Category Archives: Elimination

Establishing Mobile Outreach Teams (MOTs) for strengthening Active Case Detection with Mobile Populations in Vietnam 2016-2020

Mobile migrant populations present a special challenge for malaria control and elimination efforts. Nguyen Ha Nam and colleagues* (Nguyen Xuan Thang, Gary Dahl, James O’Donnell, Vashti Irani, Sara Canavati, Jack Richards, Ngo Duc Thang, and Tran Thanh Duong) presented their study of this group at the recent Malaria World Congress. They are also sharing what they learned below.

Mobile Migrant Populations (MMPs) are a key population for containing the spread of malaria in the border areas between Cambodia and Vietnam. The number of imported cases in Viet Nam in 2017. 12,5% of such cases caught in Binh Phuoc and Dak Nong provinces and all of them came from Cambodia. The provinces bordering Cambodia and Vietnam have been had the highest malaria transmission intensity. This borders are frequented by MMPs who have proven difficult to target for surveillance and malaria control activities.

Mobile Outreach Teams (MOTs) provide a potential approach to target malaria elimination activities for MMPs who may not be strongly supported by the regular village-based and clinic-based health services. This work describes the implementation of MOTs in Binh Phuoc and Dak Nong Provinces, which are high-risk regions along the Viet Nam-Cambodia border. These activities were conducted as part of the Regional Artemisinin-resistance Initiative (RAI) in 2017. Each MOT was comprised of 2 Commune Health Staff and 1 Village Health Worker (VHW) from the village nearest to the outreach area.

In the first phase of the pilot, 3 communes of 2 districts in Binh Phuoc and 2 communes of 1 district in Dak Nong with highest malaria cases reported from NIMPE are selected as targeted areas. The Objectives were to …

  • Design/tailor Mobile Outreach Information Education and Communication/Behaviour change communication (BCC/ IEC) Toolkit
  • Intensify case detection and quality management by increasing the coverage of diagnostics and treatment for hard to reach populations
  • Strengthen outreach to high-risk and under-served populations through MOT scouting activities to locate unreached Mobile Communities and map their locations
  • Link MMPs with health facilities and Village Health Workers

All MOT members were provided with smartphones and were trained on how to use the EpiCollect5 app to track malaria cases, record mapping information and upload real-time reports of these malaria cases. MOTs conducted 5-day outreach activities every month. These activities began with scouting out locations of the MMP communities.

Once located, the MOTs geo-tagged the location of the community, conducted a short epidemiological survey on the community and screened for malaria using Rapid Diagnostic Tests and blood smear microscopy. Active malaria cases were provided with treatment according to the National guidelines, and Long Lasting Insecticidal Nets were distributed based on results of diagnosis and the survey.

This action has led to increased diagnosis and treatment of hard to reach MMPs with increased access by those communities to malaria services. Improved understanding and increased use of malaria prevention practices hard to reach MMP communities/households. Mapped of previously unreached MMP Communities and unofficial border crossing points with malaria transmission hotspots and highly frequented crossing identified. The number of MMPs were monitored by MOTs were 2,699 accounting for 5.18% of the population in the project sites (2,699/52,095).

These screened MMPs were almost located along the border among project communes in Bu Gia Map National Forest where have a lot of unofficial border crossers, timber camp communities, and other revolving communities. 1,977 targeted people were tested for malaria. This number was achieved 73.25% of mobile migrant people (1,977/2,699). This work highlights how MOTs can target the previously unreached populations of MMPs to strengthen malaria surveillance and active case responses to reduce malaria transmission in Viet Nam.

A system of real-time data collection of malaria cases from VHWs and MOTs using mobile phone uploads was established. Border screening and tracking hard to reach communities is a useful approach to implement to identify imported cases; however, it is labor-intensive, and misses subjects crossing at unofficial borders due to limited working time of MOTs (5 days a month).

Positive cases in Binh Phuoc province are maintained for keeping track after receiving treatment due to no confirmed cases detected in targeted communes in Dak Ngo province, though these communes mainly have numerous transient timber camps moving in deep forests, and highly mobile border-crossers moving between regions and countries frequently. Future work will combine routine support from District health staff and expand the role of VHWs with motorbike provision for each MOT in order to not only to improve their quality outreach activities but also develop stronger Active Case Detection in the next phase of the project.

*Team members represent the National Institute of Malariology, Parasitology and Entomology, Hanoi, Viet Nam; Health Poverty Action, London, UK; and the Burnet Institute, Melbourne, Australia.

References

  • Kheang ST, Lin MA, et al. Malaria Case Detection Among Mobile Populations and Migrant Workers in Myanmar: Comparison of 3 Service Delivery Approaches. 2018
  • Shannon Takala-Harrison,a Christopher G. Jacob, et al. Independent Emergence of Artemisinin Resistance Mutations Among Plasmodium falciparum in Southeast Asia. 2014.
  • Imwong M, Hien TT, et al. Spread of a single multidrug resistant malaria parasite lineage (PfPailin) to Vietnam. 2017.
  • Richard J Maude,corresponding author Chea Nguon, et al. Spatial and temporal epidemiology of clinical malaria in Cambodia 2004–2013. 2014.
  • Imwong M, Nguyen TN, et al.The epidemiology of subclinical malaria infections in South-East Asia: findings from cross-sectional surveys in Thailand–Myanmar border areas, Cambodia, and Vietnam. 2015.
  • Hannah Edwards, Sara E. Canavati, et al. Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders. 2015.

Pilot Mapping, Real Time Reporting and Responding in High Risk Malaria Areas of Viet Nam

Viet Nam is among the Asia-Pacific countries focusing on eliminating malaria. Mapping helps target malaria interventions. Nguyen Xuan Thang and colleagues (James O’Donnell, Vashti Irani, Leanna Surrao, Ricardo Ataide, Josh Tram, An Le, Sara Canavati, Tran Thanh Duong, Tran Quoc Tuy, Gary Dahl, Gerard Kelly, Jack Richards, Ngo Duc Thang) presented their pilot mapping efforts at the Malaria World Congress in Melbourne recently and below share their experiences with us.

Viet Nam is focused on eliminating malaria by 2030. Viet Nam saw a 73% reduction in cases between 2013 and 2017 (NIMPE data), yet border provinces still have a high burden of malaria. However, some provinces still have a high burden of malaria. To achieve malaria elimination, it is essential to deploy targeted interventions in these locations.

Spatial Decision Support Systems (SDSS) can be used by National Malaria programs to integrate geographic elements in the management of malaria cases and facilitate targeted malaria interventions in these high-risk settings.

The objective of this work was to pilot a SDSS system for Binh Phuoc and Dak Nong Provinces in Viet Nam to facilitate ongoing surveillance and targeted malaria, as part of the Regional Artemisinin-resistance Initiative (RAI). This objective was achieved by:

  • Collecting data with cell phones

    Collecting baseline GIS data at household level and environmental characteristics associated with the area;

  • Establishing a routine data collection system that will be reported by mobile medical staff by mobile phone;
  • Integrating this data to form a spatial decision support system (SDSS);
  • Using the SDSS system for direct reporting to malaria control programs that provided strategic solutions for the prevention of disease spread and the elimination of malaria

Sample cell phone data screens

In Phase 1, a household and mapping survey was conducted in collaboration with commune, district and village health workers. Epicollect5 software was used on smartphones with GPS functionality to record mapping information (latitude and longitude) and general information on household members. During Phase 1, 10,506 households were surveyed and data was aggregated in a custom Geographic Information System (GIS) database.

The majority of the surveyed individuals were of the Kinh ethnicity (19,282; 35.4%), followed by M’Nong (4,669; 8.6%) and Mong (3,359; 6.2%). Data related to malaria among mobile populations were included in the GIS as a means to identify and describe groups at high risk for malaria e.g. forest-goers. The survey data were reviewed, cleaned and matched using the ID numbers, then aggregated with relevant administrative boundary data and linked on ArcGIS 10.2 software. This database is located in a custom GIS system and can be visualized as a spatial transmission model to support appropriate decision-making

Dots representing households

Phase 2 focused on ongoing surveillance with rapid case reporting and responses. Malaria cases diagnosed at public and local health facilities were entered into the system by Commune Health Officials. Village Health Workers were immediately notified and went to the patient’s home to undertake case investigation including further household mapping and active case detection activities. The Viet Nam National Institute of Malariology was also notified, and organized local officials to carry out an investigation into the sources of transmission (i.e. ‘hotspots’) and to implement timely interventions.

Dots representing cases

When the cases were identified, Village Health Workers went to the patient’s home to undertake operational procedures including geographic exploration, household mapping to identify the location and to identify the list of affected households. They also collected this data on EpiCollect5. Collated information on cases, transmission point, zoning of the target villages allowed for early detection of malaria outbreaks. The National Institute of Malariology can also issue guidelines when the hotspots are identified and when disease outbreaks occur

These activities are ongoing. In conclusion, a custom GIS database was developed using a household survey in Binh Phuoc and Dak Nong province of Viet Nam. Malaria cases were mapped to identify hotspots of malaria transmission and enable further active case detection and targeted interventions. This established GIS database aims to support routine case notification and to enhance the role of surveillance for active case detection and responses to achieve malaria elimination.

The authors are affiliated with the National Institute of Malariology, Parasitology, Entomology (NIMPE), Viet Nam; Burnet Institute, Australia; and Health Poverty Action, UK. Contact: xuanthang.nimpe@gmail.com

Many Neglected Tropical Diseases: What About Eliminating Them?

Testing to see if transmission of lymphatic filariasis has stopped in Burkina Faso

Two things we need to note about the list of 20 diseases that the World Health Organization and partners classify as Neglected Tropical Diseases (NTDs). First, diseases like Rabies, Snakebite/envenoming, and Leprosy, while certainly more common in the tropics now, have in the past been global in distribution. Secondly some of the diseases have not been neglected. Onchocerciasis or river blindness has been the focus of a global partnership since 1975, and transmission in the America’s and much of the Sahel in Africa has been halted. Elimination of Dracunculiasis or Guinea Worm has also been the subject of many World Health Assembly Resolutions, and concerted effort has brought the number of cases down from 3.5 million in 1986 to 30 in 2017.  What is more to the point about these diseases is that they affect neglected people, the poor and vulnerable in remote rural areas or urban slums.

Still when we can compare NTD control programs with the rise of major disease control efforts like the Global Fund to fight AIDS, Tuberculosis and Malaria, the President’s Emergency Program For AIDS Relief, the President’s Malaria Initiative, World Bank Malaria Booster Program, Global A Vaccine Initiative among others, we can see that the global community has been able to focus major financial resources on a few diseases.  Now with the Sustainable Development Goals, that focus expanded from infectious to Non-Communicable Diseases.  It is natural therefore to fear that tropical health problems that are responsible for major loss of life and economic capacity will not be adequately addressed.

A system of rewards helped identify the last cases in many guinea worm endemic countries

Based on the World Health Organization’s 2020 Roadmap on NTDs, the London Declaration on NTDs recognized a “tremendous opportunity to control or eliminate at least 10 of these devastating diseases by the end of the decade” (i.e. by 2020). These include eradication of Guinea worm disease, and elimination by 2020 of lymphatic filariasis (LF), leprosy, sleeping sickness {human African trypanosomiasis) and blinding trachoma. In addition drug access programmes should help control by 2020 schistosomiasis, soil-transmitted helminthes (STH), Chagas disease, visceral leishmaniasis and river blindness (onchocerciasis).

Five of the diseases are notable in that they can either be controlled or eliminated through Mass Drug Administration (MDA) using Preventive Chemo-Therapy (PCT). This effort is aided by drug donation programs at the global level and community based MDA at the local level. Ten companies were signatories to the London Declaration and contributed to drug donation programs to achieve MDA. According to WHO,

Preventive chemotherapy is aimed at optimizing the largescale use of safe, single-dose medicines and offers the best means of reducing the extensive morbidity associated with four helminthiases (lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiases) (6). Additionally, the large-scale administration of azithromycin – a key component of the SAFE strategy for trachoma (that is, lid surgery (S), antibiotics to treat the community pool of infection (A), facial cleanliness (C) and environmental improvement (E)) – is amenable to close coordination and, in future, possibly co-administration with interventions targeted at helminthiases.

Community health workers are the cornerstone of many NTD elimination programs

Targets for the 5 PCT diseases vary. The aim is to eliminate LF and Trachoma by 2020. Although the efforts against onchocerciasis have been running the longest, the refocus from control to elimination meant increasing the geographical scope of intervention, and now elimination may not be feasible until 2025.  With a focus mainly on the school aged and based populations, programs against schistosomiasis and STH talk of control, not elimination, although some endemic countries hope that elimination may be possible if the focus of these programs expands. So far, Togo is the only Sub-Saharan African country to have eliminated LF, and Ghana to have eliminated Trachoma.

Partnerships, funding and drug donations need to be strengthened if more countries are to join the ranks of Togo and Nepal.

On World Malaria Day the realities of resurgence should energize the call to ‘Beat Malaria’

Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.

Multilateral Initiative for Malaria (MIM) – Jhpiego Presents in Dakar

The 7th Pan African Malaria Conference holds from 15-20 April 2017, Dakar, Senegal. The conference celebrates 20 years since the initial establishment of the Multilateral Initiative on Malaria (MIM) by the Tropical Disease Research Program and partners.

During the conference next week, staff from Jhpiego malaria projects in Burkina Faso, Liberia, Nepal, Madagascar and Cameroon will share oral and poster presentations to highlight their work. Below is a list along with the location numbers.

  • Application d’un Audit de la Qualité des données (DQA) du paludisme dans le District Sanitaire de Kribi, Cameroun, SS-13 Oral
  • Contribution des Agent de Santé Communautaire (ASC) à l’amélioration de la prévention et la prise en charge du paludisme dans le district de Kribi, Cameroun, B-40 Poster
  • MOH’s effort in developing and implementing Quality Assurance plan (QAP) for Global Fund-supported antimalarial drugs: A case study of Nepal in the context of malaria elimination, C-107 Poster
  • Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy? D-115 Poster
  • Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso: Review of health worker perceptions from the baseline study D-118 Poster
  • Malaria in Pregnancy: The Experience of MCSP in Liberia, D-140 Poster
  • Improved Malaria Case Management of Under-Five Children: The Experience of MCSP-Restoration of Health Liberia project D-141 Poster
  • Experiences and perceptions of care seeking for febrile illness among caregivers, pregnant women and health providers in eight districts of Madagascar D-142 Poster

Abstracts will be shared here on the day of each presentation for those unable to attend MIM. Also check Jhpiego at Exhibit Booth 148.

Improving the efficacy of reactive screen-and-treat for malaria elimination in southern Zambia

Global Health Day 2018 sponsored by the Johns Hopkins University Center for Global Health featured a poster presentation by several colleagues on Improving the efficacy of reactive screen-and-treat for malaria elimination in southern Zambia. Fiona Bhondoekhan, William Moss, Timothy Shields, Douglas Norris, Kelly Searle, Jennifer Stevenson, Harry Hamapumba, Mukuma Lubinda and Japhet Matoba (Southern Africa International Centers of Excellence in Malaria Research, the JHU Bloomberg School of Public Health, and the Macha Research Trust, Zambia) share their findings below.

Background: Malaria screen-and-treat (called Step D in Zambia) is a reactive case detection strategy in which cases detected at a health center trigger community health workers (CHWs) to screen for secondary malaria cases within a 140-meter radius of the index case household using PfHRP2 rapid diagnostic tests (RDTs). Few studies evaluated whether an evidence-based strategy using environmental features that characterize the immediate surroundings of a household, can improve the efficiency of secondary case identification.

Objective: This study utilized the Step D and extended the screening radius to 250-meters (termed Enhanced Step D or ESD) to assess which local environmental variables can guide CHWs to identify secondary cases more efficiently. As Zambia works toward eliminating malaria, more refined and targeted case detection strategies are required to find the untreated malaria cases that could serve as potentially asymptomatic sources of infection. This study can help guide and plan reactive case detection strategies in Zambia that allow community health workers/field teams to employ an evidence-based strategy to find malaria-positive secondary households situated near index case houses more efficiently.

Methods: Demographic information, malaria diagnosis, bed-net use and ownership, cooking energy source, and household floor material were obtained from surveys. Households were stratified into malaria positive and negative secondary households using RDT and qPCR results. ArcGIS was used to generate the following local environmental variables: screening radius (140 vs. 250-meters), number of animal pens within 100-meters, distance to nearest animal pen, distance and elevation difference between index and secondary houses, as well as the following large scale environmental variables: distance to main road and nearest stream category. Generalized estimating equations (GEE) estimated the cross-sectional effect for the difference in odds of a positive vs. negative secondary household for each predictor. For the secondary analysis GEE with the same model specifications was used to estimate the cross-sectional difference in odds of a positive vs. negative household for each environmental predictor. Model fit was evaluated with the Hosmer-Lemeshow goodness of fit test and significance was evaluated as a p-value of 0.05. Statistical analyses were carried out using STATA 14.2.

Results: Screening within the index households yielded an overall parasite prevalence of 8.6%, which was higher by qPCR (8.1%) than RDT (2.7%) as seen in Table 1. Secondary households had an overall parasite prevalence of 1.9% with similar differences by test used. Key results from regression analysis seen in Table 2 include a difference in prevalence according to screening radius as well as by proximity to the nearest stream. Secondary analysis produced similar results but showed statistically significant higher odds for households where animal pens were present.

Conclusion: Screening for secondary households within low-transmission setting in Zambia could be optimized by using both local-scale indicators such as the presence of animal pens and large-scale indicators such as streams as environmental guiding tools.

Acknowledgements: This research was supported in part the Bloomberg Philanthropies and the Johns Hopkins Malaria Research Institute, and the NIH-sponsored Southern and Central Africa ICEMR 2U19AI089680.

The Monkey on the Back of Malaria Elimination

Concerning malaria elimination, “WHO grants this certification when a country has proven, beyond reasonable doubt, that the chain of local transmission of all human (emphasis added) malaria parasites has been interrupted nationwide for at least the past 3 consecutive years.” This target is challenging enough, but becomes more complicated when we consider that zoonotic transmission of malaria among monkeys and humans has been documented in Brazil and Southeast Asia. We cannot expect monkeys to sleep under bednets, so creative and realistic solutions are needed.

The Malaria Eradication Research Agenda (malERA) recognizes this problem. Plasmodium knowlesi, originally found in macaque monkeys in Southeast Asia has been dubbed the fifth human malaria due to its spread to people as deforestation has disturbed the habitat of the monkeys. In particular malERA addresses the challenge of understanding the upward trend of this malaria infection in that region and the need for better understanding of transmission dynamics and proper diagnosis.

The danger of P. knowlesi is heightened by difficulties in diagnosing it and distinguishing it from other malaria species. “Recently, the prevalence of human infection with a simian malaria parasite, P. knowlesi, has become an important issue in a wide area of Southeast Asia. The identification of this parasite by microscopy is very difficult because it resembles the P. malariae parasite. However, the symptoms caused by P. malariae and P. knowlesi are very different, with only P. knowlesi causing severe and life-threatening malaria” (Komaki-Yasuda et al.)

Reports from Brazil highlight another ‘simian hotspot.’ While P. Knowlesi represents monkey infections reaching humans, the opposite may have happened to establish a reservoir in the New World. “P. vivax lineages appearing to originate from Melanesia that were putatively carried by the Australasian peoples who contributed genes to Native Americans. Importantly, mitochondrial lineages of the P. vivax-like species P. simium are shared by platyrrhine monkeys and humans in the Atlantic Forest ecosystem, but not across the Amazon, which most likely resulted from one or a few recent human-to-monkey transfers.”  But looking even further back in natural history, Escalante and colleagues found, “compelling evidence that P. vivax is derived from a species that inhabited macaques in Southeast Asia.”

A recent study in this area found the worrying results that, “The low incidence of cases and the low frequency of asymptomatic malaria carriers investigated make it unlikely that the transmission chain in the region is based solely on human hosts, as cases are isolated one from another by hundreds of kilometers and frequently by long periods of time, reinforcing instead the hypothesis of zoonotic transmission.”

In Africa, Linda Duval and co-researchers, who found P. falciparum in blood samples from two chimpanzees belonging to two different subspecies, warn that, “If malignant malaria were eradicated from human populations, chimpanzees, in addition to gorillas, might serve as a reservoir for P. falciparum,”

It appears that the dynamics between monkeys, malaria and humans has a long history. Even once certified malaria-free countries face the threat of imported malaria from people crossing borders. Now we must recognize that the threat may already live within borders. So since existing malaria interventions to protect humans from malaria cannot be applied to monkeys, accelerated research on the genetics of the parasite and the mosquito is needed to prevent both primate groups from getting malaria.

The Long and Winding Worm, 1986-2018

Recent reports draw attention that Guinea Worm persisted in small numbers in 2017 in two countries, Chad and Ethiopia. Mali and South Sudan were the only other two countries monitored because of recent cases, but each reported none for 2017.

Guinea Worm Wrap-Up #251

We recall that 32 and 23 years have passed since the challenge to eradicate the disease was posed and the hoped for date of eradication was to be achieved. There is no doubt that the 30 cases reported in 2017 is a gigantic drop from the 3.5 million estimated globally when the war on the worm started in 1986.

To date eradication has been achieved for only small pox (though its reemergence from labs as a potential biological war agent is feared). Could it return as global warming melts permafrost (and bodies) in the permafrost of northern latitudes?

Besides Guinea Worm, only polio and malaria have received calls for eradication (malaria for the second time in history). One wonders if even small pox could be eradicated in today’s world of conflicted and failed states – the last case of smallpox was in Somalia. Both Ethiopia and Chad border South Sudan’s civil conflicts.

What had made guinea worm, like smallpox, imminently eradicable was the fact that humans were the main reservoirs of infection (not counting the defenseless crustacean, the cyclops, that served as an intermediate host for work larvae). That has not changed. WHO observed that in Ethiopia both baboons and dogs have been infected with guinea worm in the same communities where humans suffer from the disease. While it was possible to ‘contain’ the infection in dogs, that is preventing them from contaminating water supplies, it was not surprisingly difficult to do the same for baboons. The dog problem has existed in Chad for at least 5 years.

Another problem in Ethiopia was the infection of seasonal laborers who could potentially take the disease back to other areas of the country. Although a system of rewards had been put in place this did not lead to the timely identification of all cases by either community members or health workers.

The road to disease eradication is clearly not a straight line from A to B. The twists and turns should be expected as time passes because ideally an eradication should be a short-term effort that is time-limited in order to provide a clear focus and adequate funding on the end goal.

What are the implications for malaria and polio? Conflict led to the hiding of polio cases in Nigeria and longer term efforts allowed vaccine derived poliovirus to emerge. Malaria is now found in Monkeys in Malaysia and Brazil, and parasite resistance to medicines and vector resistance to pesticides threatens effective interventions.

Time is not a commodity that favors eradication. In these days of plateauing financial support for global health, the call for eradicating deadly and economically debilitating infections needs to be louder.

Asymptomatic and Sub-Microscopic Malaria: a Challenge to Elimination Efforts

WHO says that, “In settings where malaria is actively being eliminated or has been eliminated, a “case” is the occurrence of any confirmed malaria infection with or without symptoms.” Several recent studies describe the importance of paying attention to asymptomatic infections.

In the Bagamoyo District of Tanzania Sumari and colleagues collected blood samples and examined them for Plasmodium falciparum prevalence using rapid diagnostic test (RDT), light microscopy (LM) and reverse transcription quantitative PCR. While overall prevalence was higher in symptomatic children using all three methods, asymptomatic children had a higher prevalence of gametocytes using light microscopy and PCR.  They concluded that, “The higher gametocytemia observed in asymptomatic children indicates the reservoir infections and points to the need for detection and treatment of both asymptomatic and symptomatic malaria.”

The health effects of asymptomatic plasmodial infections (API) on children were documented in Rwanda. These included “Plasmodium infection was associated with anaemia, fever, underweight, clinically assessed malnutrition and histories of fever, tiredness, weakness, poor appetite, abdominal pain, and vomiting” and were generally more common with submicroscopic infection.

Besides children other groups are at risk from API.  Malaria during pregnancy is a life and health threat to both the pregnant woman and the unborn child. Thirty-seven percent of asymptomatic pregnant women who had just delivered in Colombia were found to have parasitemia. Using microscopy only 8% were identified, such that without PCR the true extent of the problem would not have been identified. Thus, there is also concern for submicroscopic malaria and well as API generally. Asymptomatic and submicroscopic infections in areas co-endemic for P. falciparum and P. vivax are major contributors to anemia, not only in children but also in adults.

Working along the China-Myanmar border area, Zhao et al. explained that, “Sensitive methods for detecting asymptomatic malaria infections are essential for identifying potential transmission reservoirs and obtaining an accurate assessment of malaria epidemiology in low-endemicity areas aiming to eliminate malaria.” Thus they tried three molecular detection methods side-by-side, namely nested PCR targeting the rRNA genes, nested RT-PCR to detect parasite rRNA, and CLIP-PCR to detect parasite rRNA.

Interestingly the presence of fever is no guarantee that malaria parasites will be found. A study in Gabon demonstrated that among febrile patients only 1% had parasites found through microscopy compared to 32% through molecular testing. These studies have demonstrated the need for a better understanding of malaria transmission across different zones and strata in a country in the light of asymptomatic and submicroscopic malaria, especially gametocytemia. This should lead to better targeting of case detection, improved treatment and better compliance with preventive measures.

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: