Lao PDR: Malaria outbreaks remain worrisome but progress is being made in response and control
Despite a substantial reduction of the malaria burden, the Lao People’s Democratic Republic continues to experience outbreaks and the country’s first-line drugs are beginning to lose effectiveness. A national strategy is being developed to tackle the challenge.
Recent years have witnessed a resurgence of malaria in several provinces of the Lao PDR, and the confirmation of artemisinin resistance has prompted the government to scale up efforts to contain artemisinin-resistant strains of the disease. Lao PDR is the fifth country in the Greater Mekong Subregion where artemisinin resistance has been confirmed.
Dr Bouasy Hongvanthong, Director of the Centre for Malaria Parasitology and Entomology (CMPE), underlined this 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. “Even though fewer malaria cases were detected in 2013 than in 2012, outbreaks continue in Saravan and Champasack. We cannot afford to be complacent.”
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 sharp rise in cases and deaths is linked to migration patterns, with an increase in the number of people flocking to work in areas of large infrastructural development projects”, Dr. Bouasy pointed out. “Artemisinin resistance is now confirmed in Champasack and Attapeu provinces and we are urgently developing an artemisinin resistance containment strategy.”
WHO, the European Union the Global Fund and USAID/PMI have provided emergency financial support to local authorities, the Ministry of Health and the non-governmental organization Health Poverty Action (HPA) to respond to the outbreaks in 2012 and 2013 in the affected provinces. In an intensive screening and treatment programme, using rapid diagnostic tests, 2500 villagers were confirmed to have malaria. Also, 28 900 long-lasting insecticide treated nets (LLINs) and 6673 long-lasting insecticide treated hammock nets (LLIHNs) were distributed in Attapeu. In addition, 12 673 LLIHNs and 34 053 repellents were distributed in affected villages throughout the southern provinces, using pooled contributions from donors.
At the community level, 150 new village malaria workers were trained to carry out early diagnosis and treatment in villages in high-transmission areas, and indoor residual spraying (IRS) was carried out in 30 high-risk villages. Village health volunteers who provide primary health care services, including diagnosis and management of basic diseases, have been reactivated to carry out early diagnosis and treatment of malaria.
Lao PDR is a relatively small country bordering Thailand, Cambodia, Viet Nam, China and Myanmar. While there is considerable out-migration to neighbouring countries, more and more migrant workers are entering Lao PDR from Viet Nam and China to work on development projects. During the 2012–2013 outbreak response – and as part of an intensive health education campaign – CMPE, WHO and HPA jointly produced roadside banners, billboards and posters to educate people about the importance of malaria prevention. The campaign included messages in multiple languages, including Lao, Chinese and Vietnamese.
In late April 2014, a WHO team comprising members from the Emergency Response to Artemisinin Resistance (ERAR) regional hub and the country offices in Cambodia and Lao PDR were in the capital Vientiane for a one-day consultation to assist CMPE to identify priority areas for intervention to achieve malaria elimination, as it prepares to finalise the Lao PDR National Malaria Strategic Plan 2015–2020.
WHO recommended including cross-border collaboration as a key component of the Strategic Plan, given that Lao PDR shares common borders with five countries in the Greater Mekong Subregion and malaria is still prevalent in remote, forest and forest fringe areas along these borders.
“Malaria is often more difficult to control in these border areas due to the terrain which is hard to access, and because of the hard-to-track population movements across the borders,” Dr Bayo Fatunmbi, technical officer with the ERAR regional hub, told the consultation. “Most of those crossing the borders are young adult men engaged in plantation work, large infrastructure projects and forest activities that expose them to outdoor biting vectors.”
The ERAR hub has also agreed to provide technical assistance for the development of an artemisinin resistance containment and elimination strategy and technical support for malaria outbreak response.
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 attract foreign investors and many large-scale development projects.
“We must urgently reach people and populations who move into the forests to clear the area for development, or in search of food and forestry products,” said Dr Bouasy. “These workers need to be educated on malaria prevention, how to seek treatment if they fall sick, and how to adhere to their full treatment regimen to help prevent artemisinin resistance.”
In collaboration with Malaria Consortium, Health Poverty Action is currently carrying out a qualitative study to better understand malaria care-seeking and preventive behaviours 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 behaviour change communication strategy at the national level to improve personal protection behaviours 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. “We need to know much more about all of this if we are to come up with effective communication and health education strategies.”
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 seek 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 initiative (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 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 is truly a significant achievement in reaching out to local communities using the private sector,” said Dr Bouasy. “This outreach must be strengthened in the years ahead, to expand our wide-ranging alliance in the fight against artemisinin resistance.”