SitRep: Myanmar

Myanmar, a Southeast Asian country on China’s border China, currently has one of the lowest rates of confirmed numbers in the world with the first cases only confirmed in late March. A month ago, we would have assumed a First Wave from China had hit countries like Myanmar early. The Ministry of Health had no COVID response until March, officials made controversial statements, and there was growing criticism on social media about their early delays. Before the research for this report, we would have assumed the extremely low numbers were either because of under-testing or a cover-up. However, evidence from neighboring countries would support the official narrative that COVID-19 likely entered the country sometime in March and Myanmar’s emphasis on centralized quarantine make us cautiously optimistic that the scale of the outbreak is indeed low.

At the time of writing, have slowly ticked up to 150 cases found in six provinces. Between March 23rd and 29th, they found eleven cases with travel history in the Unites States (5), Europe (4), UK (4), Thailand (4), Singapore (3). While the wide geographic distribution and low levels of testing capacity are arguments that the outbreak is larger, there are currently more than 3000 Persons Under Investigation and the test-to-confirmed ratio is 51:1. The number is 5.5 in the United States and 97.3 in New Zealand. This would indicate that the situation might be under control.

Vietnam tests per positive

The greatest issue of public concern over COVID-19 are the hundreds of thousands of migrant workers in places like Thailand trying to return because they’re out of work now due to lockdown and the collapse of the travel industry, or might return for the Burmese New Year. It has a huge impact in terms of increasing fear in the general public general public. This was also the case in early February, when students from Wuhan were evacuated by the Myanmar government to Mandalay for quarantine at Kandaw Nadi Hospital for fourteen days. After that, due to lack of preparation for prevention, both in human resources and technical terms, intervention and other control measures, a lot of humor appears which create fears for the people in Myanmar until the first two cases were found. Myanmar got a lot of time to prepare for combating COVID-19, but they failed to prepare enough.

Health System in Myanmar

The health care sector of Myanmar is led by Ministry of Health with the cooperation of international organization. In Myanmar, it lacks the sector for outbreaks preparation. It has two separate hospitals for outbreak. One is Waibagi Hospital in Yangon and another one is Kandaw Nadi Hospital in Mandalay. They have been in unused condition for years after the outbreak of SARS. In Myanmar, the formation of health facilities makes rural health community to access medical doctors. Myanmar hospital are ranked into 4 categories; general hospitals (up to 2,000 beds), specialist hospitals and teaching hospitals (100–1,200 beds), regional/state hospitals and district hospitals (200–500 beds), and township hospitals (25–100 beds). In rural health sectors, medical doctors are only available in station hospital, rural health centers and sub centers don’t have any medical doctor. They are supervised by health assistant. So, the availability of health services in rural areas is limited.

Current Situation of COVID-19 outbreaks in Myanmar

Officially, there was no confirmed COVID-19 in Myanmar until 23rd March, 2020. As noted earlier, both experts and civil society were skeptical about the official numbers given proximity to China and Chinese cross-border traffic. In Kachin state, Chinese people were going in and out both legally and illegally. The government also didn’t have plan to monitor or close the border. However, there were only a small number of cases in the neighboring Chinese province of Yunnan. The most trafficked border-town, Xishuangbanna, only record fifteen cases.

People believe it was due to less testing capacity of Myanmar, but Dr. Frank Smithuis, an epidemiologist and associate professor at Oxford University, working more than 20 years in Myanmar, comments the positive rate may be more than reported, but it is not possible to be a huge transmission as the number of hospitalization is normal despite the facts that outbreaks can increase the admission rate of hospital with sever COVID-19 symptoms.

Two new COVID-19 cases confirmed on 23rd March, 2020 were imported from US and UK respectively. The results were announced at midnight, but soon after the announcement of the results, panic buying was seen even in the midnight of Yangon and Mandalay, two major cities of Myanmar and City Mart and some supermarket are flooded with panic buyers. This cluster of panic buyers could increase the risk of transmission, but people were not aware of that and trying to buy dry food

The daily COVID-19 confirmed number

As of 10 AM Myanmar Standard Time, 22nd April 2020, Myanmar have 121 confirmed cases with 5 deaths and 9 recovered patients. The transmission was not more than a digit before 11st March 2020. It leapt to 10 on 12nd April, 2020 and then to 21 on 13rd Apr, 2020 which caused panic in general public. State Counselor Daw Aung San Suu Kyi also warned people more cases might be uncovered by the end of April and not to panic if the numbers rise. Currently most of the cases found are in Yangon, but there are concerns about an outbreak spreading to the rural interior where already limited healthcare capacity is stretched thin.

COVID-19 Testing

Myanmar government allocated 300 million MMK (USD 206,000) for buying equipment, medicine, laboratories and protective gear. The amount is small compared to Thailand’s budget of 1 billion baht (40 billion MMK or 34 million USD) for COVID-19 tests and 6.2 billion baht (270 billion MMK or 190 million USD) for buying medical supplies. Myanmar will likely need to rely on international donation and aids to prepare for COVID-19 response. We have found reports of China and Korea have donated tests and PPE gear

Myanmar had no lab approved for PCR testing until February 20th. All the samples collected were sent to a reference lab in Thailand for testing. After receiving the lab equipment from Thailand’s Armed Forces Research Institute of Medical Science (AFRIMS) through WHO and Japan’s National Institute of Infectious Diseases (NIID), National Center for Global Health and Medicine (NCGM) and Juntendo University through Japanese Embassy and JICA, Myanmar prepared to run an independent lab test for COVID-19 on 20th Feb 2020.

According to the government spokeperson Dr. Thar Tun Kyaw, appointed on 30th March 2020 regarding COVID-19 response, national health laboratory (NHL) can test 300 tests/days. Before the Chinese medical expert team arrived in Myanmar, the testing capacity was around 60 to 70 per days. On 8th April 2020, a Chinese team arrived and they collaborate with national health lab and help NHL to test 200 samples per day. The number of confirmed cases has increased alongside testing capacity. Currently, the testing capacity of NHL is around 300-500 tests per day and the number of confirmed cases is around 10-20 per day. Currently, Myanmar have tested 7,718 samples of suspected cases and 150 cases were confirmed, meaning 1.9% of the total samples are found to be positive.

As the whole country have only one lab for COVID-19 testing, all the hospital near or far must send the samples to Yangon for testing. National Health lab already have challenges both in human resources and testing kits. National health lab has more than 200 staff but only have seven microbiologists to perform the COVID-19 testing. The preparation and limited resources of NHL is not enough to cover the whole country if the outbreak is much larger than current numbers indicate. Even sending the samples became a challenge for hospitals and NHL.

Currently, the Myanmar government is trying to improve the testing capacity. Deputy Director of NHL, Dr. Ohnmar Swe Tin said they are planning to open another test center in Mandalay, located in upper Myanmar, to handle tests from northern Myanmar, for COVID-19 testing to reduce the burden of NHL. It will also make the northernmost part of the country to be more accessible to send the samples. A pharmaceutical company in Myanmar donated testing machines that can process 1300 samples a day. Testing capacity will be dramatically increased once this becomes available, but will still be low by international standards

CountryTests/1M PopCountryTests/1M Pop
Myanmar96Thailand2,043
Indonesia184Vietnam2,119
Laos 201Malaysia3,402
Cambodia345Singapore16,203
Philippines625Brunei27,770
Tests per 1 million population in ASEAN countries
Source – Worldometer

Plans for Confirmed Cases

The confirmed patients are sent to Kandaw Nadi Hospital if they are in Mandalay and to Waibargi Hospital and South Okkalapa Women’s Hospital and Children’s Hospital if they are in Yangon for further management. Confirmed cases from others state and regions are sent to their respective state or region hospitals. Then, government set lockdown orders for the home of the patients, and sometimes close whole streets where clusters are suspected. Because the hospital capacity of Kandaw Nadi and Waibargi Hospital is low, MoHS planned to open a separate hospital for COVID-19 cases. The place chosen is Central Institute of Civil Service (Hpaung Gyi) in Hlegu Township, Yangon Region.

Hpaung Gyi Central Institute of Civil Service have changed to Hpaung Gyi Health Center according to the WHO guidelines. At the start of operation, the center will have 240 beds, 240 HDU beds, 20 ICU beds. As a beginning steps, the hospital will be run by about 200 staffs which will be filled 20% by Military, 20% by Private Sectors and 60% by MoHS. As a second steps, the health center will expand to 480 beds, 480 HDU beds and 40 ICU beds which can later expand to 2000 bedded hospital. Currently the capacity of Waibargi Hospital has reached and so COVID-19 patients from Yangon are referred to South Okkalapa Women’s Hospital and Children’s Hospital. If there is an overload of Waibargyi hospital, some COVID-19 patients will be transferred to Hpaung Gyi Health Center. Professor Zaw Lynn Aung from University of Medicine 1, Yangon will lead the team to manage the hospital in Hpaung Gyi.

Interventions

Myanmar is relying heavily on contact tracing. A religious event in Insein Tsp, held despite a ban on public assemblies, spread more the 50 COVID-19 cases. Public health officials have tried to trace their close contacts and detected some cases in the process. Yangon government have charged four persons including a pastor to warn the public not to continue the illegal gathering of the religious and social organization. So far, most new confirmed cases are detected from close contacts of known cases. Myanmar also launched a web platform for the public to report themselves if they have close contact with the confirmed or suspected cases.

The government banned all public events from March 13th until the end of April to mitigate the spread of COVID-19. The government try several strategies to mitigate the spread of COVID-19. Myanmar have done all the interventions as far as they can to protect the imported cases not to transmit locally. So far, 21 cases were imported and 129 were community transmission. As soon as the first two cases was detected, Myanmar government started soft or partial lockdown.

At that time, most of the universities in Myanmar were holding examinations. The students’ unions requested a postponement which the government accepted. At the same time, some of the major cities in Myanmar, such as Yangon and Mandalay didn’t allow to sit in any restaurants, café and beer station and only allowed for take-away orders. People are encouraged to stay at home, hand washing, social distancing and wearing mask. To limit panic buying, government committed to keep food shops, pharmacies, and wet markets open. The highway bus system reduced the numbers of passenger to half capacity, but it was not closed at that time.

On 7th Apr 2020, the intensity of lockdown status was raised. Highway busses were banned and the lockdown become more intense. All the inns, hotels, motels, guest houses, construction companies, and clothing shops were forced to close while essential shops such as pharmacies, clinics, hospital, drug factories, gas stations, food production, restaurants, Electricity Supply Enterprise (ESE) remain opened. If closed, these shops will be punished by law. Cars for household use more than 5 passengers are not allowed. As seen in other places, the government didn’t use the word “lockdown,” which occured during Thingyan Festival (like Songkran in Thailand) long public holiday of Myanmar. The net effect is that shops are closed, though not because of the lockdown. All festival events and celebrations were banned to curb the outbreak.

After Thingyan Festival, government increased the length and intensity of lockdown. It steadily moves to hard lockdown. On 20th Apr 2020, Mandalay regional government published an order to extend the lockdown, but the number of the person in the cars for household use reduced to 4. Some more intense orders are also announced in other statement such as not to go out between 9 PM to next day 4 AM in which the mayor said it is not curfew, but just an order, and allowing only a person from each household to buy food and medicine. The government also ordered mandatory face masks to be worn outside the house. In Yangon region, more intense lockdown plan were placed for seven townships such South Okkalapa, Pa Bae Tan, Bahan, Ma Yan Gone, Shwe Pyi Tar and Hlaing Tar Yar to reduce the transmission rate. If they want to go out with more than allowed person, they need to get permission from ward administrator.

Currently, almost all the township in Myanmar are following the way of Mandalay region government.

READ: Alternatives to Hard Lockdown

https://twitter.com/ThaungTun20/status/1251372477244047365

Quarantine

Quarantine is one of the most important method to mitigate the spread of COVID-19 cases. Myanmar started quarantine for international arrivals from eight countries, then expending it for all international travelers, and finally closed the airport. Starting in March, there was massive movement of migrant workers returning home from neighboring countries like Thailand that was growing uncontrollable. MoHS commented at the time that the situation presented a very high risk of major outbreak, so created a map of returnee destinations and ordered local health centers to quarantine them. While offering some quarantine facility, most were encouraged to home quarantine because local health departments could not centrally quarantine such large numbers of people.

In response, MoHS worked with communities to develop community-based facility quarantine in every township and even in most villages. Even though government didn’t provide instructions for the village level of governance, village leaders and their people make quarantine centers to isolate all the travelers in their home villages for 14 days. MoHS, in cooperation with regional government, CSO, religious organizations and community groups also opened quarantine centers to accommodate larger numbers. The Director of the Yangon regional government said that about 3,000 quarantine centers are ready to operate that can accept at least 20,000 people. In Mandalay, at least a thousand quarantine centers are prepared.

After some of the cases emerged that didn’t show symptoms within 14 days, MoHS extended the duration of quarantine to 21 days facility quarantine and another seven days of home quarantine. Because Myanmar have less capacity in treating and testing patients, prevention with certain intervention especially quarantines can help a lot to mitigate the outbreak and detect cases as soon as they are in quarantine center.

Currently, Myanmar handled 198 hospital quarantine and 43,538 persons are in facility quarantine.

Other Government Intervention     

Myanmar is one of the poorest countries and depends on international donation in several sectors. When COVID-19 hit the country, it is quite hard for the government to manage and contain it. However, Myanmar tried several ways to slow down the transmission, help the most vulnerable, reduce the panic of the public and raise the morality of their own staffs. Some of the intervention government have implement and are still implementing and affecting are as followed:

  • Rice 8 Pyay (equivalent to 23 lb), Oil 50 Kyattar (equivalent to 0.815 kg), Pea 1 Peittha (equivalent to 1.63 kg), Onion 1 Peittha (equivalent to 1.63 kg) was given to the poor who have no regular income to cover the long Thingyan Periods which co-incided with lockdown.
  • Free Electricity up to 150 Units for household, Religious Organization and Local Non-government Organizations (excluding UN, Embassy and INGOs).
  • In cooperation with Union of Myanmar Federation of Chambers of Commerce and Industry (UMFCCI), low interest loan, 1% per year, was given to the people who are affected by COVID-19.
  • On March 22, Myanmar added mandatory 14-day quarantine for returnees who had traveled in the USA, Switzerland, Britain, the Netherlands, Austria, Belgium, Norway, Sweden and Denmark within the past fourteen days.
  • This was expanded to all people with international travel history on March 24th and travelers need a certificate declaring them free of COVID-19 issued 72 hrs before arrival.
  • On 29th March, 2020, all visas were suspended to stop the international visitors to travel Myanmar
  • Myanmar also banned all the international commercial flight until April 13, later it extend to the end of April. Medical evacuation, cargo, special flight and relief are not affected but need to pre-approval from the Department of Civil Aviation.
  • The government also temporarily reduced 50% of their workforce, except health staffs.
  • The government don’t allow staff to return home after the long Thingyan holiday to avoid the transmission of disease from other locations. Some had already returned to work in their hometown so were placed in community-based facility quarantine for 21 days and 1 week home quarantine.
  • The government asked telecoms to reduce their price to make work-at-home and home entertainment entertainment cheaper and easier.
  • State Counsellor Videoconferencing Call with Public and health staffs to know the challenges of them, to increase their bravery and morality, and to know the condition from other points of view.

These are the strategies currently practicing by Myanmar Government. With the participation of the people, challenges regarding quarantine sites were solves. Even Myanmar government make a strict rules and regulation, they mostly win the mind of people by using “request”. They even avoid using “Lockdown”, but used these in some cases as people felt panic attack if they heard this words. But in reality they are even doing “hard lockdown”. Myanmar Community initiated Applauding and Clapping Campaign for Frontlines healthcare workers to cheer and praise their good works as shown in the twitter post on 16th Apr 2020.

As seen in Vietnam, citizens are donating to the government to fight COVID-19. Government especially State Counsellor appreciate people’s participation so that people will follow the recommended instruction such as social distancing, hand washing, using face mask and home stay which can dramatically reduce the spread of COVID-19.

Economy and Food Security

COVID-19 create a race between nation economy and mitigating the spread. If the government look mostly as economy and tried to maintain it, the spread became quicker. If they tried to contain COVID-19 with soft or hard lockdown, closure of airport, school, factory and workplace, the economy will turn down. In Myanmar, the growth of economy is stagnant and seem to be down even before COVID hits. Currently, Myanmar have so many issues due to COVID-19 outbreak. The most prominent twos are factories worker strike and watermelon exports. Most factories lack raw materials and orders from their usual customers due to the pandemic, forcing some factories to close and and even more struggle. Workers on daily wages are in running into financial trouble and some are now unemployed.

In Kachin state, the northernmost part of Myanmar, the income of the people depends mainly on trading with China. Most of the fruits, products and raw material are exported to China. COVID-19 hit Myanmar during watermelon planting season, but many watermelons grown along the China-Myanmar border have been left to rot in fields because the Chinese border closed and lack of export demand. This is having a huge impact on the economy of people in the region.

Currently, there are no apparent food security problems and the government can likely manage that issue up to a certain point. There is a risk to the poor, workers on daily wages, and squatters but the government is already providing basic subsistence like good but the lockdown has is adding two weeks for food deliveries now. This means there might be a larger crisis if the domestic supply chain issues delivering food aren’t resolved soon. Furthermore, if the COVID-19 crisis continues indefinitely the government will have difficulty planning to cultivate paddy rice, fruits, and other vegetables in the rainy seasons. In that scenario, the people in Myanmar will definitely meet food security problems in the coming months. For now, though, the wet markets are open, retail grocers, and restaurants accept take-aways. While the situation seems manageable today, a terrifying food security crisis might be waiting behind the scenes.

Challenges Facing in Myanmar

So many challenges are waiting in the front for Myanmar Government to solve.

Some of these are Migrant workers coming in and out of the country, the ongoing conflict and refugee crisis in Rakhine State, and issues facing frontline healthcare workers. Currently, more than 15,000 migrant workers from China are waiting on the Chinese side of the border to return home. The Kachin state government faced this problem and are busy planning for these migrant workers to stay quarantine for 21 days. This was unexpected, and the government did not plan well for this issue. There are also fears that Kachin, given it’s proximity to China and unregulated cross-border traffic, might have an undetected community outbreak from the First Wave that might eventually reach the rest of the country.

Another 23,000 migrant workers entered Myanmar from Thailand passed the borders and entered Myanmar. Myanmar has not still prepared enough and help them. Despite no known cases of Myanmar exports to other countries, and most of them going through 14 days of quarantine in Myanmar, many workers will try to re-enter. But after Thingyan festival and long home stay and quarantine, many will try to leave the country again for work. Thailand said they will quarantine the migrant workers coming back from Myanmar for 14 days. Thailand and Myanmar should co-operate to certify COVID-free migrant workers who have already gone through quarantine.

Recently WHO vehicle carrying COVID-19 swabs was shot and attacked in Minbya Tsp, Rakhine State. This event raised public concerned about the Rakhine conflict and COVID-19. Rakhine is the place where Arakan Army and Myanmar army have clashed. The internet has been shut down in places like Ponnagyun, Mrauk-U, Kyauktaw and Minbya. With information not getting in or out, locals do not have up-to-date information on COVID-19 and no one outside Rakhine knows the COVID-19 situation there. More than 130,000 people live in Internally Displaced Persons (IDP) camps and there is widespread fear of what would happen if the pandemic reached the refugee camps there. Many areas are having conflicts. People are most concerned about a situation of COVID-19 outbreak in addition to an ongoing conflict, which would make the local community suffer in unimaginable ways. These are the kind of fears sparked by attacking WHO vehicles delivering test swabs.

There is also a shortage of doctors in Myanmar, a challenge that pre-dates COVID-19. Currently, some medical doctors are infected, and some are put into quarantine center including other health staffs such as nurses. This made the less amount of working medical doctor to be lesser. The Myanmar health system was already pressed by double burden of diseases, both communicable and non-communicable. This COVID-19 was more than these two burdens. Many Myanmar medical doctors are already burning out due to long working hours (36-48 hours consecutive duty), work pressure, and too many patients per doctor. In some places, a single doctor covers a population of 100,000.

Policy Recommmendations

Myanmar is currently on the right trend. We think these policy recommendations can help the country continue on it’s current trajectory:

  • Hospitals should be categorized. E.g. Level – 1, Level – 2, COVID-19 special hospital. From there, a systematic referral system and guidelines should be set.
  • Because Myanmar has less healthcare capacity to manage and treat COVID-19 , they should continue expanding quarantine centers which are the first line of COVID-19 defense. Stricter guidelines, rules, regulations and closer monitoring system should be established in cooperation with local authority.
  • Myanmar government needs a sustainable long-term financing plan for combating COVID-19 that doesn’t rely on donations.
  • MoHS should cooperate with GP’s by asking them to volunteer for COVID-19 front line duty, while insuring they get the training they need.
  • The government should prepare for food security problems, provide low interest loans to farmers, and provide guidelines for cultivation amidst pandemic to ensure the food security.
  • Allocate more money to support the vulnerable populations in the form of cash handouts, rather than supplying only food supply.
  • Extend the COVID-19 testing center to State and regional level by fulfilling the human resources and facilities needed so that the testing process will be increase, and state and region can response more quickly.
  • Give special care to the conflict areas and took agreement with the other parties of the conflict regarding COVID-19 outbreak
  • Ensure all the citizen get COVID-19 medical care, testing if necessary.
  • Increase the testing capacity to test passively to all suspected patients coming to hospitals and then expand to do active case finding.
  • Fulfill enough equipment and facilities for the COVID-19 designated hospitals.
  • Handle the workers crisis properly and ensure all the workers have enough food and supply during lockdown periods.
  • In state and regions, the separate COVID-19 treating center should be established to reduce the contact with the patients who are already at risk for severe illness.

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