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Objectives The aim of this study was to inform public health policy decisions through the assessment of IgG antibody seroprevalence in the population and the risk factors for SARS-CoV-2 infection. Methods The seroprevalence of IgG antibodies among different subpopulations at the end of the first and second waves of the pandemic was estimated. Various risk factors associated with seropositivity, including sociodemography, IgG antibodies against endemic human coronavirus, and vaccination status, were also assessed. Results For all 2433 consenting participants, the overall estimated seroprevalences at the end of first and second waves were 28.5% (95% CI 22.3–33.7%) and 71.5% (95% CI 62.8–80.5%), respectively. The accrual of IgG positivity was heterogeneous, with the highest seroprevalences found in urban slum populations (75.1%). Vaccine uptake varied among the subpopulations, with low rates (< 10%) among rural and urban slum residents. The majority of seropositive individuals (75%) were asymptomatic. Residence in urban slums (OR 2.02, 95% CI 1.57–2.6; p < 0.001), middle socioeconomic status (OR 1.77, 95% CI 1.17–2.67; p = 0.007), presence of diabetes (OR 1.721, 95% CI 1.148–2.581; p = 0.009), and hypertension (OR 1.75, 95% CI 1.16–2.64; p = 0.008) were associated with seropositivity in multivariable analyses. Conclusion Although considerable population immunity has been reached, with more than two-thirds seropositive, improved vaccination strategies among unreached subpopulations and high-risk individuals are suggested for better preparedness in future.

BACKGROUND: The appropriate antibiotic treatment for severe scrub typhus, a neglected but widespread reemerging zoonotic infection, is unclear. METHODS: In this multicenter, double-blind, randomized, controlled trial, we compared the efficacy of intravenous doxycycline, azithromycin, or a combination of both in treating severe scrub typhus. Patients who were 15 years of age or older with severe scrub typhus with at least one organ involvement were enrolled. The patients were assigned to receive a 7-day course of intravenous doxycycline, azithromycin, or both (combination therapy). The primary outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5. RESULTS: Among 794 patients (median age, 48 years) who were included in the modified intention-to-treat analysis, complications included those that were respiratory (in 62%), hepatic (in 54%), cardiovascular (in 42%), renal (in 30%), and neurologic (in 20%). The use of combination therapy resulted in a lower incidence of the composite primary outcome than the use of doxycycline (33% and 47%, respectively), for a risk difference of −13.3 percentage points (95% confidence interval [CI], −21.6 to −5.1; P = 0.002). The incidence with combination therapy was also lower than that with azithromycin (48%), for a risk difference of −14.8 percentage points (95% CI, −23.1 to −6.5; P

Background Medicine quality screening devices hold great promise for post-market surveillance (PMS). However, there is little independent evidence on their field utility and usability to inform policy decisions. This pilot study in the Lao PDR tested six devices’ utility and usability in detecting substandard and falsified (SF) medicines. Methodology/principal findings Observational time and motion studies of the inspections by 16 Lao medicine inspectors of 1) the stock of an Evaluation Pharmacy (EP), constructed to resemble a Lao pharmacy, and 2) a sample set of medicines (SSM); were conducted without and with six devices: four handheld spectrometers (two near infrared: MicroPHAZIR RX, NIR-S-G1 & two Raman: Progeny, Truscan RM); one portable mid-infrared spectrometer (4500a), and single-use paper analytical devices (PAD). User experiences were documented by interviews and focus group discussions. Significantly more samples were wrongly categorised as pass/fail with the PAD compared to the other devices in EP inspections (p Conclusions/significance This pilot study suggests policy makers wishing to implement portable screening devices in PMS should be aware that overconfidence in devices may cause harm by reducing inspectors’ investment in visual inspection. It also provides insight into the advantages/limitations of diverse screening devices in the hands of end-users.

An online assessment among social media-using young men who have sex with men found that 87% were willing to use HIV self-testing with online supervision. Correlates included never tested, having higher numbers of sexual partners, and seeking partners online. HIV self-testing with online supervision may be appropriate for young men who have sex with men who have high risks and may not access venue-based settings.

Population risks for neonatal hyperbilirubinaemia (NH) vary. Knowledge of local risks permits interventions that may reduce the proportion becoming severe. Between January 2015 and May 2016, in a resource-limited setting on the Thailand-Myanmar border, neonates from 28 weeks’ gestation were enrolled into a prospective birth cohort. Each neonate had total serum bilirubin measurements: scheduled (24, 48, 72 and 144 hours of life) and clinically indicated; and weekly follow up until 1 month of age. Risk factors for developing NH were evaluated using Cox proportional hazard mixed model. Of 1710 neonates, 22% (376) developed NH (83% preterm, 19% term). All neonates born vs 59 hours [48, 84] for neonates born ≥38 weeks. Risk factors for NH in the first week of life independent of gestational age were: neonatal G6PD deficiency, birth bruising, Sgaw Karen ethnicity, primigravidae, pre-eclampsia, and prolonged rupture of membranes. The genetic impact of G6PD deficiency on NH was partially interpreted by using the florescent spot test and further genotyping work is in progress. The risk of NH in Sgaw Karen refugees may be overlooked internationally as they are most likely regarded as Burmese in countries of resettlement. Given high levels of pathological jaundice in the first 24 hours and overall high NH burden, guidelines changes were implemented including preventive PT for all neonates

Background and Aims: To determine the relationship between dietary intake of niacin and glaucoma using the data from the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES). Methods: Subjects aged 40 years and older who participated in the dietary intake interview and vision health questionnaire of NHANES were included in the study. Glaucoma diagnosis by self-report was utilized. Additionally, glaucoma diagnosis by fundus imaging and International Society Geographical and Epidemiological Ophthalmology (ISGEO) criteria was used in subjects with available qualified retinal imaging. Survey logistic regression analyses were used to examine the association between daily niacin consumption and glaucoma. Results: A total of 5768 participants were included in the study. There was a significant decrease in the crude odds of self-reported glaucoma in the third (OR 0.57, 95% Cl 0.43–0.76; p < 0.001) and fourth (OR 0.57, 95% Cl 0.37–0.90; p = 0.018) quartiles of daily niacin consumption, which equated to 21.01 to 28.22 mg/day and greater than 28.22 mg/day, respectively. A similar trend was found using fundus imaging of subjects with niacin intake in the third (OR 0.42, 95% Cl 0.25–0.72; p = 0.002) and fourth (OR 0.36, 95% Cl 0.20–0.67; p = 0.002) quartiles. After adjusting for covariates, the odds of glaucoma based on fundus imaging remained significantly lower for niacin intake in the third (OR 0.49, 95% Cl 0.28–0.87; p = 0.016) and fourth (OR 0.48, 95% Cl 0.26–0.89; p = 0.022) quartile levels. Using ISGEO criteria, there was no significant association between glaucoma and daily niacin consumption. Conclusions: Greater niacin intake may be associated with a lower chance of developing glaucoma.

Background Medicine quality screening devices hold great promise for post-market surveillance (PMS). However, there is little independent evidence on their field utility and usability to inform policy decisions. This pilot study in the Lao PDR tested six devices’ utility and usability in detecting substandard and falsified (SF) medicines. Methodology/principal findings Observational time and motion studies of the inspections by 16 Lao medicine inspectors of 1) the stock of an Evaluation Pharmacy (EP), constructed to resemble a Lao pharmacy, and 2) a sample set of medicines (SSM); were conducted without and with six devices: four handheld spectrometers (two near infrared: MicroPHAZIR RX, NIR-S-G1 & two Raman: Progeny, Truscan RM); one portable mid-infrared spectrometer (4500a), and single-use paper analytical devices (PAD). User experiences were documented by interviews and focus group discussions. Significantly more samples were wrongly categorised as pass/fail with the PAD compared to the other devices in EP inspections (p, Author summary Substandard and falsified (SF) medicines threaten the lives of millions of people, especially where pharmaceutical legislation and regulation are limited. Screening for SF medicines in supply chains (‘post-market surveillance’) by medicine inspectors is crucial but currently relies only on subjective visual inspection of medicines in most countries. Many innovative portable screening technologies now exist and could be key additional assets to the current practice, but none have been extensively evaluated for medicine quality post-market surveillance. We assessed the utility and usability of six screening devices in the hands of Lao medicines inspectors in a pharmacy constructed to resemble a Lao pharmacy. Five spectrometers showed promising accuracies to identify falsified medicines, but difficulties to correctly set them up before running tests were observed. Reading and interpreting colour barcodes of the ‘paper analytical cards’–a lab-on-a-chip test by inspectors were difficult, leading to lower accuracy than with spectrometers. The study suggests that overconfidence in devices may cause harm by reducing inspectors’ investment in visual inspection—a crucial step to identify falsified medicines. Advantages/limitations of the devices are also documented to inform policy.

Background Malaria reactive case detection is the testing and, if positive, treatment of close contacts of index cases. It is included in national malaria control programmes of countries in the Greater Mekong Subregion to accelerate malaria elimination. Yet the value of reactive case detection in the control and elimination of malaria remains controversial because of the low yield, limited evidence for impact, and high demands on resources. Methods Data from the epidemiological assessments of large mass drug administration (MDA) studies in Myanmar, Vietnam, Cambodia and Laos were analysed to explore malaria infection clustering in households. The proportion of malaria positive cases among contacts screened in a hypothetical reactive case detection programme was then determined. The parasite density thresholds for rapid diagnostic test (RDT) detection was assumed to be > 50/µL (50,000/mL), for dried-blood-spot (DBS) based PCR > 5/µL (5000/mL), and for ultrasensitive PCR (uPCR) with a validated limit of detection at 0.0022/µL (22/mL). Results At baseline, before MDA, 1223 Plasmodium infections were detected by uPCR in 693 households. There was clustering of Plasmodium infections. In 637 households with asymptomatic infections 44% (278/637) had more than one member with Plasmodium infections. In the 132 households with symptomatic infections, 65% (86/132) had more than one member with Plasmodium infections. At baseline 4% of households had more than one Plasmodium falciparum infection, but three months after MDA no household had more than one P. falciparum infected member. Reactive case detection using DBS PCR would have detected ten additional cases in six households, and an RDT screen would have detected five additional cases in three households among the 169 households with at least one RDT positive case. This translates to 19 and 9 additional cases identified per 1000 people screened, respectively. Overall, assuming all febrile RDT positive patients would seek treatment and provoke reactive case detection using RDTs, then 1047 of 1052 (99.5%) Plasmodium infections in these communities would have remained undetected. Conclusion Reactive case detection in the Greater Mekong subregion is predicted to have a negligible impact on the malaria burden, but it has substantial costs in terms of human and financial resources.

Background In many endemic areas, Plasmodium vivax malaria is predominantly a disease of young adults and children. International recommendations for radical cure recommend fixed target doses of 0.25 or 0.5 mg/kg/day of primaquine for 14 days in glucose-6-phosphate dehydrogenase normal patients of all ages. However, for many anti-malarial drugs, including primaquine, there is evidence that children have lower exposures than adults for the same weight-adjusted dose. The aim of the study was to develop 14-day weight-based and age-based primaquine regimens against high-frequency relapsing tropical P. vivax. Methods The recommended adult target dose of 0.5 mg/kg/day (30 mg in a 60 kg patient) is highly efficacious against tropical P. vivax and was assumed to produce optimal drug exposure. Primaquine doses were calculated using allometric scaling to derive a weight-based primaquine regimen over a weight range from 5 to 100 kg. Growth curves were constructed from an anthropometric database of 53,467 individuals from the Greater Mekong Subregion (GMS) to define weight-for-age relationships. The median age associated with each weight was used to derive an age-based dosing regimen from the weight-based regimen. Results The proposed weight-based regimen has 5 dosing bands: (i) 5–7 kg, 5 mg, resulting in 0.71–1.0 mg/kg/day; (ii) 8–16 kg, 7.5 mg, 0.47–0.94 mg/kg/day; (iii) 17–40 kg, 15 mg, 0.38–0.88 mg/kg/day; (iv) 41–80 kg, 30 mg, 0.37–0.73 mg/kg/day; and (v) 81–100 kg, 45 mg, 0.45–0.56 mg/kg/day. The corresponding age-based regimen had 4 dosing bands: 6–11 months, 5 mg, 0.43–1.0 mg/kg/day; (ii) 1–5 years, 7.5 mg, 0.35–1.25 mg/kg/day; (iii) 6–14 years, 15 mg, 0.30–1.36 mg/kg/day; and (iv) ≥ 15 years, 30 mg, 0.35–1.07 mg/kg/day. Conclusion The proposed weight-based regimen showed less variability around the primaquine dose within each dosing band compared to the age-based regimen and is preferred. Increased dose accuracy could be achieved by additional dosing bands for both regimens. The age-based regimen might not be applicable to regions outside the GMS, which must be based on local anthropometric data. Pharmacokinetic data in small children are needed urgently to inform the proposed regimens.

ObjectivesTo understand the impact of COVID-19 and public health measures on different social groups, we conducted a mixed-methods study in five countries (‘SEBCOV—social, ethical and behavioural aspects of COVID-19’). Here, we report the results of the online survey.Study design and statistical analysisOverall, 5058 respondents from Thailand, Malaysia, the UK, Italy and Slovenia completed the self-administered survey between May and June 2020. Poststratification weighting was applied, and associations between categorical variables assessed. Frequency counts and percentages were used to summarise categorical data. Associations between categorical variables were assessed using Pearson’s χ2test. Data were analysed in Stata 15.0ResultsAmong the five countries, Thai respondents reported having been most, and Slovenian respondents least, affected economically. The following factors were associated with greater negative economic impacts: being 18–24 years or 65 years or older; lower education levels; larger households; having children under 18 in the household and and having flexible/no income. Regarding social impact, respondents expressed most concern about their social life, physical health, mental health and well-being.There were large differences between countries in terms of voluntary behavioural change, and in compliance and agreement with COVID-19 restrictions. Overall, self-reported compliance was higher among respondents who self-reported a high understanding of COVID-19. UK respondents felt able to cope the longest and Thai respondents the shortest with only going out for essential needs or work. Many respondents reported seeing news perceived to be fake, the proportion varying between countries, with education level and self-reported levels of understanding of COVID-19.ConclusionsOur data showed that COVID-19 and public health measures have uneven economic and social impacts on people from different countries and social groups. Understanding the factors associated with these impacts can help to inform future public health interventions and mitigate their negative consequences.Trial registration numberTCTR20200401002.

School settings are volatile and often violent for LGBT teens who are first coming to terms with their sexuality. We explored the attitudes of LGBT students in Thai secondary schools towards homosexuality. Students aged 12-19 years were surveyed in 393 public institutions providing secondary-school education in six regions of Thailand, selected by a multistage cluster sampling. Among 1088 LGBT-identified students, 378 (35%) reported negative attitudes toward homosexuality. Factors associated with homonegative attitudes in a multivariable logistic regression analysis were identifying as a transgender (Adjusted Odds Ratio [aOR] 2.5, 95% CI 1.5-4.1), having low academic performance (GPA scores of 2-3 [aOR 2.6, 95% CI 1.7-4.1] or less than 2 [aOR 2.1, 95% CI 1.5-2.]), and attending sexuality education classes covering topics such as bullying LGBT students (aOR 1.9, 95% CI 1.2-3.1) and safe homosexual practices (aOR 2.1, 95% CI 1.7-4.1). Sexuality education in its current form in Thai public schools may not be effective in reducing homonegative attitudes of LGBT-identified students. A more comprehensive sexuality education emphasising gender and rights along with strategies addressing social disparities due to sexual orientation is needed to enable Thai LGBT teens to accept their sexuality without shame and self-disrespect.

The use of a Kaplan–Meier (K–M) survival time approach is generally considered appropriate to report antimalarial efficacy trials. However, when a treatment arm has 100% efficacy, confidence intervals may not be computed. Furthermore, methods that use probability rules to handle missing data for instance by multiple imputation, encounter perfect prediction problem when a treatment arm has full efficacy, in which case all imputed values are either treatment success or all imputed values are failures. The use of a survival K–M method addresses this imputation problem in estimating the efficacy estimates also referred to as cure rates. We discuss the statistical challenges and propose a potential way forward. The proposed approach includes the use of K–M estimates as the main measure of efficacy. Confidence intervals could be computed using the binomial exact method. p-Values for comparison of difference in efficacy between treatments can be estimated using Fisher’s exact test. We emphasize that when efficacy rates are not 100% in both groups, the K–M approach remains the main strategy of analysis considering its statistical robustness in handling missing data and confidence intervals can be computed under such scenarios.

Background In Thailand, drug use is widely observed, especially among vocational-school students, who are more inclined to use various types of drugs and to experience pride-based violence (violence based on institutional pride, honor, or on seniority status) than any other groups of students. Drug use contexts differ based on sexual orientation and gender identity (e.g., clubs). This study aims to examine the prevalence and correlates of poly-drug use (the use of at least three types of drugs) among vocational-school students, with a focus on sexual orientation and gender identity. Methods In this study, 638 vocational school students living in Bangkok metropolitan area participated in a three-year longitudinal survey of four vocational schools. Experiences of violence, sexual behaviours, and poly-drug use were assessed and analyzed using multivariable logistic regression. Results About one tenth of all students (11.3%) reported poly-drug use, a fifth among Lesbian, Gay, Bisexual and Transgender (LGBT) students (20.2%) and almost a tenth of heterosexual students (9.8%). In the multivariable logistic model of LGBT students, GPA, pride-based violence, intoxicated sex, and counseling needs were significantly associated with poly-drug use (AOR = 4.62; 95% CI 1.17–18.29, AOR = 6.01; 95% CI 1.31–27.32, AOR = 5.17; 95% CI 1.10–24.28, AOR = 4.64; 95% CI 1.16–18.54, respectively). Likewise, among heterosexual students, GPA and intoxicated sex were significantly associated with poly-drug use (AOR = 2.02; 95% CI 1.09–3.75, AOR = 5.31; 95% CI 2.81–10.04, respectively). Conclusions LGBT vocational-school students have significantly higher prevalence of poly-drug use than their heterosexual peers. Correlates include lower GPA, having experienced pride-based violence and intoxicated sex. School-based intervention programs should also address pride-based violence and intoxicated sex in their harm reduction programs.

In the absence of a vaccine and widely available treatments for COVID-19, governments have relied primarily on non-pharmaceutical interventions to curb the pandemic. To aid understanding of the impact of these public health measures on different social groups we conducted a mixed-methods study in five countries (‘SEBCOV - Social, ethical and behavioural aspects of COVID-19’). Here we report the results of the SEBCOV anonymous online survey of adults.Overall, 5,058 respondents from Thailand, Malaysia, the United Kingdom, Italy and Slovenia completed the self-administered survey between May and June 2020. Post-stratification weighting was applied, and associations between categorical variables assessed.Among the five countries, Thai respondents appeared to have been most, and Slovenian respondents least, affected economically. Overall, lower education levels, larger households, having children under 18 in the household, being 65 years or older and having flexible/no income were associated with worse economic impact. Regarding social impact, respondents expressed most concern about their social life, physical health, and mental health and wellbeing.There were large differences between countries in terms of voluntary behavioural change, and in compliance and agreement with COVID-19 restrictions. Overall, self-reported compliance was higher among respondents reporting a high understanding of COVID-19. UK respondents felt able to cope the longest and Thai respondents the shortest with only going out for essential needs or work, with 60% and 26% respectively able to cope with 29 days or longer. Many respondents reported seeing news that seemed fake to them, the proportion varying between countries, and with education level and self-reported levels of understanding of COVID-19.Our data showed that COVID-19 public health measures have uneven economic and social impacts on people from different countries and social groups. Understanding the factors associated with these impacts can help to inform future public health interventions and mitigate their negative consequences on people’s lives.SummaryWhat is already known?COVID-19 public health measures and lockdowns most negatively affect those who are socio-economically disadvantaged.Misinformation about COVID-19 is widespread.What are the new findings?In the countries in which we conducted our survey, lower education levels, larger households, having children under 18 in the household, being 65 years or older and having flexible/no income were associated with worse economic impact.There were large differences between countries in terms of voluntary change of behaviour, as well as compliance and agreement with COVID-19 related public health measures.Younger age and lower education levels appear to be associated with lower self-perceived levels of understanding of COVID-19.A significant proportion of the population received conflicting information and news that seemed fake to them, in particular about coronavirus being an engineered modified virus.What do the new findings imply?Our findings imply that there are significant differences in how people from different social groups and different countries experienced COVID-19 and related public health measures, and any support initiatives should take this into account.Our findings confirm that communication around COVID-19 could be improved, and help identify specific areas to target (e.g. origin of virus) and specific groups of people who may benefit most from improved communication (e.g. younger people, those with lower levels education).

In many countries, housing is used for wealth accumulation and provides financial security in old age. We tested the hypothesis that household wealth, measured by housing quality and ownership of durable assets, would increase with age of the household head.We conducted a survey of household heads in 68 villages surrounding Mtwara town, Tanzania and recorded relevant demographic, housing and social characteristics for each household. The primary analysis assessed the relationship between age of the household head, quality of the house structure and socio-economic score (SES) using multivariate analysis. Principal Components Analysis (PCA) was used as a data reduction tool to estimate the social-economic status of subjects based on relevant variables that are considered as proxy for SES.Of 13 250 household heads were surveyed of whom 49% were male. Those at least 50 years old were more likely to live in homes with an earth floor (86%) compared to younger household heads (80%; P 0.0001), wattle and daub walls (94% vs. 90%; P 0.0001) and corrugated iron roofs (56% vs. 52%; P 0.0001). Wealth accumulation in the villages included in the study tends to be an inverted V-relationship with age. Housing quality and SES rose to a peak by 50 years and then rapidly decreased. Households with a large number of members were more likely to have better housing than smaller households.Housing plays a critical role in wealth accumulation and socio-economic status of a household in rural villages in Tanzania. Households with a head under 50 years were more likely to live in improved housing and enjoyed a higher SES, than households with older heads. Larger families may provide protection against old age poverty in rural areas. Assuring financial security in old age, specifically robust and appropriate housing would have wide-ranging benefits.Dans de nombreux pays, le logement est utilisé pour l'accumulation de richesse et offre une sécurité financière à un âge avancé. Nous avons testé l'hypothèse selon laquelle la richesse des ménages, mesurée par la qualité du logement et la possession d'actifs durables, augmenterait avec l'âge du chef de ménage. MÉTHODES: Nous avons mené une enquête auprès des chefs de ménage dans 68 villages entourant la ville de Mtwara, en Tanzanie et enregistré les caractéristiques démographiques, de logement et sociales pertinentes pour chaque ménage. L'analyse primaire a évalué la relation entre l'âge du chef de ménage, la qualité de la structure du logement et le score socioéconomique (SES) à l'aide d'une analyse multivariée. L'analyse en composantes principales (ACP) a été utilisée comme outil de réduction des données pour estimer le statut socioéconomique des sujets sur la base de variables pertinentes qui sont considérées comme une approximation du SSE. RÉSULTATS: 13.250 chefs de ménage ont été interrogés, dont 49% de sexe masculin. Les personnes âgées d'au moins 50 ans étaient plus susceptibles de vivre dans des maisons avec un sol en terre (86%) que les chefs de ménage plus jeunes (80%; P0,0001), des murs en clayonnage enduit de torchis (94% contre 90%; P0,0001) et des toitures en tôle ondulée (56% contre 52%; P0,0001). L'accumulation de richesse dans les villages inclus dans l'étude a tendance à être une relation en V inversée avec l'âge. La qualité du logement et le SSE ont atteint un sommet de 50 ans, puis ont rapidement diminué. Les ménages comptant un grand nombre de membres étaient plus susceptibles d'avoir un meilleur logement que les ménages plus petits.Le logement joue un rôle essentiel dans l'accumulation de richesse et le statut socioéconomique d'un ménage dans les villages ruraux de Tanzanie. Les ménages dont le chef avait moins de 50 ans étaient plus susceptibles de vivre dans un logement amélioré et jouissaient d'un SSE plus élevé que les ménages dont le chef était plus âgé. Les familles plus nombreuses pourraient offrir une protection contre la pauvreté aux personnes âgées dans les zones rurales. Assurer la sécurité financière dans la vieillesse, en particulier un logement solide et approprié, aurait des avantages considérables.

Highlights • Evidence on causes of fever is limited in Southeast Asia, especially in primary care • Point-of-care diagnostic tools could guide health workers’ antibiotic prescription • C-reactive protein was significantly increased in case of bacterial infections • Most primary care patients recovered regardless of antibiotic prescription • Antibiotic prescription should be an exception in the primary levels of care, Objectives We investigated causes of fever in the primary levels of care in Southeast Asia, and evaluated whether C-reactive protein (CRP) could distinguish bacterial from viral pathogens. Methods Blood and nasopharyngeal swab specimens were taken from children and adults with fever (>37.5˚C) or history of fever (

HIV-related factors and suicide-risk status were assessed among YMSM aged 18-24 years recruited through various MSM-related online social apps in Bangkok (N = 1394). The online survey assessed demographic characteristics, sexual behaviours and suicide-risk status. Measure of suicide risk was taken from the Suicidal Behaviors Questionnaire-Revised (cut-off score of seven or higher). Among participants, 249 (17.9%) reported suicide-risk. In multivariable logistic regression, correlates of suicide-risk status included having sometimes or often ever participated in group sex (AOR=1.58, 95% CI: 1.17-2.14), having received money or opportunities for sex (AOR=1.54, 95% CI: 1.09-2.17), often seeking partners online (AOR=1.59, 95% CI: 1.05-2.39), inconsistent condom use (AOR=1.67, 95% CI: 1.26-2.21), and self-assessed as having "medium" or "high" HIV risk (AOR=2.53, 95% CI: 1.61-3.98 and AOR=3.35, 95% CI: 1.92-5.82, respectively). Findings suggest that HIV risk behaviours shown by YMSM are significantly associated with higher risk of suicide.

Author(s): Phommasone, Koukeo; van Leth, Frank; Peto, Thomas J; Landier, Jordi; Nguyen, Thuy-Nhien; Tripura, Rupam; Pongvongsa, Tiengkham; Lwin, Khin Maung; Kajeechiwa, Ladda; Thwin, May Myo; Parker, Daniel M; Wiladphaingern, Jacher; Nosten, Suphak; Proux, Stephane; Nguon, Chea; Davoeung, Chan; Rekol, Huy; Adhikari, Bipin; Promnarate, Cholrawee; Chotivanich, Kesinee; Hanboonkunupakarn, Borimas; Jittmala, Podjanee; Cheah, Phaik Yeong; Dhorda, Mehul; Imwong, Mallika; Mukaka, Mavuto; Peerawaranun, Pimnara; Pukrittayakamee, Sasithon; Newton, Paul N; Thwaites, Guy E; Day, Nicholas PJ; Mayxay, Mayfong; Hien, Tran Tinh; Nosten, Francois H; Cobelens, Frank; Dondorp, Arjen M; White, Nicholas J; von Seidlein, Lorenz | Abstract: BackgroundMass administrations of antimalarial drugs (MDA) have reduced the incidence and prevalence of P. falciparum infections in a trial in the Greater Mekong Subregion. Here we assess the impact of the MDA on P. vivax infections.MethodsBetween May 2013 and July 2017, four villages in each Myanmar, Vietnam, Cambodia and Lao PDR were selected based on high prevalence of P. falciparum infections. Eight of the 16 villages were randomly assigned to receive MDA consisting of three-monthly rounds of three-day courses of dihydroartemisinin-piperaquine and, except in Cambodia, a single low-dose of primaquine. Cross-sectional surveys were conducted at quarterly intervals to detect Plasmodium infections using ultrasensitive qPCR. The difference in the cumulative incidence between the groups was assessed through a discrete time survival approach, the difference in prevalence through a difference-in-difference analysis, and the difference in the number of participants with a recurrence of P. vivax infection through a mixed-effect logistic regression.Results3,790 (86%) residents in the intervention villages participated in at least one MDA round, of whom 2,520 (57%) participated in three rounds. The prevalence of P. vivax infections fell from 9.31% to 0.89% at month 3 but rebounded by six months to 5.81%. There was no evidence that the intervention reduced the cumulative incidence of P.vivax infections (95% confidence interval [CI] Odds ratio (OR): 0.29 to 1.36). Similarly, there was no evidence of MDA related reduction in the number of participants with at least one recurrent infection (OR: 0.34; 95% CI: 0.08 to 1.42).ConclusionMDA with schizontocidal drugs had a lasting effect on P. falciparum infections but only a transient effect on the prevalence of P. vivax infections. Radical cure with an 8-aminoquinoline will be needed for the rapid elimination of vivax malaria.

Background Trials to assess the efficacy of the radical cure of Plasmodium vivax malaria with 8-aminoquinolines require that most post-treatment relapses are identified, but there is no consensus on the optimal duration of follow-up in either symptomatic or asymptomatic vivax malaria. The efficacy of a 14-day course of primaquine on the cumulative incidence of recurrent asymptomatic P. vivax infections detected by ultrasensitive quantitative PCR (uPCR) as a primary endpoint was assessed. Methods A randomized, placebo-controlled, single-blind trial was conducted in four villages of the Lao PDR during 2016–2018 nested in a larger project evaluating mass drug administrations (MDA) with dihydroartemisinin-piperaquine (DP) and a single low-dose primaquine to clear Plasmodium falciparum infections. In the nested sub-study, eligible participants with mono- or mixed P. vivax infections detected by uPCR were randomized to receive either 14 days of primaquine (0.5 mg/kg/day) or placebo during the last round of MDA (round 3) through directly observed therapy. Participants were checked monthly for 12 months for parasitaemia using uPCR. The primary outcome was cumulative incidence of participants with at least one recurrent episode of P. vivax infection. Results 20 G6PD-normal participants were randomized in each arm. 5 (29%) of 20 participants in the placebo arm experienced asymptomatic, recurrent P. vivax infections, resulting in a cumulative incidence at month 12 of 29%. None of the 20 participants in the intervention arm had recurrent infections (p = 0.047 Fisher’s exact test). Participants with recurrent P. vivax infections were found to be parasitaemic for between one and five sequential monthly tests. The median time to recurrence of P. vivax parasitaemia was 178 days (range 62–243 days). Conclusions A 14-day course of primaquine in addition to a DP-MDA was safe, well-tolerated, and prevented recurrent asymptomatic P. vivax infections. Long follow-up for up to 12 months is required to capture all recurrences following the treatment of asymptomatic vivax infection. To eliminate all malarias in settings where P. vivax is endemic, a full-course of an 8-aminoquinolines should be added to MDA to eliminate all malarias. Trial registration This study was registered with ClinicalTrials.gov under NCT02802813 on 16th June 2016. https://clinicaltrials.gov/ct2/show/NCT02802813

Background Trials to assess the efficacy of the radical cure of Plasmodium vivax malaria with 8-aminoquinolines require that most post-treatment relapses are identified, but there is no consensus on the optimal duration of follow-up in either symptomatic or asymptomatic vivax malaria. The efficacy of a 14-day course of primaquine on the cumulative incidence of recurrent asymptomatic P. vivax infections detected by ultrasensitive quantitative PCR (uPCR) as a primary endpoint was assessed. Methods A randomized, placebo-controlled, single-blind trial was conducted in four villages of the Lao PDR during 2016–2018 nested in a larger project evaluating mass drug administrations (MDA) with dihydroartemisinin-piperaquine (DP) and a single low-dose primaquine to clear Plasmodium falciparum infections. In the nested sub-study, eligible participants with mono- or mixed P. vivax infections detected by uPCR were randomized to receive either 14 days of primaquine (0.5 mg/kg/day) or placebo during the last round of MDA (round 3) through directly observed therapy. Participants were checked monthly for 12 months for parasitaemia using uPCR. The primary outcome was cumulative incidence of participants with at least one recurrent episode of P. vivax infection. Results 20 G6PD-normal participants were randomized in each arm. 5 (29%) of 20 participants in the placebo arm experienced asymptomatic, recurrent P. vivax infections, resulting in a cumulative incidence at month 12 of 29%. None of the 20 participants in the intervention arm had recurrent infections (p = 0.047 Fisher’s exact test). Participants with recurrent P. vivax infections were found to be parasitaemic for between one and five sequential monthly tests. The median time to recurrence of P. vivax parasitaemia was 178 days (range 62–243 days). Conclusions A 14-day course of primaquine in addition to a DP-MDA was safe, well-tolerated, and prevented recurrent asymptomatic P. vivax infections. Long follow-up for up to 12 months is required to capture all recurrences following the treatment of asymptomatic vivax infection. To eliminate all malarias in settings where P. vivax is endemic, a full-course of an 8-aminoquinolines should be added to MDA to eliminate all malarias. Trial registration This study was registered with ClinicalTrials.gov under NCT02802813 on 16th June 2016. https://clinicaltrials.gov/ct2/show/NCT02802813

Background Sample size calculations for cluster randomized trials are a recognized methodological challenge for malaria research in pre-elimination settings. Positively correlated responses from the participants in the same cluster are a key feature in the estimated sample size required for a cluster randomized trial. The degree of correlation is measured by the intracluster correlation coefficient (ICC) where a higher coefficient suggests a closer correlation hence less heterogeneity within clusters but more heterogeneity between clusters. Methods Data on uPCR-detected Plasmodium falciparum and Plasmodium vivax infections from a recent cluster randomized trial which aimed at interrupting malaria transmission through mass drug administrations were used to calculate the ICCs for prevalence and incidence of Plasmodium infections. The trial was conducted in four countries in the Greater Mekong Subregion, Laos, Myanmar, Vietnam and Cambodia. Exact and simulation approaches were used to estimate ICC values for both the prevalence and the incidence of parasitaemia. In addition, the latent variable approach to estimate ICCs for the prevalence was utilized. Results The ICCs for prevalence ranged between 0.001 and 0.082 for all countries. The ICC from the combined 16 villages in the Greater Mekong Subregion were 0.26 and 0.21 for P. falciparum and P. vivax respectively. The ICCs for incidence of parasitaemia ranged between 0.002 and 0.075 for Myanmar, Cambodia and Vietnam. There were very high ICCs for incidence in the range of 0.701 to 0.806 in Laos during follow-up. Conclusion ICC estimates can help researchers when designing malaria cluster randomized trials. A high variability in ICCs and hence sample size requirements between study sites was observed. Realistic sample size estimates for cluster randomized malaria trials in the Greater Mekong Subregion have to assume high between cluster heterogeneity and ICCs. This work focused on uPCR-detected infections; there remains a need to develop more ICC references for trials designed around prevalence and incidence of clinical outcomes. Adequately powered trials are critical to estimate the benefit of interventions to malaria in a reliable and reproducible fashion. Trial registration: ClinicalTrials.govNCT01872702. Registered 7 June 2013. Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT01872702

Background Adding 8-aminoquinoline to the treatment of falciparum, in addition to vivax malaria, in locations where infections with both species are prevalent could prevent vivax reactivation. The potential risk of haemolysis under a universal radical cure policy using 8-aminoquinoline needs to be weighed against the benefit of preventing repeated vivax episodes. Estimating the frequency of sequential Plasmodium vivax infections following either falciparum or vivax malaria episodes is needed for such an assessment. Methods Quarterly surveillance data collected during a mass drug administration trial in the Greater Mekong Subregion in 2013–17 was used to estimate the probability of asymptomatic sequential infections by the same and different Plasmodium species. Asymptomatic Plasmodium infections were detected by high-volume ultrasensitive qPCR. Quarterly surveys of asymptomatic Plasmodium prevalence were used to estimate the probability of a P. vivax infection following Plasmodium falciparum and P. vivax infections. Results 16,959 valid sequential paired test results were available for analysis. Of these, 534 (3%) had an initial P. falciparum monoinfection, 1169 (7%) a P. vivax monoinfection, 217 (1%) had mixed (P. falciparum + P. vivax) infections, and 15,039 (89%) had no Plasmodium detected in the initial survey. Participants who had no evidence of a Plasmodium infection had a 4% probability to be found infected with P. vivax during the subsequent survey. Following an asymptomatic P. falciparum monoinfection participants had a 9% probability of having a subsequent P. vivax infection (RR 2.4; 95% CI 1.8 to 3.2). Following an asymptomatic P. vivax monoinfection, the participants had a 45% probability of having a subsequent P. vivax infection. The radical cure of 12 asymptomatic P. falciparum monoinfections would have prevented one subsequent P. vivax infection, whereas treatment of 2 P. vivax monoinfections may suffice to prevent one P. vivax relapse. Conclusion Universal radical cure could play a role in the elimination of vivax malaria. The decision whether to implement universal radical cure for P. falciparum as well as for P. vivax depends on the prevalence of P. falciparum and P. vivax infections, the prevalence and severity of G6PD deficiency in the population and the feasibility to administer 8-aminoquinoline regimens safely. Trial registration ClinicalTrials.gov Identifier: NCT01872702, first posted June 7th 2013, https://clinicaltrials.gov/ct2/show/NCT01872702. This study was registered with ClinicalTrials.gov under NCT02802813 on 16th June 2016. https://clinicaltrials.gov/ct2/show/NCT02802813

Background Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)–was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage. Methods and Findings Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study’s ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage. Conclusions The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.