Malaria in the Asia Pacific

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.


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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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Are your current malaria diagnosis and treatment practices in line with national guidelines?

No Yes

Understanding and adhering to national policy and international guidelines

International guidelines for malaria control are developed by the World Health Organization (WHO). Links to their guidelines for prevention, diagnosis, treatment, communications, surveillance and monitoring and evaluation aspects of malaria control programmes are included in the additional resources section.

National malaria control programmes use these international guidelines to develop their own national malaria policies and strategies for malaria control within their country. These typically include detailed guidelines for prevention approaches that should be supported, diagnosis approaches to be used, and treatment guidelines for uncomplicated and severe malaria of different types and in different patient categories. These detailed national guidelines often include specific instructions for variation within the country depending on epidemiology and context.

All malaria control activities should adhere to international guidelines. In addition, it is good practice to adhere to national guidelines. These should almost certainly be adhered to where community-wide activities are undertaken, and should generally also be adhered to for interventions targeting employees, unless there are compelling reasons otherwise.

Reasons for adhering to national guidelines include:

• Improving the likelihood that activities will be sustainable by building capacity relating to national approaches in the local health system or local organizations.
• Improving the likelihood that company activities can be used to leverage additional or continuing funding from the government or other regional donors.
• Responsibility to support the goals and plans of the host government.

Compelling reasons to veer from national guidelines when considering employee health may include:

• If national policies are not in-line with international best practice.
• If national policies are based on a context of insufficient funding, and the company is able to commit to supporting higher cost but more effective interventions.

Do you have a policy for management of severe malaria in line with best practice guidelines?

No Yes Check best practice guidelines

Managing severe malaria

If the malaria illness has already developed past the early ‘uncomplicated’ stages the patient should be hospitalized. Artesunate suppositories are available for the pre-referral treatment of severely ill patients who present at peripheral health facilities, which do not have in-patient facilities. Until recently quinine was the first-line treatment for severe falciparum malaria, but current WHO guidelines state that intravenous artesunate should now be used in preference to quinine followed by a complete course of ACT. While quinine remains a highly effective drug for the treatment of severe malaria it has unpleasant side effects and so is best avoided, except where artemisinin resistance has been documented.

[Image:…]

This table gives an overview of the recommended control approaches including case management in the Asia-Pacific region

[(Table 2: control approaches, in images folder)– and link it to the interactive map]

Click here to go to the ‘Additional Resources’ section and find resources and links to websites with further information on Managing severe malaria.

ADDITIONAL RESOURCES
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Steps in establishing good quality malaria case management services include:

1. Determining the type of malaria parasites found in this site
2. 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:
   
   1. Patient characteristics (signs, symptoms, history) that indicate the need for a malaria diagnostic test.
   2. Procedures for diagnosis including time targets.
   3. Recording procedures.
   4. Procedures following a negative result including:
      1. Time-frame and indicators for repeat testing
      2. Considerations for alternate diagnosis
3. Developing guidelines for transport, storage and handling of RDTs if these are to be used. A good resource for this is available here.
4. 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:
   
   1. Recommended treatment for each malaria species
   2. Recommended treatment and clinical management depending on severity of illness: uncomplicated malaria versus severe malaria
   3. Recommended treatment and clinical management for special groups including those with HIV, pregnant women, young children, those on malaria chemoprophylaxis.
   4. Detailed referral guidelines.
5. Developing a clear, succinct written malaria case management guidelines document for local use (this could be based on international guidelines available here).
6. Developing brief job-aides which can be displayed or referred to at the clinic or lab.
7. Identifying reliable suppliers of high quality diagnosis and treatment commodities.
8. Establishing a quality control strategy
9. 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.

Who are your clinical services available to?

Employees Employees Families Community Other

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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Do you collect and regularly review any malaria data?

Yes No

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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You may want to review this information to check if there is any more you could be doing with your malaria data

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Surveillance and outbreak detection and response

Malaria surveillance is important in every epidemiological setting but it is important to note that it takes different forms.

In areas of very low malaria incidence, where elimination is a realistic goal, programmes will need to identify and respond to every potential malaria case. This entails ensuring that every possible malaria case is accurately diagnosed, and that confirmed malaria cases are treated effectively. Where funds allow, active case detection may also be used. This means taking the tests to the community rather than waiting for symptomatic people to present themselves to a healthcare provider. Active case detection may involve screening whole communities in areas where malaria cases are expected.

In areas of moderate and unpredictable malaria transmission surveillance is particularly important to maintain accurate information on the geographical distribution of the disease. Surveillance of this kind is used to target control efforts and to detect early signs of malaria outbreaks, so that a timely response can be initiated to prevent or limit the size of epidemics. Often such surveillance is conducted through routine reporting of malaria cases identified at health facilities and by peripheral healthcare providers such as village health workers. Efforts need to be made to ensure that this reporting system is accurate and timely. The resulting data needs to be analysed correctly and acted upon swiftly and appropriately.

Upon detection of an outbreak programme managers should conduct an outbreak investigation. This should involve:

• A visit to the sites reporting an upsurge in cases,
• Investigation of the quality of data and the validity of the reported upsurge in cases,
• Mapping the cases and investigating their likely origins,
• Focal screening and treatment of any additional cases.

If an outbreak is confirmed the officer responsible should immediately initiate an outbreak response. This should involve:

• Entomological assessment and design of vector control response if appropriate. Most commonly any response would involve indoor residual spraying and/or ensuring everyone at risk has access to an insecticide treated bed-net.
• Active case detection throughout the target area with expansion of the target area as appropriate if additional cases are identified. This should continue until caseload falls to normal levels.
• Communication campaigns to remind communities how to protect themselves and seek treatment,
• Continued close monitoring of case reports from the target area and surrounding epidemic prone areas after the outbreak is brought under control.

Malaria surveillance data from all areas is also key to assessing programme impact over time. Where scientific methodology is applied, malaria surveillance data can be used to assess the impact of specific interventions in specific settings, an essential step in the design of locally appropriate malaria control strategies in areas of residual transmission for example.

Routine surveillance is also required at the national level to monitor drug and insecticide resistance. This surveillance enables programmes to ensure that only effective drugs and insecticides are used. In the event of early signs of resistance being detected, prompt action can be taken to avoid treatment or intervention failure and thereby prevent malaria resurgence.


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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.


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