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Archive for June 2014

Malaria outbreaks continue in Lao PDR

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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.

Lao PDR malaria deaths

“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.



Written by malariacontainment

June 19, 2014 at 10:31 am

Posted in Uncategorized

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

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

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.

Written by malariacontainment

June 19, 2014 at 10:21 am

Posted in Uncategorized