Ngamphol Soonthornworasiri

Effects of edutainment on knowledge and perceptions of Lisu mothers about the immunisation of their children

Objective: This study assessed the immediate effects of edutainment modules on changes in knowledge and perceptions towards the Expanded Programme for Immunisation (EPI) among an under served minority (Lisu) population. Method: An edutainment module was developed on mobile tablets for use by village health volunteers. As the study was conducted among a vulnerable population in a low-resource setting, it was designed as a simple pre–post assessment without a comparison group. Results: Participating Lisu mothers accepted and understood the edutainment module, and the intervention appears to have successfully improved their knowledge and perceptions of EPI. Tests showed a significant immediate improvement in knowledge, and an increasing proportion of participants reported having positive perceptions of the EPI process. The edutainment module may be an effective tool for highlighting the importance of appropriate practices and addressing misconceptions. Conclusion: The edutainment modules were considered user-friendly and attractive health-promotion tools by both health-care providers and villagers. This initiative’s effect on knowledge and perceptions towards child immunisation programmes among this group showed the positive potential of using modern technology when approaching hard-to-reach, under-vaccinated populations.

Estimating the Impact of Expanding Treatment Coverage and Allocation Strategies for Chronic Hepatitis C in a Direct Antiviral Agent Era

Hepatitis C virus (HCV) infection is an important worldwide public health problem, and most of the global HCV burden is in low- to middle-income countries. This study aimed to estimate the future burden of chronic hepatitis C (CHC) and the impact of public health policies using novel antiviral agents in Thailand. A mathematical model of CHC transmission dynamics was constructed to examine the disease burden over the next 20 years using different treatment strategies. We compared and evaluated the current treatment (PEGylated interferon and ribavirin) with new treatments using novel direct-acting antiviral agents among various treatment policies. Thailand’s CHC prevalence was estimated to decrease 1.09%–0.19% in 2015–2035. Expanding treatment coverage (i.e., a five-fold increment in treatment accessibility) was estimated to decrease cumulative deaths (33,007 deaths avoided, 25.5% reduction) from CHC-related decompensated cirrhosis and hepatocellular carcinoma (HCC). The yearly incidence of HCC-associated HCV was estimated to decrease from 2,305 to 1,877 cases yearly with expanding treatment coverage. A generalized treatment scenario (i.e., an equal proportional distribution of available treatment to individuals at all disease stages according to the number of cases at each stage) was predicted to further reduce death from HCC (9,170 deaths avoided, 11.3% reduction) and the annual incidence of HCC (i.e., a further decrease from 1,877 to 1,168 cases yearly, 37.7% reduction), but cumulative deaths were predicted to increase (by 3,626 deaths, 3.7% increase). Based on the extensive coverage scenario and the generalized treatment scenario, we estimated near-zero death from decompensated cirrhosis in 2031. In conclusion, CHC-related morbidity and mortality in Thailand are estimated to decrease dramatically over the next 20 years. Treatment coverage and allocation strategies are important factors that affect the future burden of CHC in resource-limited countries like Thailand.

Burden of Liver Abscess and Survival Risk Score in Thailand: A Population-Based Study

In Thailand, the burden of liver abscess, a life-threatening infectious disease, has not been thoroughly evaluated. We developed a predictive scoring system to estimate survival of patients with liver abscess using information from the 2008-2013 Nationwide Hospital Admission Data to evaluate the burden of liver abscess in Thailand. All patients with primary diagnosis of pyogenic liver abscess (PLA) and amoebic liver abscess (ALA) were included. Epidemiological data, baseline characteristics, hospital course, and survival were analyzed. Overall, 11,296 admissions comprising 8,423 patients from 844 hospitals across Thailand were eligible for analysis. The mean age was 52 ± 17 years and 66.1% of patients were male. ALA was significantly prevalent in southern and western border regions of Thailand, and PLA occurred nationwide. The highest incidence of liver abscess occurred in the rainy season (June-November, P < 0.01). The median length of hospital stay was 8 days (interquartile range = 4-13 days), and mean direct cost of hospitalization was 846 ± 1,574 USD. The overall inhospital mortality rate was 2.8%. Incidence of ALA decreased over the 5-year study period, whereas PLA incidence increased (P < 0.01). Using multivariable Cox regression methods with stepwise variable selection, we developed a final model with five highly significant baseline parameters associated with increased 60-day mortality: older age, PLA, underlying chronic kidney disease, cirrhosis, and human immunodeficiency virus infection. Range of estimated probability of 60-day survival was 95-16% at cumulative risk score 0-13. This simplified score is practical, and may help clinicians prioritize patients requiring more intensive care.

Effectiveness of Implementation of Electronic Malaria Information System as the National Malaria Surveillance System in Thailand.

Background In moving toward malaria elimination, one strategy is to implement an active surveillance system for effective case management. Thailand has developed and implemented the electronic Malaria Information System (eMIS) capturing individualized electronic records of suspected or confirmed malaria cases. Objective The main purpose of this study was to determine how well the eMIS improves the quality of Thailand’s malaria surveillance system. In particular, the focus of the study was to evaluate the effectiveness of the eMIS in terms of the system users’ perception and the system outcomes (ie, quality of data) regarding the management of malaria patients. Methods A mixed-methods technique was used with the framework based on system effectiveness attributes: data quality, timeliness, simplicity, acceptability, flexibility, stability, and usefulness. Three methods were utilized: data records review, survey of system users, and in-depth interviews with key stakeholders. From the two highest endemic provinces, paper forms matching electronic records of 4455 noninfected and 784 malaria-infected cases were reviewed. Web-based anonymous questionnaires were distributed to all 129 eMIS data entry staff throughout Thailand, and semistructured interviews were conducted with 12 management-level officers. Results The eMIS is well accepted by system users at both management and operational levels. The data quality has enabled malaria personnel to perform more effective prevention and control activities. There is evidence of practices resulting in inconsistencies and logical errors in data reporting. Critical data elements were mostly completed, except for a few related to certain dates and area classifications. Timeliness in reporting a case to the system was acceptable with a delay of 3-4 days. The evaluation of quantitative and qualitative data confirmed that the eMIS has high levels of simplicity, acceptability, stability, and flexibility. Conclusions Overall, the system implemented has achieved its objective. The results of the study suggested that the eMIS helps improve the quality of Thailand’s malaria surveillance system. As the national malaria surveillance system, the eMIS’s functionalities have provided the malaria staff working at the point of care with close-to-real-time case management data quality, covering case detection, case investigation, drug compliance, and follow-up visits. Such features has led to an improvement in the quality of the malaria control program; the government officials now have quicker access to both individual and aggregated data to promptly react to possible outbreak. The eMIS thus plays one of the key roles in moving toward the national goal of malaria elimination by the next decade.

Factors affecting mortality and resource use for hospitalized patients with cirrhosis: A population-based study

Abstract Hospitalizations for advanced liver disease are costly and associated with significant mortality. This population-based study aimed to evaluate factors associated with in-hospital mortality and resource use for the management of hospitalized patients with cirrhosis. Mortality records and resource utilization for 52,027 patients hospitalized with cirrhosis and/or complications of portal hypertension (ascites, hepatic encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, or hepatorenal syndrome) were extracted from a nationally representative sample of Thai inpatients covered by Universal Coverage Scheme during 2009 to 2013. The rate of dying in the hospital increased steadily by 12% from 9.6% in 2009 to 10.8% in 2013 (P < .001). Complications of portal hypertension were independently associated with increased in-hospital mortality except for ascites. The highest independent risk for hospital death was seen with hepatorenal syndrome (odds ratio [OR], 5.04; 95% confidence interval [CI], 4.38–5.79). Mortality rate remained high in patients with infection, particularly septicemia (OR, 4.26; 95% CI, 4.0–4.54) and pneumonia (OR, 2.44; 95% CI, 2.18–2.73). Receiving upper endoscopy (OR, 0.29; 95% CI, 0.27–0.32) and paracentesis (OR, 0.93; 95% CI, 0.87–1.00) were associated with improved patient survival. The inflation-adjusted national annual costs (P = .06) and total hospital days (P = .07) for cirrhosis showed a trend toward increasing during the 5-year period. Renal dysfunction, infection, and sequelae of portal hypertension except for ascites were independently associated with increased resource utilization. Renal dysfunction, infection, and portal hypertension-related complications are the main factors affecting in-hospital mortality and resource utilization for hospitalized patients with cirrhosis. The early intervention for modifiable factors is an important step toward improving hospital outcomes.

Hepatitis B vaccination for international travelers to Asia

There is a wide range in prevalence of hepatitis B virus (HBV) infection and HBV immunization programs between different regions. Hepatitis B is a vaccine preventable disease yet is still endemic in the majority of countries in Asia. Despite the decreasing global prevalence of chronic HBV infection, there is still considerable risk of HBV infection among international travelers to high endemic areas. Numbers of international travelers are expected to increase year by year; thus immunization among this cohort is a crucial preventive measure. Among international travelers to Asia, HBV immunization should be recommended for those without previous HBV vaccination who plan to travel to countries with intermediate to high prevalence of HBV, and especially for those individuals at greater risk of HBV infection; including travelers engaging in casual sex, getting a tattoo or piercing, and those having dental surgery or other medical procedures. Longer duration of travel is also associated with a greater risk of HBV infection. Travelers from low HBV prevalence countries, especially those born before implementation of universal HBV vaccination, might benefit from HBV vaccination during long-term traveling to HBV intermediate to high endemic country.

Enhancing Epidemic Detection Using Syndromic Surveillance and Early Notification Methods

Objective This paper presents an investigation using early notification methods to enhancing epidemic detection in syndromic surveillance data from royal Thai army in Thailand. Introduction Early Notification Detection Systems have taken a critical role in providing early notice of disease outbreaks. To improve the detection methods for disease outbreaks, many detection methods have been created and implemented. However, there is limited information on the effectively of syndromic surveillance in Thailand. Knowing the performance, strengths and weakness of these surveillance systems in providing early warning for outbreaks will increase disease outbreak detection capacity in Thailand. Methods This study describes and compares the capabilities of various outbreak detection algorithms using 37,043 unique syndromic daily reports based on medical information from both civilian and military personnel from the Unit Base Surveillance of Royal Thai Army (RTA) along the Thai-Myanmar and Thai-Cambodia boarder areas. Traditional epidemic detection method: mean plus two SD were compared with algorithms for early notification methods and which included regression, regression/EWMA/Poisson, CDC-C1, CDC-C2 and CDC-C3. Early notification and epidemic detection methods were compared according to their ability to generate alert notifications. Sensitivity, specificity, positive predictive value (PPV), negative predictive value and overall accuracy to detect or predict disease outbreaks were estimated. Results This study shows that the preliminary results are promising for epidemic detection by early notification methods in syndromic surveillance in Thailand. The majority of syndromic records were categorized into 12 symptoms. The three most common symptoms were respiratory, fever and gastrointestinal illness (11,501; 9,549 and 4,498 respectively). The results from the early notification systems were analyzed and their performances were compared with traditional epidemic detection method according to their ability to generate early warning alerts for the 3 symptoms. In our study regression/EWMA/Poisson method had higher specificity across the 3 symptoms (94.5%, 94.7% and 95.9% respectively), but generated lower sensitivity (22.6%, 40.4% and 23.1%). CDC-C1, CDC-C2 and CDC-C3 algorithms are easy to understand and are widely used. CDC-C3 had higher sensitivity to detect gradual disease outbreak effects (64.2%, 70.2% and 57.7%), but it is known to produce higher alarm rates/false positive signals. Conclusions Within the syndromic surveillance data of RTA, the CDC algorithm is the best chosen to use in the syndromic system due to being easy to understand and implement in a system with high sensitivity. CDC-C2 is the best early notification detection method due to its high sensitivity and PPV. However, CDC-C3 is shows the highest sensitivity, but exhibits the lowest specificity and PPV for all symptoms including a high alarm rates. To be useful, early notification detection methods must have acceptable operating characteristics. Consequently, we should select the most appropriate algorithm method to explain the data well and in order to improve detection of outbreaks. The comparison methods used in this study may be useful for testing other proposed alert threshold methods and may have further applications for other populations and other diseases. References 1. Chretien JP, Burkom HS, Sedyaningsih ER, Larasati RP, et al. Syndromic Surveillance: Adapting Innovations to Developing Settings. PLoS Medicine 2008; vol 5: page 1-6. 2. Burkom HS, Elbert Y, Magruder SF, Najmi AH, Peter W, Thompson MW. Developments in the roles, features, and evaluation of alerting algorithms for disease outbreak monitoring. Johns Hopkins APL Technical Digest 2008; vol 27: page 313.

Immunodominance of LipL3293–272 peptides revealed by leptospirosis sera and therapeutic monoclonal antibodies

BACKGROUND/PURPOSE Leptospirosis is a neglected zoonosis, imposing significant human and veterinary public health burdens. In this study, recombinant LipL3293-147 and LipL32148-184 middle domain of LipL3293-184, and LipL32171-214, and LipL32215-272 of c-terminal LipL32171-272 truncations were defined for immunodominance of the molecule during Leptospira infections revealed by leptospirosis sera. RESULTS IgM-dominant was directed to highly surface accessible LipL32148-184 and Lipl32171-214. IgG dominance of LipL32148-184 revealed by rabbit anti-Leptospira sera and convalescent leptospirosis paired sera were mapped to highly accessible surface of middle LipL32148-184 truncation whereas two LipL32148-184 and LipL32215-272 truncations were IgG-dominant when revealed by single leptospirosis sera. The IgM-dominant of LipL32148-214 and IgG-dominant LipL32148-184 peptides have highly conserved amino acids of 70% identity among pathogenic and intermediate Leptospira species and were mapped to the highly surface accessible area of LipL32 molecule that mediated interaction of host components. IgG dominance of two therapeutic epitopes located at LipL32243-253 and LipL32122-130 of mAbLPF1 and mAbLPF2, respectively has been shown less IgG-dominant (<30%), located outside IgG-dominant regions characterized by leptospirosis paired sera. CONCLUSION The IgM- and IgG-dominant LipL32 could be further perspectives for immunodominant LipL32-based serodiagnosis and LipL32 epitope-based vaccine.

Monitoring arbovirus in Thailand: surveillance of dengue, chikungunya and Zika virus, with a focus on coinfections

Infections caused by arboviruses such as dengue virus (DENV), chikungunya virus (CHIKV), and Zika virus (ZIKV) frequently occur in tropical and subtropical regions. These three viruses are transmitted by Aedes (Ae.) aegypti and Ae. albopictus. In Thailand, the highest incidence of arbovirus infection and the high circulation of Aedes mosquito mainly occurs in the Southern provinces of the country. Few studies have focused on the incidence of co-infection of arboviruses in this region. In the present study, a cross-sectional study was conducted on a cohort of 182 febrile patients from three hospitals located in Southern Thailand. Surveillance of DENV, CHIKV and ZIKV was conducted from May to October 2016 during the rainy season. The serological analysis and molecular detection of arboviruses were performed by ELISA and multiplex RT-PCR respectively. The results demonstrated that 163 cases out of 182 patients (89.56%) were infected with DENV, with a predominance of DENV-2. Among these DENV positive cases, a co-infection with CHIKV for 6 patients (3.68%) and with ZIKV for 1 patient (0.61%) were found. 19 patients out of 182 were negative for arboviruses. This study provides evidence of co-infection of arboviruses in Southern Thailand and highlight the importance of testing DENV and other medically important arboviruses, such as CHIKV and ZIKV simultaneously.

Characteristics and outcomes of cholangiocarcinoma by region in Thailand: A nationwide study.

AIM To identify the potential risk factors of cholangiocarcinoma, we determined the characteristics of cholangiocarcinoma patients among 5 different regions of Thailand. METHODS All patients diagnosed with cholangiocarcinoma between 2008 and 2013 were identified using the Nationwide Hospital Admission Data registry (n = 39421). Baseline characteristics, comorbidities and survival were abstracted. RESULTS The annual incidence during the study period was stable in all regions. Most patients lived in the Northeast (62.8%), followed by the North (16.9%), Central (12.3%), Bangkok (5.4%), and South (n = 2.6%) regions (P < 0.0001). Significantly more cholangiocarcinoma patients had diabetes, cirrhosis, and chronic viral hepatitis B/C infection than non-cholangiocarcinoma participants (diabetes: 11.42% vs 5.28%; cirrhosis: 4.81% vs 0.92%; hepatitis B: 0.74% vs 0.12%; and hepatitis C: 0.50% vs 0.10%, P < 0.0001 for all, respectively). The overall 1-year mortality rate was 81.7%, with a stable trend over time. CONCLUSION Diabetes and chronic liver diseases may be associated with cholangiocarcinoma in the Thai population.