Posts Tagged ‘thailand’
CONTAINMENT’s Nat Sumon accompanied an Armed Forces Medical Research Institute for Medical Science (AFRIMS) mobile unit to a remote location on the Thailand side of the border to screen soldiers for malaria.
Over the course of history, in times of war, more soldiers have died from malaria than in direct combat. During the Vietnam War (1962–1975), malaria felled more combatants during the war than bullets. The disease reduced the combat strength of some units by half.
Over 40,000 cases of malaria were reported in U.S. Army troops alone between 1965 and 1970 with 78 deaths. The U.S. Army established a malaria drug research program when U.S. troops first encountered drug resistant malaria during the war. In 1967, Chinese scientists set up Project 523 – a secret military project – to help the Vietnamese military defeat malaria by developing artemisinin based anti malarial formulations.
For the Thai army, malaria still remains a threat despite the drastic fall in cases of falciparum malaria – the most fatal form of the mosquito-borne disease. According to 2010 Royal Thai Army statistics, 572 soldiers contracted malaria along the Thai-Cambodian border and constituted one-fourth of overall malaria patients seeking treatment in the area.
Many Thai soldiers used to harsh tropical jungle conditions are well aware of protective measures. If they fall sick, they are instructed to go either to local malaria clinics or local hospitals to have their blood tested on a weekly basis.
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.
The ‘Love Your Health’ radio program hosted by the head of the Malaria Clinic in Khaeng Harng Maew District, Chanthaburi is a community favourite. CONTAINMENT’s Nat Sumon tells why.
If you live in Khaeng Harng Maew district, Chanthaburi, where there is only one strong radio frequency, your favorite entertainment channel would definitely be the local radio network FM95.75.
Among the variety of programs carried by FM95.75, the most popular slot seems to be a one-hour health program every Wednesday called “Rak Sukaphab” or “Love Your Health”. Undoubtedly the listening audience, attracted by the easy-listening music, tune in faithfully every Wednesday to the health program that has helpful tips on how to lead a healthy lifestyle.
“Love Your Health” also has a call-in facility that allows listeners to interact with the presenter Anukoon Charunthup, who is also head of the Malaria Clinic in Khaeng Harng Maew District, Chanthaburi. The program allows listeners to phone in to ask any health-related questions they might have. And as an indication of the radio program’s popularity, the station’s phone is always ringing off the hook.
Anukoon tells CONTAINMENT that he began hosting the “Love Your Health” radio program about five years ago when the local radio network was just launched.
“Chantaburi is no stranger to vector-borne diseases,” he says. “The health topics that I cover in my radio program range from malaria, dengue and other mosquito-borne diseases.”
Anukoon’s radio program is important for Khaeng Harng Maew residents especially during the rainy season. “It’s the rainy season when diseases like malaria and dengue are rife and I use the radio program to disseminate preventive messages and tips on how listeners will be able to protect themselves from falling sick,” he adds.
But there is a humourous side to Anukoon, too. He tells CONTAINMENT that malaria is also known as “khai-mae-yai-bua” in Thai, which means “fever that pisses your mother-in-law off!”
Anukoon explains. “When you have malaria, you can’t work to feed your family, and that’s when the mother-in-law becomes cross because her daughter and grandchildren would have to go hungry.”
The Malaria Clinic head in Khaeng Harng Maew District made it clear that the most vulnerable group to malaria are male wage earners.
“Because of this, my program gives advice on where these workers would be able to get mosquito repellents and insecticide-treated bed nets to prevent themselves from getting malaria,” adds Anukoon. The “Love Your Health” radio call-in program also tells these workers where the locations of the malaria clinics are and assures them that diagnosis and treatment is free of charge.
Though Anukoon believes that local people are very acquainted with malaria, its symptoms, and vector control and prevention measures, he, however, tells CONTAINMENT that they need to be reminded of the dangers of malaria during the rainy season.
Anukoon has been presenting “Love Your Health” for about five years and is now building up the capacity of his staff to co-host the show to add diversity to the radio program and also fill in as main presenters when he has to travel outside the district for meetings and workshops.
“My hope is that by building up the capacity of my staff as presenters, they would in turn be able to start their own malaria radio shows if they are promoted and transferred out of the district,” he explains.
But wearing two hats at one time can be tiring for Anukoon. “I frequently get calls from listeners asking me where I was in the previous week, for instance, because they didn’t hear my voice on radio,” he explains.
But the rewards are always gratifying. “Every week I get e-mails and calls from listeners telling me how much they enjoyed my show and how useful the health messages were to them,” says Anukoon. “That’s enough to keep me going.”
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.
CONTAINMENT recently spoke to Dr. Robert Newman, Director of WHO’s Global Malaria Program, who was on a field visit to Pailin in Western Cambodia.
There is a long history in malaria control efforts. What’s different now and how has the landscape changed?
Obviously the big issue here right now is the emergence of resistance to artemisinins and this is not just an issue along the Cambodian – Thailand border, but is also a global issue. We rely very heavily on artemisinin-based combination therapies or ACTs and artemisinin is the key ingredient in that combination.
And the stakes are very high because right now we do not have other drugs in the development pipeline that are likely to reach markets before five years, the earliest. And that is an optimistic projection.
So it is really critical that we bring all forces together to try and preserve the efficacy of these valuable medicines.
Here in Western Cambodia we have an extraordinary effort made by the Cambodian National Malaria Control Program and their counterpart program in Thailand to contain the spread of these resistant parasites. The efforts here, I think, have been groundbreaking in their comprehensiveness. Some of the approaches that have been taken are also novel and pioneering.
The Cambodian government has banned the sale of monotherapies. Do you think there should be a similar ban regionally within the Association of Southeast Asian Nations or ASEAN?
Absolutely. I think we all agree now at this point that the use of oral artemisinin monotherapies is probably the single greatest factor for the spread of artemisinin-resistant parasites. In 2007 there was a World Health Assembly resolution that called for a halt in the marketing and use of these compounds.
The worst 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]…
While there has been some forward movement in the number of countries that have complied both in terms of shutting down the manufacturer, marketing of these drugs and to some extent in their use, we still have to go some way. This is such an urgent issue. The time to do that is now.
We need all countries, globally – particularly here in the Greater Mekong sub-region and ASEAN to ensure that these dangerous medicines are removed immediately from the market place.
What are the differences between containment and elimination; elimination and eradication?
Containment would mean in this context that we take these resistant parasites and don’t let them spread outside the area where they have been identified. So at this point the confirmed areas are along the Thai-Cambodian border, although there are other areas in the Greater Mekong sub-region where we have suspicion of their emergence.
Elimination would mean that we would actually be able to eliminate all of the parasites. That is a very difficult thing to document. Obviously, if we are able to eliminate these resistant parasites then the risk of their spread is essentially gone.
The term elimination is more generally used to refer to the reduction at the country level of local transmission of malaria to zero. So usually we talk of eliminating malaria at a country level.
Eradication is reserved for the global incidence of malaria going to down to zero. And that’s for all plasmodium species and not just for falciparum. That obviously remains the ultimate public health goal, although I believe that will take 40 or more years to achieve. It would require the development of new transformative tools that we do not have, yet.
What’s the worst case scenario for MDR-falciparum malaria?
The worst 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].
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.
Right now we have resistance to artemisinins, but artemisinin-based combination therapies (ACTs) still remain efficacious. That is a very important message.
But 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.
As you know we still have more than 700,000 estimated deaths a year in Africa from malaria. We rely entirely on ACTs for the treatment of falciparum malaria. If we were to lose those medicines in Africa, that would be a catastrophe. This is precisely what the extraordinary efforts in the Containment Project, here, in the Greater Mekong sub-region are trying to prevent.
The World Health Organization has been working intensely with the health ministries of Cambodia and Thailand, in a Bill & Melinda Gates Foundation-funded project, to try to wipe out malaria along the Thai-Cambodian border. Encouraging widespread use of mosquito nets is a key part of the strategy to contain the drug resistant malaria parasites. See photos
Pong Nam Ron District, Chantaburi Province — “Mom” lives in this camp with other people who come and go between Thailand and their homes in Cambodia whenever there is work.
A recent secondary school leaver, “Mom” said her family spends about two months here before they go home to Boseth Commune in Kampong Speu, a province located southwest of Cambodia’s capital Phnom Penh, or a day’s drive away from Chantaburi on the Thai side.
In her Thai, which was understandable though not fluent, she remembered having repeated the journey about 10 times, and having done some work herself on some occasions. “We pick whatever fruit is in season,” she said.
About 20 people who usually spend less than six months just inside Thailand were living in this camp when a team from the officials from Bureau of Vector Borne Diseases, World Health Organisation and the Malaria Consortium paid a visit. The conditions at the camp located on the edge of a longan orchard were stark. Spindly tree trunks propped up the houses, with synthetic fiber sheeting or newspaper sheets as walls. But there were water jars in the camp, suggesting some permanency or continuity in the movements of these itinerant workers.