Avoiding a Potential Public Health Crisis

The Thai-Cambodian border is a known hotspot for the emergence of drug resistant malaria and recently resistance to the most effective drug for treating malaria, artemisinin, has been discovered in this area.

Drug-resistant malaria is the frontline in the battle against malaria in Southeast Asia

The Thai-Cambodian border is a known hotspot for the emergence of drug resistant malaria and recently resistance to the most effective drug for treating malaria, artemisinin, has been discovered in this area. Containing the potential spread of this resistance in this area has been the focus of national and international health agencies for a number of years, but this is now changing. Not only is containment proving extremely difficult due to the particular nature of the area which involves many internal migrations and cross border movements, in addition the resistant parasite is emerging spontaneously in other parts of Greater Mekong Subregion (GMS). Resistant malaria poses a serious threat to the international communities' efforts to reduce malaria mortality and morbidity. To prevent the resistance spreading any further it will be necessary to completely eliminate malaria from the region. If this is not accomplished then all of the excellent progress of the past decade will be jeopardised.

The Malaria Consortium's Communications Team asked representatives of three organisations on the frontline of this fight to talk about migrants and malaria, the use of SMS technology in the fight against malaria , drug resistance and how to scale up efforts to eliminate it.

Malaria Consortium's Sophal Uth is Field Office Coordinator based in Pailin, where the NGO has been working with the Cambodian and Thai governments and other partners on multiple fronts to help prevent this drug resistance from spreading. Regina Rabinovich chairs the Malaria Eradication Scientific Alliance (MESA) Steering Committee. She's also Director of the ISGlobal Malaria Elimination Initiative and ExxonMobil Malaria Scholar in Residence at Harvard University. Dr Walter M. Kazadi is Coordinator of the World Health Organization (WHO) Emergency Response to Artemisinin Resistance (ERAR) hub.

Which populations are at highest risk of malaria and what can be done?

Sophal: We work with migrant populations, forest workers and rubber tappers. Because they work in the forest, often at night, these groups face much higher risk of contracting malaria and, since they are very mobile, they risk spreading the resistant parasite around the region.

Regina: Migrants and other indigenous populations are special risk groups, not only in Asia but in many other communities. It will take focused interventions to reach, create trust, educate and sustain malaria interventions in these groups.

What can be done to protect them?

Sophal: Because the parasites are becoming resistant to the anti-malaria drugs, patients haven't been recovering as quickly. Malaria Consortium has used various methods to reach these groups, through a pilot project screening migrants and local Pailin residents without symptoms, but who may be carriers of the parasite, a cross-border project diagnosing migrants along the Cambodian border with Thailand, Laos and Vietnam and the MESA funded project screening family members and neighbours of people who have had malaria to detect people who have malaria but don't show symptoms.

Regina: Resistance, both insecticide and drug, are of primary concern. There are promising novel candidates in the pipeline developed by industry partners and the Innovative Vector Control Consortium. Once we have improved tools, the challenge becomes getting them to the most vulnerable people.

How can SMS technology help?

Sophal: We are using SMS technology as a new method of sending information in real-time whenever a malaria case is detected. Working with the government, we have equipped and trained village malaria workers to be able to send an SMS when they have found a malaria case. This provide a location code and the patient's gender and age and automatically alerts the malaria mobile team who immediately locate the case and screen all family members to check for additional malaria cases. The SMS messages are also being used to refer the patient from private pharmacies to public health facilities. We use the system to follow up with patients and find out whether their treatment had been successful If not, it might indicate a resistant strain of the disease. The mobile phone enables initial diagnosis, treatment and follow-up information being reported in real-time.

Regina: The amazing advance of individual SMS technology in the most remote villages creates a new pathway to rapid reporting. This is happening at a global scale. Both in health facilities, where health workers help creating a database for country malaria leaders, and in local communities, which are important sources of information as levels of the disease drop and our strategies become focused on identifying pockets of transmission. SMS has also been used for other malaria activities, such as validating the quality of drugs, an important factor in slowing the creation of resistance globally.

What is WHO's role?

Walter: We set up the Emergency Response to Artemisinin Resistance (ERAR) which provides technical leadership and support to GMS countries in eliminating malaria in the region. More specifically, through ERAR leadership, the GMS Malaria Elimination Strategy was developed, which takes on a coordinated, regional scope involving six countries, with a key goal of eliminating malaria in the region by 2030. The Strategy is envisioned to speed up efforts by being adopted in national malaria programmes, through updated national health policies and actionable planning frameworks.

What has to happen next?

Regina: The scaling up of effective tools has resulted in impressive gains in lives saved. But none of these tools remain impressive in the face of resistance; continued investment in research is an essential component of the path forward.

Walter: Mindful of the gains of past decades, the momentum to stop the emergence and spread of artemisinin resistant parasites has stepped up. It is time to eliminate all forms of malaria from the GMS. Once beaten, twice shy, the experience of 1950s with chloroquine resistance spreading to other regions of the malaria endemic world should not be allowed to repeat itself. It is time to defeat malaria, let us invest in the future.

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