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Guest editorial: “End Malaria for Good”- a few key messages based on the Cambodian experience

June 23, 2016 - 07:27 -- Bart G.J. Knols
The editorial below was contributed by Sara E Canavati and Jack S Richards. Contact details below.
 
World Malaria Day (WMD) is an international observance established in 2007 and commemorated every year on 25 April to recognize global efforts to control malaria. The theme for 2016 was “End Malaria For Good”, which focused on malaria elimination. Following the great progress made under the Millennium Development Goals, it is important to continue building on this success as we transition into the Sustainable Development Goals [1] and the recently launched Global Technical Strategy for Malaria (GTS) [2]. The aim of the piece is to briefly reflect on WMD 2016 and consider a few key operational issues on malaria elimination that may lie ahead for the coming year.

Populations at high-risk can't be overlooked anymore
Moving from malaria control to elimination requires National Malaria Control Programs to target interventions at populations at higher risk, especially those with poor access to health services. Many countries are now finding that highly mobile and difficult to reach groups, often referred to as mobile and migrant populations (MMPs), are becoming the highest risk groups. Understanding the complex heterogeneity of these different groups and how to best serve their health needs is becoming increasing recognised and is critical for achieving malaria elimination. It is well documented that many of these groups pose major challenges for the test, treat, and track paradigm and that failure to identify these groups results in an ongoing reservoir of infection and ongoing transmission [3]. In Cambodia, strategies have been developed to deliver tailored interventions to populations at high-risk [4, 5].
 
“Ending Malaria for Good”: Surveillance! Surveillance! Surveillance!
As we increasing move towards malaria elimination, there is an increasing need to enhance case finding and to track high intensity interventions. This requires more sophisticated approaches to surveillance and response, ideally in real-time. Improving national surveillance systems also enables enhancing the local health systems especially when using a system that integrates multiple diseases into the same platform. As an example, in Cambodia village-level surveillance has been proven to be highly effective [6]. Village Malaria Workers (VMWs) are a key component of the surveillance system in Cambodia contributing more than 50% of reporting of malaria cases [7]. A recent health system assessment highlighted that the Cambodian VMWs play a critical role in malaria surveillance [8]. Other mechanisms like partnerships with national border control and migrant organizations, like the International Organization for Migration, can provide solutions to cross-border surveillance. Such approaches have proven to be highly effective on the Cambodian Borders [9]. 
 
“Ending Malaria for Good”: the key role of regional malaria agencies
The critical roles of international agencies like the World Health Organisation and national malaria control programs in malaria elimination is obvious to all, but the vital links provided by regional organisations is often under-recognised. Such groups play an important role in obtaining and disseminating locally-relevant best-practice, co-coordinating regional responses, and high-level political advocacy. Importantly, these regional bodies need the support of the entire malaria community, especially from malaria endemic countries. There is a need for leaders from malaria endemic countries to get engaged with these regional bodies because they can be an efficient mechanism to create regional solutions that cut across nation-specific approaches. Such groups include: the African Leaders Malaria Alliance (ALMA), which seeks to ensure that country leaders support malaria elimination and secure sufficient resources; the Asia Pacific Malaria Leaders Alliance (APLMA), which uses “case-by-case” advocacy for in-country domestic funding; and the Asia Pacific Malaria Elimination Network (APMEN), which focused on assisting countries to implement tools for domestic financing as well as providing technical assistance and capacity building.  
 
Political will in malaria endemic countries is considered to be key to achieve malaria eradication
The World Health Organization (WHO) has recently advised that “through […] political will, affected countries can speed progress towards malaria elimination and contribute to the broader development agenda as laid out in the 2030 Agenda for Sustainable Development” [10]. There are many challenges to be faced when shifting into a strategy of malaria elimination. Many of these challenges test the resolve and political will that has been built up over many years. For instance, malaria elimination activities often require intensive active case finding or mass drug administration strategies, which can place a significant strain on health staff and financial resources. As malaria becomes less prevalent, politicians and health decision makers tend to lose their focus on malaria, and become more willing to invest in other health outcomes that seem more urgent. As such, it is important that malaria professionals unite to advocate strongly for the benefits of long-term commitment to malaria elimination programs and to commit to the ongoing investments to ensure that these objectives are attained. A recent report described The Kingdom of Cambodia’s 2016 WMD celebrations as a prime of example of how political will is currently being exercised through high-level governmental support for malaria elimination [11]. 
 
Keeping malaria elimination high on the agenda without neglecting other life-threatening diseases
Disease elimination strategies have historically adopted highly intensified vertical responses using a disease-specific seek-and-destroy approach. This works well for diseases with relatively simple intervention strategies like vaccines or mass drug administration, but may not necessarily serve as the best model for a complex vector-borne disease like malaria. In 2008 Cambodia widened the Village Malaria Worker Programme’s scope to cover pneumonia and diarrhea in children under-five – further increasing impact and cost effectiveness and its impact on child mortality can be expected to rise sharply [12].  Engagement with communities, health works and politicians is more likely to be sustained if we can start to articulate the concepts of malaria elimination as a broader health agenda rather than maintaining a single disease focus. Of course, many oppose this view and see the need to maintain a sharp focus on malaria alone, so that the message and effort are not diluted. In a development and health sector which is experiencing ever increasing difficulties with funding, it will soon become difficult to justify screening or treating thousands of malaria unaffected people, not find and treat those few that are infected. Communities also understand the concept of burden of disease and will soon demand health activities that address malnutrition, TB, HIV, and other prevalent diseases. Malaria elimination cannot be seen as separate issue anymore and we need to start adopting malaria elimination strategies that include assessments and activities for other diseases that are locally relevant.
 
Looking forward to a happier malaria day in 2017
It is already less than a year until World Malaria Day 2017 and there is a lot of work to be done. Let’s be strong advocates, supporters of local, regional and international collaboration, builders of surveillance systems and better health systems for all diseases as we continue towards malaria elimination.
 
References
1. Nations U: Transforming our world: the 2030 Agenda for Sustainable Development. Geneva: United Nations; 2015.
2. Global Technical Strategy for Malaria. Geneva: World Health Organization; 2015.
3. Wen S, Harvard KE, Gueye CS, Canavati SE, Chancellor A, Ahmed B-N, Leaburi J, Lek D, Namgay R, Surya A, et al: Targeting populations at higher risk for malaria: a survey of national malaria elimination programmes in the Asia Pacific. Malaria Journal 2016, 15:1-14.
4. Guyant P, Canavati SE, Chea N, Ly P, Whittaker MA, Roca-Feltrer A, Yeung S: Malaria and the mobile and migrant population in Cambodia: a population movement framework to inform strategies for malaria control and elimination. Malaria Journal 2015, 14:1-15.
5. Canavati SE, Chea N, Guyant P, Roca-Feltrer A, S Y: Strategy to address migrant and mobile populations for malaria elimination in Cambodia, MMP Strategy. Phnom Penh: National Center for Parasitology, Entomology and Malaria Control (CNM); 2013.
6. Hustedt J, Canavati SE, Rang C, Ashton RA, Khim N, Berne L, Kim S, Sovannaroth S, Ly P, Ménard D, et al: Reactive case-detection of malaria in Pailin Province, Western Cambodia: lessons from a year-long evaluation in a pre-elimination setting. Malaria Journal 2016, 15:1-10.
7. Maude RJ, Nguon C, Ly P, Bunkea T, Ngor P, Canavati de la Torre SE, White NJ, Dondorp AM, Day NP, White LJ, Chuor CM: Spatial and temporal epidemiology of clinical malaria in Cambodia 2004–2013. Malaria Journal 2014, 13:1-15.
8. Canavati SE, Lawpoolsri S, Quintero CE, Nguon C, Ly P, Pukrittayakamee S, Sintasath D, Singhasivanon P, Peeters Grietens K, Whittaker MA: Village malaria worker performance key to the elimination of artemisinin-resistant malaria: a Western Cambodia health system assessment. Malaria Journal 2016, 15:1-15.
9. Edwards HM, Canavati SE, Rang C, Ly P, Sovannaroth S, Canier L: Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders. PLoS One 2015.
10. WHO: On World Malaria Day, a push to eliminate malaria. In http://whoint/mediacentre/news/releases/2016/world-malaria-day/en/ 2016.
11. Canavati SE, Quintero CE, Bou T, Khieu V, Leang R, Lek D, Ly P, Muth S, Lim KS, Tuseo L, et al: World Malaria Day 2016 in the Kingdom of Cambodia: high-level governmental support embodies the WHO call for “political will to end malaria”. Malaria Journal 2016, 15:1-4.
12. Hewitt S: A review of Cambodia’s Village Malaria Worker Project. Phnom Penh: World Health Organization; 2012.
 
Author contact details
 
Sara E Canavati* (corresponding author):  85 Commercial Road, Melbourne, Victoria, Australia 3004; Centre for Biomedical Research, Burnet Institute, Cambodia, email: sara.canavati@burnet.edu.au
Jack S Richards:  85 Commercial Road, Melbourne, Victoria, Australia 3004; Centre for Biomedical Research, Burnet Institute, Melbourne, Australia, email: richards@burnet.edu.au
 

Comments

Submitted by David Warhurst (not verified) on

"it will soon become difficult to justify screening or treating thousands of malaria unaffected people, not find and treat those few that are infected"

Here you contrast large numbers of malaria unaffected people with the few that are infected. You should have used the word affected and not infected? How can we work out what you are trying to say?

Presumably you are contrasting infected but unaffected with infected and symptomatic, which would be quite logical.

Using the right word is important

Sara Canavati's picture
Submitted by Sara Canavati on

Dear David,

Thank you very much for your comment. I agree that the terminology was unclear. We were trying to comment on resources required screening large numbers of asymptomatic people to identify the few cases that are infected.

All the best, Sara