Category Archives: Asia

Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia

Our colleague Sara Canavati attended the recent meeting on civilian and military collaboration to eli8minate malaria in Southeast Asia. Herein she shares some of the highlights of the meeting. Sara is affiliated with both the Centre for Biomedical Research, Burnet Institute, Melbourne, Australia and the Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok.

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The Heads of State from ASEAN member nations stated their commitment to an “Asia Pacific free of Malaria by 2030” at the 9th East Asia Summit. This mandate for a malaria-free Asia Pacific creates an unprecedented opportunity to strengthen ties between civilian and military health systems and regional militaries.

On 26-28 June 2017, the Armed Forces Research Institute of Medical Science (AFRIMS) organized a meeting titled: “Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia” in Bangkok, Thailand. The meeting brought together Ministry of Defense and Ministry of Health malaria officials from Myanmar, Thailand, Cambodia, Laos, Indonesia, Vietnam, Australia, and the United States.

Since malaria is a common problem in the military, and since malaria does not know borders, regional collaborations involving all affected populations are important to achieve malaria elimination. The meeting was instrumental for reviewing existing military and civilian national malaria collaborations, identifying and prioritize key areas of mutual military-civilian interest, and discussing ways in which regional militaries can assist national malaria elimination goals.

Three action points on how the civilian and military sectors can more effectively collaborate to achieve elimination in four areas of mutual interest (Case Detection and Management and Disease Prevention; Surveillance, Monitoring and Evaluation; Operational Research/Training and Advocacy) were identified and documented by meeting attendees through a breakout team format.

Advocacy for malaria elimination was the theme that military attendees found most challenging due to the hierarchical structure of the military.  Among several presentations, East Africa Malaria Task Force and Experiences from African Military Medical Departments were shared to serve as an example of military-advocacy. Financing was another key barrier identified. The chair of the regional steering committee (RSC) for the Global Fund, Prof Arjen Dondorp and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM) Geneva assured their support and commitment to finance military operations for malaria elimination in South East Asia. This was a historical achievement as this will be the first time ever the GFTAM finances the military for malaria elimination.

One significant outcome of the meeting is that the military will now be represented in the RSC for the Global Fund “Regional Artemisinin-resistance Initiative 2 Elimination (RAI2E)” malaria grant.

Links to some of Sara’s recent malaria publications:

Nepal on the Path to Malaria Elimination

Jhpiego’s Emmanuel Le Perru has been placed with Nepal’s malaria control program by the Maternal and Child Survival Program (USAID) to strengthen the agency’s overall response to malaria as well as ensure top performance of Nepal’s Global Fund Malaria grant. Emmanuel shares his experiences with us here.

From 3,000 cases in 2010, Nepal reported around 1,000 cases in 2016, including 85% Plasmodium vivax cases. However private sector reporting is almost null so number of total cases may be the double. Nepal’s National Malaria Strategic Plan (NMSP) targets Elimination by 2022 (0 indigenous cases) with WHO certification by 2026.

Ward Level Micro-stratification is an important step for targeting appropriate interventions. Key interventions in the NMSP include case notification system by SMS (from health post workers or district vector control inspectors) to a Malaria Disease Information System, later to be merged with DHIS2. Case investigation teams conduct case and foci profiling as well as “passive cases” active detection and treatment (including staff from district such as surveillance coordinator, vector control inspector, and entomologist).

Malaria Mobile Clinics actively search/treat new cases in high risk areas (slums, brick factories, river villages or flooded areas, migrant workers villages, etc.). PCR diagnosis with Dry Blood Spot or Whole Blood is used to identify low density parasite cases, relapses or re-introduction. Coming up in April-June 2018 will be a Pilot of MDA (primaquine) for Plasmodium vivax in isolated settings (80% of cases in the country are P vivax).

Recent successes in the national malaria effort include the number of cases notified by SMS went from 0% to 45%. Also the number of cases fully investigated went from 22% to 52%, though this needs to go up to 95% for elimination. 73% of districts are now submitting timely malaria data reports per national guidelines, an increase from 52% in November 2015.

The border runs right through this town making importation of malaria cases easy

The Global Fund (GFATM) malaria grant rating went from B2 to A2. Nepal Epidemiology Disease Control Division (EDCD), WHO and GFATM are keen to pilot MDA for P vivax in isolated setting which MCSP/Jhpiego Advisor taking the lead.

Moving forward the malaria elimination effort needs to address Indo-Nepal Cross boarder collaboration since 45% cases are imported. Hopefully WHO will help EDCD Nepal to propose a plan of action to India. The program still needs to convince partners of relevance of malaria mobile clinics vs community testing and of the relevance of MDA for P vivax. More entomological and PCR/laboratory expertise is needed. With these measures malaria elimination should be in sight.

Myanmar – update on malaria indicators

Myanmar is one of the countries at the epicenter of the developing resistance of malaria parasites to artemisinin based drugs. This means there is a strong need for prompt, appropriate and thorough diagnosis and treatment of febrile illnesses and malaria as well as the regular use of effective malaria preventive technologies. The 2015-16 Demographic and Health Survey for the country is thus a timely source of information to improve malaria interventions. Highlights from the DHS follow.

The first major concern is both lack of insecticide treated nets as well as low use of those available as the pie chart from the DHS makes clear. Ironically 97% of households have some kind of net, but 73% do not have an insecticide treated one. Although the Global Fund has supported distribution of 4.3 million ITNs in the country, there are over 56 million people living there. The US President’s Malaria Initiative has procured nearly 900,000 ITNs for the country. Although low across all economic strata, the lowest wealth quintile have the highest ITN possession (35%).

The 2013 concept note submitted by Myanmar to Global Fund under the new funding mechanism identifies many of the challenges: “Factors that may cause inequity to services for treatment and prevention: There are several population groups, which are poorly served by the health system and malaria services such as those living in remote border areas, migrant populations, forest workers and miners where malaria transmission is intense. Many of them are internal and external migrants who usually have limited access to malaria prevention and control. Major factors include distance from health facilities and poor awareness of malaria and its prevention.”

Key strategies in the Global Fund Concept Note do address quality malaria diagnostics and appropriate treatment. Unfortunately DHS results do not yet show the impact of improved diagnosis and treatment. “Overall, 16% of children under age 5 had a fever in the 2 weeks before the survey. Advice or treatment was sought for 65% of these children with recent fever, and 3% had blood taken from a finger or heel, presumably for diagnostic testing.” A variety of public and private sources were used to seek fever treatment, but “Only 1% of children received antimalarial drugs for treatment of fever in the 2 weeks preceding the survey.”

In addition to formal donors, there are coalitions and consortia who provide encouragement, technical assistance, advocacy and capacity building for eliminating malaria in the Asia-Pacific region. While the country needs to take stronger leadership in malaria elimination, all groups need to come together and strengthen the malaria interventions in Myanmar as these have implications for eliminating the disease in the region as a whole.

Press Release: Bangladesh joins APMEN as new Country Partner

Bangladesh joins the Asia Pacific Malaria Elimination Network (APMEN) as Country Partner

apmen_bannerThe Asia Pacific Malaria Elimination Network (APMEN) is pleased to announce Bangladesh as the 16th Country Partner to join the Network.

APMEN brings together countries in the Asia Pacific region that have adopted a national or sub-national goal for malaria elimination, and connects them with a broad range of regional and global malaria partners to develop best practices for eliminating the disease. By strengthening linkages in eliminating countries, APMEN addresses important regional challenges such as Plasmodium vivax, and provides a forum for the discussion of important issues such as the spread of anti-malarial drug resistance.

Malaria remains endemic in 13 of the 64 districts in Bangladesh, and more than 13 million1 people are still at risk of the disease. Malaria control and elimination activities fall under the National Malaria Control Program (NMCP) of the Ministry of Health and Family Welfare. The NMCP is currently aiming for malaria pre-elimination in four districts, with the goal of Bangladesh becoming malaria-free by 2020.

Director of Disease Control in Bangladesh and Public Health and Infectious Disease Specialist, Professor Be-Nazir Ahmed, expressed his gratitude towards APMEN at the formalization of this important partnership, saying that it is another step forward for Bangladesh and the region to eliminate the disease.

The spatial distribution of Plasmodium falciparum malaria endemicity map in 2010 in Bangladesh - http://www.map.ox.ac.uk/browse-resources/endemicity/Pf_mean/BGD/

The spatial distribution of Plasmodium falciparum malaria endemicity map in 2010 in Bangladesh – http://www.map.ox.ac.uk/browse-resources/endemicity/Pf_mean/BGD/

“Bangladesh is moving very quickly towards elimination after concerted national efforts to focus on malaria control,” Professor Be-Nazir said.

“By joining APMEN, Bangladesh now has many windows of opportunities to learn from other eliminating countries in our region as we face similar challenges.”

According to the World Health Organization, Bangladesh has reduced the number of confirmed malaria cases from nearly 440,000 in 2000 to less than 30,000 in 2012; a 93% overall decline2. The success is a result of intensive control interventions such as high coverage and increased use of insecticide-treated nets, increased use of rapid diagnostic tests and effective antimalarial treatment, as well as the deployment of a high number of community health workers in collaboration with NGOs and augmenting services at the health facilities. The combination of technical and human resource capacity serves as a strong example of how national and international efforts can lead to reduced malaria transmission3.

Bangladesh, like many other APMEN Country Partners, face many challenges en route to its national elimination goal of 2020, namely  ensuring services  reach mobile populations in highly endemic districts such as the Jhum cultivators4, and sustaining commitment by the government, communities and development partners to malaria control and elimination.

Malaria was nearly eliminated from Bangladesh pre-1970, but never disappeared in the eastern border regions which are associated with tea gardens and forests. These districts have international boundaries with the eastern states of India and partly with Myanmar. In the 1990s, malaria re-emerged as a major public health concern.

A key Bangladesh public health organization, the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), joined APMEN as a Partner Institution in August 2013.

APMEN Joint Secretariat (UQ) Office, School of Population Health | Room 117 | Public Health Building, Herston Road | Herston Qld 4006| Australia,  Email: apmen@sph.uq.edu.au | Website: www.apmen.org |  Phone (within Australia): 07 3365 5446 | Phone (from outside Australia): 61 7 3365 5446

Asia-Pacific: a region of contrasting hopes for eliminating malaria

The burden of malaria in the Asia-Pacific region, being much lower than that of Africa, has led to some neglect in the past when it comes to rolling back the disease. Two news reports today show why neglect is not an option is global country-by-country elimination os the disease is to be achieved.

eliminating-malaria-in-the-philippines-sm.jpgHope was expressed clearly by national Department of Health authorities in the Philippines who exclaimed that “THE Philippines could be malaria-free by 2020 as the number of cases declined by 80 percent in the recent years, the Department of Health (DOH) said on Friday.” The article in the Manila Sun-Star quoted Health Secretary Enrique Ona who said “The government has recorded 9,642 malaria cases in 2011 as compared to 43,441 in 2003.”

A close accounting of the 58 provinces that are considered endemic in the Philippines found that nine have had no cases in the past three years, and forty have been reporting less than 1 case per 1000. While definitely being optimistic about the prospects of overall elimination from the country, the Health Secretary is realistic as quoted by the Sun-Times: “The journey towards elimination status is more difficult than working for a reduction in cases and we will need more commitments and resolutions of the different sectors to be consolidated into a singular, comprehensive initiative so that the whole country, not just the 58 endemic provinces, will be declared malaria-free by 2020.”

The situation in another regional partner is more dire. VOA reports that the problem of malaria drug resistance is “more severe in Cambodia than anywhere else in the world.” The National malaria Center in Cambodia found that, “About 17 percent of all cases in the Cambodian-Thai border area of Pailin were drug-resistant in 2011, up from 10 percent the year before.”

On the positive side, even though the proportion of drug-resistant cases in increasing, the total number of cases continues to decrease. Still, there is concern about ramification of the situation “beyond borders.” Travel and migration among the Mekong region countries means that resistance may not stay put in Pailin. A comprehensive control program, not just reliance on treatment, needs to be in place throughout the region.

Fortunately there are groups like the Asia Pacific Malaria Elimination Network (APMEN) that brings countries in the region together to address common and cross-border challenges. APMEN recognizes that, “Elimination requires a different strategy than sustained control,” and is thus, in am important position to help the rest of the world learn innovative approaches to put paid to malaria.

Vietnam To Tackle Ending Malaria with Asia Pacific Malaria Elimination Network

apmen_banner.gifPress Release from APMEN

In an important step toward achieving malaria elimination, Vietnam officially joins the Asia Pacific Malaria Elimination Network (APMEN) today. APMEN brings together countries in the Asia Pacific that have adopted a national or sub-national goal for malaria elimination, and connects them with a broad range of regional and global malaria partners to develop best practices for eliminating malaria and to efficiently address region-specific challenges, like Plasmodium vivax.

Vietnam has made great strides in improving the health of its citizens, which includes reducing the risk of malaria throughout the country. Malaria deaths have plummeted by 91% in the last decade, from 71 deaths in 2000 to 14 in 2011. Reported cases of malaria have also dropped by 85%, declining from 300,000 cases to 45,000 in 2011. However, similar to other countries in the Asia Pacific region, Vietnam faces substantial challenges to eliminating malaria, which include the increasing spread of drug-resistant malaria parasites and continuous movement of populations between malaria-free and malaria-endemic areas.

The most malarious regions in Vietnam – remote, forested areas – are also the country’s hardest places to reach, and require more responsive surveillance systems to effectively track down and treat malaria cases. By joining APMEN, Vietnam aims to harness the region’s collective experience, research findings and program recommendations to take on the final – and perhaps most difficult – steps to eliminating malaria. itn-in-high-endemic-area-vietnam.jpgVietnam’s malaria program, the National Institute for Malariology, Parasitology, and Entomology (NIMPE), recently completed its National Strategy for Malaria Control, Prevention and Elimination 2011-2015. With this strategic plan,

Vietnam outlined its goals of controlling and reducing malaria in higher burden areas, and the implementation of a spatially progressive malaria elimination strategy in low transmission regions. APMEN is a country-led network focused on generating and disseminating evidence-based information on what works to drive down malaria and achieve elimination in the Asia Pacific.

APMEN was developed in 2009 in response to a call to action by countries in the region to tackle malaria elimination. With Vietnam as the newest addition, APMEN connects its 12 other network countries— Bhutan, Cambodia, China, Democratic People’s Republic of Korea, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu— in an effort to learn from each other’s malaria program approaches, translate research into action and consider optimal program implementation.

More reading about eliminating malaria in Vietnam can be found through the UCSF Global Health Group’s country profiles. APMEN country partners work together to sustain the gains made in malaria control and ensure financial and political support for malaria elimination in the region. Further information regarding APMEN can be viewed at www.apmen.org.

Mumbai – is transmission season increasing?

The Times of India reports that, “Malaria is no longer restricted to just monsoon months as in the past. Spurred on by widespread construction activity and the resulting poor sanitation, the disease has becomes a round-the-year feature in Mumbai, killing less people but afflicting more.”

An increase was noted: “In all, 76,755 contracted the ailment in 2010, 74% more than the 2009’s figure of 44,035,” but with fewer deaths (better case management?), but it is not clear whether these cases were parasitologically diagnosed.

A member of the medical association attributes the increase, especially the off-season rise, to human activity – construction projects. The official stated that, “Construction sites have puddles of water in which mosquitoes breed. Since construction work goes on throughout the year, so does the breeding. This obviously increases the incidence of malaria.”

Worry was also expressed about, “resistance developed by the Anopheles albimanus mosquito that the civic body’s insecticide fumigation has no effect on it.” This has led the city to consider using “bacillus thuringiensis variety israelensis” for control.

Ironically, in pointing out that, “Another reason for the spread of malaria, which is caused by a parasite called plasmodium, during non-monsoon months is that plasmodium can stay in the body for a long period,” the article raises the possibility that the upswing may not be fully due to new transmission.

asia-in-wmr-2008.gifAside from these possible limitations on the validity of the data,  the potential for increased transmission is worrisome, especially in a part of the world that has received less (but increasing) attention from the Roll Back Malaria Partnership. The map from the 2008 World Malaria Report shows the extent of the problem in Asia.

India has a double problem with malaria, hosting both P. vivax and P falciparum.  A recently published article reports that while the national control program has introduced artemisinin-based combination therapy for P. falciparum as a first-line treatment, the older drugs, chloroquine (CQ) and Sulphadoxine-Pyrimethamine (SP) are still available. Unfortunately Shrabanee Mullic and colleagues found that, “In Jalpaiguri District the overall failure rate of CQ was 61% and of SP 14%, which was well above the WHO recommended cut-off threshold level (10%) for change of drug policy.”

Other research in India examined vector control with positive effects. “A study was conducted to evaluate the preventive efficacy of insecticide-treated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothill area of Assam, India, with forest ecosystem.” The researchers found that, “The total vector population in the three intervention sectors decreased significantly compared with that of the non-intervention one.”

Overall, malaria in India is a complex phenomenon with different forms of the parasite, different ecological settings and different levels of government involved. More attention is needed to address this complex situation is malaria is ever to be eliminated.