Trained volunteers improve their communities’ health service in rural Myanmar

Approx reading time: 2 mins

During a one-year pilot project in Myanmar’s western Sagaing region, malaria volunteers from 90 selected communities received continuous training on how to diagnose and treat three of the top child killing diseases (malaria, pneumonia and diarrhoea) and screen for malnutrition, an approach called integrated community case management (iCCM). The communities were selected because of their remoteness, lack of government health staff, the relatively high numbers of malaria and high rates of children under five with pneumonia and diarrhoea.

Malaria volunteers undergo refresher training in Kalay District

Malaria Consortium organised the first training of trainers in June 2016, under the leadership of the Ministry of Health and Sports, with monthly refresher trainings since January 2017.

Township health staff and the regional malaria control programme team were trained to become master trainers. These master trainers then cascaded their knowledge down to the malaria volunteers and their supervisors (midwives and health assistants). They taught the volunteers how to diagnose and treat malaria, pneumonia and diarrhoea and how to screen for malnutrition and midwives and health assistants how to supervise the volunteers practising the iCCM approach.

Malaria Consortium and the master trainers worked closely together to define the content and organise refresher trainings for malaria volunteers. “We learnt from each other,” Dr Moe Myint Oo, Malaria Consortium Myanmar Programme Manager said. “Every month, we analysed patient registers and supervision reports and gaps were addressed at the next month’s training. Particular malaria volunteers with weaker skills would receive more attention during the supervision and training.”

U Phone Myint Kyaw at a monthly supervision visit to Mandar village malaria volunteer U Kyaw Zin Lin

The malaria volunteers were already part of an existing network established by the Ministry of Health and Sports. Thanks to the training, the volunteers have now successfully demonstrated they can take on additional skills to improve the health services in their communities for malaria, pneumonia, diarrhoea and malnutrition. With new skills added to their duties, malaria volunteers remain an important asset to their remote communities.

U Phone Myint Kyaw, health assistant for Mandar village confirmed this, “Our malaria volunteer can treat simple pneumonia and diarrhoea and refer a serious case to the nearest health centre, he learnt to count a child’s breathing rate, prescribe antibiotics properly and record the data. Thanks to the timely treatment and referral, under five mortality can be reduced.”

The pilot’s success is reflected in a grant Malaria Consortium recently won from Comic Relief and GSK which will continue to support the populations of Sagaing region. The project will cover three additional townships (Kathar, Wuntho and Kawlin) for the next two years.

Funding for the pilot came from Vitol Foundation and UK Aid from the UK Government.

MC in the news: Dengue

Approx reading time: 4 mins

Last week Malaria Consortium Myanmar was in the news with a story about dengue. We worked with Oliver Slow, a journalist to talk about our work and the dengue situation in the country.

The story “The dreaded dengue on the rise” was published in Frontier Myanmar print and online newspaper, an “unbiased voice in transitional Myanmar”

The number of reported cases is rising and more countries are being affected, but dengue fever remains one of the most neglected tropical diseases.

For Ko Yan Naing Soe, 18, it started with a high fever. Thinking it was nothing serious, he didn’t seek medical advice.

“But after four days of a constant high fever, my family took me to the township hospital where I was diagnosed with dengue fever,” Yan Naing Soe, who was 13 at the time, told Frontier.

The township hospital did not have the facilities to perform the necessary blood transfusions, so he was transferred to a children’s hospital in Dagon Township.

“It was quite serious for a while, but after about a week I returned to normal and was released after 10 days. It was lucky they diagnosed it early,” he said.

Although rare, in extreme cases dengue can lead to death.

Last year saw a surge in dengue fever cases worldwide. In Myanmar, 43,845 cases and 140 deaths were reported, of which 135 were children under 14, World Health Organization figures show.

“Dengue cases were reported from all States and Regions, among which Sagaing, Ayeyarwaddy and Mandalay had the highest cases reported,” a WHO spokesperson told Frontier.

In 2016, there has been no reported dengue outbreak. To the end of August 1,505 cases had been reported, including 30 deaths, the spokesperson said.

Dengue is transmitted by female Aedes aegypti mosquitoes (the same species that transmits Zika, yellow fever and chikungunya). Female mosquitoes do not actually feed on human blood for their own nutritional purposes; the protein is needed to produce eggs. So really they’re just being good mothers – something to think about the next time you swat at a mosquito buzzing around your ear.

One of the first recorded cases of dengue was noted by a founding father of the United States, Benjamin Rush, who wrote of “bone-break fever” in As It Appeared in Philadelphia, in the Summer and Autumn of the Year 1780 – a book title that doesn’t exactly roll off the tongue.

The Aedes mosquito was wiped out in Central and South America in the 1950s and 1960s, but it would later return. No such eradication was ever achieved in Asia.

“A severe form of haemorrhagic fever, most likely akin to DHF [dengue haemorrhagic fever, a severe form of the disease], emerged in some Asian countries following World War II,” according to a WHO handout on the disease.

Before 1970, only nine countries had experienced severe dengue epidemics, but that has since grown to more than 100 nations worldwide. Southeast Asia is one of the most severely affected regions, together with the Americas and Western Pacific, according to the WHO.

The UN agency’s figures show that cases in the three regions exceeded 1.2 million in 2008 and over 3.2 million in 2015. “Recently the number of reported cases has continued to increase,” WHO said.

“Countries across Southeast Asia are seeing increased prevalence [in dengue],” said Dr Prudence Hamade, senior technical adviser for Malaria Consortium. “Factors include the migration of people, global warming and increased urbanisation.”

She told Frontier that poor living conditions, including a lack of access to clean water and poor sewage disposal, were fertile feeding grounds for mosquitoes and created “ideal conditions” for the spread of dengue in cities.

A major challenge in diagnosing dengue is the similarity in symptoms with other diseases including malaria and Zika, the latter of which has seen its first cases in Southeast Asia in recent weeks. Symptoms for dengue include high fever, severe headaches, joint and muscle pains, and rashes.

In late 2015 and early this year, the first dengue vaccine, Dengyvaxia, was registered for use in people between nine and 45 years of age in endemic countries.

“Some countries are already deploying it, however it is only partially effective in preventing the disease and only useful in patients nine years and older,” said Dr Hamade. Some of the most vulnerable to death from the disease are young children.

“The most effective way to remove the threat of dengue is to control the mosquitoes that spread the disease. It is therefore important to monitor the presence of these mosquitoes and, if found, to take measures to remove them,” she said.

Measures include being active in looking for mosquitoes, removing breeding sites (mosquitoes can breed in a bottle-cap of water) and protecting from mosquito bites during the day.

A major difficulty in combating dengue is that the Aedes mosquito is active during the day, meaning that mosquito nets are not as effective and outdoor workers are more vulnerable, said Dr Jeffrey Hii, senior vector specialist for Malaria Consortium Asia. His organisation is looking into insecticide-treated clothing for people who work outdoors.

Malaria Consortium is also advocating for more funding for dengue programs worldwide. The organisation argues that while malaria programs receive significant attention and funding, those related to the control of dengue are “seriously underfunded”.

Dengue is classified as one of the 17 recognised neglected tropical diseases, which are typically related to poverty, endemic to the tropics and have poor research funding.

“However, even within NTD circles, it has often been further neglected,” said Dr Hii. It was not one of the 10 NTDs selected by the London Declaration in 2012 as a priority disease to be eradicated.

“There has been a major lack of investment in dengue prevention and control, which has also been mirrored by a lack of policy dialogue within the international community and among governments,” said Dr Hii.

“While remarkable progress has been made against the majority of these 10 NTDs … we have not seen the same high-profile announcements or a commitment to tracking data and progress for dengue. Simply put, it is neglected.”

Resistance in the fight against malaria

Approx reading time: 4 mins

A growing public health risk originating in Asia, drug resistance, is threatening to undermine gains in malaria control

Significant progress has been made in recent years in the fight against malaria. Since 2000, mortality from malaria has decreased by over 25 percent globally. Scale-up of effective malaria interventions, including the use of artemisinin-based combination therapies – the most effective drug for treating the disease – have been instrumental to this success. However, growing resistance to artemisinins by the malaria parasite has been emerging in Southeast Asia and is threatening to reverse the gains that have been made to date. In this interview, Senior Technical Officer at Malaria Consortium, Dr Prudence Hamade, explains how dangerous a spread the spread of parasite resistance to anti-malarial drugs could be in Asia and beyond.

Q: Can you explain what drug-resistant malaria is and what the state of resistance is now in Southeast Asia?

A: Drug-resistant malaria refers to the strain of malaria parasites that have begun to show resistance to the drug currently being used to kill them. It occurs when a parasite is exposed to a specific drug, often over a long period of time, and successfully changes itself to avoid being killed. Increasingly over the last two or three years, we have noticed that artemisinin, the most effective drug we’ve ever had against malaria, is not working as well as it was in the early days, especially in Asia. It is used in combination with a partner drug, so the treatment is known as artemisinin-based combination therapy or ACT. The drugs clear the parasite from the blood very quickly, which in turn reduces the window for transmission of the parasite from one person to another. ACTs still cure the majority of people within 28 days, but in certain parts of Southeast Asia, there is more and more evidence that the parasite is surviving for longer, which indicates that resistance to artemisinin is on the rise.

Q: Where exactly are the problem areas?

A: The major hotspot for resistance to artemisinin is on the Thai-Cambodia border, where resistance was first detected in 2008. It has since been found elsewhere in Asia: on the Thai-Myanmar border and more recently in Vietnam. Although resistance in these areas is not at the levels we are witnessing along the Thai-Cambodia border, it is a clear indication that resistance to artemisinin is on the rise in the region.

Q: Why is Asia referred to as the hotspot for anti-malarial drug resistance?

Resistance to some of the most effective anti-malarial drugs we have used in the past first emerged in Southeast Asia: resistance to chloroquine for example was detected in the 1950s and Sulphadoxine-Pyrimethamine in the 1990s. Resistance to these drugs is now widespread throughout the world in many malaria endemic countries. Why Southeast Asia is the origin of this resistance is not completely clear but has been linked to the fact that artemisinin was introduced earlier there than elsewhere. Issues around the regulation of antimalarial drugs in the region and the use of monotherapies (where artemisinin is used alone rather than in combination treatments) have also been identified as likely contributors.

Q: The number of cases of malaria in Asia is much lower than in sub-Saharan Africa. Why then is artemisinin resistance in Asia such a grave public health concern?

A: If artemisinin was to stop working in Asia, it would mean that the number of cases of malaria in Asia would increase and become much more serious – because we won’t be able to reduce transmission or treat cases as effectively as before – and mortality will increase. The real worry is that this resistance could spread to Africa (where almost 600,000 people died from malaria in 2010), perhaps transferred by migrants, or emerging spontaneously. At the moment, we are still a long way from having another anti-malarial drug that is as effective or tolerated as well by patients as ACTs. It would then be highly likely that we would see an increase in morbidity and mortality from the disease.

Q: So how serious is the potential spread of resistance from Asia to Africa?

A: When resistance to chloroquine spread to Africa in the 80s and 90s, there were not adequate surveillance systems in place and it took a long time to detect. As a result there was an increase in the number of people dying from malaria. Pregnant women and young children in Africa are particularly vulnerable to malaria because they are the most likely to have either low or no immunity to the diseases, so if resistance to artemisinin were to spread to Africa now or in the next couple of years, the number of deaths among these groups in particular are likely to rise. It would also be more difficult to contain the spread of artemisinin resistance in Africa because of the widespread nature of the disease.

Q: What needs to be done to stop the spread of resistance in Asia?

A: The best case scenario would be to eliminate malaria from the region entirely. That would be extremely complicated but it could be possible. The first step to controlling the spread of resistance is to improve surveillance. We need good reporting systems in place because we need to know where the resistant malaria parasites are located in order to treat and eliminate the drug-resistant strains from those patients. That is the only way to stop the resistant strain spreading: to eliminate the resistant parasites as rapidly as possible by curing the patient quickly, thereby reducing the chances of those parasites being transmitted via mosquitoes to other people.

Q: So what is happening now?

A: The Bill & Melinda Gates Foundation funded the Containment Project, the first major initiative to contain artemisinin resistance in Southeast Asia. This project brought together regional governments and partners, including Malaria Consortium, to develop and implement a multi-pronged strategy to contain the resistance. Now, with support from the Global Fund and AusAid, partners in the region are trying to move beyond containing malaria and resistance, to eliminating malaria from the region altogether.