Malaria Elimination in the Greater Mekong Subregion: Challenges and Prospects

Abstract Background Mass drug administration (MDA) has received growing interest to accelerate the elimination of multi-drug resistant malaria in the Greater Mekong Subregion. Targeted MDA, sometimes referred to as focal MDA, is the practice of delivering MDA to high incidence subpopulations only, rather than the entire population. The potential effectiveness of delivering targeted MDA was demonstrated in a recent intervention in Kayin State, Myanmar. Policymakers and funders need to know what resources are required if MDA, targeted or otherwise, is to be included in elimination packages beyond existing malaria interventions. This study aims to estimate the programmatic cost and the unit cost of targeted MDA in Kayin State, Myanmar. Methods We used financial data from a malaria elimination initiative, conducted in Kayin State, to estimate the programmatic costs of the targeted MDA component using a micro-costing approach. Three activities (community engagement, identification of villages for targeted MDA, and conducting mass treatment in target villages) were evaluated. We then estimated the programmatic costs of implementing targeted MDA to support P. falciparum malaria elimination in Kayin State. A costing tool was developed to aid future analyses. Results The cost of delivering targeted MDA within an integrated malaria elimination initiative in eastern Kayin State was approximately US$ 910,000. The cost per person reached, distributed among those in targeted and non-targeted villages, for the MDA component was US$ 2.5. Conclusion This cost analysis can assist policymakers in determining the resources required to clear malaria parasite reservoirs. The analysis demonstrated the value of using financial data from research activities to predict programmatic implementation costs of targeting MDA to different numbers of target villages.

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Evolution of Plasmodium vivax populations in border areas of the Greater Mekong Subregion during malaria elimination

10.21203/rs.2.22640/v1 ◽

2020 ◽

Author(s):

Yuling Li ◽

Yubing Hu ◽

Yan Zhao ◽

Qinghui Wang ◽

Huguette Gaelle Ngassa Mbenda ◽

...

Keyword(s):

Genetic Diversity ◽

Plasmodium Vivax ◽

Malaria Elimination ◽

Scale Up ◽

Transmission Dynamics ◽

Clinical Samples ◽

Effective Population ◽

Border Areas ◽

Greater Mekong Subregion ◽

International Border

Abstract Background: Countries within the Greater Mekong Subregion (GMS) of Southeast Asia have committed to eliminating malaria by 2030. Although malaria situation has greatly improved, Plasmodium vivax remains at international border regions. Therefore, to gain a better understanding of transmission dynamics, knowledge on the evolution of P. vivax populations after the scale-up of control interventions will guide more effective targeted control efforts. Methods: We investigated genetic diversity and population structures in 206 longitudinally collected P. vivax clinical samples in two international border areas at the China-Myanmar border (CMB, n=50 in 2004 and n=52 in 2016) and western Thailand border (n=50 in 2012 and n=54 in 2015). Parasites were genotyped using 10 microsatellite markers. Results: Despite intensified control efforts, genetic diversity in the four populations remained high (HE = 0.66-0.86). The proportions of polyclonal infections showed substantial decreases to 23.7 and 30.7% in the CMB and western Thailand, respectively, with corresponding decreases in the multiplicity of infection. Consistent with the shrinking map of malaria transmission in the GMS over time, there were also increases in multilocus linkage disequilibrium, suggesting of more fragmented and increasingly inbred parasite populations. There were considerable genetic differentiation and subdivision with the four tested populations. Various degrees of clustering were evident between the older parasite samples collected in 2004 at the CMB with the 2016 CMB and 2012 Thailand populations, suggesting some of these parasites had shared ancestry. In contrast, the 2015 Thailand population was genetically distinctive, which may reflect a process of population replacement. The moderately large effective population sizes and proportions of polyclonal infections highlight the necessity of further coordinated and integrated control efforts on both sides of the borders in the pursuit of malaria elimination. Conclusions: With enhanced control efforts on malaria elimination, P. vivax population in the GMS has fragmented into a limited number of clustered foci, but the presence of large P. vivax reservoirs still sustains genetic diversity and transmission. These findings provide new insights into P. vivax transmission dynamics and population structure in this area.

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Private sector opportunities and threats to achieving malaria elimination in the Greater Mekong Subregion: results from malaria outlet surveys in Cambodia, the Lao PDR, Myanmar, and Thailand

Malaria Journal ◽

10.1186/s12936-017-1800-5 ◽

2017 ◽

Vol 16 (1) ◽

Cited By ~ 3

Author(s):

Sochea Phok ◽

◽

Saysana Phanalasy ◽

Si Thu Thein ◽

Asawin Likhitsup

Keyword(s):

Private Sector ◽

Malaria Elimination ◽

Lao Pdr ◽

Greater Mekong Subregion

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Evolution of Plasmodium vivax populations in border areas of the Greater Mekong Subregion during malaria elimination

10.21203/rs.2.19786/v1 ◽

2019 ◽

Author(s):

Yuling Li ◽

Yubing Hu ◽

Yan Zhao ◽

Qinghui Wang ◽

Huguette Gaelle Ngassa Mbenda ◽

...

Keyword(s):

Genetic Diversity ◽

Plasmodium Vivax ◽

Malaria Elimination ◽

Scale Up ◽

Transmission Dynamics ◽

Clinical Samples ◽

Effective Population ◽

Border Areas ◽

Greater Mekong Subregion ◽

International Border

Abstract BackgroundCountries within the Greater Mekong Subregion (GMS) of Southeast Asia have committed to eliminating malaria by 2030. Although malaria situation has greatly improved, Plasmodium vivax remains at international border regions. Therefore, to gain a better understanding of transmission dynamics, knowledge on the evolution of P. vivax populations after the scale-up of control interventions will guide more effective targeted control efforts. MethodsWe investigated genetic diversity and population structures in 206 longitudinally collected P. vivax clinical samples in two international border areas at the China-Myanmar border (CMB, n=50 in 2004 and n=52 in 2016) and western Thailand border (n=50 in 2012 and n=54 in 2015). Parasites were genotyped using 10 microsatellite markers. ResultsDespite intensified control efforts, genetic diversity in the four populations remained high (HE = 0.66-0.86). The proportions of polyclonal infections showed substantial decreases to 23.7 and 30.7% in the CMB and western Thailand, respectively, with corresponding decreases in the multiplicity of infection. Consistent with the shrinking map of malaria transmission in the GMS over time, there were also increases in multilocus linkage disequilibrium, suggesting of more fragmented and increasingly inbred parasite populations. There were considerable genetic differentiation and subdivision with the four tested populations. Various degrees of clustering were evident between the older parasite samples collected in 2004 at the CMB with the 2016 CMB and 2012 Thailand populations, suggesting some of these parasites had shared ancestry. In contrast, the 2015 Thailand population was genetically distinctive, which may reflect a process of population replacement. The moderately large effective population sizes and proportions of polyclonal infections highlight the necessity of further coordinated and integrated control efforts on both sides of the borders in the pursuit of malaria elimination. ConclusionsWith enhanced control efforts on malaria elimination, P. vivax population in the GMS has fragmented into a limited number of clustered foci, but the presence of large P. vivax reservoirs still sustains genetic diversity and transmission. These findings provide new insights into P. vivax transmission dynamics and population structure in this area.

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Entomological determinants of malaria transmission in Kayin state, Eastern Myanmar: A 24-month longitudinal study in four villages

Wellcome Open Research ◽

10.12688/wellcomeopenres.14761.1 ◽

2018 ◽

Vol 3 ◽

pp. 109 ◽

Cited By ~ 6

Author(s):

Victor Chaumeau ◽

Bénédicte Fustec ◽

Saw Nay Hsel ◽

Céline Montazeau ◽

Saw Naw Nyo ◽

...

Keyword(s):

Malaria Transmission ◽

Infection Rate ◽

Malaria Elimination ◽

Malaria Vectors ◽

Bed Nets ◽

Biting Rate ◽

Multiple Species ◽

Few Data ◽

Greater Mekong Subregion ◽

Human Biting Rate

Background: The Thailand-Myanmar borderland is an area endemic for malaria where transmission is low, seasonal and unstable. The epidemiology has been described but there is relatively few data on the entomological determinants of malaria transmission. Methods: As part of a pilot study on Targeted Malaria Elimination, entomological investigations were conducted during 24 months in four villages located in Kayin state, Myanmar. Anopheles mosquitoes were identified by morphology, and molecular assays were used in order to discriminate between closely related sibling species of malaria vectors. Plasmodium infection rate was determined using quantitative real-time PCR. Results: The biodiversity of Anopheles entomo-fauna was very high and multiple species were identified as malaria vectors. The intensity of human-vector contact (mean human-biting rate= 369 bites/person/month) compensates for the low infection rate in naturally infected populations of malaria vectors (mean sporozoite index= 0.4 and 1.7 /1,000 mosquitoes for P. falciparum and P. vivax respectively), yielding intermediary level of transmission intensity (mean entomological inoculation rate= 0.13 and 0.64 infective bites/person/month for P. falciparum and P. vivax, respectively). We estimated that 65% of the potential infective bites are not prevented by mosquito bed nets because of outdoor and early biters. Conclusion: This study provided a unique opportunity to describe the entomology of malaria in low transmission settings of Southeast Asia. Our data are important in the context of malaria elimination in the Greater Mekong Subregion.

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Community Engagement for Malaria Elimination in the Greater Mekong Subregion: a Qualitative Study Among Malaria Researchers and Policymakers

10.21203/rs.3.rs-1008558/v1 ◽

2021 ◽

Author(s):

Nils Kaehler ◽

Bipin Adhikari ◽

Phaik Yeong Cheah ◽

Lorenz von Seidlein ◽

Nicholas PJ Day ◽

...

Keyword(s):

Community Engagement ◽

Malaria Elimination ◽

Linguistic Diversity ◽

Malaria Prevention ◽

Structured Interviews ◽

Policy Makers ◽

Malaria Research ◽

Local Staff ◽

Participatory Engagement ◽

Greater Mekong Subregion

Abstract IntroductionCommunity engagement has increasingly received attention in malaria research and program interventions, particularly as countries approach closer to malaria elimination. Although strategies and aspects of community engagement are constantly developing, little is known about how those who implement research or programs view community engagement. This article explores the perspectives of researchers and policy makers in the Greater Mekong Subregion (GMS) on community engagement for malaria control and elimination. MethodsSemi-structured interviews were conducted among 17 policymakers and 15 senior researchers working in the field of malaria. All interviews were audio-recorded and transcribed in English. Transcribed data were analyzed using deductive and inductive approach in QSR NVivo. Themes and sub-themes were generated. ResultsResearchers and policymakers emphasized the importance of community engagement in promoting participation in malaria research and interventions. Building trust with the community was seen as crucial. Respondents emphasized involving authority/leadership structures and highlighted the need for intense and participatory engagement. Geographic remoteness, social, cultural, and linguistic diversity were identified as barriers to meaningful engagement. Local staff were described as an essential ‘connect’ between researchers or policy makers and prospective participants. Sharing information with community members, using various strategies such as visualization of message including creative and participatory methods were highlighted. ConclusionsAs malaria continues to decline across the GMS, countries have set elimination goals. In this context, policy makers and researchers involved in malaria prevention and control in the region viewed community engagement as crucial for promoting participation in research or programmatic interventions. Given the difficulties of the “last mile” to elimination, sustained investment in community engagement is needed in isolated areas of the GMS where malaria transmission continues.

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A mobile phone application for malaria case-based reporting to advance malaria surveillance in Myanmar: a mixed methods evaluation

Malaria Journal ◽

10.1186/s12936-021-03701-6 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Win Han Oo ◽

Win Htike ◽

Julia C. Cutts ◽

Kyawt Mon Win ◽

Kaung Myat Thu ◽

...

Keyword(s):

Mobile Phone ◽

Malaria Case ◽

Malaria Elimination ◽

Reporting System ◽

Evaluation Study ◽

Malaria Surveillance ◽

Mobile Phone Application ◽

Mixed Methods Evaluation ◽

Greater Mekong Subregion ◽

Case Based

Abstract Background To achieve malaria elimination in the Greater Mekong Subregion, including Myanmar, it is necessary to ensure all malaria cases are detected, treated, and reported in a timely manner. Mobile phone-based applications for malaria reporting, case management, and surveillance implemented at a community-level may overcome reporting limitations associated with current paper-based reporting (PBR), but their effectiveness in this context is unknown. Methods A mixed methods evaluation study was undertaken to determine the effectiveness of a national Malaria Case-Based Reporting (MCBR) mobile phone application in improving malaria case reporting compared to the existing PBR reporting system in Myanmar. Methods included secondary analysis of malaria case report data, questionnaires, focus group discussions and field observations of community volunteers, interviews and direct observations of malaria programme stakeholders, and cost analysis. Using a combination of these approaches the following areas were investigated: data quality and completeness, data access and usage, capacity for timely reporting, the acceptability, functionality, and ease of use of the application and facilitators and barriers to its use, and the relative cost of MCBR compared to the PBR system. Results Compared to PBR, MCBR enabled more accurate and complete data to be reported in a much timelier manner, with 63% of MCBR users reporting they transmit rapid diagnostic test outcomes within 24 h, compared to 0% of PBR users. MCBR was favoured by integrated community malaria volunteers and their supervisors because of its efficiency. However, several technical and operational challenges associated with internet coverage, data transmission, and e-literacy were identified and stakeholders reported not being confident to rely solely on MCBR data for programmatic decision-making. Conclusions Implementation of MCBR provided timely and accurate data for malaria surveillance. Findings from this evaluation study will enable the optimization of an application-based reporting system for malaria monitoring and surveillance in the Greater Mekong Subregion and advance systems to track progress towards, and certify, the achievement of malaria elimination targets.

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Motivation To Test, Treat, and Report Malaria Cases: A Quantitative Assessment Among Private Sector Providers in The Greater Mekong Subregion

10.21203/rs.3.rs-637992/v1 ◽

2021 ◽

Author(s):

Morgan Brown ◽

Paul Bouanchaud ◽

Kemi Tesfazghi ◽

Saysana Phanalasy ◽

May Me Thet ◽

...

Keyword(s):

Private Sector ◽

Malaria Elimination ◽

Lao Pdr ◽

Two Dimensions ◽

Health Providers ◽

Financial Gain ◽

Provider Characteristics ◽

Confirmatory Factor ◽

Gates Foundation ◽

Greater Mekong Subregion

Abstract Accurately testing, treating, and tracking all malaria cases is critical to achieving elimination. Ensuring health providers are able and motivated to test, treat, and report cases is a necessary component of elimination programs, and particularly challenging in low endemic settings where providers may not encounter a large volume of cases. With funding from the Bill & Melinda Gates Foundation, this study aimed to identify and validate distinctive subtypes of motivation among private sector providers enrolled in the Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) program, implemented by Population Services International. Quantitative questionnaires were administered electronically in person by trained enumerators to various provider groups in Myanmar, Lao PDR, and Vietnam. A three-stage confirmatory factor analysis was then conducted in STATA. Following this analysis, a two-factor solution that describes motivation in this population of providers was identified, and providers were scored on the two dimensions of motivation. Provider motivations were analyzed by provider characteristics, and associations with intentions and outcomes related to malaria service provision were explored. These providers, who are often assumed to only be financially motivated, engaged in malaria elimination activities because of both internal and external motivational factors that are independent of remuneration or financial gain. Motivation varied by provider characteristics and was associated with outcomes of importance to malaria elimination. Understanding components of provider motivation to test, treat, and report malaria cases in elimination settings will ensure that malaria programs can establish mechanisms to encourage lasting engagement by providers in pursuit of elimination goals.

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