The Edge of Elimination

Racing drug resistance to end malaria in the Mekong

By The Global Fund

April 23^rd, 2017

You won’t find the village of Bus Saam on most maps. Nor the earthen tracks that lead to this collection of wooden homes surrounded by sorghum and rice fields in western Cambodia. When the rainy season comes and dissolves the dirt roads into deep, sticky mud, the 1,000 residents are even more acutely isolated – far from the edge of anything like a town and a three-hour walk to the nearest health center.

In remote communities like Bus Saam, even a treatable illness like malaria can be fatal. But it doesn’t have to be. Ya Yoeun, a 42-year-old husband and father was recently cured of malaria, and in many ways, he epitomized the current state of malaria in Cambodia. He had traveled east from his home to a province on the border with Viet Nam, where he worked with a timber operation. The work meant spending nights in the forest exposed to malaria-carrying mosquitos. There he became infected and, when too sick to work, he returned home.

As malaria rates drop, the last cases will be found in the most remote places.

Ya Yoeun was cured thanks to village malaria workers. The Global Fund supports nearly 20,000 malaria volunteers in the region.

And yet, “There’s no malaria here,” said Dr. Jean-Oliver Guintran, medical officer for WHO’s malaria program in Cambodia. His satisfaction was tinged with a hint of comedic exasperation; it had been a long journey to get to a place where the absence of something is proof of success.

“This is the story of malaria elimination,” said Guintran. “The more successful we are, the harder it becomes to reach the last holdouts – the most remote places, the people who are migrating for work, doing jobs that expose them to infection.”

Cambodia, along with Laos, Myanmar, Thailand and Viet Nam – together known as the Greater Mekong Region – is in a race to reach those elusive cases and eliminate malaria. It’s not the first attempt to rid the region of this killer parasite. The first coordinated, concerted efforts date back half a century. But for a host of reasons – from mosquitos developing insecticide resistance to donors dialing back funding – the campaign was abandoned. The goal was changed to focus on saving lives and decreasing cases, but the aspiration of elimination was left behind.

This is the story of malaria elimination. The more successful we are, the harder it becomes.

Rubber tappers are at risk of malaria because they work or sleep in forests, where they may be bitten by infected mosquitoes.

The Global Fund’s partner PSK supports mobile malaria workers who provide rubber tappers information, mosquito nets, testing and treatment.

Today there is a renewed commitment to eliminating malaria and a sense of urgency spurred by the specter of drug resistance.

Cambodia was ground zero in the early 1960s for the first wave of drug-resistant malaria, which rendered the drug of choice, chloroquine, ineffective against the most lethal of the four strains of the parasite. This resistance was a consequence of multiple factors, including ineffective and counterfeit drugs, and poor patient adherence to the prescribed treatment.

This drug resistance brought a kind of emergency.

With the single-drug regimen sidelined, scientists sought new compounds and combinations that could clear the parasite from a patient’s bloodstream. Today, artemisinin is the key ingredient in the most effective of these; when paired with another drug, ACT – or artemisinin combination therapy – is the gold standard for malaria treatment.

But of five ACT regimens approved by the World Health Organization, four have been rendered useless by drug resistance in Cambodia. Drug resistance has also been found in the other countries of the region; if the resistance seen in the Mekong were to spread to India or sub-Saharan Africa – where the malaria burden is highest – it would be a devastating setback to global elimination efforts and almost certainly reverse the hard-won decline in death rates.

“This drug resistance brought a kind of emergency,” said Naeem Durrani, program coordinator for UNOPS, which manages the Global Fund’s Regional Artemisinin-resistance Initiative (RAI) grant in Cambodia. “The goal here, and the only answer, is elimination. RAI is helping to intensify efforts to eliminate multidrug-resistant malaria within its geographical borders and prevent its spread to other regions, other countries.”

And it’s working.

RAI supports countries to purchase and distribute insecticide-treated nets, rapid diagnostic tests and quality-assured drugs.

“Cambodia exceeded its targets in 2016 to reduce malaria incidence rates and deaths. There was only one malaria death in the whole country last year,” said Guintran of WHO. “But we know it’s only a matter of time before drug resistance catches up with the current ACT regimen. So even as the number of cases drop, we have to be more aggressive about surveillance. We have to find and treat every case so we don’t have human reservoirs of malaria parasites that can reintroduce the disease in places that are now malaria-free.”

We know it’s only a matter of time before drug resistance catches up.

That could have happened when Ya Yoeun returned home to his village, Bus Saam. Instead, the people and systems put in place by local experts with support from the Global Fund did exactly what they were meant to – diagnosed, treated and cured the case, and followed up in the community to ensure no further infection.

When Ya Yoeun tested positive for malaria, health workers followed up with testing in the community to ensure it hadn’t been reintroduced.

A simple blood test can detect malaria in 15 minutes.

Case management and surveillance, including records from every village, are essential to reach elimination.

That successful response started with Bus Saam’s village malaria workers, Rong Lis and Lay Sokun. They have been active for years educating their neighbors about prevention measures, like sleeping under an insecticide-treated net, and how to recognize the symptoms. When a neighbor experiences a fever or worries they have been exposed, they can go immediately to Rong Lis or Lay Sokun for a test that gives a result in 15 minutes. The village malaria workers have a supply of medicine so treatment can be started immediately, but the majority of their efforts go toward education and prevention. As of March 2017, Ya Yoeun’s was the only case for the year, and the two cases in 2016 were “imported” from other provinces. Guintran was right: No malaria here.

Village malaria worker Rong Lis regularly reminds her neighbors about risks and prevention measures for malaria.

Lay Sokun, village malaria worker, distributes mosquito nets in Bus Saam.

Malaria is especially dangerous for children under 5. Village malaria workers ensure parents are aware of prevention measures and symptoms.

“Even in places where there’s really no village, RAI partners support mobile malaria workers, who might be active at a forest worksite, or even a well trafficked border crossing,” said Durrani. “This is a nationwide network that is testing and treating cases, supporting prevention activities and providing the essential information we need to keep the elimination strategy on track.”

We have victory within our sights.

With RAI’s support, these national elimination strategies are coordinated across the five countries of the Greater Mekong. As infected people can freely traverse borders, a regional approach is the only solution. “It’s a step-by-step process,” explained Durrani. “First is a comprehensive plan for malaria control in places where the prevalence is still high. Then we get levels down to qualify for elimination and finally wipe it out from areas with low prevalence. But it takes partners and commitment from the government down to the village and, of course, it takes investment to see it through. We have victory within our sights.”

Taking services on the road. The Global Fund’s partner Malaria Consortium manages four mobile malaria posts along the Cambodia/Laos border.

Malaria transmission is high in forested border regions. Mobile malaria posts find and treat cases that might otherwise go undetected.

While RAI’s focus remains regional, its impact in the coming years will be global. The programs and partners supported by the initiative are not only halting the spread of drug-resistant malaria, they are demonstrating the policies and practices required to get to zero.

Back in Bus Saam, village malaria worker Rong Lis said, “I like to learn new things and to help people. I would like to have more training and help my community stay healthy.” As Cambodia edges closer to elimination, the health center may want to find a new cause for this dedicated health advocate. It seems malaria’s days are numbered.