Within the diverse aggregates of te

Within the diverse aggregates of temporary mobile/migrant workers in Kawthaung and Bokepyin townships (Figures 2 and 3), the working hours of adult migrant workers including women varied with the type of economic activities. Transportation constraints, as well as severe weather and security concerns particularly at night, hampered the workers’ access to formal health services for EDPT. Even though some study aggregates were within the reach of malaria care providers and the public health facilities (Figures 2 and 3), their frequency of visits to the assigned migrant aggregates was unknown, and a high mobility of some temporary aggregates (e.g. fishing communities who moved every 2–3 months) may make the provider visit difficult. The distribution mechanisms of commodities such as ITNs/LLINs, rapid diagnostic test (RDT), and artemisinin combination therapy (ACT) to these aggregates through public health facilities required special attention. Replacement of oral artemisinin-based monotherapy in market with subsidized ACT and RDT through social marketing was designated as one of the key activities of NMCP [9]. We found that there were many multilingual ethnic groups in the region, and the distribution of health education messages only in Myanmar language may lead to limited understanding and receptiveness. Although the majority of the migrant populations understood Myanmar language, limited education level may impede their understanding of the message [11]. As shown in other studies conducted in similar circumstances [8,14-16], these physical, social and language barriers in the study population likely increase the potential risk in malaria transmission and spread of artemisinin resistance. Effective communication in this diverse high-risk group is critical and may be better reached by the use of simple language, inclusion of common ethnic languages in addition to Myanmar, and/or well-trained motivated interpreters.

About a one-half of the study population did not know that malaria should be diagnosed using microscopy or RDT, and only negligible number could name the recommended malaria drugs. This observation is consistent with the previous finding during the MARC survey [1]. As observed in other studies [16], self-medication practices were common, andthe private sector was typically preferred over the public sector. The majority of the migrant workers reported to rely on cocktail mixtures of drugs or artemisinin monotherapy, rather than prescribed ACT, freely available in the unregulated private sectors. The limited availability of ACT has been seen in the past due to inconsistent supplies and stock-outs, as reported in MARC Health Facility Survey in 2012 [1]. However with a highly successful marketing of subsidized ACT, these events are likely to be rare.

Interestingly there is a significant discrepancy in knowledge, attitude and practice of ITNs/LLINs. Apparently two nets per 5 persons was reported to be inadequate. Despite good knowledge of ITNs as protective measure of malaria, the reported rate of ITN use was low. Many of the migrant workers were outdoor night-time workers (e.g. plantation workers, wood cutters, rubber tappers, rat-catchers, etc.), and they did not use ITNs/LLINs, consistent with previous findings in Thailand [17]. Innovative methods of personal protection and behavioral change models are needed to optimize the use of ITNs/LLINs in the high-risk populations.

Currently, the non-governmental organizations (NGOs) working for malaria in villages/migrant aggregates in study townships included Myanmar Medical Association, Population Services International, and World Vision, Myanmar. Myanmar is the third country to initiate multilateral actions against artemisinin resistance in the Greater Mekong Sub-region, with support from Department for International Development (DFID) [18]. Our finding indicated that the majority of the respondents preferred volunteers (>75%) to strengthen prevention and control measures against malaria and over 50% preferred to channel information, education and communication (IEC) messages through collaboration in the locality. Findings from our study and others highlighted the need to improve the mechanisms of communication and coordination among multiple partners engaged in artemisinin resistance [8,9]. Potential strategies to maximize accessibility to malaria interventions may include the following: 1) tracking of foci of infections in mobile populations and mapping of the extent and distribution of malaria infections [19]; 2) real-time frequent sharing of information on drug resistant malaria; 3) frequent update of counterfeit and sub-standard antimalarial drug use; 4) setting up contact screening points for improved availability and use of RDTs and optimal use of quality antimalarial drugs.