We conducted a descriptive study involving secondary data collection. We included all dengue deaths reported to the Vector Borne Disease Control (VBDC) Programme in Myanmar during 2017–18.

Myanmar, a tropical country, is located in the Southeast Asia Region, bordering the Republic of China on the north and northeast, Laos on the east, Thailand on the southeast, Bangladesh on the west, and India on the northwest. Myanmar is still a predominantly rural country, with around 30% of the population living in urban areas ¹⁴ . The country is divided administratively into Nay Pyi Taw union territory and 14 states and regions and consists of 74 districts and 330 townships ¹⁵ .

Doctors are first available at sub-township level station hospitals. Basic health staff at the level of rural health centres (below station hospital) and sub-centres (below rural health centre) provide comprehensive primary health care. Specialists are available at district level hospitals.

SD BIOLINE dengue rapid test kits (includes NS1 Antigen, IgG antibody and IgM antibody) and packed cell volume (PCV) using a centrifuge machine (microhaematocrit or haematocrit) are available at some of the station hospitals. PCV and platelet counts using haematology auto analysers are available at district hospitals and above. The NS1 antigen ELISA test is available only at National Health Laboratory, Yangon, and is used for evaluation of rapid test kits. Diagnosis, treatment and monitoring of dengue patients in health care facilities highly depends on the availability of doctors (at station hospitals), rapid test kits, centrifuge machine and complete haemogram (for platelet count). The laboratory facilities may not be available as assigned or sometimes may malfunction. All the severe or complicated dengue (confirmed or suspected) patients are referred to the nearby district, regional or tertiary hospital.

In 2011, the Myanmar Paediatric Society published Paediatric Management Guidelines (second edition) and updated them in 2018 ¹⁶ . The chapters for dengue were adopted from the 2009, 2011 and 2012 WHO guidelines ^{8, 12, 17} . In 2018, the National Guideline for Clinical Management of Dengue for doctors and basic health staff were published ^{18, 19} . Training has been provided to basic health staff and doctors since 2018 in selected states and regions based on funding availability. It is being expanded to the whole country from 2019.

The assistant director or team leader is responsible for VBDC Programme planning and implementation at the state and regional levels. All hospitals maintain a dengue register for admitted patients. The VBDC works closely with the department of medical services to collect data on dengue morbidity and mortality by using dengue register. In case of a laboratory confirmed dengue with any grading at hospital, VBDC staff, basic health staff and community volunteers carry out dengue prevention and control activities within a 100 meter radius of the patient’s house.

If there is any dengue death, hospitals are expected to inform VBDC staff immediately. VBDC staff go to the hospital and fill out a dengue death investigation form and report back to the central VBDC office.

Dengue patients that do not get admitted are not reported to the VBDC. The dengue patients managed by the private sector are not routinely reported to the programme, except one private hospital which reported one dengue death during 2017–18.

A line list of all dengue deaths was prepared in March 2019 by using the dengue death reports submitted to central VBDC Programme by State and Regional offices. Though we were planning to extract data from death investigation forms, it was found that they were not filled out in the prescribed format. Therefore, data were extracted from the hospital case records to a structured data collection form. These paper-based hospital case records were sent to principal investigator.

The data collected included age, sex, state or region, dengue grading at admission, hospital name, date of admission, type of diagnosis (laboratory/clinical), type of first health care provider visited and cause of death. The dates of onset of fever, first health care provider visited after fever, diagnosis, admission and death were also collected. Operational definitions for ecological regions and dengue grading have been summarized in Table 1.

The data were double-entered and validated using EpiData entry software (version 3.1, EpiData association, Odense, Denmark) and analysed using STATA (version 14.2 College Station, Texas). The profile was summarized using frequencies and proportions. Patient level (fever onset to first health care provider visit), health system level (first health care provider visit to diagnosis) and total diagnosis delay (fever onset to diagnosis) were calculated. The hospital stay duration was calculated from date of admission to date of death. The duration and delays in days were summarized using the median and interquartile range (IQR).

Administrative approval for the study was obtained from the VBDC Programme and ethics approval was received from Ethical Review Committee, Department of Medical Research, Myanmar (Ethics/DMR/2018/149 dated 7 December 2018) and Ethics Advisory Group, The Union, Paris, France (EAG number 45/18 dated 23 August 2018). As this study involved review of routinely collected secondary data, a waiver for informed consent was sought and approved by the ethics committees. This study involved the use of patient medical data in which all data analysed were anonymized.

The characteristics of these 304 reported deaths at admission and cause of death are described in Table 2. Of 304 deaths, 184 (60.5%) were among females. The median age was six (IQR: 3, 9) years, 233 (76.6%) deaths were among children (<10 years) and 246 (80.9%) were reported during the wet (June to October) season. Dengue shock syndrome at admission was seen in 169 (55.6%) and at death in 257 (84.5%). Of 304 deaths, 36 (11.8%) were reported from the township level hospital or below and the remaining were from higher level facilities.

The type of first health provider visited after fever onset was not recorded for 142 (46.7%) patients and 57 (18.8%) got directly admitted to hospital where they died. Among patients who had a first health care provider visit (that was recorded) before getting admitted to the hospital where they died (n=105), 32 (30.5%) either went to a chemist or untrained provider or self-medicated ( Table 2).

The date of onset of fever was only available for 208 (68.4%) patients. Of these 208, the patients were admitted after a median of four (IQR: 3, 5) days after fever onset. The median patient level delay was three (IQR: 1, 4) days and median health system level diagnosis delay was zero (IQR: 0, 2) days. Total diagnosis delay was four (IQR: 3, 5) days ( Table 3).

Of 304, 81 (26.6%) patients died within 24 hours of admission. Before admission, dengue fever was diagnosed in only 26 (8.5%) ( Figure 1).

This study has five implications for policy and practice. First, a review of health system preparedness to suspect, diagnose, monitor, refer and treat dengue is required at peripheral health facilities as most patients were admitted without a diagnosis of dengue fever. This includes review of availability of rapid test kits at station hospitals and above. Considering the burden of dengue is similar to malaria in Myanmar, availability of test kits should be ensured at the level of station hospitals and preferably up to the grass roots level for evaluation of undifferentiated fever ¹⁷ . Training of basic health staff and doctors of all regions regarding the updated 2018 national guidelines is required. Guidelines for the management of undifferentiated fever should be developed ²⁶ . This will especially be beneficial for health care providers in peripheral health facilities.

Second, as death investigation forms were not filled out in the prescribed format for all dengue deaths, we recommend quarterly dengue death reviews at regional and national levels. This will indirectly ensure that states and regions fill out the dengue investigation forms in the prescribed format and submit them to the VBDC Programme regularly.

Third, we recommend a similar study among all the reported dengue patients to confirm whether these findings are present (or not). Fourth, to address patient level delay there is a need to raise awareness in the community regarding health seeking for undifferentiated fever. Finally, the following four indicators may be added to the monthly forms in the health management information system in health facilities: i) total suspected with dengue ii) total confirmed dengue and iii) diagnosis within three days of fever among confirmed dengue.

We collected nationwide data of all reported dengue deaths and this represents the ground reality. Data were robust as they were double entered and validated.

There were two major limitations in the study. First, death investigation forms were not being filled out. The reason for this is not known. This resulted in many missing variables as these were not available in the hospital case records. This includes details on the first health care provider visited and various dates. Diagnosis delay related findings are limited by the absence of the date of fever onset in one-third of patients. These forms also help the programme at a national level to review the causes of death, identify preventable health system related causes and take timely action.

Second, the variables recorded in hospital represent the clinical condition of the patients and other important variables for dengue prevention and control such as previous episodes of dengue, comorbidities, housing, income, occupation/school places, travel history, utilization of bed net, use of mosquito repellent were not routinely available.

To conclude, this study reported a long diagnosis delay after fever onset among dengue deaths reported over two years in Myanmar. This calls for an urgent review of health system preparedness to suspect, diagnose, monitor, refer and treat dengue at peripheral health centres and patient level factors for better understanding of reasons for diagnosis delay. Filling out of dengue death investigation forms should be ensured and corrective action be taken through regular regional and national dengue death reviews.

Figshare: Nwe Ni Linn et al 2020 dataset v2. https://doi.org/10.6084/m9.figshare.12355958.v1 ²⁷

This project contains the following underlying data:

Data_NNL.xlsx (all de-identified variables extracted for this study, alongside a codebook explaining all fields and field values).

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).