Accelerating malaria elimination in Cambodia: an intensified approach targeting at-risk populations | Malaria Journal

Reinforcing Program Goals

The IP has two objectives aimed at reducing transmission in areas of the country with the highest malaria burden: (1) to improve program coordination to ensure full implementation of the country’s Malaria Elimination Action Framework (MEAF) (2016-2020) and (2) to implement proactive approach to deploy interventions to rapidly reduce parasite hosts in high-risk populations. This IP focuses on forest visitors and migrants and mobile populations (MMPs) who may enter the forest for logging or other economic purposes and may stay in the forest for up to 2 weeks per trip. The first phase of the IP (IP1) took place from October 2018 to October 2019. The second phase of the IP (IP2) ran from November 2019 to December 2020.


To identify geographic areas for intervention, CNM and partners used MIS data to identify provinces, operational areas (ODs) and villages with the highest burden of reported malaria cases. IP1, seven provinces and nine ODs were selected (Figure 1). Among the selected ODs, the 30 most burdened HFCAs were selected for inclusion in the IP. These 30 HFCAs accounted for 75% of all malaria cases in the country in 2018 and 2019. Sites were reselected at the start of IP2; six of the seven provinces remained unchanged, with one change replacing Preah Vihear with Sihanoukville as conditions in Preah Vihear improved. 12 OD highest Plasmodium falciparum Cases were selected (as opposed to malaria cases of any species) and 36 HFCAs were selected among these 12 ODs. 77% of these HFCAs Plasmodium falciparum Cases occurred in the country between January 2018 and June 2019, the largest number of HFCAs considered procedurally feasible for operational and management strengthening activities. Overall, 45 HFCAs were included during IP; 21 HFCAs in IP1 and IP2, 9 HFCAs in IP1 only, and 15 HFCAs in IP2 only. A complete list of HFCAs included in the IP is provided in Additional File 1: Table S1. CNM used MIS data and consultations with each HFCA to identify ‘village hotspots’, areas where at-risk forest dwellers live or transit. These 141 hotspots (Additional file 1: Table S1) became the focal geographic sites for IP intervention. Each site received technical support from CNM, World Health Organization (WHO), Clinton Healthcare Initiative (CHAI), and civil society organizations located in the corresponding geographic area, namely Catholic Relief Services, CARE, Population Services International (PSI) , University Research Corporation (URC).

picture. 1

Selected sites receiving intensive program interventions and number of mobile malaria workers (MMWs) assigned according to identified malaria hotspots


In line with the main objectives of the IP, the implementation of OD received additional support from CNM, WHO and CSO to improve program coordination and ensure effective implementation of case management, including high levels of malaria detection, comprehensive treatment of all those diagnosed with malaria, and Effective referral for any serious cases. At the beginning of each phase of IP, long-lasting insecticide-treated nets (LLINs) were distributed to all households in targeted villages that did not have enough nets (less than one net per 1.8 people). Additional LLINs can then be distributed sequentially during the IP. IP includes additional technical support and supervision from CNM to OD, verifying optimal LLIN coverage in high-incidence villages, and ensuring full attendance at VMW monthly meetings. VMW holds monthly meetings to set testing goals and replenish case management supplies. ODs are encouraged to attend meetings to review data and guide performance.

The second goal of the IP is to implement an aggressive approach targeting high-risk populations and accelerating decline Plasmodium falciparum Cases in the target site. The main intervention is to hire additional MMWs, which target IP sites and identified hotspots. MMW is based closer to the forested areas where MMPs typically travel, and conducts specialized activities focusing on forestry workers and migrant populations. MMW performance is continuously tracked through monthly VMW/MMW meetings. MMW also participated in several training sessions in the IP course to ensure their knowledge on malaria detection and treatment was up to date and expanded their toolkit (e.g. adding paracetamol and mebendazole to treat those who tested negative for malaria people). There is also a certain number of MMWs within target sites that are managed not through CNM and IP, but through the Malaria Alliance (13). These MMWs are considered MMWs (not IPs) in the following analysis.

MMW’s responsibilities include:

  1. 1)

    Testing: Rapid diagnostic test (RDT) for all suspected cases according to CNM’s criteria, i.e. anyone who has a fever or has been to the forest in the past 1 week.

  2. 2)

    Treatment: Provide antimalarial treatment according to national guidelines, including single low-dose primaquine (SLDP) for all Plasmodium falciparum/mix Eligible individual case(14). IP expands access to SLDP for non-pregnant, non-breastfeeding individuals weighing 20kg and above, up from previous requirement of 50kg, and actively follows MMW to ensure all Plasmodium falciparumThe /mix case has received SLDP.

  3. 3)

    Tracking: Keep complete records of all activities including patient consultations on case report forms, active case detection (ACD) activities, questionnaires and forest pack registration.

  4. 4)

    Referral: Refer severe cases immediately to a health facility.

  5. 5)

    Malaria Knowledge: Attend VMW/MMW training and regular monthly meetings to ensure familiarity with malaria diagnosis and treatment.

  6. 6)

    work overtime Especially when the rangers are active, which means they are available 24 hours if a patient needs services.

  7. 7)

    Active detection and treatment: Twice a month, travel to forest malaria hotspots for ACD.

  8. 8)

    Commodity Availability: Maintain adequate stocks of RDTs and malaria drugs; attend monthly meetings, report on stocks, provide paper reports, replenish stocks.

  9. 9)

    Forest pack distribution: Distribute forest packs to target groups. The Forest Backpack includes backpack, information, education and communication/behavior change communication (IEC/BCC) materials, hammock netting and (added to IP2) insect repellent. Insect repellant supplements are also available. The first forest pack distribution took place in May 2019.

  10. 10)

    Executing IEC/BCC activities: hosting information sessions to educate the community on the signs and symptoms of malaria, providing health education to patients during consultations, regularly playing speaker recordings and displaying educational posters.

  11. 11)

    Optional product available for negative malaria casessuch as paracetamol for fever reduction and mebendazole for deworming according to national treatment guidelines (IP2 only).

  12. 12)

    Identifying Travelers: MMW requires any MMP who tests positive to provide contact information for their traveler. Invite fellow travelers to test and provide malaria prevention information (IP2 only).

For MMWs to perform their mandate effectively, the supply chains for RDTs, Artemisinin Combination Therapies (ACT) (artesunate mefloquine (ASMQ) and primaquine) and forest packaging need to be improved. At a central level, CNM holds monthly supply chain meetings with key partners such as UNOPS, WHO and executive civil society organizations to ensure that supply channels are accurately forecasted, ordered and distributed to subnational levels in a timely manner, coordinating storage with central healthcare and local partners. The working group also monitored appropriate supplies such as scales, thermometers, gloves and uniforms that MMWs needed to allow MMWs to identify themselves (in IP2).

In non-Indigenous settings, national surveillance and case management guidance was followed. In short, the standard of care is RDT or microscopy in all suspected cases and ACT in all cases (Plasmodium falciparum, Plasmodium vivax and mixed infections), SLDP for Plasmodium falciparum/mix cases and refer any serious cases to hospital. According to national stratification (3025 in 2018, 3376 in 2019, and 3675 in 2020), VMWs were located in the most burdened villages. All malaria cases from HCs were entered into MIS at the time of diagnosis, while all cases from VMWs were entered on a monthly basis following monthly VMW meetings, which also served as regular surveillance of VMWs.

For most of the IP period, Cambodia had no access to radical cures, and Plasmodium vivax Cases received ACT treatment. From November 2019 to December 2020, eradication trials were conducted in 4 provinces, one of which (Kampong Speu) was also included in the IP.Above the pilot, any adult male Plasmodium vivax Cases were referred to the nearest HC and tested for G6PD deficiency. If their G6PD is normal, they will receive primaquine for 14 days. All other cases were treated with ACT.

monitoring and evaluation

Data on malaria detections and cases are usually entered into data management systems by health centers (HCs), VMWs and MMWs. Each partner involved in the IP also collected malaria test and case data, categorized by cadre, sent to CNM and verified their data in a ‘CSO Scorecard’, and data on IP interventions such as the number of forest packs distributed , ACD visits and attendance at VMW/MMW monthly meetings. Compare MIS data with CSO scorecard data and work with CSO to clarify any errors or discrepancies (e.g. missing data, more cases than tests, incorrect sum of malaria types and total cases) Make corrections. Malaria data are analyzed monthly (including mapping of case data to track any changes in malaria epidemiology) by central CNM staff with support from WHO and CHAI. CNM leads partner meetings for problem solving and decision making. The goal of these “Data Review and Action Sessions” is to provide consistent data review, provide feedback to the CSO and facilitate timely action, such as responding to stock-outs and flagging HC/MMWs for non-performed target outreach visits.

data analysis

The data analysis timeline covers pre-IP (January 2018-September 2018), IP1 (October 2018-October 2019) and IP2 (November 2019-December 2020). Data for all HFCAs in Cambodia came from the CSO Scorecard, Cambodia Malaria Information System (MIS) and the WHO Malaria Elimination Database (MEDB). This included IP intervention data (number of MMWs, number of MMW outreach visits, forest packs distributed, LLINs distributed, repellents distributed) and malaria epidemiology data (tests, treatments, cases). Use “MMW Forest Pack questionnaires” to gather information about forest packs across IP. In March 2020, a review of these questionnaires provided more information on the distribution of forest packets during the IP period.

To analyze whether IP is a factor driving the decline in malaria cases implementing HFCA, Plasmodium falciparumThe /mix case was compared before and during IP. For this analysis, HFCA was considered IP HFCA if it had been included in any phase of IP (n = 45).First, by fitting a separate Poisson regression model (log link) to Plasmodium falciparum/mix cases in (1) Non-IP HFCAs, (2) IP HFCAs (pre-IP rollout) and (3) IP HFCAs (post-IP rollout). Counterfactual trends for IP HFCA were inferred using the IP forward intercept and gradient parameters.Second, controlled interrupted time series analysis by fitting a Poisson regression model Plasmodium falciparum/Hybrid IP Cases in HFCA, monthly fixed term (to account for seasonality), Plasmodium falciparum/Mix cases in non-IP HFCA (to control for drops outside of IP) and time points of interaction with IP phases (pre/post IP rollout). To account for autocorrelation, standard errors and confidence intervals were calculated using the Newey-West method with a lag of 1. The formula published by Altman and Bland (15) was used to calculate the statistical significance of the difference between the ratios. Data analysis was done and graphs were prepared using RStudio (v 4.0.2, Vienna, Austria).

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