Malaria Elimination
19 April 2023 | Spotlight
Eliminating malaria in Lao PDR: 460 000 to 2300 cases in 25 years
My dream is to not have any [malaria] cases in the village. I will keep working until it is eliminated.
Driven by new ‘accelerator’ strategies to eliminate the disease, malaria cases in Lao PDR have plummeted from an estimated 462000 in 1997 to 2305 in 2022.
Twenty five years ago, cases were rampant. Disruption of employment and education brought significant economic consequences. Thousands of lives were lost, and tens of thousands more were devastated by the disease’s long-term impacts.
More recently, immense progress has been made by the Ministry of Health and partners, with Lao PDR aiming to eliminate Plasmodium falciparum – the deadliest of the five malaria parasites – by the end of 2023.
“Malaria now only affects a small proportion of the population,” said the Ministry of Health’s Dr Rattanaxay Phetsouvanh, Director General, Department of Communicable Diseases Control. “Cases are found in just 10% of the country’s health facilities, across five of the country’s 18 provinces.”
“However, these remaining pockets are almost entirely remote, extremely hard-to-reach communities. Communities that are now most impacted by malaria in Lao PDR are ethnic minority groups.”
Mostly, these groups live and work in heavily forested locations that are ideal habitats for malaria mosquitos and difficult for health services to access – posing challenges for the “final push”.
The health sector has continued to deliver and improve routine responses – focusing on fast and early diagnosis and treatment – but the evolving situation has required a change in approach.
Key to recent successes is increased outreach efforts by volunteer village malaria workers and “accelerator” strategies – more innovative, aggressive approaches that focus on the proactive elimination of the disease.
A mother of two and part-time farmer, Khounmy is one of many village malaria workers supporting the enhanced efforts across 60 villages in the five at-risk provinces.
A core part of Khounmy’s efforts to support the acceleration of malaria elimination is taking education, testing, treatment, malaria surveillance, and items like bed nets to isolated groups of people, particularly farmers and those working in forests.
“I want to protect the community,” she said during a village visit in rural Attapeu Province.
“My dream is to not have any cases in the village. I will keep working until it is eliminated.”
Raised and having worked on a nearby farm, Khounmy loved her rural upbringing but suffered from severe malaria and saw her family experience the same.
"When I was a child, I had a lot of malaria problems,” she said, “I don’t want this to happen to others."
“I can do this by testing the people around me, giving them medicines, sending them to the health centre and explaining how they can be protected from malaria – this makes me very proud.”
As part of elimination efforts, malaria workers go beyond villages, visiting informal settlements to provide preventative treatment to people staying in forests or fields. The government provides training for the workers and community, while WHO’s provincial-based experts support various ongoing activities.
While the village malaria workers provide much of the workforce, the innovative tactics are the result of adaptation by the Ministry of Health, local officials and WHO staff – drawing on insights from village leaders and community members.
“The need has been shifting from a ‘routine’ footing to an ‘elimination’ mindset,” said Matt Shortus, WHO Lao PDR’s malaria team leader. “To do that, we’ve had to get creative and accelerate our approaches.”
“These efforts have included targeted mass drug administration, preventative treatment, regular testing for fever – a key symptom of the disease – and distribution of long-lasting nets treated with mosquito repellent.”
“Preventative treatment and mass drug administration treat symptom-free people carrying the disease, eliminating the reservoir of the parasite and disrupting its spread,” says Shortus.
"This is how we’re breaking the cycle and making progress in eliminating the fatal type of malaria."
To assist these efforts, WHO has deployed staff in the two highest-risk provinces. Beyond regular support, they profile and map high-risk, difficult-to-reach groups and behaviours to tailor responses, analyze data and impact, and modify approaches as necessary.
While progress has been and continues to be made, several significant challenges remain – significant enough to pose a threat to the progress made so far.
“Progress has been remarkable, but we must address the key challenges that remain,” says Senior Program Officer Doungkamon Oeuvray from the Global Fund to Fight AIDS, Tuberculosis and Malaria, a major supporter of elimination efforts. “This includes reaching the most remote communities with prevention and testing and addressing increased resistance of malaria parasites and medications.”
“Business as usual will not eliminate malaria, which is why investments in innovative tools and new strategies are absolutely essential right now.”
Khounmy is well aware of the most practical problem. “I still see malaria in the village,” she said, “people are still in the farms, still live in the farms, in the fields – they don’t stay together, and it’s difficult to identify them.”
As the pockets of the disease continue to shrink, this challenge will only worsen and require more targeted outreach and monitoring to close gaps.
“More concerningly, we face the constant risk of an outbreak setting the work back, as Lao PDR saw in 2013 – 2015,” said WHO’s Shortus, “but we can mitigate this with the work we are doing.”
"The greatest threat is global – the increasing resistance of malarial parasites to medications."
“Unfortunately, the most lethal parasite, Plasmodium falciparum, has developed resistance to most commonly available antimalarial drugs, particularly in Southeast Asia. This means intensive and focused efforts are needed to maintain gains and move towards elimination. The sooner we get this done, the better.”
An enhanced surveillance system allows for both the tracking of cases and monitoring of the effectiveness of common anti-malarial drugs.
In Lao PDR, village malaria workers now collect and report data digitally via mobile phones and a dedicated web platform. This data feeds into the national malaria surveillance and health information systems, helping to inform responses.
This system is also driving a final step towards elimination – preparing for WHO’s malaria elimination certification process. Taking this a step further, the Ministry of Health and WHO have developed a provincial-level verification process, allowing parts of the country to be considered malaria-free while efforts progress in other parts of the country.
For Khounmy and other malaria workers like her, while national elimination is a lofty goal, the real impacts are felt among her community.
“There is a big difference from ten years ago and now,” said Boun-oy, another village malaria worker. “Cases were so very many at that time. Ten years ago, my cousin’s daughter died of malaria; she was six.”
“We had medicines, but things have changed. We have new medicines, rapid tests. I have the ability to test people who are sick and I can treat them. I want to help and protect them.”
“People’s understanding has improved,” he explains. “Now they know [malaria] is severe, they come early for testing, and they sleep under a bed net – this is an improvement.”
“There are still cases, but they are lower than before.”
It’s something Khounmy agrees with: “Now, with good tests and good medicines, we can prevent malaria.”
WHO Lao PDR and WHO’s Mekong Malaria Elimination (MME) Programme provide technical assistance to the country’s national malaria programme to maintain and improve the quality of routine interventions, and deploy innovative, aggressive strategies aimed at proactive disease elimination. These are increasingly focused on finding cases that remain in ethnic minority communities in remote, forested, hard-to-reach places. This assistance is made possible with financial support from The Global Fund – via the United Nations Office for Project Services (UNOPS) – as well as the United States Agency for International Development (USAID), and the Bill & Melinda Gates Foundation. Implementation is supported by a range of civil society organizations, assisting village malaria workers.