Archive for September 2010
Malaria is public health problem in Cambodia’s remote communities near forested areas, where villagers work in the jungle as woodcutters. The village malaria worker (VMW) project, run by the Cambodian government’s National Centre for Parasitology, Entomology and Malaria Control (CNM) with technical support from WHO, plays a big role in making these communities accessible for the accurate diagnosis and treatment of malaria.
THE explosive spread of mobile phone networks across the developing world has created a unique opportunity to significantly transform how countries can tackle global health challenges, including the containment of drug-resistant malaria along the Thai-Cambodian border.
The Disease and Treatment Monitoring of Malaria (DTMM) module, a part of the Better Border Healthcare Program created by the Centre of Excellence for Biomedical and Public Health Informatics at Mahidol University or Biophics, uses mobile and web-based technology to alter treatment-seeking behaviours and facilitate better treatment and care for malaria patients in low-resource settings. It has speeded up detection at the point-of-care, made reporting to decision-makers close to real time, and improved the accuracy of mapping malaria risk locations.
WORKING closely with the governments of Cambodia and Thailand, the World Health Organization has developed an ambitious cross-border malaria containment project in a bid to eliminate malaria resistant parasites and wipe out the mosquito-borne disease along the border areas of two countries.
This $22.5-million project, funded by the Bill & Melinda Gates Foundation, uses a combination of prevention and treatment methods that have proven to be effective against malaria. The project strategy includes large-scale distribution of long-lasting insecticide-treated mosquito nets, free early diagnosis and treatment of malaria at the village level, 24-hour health facilities to diagnose and treat malaria and intensive surveillance of positive cases as well as other education programmes and innovative means to reach the mobile migrants.
In early 2009, WHO warned that Plasmodium parasites resistant to artemisin had emerged along the Thai – Cambodia border, posing a serious threat to global efforts control malaria. However, there are promising signs that efforts to eliminate malaria resistance along the common border are making significant gains.
See You Tube video
An interview with Dr. Doung Sochet, Director National Center for Parasitology, Entomology and Malaria Control.
- There is evidence of artemisinin-resistant malaria in Western Cambodia, particularly along the Cambodian-Thai border. What efforts are being made to reduce the morbidity and mortality rates there?
We have been working with different partners, especially with WHO, with funding from the Global Fund. We have deployed our people along the Cambodian-Thai border. We have also made big efforts to distribute long-lasting insecticide-treated nets (LLINs) to people in the area. We are also making concerted efforts to control the sale, by retail outlets and in the markets, of counterfeit and substandard anti-malarials in the targeted area that we call Zone 1. Besides that we are also doing mass screening of children, women and men in Zone 1 to diagnose and treat malaria. Our aim is to contain and eliminate artemisinin-resistant falciparum malaria in Zone 1.
The results have been very encouraging. It is an indication that our containment strategy is working in the high transmission areas. Let me give you an example. Previously when we first started mass screening of about 3,000 people we found over 100 positive falciparum malaria cases. Recently we did screening of the same size of people and only found only eight positive cases. This drop in the number of positive cases is very significant. In 2009, we had no deaths due to falciparum malaria in the area, especially in Pailin.
Counterfeit and substandard anti-malarials are one of the causes for the emergence of MDR-falciparum malaria. What are the efforts to eliminate these counterfeit and substandard drugs sold by the private sector and also enforce the ban on oral artemisinin monotheraphy?
We provide regular monthly trainings to all companies involved in the import and export of pharmaceutical products. We have also communicated to all pharmacies and drug-sellers of the Ministry of Health’s ban on monotheraphies. It is important to inform the drug-sellers first, before we do law enforcement with the Justice Police who go around inspecting pharmacies and other drug retail outlets. The drug-sellers have to be made aware of the dangers and the harm they could cause with the sale of fake anti-malarials and monotheraphies.
We raise this awareness by constantly putting out Information, Education and Communication (IEC) materials, which are distributed to communities, warning of the dangers of monotheraphies and the dangers of buying fake drugs. These IECs also inform the public that the government has banned the marketing and sale of “single-drug” artemisinin malaria medicines, in order to prevent malaria parasites from developing resistance to this drug.
The high use of artemisinin in Cambodia consists of monotheraphies provided through the private sector. This problem can be overcome if more Cambodians use health services provided by the government. Is this happening?
This is a key issue in our containment programme with WHO. Ten years ago our health structures were still weak because we lacked human resources at the grassroots level. Even our in-country health infrastructure was not strong enough. We did not have proper roads; we did not have health facilities in the remote areas. So we cannot blame people, at that time, for going to the private sector because the public sector did not have enough capacity. Also during that time people in the public sector were very poorly paid, and so there was not much commitment to provide services. So sick people just flocked to the private sector. Even if you went to the villages, the smallest drug retailer was able to provide some form of health service. But now things have changed. The government has committed more funds for health infrastructure. Health facilities have improved and there are more incentives now for public health workers. International donors have supported us in improving our health infrastructure.
We have created more access to the health facilities, now, for the people. And there is a concerted effort to encourage them to use government facilities, rather than to go to the private sector. We are also engaging the private sector and encouraging them to refer malaria cases to the government health centers.
One big concern is malaria on the move. How important is the role of village malaria workers or VMWs in the diagnosis and treatment of villagers in the hard-to-access areas?
About a decade ago, we had very poor health facilities in the villages. We had difficulty accessing people in the remote areas. Health workers had to walk for two to three hours to meet these mobile migrants who were in the forest. There were many instances where the health workers could not meet these people. Hence there was an urgent need to reach out to them. Because of this we decided to pilot a project where volunteers would be able to diagnose and treat malaria in their own communities. This has been successful.
The villagers themselves do the selection of the village malaria workers. They are the best people to know who is competent enough to be trained to do diagnosis and treatment. In each village, there is a male and female volunteer malaria worker. Once the village malaria workers are chosen by the people, we then step in and do the training. The aim is to contain and eliminate malaria at the village-level. The treatment is free, and now we have scaled it up to all provinces.
Interview with Dr Wichai Satimai, Director, Bureau of Vector-Borne Diseases, Thailand.
Please identify one benefit Thailand has enjoyed from the project, mainly supported by the Bill and Melinda Gates Foundation, to contain and eliminate malaria parasites tolerant to artemisinin in Southeast Asia.
The support Thailand has appreciated in particular from the Bill and Melinda Gates Foundation has been the boost in human resources and equipment. With more full time and part-time staff here at the Bureau of Vector Borne Diseases, and in the border areas, including translators at malaria clinics and IT people, and the equipment we need for containment activities – such as motorcycles (42), good microscopes (40), and pickup trucks (seven which replaced 20-year-old ones) – we have made much progress.
Since malaria control remains on Thailand’s national agenda, which is evident in the Bureau of Vector-Borne Disease’s partnership in the project, how do you think the question of malaria control should be raised?
The malaria situation in Thailand is better than before with incidence down from about 100,000 say ten years ago to about 25,000 now, among Thais and non-Thais. However, with the emergence of new, epidemics such as SARS, or H1N1, non-communicable diseases and illnesses deriving from environmental and chemical causes, the human resources and budget have to be shared.
With regard to containment of artemisinin-resistance, we would like people in Thailand and other countries around the world to know that this is similar to resistance to Fancidar (sulfadoxine-pyrimethamine), which also spread. It means we have to ask specialists from international organizations to help us. Hence we have to co-operate with the World Health Organization, the Bill and Melinda Gates Foundation, the Global Fund. At the Global Fund’s Round 7, two research groups participated. We are asking Global Fund Round 10 to include 12 non-governmental organisations that work with us as recipients. We need their experience in working with migrants. We realise that patients, nearly half of them migrants moving from nearby countries, are undocumented and may be afraid of the government.
The secretary-general of the World Health Organization has made clear that health issues transcend all borders. Please reflect on how this applies to Thailand’s co-operation with Cambodia and other neighbours.
The principle is we would like to work closely with Cambodia. Unfortunately, there is a language problem between Thais and and Cambodians that needs to be improved. This affects containment, because we cannot do follow-up work on people who cross the border after 28 days.
With other countries who share borders with Thailand, for example with Malaysia, and Laos, we do not have as much of a language problem. With Myanmar, many of their nationals cross the border because they accept and know our facilities, and appreciate that these are free of charge, including long-lasting insecticide-treated nets. It’s a push and pull situation.
I agree totally with the WHO secretary general. We cannot stand alone. Thailand has to work with nearby countries. Today (Sept 1), the Department of Disease Control is meeting with Myanmar, whose officers have come to discuss co-operation in tuberculosis and malaria. For nearly nine years, we have our shared our experiences. We have other channels to work together with neighbours. This includes the capacity-building programme for the Mekong Region countries supported by the USAID and the ADMECs (Ayewaddy-Chaophraya-Mekong Economic Co-operation Strategy), whose health officers met in Thailand Aug 26-27 to fine-tune activities. All of these come to the same direction: to reduce our burden of diseases.
Please comment on attempts to strengthen surveillance, reporting and health care systems at the tambon level.
We have a vertical programme for malaria control in Thailand. We have a malaria clinic at village level, but it is not in every village, only in some. We have added on malaria posts. In every village, where there are malaria cases, for more than six months a year, we establish a malaria post. The malaria post workers are chosen from villagers who can speak the local language whom we train to draw blood, use the rapid diagnostic test kits and dispense drugs. This is not at the tambon level but at the village level. The health centre at tambon level [only] carries out rapid diagnostic tests.
THE diagnosis begins: “What’s your name?”
“How long have you been sick?”
“Did you ever have malaria before?”
“Yes, five years ago.”
“How do you feel now?”
“I have a fever and I feel a shiver in my body.”
The blood test begins.
“Wait 15 minutes!”
One, two, three, four, five… 15 minutes have passed.
“You have no malaria.”
To a stranger, Rin Tith, a 30-year-old father from Angdong Pee village in Cambodia’s Pailin province, looks like a professional physician the way he does the diagnosis, the test and treatment. But he is no medical doctor.
He is just a Malaria Education Village Volunteer, better known as Village Malaria Worker or VMW, who has been trained to do the diagnosis, the test and treatment for malaria at the village level. This project is part of Cambodia’s malaria containment efforts spearheaded by the World Health Organization and implemented by the Cambodian National Malaria Centre.
Rin Tith continues. He tells the sick migrant worker that his illness is just a normal fever. Then, he gives him a few fever pills and reminds him to sleep in a mosquito net to avoid getting malaria.
The patient returns home.
Under its ambitious containment strategy, the Cambodian National Malaria Center (CNM) has trained almost 3,000 VMW’s nationwide, including 86 villagers in Pailin.
These “foot soldiers,” as an expert puts it, received a three-day training to do the diagnosis, the test and the treatment in their villages for farmers and other people.
To target the mobile workers, CNM has trained more than a hundred Migrant Malaria Workers, or MMW’s, who were chosen among the migrant workers themselves. Upon completion of the training, each VMW was provided with a bicycle, a pair of boots, a bag, a flashlight, a raincoat and a cooler box to keep medicines plus a 10-dollars-monthly support.
But, it’s usually personal stories and experience that motivate villagers to become voluntary VMWs.
Rin Tith says that he himself has been sick with malaria 20 times since he moved to Pailin nine years ago. So, he says he immediately took the offer when he was asked to be a VMW a few years ago. His main purpose is to help fight malaria.
Top Malay, a 22-year-old farm owner in Pailin’s Suon Ampov Keut village, says she decided to become a VMW because she wanted to learn the skills and to help people avoid getting sick, particularly the migrant laborers she hired to work on her farm.
“We gave them mosquito nets and educated them about malaria,” she says when the laborers return to Pailin during the corn harvest twice a year.
Malaria Champion: Yeang Chheang
It was 1962 when Mr. Yeang Chheang, then a 24-year-old malaria specialist, was on a mission to Cambodia’s southwest coastal town of Sihanouville, when he was called back to the capital.
He was re-assigned to carry out yet another greater mission to the northwestern tip of the country on the border with Thailand. He was sent to Pailin, where a malaria outbreak was devastating the lives of hundreds of people from all walks of life.
Mr. Chheang was tasked to contain this outbreak. So, without delay, he set off to Pailin.
He recalled that during this outbreak, between 20 and 30 Pailin residents died from malaria everyday.
“So many people were dying that the crematorium overflowed [as it exceeded its capacity to cremate too many bodies],” he remembered.
SA KAEO, Eastern Thailand — This lady responsible for the province’s malaria control activities shows dedication and know-how, going out into the sun to check out a mobile clinic, and presenting power points to a room full of experts pressing her to say more.
When Uraiwan Tattong speaks, you have to listen, not only because of what she has to say, but because her voice has a warmth of tone and quality of texture that would make her a contralto if she were to take up singing.
She affirms that the project to contain killer malaria parasites tolerant to artemisinin has had a positive impact here. “It has helped reduce the incidence of malaria by about 50 per cent in one year, I would say,…through all activities.”
The so-called Fixed Schedule Malaria Clinic, which are placed right on the border with Cambodia, “enables us to draw blood samples and verify through microscopy if they are positively carrying malaria parasites quickly”. By quickly, she means 20 minutes.
In this province, the quick-fix delivery clinic happens twice a week at three points along the border and began operating in March 2009.
At 54, Ms. Uraiwan has played a responsible role in curbing vector-borne diseases in this part of eastern Thailand for some years. She became head of the centre that deals malaria and other vector-borne diseases here in Sa Kaeo in October 2009, after serving in the same position in Si Racha, further southwest, for two years.
She hesitated to admit that coming here was something of a promotion, but she did say that the seaside town of Si Racha, on the Gulf of Thailand, “is smaller than Sa Kaeo.” Asked what her sights were in the six years she has left before the mandatory retirement age of 60, she replied “that’s up to my higher-ups.”
Both Sa Kaeo and Si Racha come under the same regional office based in Chon Buri, where Khun Uraiwan graduated at Burapha University in Public Health Science.
Difficulties in Cambodia, from the 1970’s through the early 1990’s, especially along the border with Thailand has compromised Cambodia’s malaria control efforts for many years.
However, having been trained in public health, Khun Uraiwan knows that issues verging on life and death transcend all others, and, through her work, has tried hard to build trust among nationals of Thailand’s neighbour, no matter what is happening on other fronts.
IN essence mobile, the strength of the so-called fixed-schedule malaria clinics lie in their quick, on-spot detection of the plasmodium parasite in humans.
Operating right on the border, in villages where Thailand and Cambodia meet, the clinics were introduced by the project, funded by the Bill & Melinda Gates Foundation, to contain artemisinin-resistant falciparum malaria
From border checkpoints in Trat, on the southeastern most tip of Thailand, the mobile clinics are also open to residents and travellers criss-crossing at Chantaburi, Sa Kaeo, Buri Ram, Surin, Si Saket and Ubon Ratchathani,
A site visit in June to a border checkpoint in Ban Khao Din, under the jurisdiction of Sa Kaeo Province, found unmistakeable action under a tree that provided scant protection from the late morning sun. In the foreground, a young man wearing a white surgical mask, crisp white jacket, and sanitised gloves, was drawing blood from an older man, with children milling around. Behind him, an older, chunkier man who later identified himself as an interpreter able to speak Cambodian, Not far away, a microsopist was poring over slides of blood samples.
Akorn Vejjakarn, 32, was drawing blood that would be sent over to microscopist Anant Mathanithipakdee, 46, sitting in a slightly shadier place further inside the Thai border.
“I like the work. I feel I’m helping to save lives,” said Akorn. Taking blood samples from under the tree was a change from working at the Malaria Clinic in Wattananakorn District, where he had been for two years.
Sirichai Srisompong, 40, openly admitted he was a merchant and that was how he had picked up the ability to speak Cambodian. The head of the Malaria Clinic at Wattananakorn District, Chaiyong Kularb, said Sirichai, who seemed a jolly fellow, also served as the deputy village headman of Ban Khao Din.
Mr Chaiyong said the mobile clinics in Sa Kaeo, operating twice a week at different border checkpoints, began functioning in March 2009.
In Trat and Chantaburi, the same kind of clinics began operating in the following April.
“There are such mobile clinics at border points in all the seven provinces but they began operating at different times depending on their readiness,” said Prapas Tamata, National Project Co-ordinator.
There is no doubt the introduction of this quick-action and mobile unit, has speeded up the work of malaria detection.