Posts Tagged ‘community health workers’
CONTAINMENT’s Moeun Chhean Nariddh caught up with Dengue Fever’s Chhom Nimol in Battambang.
“Oh, oh, oh, Chumno kadeuk oi own neuk srok, neuk dol yeay ta, mingmear, pa’own bong…Yeung thloip roth leng trosorng, eilov nuon la’orng khleath tov sen chhnay. Oh, oh, oh…
“Oh, oh, oh, winter breeze makes me miss my home town, miss my grandparents, aunts and uncles, brothers and sisters. We used to go for a walk together, but now I am far away from you. Oh, oh, oh…”
Cambodian singer Chhom Nimol of the Dengue Fever begins to sing the first few lines of her newly recorded song “Uku” without music at the request of a journalist from in the studio of Battambang’s National Radio of Kampuchea before her scheduled performance in the evening.
“I used to have malaria in the refugee camp … I was shivering and it was hard for me to endure the fever and chills…”
With or without music, her voice can easily draw attention from the keen audience and listeners through sound waves that travels hundreds of kilometers away from the studio and the open-air live concert.
What makes her performance in Battambang special is that the sound waves not only carry her beautiful voice to the audience, but they also bring along messages about malaria to many people most at risk of getting the disease in remote areas along Cambodia’s common border with Thailand.
On November 16, Nimol was giving her third performance in Cambodia to Battambang after Kampot and Siem Reap provinces as the front-lady for the Dengue Fever band – a popular US west coast Khmer-American psychedelic rock band. Dengue Fever’s trip to the Mekong region is sponsored by the US Embassy to bridge cultural ties between Cambodia and the United States.
Noting the important occasion and the popularity of the music band, USAID-funded University Research Co., LLC, or URC, had approached the music concert organizers and asked for malaria messages to be read during the event.
“This is a very rare occasion that the Dengue Fever has come to perform in Battambang,” said Kharn Lina, URC’s communications specialist. “Many people in the audience who watched the performance might be working in the malaria-affected areas and could take the messages back to their relatives and friends.”
She said that the recent floods in Cambodia made it even more crucial for people to get enough information and knowledge about how to protect themselves and to get treatment for malaria since there could be more mosquitoes that transmitted the disease to people.
For Nimol, malaria is an illness that will always stay in her mind.
“I used to have malaria in the refugee camp,” she recalls. “I was shivering and it was hard for me to endure the fever and chills when I was young.”
She said it was very important that people sleep in insecticide treated nets so that they could protect themselves from getting malaria.
Nimol said she had spent one year with her family in the refugee camp on the border with Thailand before returning to Battambang in 1992, to resume her education at junior high school level. Cambodia then was under the administration of the United Nations following the end of a 12-year proxy-civil war where battlelines were drawn on then Cold War rivalries. After three years, she said she went to Phnom Penh and continued her studies for another two years.
With encouragement from Chhom Chorvin, her elder sister who was also a singer, Nimol said she started to learn to sing old songs from the 1960s and 1970s by the late Cambodian singers.
Though she was a new singer, Nimol’s voice hadn’t gone unnoticed.
In 1997, she said she decided to register in a song contest organized by Apsara TV in Phnom Penh and won first prize as the best female singer.
She was 16 years old then.
In 2001, she went to the United States and performed at a Cambodian restaurant in Long Beach with her elder sister.
Then, her golden opportunity arrived.
Nimol said Dengue Fever was looking for Cambodian singers at different restaurants in California and they finally came to the Dragon House Restaurant, where she was singing.
“[Dengue Fever] became interested in my voice and body movements,” she said with a smile.
Dengue Fever then invited her to join the band.
In addition to the old songs and music, Nimol said she had also composed new songs like “Uku” herself with help from her American band-mates who composed the music.
“I just do ‘noy, noy, noy’ and they will come up with the music,” she said.
Nimol said she had performed in many countries in Europe apart from the US. However, she said her chance to return and perform in Battambang was just like a dream.
“For me, I am very happy. I just can’t tell you how excited I am,” she said as the cool dry wind started to blow outside, signalling a change in the usual hot humid weather.
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.
Despite language difficulties, migrant Mon rubber plantation workers in Thailand’s Trad province give their full cooperation to malaria workers in the fixed-schedule clinics. Nat Sumon reports.
The economy of Trad, along the Thai-Cambodian border, is fuelled by mobile migrant workers from Cambodia who meet the Thai province’s labour shortages in fruit-picking, rice harvesting, logging, rubber tapping, construction work and retail businesses. But now the economic landscape seems to be changing fast with the influx of migrant workers from Myanmar. And they can be found almost everywhere in Thailand – including Trad’s rubber plantations.
While a worker can make a decent living from tapping rubber, because of the current high global prices, Thais, however, find that job unattractive. Because of this acute shortage of labour in Thai rubber plantations, owners have not much of a choice but to seek workers from neighbouring countries. And mobile migrant workers from Mon State in Myanmar have answered that clarion call, albeit at wages lower than Thais.
Sitting leisurely in his cousin’s thatch-roofed wooden house, Kyaw Htoo (not his real name) recalled his journey from Mon State 13 years ago. He was a rubber tapper in Myanmar before moving to Thailand. He said the Mon community in Trad had grown over the years, crossing the Thai-Myanmar border in the west to work in the numerous rubber plantations in Thailand’s far-flung eastern province.
“More and more Mon workers cross the border because of word-of-mouth that there are jobs in the rubber plantations,” said Kyaw Htoo.
Nonetheless, there is a public health concern with this influx of Mon migrant workers from malaria-endemic Myanmar. Cross-border and mobile migrant populations could be the source of the spread of multi-drug resistant malaria parasites due to their back and forth travel between malaria endemic areas and their place of work.
Because of these concerns, the fixed-schedule malaria clinics run by the Bureau of Vector-Borne Diseases (BVBD), with technical assistance from WHO, were introduced to the Bill & Melinda Gates Foundation-funded Containment Project to enable on-the-spot detection of the plasmodium parasite in the itinerant workers. These fixed-schedule malaria clinics operate right on the border, in villages where Thailand and Cambodia meet.
Kyaw Htoo and his cousins first got to know about the mosquito-borne disease during the visit of a malaria worker from the Bor Rai fixed-schedule malaria clinic. “There was a language barrier at first. Though we did not fully understand the disease, we now know it’s caused by mosquitoes,” said Kyaw Htoo.
“The malaria worker told us to sleep under insecticide-treated nets, wear long clothes to protect ourselves from mosquito bites while we were out tapping rubber before dawn, and apply mosquito repellent,” added the Mon worker. “We understood that clearly and we are following exactly what the malaria worker told us,” he emphasized.
Aung Naing (not his real name), a cousin of Kyaw Htoo, moved to Trad from Mon State a couple of years ago.
“Whenever I have a fever, I’ll go to the malaria clinic to have my blood tested for malaria,” he revealed. Then he paused and smiled. “So far none of the Mon workers here have tested positive for malaria,” Aung Naing pointed out. “We take seriously all the preventive measures, as instructed to us by the malaria worker.”
Like Kyaw Htoo and Aung Naing, 18-year-old Htun Htun (not his real name) who moved to Trad province after spending five years in rubber plantations in southern Thailand, does not fully understand the causes of malaria. But he told CONTAINMENT that he took the malaria worker’s advice on disease prevention seriously.
The usefulness of the early diagnosis and treatment provided by the fixed-scheduled malaria clinics run by BVBD is clearly evident.
Every week Mr. Angkoon Chawilai, one of the malaria workers in Bor Rai Malaria clinic, would visit the rubber tappers in his area to do blood tests and administer treatment if there are positive cases, give out ITNs and mosquito repellents and educate the Mon populations on malaria prevention.
“The local people know me and I’ve always have had good cooperation from the rubber tappers,” said Mr. Chawilai. “The Mon rubber workers are very receptive to malaria prevention information,” he added.
The malaria worker revealed that Mon migrant workers in the rubber plantations were less mobile compared to those migrant workers involved in logging and seasonal fruit-picking.
“This is a positive point when it comes to malaria containment because their movements are controlled as they’re not moving about from place to place spreading the malaria parasite,” Mr. Chawilai pointed out.
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.”
The drive to Ou Nonoung village in Western Cambodia’s Ta Sanh district is not for the faint-hearted. The almost 45 degree climbs and the steep plunges on the dirt track certainly calls for skilled driving of the 4-WD.
One wrong turn and the vehicle could turn turtle. One wrong detour into the bush and the 4-WD could set off one of the hundreds of unexploded ordinances in the soft dirt – a stark reminder of the war-torn years that almost sent Cambodia back to the Dark Ages.
Ou Nonoung village, in the foothills just below the Cardamom Mountains, lies at the fringe of the forests. In this ’old village’ that goes back to the dark Khmer Rouge-era, villagers have their farms in forest clearings. Throughout the year for rice cultivation and agricultural activities they stay overnight in temporary shelters. These movements in relation to agricultural activities have been identified as risk factors associated with malaria infection.
In these harsh conditions, village malaria workers or VMWs play a crucial role in the early detection and treatment of the killer falciparum malaria. But developments lately have been disturbing.
Records from the Ou Nonoung VMW between September 2010 to February 2011 indicate that six villagers had tested positive for falciparum malaria. The results were from rapid diagnostic tests (RDTs). And out of the six Pf positive cases, three still had plasmodium parasites in their blood after a three-day course of treatment with dihydroartemisinin-piperaquine – the artemisinin combination therapy for uncomplicated falciparum malaria currently used along the Thai-Cambodian border.
The Day Three positive cases were verified by microscopy in the Ta Sanh district health center, from blood slides prepared by the VMW from the patients’ blood samples after the three-day course of treatment.
Though the Pf positive cases are relatively small due to active interventions in the Bill & Melinda Gates-funded Containment Project, the presence of Day Three positive patients is a cause for concern.
WHO’s ‘Guidelines for the treatment of malaria’ indicate that: “To eliminate at least 90 percent of the parasitaemia, a three-day course of the artemisinin is required to cover up to three post-treatment asexual cycles of the parasite. This ensures that only about 10 percent of the parasitamia is present for clearance by the partner medicine, thus reducing the potential for development of resistance.” This is the rationale for using dihydroartemisinin and its partner drug piperaquine that is available as a co-formulated tablet.
Host immunity and splenic function are important contributors to parasite clearance after artemisinin treatment. Reduction in herd immunity, perhaps resulting from reduced transmission, could decrease parasite clearance in Cambodia
The question asked is that if symptoms persist 3-14 days after initiation of drug therapy in accordance with the recommended treatment regimen, is that an indication of resistance?
In a recent interview with CONTAINMENT, in Pailin in western Cambodia, Dr. Robert Newman, WHO’s Global Malaria Program director, warns of a worse case scenario.
“The worse case would be the spread of the delay in clearance of the [plasmodium] parasites. Right now we are finding an increase in the percentage of patients who are still positive on Day 3. That will be the hallmark of this problem [of resistance],” said Dr. Newman.
Added Dr. Newman: “If that were to continue to worsen, artemisinins would become less and less efficacious. It would then take longer and longer for patients to clear [plasmodium parasites in their blood], and we could get to the point of truly having failures to ACTs.”
But Dr. Newman clarified that though there is resistance to artemisinins, artemisinin-based combination therapies (ACTs) still remain efficacious. “That is a very important message,” he stressed.
But he issued a stark warning. “If that situation worsens, if were to lose ACTs, and if it spreads to the shores of Africa, we could have a public health catastrophe.”
Acknowledging that there is slow clearance rate in Western Cambodia, Anderson, et al. (2010)  ask whether slow clearance rate results from parasite, host, or other factors specific to the population in that part of the country.
Writing in the ‘The Journal of Infectious Diseases’, quoting previous studies on the comparison of parasites in Western Cambodia to that in the western part of Thailand along the Thai-Myanmar border, the authors point out that: “ Parasites with slow clearance rate after ACT do not show increased resistance to artemisinin compounds with conventional in vitro testing compared with parasites from western Thailand, which show rapid clearance rate.”
The authors offer several explanations for slow clearance rates.
“Host immunity and splenic function are important contributors to parasite clearance after artemisinin treatment. Reduction in herd immunity, perhaps resulting from reduced transmission, could decrease parasite clearance in Cambodia,” they write.
 Anderson, T., Nair. S., Nkhoma, S., Williams, J., Imwong, M., Yi, P., Socheat, D., Das, D., Chotivanich,K., Day, N., White,N., Dondorp, A. 2010, “High heritability of malaria parasite clearance rate indicates a genetic basis for Artemisinin resistance in Western Cambodia”, The Journal of Infectious Diseases, vol. 201, no. 9, pp. 1326 – 1330.
Dr. Kheang Soy Ty, Chief of Party of the USAID-funded Cambodia Malaria Prevention and Control Project (MCC) and Khorn Linna, a communications specialist with Partners for Development (PFD) tell CONTAINMENT of their efforts to raise malaria awareness among mobile migrant workers. The MCC, in partnership with Partners for Development, works in Cambodia’s western provinces where malaria is a serious public health problem.
Why has the project chosen taxi-drivers to spread knowledge among migrant workers about the cause of malaria?
Dr. Soy Ty: Before we chose this strategy, we did focus group discussions (FGDs) with village chiefs and staff in health centers. The FGDs also included those from the mobile and migrant population. The FGD results indicated that the majority of migrant workers, from other provinces, used taxis to get to Western Cambodia. For many of these migrant workers, especially from the southeastern part of Cambodia that borders Vietnam, the taxi drivers are their first point of contact in the West. Also from the FGDs we found out that the popular taxi routes are from Battambang to Samlaut; Battambang to Sampov Luo; and Battambang to Pailin.
The southeast part of Cambodia has no falciparum malaria cases. So you have people moving from areas of low endemicity to areas of high endemicity. The migrant workers make their way to the West, especially during the harvest season, to work in the plantations.
How are the taxi-drivers trained to raise awareness of malaria among migrant workers?
Khorn Linna: First we conducted an FGD with three groups of taxi drivers that carried migrant workers along the following routes: Battambang to Samlaut; Battambang to Sampov Luo; Battambang to Pailin. We wanted to find out whether we could collaborate with these drivers and we also wanted to assess their basic knowledge on malaria prevention. Besides that, the FGDs also gave us a good opportunity to find out from the taxi drivers what were the best kinds of IEC [Information, Education and Communication] materials that they [taxi drivers] could give out to their migrant worker passengers.
After the FGDs, we started the first training of taxi drivers in Battambang. We had 33 drivers from the three different locations in the training. The training was to ensure that the taxi drivers disseminated accurate information on malaria prevention and treatment to their migrant worker passengers. Because they were the primary message providers, as the first point of contact for migrant workers, we also had to make sure these taxi drivers had good communication skills.
Now we have 33 taxi drivers in our network and we plan to conduct quarterly workshops to monitor and evaluate their activities, and also evaluate the IEC materials that we have developed jointly with the drivers.
Are the taxi-drivers also trying to change the treatment-seeking behaviour of migrant workers – like seeking out the village malaria worker first for diagnosis and treatment if they have fever, rather than going to the pharmacy for self-medication?
Dr. Soy Ty: In the training programmes, we ensure that the taxi drivers themselves have accurate information on malaria transmission and also adequate knowledge of the vector in its ability to transmit malaria. Also through the training programmes, the drivers know the symptoms of malaria or suspected malaria – the fevers, chills, headaches, cold sweats etc. The taxi-drivers are also made aware of the location of health facilities and village malaria workers along the Pailin, Samlaut and Sampov Luo routes, where migrant workers can get free diagnosis and treatment for malaria. All these packets of information are important because the taxi drivers will be able to advise the migrant workers on what to do if they have fever and where to seek free diagnosis and treatment, rather than going to the drug outlets or pharmacies first.
BBC’s Health Check reports from Pailin on the efforts of WHO and Malaria Consortium to contain and eliminate artemisinin-resistant falciparum malaria along the Thai-Cambodian border.
In hot humid Cambodia, maintaining a ‘cool chain’ can be a problem. But the Cambodian National Centre for Parasitology, Entomology and Malaria Control (CNM) has an innovative solution. It has developed the Cambodian Cooler Box, with technical support from WHO and support from the USAID-funded University Research Co (URC), for perishable medical commodities in remote communities.
Since malaria rapid diagnostic tests (RDTs) were introduced in Cambodia in 1996, the use of these tests has increased steadily.
The malaria containment project in Cambodia funded by the Bill & Melinda Gates Foundation uses RDTs to improve diagnosis of febrile illness in remote malaria-endemic areas where microscopy diagnostic services are not readily available.
Rising treatment costs due to introduction of artemisinin combination therapy has further raised the importance of proper malaria diagnosis prior to treatment, and the urgency to contain and eliminate emerging artemisinin-resistant malaria in western Cambodia has made rapid access, at community level, to both RDTs and anti-malarial drugs a priority for the Cambodian National Centre for Parasitology, Entomology and Malaria Control (CNM).
Malaria RDTs are lateral-flow tests based on interactions of biological agents (antibodies and antigens) attached to or flowing along a nitro-cellulose strip. They are therefore sensitive to degradation by heat and humidity.
Heat can damage RDTs through deconjugation of the antibody-dye conjugate, detachment of the bound antibody from the nitrocellulose, loss of ability of the antibody to bind to antigen, and degradation of the nitrocellulose strip.
While packaging in moisture-proof envelopes can prevent exposure to humidity, if RDTs are stored at temperatures exceeding the recommended temperature it is likely that loss of sensitivity will occur and the shelf life of the RDTs will be reduced.
Previous studies in Cambodia have demonstrated storage temperatures for RDTs much higher than 30°C in remote health facilities. Temperatures in drug storerooms in some health centres can reach 42.5°C.
CNM, with technical support from WHO and support from the USAID-funded University Research Co (URC), has pioneered the introduction of evaporative cooler boxes for storage of medical supplies in remote clinics in Cambodia, known locally as the “Cambodian Cooler Box” (CCB).
Cooling is based on the principle that water absorbs heat from its surroundings when changing from a liquid phase to its higher energy gaseous phase (evaporation). As heat is absorbed from the surroundings of the damp sacking cover, particularly from the galvanized iron sides of the box with which the sacking is in direct contact, the box sides and contents are cooled.
Evaporative cooling is an ancient technology that is still used for making water cool. While the idea is not new, the principle has not been put to use on a large scale to allow extension of important health interventions.
The CCB uses local materials and construction, and the prototypes cost only $25 to produce. Significant cooling can be achieved despite Cambodia being cooler than many other malaria-endemic countries and having high humidity, both of which should reduce the relative efficiency of evaporative cooling.
Development of a “cool chain” is not only important for many RDTs, it is also important for many medicines. Medicines are commonly stored and transported under the same conditions as RDTs in developing countries. In general, medicines should be stored under conditions similar to RDTs.
The study for this paper was done in two phases. Phase 1 was a pilot study conducted in Sampov Loun operational district storeroom and Ankor Ban Health Centre in Battambang province, Cambodia, from May to July, 2004. The province has a clearly defined dry season (December to May) and rainy season (June to November). The maximum temperature in the dry season can reach 38°C. This phase of the study was designed to demonstrate the temperature and humidity differences in the storerooms at ambient temperature, in the CCB without water and in the CCB with water.
Phase 2 was conducted in Sampov Loun, Serey Meanchey health centre storeroom and, Barieng Tlek storeroom in Battambang province, Cambodia between November 2005 and December 2006. These areas are malaria-endemic for both Plasmodium falciparum and Plasmodium vivax, and RDTs use used for malaria diagnosis. This phase of the study focused on investigation of temperature and humidity to which the RDTs were exposed and the stability of the RDTs during exposure to temperature and humidity in three conditions; ambient room temperature, CCB without water and, CCB with water (as designed).
The results indicate that a low-cost, locally produced product employing evaporative cooling technology can effectively maintain safe storage temperatures well-below room temperatures in tropical conditions, even in the presence of relatively high ambient humidity. This has applications for the maintenance of quality of diagnostics and drugs in clinics in village-based settings.
This is an edited condensed version of the article “Low-technology cooling box for storage of malaria RDTs and other medical supplies in remote areas” by Lon Chanthap, Frédéric Ariey, Duong Socheat, Reiko Tsuyuoka and David Bell that appeared in Malaria Journal, Vol: 9, 2010. The full open-access article can be downloaded from http://www.malariajournal.com/content/9/1/31