World of Genomics: Thailand – original article written by Shannon Gunn, 2021. Updated by Lyndsey Fletcher, 2023.
In this week’s World of Genomics, we head on over to the ‘Land of Smiles’, also known as Thailand. With support from the Thai government and growing investment in the field, Thailand is becoming an exciting place for genomics 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. It has borders with Myanmar, Laos, Cambodia and Malaysia. It also has maritime borders with India, Indonesia and Vietnam.
Some of Thailand’s first settlers came from Austroasiatic areas, and later from the Kra-Dai (Tai-Kadai) group, who migrated from southern or south-eastern China. The first Thai kingdom was established in the 14th century.
Thailand was primarily an agricultural country, but since the 1960s increasing numbers of people have moved to the capital, Bangkok, and other major cities.
Interestingly, Thailand is also home to some of the oldest dinosaur fossils that have been found, highlighting a rich biological history!
Geographic and demographic information
Summary statistics:
- Land area: 513,120 km2
- Gross domestic product (GDP):
- Total: $574.2 billion (2023 estimate)
- Per capita: $8,181 (2023 estimate)
Population statistics:
- Population size: 71.6 million (2021)
- Birth rate: 9 per 1000 (2021)
- Death rate: 8 per 1000 (2021)
- Infant mortality rate: 7 per 1000 (2021)
- Average life expectancy: 79 (2021)
- Male: 75 (2021)
- Female: 83 (2021)
- Ethnicity: 80% Thai (37% Central Thai, 25% Thai Lao (Northeastern Thai), 8% Lanna (Northern Thai), 8% Dambro (Southern Thai), 2% Western Thai), 10% Thai Chinese, 3% Khmer, 7% other including Thai-Malays.
Healthcare system
In 2002, universal healthcare was introduced in Thailand. There are three main public health insurance schemes which cover 85% of the Thai population. These include the Civil Servant Medical Benefit Scheme (CSMBS), for civil servants and their dependents. This covers around 5.3 million people with an open-ended budget. The second scheme is the Social Security Health Coverage Scheme (SSH) – a tripartite contribution between the government, employers and employees in the private sectors. The third is the Universal Coverage Scheme (UCS) – the largest of the three schemes, covering approximately 71% of Thai people. Each of these schemes has its own legislation and governing bodies.
Since universal healthcare was introduced, government health expenditure has significantly increased, from 2.08% of GDP in 2002 to 3.07% of GDP in 2020. However, access to medical care in rural areas still lags behind that in cities. Multiple interventions have been introduced to tackle this, including a healthcare curriculum reflecting rural health problems and financial incentives.
Health priorities
Significant challenges in the Thai health sector include financial issues and an ageing population. Longer life expectancy and a 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 population 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.
In 2017, in collaboration with the World Health Organisation (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. This is partly because, 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. The United Nations’ Sustainable Development Goals 2022 report indicated that tuberculosis is the only remaining major infectious disease in Thailand.
In 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 the Thai market, an increase in obesity has also been seen among the population. In addition, food safety concerns are prevalent in 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 from the UK and US established clinical genetic services in Thailand in both haematology and paediatric departments. 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 lengthy struggle. Over 30 years ago, molecular genetic testing for thalassaemia was introduced in Thailand, the first available genetic test excluding karyotyping. The country has a high incidence 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.
In 2023, the National Health Security Office (NHSO) expanded the list of reimbursable newborn screening tests to include 24 rare diseases including inborn errors of metabolism (IEM). Also, the NHSO has set up a referral system specifically for paediatric rare diseases in 7 teaching hospitals in the University Hospital Network (UHOSNET) across Thailand.
Pharmacogenomics research began in 2004 in Thailand. Pharmacogenetic testing, such as screening for the variants HLA-B*15:02 and HLA-B*58:01 that predispose an individual to adverse drug effects, has been covered by the UCS since 2018. 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 medical research institutes. However, their use is limited by a lack of well-trained bioinformaticians and professionals in other disciplines related to human genetics. Despite great progress, the Thai workforce still has few clinical geneticists and genetic counsellors. However, during the past few years, there have been attempts to upskill and reskill the health care workforce. For example, training on genetic counselling for healthcare professionals, precision medicine training for medical technologists and short training courses in bioinformatics analysis. Thailand has plans to build a workforce to serve the increasing demands for genomic medicine and aims to train 30 clinical geneticists, 100 genetic counsellors, 100 molecular geneticists/biologists/pathologists and 500 computational bio-scientists/bioinformaticians/genetic epidemiologists within the next 5 years.
Regarding ethical and legal issues, Thailand has recently implemented the Notification of the Ministry of Public Health on “Standard of practices for genomic medicine service” under the MEDICAL FACILITIES ACT, B.E. 2541 (1998) to specify the requirements in professionals, practices, equipment and facilities for hospitals and clinics that provide genomic medicine. Also, due to the PERSONAL DATA PROTECTION ACT, B.E. 2563 (2021), a patient’s consent for genetic testing and storage of personal genetic data must be obtained for both clinical research and within the genetic testing service.
At the forefront of many of these changes is Genomics Thailand, an initiative to sequence 50,000 Thai genomes for use in research and healthcare by 2024. The initiative is supported by both the Thai Ministry of Health and the Ministry of Higher Education, Science, Research and Innovation.
The initiative has priorities in five different areas – cancer, rare disease, non-communicable disease, emerging infectious diseases and pharmacogenomics. Eligible patients are recruited into the programme via the clinical research network at hospitals and research institutes and blood samples are sent to the National Bioresource Centre. Their DNA is then extracted and deposited into a centralised biobank, before being sent to the Thailand Genome Sequencing Center, and then to the National Genome Data Center for interpretation. These results can then be used to inform patient care.
Prior to the development of the Thailand Genome Sequencing Center (as part of this initiative), there were very few laboratories that could carry out whole genome sequencing. When developing the centre, it was crucial that a local Thai partner was involved so that Thai scientists could learn how to run large-scale sequencing projects. The Thailand Genome Sequencing Centre has been operating since April 2022 and as of May 2023 has sequenced more than 14,000 human genomes. As of June 2023, the Genomics Thailand Initiative has recruited more than 25,000 patients. This includes approximately 10,000 rare disease patients, 7,000 cancer patients, 6,700 patients with non-communicable diseases, 2,000 patients with infectious diseases and 2,100 patients for pharmacogenomic research.
The initiative has already led to the implementation of reimbursable BRCA1/2 genetic testing to screen for familial breast and ovarian cancer, covered by the UCS, and it is expected that more genetic testing will soon be included in the Thai health system.
Notable projects
Genomics Thailand Initiative: In 2019, the Thai government launched the Genomics Thailand Initiative to sequence the genomes of 50,000 Thai individuals within 5 disease groups; cancers, rare diseases, non-communicable diseases, infectious diseases and pharmacogenomics. It aims to build an infrastructure to harness genomic information and provide a bioinformatics platform for both researchers and health care service personnel to access genome analysis tools. One long-term goal is to gain better preventative information and provide better health outcomes for southeast Asian populations. Currently, the Genomics Thailand Consortium has more than 40 participating national agencies, institutes, medical schools and hospitals. The first phase of cataloguing 50,000 human whole genome sequences is expected to be finished in 2025. It is also hoped that integrating genomic medicine into the health system will raise the standard of healthcare as a whole.
Southeast Asian Genome-Sequencing Project: Thailand was 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).
National Biobank of Thailand (NBT): NBT was established in 2019 to serve as the first long-term biobanking infrastructure for the nation. NBT works with many stakeholders to promote an efficient and sustainable conservation program for Thailand’s bio-resources. In addition to the conservation mission, NBT has been entrusted by the government and the Genomics Thailand consortium to process 50,000 human genomes and construct the first Thai genetic reference database, that will soon become the core infrastructure of Thailand’s genomic medicine service.
Notable organisations and companies
Ministry of Public Health (MOPH): MOPH is a Thai governmental body responsible for the oversight of public health in Thailand. MOPH proposed the National Strategic Action Plan “Genomics Thailand” in 2019 aiming to expand genomic medicine in the public health system of Thailand and provide equal access to a quality genomic medicine service.
Health System Research Institute (HSRI): Established by the Health Systems Research Institute Act of 1992. It is an autonomous state agency, which allows the institute to function more flexibly in an ever-evolving economic, social and political environment. Working in partnership with multilevel public and private agencies, HSRI’s main goal is to achieve effective knowledge management in the health system. HSRI oversees “Genomics Thailand” and is the current fund manager responsible for genomic medicine research in Thailand.
Eastern Economic Corridor Office of Thailand (EECO): EECO is a vital public agency aiming to encourage investment, uplift innovation and advance technology in Thailand for future generations. EECO has been appointed by the Cabinet to drive the economy based on genomic medicine and provide facilities for international collaboration, investment and technology transfer.
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.
Chulalongkorn University’s Excellence Centre for Genomics and Precision Medicine: Founded in 2019 due to rapid advances and continuing growth of knowledge in genetics and genomics over the recent decades. It has since expanded and aims to provide comprehensive clinical genomics services for patients with genetic diseases, create new knowledge and generate innovations in genomics and precision medicine. It also provides training in these fields.
Preventive Genomics and Family Check-up Services Centre, Bumrungrad Hospital: The hospital provides comprehensive genetic testing services by a team of interdisciplinary doctors from pre-test counselling, genetic testing and post-test counselling with specialty doctors. Bumrungrad Hospital has already implemented next generation sequencing in its laboratory.
Notable individuals
Yong Poovorawan (1950-): Poovorawan is a medical professor in 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.
Anavaj Sakuntabhai (1962-): Sakuntabhai is a Thai researcher who specialises in understanding human genetic susceptibility to infectious diseases such as dengue fever and malaria.
Vorasuk Shotelersuk (1969-): Shotelersuk is a paediatric geneticist who works on rare diseases and has identified many new disease genes. He is the Associate Dean for Research Affairs, the founding and current Director of the Centre of Excellence for Medical Genomics of the Faculty of Medicine, Chulalongkorn University, and the vice president of the Genetics Society of Thailand. He has over 180 published research articles and more than 3,600 citations.
Surakameth Mahasirimongkol (1976-): Currently working at the Department of Medical Sciences, Ministry of Public Health, Thailand, he carries out research in epidemiology, genetic epidemiology and tuberculosis. He is involved in numerous projects in pharmacogenomic research and has worked in linking human genomic variations with severe adverse side effects of drugs and vaccines. He also studies the role of human disease susceptibility genes in infectious diseases such as tuberculosis.
Future genomics landscape
In 2016, only 14% of genome-wide association studies had been conducted on Asian populations. Thailand is making huge strides to improve this and understand genomics on a local scale. The Genomics Thailand Initiative will provide much needed insights, helping to understand the country’s genomic complexity. The initiative will also hopefully lead to more genetic services becoming available to the public and the research capacity of the nation increasing.
There is currently a five-year target to train 30 clinicians, 100 genetic counsellors, 100 molecular geneticists and 500 bioinformaticians in Thailand. In 2021, 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 has had to start from scratch. As a result, a group has been tasked with exploring the ethical, legal and social implications, and drafting legislation and regulations around genomic medicine.
There is now a lot of support from the Thai government for genomics projects, and the future research landscape in Thailand looks very bright.
References
- National Health Security Office. https://www.nhso.go.th/
- https://dashboards.sdgindex.org/profiles/thailand/indicators
- Shotelersuk V, Limwongse C, Mahasirimongkol S. Genetics and genomics in Thailand: challenges and opportunities. Molecular genetics & genomic medicine. 2014 May;2(3):210.
- Shotelersuk V, Tongsima S, Pithukpakorn M, Eu-ahsunthornwattana J, Mahasirimongkol S. Precision medicine in Thailand. American Journal of Medical Genetics. 2019;181C:245-253.
- 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/
- https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=TH
