) and interobserver error was assessed by the Bland and Altman 95% limits of agreement method.ResultsA total of 4188 ultrasound measurements (12 per woman) were obtained in 349 pregnancies at a median gestational age of 27 (range, 16–40) weeks in 2008. The ICC for BPD, HC, AC and FL was greater than 0.99 for all four trainees and the doctor (range, 0.996–0.998). For gestational ages between 18 and 24 weeks, interobserver 95% limits of agreement corresponding to differences in estimated gestational age of less than ± 1 week were calculated for BPD, HC, AC and FL. Measurements by local health workers showed high levels of agreement with those of the expatriate doctor.ConclusionsLocally trained health workers working in a well organized unit with ongoing quality control can obtain accurate fetal biometry measurements for gestational age estimation. This experience suggests that training of local health workers in developing countries is possible and could allow effective use of obstetric ultrasound imaging. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

Castor oil for induction of labour: Not harmful, not helpful

Castor oil is one of the most popular drugs for induction of labour in a non-medical setting; however, published data on safety and effectiveness of this compound to induce labour remain sparse. To assess the safety and effectiveness of castor oil for induction of labour in pregnancies with an ultrasound estimated gestational at birth of more than 40 weeks. Data were extracted from hospital-based records of all pregnant women who attended antenatal clinics on the Thai-Burmese border and who were more than 40 weeks pregnant. The effectiveness of castor oil to induce labour was expressed as time to birth and analysed with a Cox proportional hazards regression model. Measures associated with safety were fetal distress, meconium-stained amniotic fluid, tachysystole of the uterus, uterine rupture, abnormal maternal blood pressure during labour, Apgar scores, neonatal resuscitation, stillbirth, post-partum haemorrhage, severe diarrhoea and maternal death. Proportions were compared using Fisher's exact test. Of 612 women with a gestation of more than 40 weeks, 205 received castor oil for induction and 407 did not. The time to birth was not significantly different between the two groups (hazard ratio 0.99 (95% confidence interval: 0.81 to 1.20; n = 509)). Castor oil use was not associated with any harmful effects on the mother or fetus. Castor oil for induction of labour had no effect on time to birth nor were there any harmful effects observed in this large series. Our findings leave no justification for recommending castor oil for this purpose.

Low seroprevalence of HIV and syphilis in pregnant women in refugee camps on the Thai-Burma border

Refugee and migrant populations are considered to be at high risk from sexually transmitted infection (STI) and HIV. Cross-sectional surveys for syphilis and HIV were conducted in antenatal clinics (ANCs) on the Thai-Burmese border. In Mae La refugee camp, the seroprevalence of HIV and syphilis were 0.2% (one of 500) (95% CI 0-1.1) and 0% (0 of 404) (95% CI 0-0.9) in 1997; and 0.4% (two of 500) (95% CI 0.1-1.4) and 0.4% (three of 741) (95% CI 0.1-1.2) in 2005, respectively; syphilis seroprevalence in migrant women in 2005 was 0 (0 of 234) (95% CI 0-1.6). The seroprevalence was lower than that reported from surrounding ANCs for Thai or Burmese women. Focus group discussions with HIV-negative and -positive pregnant refugee women established that aspects of Karen culture and isolation (geographical and political) had a significant protective role from HIV and STI. This survey has resulted in programmatic changes in services to pregnant women in this area.

Auditory assessment of patients with acute uncomplicated Plasmodium falciparum malaria treated with three-day mefloquine-artesunate on the north-western border of Thailand

BackgroundThe use of artemisinin derivatives has increased exponentially with the deployment of artemisinin combination therapy (ACT) in all malarious areas. They are highly effective and are considered safe, but in animal studies artemisinin derivatives produce neurotoxicity targeting mainly the auditory and vestibular pathways. The debate remains as to whether artemisinin derivatives induce similar toxicity in humans.MethodsThis prospective study assessed the effects on auditory function of a standard 3-day oral dose of artesunate (4 mg/kg/day) combined with mefloquine (25 mg/kg) in patients with acute uncomplicated falciparum malaria treated at the Shoklo Malaria Research Unit, on the Thai-Burmese border. A complete auditory evaluation with tympanometry, audiometry and auditory brainstem responses (ABR) was performed before the first dose and seven days after initiation of the antimalarial treatment.ResultsComplete auditory tests at day 0 (D0) and day 7 (D7) were obtained for 93 patients. Hearing loss (threshold > 25 dB) on admission was common (57%) and associated with age only. No patient had a threshold change exceeding 10 dB between D0 and D7 at any tested frequency. No patient showed a shift in Wave III peak latency of more than 0.30 msec between baseline and D7.ConclusionNeither audiometric or the ABR tests showed clinical evidence of auditory toxicity seven days after receiving oral artesunate and mefloquine.

Thrombocytopaenia in pregnant women with malaria on the Thai-Burmese border

BackgroundHaematological changes associated with malaria in pregnancy are not well documented, and have focused predominantly on anaemia. Examined here is thrombocytopaenia in pregnant women infected with Plasmodium falciparum or Plasmodium vivax in a low transmission area on the north-western border of Thailand.MethodsIn this observational study we reviewed the platelet counts from routine complete blood count (CBC) in a cohort of healthy and malaria infected Karen pregnant women attending weekly antenatal clinics. A platelet count of 75,000/μL was the threshold at 2 standard deviations below the mean for healthy pregnant women used to indicate thrombocytopenia. Differences in platelet counts in non-pregnant and pregnant women were compared after matching for age, symptoms, malaria species and parasitaemia.ResultsIn total 974 pregnant women had 1,558 CBC measurements between February 2004 and September 2006. The median platelet counts (/μL) were significantly lower in patients with an episode of falciparum 134,000 [11,000–690,000] (N = 694) or vivax malaria 184,000 [23,000–891,000] (N = 523) compared to healthy pregnant women 256,000 [64,000–781,000] (N = 255), P < 0.05 for both comparisons. Plasmodium falciparum and P. vivax caused a 34% (95% CI 24–47) and 22% (95% CI 8–36) reduction in platelet count, respectively. Pregnant compared to non pregnant women were at higher risk OR = 2.27 (95%CI 1.16–4.4) P = 0.017, for thrombocytopaenia. Platelets counts were higher in first compared with subsequent malaria infections within the same pregnancy. Malaria associated thrombocytopaenia had a median [range] time for recovery of 7 [2-14] days which did not differ by antimalarial treatment (P = 0.86), or species (P = 0.63) and was not associated with active bleeding.ConclusionPregnant women become more thrombocytopenic than non-pregnant women with acute uncomplicated malaria. Uncomplicated malaria associated thrombocytopaenia is seldom severe. Prompt antimalarial treatment resulted in normalization of platelet counts within a week.

Plasmodium vivax resistance to chloroquine in Dawei, southern Myanmar

To assess the efficacy of chloroquine in the treatment of Plasmodium vivax malaria in in Dawei District, southern Myanmar. Enrolled patients at Sonsinphya clinic >6 months of age were assessed clinically and parasitologically every week for 28 days. To differentiate new infections from recrudescence, we genotyped pre- and post-treatment parasitaemia. Blood chloroquine was measured to confirm resistant strains. Between December 2002 and April 2003, 2661 patients were screened, of whom 252 were included and 235 analysed. Thirty-four per cent (95% CI: 28.1-40.6) of patients had recurrent parasitaemia and were considered treatment failures. 59.4% of these recurrences were with a different parasite strain. Two (0.8%) patients with recurrences on day 14 had chloroquine concentrations above the threshold of 100 ng/ml and were considered infected with chloroquine resistant parasites. 21% of failures occurred during the first 3 weeks of follow-up: early recurrence and median levels of blood chloroquine comparable to those of controls suggested P. vivax resistance. Plasmodium vivax resistance to chloroquine seems to be emerging in Dawei, near the Thai-Burmese border. While chloroquine remains the first-line drug for P. vivax infections in this area of Myanmar, regular monitoring is needed to detect further development of parasite resistance.

Safety of benzyl benzoate lotion and permethrin in pregnancy: a retrospective matched cohort study

To assess the safety of benzyl benzoate lotion (BBL) and permethrin, topical treatments for scabies, during pregnancy. A retrospective controlled cohort study. Refugee and migrant women attending antenatal clinics (ANC) on the Thai-Burmese border between August 1993 and April 2006. Women treated with either BBL (25%) or permethrin (4%) were identified from a manual search of antenatal records. Each case of scabies was matched with four scabies-free controls for gravidity, age, smoking status, malaria, period of treatment and gestational age at treatment. Conditional Poisson regression was used to estimate risk ratios for outcomes of pregnancy (proportion of abortions, congenital abnormalities, neonatal deaths, stillbirths and premature babies), mean birthweight and estimated median gestational age, for scabies and scabies-free women, independently for BBL and permethrin. There were no statistically significant differences in pregnancy outcomes between women who were treated with either BBL (n = 444) compared with their matched controls (n = 1,776) or permethrin (n = 196) treated women and their matched controls (n = 784). Overall, only 10.9% (n = 66) of treatments were in the first trimester. Retreatment rates were higher with BBL 16.4%, than permethrin 9.7%, P = 0.038. Scabies was more common during cooler periods. We found no evidence of adverse effects on pregnancy outcome due to topical 25% BBL or 4% permethrin.

Acquired haemophilia A in early pregnancy associated with Plasmodium vivax malaria and hyperthyroidism

Karen women in refugee camps on the Thai-Burmese border attend weekly antenatal clinics for early detection and treatment of malaria to prevent maternal death. In July 2000 a previously healthy 17-year-old primigravida presented at 13/+3 weeks gestation with one week of fever headache joint and eye pain and intermittent mucosal bleeding (nose five days and gum two days). She denied taking medications or herbal preparations except paracetamol. Her blood slide showed Plasmodium vivax parasitaemia (27/µL) haematocrit of 32% with normal red and white cell indices and a platelet count of 119 × 109/L. Dengue and HIV serology were negative. The patient was treated with oral chloroquine phosphate folate vitamin C and intramuscular vitamin K. On day three significant gum and nose bleeding occurred and required an adrenaline pack. Her platelet count of 164 × 10/9/L and prothrombin time of 18.4 s (11-18) were normal while the activated partial thromboplastin time 38.3 s (23-29) INR 1.50 and serum transaminases (AST 219 U/L (5-40) ALT 150 U/L (5-40)) were increased. On day five her haematocrit was 21% with a bleeding time of > 10 min and her blood was incoagulable in vitro. On day six continued mucosal bleeding and symptomatic anaemia (haematocrit 19%) required transfusion of screened fresh whole blood from her husband (relatives are locally the usual source of blood). On day seven active bleeding had ceased and she was discharged on oral haematinics. (excerpt)

A Survival Story from the Thai-Burmese Border: The Struggle for Education in the Burmese Community in Thailand

The Burmese refugee/migrant community on the Thai-Burmese border figures prominently among “refugee diasporas” in the world today. This article describes efforts of Burmese people within this community to provide basic education to their youth in extra-legal migrant schools in the midst of the unwelcoming environment created by the Thai government’s refugee policy. It argues that this community needs greater support than it is currently receiving in order to achieve recognition and security given the impossibility of safe and voluntary repatriation to Myanmar in the foreseeable future. The article closes with a number of specific proposals for facilitating the delivery of education to Burmese “migrant” youth in the Burmese community in Thailand through intervention by both state and nonstate actors.

Deployment of Early Diagnosis and Mefloquine- Artesunate Treatment of Falciparum Malaria in Thailand: The Tak Malaria Initiative

BackgroundEarly diagnosis and treatment with artesunate-mefloquine combination therapy (MAS) have reduced the transmission of falciparum malaria dramatically and halted the progression of mefloquine resistance in camps for displaced persons along the Thai-Burmese border, an area of low and seasonal transmission of multidrug-resistant Plasmodium falciparum. We extended the same combination drug strategy to all other communities (estimated population 450,000) living in five border districts of Tak province in northwestern Thailand.Methods and FindingsExisting health structures were reinforced. Village volunteers were trained to use rapid diagnostic tests and to treat positive cases with MAS. Cases of malaria, hospitalizations, and malaria-related deaths were recorded in the 6 y before, during, and after the Tak Malaria Initiative (TMI) intervention. Cross-sectional surveys were conducted before and during the TMI period. P. falciparum malaria cases fell by 34% (95% confidence interval [CI], 33.5–34.4) and hospitalisations for falciparum malaria fell by 39% (95% CI, 37.0–39.9) during the TMI period, while hospitalisations for P. vivax malaria remained constant. There were 32 deaths attributed to malaria during, and 22 after the TMI, a 51.5% (95% CI, 39.0–63.9) reduction compared to the average of the previous 3 y. Cross-sectional surveys indicated that P. vivax had become the predominant species in Thai villages, but not in populations living on the Myanmar side of the border. In the displaced persons population, where the original deployment took place 7 y before the TMI, the transmission of P. falciparum continued to be suppressed, the incidence of falciparum malaria remained low, and the in vivo efficacy of the 3-d MAS remained high.ConclusionsIn the remote malarious north western border area of Thailand, the early detection of malaria by trained village volunteers, using rapid diagnostic tests and treatment with mefloquine-artesunate was feasible and reduced the morbidity and mortality of multidrug-resistant P. falciparum.

Women, Nation, and the Ambivalence of Subversive Identification along the Thai-Burmese Border

This article focuses on the making of Shan nationalism as a subversive identification against the Burmese regime and its gender ambivalence. By employing a feminist critique of nationalism, it explores the relationship between women and nation within the movement for political independence among the Shan people. The article examines the way in which the imagined Shan nation has become a gender construct and is negotiated and contested by Shan women. Through the experiences of the displacement of Shan women exiles, the tension between the master and marginal narratives about the nation has become crucial to how women (re)construct their transnational identities. As women's voices are far from homogeneous and coherent, multiple and divergent experiences characterize the distinctive ways in which Shan women have come to terms with their ambivalent identities.

HEALTH CONCERNS OF ‘INVISIBLE’1 CROSS-BORDER DOMESTIC MAIDS IN THAILAND

With the rising number of sex venues along the Thai–Burmese border and the perceived links between migration and the HIV epidemic, the Thai authorities and NGOs have begun concerning themselves with health problems of immigrant workers and seeking effective social welfare programmes for them. However, this paper argues that formal service programmes targeting specific groups may not be enough and notes a need to call attention to officially invisible migrants, particularly domestic maids from Burma who are more vulnerable precisely because they are ‘invisible’. The ‘maid trade’ from Burma to Thailand is statistically invisible firstly because domestic work is not recognized as a formal occupation either by the employers or the employees and therefore, they fail to be registered in census data. Burmese female domestic workers in Thailand are normally recruited through informal channels facilitated by regional trans-national networks that also engage in human smuggling. Domestic workers remain invisible in Thailand also because most of them are live-in and tend to work for one family for lengthy periods of time. They are normally out of reach of labour unions, religious organizations, non-governmental organizations and public health services. The fear of being caught as ‘illegal workers’ by the authorities further hinders their contact with the public. This paper also attributes the migrants’ invisibility to the tradition of ‘domestic servitude’ in Thai society. Using three detailed case studies, the paper demonstrates how the invisibility has contributed to the health vulnerability of these women in their daily lives.

Estimation of the Total Parasite Biomass in Acute Falciparum Malaria from Plasma PfHRP2

BackgroundIn falciparum malaria sequestration of erythrocytes containing mature forms of Plasmodium falciparum in the microvasculature of vital organs is central to pathology, but quantitation of this hidden sequestered parasite load in vivo has not previously been possible. The peripheral blood parasite count measures only the circulating, relatively non-pathogenic parasite numbers. P. falciparum releases a specific histidine-rich protein (PfHRP2) into plasma. Quantitative measurement of plasma PfHRP2 concentrations may reflect the total parasite biomass in falciparum malaria.Methods and FindingsWe measured plasma concentrations of PfHRP2, using a quantitative antigen-capture enzyme-linked immunosorbent assay, in 337 adult patients with falciparum malaria of varying severity hospitalised on the Thai–Burmese border. Based on in vitro production rates, we constructed a model to link this measure to the total parasite burden in the patient. The estimated geometric mean parasite burden was 7 × 1011 (95% confidence interval [CI] 5.8 × 1011 to 8.5 × 1011) parasites per body, and was over six times higher in severe malaria (geometric mean 1.7 × 1012, 95% CI 1.3 × 1012 to 2.3 × 1012) than in patients hospitalised without signs of severity (geometric mean 2.8 × 1011, 95% CI 2.3 × 1011 to 3.5 × 1011; p < 0.001). Parasite burden was highest in patients who died (geometric mean 3.4 × 1012, 95% CI 1.9 × 1012 to 6.3 × 1012; p = 0.03). The calculated number of sequestered parasites increased with disease severity and was higher in patients with late developmental stages of P. falciparum present on peripheral blood smears. Comparing model and laboratory estimates of the time of sequestration suggested that admission to hospital with uncomplicated malaria often follows schizogony—but in severe malaria is unrelated to stage of parasite development.ConclusionPlasma PfHRP2 concentrations may be used to estimate the total body parasite biomass in acute falciparum malaria. Severe malaria results from extensive sequestration of parasitised erythrocytes.

NO EVIDENCE OF CARDIOTOXICITY OF ATOVAQUONE-PROGUANIL ALONE OR IN COMBINATION WITH ARTESUNATE

Combinations are set to become the mainstay in treatment and prophylaxis of malaria due to Plasmodium falciparum. Various antimalarials have been implicated in cardiotoxicity via prolongation of the QTc interval. Atovaquone-proguanil is an effective and increasingly popular antimalarial choice when used alone or with artesunate in areas of drug resistance. We report the results of an investigation carried out on the Thai-Burmese border in 42 patients randomized to receive either atovaquone-proguanil or atovaquone-proguanil-artesunate for three days. Electrocardiographic recordings were made at baseline and one hour after each dose. There was no statistically significant change in QTc interval between baseline and any subsequent readings in either treatment group or the cohort as a whole. We conclude that atovaquone-proguanil shows no evidence of cardiotoxicity either alone or when combined with artesunate.

Where orchids bloom: medicine on the border

The patient is a 27-year-old man. He is the last patient of a long day here on the Thai–Burmese border in a large medical clinic founded by Karen refugees of the Burmese civil war — one of the longest-running civil wars in the world. He is emaciated, quiet and somewhat nervous-looking; I can

Seasonal fluctuations in the carriage of Plasmodium vivax gametocytes in Thailand.

To study the influence of season on Plasmodium vivax gametocyte carriage, the relationship between monthly rainfall and the proportion of P. vivax patients with detectable gametocytaemia was analysed. Most of the data used came from 6807 aggregated observations collected, in a refugee camp on the Thai-Burmese border, between January 2000 and December 2002. There was a positive correlation between rainfall and the incidence of P. vivax infection (Spearman's rho=+0.42; P =0.01) but the prevalence of gametocyte carriage among those with P. vivax infection was negatively correlated with rainfall (Spearman's rho=-0.58; P <0.001). The latter, negative correlation remained significant after controlling for the proportion of visitors relative to camp residents (P =0.003). Migrations, changes in transmission patterns, seasonal haematological changes, and ultraviolet immunosuppression are discussed as potential explanations for these observations.

Seasonal variation in hyperparasitaemia and gametocyte carriage in patients with Plasmodium falciparum malaria on the Thai–Burmese border

Between January 2000 and December 2002 monthly rainfall was correlated with the proportion of patients with hyperparasitaemic Plasmodium falciparum malaria and with the proportion of patients with P. falciparum gametocytes. During the observation period 6953 cases of P. falciparum malaria were treated at the Shoklo Malaria Research Unit in Maela refugee camp on the Thai–Burmese border. Three hundred and seventy-five of these patients had ≥4% of parasitized red blood cells. Although there were more monthly malaria cases in the rainy season, rainfall was negatively correlated with the proportion of patients with hyperparasitaemia (Spearman’s ρ=−0.59, P<0.001), and the proportion of gametocyte carriers among P. falciparum cases, (Spearman’s ρ=−0.39, P=0.018). After controlling for age and the origin of the patient, the odds ratio for developing hyperparasitaemia during the dry season was 1.6 (95% CI 1.14–2.2; P=0.006). The adjusted odds ratio for gametocyte carriage during the dry season was 1.3 (95% CI 1.03–1.6; P=0.02). Migrations, changes in transmission patterns, the haematological burden of cumulative infections, and ultraviolet immunosuppression are discussed as potential explanations for these observations.

Karenni refugees living in Thai–Burmese border camps: traumatic experiences, mental health outcomes, and social functioning

In June 2001, we assessed mental health problems among Karenni refugees residing in camps in Mae Hong Son, Thailand, to determine the prevalence of mental illness, identify risk factors, and develop a culturally appropriate intervention program. A systematic random sample was used with stratification for the three camps; 495 people aged 15 years or older from 317 households participated. We constructed a questionnaire that included demographic characteristics, culture-specific symptoms of mental illness, the Hopkins Symptoms Checklist-25, the Harvard Trauma Questionnaire, and selected questions from the SF-36 Health Survey. Mental health outcome scores indicated elevated levels of depression and anxiety symptoms; post-traumatic stress disorder (PTSD) scores were comparable to scores in other communities affected by war and persecution. Psychosocial risk factors for poorer mental health and social functioning outcomes were insufficient food, higher number of trauma events, previous mental illness, and landmine injuries. Modifications in refugee policy may improve social functioning, and innovative mental health and psychosocial programs need to be implemented, monitored, and evaluated for efficacy.

Gender differences in the prevalences of human infection with intestinal helminths on the Thai-Burmese border.

Intestinal helminths are the most widespread of human parasites. Their epidemiology is greatly influenced by certain socioeconomic factors that facilitate the dispersion of human faces in the environment and thus the contamination of skin food and soil with the eggs or larvae of the parasites. Given cultural differentiation between the sexes such factors are likely to apply differently to men and women. The aim of the present study was to see if the prevalence of infection with any of several intestinal helminths in men was significantly different from the corresponding value for women. (excerpt)

A Land on Fire: The Environmental Consequences of the Southeast Asian Boom

The future of Earth's environment will be decided in Asia, home to 60 percent of the world's population and some of the world's fastest-growing economies. As an award-winning investigative journalist based in Bankok, James Fahn spent a decade grappling with the challenges facing the region's mega-cities, tropical forests, coastlines, and societies dashing toward modernity. In A Land on Fire , he shares his findings - the profound implications for global issues such as climate change, the loss of biodiversity, and the greening of world trade. He explores Southeast Asia's environmental battles through the eyes of the people fighting them, and recounts his many adventures while covering them. Whether chasing down log smugglers along the Thai-Burmese border, exposing the dumping of toxic mercury into the Gulf of Thailand by multinational oil corporations, or covering the controversy surrounding the filming of the movie The Beach , Fahn provides unique insight into the relationship between sustainable development and democracy, the crippling impact of corruption, and the environmental challenges facing us all.