Challenges in early phase of implementing the 1-3-7 surveillance and response approach in malaria elimination setting:A field study from Myanmar

Background:The National Plan for Malaria Elimination(NPME)in Myanmar(2016–2030)aims to eliminate indigenous Plasmodium falciparum malaria in six states/regions of low endemicity by 2020 and countrywide by 2030.To achieve this goal,in 2016 the National Malaria Control Program(NMCP)implemented the“1-3-7”surveillance and response strategy.This study aims to identify the barriers to successful implementation of the NPME which emerged during the early phase of the“1-3-7”approach deployment.Methods:A mixed-methods study was conducted with basic health staff(BHS)and Vector Born Disease Control Program(VBDC)staff between 2017 and 2018 in six townships of six states/regions targeted for sub-national elimination by 2020.A self-administered questionnaire,designed to assess the knowledge required to implement the“1-3-7”approach,was completed by 544 respondents.Bivariate analysis was performed for quantitative findings and thematic analysis was conducted for qualitative findings using Atals.ti software.Results:Although 83%of participants reported performing the key activities in the“1-3-7”surveillance and response approach,less than half could report performing those activities within 3 days and 7 days(40 and 43%,respectively).Low proportion of BHS correctly identified six categories of malaria cases and three types of foci(22 and 26%,respectively).In contrast,nearly 80%of respondents correctly named three types of case detection methods.Most cited challenges included‘low community knowledge on health’(43%),‘inadequate supplies’(22%),and‘transportation difficulty’(21%).Qualitative data identified poor knowledge of key surveillance activities,delays in reporting,and differences in reporting systems as the primary challenges.The dominant perceived barrier to success was inability to control the influx of migrant workers into target jurisdictions especially in hard-to-reach areas.Interviews with township medical officers and the NMCP team leaders further highlighted the necessity of refresher training for every step in the“1-3-7”surveillance and response approach.Conclusions:The performance of the“1-3-7”surveillance and response approach in Myanmar delivers promising results.However,numerous challenges are likely to slow down malaria elimination progress in accordance with the NPME.Multi-stakeholder engagement and health system readiness is critical for malaria elimination at the subnational level.

Assessment of household ownership of bed nets in areas with and without artemisinin resistance containment measures in Myanmar

Background:Myanmar lies in the Greater Mekong Subregion where there is artemisinin-resistant Plasmodium falciparum malaria.As the artemisinin compound is the pillar of effective antimalarial therapies,containing the spread of artemisinin resistance is a national and global priority.The use of insecticide-treated bed nets/long-lasting insecticidal nets(ITNs/LLINs)is the key intervention for ensuring the reduction of malaria transmission and the spread of resistant strains,and for eventually eliminating malaria.This study aimed at assessing household ownership of,access to,and utilization of bed nets in areas of Myanmar with and without artemisinin resistance containment measures.Methods:Secondary data from a nationwide community-based malaria survey conducted by the National Malaria Control Program in 2014 were analyzed.Based on evidence of artemisinin resistance,Myanmar was divided into tiers 1,2,and 3:townships in tiers 1 and 2 were aggregated as the Myanmar Artemisinin Resistance Containment(MARC)areas and were compared with tier 3 townships,which were defined as non-MARC areas.The chi-square test was used to compare groups,and the level of significance was set at P≤0.05.Results:Of the 6328 households assessed,97.2%in both MARC and non-MARC areas had at least one bed net(any type),but only 63%of households had ITNs/LLINs.Only 44%of households in MARC areas and 24%in non-MARC areas had adequate numbers of ITNs/LLINs(one ITN/LLIN per two persons,P<0.001).Nearly 44%of household members had access to ITNs/LLINs.Regarding the utilization of ITNs/LLINs,45%of household members used them in MARC areas and 36%used them in non-MARC areas(P<0.001,desired target=100%).Utilization of ITNs/LLINs among children aged below five years and pregnant women(high malaria risk groups)was low,at 44%and 42%,respectively.Conclusions:This study highlights the nationwide shortfalls in the ownership of,access to,and utilization of ITNs/LLINs in Myanmar,which is of particular concern in terms of containing the spread of artemisinin resistance.It highlights the need for priority attention to be paid and mobilization of resources in order to improve bed net coverage and utilization through bed net distribution and/or social marketing,information dissemination,and awareness-raising.