Asia Pacific Malaria Elimination Network Research Articles

Optimizing test and treat options for vivax malaria: An options assessment toolkit (OAT) for Asia Pacific national malaria control programs.

Designing policy in public health is a complex process requiring decision making that incorporates available evidence and is suitable to a country's epidemiological and health system context. The main objective of this study was to develop an options assessment toolkit (OAT) to provide a pragmatic and evidence-based approach to the development of policies for the radical cure (prevention of relapse) of vivax malaria for national malaria control programs in the Asia-Pacific region. The OAT was developed using participatory research methods and a Delphi process using a sequential multi-phase design, adapted with a pre-development phase, a development phase, and a final development phase. In the pre-development phase, a literature review was conducted to inform the toolkit development. Data collection in the development phase consisted of core research team discussions, multiple rounds of consultation with participants from National Malaria Control Programs (NMP) (online and in person), and two separate modified e-Delphi processes with experts. The final development phase was the piloting of the toolkit during the annual meeting of the Asia Pacific Malaria Elimination Network (APMEN) Vivax Working Group. We developed a tool kit containing the following elements: i) Baseline Assessment Tool (BAT) to assess the readiness of NMPs for new or improved coverage of radical cure, ii) eight scenarios representative of Asia Pacific region, iii) matching test and treat options based on available options for G6PD testing and radical cure for the given scenarios, iv) an approaches tool to allow NMPs to visualize considerations for policy change process and different implementation strategies/approaches for each test and treat option. The OAT can support vivax radical cure policy formulation among NMPs and stakeholders tailoring for their unique country context. Future studies are needed to assess the utility and practicality of using the OAT for specific country context.

Opening the policy blackbox: unravelling the process for changing national diagnostic and treatment guidelines for vivax malaria in seven countries

BackgroundThe changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency.MethodsData were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network’s Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: “context,” “actors” and “processes”.ResultsThe context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization’s endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years.ConclusionsIn the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.

Addressing hard‐to‐reach populations for achieving malaria elimination in the Asia Pacific Malaria Elimination Network countries

AbstractMember countries of the Asia Pacific Malaria Elimination Network are pursuing the regional goal of malaria elimination by 2030. The countries are in different phases of malaria elimination, but most have demonstrated success in shrinking the malaria map in the region. However, continued transmission in hard‐to‐reach populations, including border and forest malaria, remains an important challenge. In this article, we review strategies for improving intervention coverage in hard‐to‐reach populations. Currently available preventive measures, including long‐lasting insecticidal nets and long‐lasting insecticidal hammocks, and prompt diagnosis and treatment need to be expanded to hard‐to‐reach populations. This can be done through mobile malaria clinics, village volunteer malaria workers and screening posts. Malaria surveillance in the hard‐to‐reach areas can be enhanced through tools such as spatial decision support systems. Policy changes by the malaria programs will be required for implementing the strategies outlined in this article. However, strategies or tools may be suitable for some population groups but difficult to implement in other groups.

Further evidence needed to change policy for the safe and effective radical cure of vivax malaria: Insights from the 2019 annual APMEN Vivax Working Group meeting.

New diagnostics and treatment options for the radical cure of Plasmodium vivax malaria are now available. At the 2019 annual meeting of the Vivax Working Group of the Asia Pacific Malaria Elimination Network, participants took part in a roundtable discussion to identify further evidence required to introduce these new tools into policy and practice. Key gaps identified were accuracy and reliability of glucose‐6‐phosphate‐dehydrogenase deficiency tests, health system capacity, and feasibility and cost effectiveness of novel treatment strategies in routine clinical practice. As expected, there were differences in the priorities between country partners and researcher partners. To achieve the 2030 target for the regional elimination of malaria, evidence to address these issues should be generated as a matter of priority. Review of global guidelines alongside locally generated data will help to ensure the timely revision and optimisation of national treatment guidelines that will be vital to meet regional elimination goals.

Prevalence of asymptomatic submicroscopic malaria in eastern Indonesia: a cross sectional survey and spatial analysis

Abstract Background In 2013 in Indonesia, 4·8 million people were infected with malaria, and 23 483 malaria-related deaths were reported. Most infections were reported in eastern Indonesia, with two dominant species of malarial parasite: Plasmodium falciparum (62%) and P vivax (33%). Annual parasite incidence was 15·6 per 1000 population. In 2016, the Indonesian Ministry of Health announced that Indonesia would reach the WHO-defined pre-elimination stage for malaria by 2020, and be free of malaria transmission by 2030. Unfortunately, real data on incidence, surveillance, and mapping of malaria cases is scarce. This study will assess whether East Nusa Tenggara Province in eastern Indonesia should proceed with the malaria pre-elimination stage activities. Methods We did a survey of 555 people who were systematically selected from five districts in eastern Indonesia. We included healthy participants aged 14 years and older who had a blood haemoglobin concentration ≥100 g/L. We recorded baseline characteristics and risk factors for malaria infection via a standardised questionnaire, and blood samples were taken for analysis. All participants were examined by a local medical doctor. A malaria case was defined as the presence of Plasmodium spp in blood detected with nested PCR (nPCR) or microscopy. Data were collected by standard questionnaire, physical examination and laboratory tests (haemoglobin concentration measurements, microscopic analysis, and nPCR). We mapped nPCR-confirmed cases of malaria using ArcGIS 9.1 spatial and SaTScan analysis. We used univariate and bivariate statistical analysis for statistical analysis. Findings Between August, 2013, and September, 2014, we included 555 samples in our survey. 181 (32·6%) samples tested positive for malaria with n-PCR: only nine (1·6%) of these cases were detected by microscopy. P vivax was the most common Plasmodium spp detected (94 cases [51·9%]). Not using bednets was the most important risk factors for malaria in our population (OR 2·34, 95% CI 1·98–4·83); fever, which is the most commonly presented symptom, was noted in only five cases (0·9%). Results of spatial analysis showed three distinct and significant clusters: 13 cases (7·2%, p=0·0041), 54 cases (29·9%, p=0·0025), and 87 cases (48·1%, p=0·001). However, all malaria clusters were in areas of low malaria incidence. Interpretation A malaria pre-elimination programme in eastern Indonesia should be delayed. Routine treatment to stop silent transmission of malaria, and improved laboratory surveillance, are needed. Funding Asia Pacific Malaria Elimination Network (APMEN) Project number 103-02 as part of the APMEN Country Partner Technical Development Program Round-X. Major funding for APMEN is provided by Australian Government Department of Foreign Affair and Trade, alongside funds received from Bill and Melinda Gates Foundation.

Targeting populations at higher risk for malaria: a survey of national malaria elimination programmes in the Asia Pacific.

BackgroundSignificant progress has been made in reducing the malaria burden in the Asia Pacific region, which is aggressively pursuing a 2030 regional elimination goal. Moving from malaria control to elimination requires National Malaria Control Programmes (NMCPs) to target interventions at populations at higher risk, who are often not reached by health services, highly mobile and difficult to test, treat, and track with routine measures, and if undiagnosed, can maintain parasite reservoirs and contribute to ongoing transmission.MethodsA qualitative, free-text questionnaire was developed and disseminated among 17 of the 18 partner countries of the Asia Pacific Malaria Elimination Network (APMEN).ResultsAll 14 countries that responded to the survey identified key populations at higher risk of malaria in their respective countries. Thirteen countries engage in the dissemination of malaria-related Information, Education, and Communication (IEC) materials. Eight countries engage in diagnostic screening, including of mobile and migrant workers, military staff, and/or overseas workers. Ten countries reported distributing or recommending the use of long-lasting insecticide-treated nets (LLINs) among populations at higher risk with fewer countries engaging in other prevention measures such as indoor residual spraying (IRS) (two countries), spatial repellents (four countries), chemoprophylaxis (five countries), and mass drug administration (MDA) (three countries). Though not specifically tailored to populations at higher risk, 11 countries reported using mass blood surveys as a surveillance tool and ten countries map case data. Most NMCPs lack a monitoring and evaluation structure.ConclusionCountries in the Asia Pacific have identified populations at higher risk and targeted interventions to these groups but there is limited information on the effectiveness of these interventions. Platforms like APMEN offer the opportunity for the sharing of protocols and lessons learned related to finding, targeting and successfully clearing malaria from populations at higher risk. The sharing of programme data across borders may further strengthen national and regional efforts to eliminate malaria. This exchange of real-life experience is invaluable to NMCPs when scarce scientific evidence on the topic exists to aid decision-making and can further support NMCPs to develop strategies that will deliver a malaria-free Asia Pacific by 2030.

Targeting vivax malaria in the Asia Pacific: The Asia Pacific Malaria Elimination Network Vivax Working Group.

The Asia Pacific Malaria Elimination Network (APMEN) is a collaboration of 18 country partners committed to eliminating malaria from within their borders. Over the past 5 years, APMEN has helped to build the knowledge, tools and in-country technical expertise required to attain this goal. At its inaugural meeting in Brisbane in 2009, Plasmodium vivax infections were identified across the region as a common threat to this ambitious programme; the APMEN Vivax Working Group was established to tackle specifically this issue. The Working Group developed a four-stage strategy to identify knowledge gaps, build regional consensus on shared priorities, generate evidence and change practice to optimize malaria elimination activities. This case study describes the issues faced and the solutions found in developing this robust strategic partnership between national programmes and research partners within the Working Group. The success of the approach adopted by the group may facilitate similar applications in other regions seeking to deploy evidence-based policy and practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0958-y) contains supplementary material, which is available to authorized users.

Artesunate–mefloquine versus chloroquine for treatment of uncomplicated Plasmodium knowlesi malaria in Malaysia (ACT KNOW): an open-label, randomised controlled trial

The zoonotic parasite Plasmodium knowlesi has become the most common cause of human malaria in Malaysia and is present throughout much of southeast Asia. No randomised controlled trials have been done to identify the optimum treatment for this emerging infection. We aimed to compare artesunate-mefloquine with chloroquine to define the optimum treatment for uncomplicated P knowlesi malaria in adults and children. We did this open-label, randomised controlled trial at three district hospitals in Sabah, Malaysia. Patients aged 1 year or older with uncomplicated P knowlesi malaria were randomly assigned, via computer-generated block randomisation (block sizes of 20), to receive oral artesunate-mefloquine (target dose 12 mg/kg artesunate and 25 mg/kg mefloquine) or chloroquine (target dose 25 mg/kg). Research nursing staff were aware of group allocation, but allocation was concealed from the microscopists responsible for determination of the primary endpoint, and study participants were not aware of drug allocation. The primary endpoint was parasite clearance at 24 h. Analysis was by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT01708876. Between Oct 16, 2012, and Dec 13, 2014, we randomly assigned 252 patients to receive either artesunate-mefloquine (n=127) or chloroquine (n=125); 226 (90%) patients comprised the modified intention-to-treat population. 24 h after treatment, we recorded parasite clearance in 97 (84% [95% CI 76-91]) of 115 patients in the artesunate-mefloquine group versus 61 (55% [45-64]) of 111 patients in the chloroquine group (difference in proportion 29% [95% CI 18·0-40·8]; p<0·0001). Parasite clearance was faster in patients given artesunate-mefloquine than in those given chloroquine (18·0 h [range 6·0-48·0] vs 24·0 h [6·0-60·0]; p<0·0001), with faster clearance of ring stages in the artesunate-mefloquine group (mean time to 50% clearance of baseline parasites 8·6 h [95% CI 7·9-9·4] vs 13·8 h [12·1-15·4]; p<0·0001). Risk of anaemia within 28 days was lower in patients in the artesunate-mefloquine group (71 [62%; 95% CI 52·2-70·6]) than in those in the chloroquine group (83 [75%; 65·6-82·5]; p=0·035). Gametocytaemia as detected by PCR for pks25 was present in 44 (86%) of 51 patients in the artesunate-mefloquine group and 41 (84%) of 49 patients in the chloroquine group at baseline, and in three (6%) of 49 patients and two (4%) of 48 patients, respectively, at day 7. Fever clearance was faster in the artesunate-mefloquine group (mean 11·5 h [95% CI 8·3-14·6]) than in the chloroquine group (14·8 h [11·7-17·8]; p=0·034). Bed occupancy was 2426 days per 1000 patients in the artesunate-mefloquine group versus 2828 days per 1000 patients in the chloroquine group (incidence rate ratio 0·858 [95% CI 0·812-0·906]; p<0·0001). One (<1%) patient in the artesunate-mefloquine group had a serious neuropsychiatric event regarded as probably related to study drug. Artesunate-mefloquine is highly efficacious for treatment of uncomplicated P knowlesi malaria. The rapid therapeutic response of the drug offers significant advantages compared with chloroquine monotherapy and supports a unified treatment policy for artemisinin-based combination therapy for all Plasmodium species in co-endemic areas. Malaysian Ministry of Health, Australian National Health and Medical Research Council, and Asia Pacific Malaria Elimination Network.

Beyond mobile populations: a critical review of the literature on malaria and population mobility and suggestions for future directions.

BackgroundAlthough population mobility is frequently cited as a barrier to malaria elimination, a comparatively small body of literature has attempted to systematically examine this issue. This article reviews the literature on malaria and mobile populations in order to critically examine the ways that malaria elimination experts perceive the risks surrounding population mobility. The article brings in perspectives from HIV/AIDS and other infectious disease control programmes working in areas of high population mobility. The article aims to move beyond the current tendency to identify mobile populations as a risk group and suggests ways to reconceptualize and respond to population mobility within malaria elimination.MethodsThe review was commissioned by the Asia Pacific Malaria Elimination Network (APMEN). Searches were made using PubMed, ProQuest, Google and Google Scholar. The review includes English language published peer-reviewed literature and grey literature published up to November 2013.ResultsThe review identified three key themes in the literature: mobility, economic development and shifting land use; concerns about accessing mobile populations; and imported and border malaria. The review found that the literature treats mobile populations as a homogenous entity and is yet to develop a more accurate understanding of the true risks surrounding population mobility. Concerns about accessing mobile populations are overstated, and methods are suggested for working collaboratively with mobile populations. Finally, the review found that many concerns about mobile populations and imported malaria would be more productively framed as border health issues.ConclusionThe focus on mobile populations is both excessive and insufficiently examined within the current literature. By its very nature, population mobility requires malaria elimination programmes to look beyond isolated localities and demographic groups to respond to the interconnections that mobility creates between localities and population groups. Malaria programmes will gain greater clarity by refocusing the discussion away from mobile populations as a risk group and toward mobility as a system involving interconnected localities and multiple demographic groups. Rather than focusing on mobile populations as a risk group and a barrier to elimination, malaria elimination programmes ought to develop collaborative community engagement efforts in border areas and regions of high population mobility and where imported malaria is of concern.Electronic supplementary materialThe online version of this article (doi:10.1186/1475-2875-13-307) contains supplementary material, which is available to authorized users.

Active case detection for malaria elimination: a survey among Asia Pacific countries

BackgroundMoving from malaria control to elimination requires national malaria control programmes to implement strategies to detect both symptomatic and asymptomatic cases in the community. In order to do this, malaria elimination programmes follow up malaria cases reported by health facilities to carry out case investigations that will determine the origin of the infection, whether it has been imported or is due to local malaria transmission. If necessary, the malaria programme will also carry out active surveillance to find additional malaria cases in the locality to prevent further transmission. To understand current practices and share information on malaria elimination strategies, a survey specifically addressing country policies on case investigation and reactive case detection was carried out among fourteen countries of the Asia Pacific Malaria Elimination Network (APMEN).MethodsA questionnaire was distributed to the malaria control programme managers amongst 14 countries in the Asia Pacific who have national or sub-national malaria elimination goals.ResultsResults indicate that there are a wide variety of case investigation and active case detection activities employed by the 13 countries that responded to the survey. All respondents report conducting case investigation as part of surveillance activities. More than half of these countries conduct investigations for each case. Over half aim to accomplish the investigation within one to two days of a case report. Programmes collect a broad array of demographic data during investigation procedures and definitions for imported cases are varied across respondents. Some countries report intra-national (from a different province or district) importation while others report only international importation (from a different country). Reactive case detection in respondent countries is defined as screening households within a pre-determined radius in order to identify other locally acquired infections, whether symptomatic or asymptomatic. Respondents report that reactive case detection can be triggered in different ways, in some cases with only a single case report and in others if a defined threshold of multiple cases occurs. The spatial range of screening conducted varies from a certain number of households to an entire administrative unit (e g, village). Some countries target symptomatic people whereas others target all people in order to detect asymptomatic infections. The majority of respondent programmes collect a range of information from those screened for malaria, similar to the range of information collected during case investigation.ConclusionCase investigation and reactive case detection are implemented in the malaria elimination programmes in the Asia Pacific, however practices vary widely from country to country. There is little evidence available to support countries in deciding which methods to maintain, change or adopt for improved effectiveness and efficiency. The development and use of common evaluation metrics for these activities will allow malaria programmes to assess performance and results of resource-intensive surveillance measures and may benefit other countries that are considering implementing these activities.

Malaria elimination gaining ground in the Asia Pacific

Countries in the Asia Pacific region are making substantial progress toward eliminating malaria, but their success stories are rarely heard by a global audience. “Malaria 2012: Saving Lives in the Asia-Pacific,” a conference hosted by the Australian Government in Sydney, Australia from October 31 to November 2, 2012, will provide a unique opportunity to showcase the region’s work in driving down malaria transmission. One of the features of Malaria 2012 will be the Asia Pacific Malaria Elimination Network (APMEN), which has focused on harnessing the collective experiences of 13 countries through regional political and technical collaboration since its inception in 2009. Run by country partners, APMEN unites a range of partners – from national malaria programmes and academic institutions to global and regional policymaking bodies – to support each country’s malaria elimination goals through knowledge sharing, capacity building, operational research and advocacy.

Update from the Asia Pacific Malaria Elimination Network (APMEN)

Background Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realised, and research in this area has been identified by MalERA as a priority. The Pacific Malaria Initiative - a partnership between Vanuatu, Solomon Islands, AusAID, WHO, SPC and in-country partners has been supporting operational and applied research activities to understand effective ways to engage the communities in their programmes. The Asia Pacific Malaria Elimination Network has had a focus of work in community engagement, and draws upon lessons from the country programmes within the region. This paper reports upon some of the challenges faced in elimination, and the tools, approaches and insights gained in the Asia Pacific Region at the implementation level of elimination of malaria. Results The paper will present strategies developed and/or trialled in countries in the Asia Pacific Region to develop sustainable engagement by communities in the targeted locations to maintain and support malaria control activities and be engaged in the identification of malaria cases, and protection of borders. as defined in the national malaria elimination strategy. These include: community participation to reduce transmission and reservoir of infection (including IRS, source reduction, LLINs); community based treatment support for people who are using malaria treatment (vivax or falciparum) (early recognition of fever, active case detection, directly observed treatment and adherence, community based distribution support, test before treatment behaviour); develop and strengthen community self monitoring of community level surveillance. Conclusions The operational realities of moving towards malaria elimination demonstrate the need to address community participation and engagement., Approaches that have been successful in other elimination and eradication activities may form one set of strategies to trial. Additionally new tools such as GIS can support the sustaining of engagement in these efforts.

Findings of the literature review on mobility, infectious diseases and malaria

Background Imported malaria is no longer a challenge only for malaria free countries, but for countries implementing in malaria elimination strategies and seeking to address cross-border transmission. Mobility is frequently mentioned as a risk factor and a barrier to elimination by malaria researchers and policy makers. However, only a small body of research has engaged in a detailed analysis of the links between mobility and malaria transmission, and attempts to incorporate these findings into policy are rarer still. This paper presents the findings of a literature review on malaria and human mobility supported by the Asia Pacific Malaria Elimination Network (APMEN). It attempts to shift the agenda from identifying human mobility as a risk factor, to finding strategies to work collaboratively with mobile populations towards the goal of malaria elimination.

Malaria elimination in Asia–Pacific: an under-told story

[Extract] An oft-cited story describes how Sri Lanka reduced its incidence of malaria from 2·8 million cases in 1946 to a mere 17 in 1963, only to see the rate resurge in subsequent years.(1) Yet, in the past decade, Sri Lanka has brought its annual caseload down from more than 200 000 confirmed cases in 2000 to just 670 cases in 2008, with no deaths due to malaria in more than 2 years.(2) Similarly, in the Philippines, the past decade has seen nine provinces become malaria free, bringing the total to 22 of 81.(3) Eight of 20 malaria-endemic countries in WHO's Western Pacific and Southeast Asia regions achieved declines in annual cases of more than 50% from 2000 to 2008.(4) Success stories such as these reverberate throughout Asia–Pacific: in this era of renewed commitment to elimination,(5) ; (6) participants gathered in Kandy, Sri Lanka (Feb 16–19, 2010), for the second annual meeting of the Asia Pacific Malaria Elimination Network (APMEN).(7)