P. vivax malaria in Myanmar

Myanmar

Transmission characteristics

Nearly 32 million people are at risk of malaria in Myanmar from a total population of 53.4 million.
In 2022, there were an 157,533 total malaria cases (vivax, falciparum, and mixed). Political and social instability led to a nearly 650% increase in malaria cases, making Myanmar the largest contributor to South East Asia's malaria burden (92.4% of the regions indigenous cases come from Myanmar).³

Malaria transmission in Myanmar is closely associated with two malaria vectors that inhabit the forest and forest fringe: Anopheles dirus and Anopheles minimus, though there are ten species known to transmit malaria in the region.¹ The peak transmission period is between July and October for most of the country with rainfall peaking between June and August.¹ Adult males are particularly at risk of malaria owing to occupational exposure through mining, forest-related activities, rubber tapping, and construction. Malaria transmission in Myanmar is increasingly heterogeneous, with cases occurring in clusters amongst specific populations.¹

Source: World Malaria Report 2023

Surveillance

Multiple malaria surveillance approaches are used in Myanmar depending on the transmission reduction phase. Nevertheless, only a very small proportion of confirmed malaria cases are investigated. Reported cases account for around 26.93% of the estimated malaria burden (falciparum and vivax). Under-reporting of malaria is highly likely in remote areas and border areas with Thailand and China where access to government healthcare is limited.²

The National Malaria Information System (MIS) in the townships requires expansion and modernisation in support of the move towards elimination.² The country aims to implement a case-based surveillance and response system based on GIS initially in five priority states/regions with low malaria incidence which are eligible for malaria elimination, with further expansion to multiple states/regions where appropriate. In addition to MIS, malaria data needs to be incorporated into the MoH’s District Health Information System (DHIS2).²

2020 milestones/ malaria elimination

Myanmar has already met its 2020 milestones to reduce malaria mortality and malaria case incidence (falciparum and vivax) by at least 40% from 2010 levels.

The National Plan for Malaria Elimination (2016–2030) has the following objectives:

Reducing the incidence of malaria to less than 1 case per 1000 population at risk in all states/regions by 2020;
Interrupting transmission of and eliminating indigenous P. falciparum malaria at least in 6 states/regions (Yangon, Bago, Magway, Mandalay, Nay Pyi Taw Union Territory & Mon) by 2020 and throughout the entire country by 2025;
Interrupting transmission of and eliminating indigenous malaria in a phased, progressing manner across the country by 2030; and
Preventing the re-establishment of local malaria transmission due to importation in all areas where it has been eliminated before and beyond 2030.

Myanmar is included in the Mekong Malaria Elimination (MME) Initiative in the Greater Mekong sub region, supported through a Global Fund financed regional artemisinin-resistance initiative, which aims to eliminate P. falciparum by 2025 and all species of malaria by 2030.

Treatment policy for P. vivax

Chloroquine followed by 14-day primaquine for radical treatment of P. vivax.
Diagnosis and treatment is free of charge in the public sector.

G6PD testing policy

G6PD testing before treatment with primaquine is not part of the national treatment policy.

G6PD deficiency prevalence

In Myanmar, G6PD deficiency prevalence is generally over 10% and may be up to 30% in some groups. G6PD Mahidol is the most common G6PD-deficient variant.

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Region (year)	Findings	Reference
Upper Myanmar: Naung Cho, Pyin Oo Lwin, Tha Beik Kyin townships, and Mandalay (2013–2015)	In malaria patients, using a multiplex allele-specific genotyping kit, G6PD deficiency prevalence was 19.8% (50/252) overall; 20% (43/215) in males and 18.9% (7/37) in females. The predominant deficient variant was G6PD Mahidol (68%, 34/50), of which 91.2% (31/34) and 8.8% (3/34) were males and females, respectively. Other G6PD variants including Kaiping (18%, 9/50), Viangchan (6%, 3/50), Mediterranean (4%, 2/50), Union (2%, 1/50) and Canton (2%, 1/50)	Lee, et al. BMC Infect Dis 2018;18:131.
Kachin ethnic group on China–Myanmar border	Using a quantitative G6PD assay, 24% (24/100) of healthy individuals were G6PD deficient; 11% of (6/53) males had severe G6PD deficiency, while 11% (6/53) of males and 25% (12/47) of females had mild G6PD deficiency. Among the 24 G6PD-deficient subjects, 22 (92%) had the Mahidol 487G>A mutation (12 male hemizygotes, one female homozygote, and nine female heterozygotes)	Deng, et al. PLoS One 2017;12:e0177917.
Kachin (Jingpo) ethnic group on China–Myanmar border	In a survey in 1770 adults (671 males and 1099 females) using the fluorescent spot test, the overall prevalence of G6PD deficiency was 29.6% (523/1770), among which 27.9% and 30.6% were males and females, respectively. In 198 (147 females and 51 males) G6DP-deficient samples selected for genotyping mutations with known association to a deficient phenotype were detected in 43.9% (87/198) of cases. Of the 87 cases with known deficient mutations, the Mahidol variant was the most common (89.7%; 78/87), followed by the Kaiping (8.0%; 7/87) and the Viangchan (2.2%; 2/87) variants. The Canton and Chinese 4 variants were found in 1.1%. Among them, two females carried the Mahidol/Viangchan and Mahidol/Kaiping double mutations	Li, et al. PLoS One 2015;10:e0134593.
Thailand–Myanmar border (2011)	In male outpatients, the G6PD deficiency prevalence by fluorescence spot test was 13.7% (69/504) overall; 14.1% (50/354) in Karen and 12.9% (16/124) in Burman subjects. Among the 69 G6PD-deficient subjects 61 had the Mahidol variant, 3 Chinese-4, 1 Viangchan, 1 Açores, 1 Seattle and 1 Mediterranean	Bancone, et al. PLoS One 2014;9:e116063.
Burmese in Thailand (2008–2009)	Genomic analysis healthy volunteers. In Burmese, G6PD deficiency prevalence was 6.6% (21/317). Almost all (96.2%) samples from the Burmese population carried G6PD Mahidol; only one sample (3.8%) was G6PD Kaiping	Phompradit, et al. Malar J 2011;10:368.
Southern Myanmar population, but conducted in Samutsakhon province, Thailand (before 2008)	G6PD deficiency was identified in 12% (19/162) of Mon males and 10% (17/178) of Burmese males. Among 19 G6PD-deficient Mons, 12 were G6PD Mahidol; one case each was G6PD Jammu, G6PD Kaiping, G6PD Mediterranean, a novel mutation 94(C > G); and three were unidentified. Among 17 G6PD-deficient Burmese, 12 were G6PD Mahidol; one each was G6PD Coimbra, G6PD Kerala-Kalyan, and G6PD Valladolid (406C > T); and two were unidentified	Nuchprayoon, et al. J Hum Genet 2008;53:48–54.
Shan State in southern Myanmar (before 2005)	In samples from 916 members of various ethnic groups, G6PD Mahidol was present in 17.5% (160/916). The Bamar population showed the highest frequencies of G6PD Mahidol (21.2%, 66/311)	Than, et al. Int J Hematol 2005;82:119–23.
Mandalay division; Sagaing division; Sittwe district; Thandwe district in Rakheine state; Yangon City; Kaw Thaung district in Tanintharyi division (1999–2003)	In a survey using two rapid qualitative tests, 11% (121/1000) of individuals were G6PD deficient. Of 50 cases genotyped, 45 were (90.0%) G6PD Mahidol, two G6PD Coimbra, two G6PD Union, and one G6PD Canton. Taken together with data from a previous report (Iwai et al. 2001), 91.3% (73/80) of G6PD variants were G6PD Mahidol	Matsuoka, et al. J Hum Genet 2004;49:544–7.
Yangon, Mandalay; Sagaing, Sagaing division; Sittwe, Rakhine State and Kawthaung, Tanintharyi Division (2002–2003)	In a survey using the WST-8 test, G6PD deficiency (severe and mild deficiency) was detected in 10.6% (91/855); 11.6% (50/430) in males and 9.6% (41/425) in females. 6.7% (57/855) were severe (45/430 males and 12/425 females) and 4.0% (34/855) mild (5/430 males and 29/425 females). G6PD deficiency prevalence was highest in the Rakhine (20.2%, 36/178) then Shan (15.4%; 2/13), Burmese (8.5%; 42/495), Bengali (3.7%; 2/54) and Pashu (2.9%; 1/34).	Jalloh, et al. Trop Med and Int Health 2004;9:615–23.
Unspecified (before 2001)	In 30 G6PD-deficient subjects from Myanmar, 28 were G6PD Mahidol, and 1 each was Union and Canton	Iwai, et al. Hum Genet 2001;108:445–9.
Lashio township in northern Shan State, and Kyaik Ma Yaw and Mudon townships in Mon State (1997)	In a survey using the formazan ring test, 4.4% (47/1079) had severe G6PD deficiency; 6.6% (37/558) in males and 1.9% (10/521) in females. 1.4% (15/1079) had mild G6PD deficiency. By ethnic group G6PD deficiency prevalence in males was Burmese 7.2% (22/307), Chinese 4.2% (4/95), Indian (7.7% (5/65), Mon 6.8% (3/44), Shan 8.0% (2/25), Kachin 11.1% (1/9), other 0% (0/13). In females, G6PD-deficiency prevalence was 2.9% (7/243) in Burmese, 2.1% (2/96) in Chinese and 2.9% (1/34) in Shan and absent for other ethnic groups	Tantular, et al. Trop Med Int Health 2002;4:245–50
Thayarwady Township and Mingaladon, Yangon	In patients with severe falciparum malaria, 9.7% (37/383) had mild G6PD deficiency and 6.8% (26/383) had severe deficiency	Oo, et al. Bull World Health Organ 1995;73:659–65.

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Myanmar

Transmission characteristics

Surveillance

2020 milestones/ malaria elimination

Treatment policy for P. vivax

G6PD testing policy

G6PD deficiency prevalence

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South East Asia

Related resources

Malaria elimination in remote communities requires integration of malaria control activities into general health care: an observational study and interrupted time series analysis in Myanmar.

The contribution of asymptomatic Plasmodium infections to the transmission of malaria in Kayin state, Myanmar.

Prevalence of Clinical and Subclinical Plasmodium falciparum and Plasmodium vivax Malaria in Two Remote Rural Communities on the Myanmar-China Border.

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