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connued on page 8 Lessons Learned from Cambodia Useful for Region Cambodia Task Force Meeting in progress. Pix by WHO January-March 2011 T here are lessons to be learned by other countries in the Greater Mekong Sub-region as they push for containment and eventual eliminaon of artemisinin-resistant malaria. of drug-resistant malaria on the Thai-Cambodian border Quarterly Newsletter of the Strategy for the Containment of Artemisinin-Tolerant Malaria Parasites in South-East Asia Project This was the message put for- ward by the Secretary of State for the Ministry of Health, His Ex- cellency Chou Yin Sim, when he opened the third Cambodian Task Force meeting on December 3, 2010 at the Phnom Penh Hotel. “The National Task Force of Cambodia provides national su- pervision to the Containment Project funded by the Bill & Melin- da Gates Foundation,” he told the meeting attended by WHO, the National Malaria Control Centre (CNM), and their working partners. “Elimination of resistant malaria parasites will remain out of reach unless we pay adequate attention to the delivery of health services, including good surveillance of re- mote areas and migrant popula- tions. This cannot be done with- out the strengthening of health systems,” stressed H.E. Yin Sim. H.E. Yin Sim pointed out the strategies that have been effec- tive in the Containment Project. “The strategies that have been found to be effective in the Contain- ment Project have been the provi- sion of free diagnosis and treatment by village malaria workers and the promotion of the use of LLINs (long- lasting insecticide treated nets) by populations at risk of malaria, es- pecially those who stay overnight in the forest,” he told the meeting. Another important strategy was the ban on monotherapies that H.E. Yin Sim said had proven to be effective in addressing the spread of multi- drug resistant falciparum malaria. “The Ministry of Health is com- mitted to eliminating monothera- pies and perpetrators will be sub- jected to administrative measures and legal ac- tion,” he said. “In Cambodia, a ban on mon- otherapies to- gether with the Public-Private Mix initiative have achieved almost zero prevalence of artemisinin monothera- pies as well as a significant reduction in fake and substandard drugs on the market,” said H.E. Yin Sim. “I do hope this positive exam- ple and the lessons learned can be replicated in other countries in the region,” he emphasized. The US$22.5-million Containment Project funded by the Bill & Melinda Gates Foundation involves both Cambodia and Thailand. There are respective National Task

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Lessons Learned from Cambodia Useful for Region

Schoolgirl’s Malaria Knowledge Helps Family Avoid Getting Sick

Cambodia Task Force Meeting in progress. Pix by WHO

Seub Saren who educates her family in Pailin about malaria. Pix by WHO/Sonny Krishnan

CONTAINMENT is published by WHO Cambodia’s Malaria Containment Project. For enquiries please contact Dr. Najibullah Habib, Malaria Containment Project Manager, World Health Organization

Cambodia, 177-179 St. Pasteur (51), PO Box 1217, Phnom Penh OR e-mail: [email protected]

January-March 2011

There are lessons to be learned by other countries in the

Greater Mekong Sub-region as they push for containment and eventual elimination of artemisinin-resistant malaria.

“Malaria is spread by female ‘nail’ mosquitoes during nighttime.”

of drug-resistant malaria on the Thai-Cambodian border

Quarterly Newsletter of the Strategy for the Containment of Artemisinin-Tolerant Malaria Parasites in South-East Asia Project

This was the message put for-ward by the Secretary of State for the Ministry of Health, His Ex-cellency Chou Yin Sim, when he opened the third Cambodian Task Force meeting on December 3, 2010 at the Phnom Penh Hotel.

“The National Task Force of Cambodia provides national su-pervision to the Containment Project funded by the Bill & Melin-da Gates Foundation,” he told the meeting attended by WHO, the National Malaria Control Centre (CNM), and their working partners.

“Elimination of resistant malaria parasites will remain out of reach unless we pay adequate attention to the delivery of health services, including good surveillance of re-mote areas and migrant popula-tions. This cannot be done with-out the strengthening of health systems,” stressed H.E. Yin Sim.

H.E. Yin Sim pointed out the strategies that have been effec-tive in the Containment Project.

“The strategies that have been found to be effective in the Contain-ment Project have been the provi-sion of free diagnosis and treatment by village malaria workers and the promotion of the use of LLINs (long-lasting insecticide treated nets) by

populations at risk of malaria, es-pecially those who stay overnight in the forest,” he told the meeting.Another important strategy was the ban on monotherapies that H.E. Yin Sim said had proven to be effective in addressing the spread of multi-drug resistant falciparum malaria.

“The Ministry of Health is com-mitted to eliminating monothera-pies and perpetrators will be sub-jected to administrative measures

and legal ac-tion,” he said.

“In Cambodia, a ban on mon-otherapies to-gether with the Public-Private Mix initiative have achieved almost zero p r e v a l e n c e of artemisinin m o n o t h e r a -pies as well

as a significant reduction in fake and substandard drugs on the market,” said H.E. Yin Sim. “I do hope this positive exam-ple and the lessons learned can be replicated in other countries in the region,” he emphasized.The US$22.5-million ContainmentProject funded by the Bill & MelindaGates Foundation involves both Cambodia and Thailand. There are respective National Task

Forces in both Cambodia and Thailand overseeing the project.

The international level oversight is through a panel of international malaria experts in the International Task Force. So far the Internation-al Task Force has held twom e e t -ings – the first in Phnom Penh in 2009 and the other inHanoi in February 2010.

“The ultimate goal of the project is to contain the artemisinin-resist-ant malaria by removing selection pressure and reducing and ulti-mately eliminating falciparum ma-laria through a series of strategies,” said Dr. Najibullah Habib, WHO’s

Malaria Containment Project Manager.Stressed Dr. Habib: “If this resist-ance to artesunate spreads from this area to other regions or other countries, it constitutes not only a regional but a global public health issue. Therefore it’s an issue that

goes beyond just Pailin or Western Cambodia or Zone One or Zone Two – it goes regionally and globally.”

Dr. Habib explained to the TaskForce Meeting the zoning of theContainment Project. “Zone 1 in-volves not just Western Cambodia but also some areas in Thailand as well. And that’s where we have our elimination strategy – to eliminate

artemisin-resistant malaria. Zone 2 is a buffer zone to make sure the disease does not spread beyond the focal area. For Zone 3, we have now good news that Global Fund Round 9 activities are geared to-wards control in those areas includ-

ing the whole of Cambodia.”

In order to reduce selection pressure, it is imperative to use ar-temisinin-derived drugs with otherpartner drugs in the treatment offalciparum malaria.“In Zone 1 it isdihydroartemisinin-piperaquine (DHA-P); in Zone 2 it is artesuna-te plus mefloquine (A and M) and atovaquone – proguanil in Thai-land,” Dr. Habib pointed out.

....from page 1

“To avoid getting malaria, people should protect themselves from beingbitten by female ‘nail’ mosquitoes bysleeping in a mosquito net.” “Peoplewho have malaria must take proper me-dicines as prescribed by a physician.”

This is Lesson 11 at Grade 5 in Cam-bodia which young Cambodian stude-nts are taught at school as part of the curriculum for their “Applied Science”study.

However, like other lessons about such diseases as typhoid and den-gue fevers, malaria is not an inter-esting lesson for many students who

live in non-malaria infested areas. But for 14-year-old Seub Saren

who has attended a school in Siem-reap Province’s Srey Snom District, she finds this knowledge about malar-ia particularly interesting and useful for her family when they moved to Pailin, where malaria posed a serious health threat to migrant workers like her family.

“After she returned from school, she told the family how to protect our-selves from malaria,” says her father, Se Seub, who is now living and working in Pailin with his wife and four children.

Seub says he was sick with ma-laria when he came to work in Pailin three years ago and that he had to go back to Siem Reap for treatment.

However, he says he has neverbeen sick with the disease duringthe last few years after learning toprotect himself and his family as hisdaughter taught them.

Seub Saren says she knows very well about malaria from the lessons she has learned at school, which was why she could educate her family how to prevent the disease.

Like Seub Saren, other fifth graders in Pailin can also easily score a good mark for the lesson about malaria.

Nuon Phon, a Grade 5 teacher at Pailin’s Phoum Thmei Primary School, says his students are enthu-siastic to learn about malaria, “be-cause Pailin is a malaria infested area, so they are very interested.”

Unlike many other lessons about Science that is complicated and dif-ficult to learn, Nuon Phon says teaching malaria as a subject in Pai-lin is very practical and relevant.

“I asked them where they lived; they said they lived in the mountainous are-as,” says Phon as he explains the meth-odology he uses to teach his students.

“Then, I asked ‘Have you had malaria before?’ They said ‘Yes,” hecontinues. “’So, do you want to havemalaria?’ they said ‘No.’”

“What should you do?” he asks and he would prod the students withmore follow-up questions.

Moeun Chhean Nariddh

In order to reduce selection pressure, it is imperative to use artemisinin-derived drugs with other partner drugs in the treatment of falciparum malaria.

72

Law Enforcers to Get Tough on Counterfeit Medicines Reaching Out To Migrant Workers At The Thai Border

Dr. Doung Socheat, Director of CNM, addressing the workshop. Pix by WHO/Sonny Krishnan Workers from Cambodia making their way to Thailand at the border crossing in Sampov Loun. Pix by WHO/Sonny KrishnanCambodian malaria experts

and senior police officers have agreed that better cooperation and concerted efforts are needed to effectively combat malaria as well as curb the sale and smuggling of counterfeit and substandard drugs in Cambodia.

“The Ministry of Health has done a lot of work, but it would not be able to do anything without the coopera-tion of the police,” explained Gen-eral Ben Rath, Vice Commissioner for Phnom Penh Municipal Police, during a workshop on “Strengthen-ing Law Enforcement for Investiga-tion of Counterfeit Medicines and Artemisinin Monotherapy”, which was held in Siem Reap Province from November 10 to 12, 2010.

The National Centre for Para-sitology, Entomology and Malaria Control or CNM that receives tech-nical assistance from WHO, with support from the Global Fund and in cooperation with the Ministry of Interior organized the three-day training of trainers’ workshop for 55 senior police officers from 24 cities and provinces across the country.

The workshop was to improve the investigative skills of the Cambodian senior police officers to identify and crackdown on fake and substand-ard malaria drugs that have been smuggled and sold in the country.

Besides the cooperation between CNM and the police, General Ben said it was important for the Minis-

try of Health to encourage local au-thorities to provide more support to the crackdown on counterfeit and substandard drugs in Cambodia, particularly in the rural areas.

“We’ve done a lot in Phnom Penh, but not much in the provinces where people are more vulnerable due to the lack of knowledge,” he said.

Malaria parasites in the Asso-ciation of Southeast Asian Nations region or ASEAN are now resistant to almost all anti-malarial drugs, with the exception of drug combi-nations containing derivatives of ar-temisinin (artemisinin-based com-bination therapy, or ACT). Because artemisinin derivatives are remark-ably rapid in their anti-malarial ef-fects, they are much sought after.

But as they are relatively expen-sive a demand is created for cheap-er versions amongst the poorest and most vulnerable people, upon whom the counterfeiters have preyed -- with fatal results.

General Un Sovannthy,Deputy Chief of the Anti- Economic Crime Police Depa-rtment, said he agreed that the cooperation between different institutions wassignificant.

“We have had success due to the cooperation from local authorities and the courts,” he

said.“The economic police officers

are to supplement the work of other institutions.”

He said that the combat against counterfeit and substandard drugs would be even more effective if the village leaders could also be trained to identify and distinguish between good drugs from bad ones.

The Phnom Penh Poice Vice-Commissioner said the workshophad provided the participants withsubstantial knowledge and skillsso that they could do their work moreefficiently.

“Even myself, I have learned a lotfrom the workshop,” said General Ben, adding: “I think they will be able to pass on their knowledge [to other police officers in the districts].”

Meanwhile, the Cambodiangovernment has made progressin its crackdown on counterfeitmalaria drugs.

In April 2010 the United States Pharmacopia -- a non–governmen-tal, official public standards-setting authority for prescription and over-the-counter medicines – stated that Cambodia has shut down nearly 65 percent of illegal pharmacies after receiving evidence showing that they were among the main sources of substandard and coun-terfeit medicines in the country.

Pong Nam Ron District, Chantaburi Province -- “Mom” lives in this

camp with other people who come and go between Thailand and their homes in Cambodia whenever there is work.

A recent secondary school leav-er, "Mom” said her family spends about two months here before they go home to Boseth Commune in Kampong Speu, a province located southwest of Cambodia’s capital Phnom Penh, or a day's drive away from Chantaburi on the Thai side.

In her Thai, which was under-standable though not fluent, she remembered having repeated the journey about 10 times, and hav-ing done some work herself on some occasions. “We pick what-ever fruit is in season,” she said.

About 20 people who usually spend less than six months just inside Thailand were living in this camp when a team of officials from the Bureau of Vector Borne Diseas-es, World Health Organisation and the Malaria Consortium paid a visit. The conditions at the camp located on the edge of a longan orchard were stark. Spindly tree trunks propped up the houses, with synthetic fiber sheeting or newspaper sheets as walls. But there were water jars in the camp, suggesting some per-manency or continuity in the move-ments of these itinerant workers.

A family who had lived in the camp for about a year enjoyed the luxury of a wooden floor and used a traditional bed-net they bought from the local market before cross-ing the border. The bed-net accom-modated five people: the parents, children aged 11 and five, and a baby of six months. But it was an ordinary bed-net, not treated with insecticide, which would hardly pro-tect them from the female anophe-les mosquito, carrier of the Plasmo-dium falciparum parasite that can lead to death if not nipped in time.

Piyaporn Wangroongsarb, a spe-cialist in migrants for the Bureau,pointed out that people from Cam-bodia cross the border into Thai-land regularly, perhaps every month, for work because there wasconstant demand for longan fruitsin markets abroad.

A key partner in the $22.5 mil-lion Containment Project largely supported by the Bill & Melinda Gates Foundation, the Bureau of Vector-Borne Diseases “plans to impregnate ordinary nets with permethrin that either kills or re-pels mosquitoes, and to distrib-ute bed-nets already treated with the chemical to those who have no nets at all,” added Piyaporn.

Chantaburi is renowned for itswealth in fruits such as longan,

longgong, rambutan, durian, mang-osteen, among others.

But fruit-picking is rated by Pong Nam Ron District authorities as a “high risk” occupation.

The high-risk rating, explained Saowanit Vijaykadga, head of the bureau's Malaria Cluster, referred to those fruit-pickers who “stayed overnight inside orchards and did not take precautions, such as protect themselves with long-lasting insec-ticide-treated nets and repellents.”

While the Bill & Melinda Gates Foundation-funded containment project is now able to diagnose and treat falciparum malaria cases ef-fectively with quality drugs, other measures like the targeted distribu-tion of long-lasting insecticide-treat-ed nets and long-lasting insecticide-treated hammock nets, together with repellents, have significantly brought down the number of cas-es of this deadly form of malaria.

The Fixed Schedule Malaria Clinic that began operating in this malaria hot-spot area in April 2009 is strategically placed on the Thai-Cambodia border. Its twice-weekly mobile clinics enable quick diagnosis and treatment of ma-laria cases. Between April 2009 to September 2010, blood sam-ples were drawn from 3,267 peo-ple and only five of them tested positive for falciparum malaria.

Chantaburi, with Pong Nam Ron and Soi Dao districts as the busi-est areas for fruit cultivation, prob-ably ranks as the main recipient of short-term workers from Cam-bodia across the eastern border.

Trat, Sa Kaeo, Buri Ram, Surin, Si Saket, and Ubol Ratchathani are the other six provinces included in the project to contain artemisi-nin-resistant falciparum malaria. Anuraj Manibhandu

36

Dr. Duong Socheat, Directorof the National Malaria Center, alsoagreed that different institutionsneeded to cooperate in the fightagainst counterfeit drugs andmalaria.

“As you know, there are coun-terfeit medicines in Cambdodia,” he told the workshop. “Malaria can cause death but it is preventable.”

He continued: “When people are sick, they normally go to pri-vate pharmacies [and] they may

get counterfeit medicines. [So], we need law enforcement officers to implement the laws effectively.”

Dr. Duong Socheat said getting rid of fake and substandard drugs is important in combating malaria in Cambodia. Moeun Chhean Nariddh

....from page 2

A Day in the Life of a Drug Inspector in Pailin Using Taxi Drivers and Radio to Reach Mobile Migrant WorkersCONTAINMENT’s Moeun Chhean Nariddh follows Justice Police Officer Nuth Tith on his rounds in the Pailin market in North-West Cambodia.

Dr. Kheang Soy Ty, Chief of Party of the USAID-funded University Research Co (URC) and Khorn Linna, URC’s communications specialist, tell CONTAINMENT of their efforts to raise malaria awareness among mobile migrant workers.

Justice Police Officer Nuth Tith inspecting a Pailin pharmacy's display cabinet. Pix by WHO/Moeun Chhean Nariddh

URC's Dr. Kheang Soy Ty (left) and Khorn Linna. Pix by WHO/Sonny Krishnan

It’s almost noon now in Cambodia’s Pailin province on the

northwestern border with Thailand. Nuth Tith, a middle-aged health official, quickly changes his clothes and wears a new police uniform.

Why has the project chosen taxi-drivers to spread knowledge

among migrant workers about the cause of malaria?

With a light blue shirt and dark blue trousers together with a sky blue cap, Nuth Tith l o o k s no different from a police officer.

The only difference is that the sign on his shirt is a medical sym-bol instead of the normal Singha, orKing of Lions, emblem used by other national police officers. An-other thing is that he does not have a revolver in his belt andneither does he carry handcuffs.

Yet, he is not a normal poli- ceman. Trained as one of the five justice police officers in Pailin,Nuth Tith’s duty is to inspect pharmacies and drug stores to make sure that no counterfeit or substandard malaria drugs are on sale.

Dr. Soy Ty: Before we chose this strategy, we did focus group discussions (FGDs) with village chiefs and staff in health centers. The FGDs also included those from the mobile and migrant population. The FGD results indicated that the majority of migrant workers, from other provinces, used taxis to get to Western Cambodia. For many of these migrant workers, especially from the southeastern part of Cambodia that borders Vietnam, the taxi drivers are their first point of contact in the West. Also from the FGDs we found out that the popular taxi routes are from Battambang to Samlaut; Battambang to Sampov Loun; and Battambang to Pailin.

The southeast part of Cambodia has no falciparum malaria cases. So you have peo-ple moving from areas of low endemicity to ar-eas of high endemicity. The migrant workers make their way to the West, especially during the harvest season, to work in the plantations.

How are the taxi-drivers trainedto raise awareness of malariaamong migrant workers?

Khorn Linna: First we conducted an FGD with three groups of taxi drivers that carried migrant workers along the following routes: Battambang to Samlaut; Battambang to Sampov Loun; Battambang to Pailin. We wanted to find out whether we could collabo-rate with these drivers and we also wanted to assess their basic knowledge on malaria prevention. Besides that, the FGDs also gave us a good opportunity to find out from the taxi drivers what were the best kinds of IEC [Information, Education and Communi -

He is now ready to carry out his tasks.

After a ten-minute ridefrom the provincial hos-pital, he hops out of the car and rushes to a line of drug stores at a small market near Pailin.

“Do you have any malaria drugs left?” he asks Phat Sambo, a 28-year old drug sell-er at the front row.

“No!” she replies, laughing.He searches the drug cabinet but finds no malaria drugs on sale.

“Now, put these flyers on the wall and don’t put any other pictures,” he advices and hands out a few anti-malaria drug flyers to Sambo.

Nuth Tith says the justice police officers would inspect the pharma-cies and drug stores every three months as part of the efforts to stop the sale of malaria drugs and other fake and substandard medicines.

“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.

Now, the drug inspector has got back into the car and moved to the pharmacies in Pailin market. He stops by a pharmacy run by 36-year-old Sor Pov, who’s been selling medicines for the past eight years.

When asked if she has re-

ceived any patients who have come to buy malaria medicines, she replies that only about one in every 100 people have asked for malaria drugs at her store.

Duch Vanda, a 43-year-old ven-dor who sells medicines at a phar-macy next to Sor Pov’s, agrees that the number of people seeking malar-ia medicines has sharply declined.

“Now, almost nobody asks for malaria drugs,” he claims.

As instructed by the justice po-lice, both Sor Pov and Duch Vanda say they would refer any malaria patients to get free treatment at the health centers or village malaria workers around Pailin, if any cus-tomer asks to buy malaria medicines.

Sambo says the justice po-lice officers have visited her store five times now since she start-ed selling drugs two years ago.

“I think the anti-malaria cam-paign has been very successful, because there are no more ma-

laria patients,” Sor Pov points out.

Drug inspector Nuth Tith then continues to the last pharmacy in the same row at Pailin market. But, he still cannot find any ma-laria or other fake drugs either.

Tith says that since he start-ed his new drug inspection job three years ago, he has found less and less malaria drugs in the 25 pharmacies and drug stores he constantly inspects in Pailin.

After visiting the last pharmacy, Nuth Tith returns to the provin-cial hospital with a smile, proving that his work has been a success.

“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.

cation] materials that they [taxi drivers]could give out to their migrant worker passengers.

After the FGDs, we started the first train-ing of taxi drivers in Battambang. We had 33 drivers from the three different locations in the training. The training was to ensure that the taxi drivers disseminated accurate infor-mation on malaria prevention and treatment to their migrant worker passengers. Because they were the primary message provid-ers, as the first point of contact for migrant workers, we also had to make sure these taxi drivers had good communication skills.

Now we have 33 taxi drivers in our net-work and we plan to conduct quarterly work-shops to monitor and evaluate their activi-ties, and also evaluate the IEC materials that we have developed jointly with the drivers.

Are the taxi-drivers also trying to change the treatment-seek-ing behaviour of migrant work-ers – like seeking out the village malaria worker first for diagno-sis and treatment if they have fever, rather than going to the pharmacy for self-medication?

Dr. Soy Ty: In the training progra-mmes, we ensure that the taxi drivers them-selves have accurate information on malaria transmission and also adequate knowledge of the vector in its ability to transmit ma-laria. Also through the training programmes, the drivers know the symptoms of malaria or suspected malaria – the fevers, chills, headaches, cold sweats etc. The taxi-driv-ers are also made aware of the location of health facilities and village malaria work-ers along the Pailin, Samlaut and Sampov Loun routes, where migrant workers can get free diagnosis and treatment for malaria.

All these packets of information are im-portant because the taxi drivers will be able to advise the migrant workers on what to do if they have fever and where to seek free diagnosis and treatment, rather than go-ing to the drug outlets or pharmacies first.

Are the taxi drivers also distributingbed-nets to migrant workers?

Dr. Soy Ty: Not at this stage ofthe project. We recognize the role of taxi drivers in distributing bed-nets.

But the question is: from where should we get the bed nets?

This is a question of sustainability and we need to coordinate with the National Malaria Programme. Recently URC and its other partners discussed bed-net distribu-tion using a voucher system, where taxi driv-ers could give out vouchers to their migrant worker passengers. The migrant workers then can redeem them for bed-nets at the public health facilities in the areas where they are going to find work. We hope to be able to get bed-nets from the National Malaria Program for this pilot programme.

We are also thinking one step further in working with the private sector – especially with the drug outlets and pharmacies. These places are popular with Khmers, so why not they be also used to sell highly subsidised bed-nets?

In your behaviour change com-munication efforts, how do youencourage migrant workers to use bed-nets?

Khorn Linna: Most of the migrant workers are from provinces where there is no malaria.

So the majority of them really don’t know about the mosquito-borne disease. It’s not a matter of just making available Inform-ation, Education and Communication (IEC) materials but also determining which is the best way to reach them in terms of increas-ing their knowledge on malaria. We found, through FGDs, that radio as a channel of communication was the best means to reach out these migrant workers. Based on the findings of the FGDs, we have started working with [a media development INGO] Equal Access to produce interactive radio call-in shows. These radio programs are re-ally popular with migrant workers because it enables them to interact with the presenters, with calls made to the radio station on their mobile phones.

4 5

Affordable ACTs For All Cambodians Universal Access to Effective Malaria TreatmentDr. Kheng Sim, Vice-Director of Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) speaks to CONTAINMENT on efforts to make vital anti-malarial drugs available to Cambodians at affordable prices.

The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured artemisi-nin-based combination therapy.

Cambodia has been awarded the Affordable Medicines Facility –

Malaria (AMFm) phase 1 grant. The lessons learnt from AMFm’s Phase 1 will be used for Phase 2. Can you tell us how programs have been put in place, in Cambodia, to subsidize the cost of Artemisinin Combination Therapies (ACTs) and make them widely available for a lower cost, which should help eliminate the black market for counterfeit drugs.

Universal access to effective malaria treatment is among

the United Nations’ Millennium Development Goals. This also is among the goals of the Roll Back Malaria Partnership.

Firstly I have to state that Cam-bodia’s application to AMFm was approved this year. CNM, together with other li-censed import-ers, is now eli-gible to access ACTs at a greatly reduced price through subsidies from the Glo-bal Fund. When all parties agree on the ACT that is to be used na-tionally, one that also meets the requirement of the Global Fund quality standard, CNM and the pri-vate importers can procure these products at approximately 5% of the manufacturer’s sale price.

However the actual ACT co-payment is determined through negotiations between the Global Fund appointed agent and the manufacturer. Nonetheless due to the unique situation of emerging artemisinin resistance in Cambo-dia, there have been challenges

to identify an appropriate ACT that is also eligible to be subsidized.

CNM is working closely with our partner [WHO] to assess and tran-sition to a new ACT. In April 2010 at the national drug policy-making workshop, CNM recommended Dihydroartemisinin (DHA)-Piper-aquine as the ideal first line treat-ment for plasmodium falciparum. We hope to enter into an agree-ment with the Global Fund to en-sure that cost savings are passed on to the customer, for this ACT.

Cambodia has been suc-cessful in nearly eliminating the black market for monotherapies especially in Zone 1. Artemisinin monotherapy is a serious worry for the development of drug re-sistance.

The recent ACT Watch’s Cam-

bodia Outlet Survey 2009 indi-cated that only 8.3 % of 7,523 drug outlets surveyed sold monotherapies. The current trends indicate that this fig-ure is declining and, obviously, enforcement in the country is working. Can you tell us how the Cambodian authorities are enfor

cing the ban on monotherapies.

The National Malaria Control Program by its own cannot en-force the ban on monotherapies. For that reason the National Ma-laria Program involves other part-ners into our program. An important component is the training of police officers to enforce the ban on monotherapies and carry out inspections of private drug outlets to curb the sales of fake or sub-standard anti-malarials. CNM is also working with the Ministry of Health in the training of the Jus-tice Police, who are also empow-ered to enforce the ban on mono-therapies and prosecute violators.

Another important component is our engagement with the private sector to teach about good and bad drugs. Without private sector coop-eration we will find it hard to com-pletely eradicate monotherapies.

How difficult is it to translatepolicy into practice for the AMFmPhase 1? The supply side of ACTscan be a problem.

The AMFm is an innovative fi-nancing mechanism designed to

reduce the price of ACTs in the pub-lic and private sector. It is not a

new policy on malaria diagnosisand treatment but rather a mecha-nism to increase public access tolow cost, high quality ACT. AMFmsupporting interventions are alignedwith CNM’s existing efforts toimprove supply and strengthen thepublic sector. But we do have chal-lenges. As I said earlier that at the national workshop we selected DHA-Piperaquine as the first-line treatment for falciparum malaria. But this first-line treatment is not yet prequalified by WHO. But we are confident it will be approved soon, so that we can move for-ward in negotiations with the Glo-bal Fund for its procurement.

We hope that the new ACT willbe available soon.

In spite of high-level commit-ments, political will and substan-tial increases in financing, the attainment of this goal has re-mained elusive in most malaria endemic countries, especially in relation to artemisinin-based com-bination therapy (ACT), the treat-ment recommended as first-line by the World Health Organization (WHO) for uncomplicated malaria caused by Plasmodium falciparum.

The Affordable Medicines Fa-cility-malaria (AMFm) is a new fi-nancing mechanism to expand ac-cess to effective malaria treatment. A response to the dual challenge of poor access to quality-assured anti-malarial medicines and threats of parasite resistance to treatment, the AMFm combines price nego-tiations with a factory-gate buyer subsidy to reduce the price of ACT.

The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives. These objectives include replac-ing older and increasingly ineffec-tive anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displac-ing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the like-lihood of resistance to artemisinin.

The AMFm is hosted by the Glo-bal Fund to Fight AIDS, Tuberculosis and Malaria. The pilot phase of the programme, which includes Cam-bodia, Ghana, Kenya, Madagascar, Niger, Nigeria, the United Republic of Tanzania and Uganda, is sched-uled to last from 2010 to 2012.

The AMFm is funded from mul-tiple sources including a co-payment

Dr. Kheng Sim, Vice-Director of CNM. Pix by WHO/Sonny Krishnan

AMFm supporting interventions are aligned with CNM’s

existing efforts to improve supply and strengthen the public sector.

All Cambodians will have full access to effective malaria treatment in the AMFm scheme. Pix by WHO/Sonny Krishnan

fund of US$216 million, financed by the Bill and Melinda Gates Foun-dation, the UK Government, and UNITAID. In addition, the GlobalFund provides US$127 million tofund supporting interventions at thecountry level.

Enabling appropriate and rational use of ACT

To preserve the effectiveness of ACT over time, it is important that these life-saving medicines are used appropriately. A number of studies have shown that malaria case management, particularly in the retail sector, is unsatisfactory.

The private sector, in particulardrug outlets, should be supported and capacitated to provide appro-priate and rational management of malaria. Integrated approaches aimed at improving understand-ing and treatment of malaria can lead to tangible improvements inmanagement of malaria. Buildingon lessons learned so far, the AMFmwill work with countries and tech-nical partners to build the skills of drug shop attendants using prom-ising models, such as the Tanzania Accredited Drugs Dispensing Out-lets (ADDOs).

Regulation can play an important role in enhancing access to ACT and improving the quality of care. A number of studies have reported that subsidizing ACT may need to be supported by effective regulato-ry policies for the intervention to be effective in crowding out less effec-tive anti-malarials from the market. Countries in AMFm Phase 1 may use funds from the Global Fund to strengthen in-country regulatory systems.

Related to regulation is product quality. The AMFm will work with partners to adopt policies that as-sure product quality. For instance, AMFm uses the Global Fund’s quality assurance policy, which re-quires the procurement of WHO-

prequalified products and those that have passed stringent qual-ity assessment. Product branding serves to establish bonds among buyers, sellers and products. In many malaria-endemic countries there are various products avail-able for the treatment of malaria. The availability of a wide range of products can makes it harder for buyers to distinguish quality-as-sured products from others. ACT under the AMFm will bear a distinct logo that will serve as an identifier and sales driver.

Finally, it is important to expand access to the parasitological con-firmation of malaria, with a view to ensuring that only those who have malaria receive ACT as treatment. Most cases of presumptive treat-ment with ACT take place in the private sector. In the near- to me-dium-term, it is highly unlikely that effective public sector services will replace the private sector in most malaria-endemic countries.

Therefore, universal access to diagnostics requires the achieve-ment of universal access to these technologies in the private sector.

This is a condensed openaccess article “The quest for universal access to effective malaria treatment: how can the AMFm contribute?” written by Lloyd Matowe and Olusoji Adeyi that was published in the Malaria Journal 2010, Vol 9, issue 274.

4 5

Affordable ACTs For All Cambodians Universal Access to Effective Malaria TreatmentDr. Kheng Sim, Vice-Director of Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) speaks to CONTAINMENT on efforts to make vital anti-malarial drugs available to Cambodians at affordable prices.

The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured artemisi-nin-based combination therapy.

Cambodia has been awarded the Affordable Medicines Facility –

Malaria (AMFm) phase 1 grant. The lessons learnt from AMFm’s Phase 1 will be used for Phase 2. Can you tell us how programs have been put in place, in Cambodia, to subsidize the cost of Artemisinin Combination Therapies (ACTs) and make them widely available for a lower cost, which should help eliminate the black market for counterfeit drugs.

Universal access to effective malaria treatment is among

the United Nations’ Millennium Development Goals. This also is among the goals of the Roll Back Malaria Partnership.

Firstly I have to state that Cam-bodia’s application to AMFm was approved this year. CNM, together with other li-censed import-ers, is now eli-gible to access ACTs at a greatly reduced price through subsidies from the Glo-bal Fund. When all parties agree on the ACT that is to be used na-tionally, one that also meets the requirement of the Global Fund quality standard, CNM and the pri-vate importers can procure these products at approximately 5% of the manufacturer’s sale price.

However the actual ACT co-payment is determined through negotiations between the Global Fund appointed agent and the manufacturer. Nonetheless due to the unique situation of emerging artemisinin resistance in Cambo-dia, there have been challenges

to identify an appropriate ACT that is also eligible to be subsidized.

CNM is working closely with our partner [WHO] to assess and tran-sition to a new ACT. In April 2010 at the national drug policy-making workshop, CNM recommended Dihydroartemisinin (DHA)-Piper-aquine as the ideal first line treat-ment for plasmodium falciparum. We hope to enter into an agree-ment with the Global Fund to en-sure that cost savings are passed on to the customer, for this ACT.

Cambodia has been suc-cessful in nearly eliminating the black market for monotherapies especially in Zone 1. Artemisinin monotherapy is a serious worry for the development of drug re-sistance.

The recent ACT Watch’s Cam-

bodia Outlet Survey 2009 indi-cated that only 8.3 % of 7,523 drug outlets surveyed sold monotherapies. The current trends indicate that this fig-ure is declining and, obviously, enforcement in the country is working. Can you tell us how the Cambodian authorities are enfor

cing the ban on monotherapies.

The National Malaria Control Program by its own cannot en-force the ban on monotherapies. For that reason the National Ma-laria Program involves other part-ners into our program. An important component is the training of police officers to enforce the ban on monotherapies and carry out inspections of private drug outlets to curb the sales of fake or sub-standard anti-malarials. CNM is also working with the Ministry of Health in the training of the Jus-tice Police, who are also empow-ered to enforce the ban on mono-therapies and prosecute violators.

Another important component is our engagement with the private sector to teach about good and bad drugs. Without private sector coop-eration we will find it hard to com-pletely eradicate monotherapies.

How difficult is it to translatepolicy into practice for the AMFmPhase 1? The supply side of ACTscan be a problem.

The AMFm is an innovative fi-nancing mechanism designed to

reduce the price of ACTs in the pub-lic and private sector. It is not a

new policy on malaria diagnosisand treatment but rather a mecha-nism to increase public access tolow cost, high quality ACT. AMFmsupporting interventions are alignedwith CNM’s existing efforts toimprove supply and strengthen thepublic sector. But we do have chal-lenges. As I said earlier that at the national workshop we selected DHA-Piperaquine as the first-line treatment for falciparum malaria. But this first-line treatment is not yet prequalified by WHO. But we are confident it will be approved soon, so that we can move for-ward in negotiations with the Glo-bal Fund for its procurement.

We hope that the new ACT willbe available soon.

In spite of high-level commit-ments, political will and substan-tial increases in financing, the attainment of this goal has re-mained elusive in most malaria endemic countries, especially in relation to artemisinin-based com-bination therapy (ACT), the treat-ment recommended as first-line by the World Health Organization (WHO) for uncomplicated malaria caused by Plasmodium falciparum.

The Affordable Medicines Fa-cility-malaria (AMFm) is a new fi-nancing mechanism to expand ac-cess to effective malaria treatment. A response to the dual challenge of poor access to quality-assured anti-malarial medicines and threats of parasite resistance to treatment, the AMFm combines price nego-tiations with a factory-gate buyer subsidy to reduce the price of ACT.

The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives. These objectives include replac-ing older and increasingly ineffec-tive anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displac-ing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the like-lihood of resistance to artemisinin.

The AMFm is hosted by the Glo-bal Fund to Fight AIDS, Tuberculosis and Malaria. The pilot phase of the programme, which includes Cam-bodia, Ghana, Kenya, Madagascar, Niger, Nigeria, the United Republic of Tanzania and Uganda, is sched-uled to last from 2010 to 2012.

The AMFm is funded from mul-tiple sources including a co-payment

Dr. Kheng Sim, Vice-Director of CNM. Pix by WHO/Sonny Krishnan

AMFm supporting interventions are aligned with CNM’s

existing efforts to improve supply and strengthen the public sector.

All Cambodians will have full access to effective malaria treatment in the AMFm scheme. Pix by WHO/Sonny Krishnan

fund of US$216 million, financed by the Bill and Melinda Gates Foun-dation, the UK Government, and UNITAID. In addition, the GlobalFund provides US$127 million tofund supporting interventions at thecountry level.

Enabling appropriate and rational use of ACT

To preserve the effectiveness of ACT over time, it is important that these life-saving medicines are used appropriately. A number of studies have shown that malaria case management, particularly in the retail sector, is unsatisfactory.

The private sector, in particulardrug outlets, should be supported and capacitated to provide appro-priate and rational management of malaria. Integrated approaches aimed at improving understand-ing and treatment of malaria can lead to tangible improvements inmanagement of malaria. Buildingon lessons learned so far, the AMFmwill work with countries and tech-nical partners to build the skills of drug shop attendants using prom-ising models, such as the Tanzania Accredited Drugs Dispensing Out-lets (ADDOs).

Regulation can play an important role in enhancing access to ACT and improving the quality of care. A number of studies have reported that subsidizing ACT may need to be supported by effective regulato-ry policies for the intervention to be effective in crowding out less effec-tive anti-malarials from the market. Countries in AMFm Phase 1 may use funds from the Global Fund to strengthen in-country regulatory systems.

Related to regulation is product quality. The AMFm will work with partners to adopt policies that as-sure product quality. For instance, AMFm uses the Global Fund’s quality assurance policy, which re-quires the procurement of WHO-

prequalified products and those that have passed stringent qual-ity assessment. Product branding serves to establish bonds among buyers, sellers and products. In many malaria-endemic countries there are various products avail-able for the treatment of malaria. The availability of a wide range of products can makes it harder for buyers to distinguish quality-as-sured products from others. ACT under the AMFm will bear a distinct logo that will serve as an identifier and sales driver.

Finally, it is important to expand access to the parasitological con-firmation of malaria, with a view to ensuring that only those who have malaria receive ACT as treatment. Most cases of presumptive treat-ment with ACT take place in the private sector. In the near- to me-dium-term, it is highly unlikely that effective public sector services will replace the private sector in most malaria-endemic countries.

Therefore, universal access to diagnostics requires the achieve-ment of universal access to these technologies in the private sector.

This is a condensed openaccess article “The quest for universal access to effective malaria treatment: how can the AMFm contribute?” written by Lloyd Matowe and Olusoji Adeyi that was published in the Malaria Journal 2010, Vol 9, issue 274.

36

Dr. Duong Socheat, Directorof the National Malaria Center, alsoagreed that different institutionsneeded to cooperate in the fightagainst counterfeit drugs andmalaria.

“As you know, there are coun-terfeit medicines in Cambdodia,” he told the workshop. “Malaria can cause death but it is preventable.”

He continued: “When people are sick, they normally go to pri-vate pharmacies [and] they may

get counterfeit medicines. [So], we need law enforcement officers to implement the laws effectively.”

Dr. Duong Socheat said getting rid of fake and substandard drugs is important in combating malaria in Cambodia. Moeun Chhean Nariddh

....from page 2

A Day in the Life of a Drug Inspector in Pailin Using Taxi Drivers and Radio to Reach Mobile Migrant WorkersCONTAINMENT’s Moeun Chhean Nariddh follows Justice Police Officer Nuth Tith on his rounds in the Pailin market in North-West Cambodia.

Dr. Kheang Soy Ty, Chief of Party of the USAID-funded University Research Co (URC) and Khorn Linna, URC’s communications specialist, tell CONTAINMENT of their efforts to raise malaria awareness among mobile migrant workers.

Justice Police Officer Nuth Tith inspecting a Pailin pharmacy's display cabinet. Pix by WHO/Moeun Chhean Nariddh

URC's Dr. Kheang Soy Ty (left) and Khorn Linna. Pix by WHO/Sonny Krishnan

It’s almost noon now in Cambodia’s Pailin province on the

northwestern border with Thailand. Nuth Tith, a middle-aged health official, quickly changes his clothes and wears a new police uniform.

Why has the project chosen taxi-drivers to spread knowledge

among migrant workers about the cause of malaria?

With a light blue shirt and dark blue trousers together with a sky blue cap, Nuth Tith l o o k s no different from a police officer.

The only difference is that the sign on his shirt is a medical sym-bol instead of the normal Singha, orKing of Lions, emblem used by other national police officers. An-other thing is that he does not have a revolver in his belt andneither does he carry handcuffs.

Yet, he is not a normal poli- ceman. Trained as one of the five justice police officers in Pailin,Nuth Tith’s duty is to inspect pharmacies and drug stores to make sure that no counterfeit or substandard malaria drugs are on sale.

Dr. Soy Ty: Before we chose this strategy, we did focus group discussions (FGDs) with village chiefs and staff in health centers. The FGDs also included those from the mobile and migrant population. The FGD results indicated that the majority of migrant workers, from other provinces, used taxis to get to Western Cambodia. For many of these migrant workers, especially from the southeastern part of Cambodia that borders Vietnam, the taxi drivers are their first point of contact in the West. Also from the FGDs we found out that the popular taxi routes are from Battambang to Samlaut; Battambang to Sampov Loun; and Battambang to Pailin.

The southeast part of Cambodia has no falciparum malaria cases. So you have peo-ple moving from areas of low endemicity to ar-eas of high endemicity. The migrant workers make their way to the West, especially during the harvest season, to work in the plantations.

How are the taxi-drivers trainedto raise awareness of malariaamong migrant workers?

Khorn Linna: First we conducted an FGD with three groups of taxi drivers that carried migrant workers along the following routes: Battambang to Samlaut; Battambang to Sampov Loun; Battambang to Pailin. We wanted to find out whether we could collabo-rate with these drivers and we also wanted to assess their basic knowledge on malaria prevention. Besides that, the FGDs also gave us a good opportunity to find out from the taxi drivers what were the best kinds of IEC [Information, Education and Communi -

He is now ready to carry out his tasks.

After a ten-minute ridefrom the provincial hos-pital, he hops out of the car and rushes to a line of drug stores at a small market near Pailin.

“Do you have any malaria drugs left?” he asks Phat Sambo, a 28-year old drug sell-er at the front row.

“No!” she replies, laughing.He searches the drug cabinet but finds no malaria drugs on sale.

“Now, put these flyers on the wall and don’t put any other pictures,” he advices and hands out a few anti-malaria drug flyers to Sambo.

Nuth Tith says the justice police officers would inspect the pharma-cies and drug stores every three months as part of the efforts to stop the sale of malaria drugs and other fake and substandard medicines.

“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.

Now, the drug inspector has got back into the car and moved to the pharmacies in Pailin market. He stops by a pharmacy run by 36-year-old Sor Pov, who’s been selling medicines for the past eight years.

When asked if she has re-

ceived any patients who have come to buy malaria medicines, she replies that only about one in every 100 people have asked for malaria drugs at her store.

Duch Vanda, a 43-year-old ven-dor who sells medicines at a phar-macy next to Sor Pov’s, agrees that the number of people seeking malar-ia medicines has sharply declined.

“Now, almost nobody asks for malaria drugs,” he claims.

As instructed by the justice po-lice, both Sor Pov and Duch Vanda say they would refer any malaria patients to get free treatment at the health centers or village malaria workers around Pailin, if any cus-tomer asks to buy malaria medicines.

Sambo says the justice po-lice officers have visited her store five times now since she start-ed selling drugs two years ago.

“I think the anti-malaria cam-paign has been very successful, because there are no more ma-

laria patients,” Sor Pov points out.

Drug inspector Nuth Tith then continues to the last pharmacy in the same row at Pailin market. But, he still cannot find any ma-laria or other fake drugs either.

Tith says that since he start-ed his new drug inspection job three years ago, he has found less and less malaria drugs in the 25 pharmacies and drug stores he constantly inspects in Pailin.

After visiting the last pharmacy, Nuth Tith returns to the provin-cial hospital with a smile, proving that his work has been a success.

“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.

cation] materials that they [taxi drivers]could give out to their migrant worker passengers.

After the FGDs, we started the first train-ing of taxi drivers in Battambang. We had 33 drivers from the three different locations in the training. The training was to ensure that the taxi drivers disseminated accurate infor-mation on malaria prevention and treatment to their migrant worker passengers. Because they were the primary message provid-ers, as the first point of contact for migrant workers, we also had to make sure these taxi drivers had good communication skills.

Now we have 33 taxi drivers in our net-work and we plan to conduct quarterly work-shops to monitor and evaluate their activi-ties, and also evaluate the IEC materials that we have developed jointly with the drivers.

Are the taxi-drivers also trying to change the treatment-seek-ing behaviour of migrant work-ers – like seeking out the village malaria worker first for diagno-sis and treatment if they have fever, rather than going to the pharmacy for self-medication?

Dr. Soy Ty: In the training progra-mmes, we ensure that the taxi drivers them-selves have accurate information on malaria transmission and also adequate knowledge of the vector in its ability to transmit ma-laria. Also through the training programmes, the drivers know the symptoms of malaria or suspected malaria – the fevers, chills, headaches, cold sweats etc. The taxi-driv-ers are also made aware of the location of health facilities and village malaria work-ers along the Pailin, Samlaut and Sampov Loun routes, where migrant workers can get free diagnosis and treatment for malaria.

All these packets of information are im-portant because the taxi drivers will be able to advise the migrant workers on what to do if they have fever and where to seek free diagnosis and treatment, rather than go-ing to the drug outlets or pharmacies first.

Are the taxi drivers also distributingbed-nets to migrant workers?

Dr. Soy Ty: Not at this stage ofthe project. We recognize the role of taxi drivers in distributing bed-nets.

But the question is: from where should we get the bed nets?

This is a question of sustainability and we need to coordinate with the National Malaria Programme. Recently URC and its other partners discussed bed-net distribu-tion using a voucher system, where taxi driv-ers could give out vouchers to their migrant worker passengers. The migrant workers then can redeem them for bed-nets at the public health facilities in the areas where they are going to find work. We hope to be able to get bed-nets from the National Malaria Program for this pilot programme.

We are also thinking one step further in working with the private sector – especially with the drug outlets and pharmacies. These places are popular with Khmers, so why not they be also used to sell highly subsidised bed-nets?

In your behaviour change com-munication efforts, how do youencourage migrant workers to use bed-nets?

Khorn Linna: Most of the migrant workers are from provinces where there is no malaria.

So the majority of them really don’t know about the mosquito-borne disease. It’s not a matter of just making available Inform-ation, Education and Communication (IEC) materials but also determining which is the best way to reach them in terms of increas-ing their knowledge on malaria. We found, through FGDs, that radio as a channel of communication was the best means to reach out these migrant workers. Based on the findings of the FGDs, we have started working with [a media development INGO] Equal Access to produce interactive radio call-in shows. These radio programs are re-ally popular with migrant workers because it enables them to interact with the presenters, with calls made to the radio station on their mobile phones.

72

Law Enforcers to Get Tough on Counterfeit Medicines Reaching Out To Migrant Workers At The Thai Border

Dr. Doung Socheat, Director of CNM, addressing the workshop. Pix by WHO/Sonny Krishnan Workers from Cambodia making their way to Thailand at the border crossing in Sampov Loun. Pix by WHO/Sonny KrishnanCambodian malaria experts

and senior police officers have agreed that better cooperation and concerted efforts are needed to effectively combat malaria as well as curb the sale and smuggling of counterfeit and substandard drugs in Cambodia.

“The Ministry of Health has done a lot of work, but it would not be able to do anything without the coopera-tion of the police,” explained Gen-eral Ben Rath, Vice Commissioner for Phnom Penh Municipal Police, during a workshop on “Strengthen-ing Law Enforcement for Investiga-tion of Counterfeit Medicines and Artemisinin Monotherapy”, which was held in Siem Reap Province from November 10 to 12, 2010.

The National Centre for Para-sitology, Entomology and Malaria Control or CNM that receives tech-nical assistance from WHO, with support from the Global Fund and in cooperation with the Ministry of Interior organized the three-day training of trainers’ workshop for 55 senior police officers from 24 cities and provinces across the country.

The workshop was to improve the investigative skills of the Cambodian senior police officers to identify and crackdown on fake and substand-ard malaria drugs that have been smuggled and sold in the country.

Besides the cooperation between CNM and the police, General Ben said it was important for the Minis-

try of Health to encourage local au-thorities to provide more support to the crackdown on counterfeit and substandard drugs in Cambodia, particularly in the rural areas.

“We’ve done a lot in Phnom Penh, but not much in the provinces where people are more vulnerable due to the lack of knowledge,” he said.

Malaria parasites in the Asso-ciation of Southeast Asian Nations region or ASEAN are now resistant to almost all anti-malarial drugs, with the exception of drug combi-nations containing derivatives of ar-temisinin (artemisinin-based com-bination therapy, or ACT). Because artemisinin derivatives are remark-ably rapid in their anti-malarial ef-fects, they are much sought after.

But as they are relatively expen-sive a demand is created for cheap-er versions amongst the poorest and most vulnerable people, upon whom the counterfeiters have preyed -- with fatal results.

General Un Sovannthy,Deputy Chief of the Anti- Economic Crime Police Depa-rtment, said he agreed that the cooperation between different institutions wassignificant.

“We have had success due to the cooperation from local authorities and the courts,” he

said.“The economic police officers

are to supplement the work of other institutions.”

He said that the combat against counterfeit and substandard drugs would be even more effective if the village leaders could also be trained to identify and distinguish between good drugs from bad ones.

The Phnom Penh Poice Vice-Commissioner said the workshophad provided the participants withsubstantial knowledge and skillsso that they could do their work moreefficiently.

“Even myself, I have learned a lotfrom the workshop,” said General Ben, adding: “I think they will be able to pass on their knowledge [to other police officers in the districts].”

Meanwhile, the Cambodiangovernment has made progressin its crackdown on counterfeitmalaria drugs.

In April 2010 the United States Pharmacopia -- a non–governmen-tal, official public standards-setting authority for prescription and over-the-counter medicines – stated that Cambodia has shut down nearly 65 percent of illegal pharmacies after receiving evidence showing that they were among the main sources of substandard and coun-terfeit medicines in the country.

Pong Nam Ron District, Chantaburi Province -- “Mom” lives in this

camp with other people who come and go between Thailand and their homes in Cambodia whenever there is work.

A recent secondary school leav-er, "Mom” said her family spends about two months here before they go home to Boseth Commune in Kampong Speu, a province located southwest of Cambodia’s capital Phnom Penh, or a day's drive away from Chantaburi on the Thai side.

In her Thai, which was under-standable though not fluent, she remembered having repeated the journey about 10 times, and hav-ing done some work herself on some occasions. “We pick what-ever fruit is in season,” she said.

About 20 people who usually spend less than six months just inside Thailand were living in this camp when a team of officials from the Bureau of Vector Borne Diseas-es, World Health Organisation and the Malaria Consortium paid a visit. The conditions at the camp located on the edge of a longan orchard were stark. Spindly tree trunks propped up the houses, with synthetic fiber sheeting or newspaper sheets as walls. But there were water jars in the camp, suggesting some per-manency or continuity in the move-ments of these itinerant workers.

A family who had lived in the camp for about a year enjoyed the luxury of a wooden floor and used a traditional bed-net they bought from the local market before cross-ing the border. The bed-net accom-modated five people: the parents, children aged 11 and five, and a baby of six months. But it was an ordinary bed-net, not treated with insecticide, which would hardly pro-tect them from the female anophe-les mosquito, carrier of the Plasmo-dium falciparum parasite that can lead to death if not nipped in time.

Piyaporn Wangroongsarb, a spe-cialist in migrants for the Bureau,pointed out that people from Cam-bodia cross the border into Thai-land regularly, perhaps every month, for work because there wasconstant demand for longan fruitsin markets abroad.

A key partner in the $22.5 mil-lion Containment Project largely supported by the Bill & Melinda Gates Foundation, the Bureau of Vector-Borne Diseases “plans to impregnate ordinary nets with permethrin that either kills or re-pels mosquitoes, and to distrib-ute bed-nets already treated with the chemical to those who have no nets at all,” added Piyaporn.

Chantaburi is renowned for itswealth in fruits such as longan,

longgong, rambutan, durian, mang-osteen, among others.

But fruit-picking is rated by Pong Nam Ron District authorities as a “high risk” occupation.

The high-risk rating, explained Saowanit Vijaykadga, head of the bureau's Malaria Cluster, referred to those fruit-pickers who “stayed overnight inside orchards and did not take precautions, such as protect themselves with long-lasting insec-ticide-treated nets and repellents.”

While the Bill & Melinda Gates Foundation-funded containment project is now able to diagnose and treat falciparum malaria cases ef-fectively with quality drugs, other measures like the targeted distribu-tion of long-lasting insecticide-treat-ed nets and long-lasting insecticide-treated hammock nets, together with repellents, have significantly brought down the number of cas-es of this deadly form of malaria.

The Fixed Schedule Malaria Clinic that began operating in this malaria hot-spot area in April 2009 is strategically placed on the Thai-Cambodia border. Its twice-weekly mobile clinics enable quick diagnosis and treatment of ma-laria cases. Between April 2009 to September 2010, blood sam-ples were drawn from 3,267 peo-ple and only five of them tested positive for falciparum malaria.

Chantaburi, with Pong Nam Ron and Soi Dao districts as the busi-est areas for fruit cultivation, prob-ably ranks as the main recipient of short-term workers from Cam-bodia across the eastern border.

Trat, Sa Kaeo, Buri Ram, Surin, Si Saket, and Ubol Ratchathani are the other six provinces included in the project to contain artemisi-nin-resistant falciparum malaria. Anuraj Manibhandu

continued on page 8

Lessons Learned from Cambodia Useful for Region

Schoolgirl’s Malaria Knowledge Helps Family Avoid Getting Sick

Cambodia Task Force Meeting in progress. Pix by WHO

Seub Saren who educates her family in Pailin about malaria. Pix by WHO/Sonny Krishnan

CONTAINMENT is published by WHO Cambodia’s Malaria Containment Project. For enquiries please contact Dr. Najibullah Habib, Malaria Containment Project Manager, World Health Organization

Cambodia, 177-179 St. Pasteur (51), PO Box 1217, Phnom Penh OR e-mail: [email protected]

January-March 2011

There are lessons to be learned by other countries in the

Greater Mekong Sub-region as they push for containment and eventual elimination of artemisinin-resistant malaria.

“Malaria is spread by female ‘nail’ mosquitoes during nighttime.”

of drug-resistant malaria on the Thai-Cambodian border

Quarterly Newsletter of the Strategy for the Containment of Artemisinin-Tolerant Malaria Parasites in South-East Asia Project

This was the message put for-ward by the Secretary of State for the Ministry of Health, His Ex-cellency Chou Yin Sim, when he opened the third Cambodian Task Force meeting on December 3, 2010 at the Phnom Penh Hotel.

“The National Task Force of Cambodia provides national su-pervision to the Containment Project funded by the Bill & Melin-da Gates Foundation,” he told the meeting attended by WHO, the National Malaria Control Centre (CNM), and their working partners.

“Elimination of resistant malaria parasites will remain out of reach unless we pay adequate attention to the delivery of health services, including good surveillance of re-mote areas and migrant popula-tions. This cannot be done with-out the strengthening of health systems,” stressed H.E. Yin Sim.

H.E. Yin Sim pointed out the strategies that have been effec-tive in the Containment Project.

“The strategies that have been found to be effective in the Contain-ment Project have been the provi-sion of free diagnosis and treatment by village malaria workers and the promotion of the use of LLINs (long-lasting insecticide treated nets) by

populations at risk of malaria, es-pecially those who stay overnight in the forest,” he told the meeting.Another important strategy was the ban on monotherapies that H.E. Yin Sim said had proven to be effective in addressing the spread of multi-drug resistant falciparum malaria.

“The Ministry of Health is com-mitted to eliminating monothera-pies and perpetrators will be sub-jected to administrative measures

and legal ac-tion,” he said.

“In Cambodia, a ban on mon-otherapies to-gether with the Public-Private Mix initiative have achieved almost zero p r e v a l e n c e of artemisinin m o n o t h e r a -pies as well

as a significant reduction in fake and substandard drugs on the market,” said H.E. Yin Sim. “I do hope this positive exam-ple and the lessons learned can be replicated in other countries in the region,” he emphasized.The US$22.5-million ContainmentProject funded by the Bill & MelindaGates Foundation involves both Cambodia and Thailand. There are respective National Task

Forces in both Cambodia and Thailand overseeing the project.

The international level oversight is through a panel of international malaria experts in the International Task Force. So far the Internation-al Task Force has held twom e e t -ings – the first in Phnom Penh in 2009 and the other inHanoi in February 2010.

“The ultimate goal of the project is to contain the artemisinin-resist-ant malaria by removing selection pressure and reducing and ulti-mately eliminating falciparum ma-laria through a series of strategies,” said Dr. Najibullah Habib, WHO’s

Malaria Containment Project Manager.Stressed Dr. Habib: “If this resist-ance to artesunate spreads from this area to other regions or other countries, it constitutes not only a regional but a global public health issue. Therefore it’s an issue that

goes beyond just Pailin or Western Cambodia or Zone One or Zone Two – it goes regionally and globally.”

Dr. Habib explained to the TaskForce Meeting the zoning of theContainment Project. “Zone 1 in-volves not just Western Cambodia but also some areas in Thailand as well. And that’s where we have our elimination strategy – to eliminate

artemisin-resistant malaria. Zone 2 is a buffer zone to make sure the disease does not spread beyond the focal area. For Zone 3, we have now good news that Global Fund Round 9 activities are geared to-wards control in those areas includ-

ing the whole of Cambodia.”

In order to reduce selection pressure, it is imperative to use ar-temisinin-derived drugs with otherpartner drugs in the treatment offalciparum malaria.“In Zone 1 it isdihydroartemisinin-piperaquine (DHA-P); in Zone 2 it is artesuna-te plus mefloquine (A and M) and atovaquone – proguanil in Thai-land,” Dr. Habib pointed out.

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“To avoid getting malaria, people should protect themselves from beingbitten by female ‘nail’ mosquitoes bysleeping in a mosquito net.” “Peoplewho have malaria must take proper me-dicines as prescribed by a physician.”

This is Lesson 11 at Grade 5 in Cam-bodia which young Cambodian stude-nts are taught at school as part of the curriculum for their “Applied Science”study.

However, like other lessons about such diseases as typhoid and den-gue fevers, malaria is not an inter-esting lesson for many students who

live in non-malaria infested areas. But for 14-year-old Seub Saren

who has attended a school in Siem-reap Province’s Srey Snom District, she finds this knowledge about malar-ia particularly interesting and useful for her family when they moved to Pailin, where malaria posed a serious health threat to migrant workers like her family.

“After she returned from school, she told the family how to protect our-selves from malaria,” says her father, Se Seub, who is now living and working in Pailin with his wife and four children.

Seub says he was sick with ma-laria when he came to work in Pailin three years ago and that he had to go back to Siem Reap for treatment.

However, he says he has neverbeen sick with the disease duringthe last few years after learning toprotect himself and his family as hisdaughter taught them.

Seub Saren says she knows very well about malaria from the lessons she has learned at school, which was why she could educate her family how to prevent the disease.

Like Seub Saren, other fifth graders in Pailin can also easily score a good mark for the lesson about malaria.

Nuon Phon, a Grade 5 teacher at Pailin’s Phoum Thmei Primary School, says his students are enthu-siastic to learn about malaria, “be-cause Pailin is a malaria infested area, so they are very interested.”

Unlike many other lessons about Science that is complicated and dif-ficult to learn, Nuon Phon says teaching malaria as a subject in Pai-lin is very practical and relevant.

“I asked them where they lived; they said they lived in the mountainous are-as,” says Phon as he explains the meth-odology he uses to teach his students.

“Then, I asked ‘Have you had malaria before?’ They said ‘Yes,” hecontinues. “’So, do you want to havemalaria?’ they said ‘No.’”

“What should you do?” he asks and he would prod the students withmore follow-up questions.

Moeun Chhean Nariddh

In order to reduce selection pressure, it is imperative to use artemisinin-derived drugs with other partner drugs in the treatment of falciparum malaria.