Finding Solutions
How can we protect our employees from malaria?
I would like guidance on protecting my local workforce
Are your local workforce resident on site or do they live in communities around the site?
Site residents Communities
Site residents Communities
Note that the information on this website may not be sufficient to guide appropriate approaches since these can be highly specific to the local context so professional advice should be sought.
In the GMS malaria is transmitted mostly by An. dirus and An. minimus which are extremely efficient malaria vectors primarily found in forested and forest fringe areas. Although habits vary both geographically and seasonally, they primarily bite outdoors in the first two quarters of the night. The rate of outdoor early evening biting has increased following the widespread use of LLINs. Despite the reduced level of protection of LLINs, they are still highly recommended although they should be complemented with other measures to combat outdoor transmission. Understanding local vector behaviour is important in the design of an appropriate approach.
Transmission can be intense but is usually highly focal and often sporadic; the high-risk groups include all those spending nights in forest or forest fringe areas. These include forest-based communities (often ethnic minority groups), forest workers (such as soldiers, forest/wildlife protection workers, timber extraction teams, gem miners, wood cutters and hunters), forest fringe agricultural workers (especially seasonal migrants) and rubber tappers).
Recommended options for the GMS setting are:
APMEN has developed country profiles and other summary resources on malaria control with more detailed information specific to countries within the region. You can access these here.
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Greater Mekong Sub-region (GMS)
In the GMS malaria is transmitted mostly by An. dirus and An. minimus which are extremely efficient malaria vectors primarily found in forested and forest fringe areas. Although habits vary both geographically and seasonally, they primarily bite outdoors in the first two quarters of the night. The rate of outdoor early evening biting has increased following the widespread use of LLINs. Despite the reduced level of protection of LLINs, they are still highly recommended although they should be complemented with other measures to combat outdoor transmission. Understanding local vector behaviour is important in the design of an appropriate approach.
Transmission can be intense but is usually highly focal and often sporadic; the high-risk groups include all those spending nights in forest or forest fringe areas. These include forest-based communities (often ethnic minority groups), forest workers (such as soldiers, forest/wildlife protection workers, timber extraction teams, gem miners, wood cutters and hunters), forest fringe agricultural workers (especially seasonal migrants) and rubber tappers).
Recommended options for the GMS setting are:
- Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are peak biting times and whether vectors primarily bite and rest indoors or outdoors.
- If entomological surveys show any level of indoor biting or resting then indoor residual spraying may be appropriate for shelters in which people sleep, eat, work or spend their recreational time. Click here for more information on IRS.
- Use indoor residual spraying on the walls and roofs of any semi-outdoor areas such as verandas, covered recreational areas etc. Click here for more information on IRS.
- Fit all doors and windows with mosquito screens. Click here for more information on screening.
- Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs. Consider site location: the further away that sites can be located from forest fringe, the lower the transmission risk is likely to be. On large sites it would be beneficial to locate sleeping areas, evening recreational areas or areas where night time work is carried out as far away from forest cover as possible.
- Personal protection measures should include:
- Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country
- Application of repellents in the early evening hours, especially by workers who are typically outside throughout the night (e.g. security guards, night shift workers and those working in or near forested areas). Click here for more information on repellents.
- Consider these other personal protection measures for personnel who spend most of their working hours outdoors during and between dusk and dawn:
- Insecticide treated clothing/ uniforms
- Insecticide treated scarfs or other traditional clothing for those used to wearing these
- Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click click here to access guidance on setting up locally appropriate treatment approaches.
- Health promotion and communications activities are key to promoting safe prevention and treatment seeking behaviours. Click here for more information on communications components of a control strategy.
APMEN has developed country profiles and other summary resources on malaria control with more detailed information specific to countries within the region. You can access these here.
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Note that the information on this website may not be sufficient to guide appropriate approaches since these can be highly specific to the local context so professional advice should be sought.
Here transmission is dominated by An. culicifacies, An. stephensi and to a lesser extent An. fluviatilis. An. stephensi is the only urban vector. These vectors are common across a range of habitats and transmission is often fairly wide-spread rather than focal. The urban vectors are especially adapted to these contexts and can breed in numerous man-made containers and structures.
In cooler parts of South Asia such as Afghanistan and northern Pakistan, malaria is at the fringe of its range and transmission is fairly unstable and very seasonal, with little to no transmission in the cooler winter months.
These vectors can bite both indoors and outdoors and biting is usually during the late evening and night. They often rest indoors; in rural areas most frequently in livestock sheds. The indoor resting means that indoor residual spraying can be highly effective in these areas. Insecticide treated nets are also useful and where people sleep outside during the hotter months outdoor use of nets has been successfully promoted. Depending on the result of entomological surveys and on the context, larval control through environmental management or larviciding can sometimes be useful.
Recommended options for the South Asia setting are:
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South Asia Sub-region
Here transmission is dominated by An. culicifacies, An. stephensi and to a lesser extent An. fluviatilis. An. stephensi is the only urban vector. These vectors are common across a range of habitats and transmission is often fairly wide-spread rather than focal. The urban vectors are especially adapted to these contexts and can breed in numerous man-made containers and structures.
In cooler parts of South Asia such as Afghanistan and northern Pakistan, malaria is at the fringe of its range and transmission is fairly unstable and very seasonal, with little to no transmission in the cooler winter months.
These vectors can bite both indoors and outdoors and biting is usually during the late evening and night. They often rest indoors; in rural areas most frequently in livestock sheds. The indoor resting means that indoor residual spraying can be highly effective in these areas. Insecticide treated nets are also useful and where people sleep outside during the hotter months outdoor use of nets has been successfully promoted. Depending on the result of entomological surveys and on the context, larval control through environmental management or larviciding can sometimes be useful.
Recommended options for the South Asia setting are:
- Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are: the distribution and type of larval breeding sites, level of preference for human hosts and night biting behaviour (time and location).
- Indoor residual spraying of walls and ceilings in dwellings, livestock sheds and shelters. Click here for more information on IRS.
- Fit all doors and windows with mosquito screens. Click here for more information on screening.
- Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs.
- Based on the result of the entomological surveys, larval control measures may be appropriate in some settings, particularly urban settings or areas which are predominantly dry with few breeding sites.
- Personal protection measures should include:
- Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country
- Where malaria transmission is highly seasonal, seasonal chemoprophylaxis could be considered.
- Application of repellents in the early evening hours and later at night for those who are exposed to vector biting, especially by workers who are typically outside throughout the night (e.g. security guards and night shift workers). Click here for more information on repellents.
- Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click click here to access guidance on setting up locally appropriate treatment approaches.
- Health promotion and communications activities are key to promoting prevention and safe treatment seeking behaviours. Click here for more information on the communications component of a control strategy.
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Note that the information on this website may not be sufficient to guide appropriate approaches since these can be highly specific to the local context so professional advice should be sought.
The epidemiology of malaria in the Pacific sub-region is highly complex due in part to the diversity of behaviours exhibited by the different sibling species that make up the An. farauti and An. punctulatus species complexes. Breeding site selection, which is often determined by tolerance to salinity, and adult feeding behaviour varies throughout the region. These behaviours have a major effect on transmission patterns; in some settings for example, transmission takes place mostly in coastal areas. However, some generalizations can be drawn. In most areas a significant proportion of transmission occurs indoors late at night, which means that the use of insecticide treated nets should have a strong protective effect. Some indoor resting occurs in most areas and so IRS is also generally useful.
Larval control may be feasible in defined areas where all breeding sites can be mapped and accessed. However, generally this approach is not feasible as most vectors breed in a range of small, scattered temporary pools. Measures should be taken to avoid the creation of new breeding sites (during construction work for example) since An. punctulatus can rapidly increase in numbers in response to a proliferation of breeding sites.
In some countries, such as the Solomon Islands, wide-spread use of insecticide based control measures has reduced the importance of An. punctulatus as a vector, but has also resulted in a shift in the biting behaviour of An. farauti, which now bites earlier and outdoors. This means that ITNs and IRS alone are insufficient to provide full protection against malaria.
Recommended options for the Pacific setting include:
Special case: Indonesia Indonesia has a particularly complex malaria profile and here generalizations are more difficult to make than elsewhere.
Indonesia spans the Asia and Pacific sub-regions and has a large number of malaria transmission profiles. Bali, Java and Batam have low transmission. Sumatra, Kalimantan and Sulawesi have moderate transmission. All other provinces have moderate to high transmission.
There is high diversity of vector species on the major islands. For example, in Sumatra, An. sinensis is found inland along with the An. barbirostris complex, An. leucosphyrus/An. latens and the An. minimus complex. A number of other vector species also exist on Sumatra but none are considered dominant on the island; hence they are over- laid by the other, more dominant species. Alongside the An. sundaicus complex distributed along the coast, An. flavirostris does increase in relative ‘dominance’, by virtue of a reduced presence of other species, extending southward through Java until it is the only dominant vector species found in the Lesser Sunda islands. In Sumatra, there is very little overlap amongst the dominant species found, suggesting that each occupies a separate niche. Anopheles balabacensis dominates across most of Borneo, with some impact by the An. barbirostris complex and An. leucosphyrus/latens inland and the An. sundaicus complex on the coast. This APMEN profile gives more detail about the complex Indonesian setting.
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Pacific Sub-region
The epidemiology of malaria in the Pacific sub-region is highly complex due in part to the diversity of behaviours exhibited by the different sibling species that make up the An. farauti and An. punctulatus species complexes. Breeding site selection, which is often determined by tolerance to salinity, and adult feeding behaviour varies throughout the region. These behaviours have a major effect on transmission patterns; in some settings for example, transmission takes place mostly in coastal areas. However, some generalizations can be drawn. In most areas a significant proportion of transmission occurs indoors late at night, which means that the use of insecticide treated nets should have a strong protective effect. Some indoor resting occurs in most areas and so IRS is also generally useful.Larval control may be feasible in defined areas where all breeding sites can be mapped and accessed. However, generally this approach is not feasible as most vectors breed in a range of small, scattered temporary pools. Measures should be taken to avoid the creation of new breeding sites (during construction work for example) since An. punctulatus can rapidly increase in numbers in response to a proliferation of breeding sites.
In some countries, such as the Solomon Islands, wide-spread use of insecticide based control measures has reduced the importance of An. punctulatus as a vector, but has also resulted in a shift in the biting behaviour of An. farauti, which now bites earlier and outdoors. This means that ITNs and IRS alone are insufficient to provide full protection against malaria.
Recommended options for the Pacific setting include:
- Conduct detailed entomological surveys to determine main malaria vectors and their behaviour in the local setting. Although a complete survey is advised, behaviours of particular interest are the distribution and type of larval breeding sites as well as biting behaviour (time and location).
- Indoor residual spraying on the walls and ceilings of houses and any semi-outdoor areas such as verandas, covered recreational areas etc. in which people spend time at night sleeping, eating, working or relaxing. Click here for more information on IRS.
- Fit all doors and windows with mosquito screens. Click here for more information on screening.
- Ensure all staff sleep under insecticide treated mosquito nets whether they are sleeping indoors or outdoors. Alternative designs of insecticide treated nets such as treated hammock nets are available and could be used for workers who tend to sleep outdoors. Click here for more information on ITNs.
- Personal protection measures should include:
- Use of an appropriate chemoprophylaxis. Click here for more information on chemoprophylaxis and for information on recommended options by country. Where malaria transmission is highly seasonal, seasonal chemoprophylaxis could be considered.
- Application of repellents in the early evening hours and later at night for those who are exposed to vector biting, especially by workers who are typically outside throughout the night (e.g. security guards and night shift workers). Click here for more information on repellents.
- Effective case management is an essential element in malaria control. Differential diagnosis is important to identify malaria species and thereby support the selection of an appropriate treatment. It is also essential in order to identify other possible causes of disease. Microscopy is recommended over RDTs if possible provided that robust quality assurance is in place. Click here for more information on malaria case management and click click here to access guidance on setting up locally appropriate treatment approaches.
- Health promotion and communications activities are key to promoting prevention and safe treatment seeking behaviours. Click here for more information on the communications component of a control strategy.
Special case: Indonesia Indonesia has a particularly complex malaria profile and here generalizations are more difficult to make than elsewhere.
Indonesia spans the Asia and Pacific sub-regions and has a large number of malaria transmission profiles. Bali, Java and Batam have low transmission. Sumatra, Kalimantan and Sulawesi have moderate transmission. All other provinces have moderate to high transmission.
There is high diversity of vector species on the major islands. For example, in Sumatra, An. sinensis is found inland along with the An. barbirostris complex, An. leucosphyrus/An. latens and the An. minimus complex. A number of other vector species also exist on Sumatra but none are considered dominant on the island; hence they are over- laid by the other, more dominant species. Alongside the An. sundaicus complex distributed along the coast, An. flavirostris does increase in relative ‘dominance’, by virtue of a reduced presence of other species, extending southward through Java until it is the only dominant vector species found in the Lesser Sunda islands. In Sumatra, there is very little overlap amongst the dominant species found, suggesting that each occupies a separate niche. Anopheles balabacensis dominates across most of Borneo, with some impact by the An. barbirostris complex and An. leucosphyrus/latens inland and the An. sundaicus complex on the coast. This APMEN profile gives more detail about the complex Indonesian setting.
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Community-wide transmission of malaria and considering a buffer zone.
Although most mosquito vectors of malaria have a flight range of around 2km, this can vary considerably (for instance, one of the major Pacific vectors has an average flight range of about half this) and flight ranges greater than about 5km are not usual. Mosquitoes can spread malaria within their flight ranges so a new works site for example located within a few kilometres of an endemic community can quickly become a focus of transmission.
In areas of high transmission older children and adults develop a high degree of immunity to the disease and harbour parasites without developing symptoms. These individuals act as a permanent reservoir of parasites for the local mosquito vectors to pick up and pass on.
When considering site-wide vector control approaches, it is often wise to consider expanding control efforts into the surrounding communities to create a buffer zone of lowered transmission around the site. Where IRS is used this is particularly important since this control approach relies on achieving a community-wide impact on the mosquito vector population, shortening the average mosquito life span so that individual mosquitoes don’t live long enough for the parasite to have sufficient time to develop in the mosquito and be passed on.
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Do you want to design a malaria control programme to reduce malaria in local communities?
Yes No Help me decide
Yes No Help me decide
Protecting employees without community-wide programmes
It may be that the decision is made to focus malaria control measures on the workforce alone, without expansion to local communities. (Though, click here to read more about why expanding control measures to the local communities may be useful).
If a strategy of focusing only on the workforce is chosen then vector control efforts may be in place within but not outside the fence; yet local employees may be on rotation and returning regularly to home communities outside the fence. Measures to limit the malaria risk in employees at all times could include:
- Providing employees with malaria prevention measures that they can take with them to use when returning to home communities. This could include any of the personnel protection measures considered appropriate to the context, such as insecticide treated nets, insecticide treated traditional clothing and repellents. If this approach is taken it is highly recommended that the employees are given sufficient commodities to provide protection for their whole family. Aside from the clear ethical impetus for this approach, it also improves the likelihood that the employee will receive the protection from malaria which the company intends; rather than, for example, ensuring his/her children or other family members are protected by the one ITN provided.
- Ensuring high quality case management services are available, for prompt diagnosis and treatment should the employee fall sick with malaria. Employees should be able to access on site clinics regardless of whether they are currently on rotation on site; and the company may also consider reviewing and, where appropriate, supporting clinical services available in some of the major communities from which the workforce is drawn.
Building a community wide malaria control programme: advantages, disadvantages and options.
Disadvantages of establishing a community-wide malaria control programme:
- Costs: malaria commodity costs can be considerable (WHO, 2012 and Wafula et al., 2010)
- LLINs cost around $2.7 - $4 per net if bought in bulk, often more if bought in smaller quantities.
- ACTs cost around $1.3 - $1.4 for an adult treatment course (for the most commonly procured brand which is an artemether-lumefantrine combination).
- RDTs cost around $0.7 for a multi-species test.
- IRS costs vary considerable in relation to economies of scale. Where more than 1 million people are protected, as in large national programmes, costs per person protected will be lower; but in smaller programmes, such as those likely to be supported by private companies, costs can be around $5.5 per person protected.
- Designing and implementing an effective community-wide malaria control strategy requires specialised skills in entomology, malaria vector control, case management, community health promotion and communication.
Advantages of establishing a community-wide malaria control programme:
- A high impact option for a corporate social responsibility programme.
- An ethical responsibility if companies are working in a local area where malaria is a high priority problem and where their activities risk increasing transmission (click here for more information on the potential for businesses to affect malaria transmission).
- Lowering malaria transmission at the community scale will reduce the risk of malaria in the company’s workforce (click here for the information on community-wide transmission and the importance of a buffer zone) thereby having economic benefits for the company through reduced work time lost, improved productivity, lower healthcare costs etc. (click here for more information on the impact of malaria on businesses).
Options for establishing a community-wide malaria control programme:
Some general options planners could consider are described here. Click the links to access more information on each of these possible options. [Option titles and text for the links are shown below (Options 1 - 8).
- Technical appropriateness - linked to:
- Disease epidemiology
- Potential for impact on disease
- Alignment with international and national priorities
- Operational appropriateness – linked to:
- Capacity of local health systems
- In-house capacity in relevant areas
- Capacity available through out-sourcing
- Size and life of operation and potential for sustainability
- Cost-effectiveness and efficiency
- Equity
- Feasibility (political, financial), including consideration of options using lobby and advocacy activities to increase political will and secure additional financing
- Potential for impact on:
- Disease burden
- Company finances
- Company reputation
This appraisal will inform detailed planning undertaken in the next step.
Option 1: One off focus on community-wide LLIN coverage
Rationale: Companies could fund and support mass insecticide treated net distribution if appropriate to the setting and if ownership of LLINs is low. Depending on the epidemiological context, this could provide good community protection as long as the nets remain in use.
Approach: A one-off distribution campaign with sufficient LLINs to provide total coverage in all households in the target community (usually one LLIN per two people) – either door-to-door or through community distribution points. This would need to be accompanied by a health communication component to promote use.
Pros: Few specialized skills are required aside from advice on whether LLINs are an effective control measure in the setting.
Can have a high and instant impact in areas where LLINs are appropriate and if coverage was previously low.
Cons: Ideally a mass distribution of nets should be accompanied by an approach for communities to access replacement nets as needed, otherwise coverage levels will gradually drop. Companies are therefore encouraged to think longer term than a single distribution campaign.
Option 2: On-going community-wide prevention
Rationale: Ensuring effective vector control measures are in place community-wide in all local communities would have a high impact and help to reduce the risk of infection in those people residing within the company compound, given the community-wide impact on transmission levels.
Approach: This would need to be tailored to the local setting but could include indoor residual spraying cycles or larval site mapping and removal / treatment programmes. Community involvement would be critical and long-term engagement required. Health promotion would be a necessary component to ensure support.
Pros: Can be high impact if a well-designed programme is put in place; based on the local epidemiological context and with quality assurance measures in place for its implementation.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires strong community involvement and support for success. Requires long-term commitment and a clear exit-strategy.
Option 3: Establishing new clinics
Rationale: Where there are no malaria case management services, establishing and maintaining high quality facilities would be an effective way to reduce the rates of serious illness and death from malaria.
Approach: This could involve making clinics inside compounds accessible to communities; or building, equipping, staffing and maintaining new clinics outside the compound to serve local communities. A range of levels of involvement are possible depending on the capacity of the local health authorities or other local organisations, for example the company could establish the clinics and hand over their management to others (see below). Health promotion would be a necessary component to ensure facilities are used.
Pros: Potential for extremely high impact. Appropriate to fulfil the responsibility of care to employees and their families. Good quality clinical services may be the highest priority need if these do not exist.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires long-term commitment and a clear exit strategy. There can be high initial costs if infrastructure and equipment is needed.
Option 4: Support existing clinics
Rationale: Where existing clinics are accessible, the company could consider supporting these. This may be a more cost-effective and sustainable approach.
Approach: Health facility assessments would be needed to examine existing infrastructure, equipment, supplies, personnel and services. These should include gathering community perspectives on their needs and the current services. As discussed above, partnership with the organizations responsible for the health facilities would be essential from early planning stages throughout assessment and design of the support package. The support package could be purely financial, or could see the company contracting groups to provide infrastructure, equipment improvements or training. If this approach is taken a quality assurance component would be needed to ensure that company support is resulting in better quality of care.
Pros: May be more cost-effective than establishing new clinics. May be more sustainable, though an exit strategy and measures to ensure sustainability would need to be included in the support package. Cons: Working with partners may be problematic in some settings. Change in service provision and care approaches may be difficult to achieve in some settings. The company may have less control over quality than they had hoped. May be less opportunity than some other approaches for clear ‘branding’ of company support.
Option 5: Support other existing activities
Rationale: In some locations the local health authorities and other organisations may be very active in malaria control, or in public health with the possibility of expansion into malaria control. They may have clear plans and clear knowledge of resource gaps which the company could fill.
Approach: Discuss with all organizations working in health locally to determine if there are other activities that the company could support. The company will need to assess potential partners for capacity and appropriateness for support.
Pros: Fills an already identified need; leverages existing local skills and partnerships.
Cons: There may be few or no organisations active in the company’s location. Organisations that are active may not have the capacity to absorb additional funds or to manage expanded programmes. May be fewer opportunities than in some other approaches for clear ‘branding’ of company support.
Option 6: Contribute financially to the national malaria control programme
Rationale: All countries within this region have national malaria control programmes with clear malaria control strategies and often up to date gap analyses showing where they need additional support in order to fulfil their strategic aims. Companies with funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and likelihood of this being achieved. There could also be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact.
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 7: Contribute financially to other initiatives in country, such as the private malaria control sector
Rationale: In the Asia-Pacific region there are many private companies working in the malaria industry, from Artemisia growers to drug manufacturers and distribution companies for malaria commodities. There may be opportunities to partner with such an organization to expand its role in the malaria industry, playing a useful role in the area of malaria commodities supply.
Approach: Review local private companies working in the field. Through meetings and discussions explore opportunities for support. This process should be led by or include expert advice from specialists in the field of malaria and malaria commodities.
Pros: The role of the private sector in the malaria industry is important at a number of levels but such companies often have few opportunities to access financial support to expand their role.
Cons: Requires specialist advice on needs and appropriate areas of support. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 8: Contribute financially to regional or global bodies
Rationale: Regional organizations such as WHO regional offices, the Asian Pacific Leaders Alliance and the Asia-Pacific Malaria Elimination Network are all credible organisations working to reduce malaria in the region with clear strategies and likely existing resource gap analyses. Companies that have funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: a review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and the likelihood of this being achieved. There could be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Rationale: Companies could fund and support mass insecticide treated net distribution if appropriate to the setting and if ownership of LLINs is low. Depending on the epidemiological context, this could provide good community protection as long as the nets remain in use.
Approach: A one-off distribution campaign with sufficient LLINs to provide total coverage in all households in the target community (usually one LLIN per two people) – either door-to-door or through community distribution points. This would need to be accompanied by a health communication component to promote use.
Pros: Few specialized skills are required aside from advice on whether LLINs are an effective control measure in the setting.
Can have a high and instant impact in areas where LLINs are appropriate and if coverage was previously low.
Cons: Ideally a mass distribution of nets should be accompanied by an approach for communities to access replacement nets as needed, otherwise coverage levels will gradually drop. Companies are therefore encouraged to think longer term than a single distribution campaign.
Option 2: On-going community-wide prevention
Rationale: Ensuring effective vector control measures are in place community-wide in all local communities would have a high impact and help to reduce the risk of infection in those people residing within the company compound, given the community-wide impact on transmission levels.
Approach: This would need to be tailored to the local setting but could include indoor residual spraying cycles or larval site mapping and removal / treatment programmes. Community involvement would be critical and long-term engagement required. Health promotion would be a necessary component to ensure support.
Pros: Can be high impact if a well-designed programme is put in place; based on the local epidemiological context and with quality assurance measures in place for its implementation.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires strong community involvement and support for success. Requires long-term commitment and a clear exit-strategy.
Option 3: Establishing new clinics
Rationale: Where there are no malaria case management services, establishing and maintaining high quality facilities would be an effective way to reduce the rates of serious illness and death from malaria.
Approach: This could involve making clinics inside compounds accessible to communities; or building, equipping, staffing and maintaining new clinics outside the compound to serve local communities. A range of levels of involvement are possible depending on the capacity of the local health authorities or other local organisations, for example the company could establish the clinics and hand over their management to others (see below). Health promotion would be a necessary component to ensure facilities are used.
Pros: Potential for extremely high impact. Appropriate to fulfil the responsibility of care to employees and their families. Good quality clinical services may be the highest priority need if these do not exist.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires long-term commitment and a clear exit strategy. There can be high initial costs if infrastructure and equipment is needed.
Option 4: Support existing clinics
Rationale: Where existing clinics are accessible, the company could consider supporting these. This may be a more cost-effective and sustainable approach.
Approach: Health facility assessments would be needed to examine existing infrastructure, equipment, supplies, personnel and services. These should include gathering community perspectives on their needs and the current services. As discussed above, partnership with the organizations responsible for the health facilities would be essential from early planning stages throughout assessment and design of the support package. The support package could be purely financial, or could see the company contracting groups to provide infrastructure, equipment improvements or training. If this approach is taken a quality assurance component would be needed to ensure that company support is resulting in better quality of care.
Pros: May be more cost-effective than establishing new clinics. May be more sustainable, though an exit strategy and measures to ensure sustainability would need to be included in the support package. Cons: Working with partners may be problematic in some settings. Change in service provision and care approaches may be difficult to achieve in some settings. The company may have less control over quality than they had hoped. May be less opportunity than some other approaches for clear ‘branding’ of company support.
Option 5: Support other existing activities
Rationale: In some locations the local health authorities and other organisations may be very active in malaria control, or in public health with the possibility of expansion into malaria control. They may have clear plans and clear knowledge of resource gaps which the company could fill.
Approach: Discuss with all organizations working in health locally to determine if there are other activities that the company could support. The company will need to assess potential partners for capacity and appropriateness for support.
Pros: Fills an already identified need; leverages existing local skills and partnerships.
Cons: There may be few or no organisations active in the company’s location. Organisations that are active may not have the capacity to absorb additional funds or to manage expanded programmes. May be fewer opportunities than in some other approaches for clear ‘branding’ of company support.
Option 6: Contribute financially to the national malaria control programme
Rationale: All countries within this region have national malaria control programmes with clear malaria control strategies and often up to date gap analyses showing where they need additional support in order to fulfil their strategic aims. Companies with funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and likelihood of this being achieved. There could also be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact.
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 7: Contribute financially to other initiatives in country, such as the private malaria control sector
Rationale: In the Asia-Pacific region there are many private companies working in the malaria industry, from Artemisia growers to drug manufacturers and distribution companies for malaria commodities. There may be opportunities to partner with such an organization to expand its role in the malaria industry, playing a useful role in the area of malaria commodities supply.
Approach: Review local private companies working in the field. Through meetings and discussions explore opportunities for support. This process should be led by or include expert advice from specialists in the field of malaria and malaria commodities.
Pros: The role of the private sector in the malaria industry is important at a number of levels but such companies often have few opportunities to access financial support to expand their role.
Cons: Requires specialist advice on needs and appropriate areas of support. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 8: Contribute financially to regional or global bodies
Rationale: Regional organizations such as WHO regional offices, the Asian Pacific Leaders Alliance and the Asia-Pacific Malaria Elimination Network are all credible organisations working to reduce malaria in the region with clear strategies and likely existing resource gap analyses. Companies that have funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: a review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and the likelihood of this being achieved. There could be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Establishing malaria diagnosis and treatment facilities
Reducing the likelihood of serious illness and death from a case of malaria depends on:
- High quality and appropriate diagnostic services being available
- People with suspected malaria accessing these services
- Case management guidelines being followed by clinical staff
- Treatment being adhered to by patients if not directly administered or observed.
Establishing sound guidelines and high quality facilities are one step in this process, but maintaining quality of services and ensuring communities access facilities are also critical and should also be addressed. Click to access more information on quality control for malaria case management services and on health promotion and communication strategies.
Steps in establishing good quality malaria case management services include:
- Determining the type of malaria parasites found in this site
- Deciding which approach to diagnosis will be taken [Malaria diagnosis requires specialized equipment – either rapid diagnostic tests (RDTs) which require appropriate transport and storage, or microscopy for which both specialized equipment and skills are required. In the Asia-Pacific context where both vivax and falciparum malaria are present and co-infection is common, microscopy may be the best choice where it is considered feasible. RDTs that can differentiate between falciparum and vivax malaria are available but perform less well than good microscopy. ]
Diagnosis guidelines should include:
- Patient characteristics (signs, symptoms, history) that indicate the need for a malaria diagnostic test.
- Procedures for diagnosis including time targets.
- Recording procedures.
- Procedures following a negative result including:
- Time-frame and indicators for repeat testing
- Considerations for alternate diagnosis
- Developing guidelines for transport, storage and handling of RDTs if these are to be used. A good resource for this is available here.
- Deciding which treatment guidelines will be recommended. This should always follow international best practice and almost always be in-line with national treatment guidelines.
This table gives an overview of the interventions which the World Health Organisation recommends for each country in the Asia Pacific regin. The ‘treatment’ section of the table gives details on appropriate treatment and diagnosis. The WHO global malaria report has country profiles, each of which lists the specific drugs which each country has opted for as first line recommended treatment.
However the most complete source of information is the national treatment and diagnosis, or ‘case management’ guidelines which each country develops. A search for the Ministry of Health or National Malaria Control Programme website for your country of operations should guide you to links for national treatment guideline documentation.
Click here to see more about the importance of adhering to international and local guidelines.
Treatment guidelines should include:
- Recommended treatment for each malaria species
- Recommended treatment and clinical management depending on severity of illness: uncomplicated malaria versus severe malaria
- Recommended treatment and clinical management for special groups including those with HIV, pregnant women, young children, those on malaria chemoprophylaxis.
- Detailed referral guidelines.
- Developing a clear, succinct written malaria case management guidelines document for local use (this could be based on international guidelines available here).
- Developing brief job-aides which can be displayed or referred to at the clinic or lab.
- Identifying reliable suppliers of high quality diagnosis and treatment commodities.
- Establishing a quality control strategy
- Developing a communications strategy to ensure all those permitted to access the services are aware of their availability and the basics of the services provided.
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Quality control malaria diagnosis and treatment facilities
Diagnosis
Deciding whether to use RDTs or microscopy or a combination of the two for confirmation of a malaria infection is important but an informed decision relies on the assumption that either of the tools will go on to be used in such a way as to ensure the best performance possible.
Quality control of handling
For RDTs, appropriate transport, storage and handling, in-line with the manufacturer’s recommendations, are important to ensure the RDTs remain stable and achieve their reported levels of sensitivity and specificity (rates of false negatives and false positives).
Guidelines for handling and storage of RDTs should be in place and should include recording of the conditions of storage daily. A supervisory structure should be put in place that allows checking of storage facilities at regular intervals.
The FIND manual on storage, handling and transport of RDTs can be accessed here.
Quality control of RDT use and results
- Regular supervisory checks of clinical services should include observation of RDT use to verify that user instructions are being carefully followed. It is advisable to increase supervision if the RDT product is changed as instructions for use vary from product to product.
- Regular quality assurance of results should be conducted. Blood slides should be prepared at the same time as the RDT test for a random sub-set of people tested for malaria. These should be read by a skilled microscopist (either on-site or by a referral laboratory) to confirm alignment with RDT results.
Quality control of microscopy
A random sub-set of blood smears should be sent for cross-checking by an external microscopist, likely to be available in a referral laboratory within the country. The cross-check results should be compared with the on-site results.
Quality control findings should be carefully reviewed each time to identify needs for remedial training of on-site microscopy staff.
The WHO manual on quality control of malaria microscopy can be accessed here. Whilst it is written for an audience of national managers it includes an overview of all the key steps in a quality control process.
Quality control of use of diagnostic results
Whilst a main focus of diagnostic quality control will be to ensure tests are accurate, it is also important to provide quality control for the second step in the diagnostic process which is ensuring the results are used appropriately.
Health clinic record books should require health staff to record details for every person tested for malaria, the means of testing, the result, the actions taken and the staff member responsible.
These records should be regularly checked as part of the quality control process and remedial training undertaken if appropriate.
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Considering who to make malaria clinical facilities available to.
There are four main options:
- Employees only
- Employees and their families
- All local communities within a specified area
- Anyone who comes to the clinic. (In many areas will add few additional patients to the above, it may therefore be easier to avoid making statements or guidelines about the communities who are permitted to access. This will also avoid the need to verify place of residence).
Reasons to limit access to services could include:
- To reduce the costs associated with use of commodities and other resources
- To reduce the burden on the services in-line with the staff time available
- To reduce the consumption of commodities if these are scarce or there is or is expected to be a supply problem.
However, good reasons for expanding the availability of services as far as possible include:
- The epidemiology of malaria transmission means that control of the disease is most effective if both prevention and treatment services are in place at scale and community-wide. Reducing the parasite reservoir in the local communities by prompt and effective treatment of cases is an important contributing factor to successful malaria control. Extending the availability of services is therefore not purely altruistic but will also likely reduce the impact of malaria within the workforce itself, and thus on the company.
- Availability of high quality malaria case management services is often poor in the rural and remote areas in which many companies work. Making these services available to the local communities is an undeniably useful and potentially high impact option for part of a corporate social responsibility programme.
Options to make some services available more widely and some to a more defined group are also possible. For example, a company might offer diagnostic and out-patient services to local non-employee families but refer them elsewhere for in-patient care if required, while providing full in-patient services as necessary for employees and their family members.
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Health facility based Data collection and analysis for malaria
A range of data should be collected as part of an overall surveillance strategy. Clinical data on people tested and diagnosed as well as the treatments undertaken and if possible the outcomes, are an important part of this surveillance strategy. These data can be used to track burden of disease – in general and in sub-groups – as well as to monitor performance of drugs.
Specific data that should be collected include:
- Details of all people tested for malaria: name, age, sex, occupation, residence, places visited in past month, malaria history. This should be linked to:
- Results of all malaria tests: type(s) of test, person(s) responsible, result(s) and action taken. This should be linked to:
- Results of all malaria treatments given including results of follow-up testing after treatment if recommended.
- Data summaries that will be useful:
- People tested by month and sub-group
- Test positivity rate by month and sub-group
- Number of malaria cases by month and sub-group
Specific uses that these data can be put to include:
- Tracking the disease burden over time. Looking at annual trends to ascertain when any peaks of malaria transmission occur by malaria type. This information can guide control approaches as well as inform commodity supply planning.
- Looking at the malaria incidence rates (number of cases per 1,000 population during a given period) in different sub groups, such as:
- Occupational groups: this could help identify high risk occupations which could benefit from targeted control measures.
- Residence (on-site, off-site or workers who move between locations; different off site locations) this could help identify where transmission is occurring and inform planning of vector control interventions or targeted personal protection for those in or visiting certain sites.
- Those using / not using chemoprophylaxis: this can help determine the effectiveness of the chemoprophylaxis as well as inform analysis of the cost benefits.
- Looking at the total burden of malaria to inform:
- estimates of economic impact of malaria on the company and local communities
- commodity planning
- impact evaluations
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We hope this site has helped given you an overview of the issue of malaria control in the Asia-Pacific, and answered your questions, or given you new ideas. You may now feel well equipt to set up solid programmes to protect your own staff, or to explore opportunities for getting involved outside the fence. If you would still like further support please feel free to get in contact with us.
How malaria consortium can help
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