ERAR launches technical working groups on surveillance monitoring and evaluation and advocacy and communications

As malaria incidence declines in the region, the disease is becoming
increasingly concentrated in particular localities and
demographic groups, like mobile migrant populations. Pix/WHO

4 September 2014 — Two technical working groups (TWG) of the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion (ERAR) initiative debuted in Phuket, Thailand, at the sidelines of informal consultations, held between 19 to 22 August, to discuss an action plan for mobile and migrant populations and the development of draft strategies for monitoring and evaluation and advocacy and communications.

“Consensus building is always a tough challenge but members of the two TWGs have now agreed on an organisational structure that empowers the technical working groups to work with GMS countries and their partners, in an advisory capacity, in a more efficient, focused and structured way to ensure all stakeholders remain fully represented,” said Dr. Walter Kazadi, coordinator of the ERAR Regional Hub.

The first TWG was on surveillance, monitoring and evaluation (SME), with a partnership between ERAR Hub, national malaria control programmes, technical and development partners, the private sector, academia and the military health sector.

One key lesson, learnt, in the ERAR project, is that the capacity of SME systems in the GMS differs from country-to-country. An ongoing assessment of the SME systems in the GMS countries will inform program strengthening efforts.

“Some GMS countries require more attention and this SME TWG will advise all stakeholders – from donor partners to technical partners and NGOs – on how to provide coordinated technical support,” added Dr. Kazadi. “ That support will help incorporate partners’ plans into national programmes for monitoring and evaluation, including development of standardised tools for data collection, management, analysis and use, and updated survey tools for low malaria transmission settings and elimination.”

The second TWG on advocacy and communications, with ERAR Hub, national malaria programmes, development and technical partners, the private sector and the military health sector as members, will assist GMS countries to implement communication policy decisions to move the containment of artemisinin resistance and malaria elimination agenda forward, and support advocacy for implementation of elimination strategies at national levels.

“This TWG will also assist GMS countries harmonise the development of cross-border information, communication and education materials and behavior change communication strategies for populations at risk as identified in the ERAR Framework,” said Dr. Kazadi. Establishment of this TWG happens at a turning point when the GMS is undergoing major transformation, which calls for better coordination of advocacy and communication efforts for malaria elimination.

In 2015, the Association of Southeast Asian Nations (ASEAN) Economic Community, as envisioned by ASEAN leaders in 2007, formally comes to being, ushering in a region with a single market and production base characterised by free flow of goods, services, investment, capital, and skilled labor. Intense mobility in the GMS is also expected to increase with poor young adults, who cannot earn enough to support their families in their places of origin, moving across ASEAN common borders to find employment in neighbouring countries. These developments are likely to increase health inequities, and impact on efforts to curtail multi-drug resistance malaria in the Region.

In the ERAR Framework, population groups may be at high risk due to their occupation, working for instance in mining in forested areas; others are at risk due to their mobility. People moving into new areas are more likely to seek care from unregulated, private vendors often increasing their risk of exposure to substandard drugs or oral artemisinin-based monotherapy.

Of major concern is the fate of another population group at risk, mostly overlooked in the design of programs to eliminate malaria, namely military personnel stationed at malaria endemic border areas. Due to this, it was agreed among members, in both TWGs, that representation would be sought from each GMS country’s Ministry of Defence. Also, military medicine has made significant advances in malaria prevention, control, diagnosis, and treatment and because of this, military study data could be shared with national malaria control programmes.

In both TWGs, the ERAR Regional Hub will be the secretariat with meetings among members held every three months through teleconference.

Membership of the surveillance monitoring and evaluation TWG include:

1. SME focal points from the six national malaria control programmes in the GMS.
2. Representatives from the Bill & Melinda Gates Foundation, Australian Government’s Department of Foreign Affairs and Trade, USAID/PMI, Global Fund for AIDS, TB and Malaria, Asian Development Bank/Asia-Pacific Leaders Malaria Alliance (APLMA).
3. Chair of the Regional Steering Committee of the Global Fund/Regional Artemisinin Initiative (RAI); Representative from Global Fund – RAI Regional Principal Recipient (UNOPS-Myanmar).
4. Representatives from Asia Collaborative Training Network for Malaria (ACTMalaria), Population Services International (PSI), CAP-Malaria, Asia Pacific Malaria Elimination Network (APMEN), Mekong Basin Disease Surveillance Network, and Malaria Consortium.
5. Representation from research and academia, represented by Mahidol Oxford Research Unit (MORU).
6. Representative from the private sector – represented by Myanmar Health and Development Consortium.
7. Members of the ERAR Regional Hub.

Membership of the advocacy and communications TWG include:

1. IEC/BCC focal points from the six national malaria control programmes in the GMS.
2. Representatives from the Bill & Melinda Gates Foundation, Australian Government’s Department of Foreign Affairs and Trade, USAID/PMI, Global Fund for AIDS, TB and Malaria, Asian Development Bank/Asia-Pacific Leaders Malaria Alliance (APLMA).
3. Chair of the Regional Steering Committee of the Global Fund/Regional Artemisinin Initiative (RAI); Representative from Global Fund – RAI Regional Principal Recipient (UNOPS-Myanmar).
4. Representatives from Population Services International (PSI), Malaria Consortium and Health Poverty Action (HPA).
5. Representative from the private sector – represented by Myanmar Health and Development Consortium.
6. Members of the ERAR Regional Hub.

ERAR emphasises behavior change communication as an important tool to reach at risk mobile migrant populations

A poster in Lao PDR urging families to sleep under long-lasting insecticide treated mosquito nets. Pix/WHO

25 September 2014 – La (not his real name), an 18-year-old logger, from Stung Treng province in Cambodia had a close call with death recently in Pathoumphone district of Champasack province in the south of the Lao People’s Democratic Republic. His misconception that malaria was caused by drinking contaminated water, which could have been addressed by effective behavior change communication, almost cost him his life.

Recognising the importance of effective BCC as an intervention to maximise the fight against multi-drug resistant malaria that has emerged in the GMS, the WHO Emergency Response to Artemisinin Resistance (ERAR) Regional Hub in the Greater Mekong Subregion recently organised a two-day behaviour change communication (BCC) workshop in Phuket, Thailand, to use BCC as an important tool to reach mobile migrant populations who still remain at risk, despite the declining number of malaria cases in the region.

When La returned from a forest in Pathoumphone district , where he spent a week with his co-workers seeking the much-coveted luxury rosewood, he fell ill with high fever and chills. La’s condition deteriorated rapidly and he was brought to Pathoumphone District Hospital, by his brother, in an almost unconscious state. He tested positive for falciparum malaria and was immediately treated for severe malaria. Two days later, he could sit up on his bed at the Infectious Diseases Ward and walk to the toilet. But the hospital authorities refused to discharge him until he completed his full dosage of anti-malarials. A blood test would then be done to ensure he was not carrying any more malaria parasites.

Between 2000 and 2010, Lao PDR significantly reduced its malaria burden and was on track to achieve the World Health Assembly target of cutting the malaria burden by 75% by 2015. The number of annual malaria deaths was reduced from 350 to 24, while the number of confirmed cases was cut from around 75 000 cases to 30 000 cases in 2010. However, in late 2011 malaria outbreaks began to flare up again mostly in Lao PDR’s southern provinces, with 17 deaths reported. In 2012, the disease killed 44 people, while in 2013 it took 28 lives. The presence of mutations linked to delayed parasite clearance have been found in Champasack, making Lao PDR the fifth country in the Greater Mekong Subregion with partial artemisinin resistance.

“I was very certain I was going to die,” the young logger told a team from the WHO Emergency Response to Artemisinin Resistance (ERAR), when he first met them in the Pathoumphone District Hospital.

La migrated to Champasack province in southern Lao PDR from neighbouring Stung Treng province in Cambodia recently to work for a company making furniture from luxury rosewood found in the heavily forested area. Runaway demand for luxury furniture is spurring illegal logging across the Greater Mekong Subregion, stripping forests in the area of precious Siamese rosewood and driving a chain of illegal cross-border migration.

During part of the year, La works on his family-owned paddy field in neighbouring Cambodia’s Stung Treng province. After the harvest season, however, like many other farmers in his province, he would cross the common international border into Lao PDR to work as a part-time logger for companies making high-end rosewood furniture. Rosewood can fetch thousands of dollars per cubic meter and loggers like La can earn hundreds of dollars working for companies making luxury wood furniture.

“After the rice harvest, there’s no work on the farm. But we have to find money and that’s the reason we go into the forest,” he told the ERAR team.

When asked by the ERAR team if he knew how he got malaria, he simply replied no. “I thought I got sick from drinking contaminated water and did not know malaria is caused by infected mosquito bites, until the doctor and nurses told me so,” he added.

La said he would now follow the doctor’s advice of sleeping in a long-lasting insecticide treated hammock-net whenever he is in the forest and applying mosquito repellent. “I realise that personal protection is very important in malaria prevention,” he added.

Little knowledge, less awareness and inadequate practices are important factors that need to be addressed, if progress is to be made in containing artemisinin resistance and eliminating malaria in the Greater Mekong Subregion. The movement of infected people from areas where malaria was still endemic to areas where the disease had been eliminated can lead to resurgence of the disease. Population movement can also facilitate the spread of malaria drug resistant strains.

These were the key messages at the ERAR-organised two-day BCC workshops that included government representatives from the Greater Mekong Subregion countries, non-government organizations and donor partners.

“We need to find innovative methods for delivering key health messages to the high-risk groups and hard-to-reach risk groups including mobile migrant populations,” Dr. Walter Kazadi, the ERAR Regional Hub Coordinator, told the behavior change communication workshops in Phuket.

“As we go on the path of malaria elimination, we must rethink our strategy of engaging mobile populations and ensure they have access to prevention measures and early diagnosis and treatment,” added Dr. Kazadi. “Investment in high-quality malaria BCC is good practice, and should be an integral component of malaria control strategies from the start.”

A technical working group, with national malaria programmes, NGOs, the private sector and donor partners as members, which will address behavior change communication to reach mobile populations who remain at risk, even though progress is made towards elimination, was formed at the sidelines of the Phuket workshops with the ERAR Regional Hub as the secretariat.

“Behaviour change communication strategies will need to be updated and adapted, through the technical working group, as transmission dynamics change and perception of risk is reduced when malaria cases fall,” Dr. Kazadi pointed out.

The workshops also brought forth the fact that mobile populations are often part of the same communities as their more sedentary counterparts, hence dispelling the notion that these populations are completely segregated from local communities. A good way of accessing so-called hard-to-reach populations is through social networks, peer educators, participatory development and other forms of community engagement.

One example is the USAID-supported CAP-Malaria’s innovative approach using monks, nuns and lay elderly women – also known as grannies — in predominately Buddhist Cambodia, to reach out to mobile migrants visiting pagodas in the villages.

“Monks, nuns and grannies are highly respected in Cambodian society and have much influence over the community,” said Kharn Linna, CAP-Malaria’s Communications Officer. “CAP-Malaria engages these groups to support malaria awareness through the Interpersonal Communication approach (IPC) with the goal of encouraging community members and mobile migrants to adopt positive behaviors that will reduce their risk of contracting malaria,” she added.

Since August 2013, 50 monks, nuns and grannies from 10 pagodas in Veal Veang District, in Pursat Province, and Samlot district, in Battambang Province, have received training to become malaria educators from local health center staff with the support of CAP-Malaria. Both Veal Veang and Samlot districts have a large mobile migrant workforce in the plantation sector and a dam project in the area.

The relationship between malaria transmission and population movement is complex, but attempts to eliminate malaria will be futile if they are not based on an understanding of this link.

“Key challenges remain. It is still difficult to reach mobile migrant populations particularly in border areas due to language barriers, inadequate numbers of health educators and geographical difficulties,” said Dr. Rungrawee Tipmontree, a behavior change communications specialist with Thailand’s Bureau of Vector Borne Diseases.

“We should be looking at training more migrant health volunteers in behavior change communication and using innovative techniques like inter-personal communication to reach out to migrant workers at appropriate times such as in the evenings, when they return from work,” she added.

Malaria outbreaks continue in Lao PDR

Despite the fall in malaria cases from the peak in 2012, outbreaks continue in Saravan and Champasack provinces with artemisinin resistance confirmed in Champasack and Attapeu.

There is an urgent need to control outbreaks of malaria in the southern provinces of the Lao People’s Democratic Republic and contain artemisinin resistance currently emerging there.

Dr Bouasy Hongvanthong, Director of the Centre for Malaria Parasitology and Entomology (CMPE), made this appeal at the technical consultation on improving access to malaria control services for migrant and mobile populations held in Hanoi, Viet Nam on 22 May 2014.

“Outbreaks have been happening since late 2011 in the southern provinces of Attapeu, Champasack, Saravan, Sekong, and Savannakhet, “ Dr. Bouasy told the meeting. “Despite the fall in cases in 2013 compared with 2012, the outbreak continues in Saravan and Champasack,” underlined Dr. Bouasy.

Since late 2011, malaria outbreaks began mostly in southern provinces, with Lao PDR reporting 17 deaths. In 2012, the number of deaths rose to 44 but fell to 28 in 2013. In 2009, only five deaths among 22 784 confirmed cases of malaria were reported in Lao PDR compared with 600 deaths and 70 000 confirmed cases in 1997. Between 2000 and 2011 Lao PDR had a rapid decline in malaria incidence and was in line to achieve its MDG goals.

“The sharp rise in deaths and cases is attributable to increased population movement into areas of large infrastructural development projects, plantations and forests for economic reasons,” Dr. Bouasy pointed out. “Artemisinin resistance is now confirmed in Champasack and Attapeu provinces and we are developing an artemisinin resistance containment strategy,” he revealed.

In the outbreak response by CMPE and Health Poverty Action between 2012 and 2013 in Attapeu and the affected southern provinces, with financial support from WHO, the European Union, the Global Fund and USAID/PMI, 2 500 malaria patients were detected during an intensive screen and treat programme in identified malarious villages. Also, 28 900 long-lasting insecticide treated nets (LLINs) and 6,673 long-lasting insecticide treated hammock nets (LLIHNs) were distributed in Attapeu. In addition, using pooled contributions from donors, 12 673 LLIHNs were distributed at affected villages in the southern provinces.

“At the community level, 150 new village malaria workers were trained to carry out early diagnosis and treatment in villages in the high malaria transmission areas and indoor residual spraying (IRS) was carried out in 30 high-risk villages,” said Dr. Bouasy. Also, said Dr. Bouasy, village health volunteers (VHVs) that provide primary health care services, including diagnosis and management of basic diseases “have been reactivated to carry out early diagnosis and treatment of malaria.”

As part of an intensive health education campaign, CMPE and WHO jointly produced, during the 2012-2013 outbreak response, roadside banners, billboards and posters with malaria preventive messages in Lao, Chinese and Vietnamese languages. Lao PDR is a small landlocked country bordering Thailand, Cambodia, Viet Nam, China and Myanmar. While there is considerable out migration to neighboring countries there is also an increasing number of migrant workers entering Lao PDR from Viet Nam and China to work in development projects.

In late April a WHO team comprising members from the Emergency Response to Artemisinin Resistance (ERAR) regional hub and the Cambodia and Lao PDR country offices were in the capital Vientiane for a crucial one-day consultation to assist CMPE identify crucial areas for intervention to achieve malaria elimination, as it prepares to finalise the National Malaria Strategic Plan (NSP) 2015 – 2020.

The need to have cross border collaboration as a key strategy in the NSP was recommended by the ERAR regional hub. Lao PDR shares common borders with five Greater Mekong Subregion (GMS) countries and malaria remains particularly endemic in remote, forest and forest fringe areas, which often occur along these borders.

“Malaria is often more difficult to control in these border areas due to the more inaccessible terrain, and because of unknown population movements across the borders. Most of those crossing the borders are adult men engaged in plantation work, large infrastructure projects and forest activities that expose them to outdoor biting vectors,” Dr. Bayo Fatunmbi, a technical officer with the ERAR regional hub, told the NSP consultation.

ERAR also expressed its support and agreed to provide technical assistance for the development of an artemisinin resistance containment and elimination strategy in the NSP.

The relocation of local villagers and influx of labour migrants from surrounding provinces and countries continue to present challenges to those working in the field of malaria elimination, as Lao PDR continues to open its doors to foreign investors in many large-scale development projects including hydropower, mining, commercial agriculture, infrastructure and rural development.

“These rapid economic developments in Lao PDR are changing the patterns of malaria transmission,” said Dr. Bouasy.

“Population movements into the forest to clear the area for development, or in search of food and forestry products have to be addressed and these workers need to be educated on malaria prevention and how to seek treatment if they fall sick,” he added.

Health Poverty Action is currently carrying out a qualitative study to better understand the malaria care-seeking and preventive behaviors among the at- risk mobile and migrant populations in Pathoumphone and Taoy districts of Champasack and Saravan Provinces. This study will lead to the development of a behavior change communication strategy to improve the personal protection behaviors of the at-risk populations.

“There is currently a lack of understanding about mobile migrant populations in Lao PDR related to their migration patterns, frequency of forest related travel, work routines, knowledge and behaviours regarding malaria prevention and protection measures and treatment-seeking behaviours,” said Dr. John Holveck, the Lao PDR Country Director of Health Poverty Action.

CMPE’s Dr. Bouasy pointed out that engaging the private sector is crucial in providing diagnosis and quality treatment to mobile populations that are often located in remote areas and are difficult to target and access for surveillance. In Lao PDR, patients first sought care from private providers in 63% of fever cases. In particular, private retail outlets, such as drug shops and kiosks, play an important role in the provision of malaria medicines.

Funded by the Global Fund, with technical support from WHO, the Public Private Mix (PPM) for malaria diagnosis and treatment started in September 2008 in eight districts of four target provinces. The main objectives were to increase coverage of services and reduce the availability of counterfeit anti-malarials in the private sector. Initially a total of 98 private pharmacies and 10 physicians from private clinics were trained to use rapid diagnostic test kits (RDTs) and ACTs for diagnosis and treatment of uncomplicated malaria.

Today, the PPM initiative has been expanded to include expanded to include eight provinces, 22 districts, 17 clinics and 242 private pharmacies as part of the continuous efforts made by CMPE to extend its network and reach.

“This a great achievement in reaching out to local communities using the private sector,” said Dr. Bouasy.

 

Mobile migrant populations in GMS pose a challenge to monitoring drug efficacy

Mobile migrants might be at high risk of contracting malaria due to their occupations, working, for instance, in areas just cleared of forests.

Results from the Mekong Therapeutic Efficacy Monitoring Network show increasing pockets of artemisinin resistance in the Greater Mekong Subregion. The challenge, now, is to develop innovative approaches to monitor drug resistance in highly mobile local migrant populations.

Malaria in mobile and migrant populations in the Greater Mekong Subregion (GMS) is a challenge for the containment and elimination of artemisinin resistance, including monitoring the effectiveness of anti-malaria drugs, as the discovery of mutations that neutralise artemisinin leads to efforts to chart their independent spread in different parts of the region.

“Parasite resistance to anti-malarial drugs is changing faster than was predicted and it is now known that artemisinin resistance has occurred not just at the Thailand-Cambodia border, but at multiple new areas throughout the region,” said Dr. Walter Kazadi, coordinator of the WHO Emergency Response to Artemisinin resistance (ERAR) regional hub.

With global and regional concern about the fast-evolving drug resistance situation, a Mekong Therapeutic Efficacy Monitoring Network (Mekong TES Network) was formed with the participation of member states and partners. The results of the therapeutic efficacy studies (TES) since 2008 have identified nine areas in the GMS with suspected resistance to artemisinin and three with confirmed resistance. The areas with confirmed resistance are Tak, at the Thailand-Myanmar border; Pailin at Cambodia-Thailand border and Champasak at Lao PDR-Thailand-Cambodia border.

“Therapeutic efficacy studies (TES) play an important role in supporting GMS countries develop and implement quality surveillance of antimalarial drug efficacy. The challenge is to develop innovative approaches to monitor drug resistance in local migrant populations when usual TES cannot be carried out due to their high mobility,” added Dr. Kazadi when addressing the start of two back-to-back workshops organized in Hanoi, Viet Nam, between 20 to 23 May 2014 by the ERAR regional hub in collaboration with the WHO Regional Offices for South-East Asia and the Western Pacific and the Global Malaria Programme in WHO headquarters.

The workshops were co-hosted by the National Institute of Malariology, Parasitology and Entomology of the Ministry of Health, Viet Nam with the WHO country office in Hanoi, Viet Nam.

The first workshop, with the Mekong TES Network, was to review and plan therapeutic efficacy studies to monitor antimalarial drug resistance in the GMS. The second focused on improving access to malaria control services for mobile and migrant populations in the GMS.

Intense mobility in the GMS is expected to increase in 2015 as the ASEAN Economic Community (AEC) ushers in a region with a single market and production base characterized by free flow of goods, services and labour – both skilled and unskilled. Poor young adults, who cannot earn enough to support their families in their places of origin are moving across ASEAN common borders to find employment in neighbouring countries. They are at high risk of contracting malaria due to their occupations, working, for instance, in mines and forested areas.

“Development projects in the GMS influence the malaria situation,” said Dr. Deyer Gopinath, the Malaria and Border Health Technical Officer in the ERAR regional hub. “The influx of foreign workers into one area can change the malaria parasite species ratio and can introduce drug resistant parasites. Further, without access to health services, migrant workers tend to self-medicate and exposure to unregulated substandard antimalarials and monotherapies exacerbate further the problem of artemisinin resistance,” added Dr. Gopinath.

Participants in the workshop on mobile and migrant populations in the GMS agreed to proactively seek innovative approaches to malaria prevention and treatment in these populations, including work site interventions with labour organisers, employers and the private sector. The workshop also agreed to engage other sectors, like mining and forestry, for effective control of malaria among migrant workers to reduce the risk of emergence and spread of arteminisin resistance.

“Engaging the private sector is crucial in providing diagnosis and quality treatment to mobile populations that are often located in remote areas and are difficult to target and access for surveillance,” said Dr Bouasy Hongvanthong, Director of the Centre for Malaria Parasitology and Entomology of Lao PDR.

The Mekong TES Network first met in Phuket in September 2007 where they agreed to a standardised protocol for conducting therapeutic efficacy studies. It also planned to consolidate laboratory networking across the GMS to assess and standardise molecular techniques differentiating recrudescence from reinfection, genotyping and use of molecular markers for resistance.

Participants at the TES workshop discussed the difficulty in monitoring artemisinin resistance in border areas particularly when trying to understand where the infection originally came from. They expressed concern that results found in one country influence that country’s drug policy, but in fact, the infection may have been acquired in another country. But this has also been a problem with in-country mobility of seasonal migrant workers moving across their own country, for instance, forest workers acquiring malaria infection in northwestern Cambodia then returning sick to their home province in the south.

The possible spread or independent emergence of artemisinin resistance out of the GMS region was also discussed. Participants pointed out that it would likely first occur in India, before reaching the African region. This underscored the importance of collaboration between the GMS TES network and Bangladesh, Bhutan, India, Nepal, Sri Lanka (BBINS) Malaria Drug resistance network.

“Meeting organisers invited representatives of the Indian National Institute of Malaria Research to discuss the malaria situation in India, control strategies, treatment policies and share results of their artemisinin resistance tracking studies,” said Dr Maria Dorina Bustos, Malaria Technical Officer, in WHO Thailand.

Though India is not part of the GMS TES network it, however, shares a long border with Myanmar and has a high malaria burden.

“An understanding of the malaria situation in the GMS countries benefits India and helps them to better plan malaria control activities and the tracking of artemisinin resistance, and vice versa,” added Dr. Bustos.

Topmost in the TES workshop discussions were mutations in the malaria parasite that underlie its resistance to artemisinin, which have been pinpointed for the first time. Researchers have identified mutations in the PF3D7_1343700 kelch propeller domain (K-13 propeller) of the parasite in an artemisinin-resistant parasite line, and investigated the prevalence of these mutations in patients with malaria, from samples collected between 2001 and 2012 across various provinces in Cambodia.

The researchers, in their investigations, found that in the provinces where artemisinin resistance is known to exist, the frequency of K-13 propeller mutations increased significantly over time. Conversely, this increase was not observed in provinces where there is no evidence of artemisinin resistance. Furthermore, patients who carried parasites with K-13 propeller mutations took significantly longer to clear the infection (with Day 3 positivity rate in more than 10% of cases) than patients carrying parasites without these mutations.

By testing for these genetic variants, public-health officials now plan to map malaria strains that are resistant to artemisinin derivatives in the GMS, with the hope of stemming their spread to Bangladesh, India and elsewhere.

Participants agreed that the recent identification of a marker for artemisinin resistance (mutations in K-13 gene) has led to a new working definition for both suspected and confirmed artemisinin resistance which can affect the way decisions are made about changes to drug policy. TES samples from the GMS countries are now undergoing K-13 assays in two reference laboratories in the region.

“In order to make decisions on drug policy change, we can now use TES results as well as the confirmatory results of molecular techniques. Our understanding is that the findings of K13 mutations and their correlation to clinical artemisinin resistance is evolving. For this reason, for the moment, TES results still remain the cornerstone of artemisinin resistance monitoring,” said Dr. Bustos.

All systems go for ERAR hub in Phnom Penh, Cambodia

 

ERAR staff members with donor partners in Phnom Penh.

WHO’s Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion (ERAR-GMS) hub is now fully staffed.

The first meeting of the World Health Organization ERAR –GMS staff from across the sub-region took place at the Intercontinental Hotel, Phnom Penh, Cambodia from 27-28 January 2014. It was held back-to-back with a meeting with development partners where the finalized ERAR work plan was presented for inputs. The meeting was well attended with 30 participants from the Western Pacific Region, the South East Asia Region and WHO Headquarters in Geneva.

During the two-day ERAR hub staff meeting, discussions focused on each of the thematic area work plans for 2014, namely the coordination of the hub, advocacy and communication, therapeutic efficacy monitoring and operational research, access to services for migrants and mobile populations, support to the implementation of the Myanmar Artemisinin Resistance Containment (MARC) framework, strengthening the response to artemisinin resistance containment in Viet Nam and limiting the availability of oral artemisinin-based monotherapies, substandard and counterfeit antimalarial medicines while improving the quality of ACTs. The related plans were presented by their respective focal points.

In his concluding remarks, Dr. Pieter Van Maaren, the WHO Representative in Cambodia at the time, expressed his confidence that WHO-ERAR will convince donors that WHO can and will deliver on key targets as planned. WHO’s Western Pacific Regional Director of Communicable Diseases Control, Dr. Mark Jacobs, who chaired the two-day meeting, placed emphasis on the emergency context within which the hub has been created, and stressed that rapid action is crucial.

Following the staff meeting, another meeting was held with development partners on 29 January 2014, also at the Intercontinental Hotel in Phnom Penh, to present the work plans. In attendance were representatives from the Bill & Melinda Gates Foundation (BMGF), the Australian Government’s Department of Foreign Affairs and Trade (DFAT), the United States Agency for International Development (USAID), the Asian Development Bank (ADB) and Malaria Consortium. The meeting provided an opportunity for WHO to update donors and partners on ERAR implementation progress.

Major achievements include the launching of the WHO Emergency Response to Artemisinin Resistance. Regional Framework for Action 2013 – 2015, the establishment of the ERAR Regional Hub with its full staff component, the organization of an informal consultation on operational research for accelerating malaria elimination in the context of artemisinin resistance in December 2013, with the identification of priority research topics for countries in the GMS, and the initiation of a situation analysis on the access to malaria services for migrant and mobile populations in the context of ERAR.

In his concluding remarks, WHO’s Dr. Mark Jacobs, who also chaired this meeting, expressed the organization’s appreciation for the support provided by the development partners and underscored the importance of continued collaboration to achieve a coordinated and effective response to the threat posed by artemisinin resistance.

Dr. Kazadi also informed the development partners that the ERAR website* was launched in January 2014 to serve as a key information resource, and reiterated that WHO is committed to providing technical assistance and coordination support to existing and emerging AR initiatives in the region. (*ERAR website URL: http://www.who.int/malaria/areas/greater_mekong/)

As a way forward, the following action items were recommended:

ERAR hub coordination:

• Work with GMS countries to develop a budgeted national artemisinin resistance work plan;
• ERAR Hub to facilitate country ownership of plans, budgeting and implementation efforts;
• Efforts on establishing/updating country databases to be in line with national health information system (HIS) plans;
• With other development partners, work towards establishing a contingency stockpile of essential commodities;
• ERAR Hub to document and share lessons learnt in the GMS in the form of stakeholder analysis/mapping, to showcase local solutions to local problems (government, NGO, partners and other stakeholders). This can also be used as an advocacy tool with the Asia-Pacific Leaders Malaria Alliance (APLMA);
• WHO to work with the Australian government’s (DFAT) consultants at the country level to assess challenges and needs. In-country gaps will be identified and prioritized and appropriate budgets for technical advice will be costed in the work plan.

Monitoring and evaluation (M&E):

• Work to translate the M&E indicators into existing national systems. The M&E framework in ERAR gives ownership to countries, which in turn translates into sustainability. ERAR indicators will be incorporated into M&E Plans as National Strategic Plans are updated with findings from programme reviews and studies.
• ERAR will work closely with other initiatives on artemisinin resistance e.g. APLMA and the Regional Artemisinin Initiative (RAI) to harmonize relevant indicators in the scorecards.
• M&E Technical Working Groups, which are to be established, will provide support to strengthen M&E systems at country level. Membership will comprise of representatives of key development partners with an M&E mandate such as The Global Fund, Malaria Consortium, ADB, University Research Co., etc.
• Incorporate vector surveillance and insecticide resistance monitoring in the ERAR work plan as a way forward for malaria elimination.

Advocacy and communication:

• A calendar of events that will include both malaria-related events and other events that could provide opportunities for advocacy and monitoring.
• Collaborate with APLMA’s proposed “Champions Group” to facilitate high-level advocacy with policymakers/leaders.

Migrants and mobile populations (MMPs):

• Take needed practical steps to increase access of MMPs to timely diagnosis and treatment. There is a need to acknowledge that migration patterns in the GMS are complex and migrants fall into a range of different categories from irregular, short-term migrants to long-term migrants with many sub-groups in between.
• Need innovative ways to carry out surveillance among mobile migrants using peer groups.
• ERAR could look into national issues/policies and help overcome barriers in identifying mobile communities and providing targeted information and health care to these communities. This will include conducting political as well as anthropological research to identify push and pull factors for cross-border migration.
• Country initiatives, including NGO activities, that increase mobile and migrant populations’ access to health services should be reviewed, documented and shared appropriately.

Therapeutic efficacy studies (TES):

• The time to translate TES findings to drug policies could be quick (e.g. in the case of Cambodia) or delayed for up to 2-3 years depending on the readiness of the country, among other factors such as selection time from several appropriate alternatives and delayed procurement of new selected first line drugs. WHO recommends a 10% treatment failure rate as a threshold (i.e. 10% of Day 3 positives after appropriate treatment of recommended ACT is commenced).
• ERAR’s role is to facilitate shortening the lead time between the identification of antimalarial drug resistance and change in drug policy.

Operational research (OR):

• Countries are encouraged and supported to develop proposals and share plans with donors. The Bill & Melinda Gates Foundation is interested in OR and will help in organizing donor support.
• The results and recommendations from operational research should be used to expand the knowledge base of National Strategic Plans of GMS countries. ERAR should work more closely with policy-making and regulatory bodies in countries and at regional levels to quicken decision-making.

Myanmar Artemisinin Resistance Containment (MARC) implementation:

• Coordination of several efforts by different players in Myanmar is a challenge. WHO is strengthening effective coordination with the RAI budget for programme management and M&E support for activities under RAI.

Artemisinin resistance containment in Viet Nam:

• Multi-sector involvement in resource mobilization in Viet Nam is currently limited. ERAR should engage ministries other than Health, including Planning and Finance.

Pharmaceuticals:

• There is need for a contingency plan for up-to-date stock management bearing in mind that medicines may expire if not utilized on time as a result of reduction in P. falciparum cases as transmission becomes lower.
• ERAR needs to take inventory of all the first line drugs used in the GMS and then maintain a rotating stock.
• One way of dealing with stockout is through an electronic management system of stockpile control.
• Strengthen capacity for drug regulation systems across the GMS.
• As a mechanism to coordinate the quality assurance of drugs, ERAR needs to assess quality at the point of use, especially when it comes to cross-border migrants.

In closing, Dr. Michael O’Dwyer of the Australian government’s Department of Foreign Affairs and Trade said he was encouraged by the ERAR hub’s work plan and pledged DFAT’s continued support for ERAR. The WHO Representative in Cambodia, Dr. Pieter Van Maaren, expressed his satisfaction at the comprehensive inputs and positive feedback received from development partners. He was appreciative of the renewed commitment of partners and stakeholders to support the ERAR Coordination Hub to enable it to achieve its targets and goals.

The meeting was declared closed by Dr. Jacobs, the Director of Communicable Diseases, WHO WPRO.

 

Cambodian Daughter Brings Music and Malaria Messages to Hometown

CONTAINMENT’s Moeun Chhean Nariddh caught up with Dengue Fever’s Chhom Nimol in Battambang.

Chhom Nimol endorsing a poster urging Cambodians to visit a Village Malaria Worker or the nearest health centre if they have fever. Pix by WHO/sonny krishnan

“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.

Dengue Fever at the free open-air concert in Battambang. Pix by WHO/sonny krishnan

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.

Community Malaria Workers Use SMS to Report in Real-Time

Malaria Consortium’s Ngor Pengby demonstrating how to charge a mobile phone using a solar panel. This project is in collaboration with Mobitel.Photo by WHO/Moeun Chhean Nariddh

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.

The SMS from a village malaria worker in Khmer script. Photo by Malaria Consortium/Steve Mellor

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.

AFRIMS Mobile Units Help Detect Malaria

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.

Thai soldiers line up for blood samples to be taken from them by the AFRIMS mobile unit. Pix by WHO/ Nat Sumon

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.

Migrant workers in Chantaburi on the Thailand side of the Thai - Cambodian border. Pix by WHO/Nat Sumon

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.

Radio Program in Chantaburi Offers Life-Saving Advice on Malaria Prevention

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.

Anukoon Charunthup, the presenter of “Rak Sukaphab” or “Love Your Health”. Pix by WHO/Nat Sumon

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.”