Malaria is the leading cause of death in Karen state. The malaria burden is exacerbated by human rights abuses committed by the military regime. Forced displacement and destruction of food supplies compel villagers to live or to forage for food in the jungle, where exposure to malaria is highest. Other contributing factors include widespread availability of fake anti-malarials and the prevalence of a multi-drug resistant strain of the most severe form of malaria (Plasmodium falciparum). Reducing mortality due to malaria is one of the highest priorities of the KDHW.
A 2001 survey by the Back Pack Health Worker Team (BPHWT) in its service areas found that 44% of all deaths were caused by malaria. Only 23% of malaria patients received any treatment and only about 50% of these patients completed their malaria therapy. Patients would stop when they began feeling better or if they did not like the side effects, but 76% of patients did not know the proper treatment duration for the medicines they had been issued.
In 2003, with funding and technical support from the Global Health Access Program (GHAP), KDHW initiated an integrated Malaria Control Program (MCP). The MCP applies international standards set by WHO for reducing malaria burden, including early diagnosis and treatment (EDT), widespread use of long-lasting insecticide treated nets, and malaria education. Patients are screened with a rapid diagnostic test that is low in cost and highly accurate (Paracheck®Pf), or with microscopy where available. Artemisinin-based combination therapy (ACT) is administered following the Directly Observed Therapy protocol (DOT), by which a clinic worker watches the patient while they are taking the dose and for 30 minutes afterward to make sure it is ingested, since patients with severe malaria are prone to vomiting. (ACT is recommended by the Burmese Border Guidelines and other regional authorities.)
The MCP started in 2003 with four pilot villages with a population of about 2,000. New areas were added each year so that the program now reaches 121 villages in 44 target areas with a population of 39,797. Most of the areas are within mobile health clinic coverage areas, but some are in BPHWT areas or outside both programs.
MCP areas are not coterminous with the Mobile Health Clinic areas for three reasons:
- Budgetary restrictions – the program can cover only as large a population as it has medicines and capability to serve.
- Logistical restrictions – as a control program, the MCP is most effective in villages that can be visited frequently.
- Security restrictions – the program is limited to relatively secure areas in an effort to minimize disruptions by population movements, which have occurred nevertheless.
The program has a strong focus on prevention. Insecticide-treated nets are distributed to every household, and workers make house visits to monitor net use. In an August, 2005 survey of the original target population, two years after initiation of the program, more than 90% of people reported sleeping under a net every night.
Program workers educate each family, demonstrate how to use mosquito nets, and discuss other aspects of mosquito control. Villagers learn how to care for their nets and simple ways to reduce the number of mosquitoes by cutting bushes around the house and eliminating nearby standing water.
Health care workers explain the signs and symptoms of the disease. Families are asked to bring individuals who may have malaria to the local KDHW clinic for treatment as soon as they exhibit symptoms of the disease.
MCP medics are trained every six months at the Mae Tao Clinic (MTC) in data collection, and in malaria education, and in diagnosis and treatment protocols. During the workshops, they report screening information, net distribution and usage, and treatment data. They also share anecdotes about the challenges and successes of program implementation, and collectively they decide on ways to improve the program. After the training and reporting, the medics replenish all the necessary supplies and return to their target areas to continue another round of program delivery.
An essential aspect of KDHW’s MCP has been its method of expansion. The program has relied increasingly on locally trained Village Health Workers (VHWs) to carry out the important less technical day-to-day aspects of the program. Recruitment of VHWs evolved organically, as MCP medics often were unable to reach the more remote villages in their target areas while continuing to provide normal services in the clinics. Therefore, they began training local villagers to conduct house visits, to refer symptomatic villagers to the clinic, and to provide patient follow-up. As it became clear that these villagers were an asset to the program and would facilitate coverage expansion, KDHW decided to incorporate them officially into the program. Currently VHWs are working with MCP medics in 15 of the 44 MCP areas.
Biannual refresher trainings for medics focused originally on program protocols and data collection. They now provide an opportunity for medics to practice their training skills so that they can train VHWs effectively upon returning to their target areas. This training-of-trainers model is similar to that implemented in a number of other programs, including the Mobile Obstetric Maternal Health Worker (MOM) and Reproductive and Child Health projects.
Biannual random screenings, beginning with baseline screening at inception of the programs, have been conducted to monitor P. falciparum malaria burden in the target populations of the five groups of areas brought successively into the Malaria Control Program. The areas are identified by the six-month terms in which the programs were initiated, from the term 1 programs, begun in 2003, to the term 9 programs, begun in 2007. Beginning in 2010, screenings are being conducted only once a year. Results are shown in the chart below.
In all groups of new target areas that started the MCP program, Pf malaria prevalence tended to fall until January-June 2008, when the rates rose in all areas. The program was seriously disrupted by a Burmese army offensive during 2007. Persons fleeing into MCP areas from villages that were attacked by the Burmese military also may have contributed to increases in seroprevalence in some areas.
Pf Malaria Seroprevalence in MCP Target Areas by 6-month Term
The program is currently focused on capacity building in order to provide a complete malaria control strategy. The aim is to make steady progress over the long term.
We thank our partners supporting the Malaria Control Program:
- Australian Relief and Mercy Services (insecticide treated nets)
- Child’s Dream (funding)
- Global Health Access Program (training and monitoring)