Abstract
Human population movements currently challenge malaria elimination in low transmission foci in the Greater Mekong Subregion. Using a mixed-methods design, combining ethnography (n = 410 interviews), malariometric data (n = 4996) and population surveys (n = 824 indigenous populations; n = 704 Khmer migrants) malaria vulnerability among different types of mobile populations was researched in the remote province of Ratanakiri, Cambodia. Different structural types of human mobility were identified, showing differential risk and vulnerability. Among local indigenous populations, access to malaria testing and treatment through the VMW-system and LLIN coverage was high but control strategies failed to account for forest farmers’ prolonged stays at forest farms/fields (61% during rainy season), increasing their exposure (p = 0.002). The Khmer migrants, with low acquired immunity, active on plantations and mines, represented a fundamentally different group not reached by LLIN-distribution campaigns since they were largely unregistered (79%) and unaware of the local VMW-system (95%) due to poor social integration. Khmer migrants therefore require control strategies including active detection, registration and immediate access to malaria prevention and control tools from which they are currently excluded. In conclusion, different types of mobility require different malaria elimination strategies. Targeting mobility without an in-depth understanding of malaria risk in each group challenges further progress towards elimination.
Highlights
Despite increasing understanding of the importance of ‘hot spots’ for malaria control and elimination[1], comparatively less attention is being given to populations subgroups (‘hot pops’) that are vulnerable to malaria but cannot be located in a geographically confined area due to their mobility[2]
The importance of human mobility for malaria elimination was evident in previous elimination attempts where malaria re-emerged due to surveillance systems that failed to account for the movements of human populations[16,19]
Current malaria control efforts typically target geographically stable groups: village malaria workers are assigned to highly endemic villages based on the administrative unit of the village/community; the distribution of long lasting insecticidal nets (LLIN) relies on intermittently updated census data and indoor residual spraying (IRS) focuses on stable administrative villages; all of which fail to account for mobile populations[10,17,20,21]
Summary
Despite increasing understanding of the importance of ‘hot spots’ for malaria control and elimination[1], comparatively less attention is being given to populations subgroups (‘hot pops’) that are vulnerable to malaria but cannot be located in a geographically confined area due to their mobility[2]. Given the large sociocultural differences between various types of mobile populations, it can be expected that there is no standard way to address mobility in malaria control. In this sense, targeting pastoral nomads (i.e. pastoral herders in SSA) will require a radically different approach as compared to targeting national or international migrants, or commercial itinerant workers (i.e. street vendors and traders in border regions). Residual transmission foci persist in forested areas such as the North-Eastern Cambodian province of Ratanakiri, that are largely populated by ethnic minority communities, often located at international borders and on the fringes of society, with increasing rural to rural migration to exploit new economic opportunities such as rubber plantations, gem mining and agriculture[23]. The aim of this study was to characterize the different mobile groups in one such context and related those to vulnerability to malaria
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