CONTAINMENT

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

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

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.

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Written by malariacontainment

October 3, 2014 at 1:58 pm

Posted in Uncategorized

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