World of Genomics: Thailand

For this week’s World of Genomics entry, we head on over to the ‘Land of Smiles’, also known as Thailand. With investment from the Thai government and a growing market, Thailand is becoming an exciting place for genomic projects and precision medicine.

The population of Thailand

Thailand (formerly known as Siam) is a country located in Southeast Asia, in the centre of the Indochinese Peninsula. Thailand’s first people were the Mon and Khmer, and later the Tai, who migrated from southern China. The first Thai kingdom was established in the 14^th century. Thailand was primarily an agricultural country, but since the 1960s increasing numbers of people have moved to the capital, Bangkok, and other cities. Aside from a brief period of parliamentary democracy in the mid-1970s, Thailand has periodically alternated between democracy and military rule. In modern times, Thai scientists have made several contributions to various fields of study, and even more recently, are investing within genomic medicine. Thailand harbours several rare genetic diseases that are unique to Thailand, which have contributed to the international knowledge on diseases. Interestingly, Thailand is also home to some of the oldest dinosaur fossils that have been found.

Geographic and demographic information

Summary statistics:

• Land area: 513,120 km²
• Gross domestic product (GDP):
  • Total: $1.340 billion
  • Per capita: $19,169

Population statistics:

• Population size: At the time of writing, the current population of Thailand in 2021 is 69,950,850.
• Birth rate: In 2019, the crude birth rate was 10.168 per 1,000 people.
• Death rate: In 2019, the crude birth rate was 7.786 per 1,000 people.
• Infant mortality rate: The crude infant mortality rate is 6.58 per 1,000 people.
• Average life expectancy: The average life expectancy in 2018 was 76.93 years.
• Ethnicity: Thailand is a diverse country with several ethnic groups. Thai ethnic group accounts for 92% of the population while the remaining 8 % of the population belong to the other ethnic minority groups. The Thai, Khmer and Malay people represent the largest ethnic groups in Thailand.

Healthcare system

Thailand (now an upper-middle-income country) was one of only a handful of lower-middle income countries to introduce universal coverage reforms in 2001. In 2002, universal healthcare was introduced into Thailand. The are three programs: (1) the civil service welfare system for civil servants and their families, (2) social security for private employees and (3) the universal coverage scheme for all other Thai nationals. It is regarded as one of the most ambitious healthcare reforms ever undertaken in a developing country. Since universal healthcare was introduced, public expenditure on health has significantly increased from 63% in 2002 to 77% of the total health expenditure in 2011. As access to medical care in rural areas lags behind that in the cities, multiple interventions have been applied, including introducing a curriculum reflecting rural health problems and financial incentives.

The remaining challenges in the Thailand health sector include financial issues and the ageing population. Longer life expectancy and the decline in the working population have put enormous pressure on Thailand’s economy and public welfare system. The Thailand Development Research Institute (TDRI) has even warned that the ageing society will push the country’s healthcare costs to THB ฿1.4 trillion per year within the next 15 years. Moreover, increasing financial pressures have made many question the sustainability of the Thai healthcare system. This comes from both the long-term care expenditure from the ageing population and the diminishing general tax revenue due to a shrinking labour force.

Health priorities

In 2017, in collaboration with WHO, the Ministry of Public Health in Thailand laid out five strategic priorities to address important public health issues. These included: antimicrobial resistance, global health diplomacy, migrant health, noncommunicable diseases and road safety.

A study in 2016, revealed that an average of two people die every hour from multi-drug resistant bacterial infections in Thailand. This death rate is much higher than in Europe. In Thailand, antibiotics are freely available in pharmacies without a prescription. As a result, in 2016, Thailand announced its intent to halve antimicrobial-resistant infections by 2021, joining in the battle against superbugs.

Over the past few decades, the Ministry of Public Health in Thailand and the CDC have been working together to develop intervention strategies to help fight against high-risk diseases. In more recent years, the incidence of cancer has elevated in Thailand, becoming the leading cause of death (19%). This is followed by ischemic heart disease (12%) and stroke (10%). As fast-food chains have entered into the Thai market an increase in obesity has also been seen among the population.

Major infectious diseases in Thailand include diarrhoea, hepatitis, dengue fever, malaria, HIV, Japanese encephalitis, rabies and leptospirosis. In addition, food safety concerns are common to Thailand. Microbial contamination of street food is common, as well as the use of banned or toxic pesticides and fake food products.

Genomic medicine capabilities

During the 1970s, specialists graduating from programs in the UK and US established clinical genetic services in Thailand in both haematology and paediatric departments. Then in the 1980s, cytogenetic services were introduced into Thai university hospitals. Since then, government cytogenetic laboratories have become available across the country.

The prevention and control of thalassaemia within Thailand has been a long struggle. Over 30 years ago, molecular genetic testing for thalassaemia became available and was the first available genetic test (excluding karyotypes). Thailand has a high abundance of thalassaemia and has thus contributed significantly to advancing research in haemoglobinopathies.

Prenatal diagnosis for Mendelian diseases and preimplantation genetic diagnosis (PGD) have been available for the past 30 years, with test panels now comparable to most developed countries. The Neonatal Screening Program for congenital hypothyroidism (CHT) and phenylketonuria (PKU) commenced in 1996. Screening for other inborn errors of metabolism is not funded.

Pharmacogenomics research began in 2004 in Thailand. Several variants have been identified in the Thai population, including HLA-B∗15:02 for carbamazepine. Pharmacogenetic testing has also been implemented nationwide. At Ramathibodi Hospital alone, around 3,000 patients have benefited from pharmacogenomics and personalised medicine and received partial reimbursement for some drugs.

Next-generation sequencing technologies are also becoming increasingly available in Thailand’s institutes. However, there use is limited by a deficiency in well-trained bioinformaticians. Despite the great progress, the Thai workforce is lagging behind with few clinical geneticists and no genetic counsellors.

Notable projects

• Genomics Thailand Initiative: In 2019, the Thai government launched the Genomics Thailand Initiative to sequence the genomes of 50,000 Thai individuals and build an infrastructure to harness genomic information. One long-term hope is to gain better preventative information for southeast Asian populations.
• National Biobank of Thailand (NBT): The NBT was established in 2019 with the goal to sustainably conserve and promote efficient utilisation of bio-resources, including human genome, plant, microbes and animal cell lines. The five-year pilot project will collect whole-genome sequencing data from 10,000 Thai volunteers.
• Southeast Asian genome-sequencing project: Thailand were among seven countries that participated in this project. This project focussed on identifying the prevalence of pharmacogenomic variants in 100 drug-related genes for 1,000 subjects among the Southeast Asian population. (Ruchaeroen et al, 2021)

Notable organisations and companies

• Thailand National Center for Genetic Engineering and Biotechnology (BIOTEC): BIOTEC was founded in 1983 and is a research institute conducting basic and applied research covering a wide spectrum from agricultural science to biomedical and environmental science.
• Thailand Center of Excellence for Life Sciences (TCELS): TCELS was founded in 2004 by the government of Thailand. The organisation has the responsibility of providing a link between innovation in life sciences and investment and international partnership.
• Ramathibodi Hospital’s Centre for Medical Genomics:  The Faculty of Medicine Ramathibodi Hospital, Mahidol University, is regarded as Thailand’s most prestigious medical school. Thailand’s Center for Medical Genomics joined forces with TCELS in 2014 on pharmacogenomics research.

Notable individuals

• Yong Poovorawan (1950-): Poovorawan is a medical professor paediatric hepatology at the Faculty of Medicine of Chulalongkorn University in Bangkok. He is widely recognised for his work on genetic sequencing and detection of the H5N1 avian influenza virus in Thailand.

Going forward

Thailand is making big strides in genomic medicine to better understand local susceptibility to diseases. Most of our genomic data to date focusses on individuals from European descent. In 2016, only 14% of genome-wide association studies had been conducted on Asian populations. The Genomics Thailand Initiative will provide much needed insights, helping us to understand the countries’ genomic complexity.

Nonetheless, the future of genomics in Thailand is impeded by lack of researchers. There is currently a five-year target of training 30 clinicians, 100 genetic counsellors, 100 molecular geneticists and 500 bioinformaticians. A few months ago, Guy’s and St Thomas’ NHS Foundation Trust in the UK and TCELS also signed a Memorandum of Understanding (MoU) on genetic counsellor capacity, aiming to build a partnership to support Thailand’s development of medical genomics and precision medicine.

While many countries already have the necessary infrastructure and laws in place, Thailand is starting from scratch. As a result, a group has been tasked with exploring the ethical, legal and social implications, and drafting legislation and regulations.

It is clear that there is a lot more support from Thai government for genome projects compared to previously, and it will be exciting to see how they continue to enter the genomics space and adopt precision medicine across the country.

References

• Shotelersuk V, Limwongse C, Mahasirimongkol S. Genetics and genomics in Thailand: challenges and opportunities. Molecular genetics & genomic medicine. 2014 May;2(3):210.
• Sukasem C, Jantararoungtong T, Koomdee N. Pharmacogenomics research and its clinical implementation in Thailand: Lessons learned from the resource-limited settings. Drug Metabolism and Pharmacokinetics. 2021 May 4:100399.
• There are also a series of articles on Nature exploring genomic medicine in Thailand, see link: https://www.nature.com/collections/chjcddijfc/