Tuberculosis remains the leading killer of people living with HIV (PLHIV) and HIV greatly increases the risk of reactivation tuberculosis (100 fold). Although tuberculosis prophylaxis therapy (TPT) could prevent TB reactivation in 60-90% but current regimen (INH 9 months:9H) is limited by poor implementation and low completion rate due to long duration, fear of INH resistance and dormant TB could not be killed by INH. We evaluated the safety and efficacy of a novel shorter TPT in Thailand, a high TB/HIV burden country. Methods: PLHIV on ART > 2 weeks and free of active TB are randomized to Arm A: 1 HP (isoniazid 300 mg plus rifapentine 450-600 mg once daily for 4 weeks) or Arm B: 3HP (isoniazid 700-900 mg plus rifapentine 750-900 mg once weekly for 12 weeks) from 14 hospitals in Thailand. The participants will be followed up for 3 years. The primary end point was the first diagnosis of TB or death from TB or unknown cause. This study is ongoing, plan to enroll 2500 PLHIV. However, it is affected by COVID 19 pandemic and also impurified of rifapentine. By the way, the impurified of the study drug has been approved from the US FDA that it has a few impurification so it causes a few effects to the develop cancer. This analysis is focused on 1st year with 644 PLHIV enrolled. Results: A total of 644 patients (86% male) were enrolled, 322 each were assigned to Arm A or Arm B. Median age was 30 (IQR 25-39) years, median baseline CD4 cells counts were 300 (201-415) cells/mm3, and 24% of them had baseline CD4< 200 cells/mm3. All received FDC of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)/efavirenz (EFV) for a median 1.3 months. The median duration of follow-up was 1 year at the study entry. There were no active TB or death reported. Adverse event occurred 6.1% (Arm A = 6.5% and Arm B = 5.6%) as following hepatitis (elevated ALT) (Arm A=3.1% and Arm B 4%). Majority of hepatitis were asymptomatic cases, it was found during schedule blood testing. Rash occurred 0.8% (Arm A=1.2% and Arm B 0.3%). 1 case (Arm A) had numbness of feet. Serious side effect occurred among 10 cases (Arm A=0.9% and Arm B 2.1%. Totally 2 cases developed hypersensitivity reaction (rash and hepatitis), both of them were in Arm B. The percentage of treatment completion was 93.2% and 91.6% in Arm A and Arm B, respectively. At 48 weeks after starting TB drugs, 96% and 95.7% of Arm A and Arm B had HIV RNA <50 copies/ml, respectively. Conclusion: In the treatment of latent tuberculosis infection, both Arm A and Arm B resulted in better adherence, low percentage of discontinued treatments and highly efficacy to prevent active TB. No active TB or death were reported during 1 year.


The research project on the preparedness and responses of the health services system to the COVID-19 crisis in Thailand: Hospital operation and economic and social impacts within the boundary of the health services system consisted of 6 main parts using mixed research methods, pursuing the following key objectives: (1) To study overall research areas and topics for health services system to prepare and respond to the COVID-19 situation focusing on hospital systems, and economic and social impacts within the boundary of the system by reviewing key literature and expert panel suggestions, and by piloting data collection based on the framework. (2) To study key characteristics of hospital wards and innovation in hospital services for COVID-19, and to synthesize recommendations for hospital accreditation processes by making case studies on selected hospitals, and sharing discussions in focus groups. (3) To study challenges, problems, obstacles, preparedness, adaptation and new normal in key service offerings by hospitals in response to the COVID-19 situations, and synthesize new normal that may persist after the crisis by surveying hospitals and surveyors of the hospital accreditation programs in Thailand, organizing online focus groups and case study of the Bangkok area. (4) To estimate cost and opportunity costs of a hospital in responding to the COVID-19 situation involving all kinds of activities in a hospital by working with a case-study hospital. (5) To study and monitor operations of universal health coverage schemes in Thailand in responding to the COVID-1 9 situations, including reimbursement in the fiscal year B.E.2563 by reviewing documents and analysis of the reimbursement databases of the universal coverage scheme (UCS) and (6) To study governmental mechanisms in responding to the COVID-19 situation in Thailand, including key features in different phases of the situation, policies and measures to prevent and control the pandemic situation, related factors, and consequences by examining overall situations and making case studies of selected key events.


This study has the overall goal to develop and improve mass-rearing of the SuperMosqTM bio-products or sterile male mosquitoes produced either by Sterile Insect Technique (SIT) through low-dose irradiation or by Wolbachia-induced Incompatible Insect Technique (IIT). The specific objectives are as follows: 1) develop a high-quality, low-cost, industrial scale, Aedes aegypti larval diet, 2) develop a local sex separator device for separating Ae. aegypti male and female pupae, 3) test yeast proteins for blood meal replacement of female mosquitoes, and 4) assess quality control of mass-reared immatures and sterile mosquitoes. For the development of Ae. aegypti larval diets, it was found that an alternative larval diet had very little effect on the growth and development of both male and female pupae and adults when compared to those that were reared with the standard larval diet. Moreover, when the cost of the diet was taken into consideration, it was found that the cost of an alternative larval diet was 60% lower than that of the standard diet. Therefore, it was concluded that an alternative larval diet could be applied for mass production of mosquitoes at the industrial scale as it reduces the cost of production but still yield good quality of mosquitoes. For the development of local pupal sex separator device, It was found that there was no significant different in the efficacy between the local pupal sex separator and the imported one. When the speed of sex separation and the percentage of female contamination, together with other factors such as cost, transportation, maintenance, etc. was considered, it was found that there were no significant differences in the speed of sex separation and the percentage of female contamination while the cost of the locally assembled device was 70% lower. For the development of yeast protein Ae. aegypti females, it was found that the yeast protein diet was not able to replace the general blood meal as females could not lay eggs when they were fed with the yeast protein diet. Besides, Ae. aegypti females were less attractive to the yeast protein diet when compared to the pig blood. In addition, females that were fed on the yeast protein diet were unable to produce eggs. Therefore, it is necessary to study and find other raw materials in order to improve and develop recipes that could be used to replace blood in the future. For quality control of sterile male mosquitoes using flight ability test, it was found that there was no significant difference in the escape rate of the sterile mosquitoes produced from both low-dose irradiation and Wolbachia-induced incompatibility, or the SuperMosqTM bio-products, when compared to the control ones. Therefore, it could be concluded that the low-dose irradiation and the presence of Wolbachia bacteria did not affect the flight ability of the SuperMosqTM bio-products. For quality control of sterile male mosquitoes using sterility test, it was found that sterile mosquitoes, whether they were sterile by either low-dose irradiation or by Wolbchia-induced incompatibility, could make fertile Ae. aegypti females sterile; as the latter lay unhatched eggs or even could not produce eggs at all. In other words, it could be concluded that the SuperMosqTM bio-products, sterilized by either low-dose irradiation or Wolbachia-induced incompatibility, can cause sterility in the fertile Ae. aegypti females when they were mated and that the females could not produce any offspring. For quality control of sterile male mosquitoes by assessing male mating competitiveness, it was found that both radio-sterilized and Wolbachia-induced incompatible males had nearly similar ability to compete with wild males in order to mate with Ae. aegypti females. Therefore, when the SuperMosqTM bio-products were applied for vector control, they should be released in a ratio equal to 10 times of the number of wild males in the case radio-sterilized males and only one time of the number of wild males in the case of Wolbachia-induced incompatible males, in order to effectively compete with wild Ae. aegypti male mosquitoes. For quality control of sterile male mosquitoes by assessing survival rate and life expectancy, it was found that low-dose irradiation had no effect on average survival rate and life expectancy of sterile males when compared to the control ones, while those that were sterilized by Wolbachia-induced incompatibility reduced average survival rates and shortened the life expectancy of sterile males when compared to the control ones. For quality control of sterile male mosquitoes by detection of Wolbachia bacteria, it was found that Wolbachia bacteria was 100% present in the sterile males that were randomly selected for detection in every lots of productions. Therefore, it could be concluded that Wolbachia bacteria was stably established in the SuperMosqTM bio-products.


Persistence of viral RNA in respiratory samples of COVID-19 patients and asymptomatically infected individuals is a common and important problem in the outbreak control. The main question is whether the persistence of viral RNA reflects viable virus shedding. And, if there is viable virus shedding, there is an interesting scientific question of how the virus survives in the presence of immune response, which should be developed soon after the infection. Possible explanations include a failure of developing immune response or an immune escape by viral mutations. To answer these questions, this project performed viral isolation in sequential respiratory samples and antibody detection in serum samples of 30 cases with mild-symptom or asymptomatic, who showed viral RNA positive by RT-PCR after 1 week from the diagnosis. Samples in the first week showed a large variation in the viral load levels which significantly declined in most samples from the second week forward together with positive for specific antibody in serum samples. For viral isolation, there were 6 positive samples with high viral load; 4 samples and 2 samples from the first and second week samples, respectively. The two culture positive samples from the second week, one of them had low level of neutralizing antibody in serum at the same time point and these neutralizing antibody level increased in the third and fourth week samples together with a drastic decline in viral load and negative viral culture. The other sample showed high viral load and positive viral culture together with negative neutralizing antibody in the samples from the second and third week. These data indicate that most patients and infected individuals with persistent positive RT-PCR have low level of viral load and this does not indicated shedding of viable virus. However, failure in mounting the immune response in some individuals may result in persistent shedding of viable virus. High viral load and negative neutralizing antibody may be used as markers to identify such individuals.


Since the novel coronavirus outbreak (COVID-19) was identified for the first time in China during December, 2019. The world faces the COVID-19 epidemic including Thailand. The Royal Thai Government has announced an Emergency Decree on Public Administration in an Emergency Situation B.E. 2548 which had been effected from 26 March 2020 onwards. The Royal Thai Government Gazette published an announcement prohibiting any person throughout the Kingdom from leaving their residence between 10:00 PM and 4:00 AM starting on April 3, 2020. It may impact national tuberculosis program. The main objective of this study was to compare the TB treatment outcomes during pre-and post-COVID-19 outbreak. The secondary objectives were 1. To evaluate the number of TB diagnosis test during pre- and post-COVID-19 outbreak, 2. To compare TB case notification during pre- and post-COVID-19 outbreak, and 3. To compare TB treatment outcomes during pre and post COVID-19 outbreak. A cross-sectional study was conducted in this research by using the secondary data which TB patients were registered into the NTIP program. Comparing the data of the first cohort of the fiscal year 2019 and the first cohort of the fiscal year 2020 for the topic of TB treatment outcomes pre- and post- of the first wave of outbreaks in 2019 and 2020. TB diagnosis analysis we used the data of the two cohorts (second and third cohort of the fiscal year 2019) and the data of two cohorts (second and third cohort of the fiscal year 2020) representing pre-and post- of the first wave of outbreaks in 2019 and 2020. The results of this study showed that the number of all TB cases during pre- and post- of the first wave of COVID-19 outbreak in 2019 and 2020 were 40,544 and 40,848 cases, respectively with slightly increase but not statistically different (p= 0.275). The case notification number of new and relapse cases were 38,875 and 39,231 cases, respectively with an increase but not statistically different (p=1.00). Before and after the lockdown (between the same year between cohort Q2/2020 and 3/20), there were 21,358 and 17,873 cases, respectively, a decrease of -16.3%. The number of TB patients who diagnosed by AFB smear of 23,792 (61.2%) and 25,731 (65.6%) cases, respectively showed a statistically significant increase (p<0.001). In contrast, the number of TB patients who diagnosed by only Xpert MTB/RIF of 717 (1.8%) and 577 (1.5%) cases, respectively showed a statistically significant reduction (p<0.001). In addition, during pre- and post- of the first wave of outbreaks in 2019 and 2020, the number of patients diagnosed by both AFB and Xpert MTB/RIF (AFB smear is initiated test for TB diagnosis, if AFB negative was founded the Xpert MTB/RIF is done) wirh 8,838 (22.7%) and 6,808 (17.4%), respectively showed a statistically significant reduction (p<0.001). The number of TB patients without results were 5,528 (14.2%) and 6,115 (15.6%), respectively, a statistically significant increase (p<0.001). The TB treatment outcomes of new and relapse cases during pre-and post- of the first wave of COVID-19 outbreaks in 2019 and 2020 showed that the success rate were 80.8% and 86.4%, respectively. There was a statistically significant decrease (p<0.001). Transferred-out were 0.7% and 1.3% with a statistically significant increase (p<0.001). Lost-to-follow up rate were 4.3% and 3.7%, respectively with a statistically significant reduction (p<0.001). On-treatment rate accounted for 0.8% and 6.2% with a statistically significant increase (p<0.001). In summary, this study is the first national study that presented the evidence of impact of the Covid-19 outbreak situation to TB programmes and services. Case notification number among new and relapse cases during post of the first wave of COVID-19 outbreak was lower, especially lockdown period, but not statistically different. The number of diagnosis examinations by Xpert MTB/RIF was declined. Moreover, treatment success rate trended to reduction. In order to operate TB programme effectively during the COVID-19 epidemic, an intensive TB cases finding especially among the high risk groups, for examples; out-patients and the prisoners should be done as well as screen COVID-19 in the same time. The results of this study provided the useful information of the trend of case notification, TB diagnosis test and TB treatment outcomes for prepare the TB strategies for the next wave of COVID-19 outbreaks.


Mutations of nucleophosmin (NPM1) gene represent the most frequent molecular alteration in acute myelogenous leukemia (AML), especially in the AML patients with normal karyotype. Moreover, NPM1 gene mutations have been shown to carry favorable prognostic significance in AML. Therefore, Screening of NPM1 mutations show valuable clinical importance in terms of risk assessment and treatment decisions of physician in AML patients. In this study, we developed a in house test kit for detection of NPM1 gene mutation cover 4 types (type A, B, D and type J) in 1 reaction based on Enhanced-improved and complete enrichment-co amplification at lower denaturation temperature-polymerase chain reaction (E-ice-COLD-PCR) combined with High-resolution melting (HRM) analysis. Method: For E-ice-COLD-PCR, blocker probe is very importance to block wild-type amplification. Blocker probe hybridized complete match with wild-type sequence while incomplete match with mutant sequence. After critical temperature step in each cycle, blocker probe allows completely denature mutant-blocker probe heteroduplex while wild-type-blocker probe heteroduplex remain strongly hybridized, which only allow the amplification of mutant. The PCR reaction was performed using 1x NPM1 HRM master mix, 400 nM of NPM-LNA probe, 5 ng of genomic DNA and sterile water with a total reaction volume of 25 μL. The thermocycling program consisted of an initial denaturation at 95°C for 3 min followed by 40 cycles of denaturation at 95°C for 5 s, probe hybridization at 70°C for 30 s, critical denaturation at 88°C for 40 s, primer annealing at 60°C for 10 s and extension at 72°C for 30 s, with a final extension at 72°C for 3 min. The final step was melting curve with continuous increase in temperature from 65°C to 85°C (0.2°C per acquisition, 5 s hold before each acquisition) by using CFX96 Touch Real-Time PCR or Mini MJ Thermal Cycler (conventional PCR machine) A total of 83 AML blood samples from Maharaj Nakorn Chiang Mai Hospital were evaluated by NPM1 HRM master mix, standard PCR and direct sequencing. Results: we show herein 2x NPM1 HRM master mix exhibited similar sensitivity and specificity with direct sequencing. NPM1 mutations were detected in 9 of 83 AML patients with 2x NPM1 HRM master mix. Moreover, The PCR products from E-ice-COLD PCR were confirmed by direct sequencing. The result show that 100% concordance with E-ice-COLD-PCR assay and direct sequencing with type A mutation and easily to interpretation. Interestingly, The PCR products from standard PCR show that 8 of 83 patients were positive. One sample showed inconsistent result between standard PCR assay and direct sequencing. Perhaps, the low level of mutations in wild-type background interferes the direct sequencing led to verification of the mutation sample as wild-type. Therefore, performing E-ice-COLD-PCR prior to direct sequencing allow substantial increasing the limit of detection of direct sequencing. Conclusions: Compared to standard PCR and direct sequencing, a new test kit, 2x NPM1 HRM master mix was shown to detect mutations in the NPM1 gene cover 4 types in 1 reaction. Moreover, E-ice-COLD- PCR is a PCR-based method that can be use for enrichment low level of mutated in mixtures of wild-type and mutant allele. E-ice-COLD PCR protocol can easily be integrated in the routine molecular diagnosis of AML using Real-time PCR or conventional PCR machine.


The objectives of this research were to develop a model, and to study the effectiveness of a good health promotion integrated with Buddhist ways model for prevention and control of non-communicable diseases. It was designed as two group pretest-posttest design. The samples were 99 patients with uncontrolled diabetes and or hypertension, divided into two groups: 50-person group; the study group who were managed by the model, and 49-person group: the control group managed by routine care. Data were collected using mixed method, both quantitative and qualitative approach. The research tools were: 1) the good health promotion program integrated with Buddhist ways was named in Thai as 3 Sor, 3 Orr, 1 Nor from which comprised: pray, meditation, Buddhist dialogue, nutrition, exercise, emotion, biological clockwise daily activities with Buddhist integration. 2) health assessment form 3) self-report manual 4) the knowledge test 5) the happiness test 6) the satisfaction questionnaire 7) group discussion and in-depth interview guidelines. The KR 20 of the data collecting tools no. 4 was 0.8. The Cronbach's alpha coefficients of the data collecting tools no. 5, 6 were 0.85, 0.84 respectively. The quantitative data were analyzed using descriptive statistics, paired t-test and independent t-test. The qualitative data were analyzed using content analysis. The results of the model development found 3 components: 1) the good health promotion program integrated with Buddhist ways 2) self-reporting towards the program and 3) monitoring, supporting, and empowering by the health team. The findings on the effectiveness of the model found that 1) After try-out the model, the study group had lower average in health status namely weight, waist circumference, BMI, blood pressure and blood sugar levels were significantly decreased. 2) Before try-out the model, the study group had average in health status not different with those of the control group while after try-out the model, the average of health status in study group were significantly lower than those of the control group. 3) After try-out the model, the study group had significantly higher average in the knowledge scores and higher average in happiness score towards the activities of the program. And they were satisfied with the activities of the program at a high level.


Antibody-dependent enhancement (ADE) has been considered as one of the mechanism that leads to the development of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). During secondary dengue infection monocytes can be infected by the ADE phenomenon. This study aimed to investigate the proteins involved in ADE of DENV infection in the primary human monocytes isolated from volunteers. The phosphoproteins were used to perform and analyze for protein expression using mass spectrometry (GeLC-MS/MS). The differential phosphoproteins revealed 517 altered proteins compared between isotype- and DENV-specific antibody-treated monocytes. The altered proteins revealed 253 upregulated proteins and 264 downregulated proteins. Approximately 70-80% of altered proteins was classified into binding and catalytic activity proteins, while 20-30% was proteins with molecular function regulator, molecular transducer activity, structural molecule activity, transcription regulator activity or translation regulator activity and transporter activity. Protein disulfide isomerase (PDI), which is an enzyme that had a high-ranking fold change and that catalyzes the formation, breakage, and rearrangement of disulfide bonds within a protein molecule, was selected for further study. PDI was found to be important for dengue virus infectivity during the ADE model. The effect of PDI inhibition was also shown to be involved in the early stage of life cycle by time-of-drug-addition assay. These results suggest that PDI is important for protein translation and virion assembly of dengue virus during infection in human monocytes, and it may play a significant role as a chaperone to stabilize dengue protein synthesis. Moreover, other proteins were further performed by interaction network analysis and found that most structural proteins were interacted together. Alpha-actinin was observed to be altered and may be associated to play important role in viral replication and viral infection in monocytes.


In Thailand, nowadays, there is an increasing number of terminally ill patients who need palliative care. Opioids are deemed to be an essential treatment for severe pain that can help to reduce suffering and increase the quality of life significantly. Even though opioids have been already included in the National List of Essential Medicines in Thailand, access to this kind of treatment remains a problem. This study aims to explore the factors that influence the access to opioids for palliative care in Thailand. The methodology used in this study includes literature and document review, in-depth interview, as well as focus group discussion which obtained data from personnel in the national institutes related to opioids regulation and palliative care. Key informants consisted of patients’ representatives, doctors, nurses, and pharmacists. Data collection was performed in nine secondary- and four tertiary-hospitals. Thereafter, record files were transcribed verbatim in accordance with key informants’ consent and analyzed as content analysis. This study found that obstacle factors to access opioids for palliative care are divided into four issues including (1) opioids regulations are inconsistent with practices when opioids are suddenly out of stock or nearly expired; however, hospitals cannot borrow or swap these drugs from each other. (2) Inadequate drug management system leads to insufficient amount of drugs stored in hospitals as recommended by the WHO. (3) Doctors, nurses, and pharmacists acquire scarce knowledge of and have negative perspectives toward opioids that cause them afraid to prescribe opioids. Besides that, patients and relatives and laypeople are lack knowledge and understanding of opioids which results in unacceptance. (4) Governance and palliative care system are not robust together with vague policy, deficient budget for operation, unreadiness of services, lack of monitoring and evaluation. This study recommended (1) revising regulations for consistency with opioids administration and management. (2) developing a management system for medical supplies in areas. (3) improving the education system and training for professions as well as counselling or advising patients and their relatives and within the community. (4) Promoting governance for accessing opioids.


Integration of genome sequencing in the diagnostic process for Thai infants with infantile cholestatic jaundice co-operated by Faculty of Medicine, Prince of Songkhla University and Health Systems Research Institute, Ministry of Public Health. To discover new genetic susceptibility of infantile cholestasis, next generation sequencing was implemented to operate in our study together with clinical finding and investigation. Focusing on biliary atresia, a half of cases had successful bile drainage from the hepatoportoenterostomy. According to similarity of clinical finding, the poor prognosis with naïve liver may be miss diagnosis from other cholestatic jaundice disease. Genetic biomarker became an important application to help discrimination of isolated biliary atresia and the others, improve post-operative outcome and delay queuing for liver transplantation. In our study, 64 individuals with cholestatic jaundice were included together with consent for blood sampling and genomic investigation under standard operation procedure of Genomic Thailand Consortium. All of retrieved samples and metadata information were processed at Translational Medicine Research Center (TMRC), Faculty of Medicine, Prince of Songkla University and delivered to Department of Medical Science, Ministry of Public Health. For the leftover specimens, whole exome sequencing was undergone to intensively discover pathogenic variants related to the cholestatic syndromes. Annotated exome sequences were comprehensively reviewed and discovered 45 possible deleterious variants. Moreover, genetic association was performed for SNPs located in ADD3 and EFEMP1 genes (rs2501577, rs17095355, rs6761893 and rs727878). The statistical appraisal of susceptibility shown significant association of first three SNPs with the disease together with additive biological interaction between both genes. In summary, we purpose that our study will be a beginning of implementation of high-throughput sequencing and genetic biomarker in pediatric surgical diseases.


Dengue disease is an important problem in global public health. Annually, 390 people are infected with dengue virus. The majority of infections results in asymptomatic cases. For symptomatic cases, patients will develop either mild dengue fever (DF) or severe dengue hemorrhagic fever (DHF). DF is a self-limiting disease meaning the patients will recover within 4-7 days without any significant intervention. However, DHF patients will eventually develop plasma leakage which may progress into potentially fatal hypovolemic shock known as dengue shock syndrome (DSS) without prompt and adequate fluid management. Dengue disease is caused by dengue virus which belongs to the genus Flavivirus. There are four serotypes of the virus including dengue virus 1, 2, 3 and 4. The virus is transmitted by Aedes mosquitoes. There is no antiviral drug against dengue virus and the only available vaccine has limited efficacy and elevates the risk of hospitalization from dengue disease in seronegative vaccines. We previously conducted a phase 2/3 trial by repurposing ivermectin to treat adult dengue patients. We found that ivermectin was safe, and the drug could significantly speed dengue virus non-structural protein NS1 clearance. In addition, the drug showed a potential efficacy in reducing the severity of the disease. In this study, we primarily evaluated the safety and pharmacology of ivermectin in pediatric dengue patients (age younger than 15 years and weighing more than 15 kilograms). Since ivermectin ingestibility, absorption, metabolism and excretion in pediatric patients were expected to be dissimilar from adult patients, this study was essential for determining the appropriate dose of ivermectin before conducting a trial for evaluating clinical efficacy. Two doses of ivermectin were studied: 400 μg/kg per day for three days and 600 μg/kg per day for three days. The patients in each dosage group were also stratified by weights into two groups including those weighing over 30 kg and those weighing between 15 to 30 kg. Our analyses showed that both doses of ivermectin were safe for treating pediatric dengue patients. However, no dose dependent relationship in efficacy against viral load or NS1 levels were found between the two administered doses. Advanced pharmacological analysis is required to confirm this finding. If the finding is confirmed, the more appropriate dose for phase 3 clinical trials in pediatric patients will be 400 μg/kg per day for three days.


Cancers are still the major cause of death in Thai population. Personalized treatment that targets specific genes or proteins is efficacious in cancer patients. Various molecular analyses of patients' tumors are used to determine whether they contain somatic mutations that could be used as reliable predictive biomarkers for tailoring therapy. Patients with primary lung adenocarcinomarcinoma harboring activating EGFR gene mutations respond well to targeted treatment by EGFR Tyrosine Kinase Inhibitors (EGFR-TKIs). Approximately 50 percent of Thai lung Adenocarcinomarcinoma patients have these mutated variants of EGFR gene in their tumors. Some patients who do not have EGFR mutation harbor mutations of other genes, such as ALK fusions and BRAF mutations that may benefit from treatment with other targeted therapy. However clinical samples yield nucleic acids in limited quantity and often of low quality. Sensitive molecular assays are therefore crucial to detect these somatic mutations. We engage in the development of new polymerase chain reaction (PCR)-based assays for determination of predictive molecular biomarkers for targeted medications. We have developed assays that efficiently detect clinically important mutant alleles, including mutations in EGFR, BRAF and ALK genes, presented in ultrashort nucleic acid sequences. These simple, highly sensitive and cost-effective mutation detection assays will be useful tools to enhance precision medicine in oncology.


Tobacco control is one of the most contentious political-economic issues at present. The Framework Convention on Tobacco Control (FCTC) of 2003 was crafted to be a global mechanism for tobacco control. However, the degree of tobacco control differs greatly among countries. FCTC has faced strong resistance because tobacco markets are globalized and highly profitable. This study employed global health governance (GHG) as an analytical framework and argued that the FCTC was not sufficient as an effective tobacco control instrument. It required a regional mechanism such as the European Union as well as national level actors, both state and non-state, for effective tobacco control. This research study used the European Union, France, and Germany as case studies. Findings show that France had strict tobacco control measures because political actors, non-governmental organizations, and medical personnel had strong influences on shaping tobacco control policy and took stance against transnational tobacco companies and retailers. In contrast, Germany encountered significant delays in developing effective tobacco control policies because of both the ignorance of political actors, and the weakness of the anti-tobacco civil society network. Moreover, powerful and profitable international and national tobacco companies stood firm against Germany’s tobacco control policies. This research study discovered that the European Union performed a significant role in harmonizing member states’ tobacco control policies, and ushered them in developing their own tobacco control policy measures, especially in the case of Germany. Tax measures had a positive impact on people’s health. They helped reduce the number of deaths from tobacco consumption, as well as reduce tobacco consumption rates among smokers. However, tax harmonization measures respected national jurisdiction and minimized economic impacts. Tobacco tax still remained a national source of income. This research study proposes that ASEAN and its member countries adopt the EU’s harmonization of tobacco-related legislations in order to develop ASEAN’s tobacco control mechanisms and to minimize the gap between members’ tobacco control policies.


Walking and cycling are common physical activities that can be performed regularly in daily life which provide health, environmental and economic benefits. This study aimed to 1) assess community-level walking and cycling promotion strategies or activities by stakeholders in selected communities, 2) investigate implementation gaps and 3) provide recommendations on walking and cycling promotion in community. Qualitative method was employed. A total 28 key informants in 4 communities of 4 regions were recruited: 1) King Taksin community in Bangkhla district, Chachoengsao province, 2) Suksabaijai community in Mueang Kalasin district, Kalasin province, 3) Ban Khaoniwet municipality school community in Mueang Ranong district, Ranong province, and 4) Ban Thatsobvan community in Chiang Kham district, Phayao province. Content analysis was used. The results showed that three main actors to promote walking and cycling in community were local government, civil society, and academia. These actors had different roles but worked collaboratively to achieve common goals. The implementation gaps were the negative attitude as well as improper and unsafe built environments towards walking and cycling. Recommendations for further program implementation include communication campaign to promote positive attitude and social awareness on the value of walking and cycling, improvements on built environments especially a speed reduction intervention in community, and leadership and supportive policy towards walking and cycling in daily life.


Palliative care is crucial care for cancer patients, especially those who are moving toward the end-stage. The World Health Organization states that palliative care is low cost. However, a cost analysis of such care is limited in Thailand. This study aimed to perform a cost analysis of palliative care for cancer in a community hospital. The analysis was conducted based on two perspectives: the health care provider’s and the patient’s. Cost data of 42 palliative cancer patients were recorded from January 1 to December 31, 2018. The cost of the provider’s perspective included labor and material costs from three departments: outpatient, inpatient, and home-visit, whereas the patient’s perspective covered the direct medical cost, direct non-medical cost, and opportunity cost. Results show that the average cost of the provider’s perspective was 16,525 ± 14,979 baht per patient: from outpatient 4,309 ± 7,103 baht, inpatient 10,915 ± 11,704 baht, and home care 1,301 ± 1,977 baht. The cost on provider’s perspective was mainly born by medical materials (68%). The average cost on the patient’s perspective was 38,707 ± 32,943 baht per patient: 5,262 ± 5,571 baht for outpatient, 6,231 ± 7,355 baht inpatient, 20,806 ± 20,454 baht home care, and 6,408 ± 17,336 baht for seeking other healthcare. The patient cost was predominantly opportunity cost (69%). The Ministry of Public Health and the National Health Security Office should consider the budget plan for palliative care.


Background and Rationale: Hip fracture in the elderly is a common problem in all countries worldwide and tends to increase every year along with the number of older adults. Treatment and rehabilitation of the patients take a long time, resulting in financial burdens for each country. The repeated fractures rate within 1 year was 2-11%. The current treatment of hip fracture patients was to cure and focus on the prevention of recurrent fractures. Therefore, the Refracture Prevention Program with multidisciplinary care was created. The purpose of this study was to investigate the cost-effectiveness of patients with fractured hips in Refracture Prevention Program compared with traditional treatment in healthcare provider’s aspect. Methodology: A prospective and retrospective study was conducted in 2 sample groups, with the control group receiving traditional treatment and the experimental group in the Refracture Prevention Program. Data were collected from 130 fractured hip patients of each group starting from admission day in Lerdsin Hospital for up to 1 year. The economic evaluation used a decision tree to show an incremental cost and effectiveness of each group. Results: The refracture prevention group had statistically significant higher quality-adjust life years (QALYs) than the traditional group (p < 0.05) and the program could prevent refracture better than the traditional group. Refracture rate per year reduced from 6.27% to 4.29%. The unit cost of hip fracture treatment in the Refracture Prevention Program was THB 139,504, while the traditional group was THB 150,720. The QALYs of the refracture prevention group was 0.6023, while the traditional group was 0.5106. New intervention was dominant: treatment under the Refracture Prevention Program was cheaper and better than traditional treatment. Conclusion and Discussion: The model of care for elderly patients with hip fracture should be the fracture liaison service model, with multidisciplinary cooperation and prevention of recurrent fracture risk factors. During the first year, there were 3 main costs of the program (operation, osteoporosis treatment and fall prevention) compared to only surgical treatment cost in the traditional treatment. Further study should be the long-term follow-up of the project. Besides the costing perspective, there should be a study on the financial burden of Thailand, in order to know the magnitude of the problem for future planning.


This study is a retrospective study using real-world data to compare treatment patterns with the guidelines for drug administration of the National List of Essential Medicine (NLEM) category E(2), and to compare effectiveness with the efficacy of clinical studies. This study focused on the treatment pattern and effectiveness of trastuzumab for early breast cancer (ICD-10 C50). Data were retrieved from the reimbursement database of the NLEM category E(2) during fiscal year 2015-2018. Time to follow-up was truncated at the end of fiscal year 2018. The data were analyzed by using descriptive statistics and non-parametric with Kaplan-Meier method. As a result, there were a total of 2,492 early-stage breast cancer patients, mostly between the ages of 50-59 years (37%), with a median follow-up of 34.98 months (interquartile range 16.75 months). The majority of patients received trastuzumab in accordance with the NLEM category E(2) guideline, 1,996 cases (80%) received drug less than 18 treatment cycles and 2,217 cases (89%) received drug less than 14 months. Subgroup analysis of the less than 14 months found 942 patients (38%) received the drug less than 12 months. Analyses of real-world effectiveness by using survival analysis in all trastuzumab patients found a 4-year survival rate of 80.02% (95% CI: 77.69-81.62); 78.74 % (95% CI: 76.36-80.90) for less than 18 treatment cycles, and 85.07 % (95% CI: 82.24-87.48) for the 12-14 months. These rates were lower than the efficacy reported from randomized controlled trials. Therefore, the present study of real-life data analysis concludes that most of patients received the trastuzumab in line with the NLEM E(2) guideline. Non-adherence may result in reducing the effectiveness of treatment lower than the efficacy from the RCT. However, this study did not explain the reason of non-adherence due to lack of important data, such as responses to treatment, recurrence and occurrence of side effects from drug use.


The cost of health service is an important indicator for hospital administrators in making decision for efficient health service provision. The study aimed at exploring hospital care cost and unit cost of the top five diseases of patients hospitalized at the Queen Sirikit Medical Center, Ramathibodi Hospital, in fiscal year 2016. This was a retrospective study from health care provider’s perspective covering patients hospitalized to a special medical ward of a university hospital in Bangkok. Costing data were collected using a standard tool of unit cost analysis categorized by source of expenses, namely labor cost, material cost, and capital cost. Cost analyses consisted of two major processes: 1) hospital cost and 2) cost center analysis using top-down costing method. Top-down costing included four steps: 1) cost center identification, 2) direct cost determination, 3) indirect cost determination and 4) total cost determination. Unit cost analysis of top five diseases was classified by diagnosis upon hospital admission. Results show that the annual total cost was approximately 12,448,667 Thai baht: direct cost and indirect cost was 10,373,889 and 2,074,778 baht, respectively. For the direct cost; the proportions of labor cost, material cost, and capital cost were 88 : 8 : 4. Unit costs of the top five diseases were as follows: neoplasms 19,145 baht/day and 142,769 baht/admission, diseases of the genitourinary system 17,167 baht/ day and 182,710 baht/admission, diseases of the musculoskeletal system and connective tissue 15,495 baht/day and 122,765 baht/admission, diseases of the circulatory system 12,901 baht/day and 144,488 baht/admission, and diseases of the respiratory system 9,414 baht/day and 98,573 baht/admission. Results from this study could be utilized as guidance for cost management by reduction in the unnecessary admission days while maintaining quality. This will provide benefits and efficiency improvements in resource use to Ramathibodi Hospital and clients.


The objective of this study was to estimate the cost of emergency patients in public hospitals for financial policy recommendation to the Universal Coverage for Emergency Patients (UCEP). Financial and service information for the fiscal year 2019 was gathered from eight hospitals, two of which were general hospitals of the Department of Medical Services, four regional hospitals, and two general hospitals of the Office of the Permanent Secretary, Ministry of Public Health. The traditional cost method with the cost matrix method was applied to analyze the unit cost of emergency patients. We used the cost matrix in two steps: (1) cost distribution of the fundamental cost centers to each patient based on the services received; (2) summing all medical activity costs on each patient and reporting them as individual patient data. The result showed that there were a total of 82,811 emergency patients from eight hospitals, 20,503 were triaged as resuscitation patients (red), and 62,308 emergency patients (pink). Labor costs were the highest share of the overall costs, followed by material costs, and capital costs. Unfortunately, the present study could analyze complete cost information from only one hospital (hospital A). The total cost of 18,027 emergency patients was THB 472,317,273. The average cost per person was THB 26,201, and the average cost per adjusted relative weight by diagnosis related group was THB 9,661. This costing method that required accurate hospital financial and emergency medical service information reported only data from one hospital. Further studies should explore alternative appropriate costing methods that data from more hospitals could be analyzed as more representative.


Background & Rationale: Extended length of stay (LOS) in the emergency department (ED) affects LOS in hospital, increased mortality and increased hospital resource uses. Knowing factors affecting extended ED LOS should lead to improved patient’s quality of care. Methodology: The study design was a retrospective analytical study in ED at Maharaj Nakorn Chiang Mai Hospital between January 2018 to June 2019 by collecting data from the electronic medical records. Data collection included factors expected to extend ED LOS 6 hours and longer by using multivariable logistics regression. Result: A total of 330 patients of whom 165 with ED LOS ≥ 6 hours were eligible. The risk factor for staying 6 hours and longer in the ED was having urine investigation (adjusted odds ratio [aOR] 3.43, 95% CI 2.05-5.73, p < 0.01). Moreover, patients in the evening and night shifts observed a shorter ED LOS compared to the day shift (aOR 0.26, 95% CI 0.15-0.47, p < 0.01 and aOR 0.40, 95% CI 0.21-0.77, p < 0.01, respectively). For patient presentation to ED, the refer-in patients had a shorter ED LOS compared to the walk-in patients (aOR 0.33, 95% CI 0.15-0.70, p < 0.01). Conclusion: The factors extending ED LOS ≥ 6 hours included urine investigation process and the day shift. Refer-in patients were likely to have a shortened ED LOS.


Organ transplantation is the treatment in patients with organ failure where kidney is the organ with the highest rate of transplantation in Thailand. Despite 50 years of an advancement in transplant surgical techniques and post-transplantation care, long-term kidney graft survival is not changed. One of the factor would be that the HLA matching technique used is polymerase chain reaction-sequence specific oligonucleotide (PCR-SSO, Luminex®) which has intermediate resolution for detecting variations in HLA gene. We conducted a HLA sequencing of 330 kidney transplant donors and recipients using Long-Read Single Molecule Real-Time (SMRT) Sequencing and observed the significant association of HLA long-read mismatch score to any type of rejection at 1 year post transplantation and any episode of graft rejection from transplantation to year 2021. This association was better than HLA Luminex mismatch score calculated with PCR-SSO technique. The HLA long-read sequencing information obtained from this study can be used as a reference allele for Thai population. There should be more population sequenced with HLA-long read technique to enhance robustness of the reference database. A prospective multicenter study comparing allocation of donor-recipients with HLA Luminex score versus HLA long-read score is warranted to evaluate outcomes such as death or allograft failure which were not be able to assessed in this study.


The sequential embedded mixed-method research consisted of two phases. 1) The qualitative phase is aimed to explore the situation, experience, problems, and barriers of the family pharmacists in primary care cluster. Focus group discussion was conducted in 24 pharmacists working in the primary care unit (PCU) distributed in 7 provinces of the health region, in January 2020 and April 2021. Average period of working experience was 5.6±5.0 years, and eight of them were full-time pharmacists working in the PCU. Findings of content analysis comprised three main themes: pharmacist roles; related factors from policies, colleagues, and the pharmacist; and the resolution of common drug-related problems (DRPs). Four roles of pharmacists were health services at the PCU, home health care, pharmaceutical management, and consumer protection. The patients’ care barriers were a limitation of the health information connection and information access from the PCU. Part-time working in the PCU limited the pharmacist’s roles; however, updated medication knowledge promoted the pharmacists for effective home health care with the team. In addition, local organizations also supported in home health care and the consumer protection. Communication skills, solving DRPs skill and working experience led the pharmacists to providing effective resolutions of DRPs. 2) The prospective, longitudinal quasi-experimental study was performed as quantitative phase. Data collection in 1,471 hypertensive patients for continuously three visits at the PCU in 2020. This aims to examine DRPs, blood pressure, and physician acceptance of pharmacists’ resolution change over the study including factors affecting DRPs resolutions. 379 DRPs were identified and the highest DRP was 164 non-adherence problems. Following the pharmaceutical care, all DRPs and non-adherence were significantly decreased by 3 2 .4% (X2(2)=46.78, p<0.001), and 61.0% (X2(2)=98.60, p<0.001), respectively. Blood pressure was unchanged. Physician acceptance of pharmacists’ resolution were 77.8%, 70.3% and 68.4%, at visit 0, 1 and 2 respectively. Factor affecting non-adherence resolution was physician acceptance of pharmacists’ intervention (rs=0.18, p=0.020). The family pharmacists can reduce DRPs in patients with hypertension. The relevant factor of DRPs resolution was teamwork due to working experience and skills of pharmacists. There should then be increasing experience and related skills through short course training for pharmacists.


Development of rapid diagnostic tests are a fundamental component for an effective public health system. At present, the availability of rapid diagnostic test and equipment quality in Thailand still insufficient. In this study, we aimed to develop the smartphone-controlled electrochemical sensor operated via Near Field Communication (NFC) as portable devices for screening test. This study used the electrochemical gas sensor to detect blood alcohol concentration from breath sample. For hepatitis B detection kit, the operating system was composed of a card-sized electrochemical NFC tag sensor integrated with a smartphone and antibody-modified electrode with gold nanoparticles to provide high sensitivity and β-cyclodextrin (β-CD). The modification and immobilization processes were verified by electrochemical impedance spectroscopy (EIS) and cyclic voltammetry (CV). The electrochemical immunosensor was then used to quantify Hepatitis B surface antigen (HBsAg) by measuring the current-time response obtained from amperometric detection. The current from the Fe(CN)63-/4- redox couple was measured before and after addition of HBsAg. A resistance-based lateral flow immunosensor diagnosis device (R-LFI) that integrated NFC with portable smartphone for L. interrogans detection in clinical samples. The performance of R-LFI sensor was evaluated using recombinant LipL32 (rLipL32), L. interrogans, and clinical samples. The results showed that the performance of the smartphone-based breath alcohol sensor was acceptable (SD ≤ 1.4mg%). Under optimal conditions, a linear calibration curve and a limit of detection for HBsAg were found to be 10-200 μg/mL and 0.17 μg/mL, respectively. The R-LFI device exhibited linear responses toward rLipL32 protein in phosphate buffer and L. interrogans spiked in healthy human serum samples within concentration ranging from 1 to 100 ng (limit of detection, LOD: 0.16 ng). This platform is sensitive, specific, simple, label-free, and requires small sample volume. These desirable features make it particularly suitable for resource-poor settings. However, these device improvement needs to be studied for commercial use in the future.


This research aimed to explore the roles of village health volunteers (VHV), implement processes of surveillance, prevention and control (IPC) of COVID-19 in communities among Village Health Volunteers (VHV) with key success factors and barriers. Moreover, policy suggestions were provided. This research captured lessons learned in 5 steps: define the project; collect data; verify and synthesize; store and disseminate. Methodological approaches were quantitative and qualitative parts. Surveys of 207 VHV took place in February-May 2021. Participants were recruited to take part in-depth interviews that they were VHV, policy makers and executive committees of Center of Disease Control (COVID-19 situation administration) at level of Province, District, and Sub-district in Health Region 7,8,9,10. The survey data were analyzed using descriptive and inferential statistics including frequency, percentage, mean, standard deviation and multiple logistic regression. Content analysis of interview transcripts identified IPC implement processes of COVID-19, key success factors and barriers. Findings showed that VHV had worked on 5 IPC components including searching and screening for COVID-19 in high-risk groups (97.6%), home visits for person who might have been exposed to COVID-19 (89.4%), collaborated with other organizations (87.9%), completed a record and reported (86.0%), reported and separate of high-risk groups (84.5%). Regarding to IPC of COVID-19 implementation, the level of implementation was top-down direction from national policy to area based practices. The factors statistically significantly related to IPC practices in communities were occupation, Public Health Region and multiple communication channels to the communities. It was found that the farmers VHV took place on 5 components of IPC 6.87 times more regularly than those who had other occupations (95% CI 2.63-17.91, p-value<0.001). VHV working for the Public Health Region 9 had 2.76 times more regularly in practice than other Northeastern Region (95% CI 1.17-6.53, p-value 0.021). The VHV who used more than 5 channels in provided information of COVID-19 to local people in communities included home visit; local audio announcement; leaflet; documents; and online media had 3.98 time more regularly in practices than VHV who used less than 5 channels to communicate in publicly (95% CI 1.61-9.84, P-Value 0.003). VHV who had the role to coordinate with local team network had more 6.55 time than VHV who did not take action on this role. (95% CI 0.88-48.59, P-Value 0.066). In the implement policy to practice, VHV were key persons working on control COVID-19 in their villages. They had kept taking steps to protect themselves avoiding exposure to the virus, Home visit by knocking the door with team network. Key success factors were VHV were local people with high intention, collaboration with team network and village people. VHV got facilities both financial and none-financial support, and monitoring. VHV had some barriers of their works such as their knowledge and skills of IPC, unclear IPC guidelines, level of corporate from other organizations, unclear information of policy implementation, Inadequate supplies of appropriate IPC devices, and unawareness from people. Therefore, the development should be composed of redesign of administration, capacity building providing for VHV, the support of facilities, the management of health information technology, and collaboration with network.


This research and development project aims to develop a community-based model of promoting an uptake of a living will among the elderly. It was implemented in Prapplachai Sub-district located in Uthong District in Suphanburi province. The project has 2 major phases. The first phase involved a survey of 880 samples including 360 senior population (60+), 360 family members of senior people, 120 healthcare providers, 20 village health volunteers and 20 community leaders. Besides the survey, the research team compiled qualitative data utilizing 20 in-depth interviews with senior people and focus group discussions with 26 participants consisting of the community leaders and village health volunteers. Compiled data include attitudes towards patients in a palliative care stage, knowledge and attitudes about the living will. An analysis of the quantitative data relies on descriptive statistics (mean and percentage), whereas a content analysis is applied to the compiled qualitative data. Both qualitative and quantitative data supported one another. Biases towards living wills were palpable. All groups of the sample had a limited knowledge about the meaning and benefits of living wills. They also have inadequate understanding and ability to write and to utilize the living wills. The survey results show 94 % of the samples comprising the elderly, their family members, healthcare providers, community leaders and village health volunteers have never written their living will. Almost half of the elderly (47.5%) had a thought about writing their living will. Supporting reasons persuading them to write the living will included recommending from healthcare personnel (40%), their increased age (30%), and their desire to tell their needs to the family members (30%). Nevertheless, the survey has revealed that more than a half of the ageing people (62%) expressed their need about having the doctors to choose proper medical treatments for them instead of choosing by themselves. Also, 62 % of them preferred choosing medical treatments together with their doctors. The project assessed the samples’ knowledge about living wills using 10 questions, and each question has 1 score. A comparison of knowledge scores shows that the mean scores among the elderly, family members, community leaders, healthcare staff, and village health volunteers were 7.4, 7.5, 7.6, 7.4 and 3.9 respectively. The qualitative data has unveiled that a certain number of samples confused or misunderstood that the living will is similar to a consent to treatment, a body and organ donation, and a last will. Despite having some knowledge, the studied samples barely understood a comprehensive meaning of the living will. Especially, the village health volunteers had a lowest mean score of the knowledge Items that showed their lack of knowledge were describing one’s needs, choosing a person who will make a decision for oneself, identifying a person who can make a decision in case that you cannot make it by yourself due to health conditions, do not know when the living should be used, do not know that the living will can help doctors and caregivers to communicate an issue about choices of medical treatments for patients, do not know that the living will can be revised or annulled by the owners at any time. Likewise, a majority of aging, their family members and health volunteers were unsure or did not know about a right time to compose their living will. The Community leaders as well as health volunteers did not understand that patients and their family members might refuse medical treatments recommended by the doctors if they did not want to. Also, the study illustrates that healthcare personnel has limited knowledge about the living will in some issues such as they did not know that the living will can be used to reaffirm the patient’s needs regarding the alternative treatments in case the patients could not communicate with other people, that the living will could be cancelled or be revised by the owners at any time, and that the patients have the right to refuse medical treatments. The percentages of healthcare providers who were short of knowledge mentioned above are 47%, 29% and 20 % respectively. The second phase tied up with a model development aiming at increasing an uptake of living wills among the elderly. The research team organized workshops to share research results with the community members and to facilitate drafting a plan for promoting and increasing an uptake of the living wills, especially among the elderly. The elderly peer leaders, family representatives, community leaders, health volunteers and healthcare stuff from the community hospital as well as from the sub-district health promotion hospitals were invited to participate in the workshops. The model comprises 3 key components as the followings. 1) Empowering of all stakeholders: the activities included using a participatory approach to establish a committee mechanism which is responsible for promoting the living will uptake, Providing the training of the trainers (TOT) workshop to equip participants with knowledge and skill in writing the living wills. Participants were the elderly leaders, community leaders, healthcare personnel, and health volunteers. 2) Participatory strategic planning: The committees determined strategic activities to promote an acceptance of living wills. Planned activities were identifying platforms to dissimilate knowledge and information. For example, the village health volunteers proposed setting up a group line to provide Q&A about living wills to community members, distributing information and a living will form on the sub-district official website, disseminating information via village broadcasting station as well as via the community radio program, holding training workshops to help the elderly and their family members to write living wills, and presenting cases that have had an experience writing and using the living wills. 3) Strengthening the hospital system: To work with the community hospital’s director and healthcare stuff in order to integrate tasks about living wills into the services. Moreover, to develop a guideline or instruction for patients and caregivers to ease the writing and utilizing of the living wills. The project recommends the government, local hospitals, and local administrative organizations to 1) promote comprehensive knowledge, understanding, and positive attitudes towards living wills at the community level; 2) create a clear manual and form to help people to become capable of writing their living wills, and disseminating them in a variety of available platforms, such as in hospitals, public service offices, and new social media; 3) train local change agents, such as elderly leaders, family leaders, community leaders, village health volunteers, and local healthcare personnel to have adequate knowledge and ability to transform people’s bias and misapprehension towards living wills, as well as to coach people how to write living wills; 4) developing and strengthening the healthcare staff’s skills about palliative care, care for patients with chronic diseases, advance care plan, and how to write and utilize a living will; 5) integrate promoting living wills among patients and caregivers to be a KPI (key performance index) of hospitals at all level; 6) demand that local administrative organizations build the database of people who have their living wills and share the database with hospitals; 7) encourage community leaders, health volunteers and healthcare providers work together to support a unified service with respect to the utilization of living wills.


Astrocytoma can be found to develop malignancy in 9-23 percent that is significantly associated with poor prognosis. From a literature review, lack of evidence mentioned about risk factors associated with malignant transformation. The study objectives were 1. to identify factors associated with malignant transformation 2. To identify the prognosis of astrocytoma that developed malignant transformation according to biomarkers. Method The present study was a retrospective cohort study and the study population was patients who were diagnosed with low-grade astrocytoma. The processes of the study comprised 4 processes as follows: 1. investigation of the candidate genes from fresh frozen tissue 2. Investigation of candidate gene mutations 3. survival analysis 4. nomogram development. Results Following whole-genome sequencing, IDH 1 and IDH 2 mutations were candidate genes. In 90 patients, IDH 1 and IDH 2 mutations were found in 12.2% and 10%, respectively. Malignant transformation was associated with a short survival time (log-rank test, p=0.006). Factors associated with malignant transformation were a supratentorial tumor, midline shift of more than 1 cm, the extent of resection, and IDH 1 mutations following multivariable analysis. Therefore, a nomogram was developed for predicting malignant transformation. Conclusion Malignant transformation was significantly associated with poor prognosis; therefore, a close follow-up strategy should be applied in high-risk patients.


This study had investigated contaminants and control of antimicrobial-resistant microorganisms (AMR) from hospitals and pig farms. In the study of pig farms, the questionnaire survey was conducted at four farms nearby the surface water body in Prachinburi province. It shows that 50% of the farms use antibiotics for disease prevention and treatment, while that 50% mix antibiotics with feed. The commonly used antibiotics are Amoxycillin (100%), Enrofloxacin (50%), and colistin (25%). The residual antibiotics found during the rainy season were Amoxycillin (54%), Florfenicol (14%), and Tiamulin (13%), of which the concentrations were significantly higher than those found during the summer season (P<0.05). The detection of antibiotic resistance among 143 isolates of E. coli, 29% was in pig manure, 36% in wastewater, and 33% in treated water. Nevertheless, the antibiotics that those isolates were found more than 50% resistant against were Ampicillin (90%), Florfenicol (67%), and Tetracycline (66%), 13% of ESBL. None was of Imipenem resistance. The resistant genes of E. coli were found higher for beta-lactamase followed by Tetracycline (tetA, tetB) and Aminoglycoside (aadA1, aadA2, aadB), while no mcr1 gene showed in all samples. The probability that microorganisms having identical genes of 1 pair (100%) and 80% similarity was about 20%. The study of treatment efficacy of activated sludge (AS) wastewater treatment plant of Chao Phraya Abhaibhubejhr hospital revealed 68-69% removals of basic pollutants, and 20-100% removals of 13 types of antibiotics. A similar AMR population (60-100%) to 20 antibiotics of E. coli, K. pneumoniae, and A. baumannii appeared in wastewater and the AS effluent. The study of pilot-scale membrane bioreactor (MBR) operated without excess sludge wastage in hospital wastewater treatment revealed 79-100% removals of basic pollutants and 32-100% removals of antibiotics. The MBR could effectively remove microorganisms (100%). Antimicrobial resistant test in the MBR sludge revealed higher percentages of sensitive colonies, especially those of K. pneumoniae and A. baumannii >80% were sensitive to 75-85% of tested antibiotics. The 1-2 log reduction of antibiotic resistance genes (ARGs) in the influent with 106-1010 copies/ml by the MBR had been achieved. The use of post-chlorination and ozonation slightly improved in removals of ARGs.


This study is a documentary research and aimed to study and review the contents of international cooperation frameworks at global, regional and national levels concerning issues on migration management and health care provision for migrant workers and cross-national populations and health collaboration frameworks between Thailand and Mekong sub-region countries, especially Cambodia, Lao PDR and Myanmar as well as mechanisms for implementation, coordination, monitoring and evaluation of the international cooperation frameworks. Results of the study revealed that global and regional international cooperation frameworks, with selected criteria mentioned above, have provided concepts and guiding principles for migration management and promotion of migrant and refugee health, which are harmoniously interlinked and aimed to realize the sustainable development goals (SDGs) that facilitate orderly, safe, regular and responsible migration and mobility of people (SDG target 10.7) and ensure healthy lives and promote well-being for all at all ages (SDG goal 3) including achieve universal health coverage (SDG target 3.8). The concepts and guiding principles can be applied by member countries as guidelines for dealing with problems and issues related to migrant workers and cross-national populations or can be used as conceptual frameworks for developing additional agreements to address the issues with countries of mutual interests. Since health management for migrant workers cannot be carried out alone by one country, collaboration and cooperation among the countries of origin or the sending countries and countries of destination or receiving countries are required. As movement of migrant workers can provide both positive and negative impacts on the economic development of countries and the region, integration of migrant health management as a public health issue of international cooperation in existing regional economic cooperation frameworks, such as ACMECS and GMS will help mobilize resources and efforts from member countries to address this issue in more effective and concrete ways, thus, makes the migration to be a positive impact for the overall economic development of the member countries and the region. Recommendations for better dealing with the challenges on provision of health services for migrants and cross-border population have been emphasized on the development of health and health-related policies to solve the obstacles at national level, such as to integrate primary care services or community-based health care provided at migrant community health centers with support and assistance of migrant health workers and migrant health volunteers to be a part of existing universal health insurance system for migrant workers and cross-border population, and the development of bilateral and multilateral international cooperation to mobilize efforts and collaboration in order to reduce negative impacts to the overall economic and social development of the region.


The project, Health Service design in Primary care under situation Covid - 19 diseases Study case of district Yarang, Pattani Province., aimed to stimulate health personnel to recognize the importance of primary health care system and to design their own service delivery responding to unique context complexity at local level in the southern part of Thailand. The project consists of 2 processes as followed. 1) Self-review of Pattani’s health personnel in primary care system to respond to recommended procedures regarding the COVID - 19 epidemic control in communities. The procedures were based on the WHO primary care framework, a framework with community network partners and the analysis of the complexity of the epidemic situation. There has been a response to the government policies and agreements at the area level in order to achieve 3 goals, namely 1) Safety of personnel and provider, 2) Strong community for disease management, and 3) Effective disease control. As a result, target personnel could understand the complexity of the problems and be motivated to develop health service to respond problems that arise. At the same time, the researcher realized that the policy imperative to the main responsible agencies at the national level. There should be preparation and readiness of the whole structure, specific budgets and personnel to cope with future outbreaks and response to chronic disease problems that may require a different management approach. 2) Target personnel development for new health service design by using “Design Thinking” process. The result of the development was a new working design and service system responding to complex health problems at the local level in 4 issues: 1) Anemia problem in pregnant women, 2) Expanding the services access to vulnerable groups, 3) The development of rehabilitation service for stroke patients (Intermediate care), and 4) The development of health service systems for uncontrolled hypertension and diabetes patients. Regarding the new delivery processes design, it was found that the health personnel placed greater emphasis on the primary health care system and the patients were more confident about receiving the service, as evidenced by the co-rehabilitation of 21 stroke patients revealed that 18 patients (85.71%) had increased ADL levels and improved clinical outcomes in a sample of 22 pregnant women with anemia were able to manage the problem in 14 cases (66.66%) without anemia. In addition, all four services were prepared in order to response to the potential recurrent of COVID-19 epidemic in Pattani.


“The Social Return on Investment Projects (SROI) under the Implementation of the District Health Board (DHB): 4 Case Studies” aimed to analyze social return on investment (SROI) of district health board and to assess the implementation of district health quality development under the drive of 4 DHBs in order to synthesize policy recommendations for the short, intermediate, and long terms of district health quality development through all concerned stakeholders’ engagement. There are 4 projects in the 4 targeted areas, as follows: 1) Elderly care in Bang Kruai DHB, Nonthaburi Province; 2) Waste and environmental management in Phimai DHB, Nakhon Ratchasima Province; 3) Traffic Accident reduction of in Suk Samran DHB, Ranong Province, and; 4) Good agriculture and safe food in Laplae DHB, Uttaradit Province. Mixed methodology was implemented based on the concept of social return on investment (SROI), under the guideline on the implementation of district health board (DHB), through documentary research from secondary data, survey questionnaire, focus group, and in-depth Interviews as data collection process. The results of social value or and the change in the community was transformed into financial proxy by net present value (NPV) analysis, 6% and 3% discount rates, cost-benefit analysis, payback period, and the ratio of SROI. Inputs, activities, outputs and outcomes were also analysed in the establishment of mapping outcome process. The conclusions from the focus group were made into impacts that required deadweight analysis by focusing on the weights of changing activities and other supporting factors that affected attributions. Then, financial proxies of the projects were calculated under the guideline on district health board (DHB). The results of SROI study from the project implementation in 5, 10, and 15 years with the use of discount rate at 6 and 3 percent were revealed as follows. 1) The elderly care project of Bang Kruai DHB, the SROI with 6% discount rate used of this project is -0.18 (in 5 years), 0.15 (in 10 years), and 0.26 (in 15 years). The calculated SROI with 3% discount rate revealed -0.17 in 5 years, 0.22 in 10 years and 0.38 in 15 years. The result showed the payback period in 4.72 years (5 years), 6.43 years (10 years), and 8.73 years (15 years). These implies that the calculation of SROI with 6% and 3% of discount rate mean every 1 THB of investment in the elderly care project of Bang Kruai DHB, - 0.18 THB in 5 years, 0.15 THB in 10 years, and 0.26 THB in 15 years of social value is created when the discount rate is at 6%; however, if the 3% discount rate is used, every 1 THB of investment in the elderly care project of Bang Kruai DHB, - 0.17 THB in 5 years, 0.22 THB in 10 years, and 0.38 THB in 15 years of social value is created, respectively. 2) The waste and environmental management of Phimai DHB, the SROI with 6% discount rate used of this project is 6.80 (5 years), 6.76 (10 years), and 6.18 (15 years). The calculated SROI with 3% discount rate revealed 7.52 in 5 years, 7.98 in 10 years and 7.75 in 15 years. The result showed the payback period in 13 days for 5 years, 26 days for 10 years, and 1.28 months for 15 years. These implies that every 1 THB of investment in the waste and environmental management of Phimai DHB is able to create social values at 6.80 THB in 5 years, 6.76 THB in 10 years, and 6.18 THB in 15 years if the discount rate is at 6%, while the discount rate at 3% explores every 1 THB of investment in the waste and environmental management of Phimai DHB is able to create social values at 7.52 THB in 5 years, 7.98 THB in 10 years, and 7.75 THB in 15 years. 3) The traffic accident reduction project of Suk Samran DHB, the SROI with 6% discount rate used of this project is 13.02 (5 years), 11.38 (10 years), and 10.01 (15 years). The calculated SROI with 3% discount rate revealed 14.16 in 5 years, 13.19 in 10 years and 12.30 in 15 years. The result showed payback period in 0.30 months (5 years), 0.61 months (10 years), and 0.91 months (15 years). These implies that every 1 THB of the traffic accident reduction project of Suk Samran DHB invested, 13.02 THB in 5 years, 11.38 THB in 10 years, and 10.01 THB of social value is created when using 6% discount rate, while if discount rate is at 3%, every 1 THB of the traffic accident reduction project of Suk Samran DHB invested, 14.16 THB in 5 years, 13.19 THB in 10 years, and 12.30 THB in years of social value is created. 4) The good agriculture and safe food project of Laplae DHB, the SROI with 6% discount rate used of this project is 1.10 (in 5 years), 1.36 (in 10 years), 1.34 (in 15 years).The calculated SROI with 3% discount rate revealed 1.21 in 5 years, 1.62 in 10 years and 1.71 in 15 years. The result showed the payback period in 1.70 years (for 5 years), 2.80 years (for 10 years), and 4 years (for 15 years). These implies that every 1 THB of the good agriculture and safe food project of Laplae DHB invested, the social value at 1.10 THB in 5 years, 1.36 THB in 10 years, and 1.34 THB in 15 years is created if calculating with 6% discount rate. However, if 3% of discount rate is used, The investment of every 1 THB of the good agriculture and safe food project of Laplae DHB is likely to create the social value at 1.21 THB in 5 years, 1.62 THB in 10 years, and 1.71 THB in 15 years.


Molecular subtyping of muscle-invasive bladder cancer (MIBC) predicts disease progression and treatment response. However, present subtyping techniques are based primarily on transcriptomic analysis, which is relatively expensive. Subtype classification of protein levels by immunohistochemistry (IHC) are more affordable and feasible to perform in a general pathology laboratory. Recent data demonstrated that GATA3, CK20, CK5/6, and CK14 protein levels were correlated with MIBC molecular subtypes. We aimed to evaluate the correlation of those IHC markers with survival outcomes after radical cystectomy in Thai patients. Moreover, we aim to evaluate molecular subtypings by mRNA expression analysis. We evaluated the IHC-based subtypes in MIBC, as classified by GATA3, CK20, CK5/6, and CK14 expression in 132 MIBC patients who underwent radical cystectomy followed by adjuvant chemotherapy (2008–2016). All individual markers and clinicopathological parameters were analyzed against treatment outcomes after radical cystectomy and some selected tissues were sent for whole transcriptome sequencing and clustering from mRNA expression. The result showed that the mean patient age was 65.6 years, and the male to female ratio was 6.8:1. Positive IHC expression rates of GATA3, CK20, CK5/6, and CK14 were 80.3%, 50.8%, 42.4%, and 28.0%, respectively. The 5-year overall survival (OS) was 27.0% (95% confidence interval (CI) 19.6%–35.0%). Only GATA3 and CK5/6 were significantly associated with survival outcome (log-rank p-values = 0.004 and 0.02). GATA3 and CK5/6 were then used to establish subtypes, which were luminal (GATA+ and CK5/6−, 38.6%), basal (GATA− and CK5/6+, 12.9%), mixed (GATA+ and CK5/6+, 37.9%), and double-negative (GATA− and CK5/6−, 10.6%). Patients with the mixed subtype had a significantly better 5-year OS at 42.8%, whereas patients with the double-negative subtype had the worst prognosis among the four groups (5-year OS 7.14%). In the multivariable analysis, lymph node status and subtype independently predicted survival probability. The double-negative subtype had a hazard ratio of 3.29 (95% CI 1.71–6.32). In conclusion, subtyping using GATA3 and CK5/6 was applicable in MIBCs, and patients with the double-negative subtype were at the highest risk and may require more intensive therapy and mRNA subtyping by mRNA expression must showed the significant relationship with survival rate.


Currently, there is a rapid increase in the international migration around the world. This may be due to various reasons, such as political situation in their home countries (refugees or asylum seekers), job or business opportunity, works, studies, or to start and/or to live with families. In 2017, it was found that approximately one fourth (25.7%) of international migrants resided in overseas more than 3 months with the purpose of working or starting families, so-called “Expatriates (Expats)”, accounted for 0.9 of the world population (7.6 billion). In Thailand, according to the data of Foreign Workers Administration Office, Department of Employment, Ministry of Labour (as of October 2019), there were foreigners who obtained a working permit in the country totally 3,028,000 people. Most of them were migrant workers from Cambodia, Lao PDR, Myanmar, and Vietnam (CLMV), which were 2,748,189 people. When considering only skilled workers (excluding CLMV workers), there were 166,896 people (6.07%). More than half (92,860 people; 55.64%) of these skilled workers lived in Bangkok, while the rest were scattering in other regions (74,030 people; 44.36%). Of those who lived in other regions, 7.19% (5,330 people) lived in the north-eastern region. However, this figure was the record of foreigners with a work permit only. There would have been many foreigners that come in and out as a tourist and temporarily stay in the country by marrying Thai women or living with Thai partners, whom Thai people called “Keui Farang” -- which literally means “Caucasian son-in-law” – with the term “Farang” referring to Caucasians. Although there are increasing trends of international migration globally as well as substantial numbers of Expats in Thailand, there are limited studies to investigate health and well-being or health related issues among these people. There may be some studies about neighboring migrant workers; however, the studies about Expats, particularly those come from Europe or America who have families in Thailand are very scarce. This study aimed to explore the situation of Expats’ health, especially health service utilization, health insurance, and unmet need. This information is very important and useful for health systems design in responsive to health need of this group of people in Thailand. Methods This study employed a mixed method design, focusing on Expats who came to have families and live in the northeast of Thailand only or son-in-law foreigners (not only westerners as there might have been male Expats from other places e.g., Middle-eastern, Asian, or Asia-pacific countries). The purposively selected study areas comprised three provinces: Nong Bua Lam Phu, Udon Thani, and Khon Kaen. Quantitative data were an analysis of 43 files (Health service data of public hospitals that are annually submitted to the Health Data Center of the Ministry of Public Health (MOPH)). Also, the health survey among son-in-law foreigners by using the survey questionnaire (68 questions) adapted from the Health Welfare Survey questionnaires of the National Statistics, which consisted of 83 respondents. Qualitative data included the reviews of literature conducted in Thailand and elsewhere, and the in-depth interviews and focus group interviews purposively conducted among 42 participants. interviewees comprising 6 MOPH policy makers, 4 representatives from other ministries that deal with foreigner-related work (Ministry of Justice, Ministry of Foreign Affairs, Ministry of Social Development and Human Security, and Immigration Bureau of the Royal Thai Police Headquarters), 1 NGO staff, 3 academics, 1 Deputy Director of a Provincial Health Office, 1 Director of a District Health Office, 11 public health officers, 4 registered nurses, 2 staff from the international affairs unit of a private hospital, and 9 expatriates comprising 6 different nationalities (2 French, 2 English, 1 Swedish, 1 American, 1 Australian, 1 Swiss and 1 Canadian).


Coronavirus disease 2019 (COVID-19) is a new emerging infectious disease that needs effective
risk communication, one of the key components of public health emergency responses. During
the pandemic, migrant workers face many significant challenges especially language and cultural
barriers hampering access to health risk information. This study aims to explore health risk
communication structure and processes, identify the communication network, and explore factors
related to the outcomes of health risk communication practices among migrant workers during
the COVID-19 pandemic in Thailand.
We conducted a mixed-method cross-sectional design on in migrant workers who lived in the
headquarter district of Samut Sakhon, Ranong, and Phuket provinces between November 2020
and June 2021. For qualitative approach, representatives from central and local public health
organisations, non-governmental organisations, local government units, and migrant community
members were purposively recruited with some additional interviewees recruited by snowball
sampling. Thirty-six key informants participated in the semi-structured interview. Deductive
thematic analysis was applied. For quantitative approach, first, we used social network analysis.
Fifty-six respondents from migrant communication were purposively recruited and were asked to
complete the questionnaire. Results from the questionnaires were used to outline sociogram to
assess how the information flew and actors that influenced the data flow most. We also surveyed
a total of 288 migrant workers to evaluate risk communication outcomes and related factors that
affected awareness toward public health measures and self-reported practices during COVID-
19. Logistic regression with robust standard errors were employed.
The findings showed that there were various activities around health risk communication. Though
health risk communication plan viewed migrant workers as a target group, there was no formal
governing body responsible for guiding communication plan. Moreover, there was no monitoring
tool or evaluation process for health risk communication. For social network analysis, migrant
health volunteers and local media were key sources of information. The centrality score was
higher in rural migrant communities compared with the urban ones-implying huge dependency
of communication within limited number of actors in rural areas. For quantitative survey on attitude
and self-reported preventive practices, most of respondents were aware of public health
measures (85%) and performed preventive practices (70%) during COVID-19 pandemic. Frequent reception of health information and having up to primary school education showed a
statistically significant association with preventive practices compared with those who hardly
received health information and the uneducated. Middle-aged migrant workers demonstrated a
significantly lower level of preventive practices than the younger migrant workers. A long stay in
Thailand was significantly related to lower degree of awareness toward public health measures.
In conclusion, clear governing body led by the government with intersectional collaboration, and
active engagement from community members such as migrant health volunteers are key to
effective communication with migrants. Dissemination of information for migrants should be done
through various channels especially local media in migrants’ languages, for instance, print and
online media with consideration of different migrant characteristics and capabilities especially.
The communication strategies should not overlook certain groups of migrants who were likely to
face difficulty in accessing health information (such as elder migrant workers and the uneducated
ones).


This research and development project aimed to develop a guideline for implementation in the prevention of loss to follow up among newly diagnosed pulmonary tuberculosis patients which are appropriate for each TB patient target group characteristic and practices of hospital personnel and hospital context. The project methodology applied collaborative quality improvement concepts of The Institute for Healthcare Improvement (IHI), the USA which consisted of 8 steps including 1) selecting the topic to be improved 2) inviting the experts to participate 3) inviting organizations to participate and establish a team 4) knowledge sharing 5) implement improvement 6) evaluate changes 7) assess and evaluate and 8) conclude outcome and distribution. The duration of the project was one year. Participating hospitals consisted of 17 Regional and General hospitals under the Ministry of Public Health. Hospital personnel who participated in the project consisted of 83 personnel including 10 physicians, 29 registered nurses from TB clinic, 16 pharmacists, 12 social workers, 9 infection control nurses, 5 public health officers, and 2 community health officers. Three face-to-face workshops were conducted for the participating personnel to spread knowledge on concepts and methods of collaborative quality improvement, applying collaborative quality improvement in determining preventive measures to prevent loss to follow-up among newly diagnosed pulmonary TB patients, to present causes of loss to follow up from data of participating hospitals. The experts gave information on preventive measures to prevent loss to follow up from literature reviews. Brainstorming, opinion and experience sharing, and reviewing problems and factors related to loss to follow-up sessions were conducted to conclude causes of loss to follow-up among newly diagnosed pulmonary TB patients of hospitals in each region, determine concrete and appropriate measures for solving each important cause of loss to follow-up according to patients’ characteristics, practical, and sustainable for implementation. Project responsible personnel developed a guideline for prevention of loss to follow-up among newly diagnosed pulmonary TB patients using the conclusions from the project workshops and literature reviewed. The outcome of the project was a “Guideline for prevention of loss to follow-up among newly diagnosed pulmonary tuberculosis patients”, which consisted of 3 parts: Chapter 1) Knowledge on Tuberculosis for hospital personnel which included TB pathogen, mode of transmission of TB, risks of TB infection, latent tuberculous infection and TB, factors affecting TB treatment and prevention of TB transmission by patients, environment, personnel and social, TB drug, side effects and caution in TB drug treatment, storage of TB drug, surveillance of side effects of TB drug, caring for patients with side effects of TB drug, education of newly diagnosed pulmonary TB patients, and counseling. Chapter 2) Self- care recommendation for TB patients which included details on TB drug administration, follow-up, prevention of TB transmission, general health care, and nutrition. and Chapter 3) Guideline for caring of newly diagnosed pulmonary TB patients to prevent loss to follow-up consisted of patient preparedness, TB patient education, creating awareness for continuous treatment, encouragement, empowerment, stress management, right to treatment, follow-up and referral system, networking, collaboration and resources both inside and outside hospitals.


The outbreak of Coronavirus disease 2019 (COVID-19) has a massive impact on health and well-being in all populations especially the vulnerable populations. Due to their vulnerability and limited opportunity to access health services, vulnerable populations have a greater health risk compared with other populations. Despite existing universal health insurance for all populations in Thailand including Universal Health Coverage Scheme (UCS), Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS), and Health Insurance Card Scheme (HICS) for migrant workers and their dependents, there remain some uninsured populations. Therefore, this study aimed to provide policy recommendations to improve the health systems for vulnerable populations in Thailand during the COVID-19 pandemic. Both quantitative and qualitative studies were performed. Firstly, the situation of access to health services among vulnerable populations in Thailand during COVID-19 was studied by using the hospital service records of the Ministry of Public Health (MOPH) (43 folders), a secondary data, from National Health Security Office (NHSO) from January 2020 to June 2021. Secondly, document review regarding access to health services for vulnerable population. s. Lastly, in-depth interviews and focus group discussions on relevant stakeholders were performed to develop recommendations for improving health services for vulnerable populations. In this regard, a total of 39 participants including policymakers, staff responsible for taking care of vulnerable populations, and vulnerable populations were selected by purposive sampling and snowball sampling. The findings demonstrated that vulnerable populations the COVID-19 screening test utilised by vulnerable populations accounted for approximately 1,154,355 records (included all insurance schemes) during January 2020 – June 2021. Focused only on the UCS, there were COVID-19 screening tests in total 939,444 times. The number of visits of vulnerable people receiving COVID-19 tests and treatment in both outpatient (OP) and inpatient (IP) care was about 9,288. The number of deaths of vulnerable populations due to COVID-19 was 216.


The purpose of this mixed-method study was to 1) develop a model of telemedicine and medication management system for peritoneal dialysis patients 2) develop an application for remote assessment of peritoneal dialysis patients using lessons learned from the COVID 19 pandemic and 3) examine the effectiveness of a model of telemedicine for peritoneal dialysis patients. The sample was composed of nephrologists, pharmacists, peritoneal dialysis nurses, and peritoneal dialysis patients and caregivers. Purposive sampling was used to select the participants. The study was composed of 3 phases: phase 1 situation analysis; phase 2 design and development of a model of telemedicine for peritoneal dialysis patients; and phase 3 examines the effectiveness of a model of telemedicine for peritoneal dialysis patients. The research instruments were a semi-structured interview guide and a model of telemedicine for peritoneal dialysis patients, including 1) telemedicine for peritoneal dialysis patients 2) medication management system for peritoneal dialysis patients and 3) application for remote assessment of peritoneal dialysis patients; feasibility of telemedicine in peritoneal dialysis patients' questionnaire; cost record form; satisfaction of multidisciplinary team in peritoneal dialysis patients' questionnaire; and satisfaction of peritoneal patients' and caregivers' questionnaire. All the questionnaires were developed and validated by five experts. The qualitative data was analyzed using content analysis. The quantitative data was analyzed using descriptive statistics including frequency, percentage, median, interquartile rank, Wilcoxon signed-rank test, and Paired t-test. The results of this study revealed that: 1. The results of the situation analysis study showed that 1) patients and their caregivers have difficulty getting to the hospital as scheduled and have a fear of contracting COVID 19 from hospital visits. The problems with the continuity of taking medication for both chronic kidney disease and comorbidities. Furthermore, there is a limit of home visits during COVID 19 situation 2) patients and multidisciplinary teams suggested that during COVID 19, the methods of care in peritoneal dialysis patients, including treatment and home visits, be adjusted by phone and through online platforms such as line application. Providing peritoneal dialysis patients and caregivers with the knowledge they require for health care. Developing a friendly medication management system for peritoneal dialysis patients and caregivers to decrease travel time and the opportunity to contract COVID 19 and 3) giving information about treatment and self-care of peritoneal dialysis patients during a COVID 19 crisis situation through a line application or other that can be downloaded to a mobile phone and used to communicate with the doctor and nurse when abnormal symptoms and problems are discovered immediately. The results from this study indicated that although the cost of medical and nursing care and the time of health care service spent on telemedicine was higher than those of normal service. Patients and caregivers, on the other hand, paid less for travel to the hospital, spent less time getting to the hospital, and waited less time in the hospital than those in regular service. Furthermore, the multidisciplinary team, patients, and caregivers were satisfied with the telemedicine. As a result, the health-care system may apply the findings of this study to other chronic conditions.