Archive for the ‘Cambodia’ Category
Moeun Chhean Nariddh reports on a mobile phone-based frontline reporting system for detected malaria cases, implemented in Kampot province.
From her house in Snay Anchit Village, about five kilometers from the health center in Kampot provonce’s Chum Kiri district, 20-year-old village malaria worker Kong Lida can clearly hear the noise of a generator roaring in the distance. This generator is an important source of power where Lida and other villagers have their car batteries charged everyday so that their houses can be lit up at night from electric lamps and at the same time charge up their mobile phones.
But soon Lida and other village malaria workers in her village and other communes will not need to pay the generator owner to have their car batteries charged anymore. Now, all these VMWs will get their power from a ubiquitous source of energy – namely solar power.
As part of the country’s malaria elimination strategy, the National Center for Parasitology, Entomology and Malaria Control or CNM, with technical support from Malaria Consortium (MC) and WHO, has launched a pilot program to train VMWs in Kampot, Siem Reap and Kampong Cham provinces on how to send simple mobile phone text messages (SMS) to report in real time on detected malaria cases. These SMS messages also support the paper reporting that feeds into the health information system from the health centers.
CNM and MC also provide each of the VMWs with a solar panel and a lamp together with a mobile phone and a charger since there is no electricity in their villages.
Cambodia is currently seeing a revolution in communications with the roll-out of affordable wireless services to much of the rural population. The potential of approaches based on mobile phones and web-based technology to address the gaps in field data collection for malaria is now widely recognized.
“I think using a mobile phone is good, because I can report immediately when I come across a malaria case,” said village malaria worker Lida. Previously, the VMWs would record the data in a logbook which they would then report to the health centers at the end of every month before it was sent to the operational district hospitals and finally to CNM.
InSTEDD, an innovative humanitarian technology NGO, designed the system, utilizing SMS messages in Khmer script that interact with mapping software to generate maps on the World Wide Web for the locations of malaria cases reported by the VMWs. These malaria cases are also known as Day Zero cases, to indicate the locations of the patients before they are given appropriate and effective treatment.
Respondent-Driven Sampling on the Thailand-Cambodia Border: Can Malaria Cases be Contained in Mobile Migrant Workers?
Respondent driven sampling methodology, for hidden populations, is an effective strategy to study the migrant populations from Myanmar and Cambodia on the Thailand-Cambodia border, write Amnat Khamsiriwatchara, Piyaporn Wangroongsarb, Julie Thwing, James Eliades, Wichai Satimai, Charles Delacollette and Jaranit Kaewkungwal in the Malaria Journal.
There is substantial population movement across the Thai-Cambodian border that is largely driven by economics. Migrants from both Cambodia and Myanmar settle for varying periods of time in Thailand, often in search of work. The International Organization of Migration reported that Thailand has attracted increasing numbers of migrant workers, mostly from neighbouring countries with over one million registered migrant workers entering the country since 2004.
Channels for migration, in particular labour migration, are defined by the policy of the destination country, usually in response to the demand of domestic labour markets for foreign workers. When the supply through established channels does not match the demand, irregular migration dynamics develop, and migrants enter illegally and undocumented.
While various government ministries attempt to collect data on migrant workers, they usually have information on the number of registered migrants and those applying for work permits, but little information on the unregistered migrants. The true size of the migrant worker population in Thailand, in particular of irregular migrants, is notoriously difficult to quantify.
Rather than classifying migrant workers as documented or undocumented, the Thailand Ministry of Public Health defines migrants who have been in Thailand for more than six months as M1, and migrants who have been in Thailand for less than six months as M2.
Both M1 and M2 migrants are eligible to receive diagnosis and treatment for malaria free of charge at malaria clinics in border zones. Patients who cross the border for a day to seek treatment at the border clinics are counted among the M2. Migrants in Thailand account for a higher proportion of cases than Thai citizens, especially among the M2 migrants.
CONTAINMENT’s Moeun Chhean Nariddh profiles a popular interactive radio program on malaria education broadcast from Battambang.
As the sun sets in a late afternoon in Cambodia’s Battambang province, many housewives, shopkeepers, farmers and others stay glued to their radio sets to listen to music and songs played from FM radio stations along both sides of the Steung Sangke – a legendary river that was embroidered in many fond Khmer love songs and romantic music from the 1960s and 1970s.
Before too long, this entertainment comes to an abrupt end on the Chamkar Chek National Radio as the clock strikes 5pm.
Unlike the DJs at other private stations who continue playing music or singing karaoke songs along with their listeners, Soeum Chamnan at Chamkar Chek Radio is now engaged in a more serious radio show. She changes from entertaining her audience to helping save lives of people who are at risk of getting malaria.
For an hour from 5pm to 6pm, every Friday, Chamnan’s task is to coordinate a radio talk show, jointly produced by the USAID-funded Malaria Control in Cambodia, Equal Access and the National Malaria Control Center, during which listeners pose questions to experts about how to protect themselves and get treatment for the mosquito-borne disease. The radio program is also fully funded by USAID.
CONTAINMENT recently spoke to Dr. Char Meng Chuor the new Director of the National Center for Parasitology, Entomology and Malaria Control (CNM).
One big concern is malaria on the move. How important is the role of village malaria workers or VMWs in the early diagnosis and treatment of mobile migrant workers?
Yes, indeed, malaria on the move among mobile migrant workers is worrying. But first let me clarify one thing on terminology. I like to refer to the village malaria workers as community health workers because they can also work on other diseases at the community-level. At present in each health centers there are only seven to eight full-time health staff as first-line health workers. And as you know most of the villages are far from the health centers. So we need these community health workers to support the work of the health centers.
When Khmer people fall sick, they end to seek treatment from the nearest source available to them. And most often, these community health workers are nearest to them. For that reason they are so important in the fight to contain multi-drug resistant malaria. These community health workers not only carry out early diagnosis and treatment, but they also provide vital information to the mobile migrant workers on how they can protect themselves against malaria.
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?
First of all, we have to ensure that communities must have access to genuine medicines. This is essential. We can ban oral monotherapies, but if sick people do not know where to get effective anti-malarials, we will go back to square one. Secondly I need to emphasize the importance of law enforcement. The elimination of malaria by 2025 is a government priority and so it’s important that legislation is in place for the law enforcers to start the crackdown of counterfeit malaria medicines.
But let us not forget that we have to also work with the private sector through partnerships. We are now drafting the strategy for the public-private mix, in terms of malaria. We’re still in the learning process, when it comes to dealing with the private sector. But there’s a lot of donor goodwill to provide technical assistance. The chink in the armour is the private sector because most Khmers when they fall sick go to the pharmacies or drug stores first. We have to convince the private sector on why they need to be good and responsible providers to prevent a public health emergency that could cross borders.
What are the lessons learnt from the Containment Project, and how can these lessons be used as we move from malaria control to elimination?
CNM has been implementing the containment project since January 2009, and we have many lessons to share. The first and most important lesson is that it is possible to reduce malaria incidence in the target zones through good management and implementation of proven strategies in malaria control, such as high-level coverage of long-lasting insecticide treated bed nets, provision of free diagnosis and treatment at the community level, and engagement of the community through malaria education and awareness programs. CNM, through the support of the Bill and Melinda Gates Foundation and the assistance of technical partners such as WHO, Institute Pasteur and Malaria Consortium, and others, has helped us achieve this.
We have also found that, when malaria cases begin to decrease, the role of systematic gathering of health information, including malaria surveillance and response becomes very important. As malaria cases decrease in Cambodia and we are on our path towards elimination, we need to strengthen surveillance systems to capture information on cases up to the village level, and also concentrate on responding to increases in cases through distribution of bed nets and indoor residual spraying.
Another lesson learned is the need to engage and work closely with the private sector in order to be informed of those malaria cases treated by the private sector, in pharmacies and private clinics, and to provide incentives to the private sector to help in the fight against the sale and manufacture of artemisinin monotherapies, as well as fake and substandard drugs.
Also, we need to be sure to have the full support and participation of communities in the fight against artemisinin-resistant malaria, and also move towards elimination. This can be facilitated through wide-ranging media awareness campaigns, community mobilization through local community organizations and distribution of information, education and communication materials, as well as advocacy by involved leaders and authorities.
Em Khin Vorac, Deputy Director General, Department of Customs and Excise of the Government of Cambodia, speaks to CONTAINMENT’s Moeun Chhean Nariddh in Phnom Penh.
How is the General Department of Customs and Excise involved in the fight against counterfeit products and medicines?
With support from the Mekong Priority Solidarity Fund Project, coordinated by the French Embassy, we are active partners with other project members including the Ministry of Interior. We have had a number of meetings and workshops on the joint crackdown on counterfeit products and medicines. Our Customs officers are now positioned at different checkpoints along the land borders with Thailand, Vietnam and Laos. Most of the counterfeits, originating from neighbouring countries, seem to be getting through these checkpoints and for this reason we have increased the number of Customs personnel at these border crossings.
Our Customs officers remain vigilant. Some of these counterfeit medicines are smuggled through in small quantities in people’s handbags. Sometimes, they conceal them with lawful goods. For example, they might conceal about ten small cantons (of counterfeit medicines) with sacks of cement, piles of iron, boxes of cakes and sweets and other items where Customs duties have been paid. Under such circumstances it can get difficult to check all items coming into the country through these land borders.
Members of the Buddhist clergy certainly have an important role to play in positive behaviour change when it comes to malaria prevention, writes CONTAINMENT’S Moeun Chhean Nariddh.
In a spacious, yet unfinished dinning hall at Serey Mongkul Pagoda near the Cambodian-Thai border in Battambang Province, young and old villagers sing songs and play games with health workers and malaria experts at a handover ceremony, to local villagers, of a positive behaviour change communication project to fight malaria.
Men, women, boys and girls brave their usual shyness and stand up to answer quizzes and questions posted by communication and public health experts from Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) and the international NGO Malaria Consortium to test their knowledge and understanding about malaria.
In contrast with the mostly blue-collared polo T-shirts worn by staff from CNM, Malaria Consortium and community leaders, about half a dozen monks in saffron robes watch and listen with great attention to how the villagers answer the questions and quizzes.
In fact, these monks are here with a reason. In the campaign to fight malaria, Buddhist monks have been involved to help educate villagers about malaria and how to protect themselves from the mosquito-borne disease.
It is here that Malaria Consortium and CNM, with the support of the World Health Organization’s Containment Project, pioneered an innovative behaviour change communication strategy called ‘Positive Deviance’ or PD. Three villages, Kampong Chamlang Leu, Ploav Praim Muy and Samsep, selected for the study were from Sampov Loun, a district of Battambang province.
The PD approach initiates community dialogue, respects local wisdom and provides social proof by identifying positive practices from within the community which ensure acceptance and expedite the process of behavior change. It allows community members to be active beneficiaries, engaged as full partners to play a role in their own health and protection from malaria.
“I preach Buddhism and teach people about malaria and dengue fever,” explains Venerable Pich Bunthoeun, the 45-year-old abbot of Serey Mongkul Pagoda. He adds: “The monks have a very important role to educate people about malaria.”
Venerable Buntheoun says people give more respect to the monks and will follow their advice when they tell them to do good things.
“When the monks say anything, people listen to them more than ordinary persons,” he says.
The abbot says he and other monks attended a three-day training seminar in Battambang province in April 2009 and learned various knowledge and skills on how people can prevent and get treatment for malaria.
The Venerable says he got enough knowledge to teach people and that people have also known a lot about the disease partly thanks to the teaching by the monks.
“I am happy that people and children have good health,” Venerable Bunthoeun says with a smile, adding that he hopes that he will continue the work to fight malaria.
Loch Yoeum, 60, says she has lived for 13 years in Komrieng District’s Takrey Commune, where Serey Mongkul Pagoda is located.
She says there used to be a lot of forests around these areas and that people were falling sick from malaria, including herself.
Yoeum says the monks have told people to clean the environment, sleep in mosquito nets and to wear long-sleeved shirts to avoid malaria.
“People are poor, so it will be more difficult if they get sick,” she explains.
The findings in Malaria Consortium’s report titled: “The ‘Positive Deviance’ approach to improve malaria outcomes among mobile and migrant workers in Cambodia” indicate that most of the community members and migrant workers believed that men especially mobile and migrant workers, ‘kamakor and kachport’, (corn collectors) are the high-risk group for malaria. The female mobile workers also noted that men are most vulnerable to get malaria as they work at night in the farm or forest.
The Malaria Consortium report, however, has several positive stories one of which is on a migrant worker’s wife.
“A migrant worker’s wife always pack a hammock net in her husband’s luggage, whenever he goes to the farm and reminds him, ‘Eing eing mon chol dek kom plech chang mong’ (Darling! Do not forget to use the bed‐net before you sleep to avoid malaria).”
Dr. Meas Tha, Deputy Director of the National Centre for Parasitology, Entomology and Malaria Control (CNM), says malaria experts and campaigners would involve the monks to help educate people during big festivals such as the World Malaria Day and other national holidays.
He says the monks are more influential and people think that when the monks tell them to do anything they mean to advise them to go along the right path for their happiness.
“The monks are the role model for people to follow,” he says.
Prime Minister Hun Sen revealed that the Royal Government of Cambodia has launched a national strategic plan to eliminate malaria in the country by 2025.
“This national strategic plan, from 2011 to 2025, is an important reference document, which indicates a clear path, phase by phase and a clearly defined goal — that is a Cambodia without malaria,” he told the 32nd National Health Congress held in Phnom Penh on 15 March.
Meanwhile, the premier said that he understood that malaria remains an immediate public health concern and an economic burden among Cambodians. He added that there are still Cambodians falling sick due to malaria and unable to work, but there were relatively few deaths from the mosquito-borne disease.
Cambodia’s Health Minister Mam Bun Heng said the number of people getting sick or dying from malaria has decreased in almost all the provinces. He said that the number of deaths from malaria in Cambodia fell by 53.8 percent in 2010, compared with the previous year.
The Health Minister said the National Health Congress had discussed the disease and was determined to implement the national strategic plan to eliminate malaria in Cambodia by 2025.
Premier Hun Sen stressed that malaria could be eliminated and reminded the National Health Congress that Cambodia had been successful in eliminating polio, even when the country was still divided between areas controlled by the government and the Khmer Rouge.
“Fortunately, the Khmer Rouge [forces] were integrated into the government, so we tried to send the polio vaccine immediately to those areas previously controlled by the rebels,” he said, adding: “So Cambodia was declared polio-free in 2002.”
The Prime Minister reiterated that Cambodia would work in the next 15 years towards the eradication of malaria in the country by using the national strategic plan.
“I hope that all parties involved, including the Health Ministry of the Royal Government of Cambodia and the development partners will use this national strategic plan as a compass for effective implementation,” he said.
The premier said he acknowledged that malaria cases had substantially decreased in general. “But, we need a series of campaigns and activities so that malaria will go down [further] towards the zero rate of malaria transmission by the year 2025,” he added.
“For me, I am optimistic that by 2020 or 2021 [malaria] should be gone completely,” he told Cambodian health officials attending the National Congress.
Moeun Chhean Nariddh
Malaria Consortium, with the support of the Bill & Melinda Gates Foundation-funded Containment Project, is pioneering a Day 3 positive alert system in Ta Sanh district, western Cambodia, using mobile phone and web-based technology to facilitate response in real-time. CONTAINMENT’s Sonny Inbaraj reports.
EFFECTIVE containment of multi-drug resistant falciparum malaria depends on timely acquisition of information on new cases, their location and frequency. This is to plan interventions and focus attention on specific locations to prevent an upsurge in transmission.
Response in western Cambodia’s Ta Sanh district involves combining the process of positive diagnoses through microscopy of Day 3 positives at the Ta Sanh health centre from blood slides sent by Village Malaria Workers, to an alert system using mobile phone and web-based technology to help pinpoint potential outbreaks of malaria and target interventions to foci where parasite reservoirs are likely to be present.
The proportion of patients who still carry malaria parasites on the third day of treatment is currently the best measure available of slow parasite clearance and can be used as a warning system for confirmation of artemisinin resistance.
In Ta Sanh, the Village Malaria Workers or VMWs play a crucial role in the early detection and treatment of the killer falciparum malaria. In September 2010 the USAID-funded Cambodia Malaria Prevention and Control Project (MCC), implemented by University Research Co., LLC (URC), trained these VMWs to prepare blood slides from those who tested positive for falciparum malaria from rapid diagnostic tests. They were also trained to carry out a three-day directly observed treatment (DOT) of the Pf cases with the co-formulated ACT dihydroartemisinin – piperaquine.
Chou Khea, a 21-year-old Village Malaria Worker, trained by MCC in Ta Sanh district’s remote Ou Nonoung village tells CONTAINMENT how she carries out DOT.
“Immediately after a villager tests positive for falciparum malaria in a rapid diagnostic test (RDT), I prepare the blood slides. Then I give the drugs, which the villager has to take in front of me,” says Khea.
“On Day 2 and Day 3, I’ll go to the villager’s house and make sure that the drugs are again taken in my presence,” she adds. “After 72 hours from the first intake of the anti-malaria drugs, I’ll be at the villager’s house again to take his or her blood sample for preparing another blood slide.”
Chou Khea then takes the Day Zero and Day 3 slides, together with the used RDT, to the Ta Sanh Health Centre 30-kilometres away from her village.
“I usually take a motor-dop (motorcycle taxi) to the health centre. But most of the motor-dop drivers are reluctant to use the track to health centre in the rainy season because of the slippery mud. Also many of them are scared of the wild animals and land-mines in the area,” she tells CONTAINMENT with concern. “I hope to have my own motorcycle soon, so that I’ll be able to transport the slides and RDTs faster,” she adds with a smile.
At the Ta Sanh Health Centre, the Day 3 slides are examined by a microscopist and if asexual malaria parasites are seen they are graded as positive. The microscopist immediately sends out an SMS on a mobile phone, using a dedicated number, to a database indicating the village code and the sex of the patient.
Malaria Consortium pioneered the use of this alert system in Ta Sanh, with support from Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) and the World Health Organization’s Malaria Containment Project funded by the Bill & Melinda Gates Foundation.
Malaria Consortium’s Information Systems Manager Steve Mellor explains the use of cellular text messaging (SMS) as a viable tool to send alerts and map Day 3 positives in real-time on Google Earth.
“We use FrontlineSMS, an open-source software, that enables users to send and receive text messages with groups of people through mobile phones,” Mellor tells CONTAINMENT.
“FrontlineSMS interfaces with an MS Access database system that was developed to host the SMS data and to provide validation on the data received and to send an automatic reply to the sender containing any validation errors found, or to confirm that the data has been accepted,” he adds.
There are plans to upscale this mobile phone and web-based alert system with InSTEDD, an innovative humanitarian technology NGO, to map all Day Zero cases…
In the Access database, a script interfaces with Google Earth and maps out the locations of the Day 3 positives based on the village code. The mapping on Google Earth is essential as it gives a clear visualisation of the terrain and helps CNM, WHO and the USAID-funded Cambodia Malaria Prevention and Control Project (MCC) to plan coordinated interventions in terms of case follow-up on Day Zero and Day 3 and carry out epidemiological and entomological investigations.
“All this happens in real-time and alert text messages are sent out simultaneously to the operational district malaria supervisor, the provincial health department, CNM and the administrators of the database,” Mellor points out.
There are plans to upscale this mobile phone and web-based alert system with InSTEDD, an innovative humanitarian technology NGO, to map all Day Zero cases. Malaria Consortium and CNM are also in direct talks with Mobitel, one of Cambodia’s main telecommunication carriers.
“We are in negotiations with Mobitel for a free number and also free SIM cards to be distributed to health centre staff and village malaria workers,” Mellor reveals. “After all, this is for a public good.”
Besides plans to map all Day Zero cases, Malaria Consortium is also exploring the possibility of sending alert messages in Khmer script.
“This will be a breakthrough and we hope this will help facilitate a quick response mechanism from CNM and other partners,” says Mellor.
Chhean Nariddh Moeun profiles Ta Sanh Health Centre’s microscopist Tith Phanny.
In this remote village in Samlaut district where Hollywood actress Angelina Jolie adopted a Cambodian boy, pregnant women come to Ta Sanh Health Center to give birth to their babies or get their pregnancy checked. Other patients come here to get their blood tests and treatment for malaria, TB or HIV/AIDS.
However, many of them have one thing in common: the health centre worker who sees and treats them is the same person. And that person is nobody other than Tith Phanny.
As a former Khmer Rouge medic, Phanny says she had been trained as a midwife, a microscopist, and to provide blood tests and treatment for malaria, TB and HIV/AIDS.
Phanny, who thinks she is 50 minus or plus a year or two, reckons that she has helped several hundred women deliver their babies since she became a midwife in the early 1990s.
She says that she remembers helping deliver a baby for a pregnant woman who came to Ta Sanh Health Center 18 years ago. The baby was born as a healthy girl and grew up in the village near the Cambodian-Thai border once controlled by the Khmer Rouge.
“Some babies of the women I helped with their childbirth in the past have grown up, got married and come to deliver their own babies,” she proudly talks of the two generations of mothers she has helped.
Due to the lack of health workers, Phanny says she had learned her different medical skills from her hands-on experience working with various Khmer Rouge medics during the civil war in Cambodia.
She was assigned to do various things, including taking care of wounded soldiers and treating malaria patients who she thinks sometimes outnumbered the wounded…
Back then, she says she was assigned to do various things, including taking care of wounded soldiers and treating malaria patients who she thinks sometimes outnumbered the wounded.
Phanny says it was her own tragic past that had encouraged her to determine to help others. While living in a children’s mobile unit in Kandal province under the Khmer Rouge, she says she was separated from her family when the Vietnamese forces defeated the Khmer Rouge in 1979.
She says she had to follow others to the Thai border, where the fighting was very tense. In the 1980s, she says she was wounded twice — first in her head by shrapnel from a rocket fired by the Vietnamese and second when she stepped on a landmine and lost her right toe.
Miraculously, she survived the two incidents. Yet, it was not the end of her ordeal.
Phanny says she almost died several times from the scourge of malaria in the 1990s. She says she once went into a deep coma and had to receive successive intravenous drips several months before she regained her consciousness and recovered.
In 1996, the Khmer Rouge struck a deal with the government to end the war. It was the first time Phanny says she could enjoy peace after more than two decades of civil war and fighting.
After the Khmer Rouge was reintegrated into the Cambodian society, Phanny says she was sent to Phnom Penh and Battambang province for one month each to attend formal training in midwifery.
However, Phanny says she still juggles between different jobs at the Ta Sanh Health Center, from midwifery to microscopy, to blood tests and treatments for malaria, TB and HIV/AIDS.
She is indeed a busy woman. As Phanny is working on her microscope in the laboratory, she receives an urgent call to help deliver a baby for a woman.
“I run back and forth from the laboratory to the delivery room,” she says, adding she stays at the health center seven days a week.
Dr. Pov Pheng, deputy Chief of Ta Sanh Health Center, speaks highly of Phanny.
“She is very active,” he says, “She is very diligent in her work.”
Despite the hard work, Dr. Pheng says Phanny and other health workers at his hospital receive the same monthly salary of about $70. Yet, he says the amount is almost ten times more, compared to 10 years ago when they were paid only about eight dollars per month.
Regardless of the money she gets, Phanny never complains about her job.
“I am here 24 hours [a day],” she says, “I am always busy [but] I am happy with the work.”