Browsing by Author "Khonputsa P."
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Item Metadata only Antimalarial chemoprophylaxis for forest goers in southeast Asia: an open-label, individually randomised controlled trial(2023-01-01) Tripura R.; von Seidlein L.; Sovannaroth S.; Peto T.J.; Callery J.J.; Sokha M.; Ean M.; Heng C.; Conradis-Jansen F.; Madmanee W.; Peerawaranun P.; Waithira N.; Khonputsa P.; Jongdeepaisal M.; Pongsoipetch K.; Chotthanawathit P.; Soviet U.; Pell C.; Duanguppama J.; Rekol H.; Tarning J.; Imwong M.; Mukaka M.; White N.J.; Dondorp A.M.; Maude R.J.; Mahidol UniversityBackground: Malaria in the eastern Greater Mekong subregion has declined to historic lows. Countries in the Greater Mekong subregion are accelerating malaria elimination in the context of increasing antimalarial drug resistance. Infections are now increasingly concentrated in remote, forested foci. No intervention has yet shown satisfactory efficacy against forest-acquired malaria. The aim of this study was to assess the efficacy of malaria chemoprophylaxis among forest goers in Cambodia. Methods: We conducted an open-label, individually randomised controlled trial in Cambodia, which recruited participants aged 16–65 years staying overnight in forests. Participants were randomly allocated 1:1 to antimalarial chemoprophylaxis, a 3-day course of twice-daily artemether–lumefantrine followed by the same daily dosing once a week while travelling in the forest and for a further 4 weeks after leaving the forest (four tablets per dose; 20 mg of artemether and 120 mg of lumefantrine per tablet), or a multivitamin with no antimalarial activity. Allocations were done according to a computer-generated randomisation schedule, and randomisation was in permuted blocks of size ten and stratified by village. Investigators and participants were not masked to drug allocation, but laboratory investigations were done without knowledge of allocation. The primary outcome was a composite endpoint of either clinical malaria with any Plasmodium species within 1–28, 29–56, or 57–84 days, or subclinical infection detected by PCR on days 28, 56, or 84 using complete-case analysis of the intention-to-treat population. Adherence to study drug was assessed primarily by self-reporting during follow-up visits. Adverse events were assessed in the intention-to-treat population as a secondary endpoint from self-reporting at any time, plus a physical examination and symptom questionnaire at follow-up. This trial is registered at ClinicalTrials.gov (NCT04041973) and is complete. Findings: Between March 11 and Nov 20, 2020, 1480 individuals were enrolled, of whom 738 were randomly assigned to artemether–lumefantrine and 742 to the multivitamin. 713 participants in the artemether–lumefantrine group and 714 in the multivitamin group had a PCR result or confirmed clinical malaria by rapid diagnostic test during follow-up. During follow-up, 19 (3%, 95% CI 2–4) of 713 participants had parasitaemia or clinical malaria in the artemether–lumefantrine group and 123 (17%, 15–20) of 714 in the multivitamin group (absolute risk difference 15%, 95% CI 12–18; p<0·0001). During follow-up, there were 166 malaria episodes caused by Plasmodium vivax, 14 by Plasmodium falciparum, and five with other or mixed species infections. The numbers of participants with P vivax were 18 (3%, 95% CI 2–4) in the artemether–lumefantrine group versus 112 (16%, 13–19) in the multivitamin group (absolute risk difference 13%, 95% CI 10–16; p<0·0001). The numbers of participants with P falciparum were two (0·3%, 95% CI 0·03–1·01) in the artemether–lumefantrine group versus 12 (1·7%, 0·9–2·9) in the multivitamin group (absolute risk difference 1·4%, 95% CI 0·4–2·4; p=0·013). Overall reported adherence to the full course of medication was 97% (95% CI 96–98; 1797 completed courses out of 1854 courses started) in the artemether–lumefantrine group and 98% (97–98; 1842 completed courses in 1885 courses started) in the multivitamin group. Overall prevalence of adverse events was 1·9% (355 events in 18 806 doses) in the artemether–lumefantrine group and 1·1% (207 events in 19 132 doses) in the multivitamin group (p<0·0001). Interpretation: Antimalarial chemoprophylaxis with artemether–lumefantrine was acceptable and well tolerated and substantially reduced the risk of malaria. Malaria chemoprophylaxis among high-risk groups such as forest workers could be a valuable tool for accelerating elimination in the Greater Mekong subregion. Funding: The Global Fund to Fight AIDS, Tuberculosis and Malaria; Wellcome Trust.Item Metadata only Community engagement among forest goers in a malaria prophylaxis trial: implementation challenges and implications(2023-12-01) Conradis-Jansen F.; Tripura R.; Peto T.J.; Callery J.J.; Adhikari B.; Ean M.; Jongdeepaisal M.; Pell C.; Khonputsa P.; Murgia R.; Sovannaroth S.; Müller O.; Cheah P.Y.; Dondorp A.M.; von Seidlein L.; Maude R.J.; Mahidol UniversityBackground: Malaria transmission in Southeast Asia is increasingly confined to forests, where marginalized groups are exposed primarily through their work. Anti-malarial chemoprophylaxis may help to protect these people. This article examines the effectiveness and practical challenges of engaging forest-goers to participate in a randomized controlled clinical trial of anti-malarial chemoprophylaxis with artemether-lumefantrine (AL) versus a control (multivitamin, MV) for malaria in northeast Cambodia. Methods: The impact of engagement in terms of uptake was assessed as the proportion of people who participated during each stage of the trial: enrolment, compliance with trial procedures, and drug intake. During the trial, staff recorded the details of engagement meetings, including the views and opinions of participants and community representatives, the decision-making processes, and the challenges addressed during implementation. Results: In total, 1613 participants were assessed for eligibility and 1480 (92%) joined the trial, 1242 (84%) completed the trial and received prophylaxis (AL: 82% vs MV: 86%, p = 0.08); 157 (11%) were lost to follow-up (AL: 11% vs MV: 11%, p = 0.79); and 73 (5%) discontinued the drug (AL-7% vs MV-3%, p = 0.005). The AL arm was associated with discontinuation of the study drug (AL: 48/738, 7% vs 25/742, 3%; p = 0.01). Females (31/345, 9%) were more likely (42/1135, 4%) to discontinue taking drugs at some point in the trial (p = 0.005). Those (45/644, 7%) who had no previous history of malaria infection were more likely to discontinue the study drug than those (28/836, 3%) who had a history of malaria (p = 0.02). Engagement with the trial population was demanding because many types of forest work are illegal; and the involvement of an engagement team consisting of representatives from the local administration, health authorities, community leaders and community health workers played a significant role in building trust. Responsiveness to the needs and concerns of the community promoted acceptability and increased confidence in taking prophylaxis among participants. Recruitment of forest-goer volunteers to peer-supervise drug administration resulted in high compliance with drug intake. The development of locally-appropriate tools and messaging for the different linguistic and low-literacy groups was useful to ensure participants understood and adhered to the trial procedures. It was important to consider forest-goers` habits and social characteristics when planning the various trial activities. Conclusions: The comprehensive, participatory engagement strategy mobilized a wide range of stakeholders including study participants, helped build trust, and overcame potential ethical and practical challenges. This locally-adapted approach was highly effective as evidenced by high levels of trial enrolment, compliance with trial procedures and drug intake.Item Metadata only Cost, health impacts and cost effectiveness of iceless refrigeration in India's last-mile vaccine cold chain delivery(2023-04-03) Plewes K.; Khonputsa P.; Day N.P.J.; Lubell Y.; Mahidol UniversityBACKGROUND: Compared with ice-based vaccine carriers (IBVCs), iceless vaccine carrier (ILVC) last-mile delivery could optimize vaccine effectiveness by reducing spoilage. We estimated ILVC-associated spoilage costs averted and cost effectiveness. METHODS: IBVC vaccine spoilage costs were estimated for six vaccines. ILVC incremental costs were based on yearly ILVC cost over total doses. Cost effectiveness was estimated via Markov modeling of rotavirus vaccine. RESULTS: The spoilage cost using IBVCs was US$9 603 294. Using ILVCs, the incremental cost per vaccine dose was US$0.026, the cost-benefit ratio was 0.28, the number of averted disability-adjusted life years was 0.03 per child and there was a saving of US$0.80 per child vaccinated. CONCLUSIONS: ILVCs may bring cost savings and health gains compared with IBVCs.Item Metadata only Expanded roles of community health workers beyond malaria in the Asia-Pacific: A systematic review(2024-10-16) Jongdeepaisal M.; Khonputsa P.; Sirimatayanant M.; Khuenpetch W.; Harriss E.; Maude R.J.; Jongdeepaisal M.; Mahidol UniversityIn the Greater Mekong Subregion (GMS), community health workers (CHWs) are a key component of malaria elimination strategies. As malaria declines, support for, and uptake of, malaria services may also subsequently decrease. Expanding their roles beyond malaria has been proposed to sustain the services. A systematic review was conducted to identify and characterize programmes with CHWs providing services in addition to those for malaria in the Asia Pacific. This review describes the expanded roles, identifies evidence of impact or success of the programmes, and explores strategies to ensure sustainability and factors for effective implementation to inform the design of malaria CHW programmes. Searches were conducted in 6 databases, for grey literature, and in bibliographies of retrieved articles. Data were extracted from 38 published articles, 12 programme reports, and 4 programme briefs and analysed using thematic coding and descriptive analysis. Twenty-nine programmes were identified with CHWs performing both malaria and non-malaria roles in the Asia Pacific. There was evidence of impact on malaria incidence in 4 of these, none on malaria mortality, and 4 on other diseases. Monitoring and evaluation mechanisms, multi-sectoral stakeholder collaborations, and adequate training and consistent supervision of CHWs were key to effective programme implementation. Integration of programmes into broader health services, ongoing political and funding support, and engagement with local communities were found to contribute to sustaining provision of health services by CHWs. Expanding CHW roles depends on programme management and strengthening linkages with local health systems. To sustain malaria CHW services, countries need adequate policies and financing, and sufficiently strong health systems to deliver basic health services that are adapted to the health needs of the community which means transitioning away from vertical disease programs. Further research should explore programmes that have not been captured in this review and address gaps in measuring malaria outcomes.Item Metadata only Expanded roles of community health workers to sustain malaria services in the Asia-Pacific: A landscaping survey(2024-08-14) Jongdeepaisal M.; Sirimatayanant M.; Khonputsa P.; Hein P.S.; Buback L.; Beyeler N.; Chebbi A.; Maude R.J.; Jongdeepaisal M.; Mahidol UniversityMalaria Community Health Workers (CHWs) in the Greater Mekong Subregion (GMS) are an important component of malaria elimination efforts. As malaria declines with intensified efforts to eliminate by 2030, expanding their roles beyond malaria could help to sustain funding and provision of malaria services at the community level. Evidence of how programmes have implemented and managed CHWs performing both malaria and non-malaria roles across the Asia-Pacific region can provide insight into the viability of this strategy. A short survey was distributed to national malaria programmes and implementing organizations in the Asia-Pacific region in 2021–2022. The survey identified CHW programmes in the region, and collected information on malaria and non-malarial services provided by CHWs, characteristics of each identified programme, and the impact of COVID-19 on these programmes. 35 survey responses identified 28 programmes in 14 countries. The most frequently reported services provided by malaria CHWs were health promotion and education for malaria (13/14 countries) and other diseases (11/14); and COVID-19 related activities (10/ 14). Most programmes were financed wholly through donor funding (18/28 programmes), or donor plus government funding (6/28). Of 21 programmes which performed programme evaluation, only 2 evaluated their impacts on diseases beyond malaria. Declining donor funding, and COVID-19 related travel and activity restrictions were identified as implementation challenges. CHWs across the Asia Pacific provide a range of health services with malaria and are resilient under changing public health landscapes such as the COVID-19 pandemic. Further investigation into the impact of additional roles on malaria CHW performance and targeted health outcomes is needed to verify the benefits and feasibility of role expansion. As the GMS approaches elimination, and funding declines, verifying the cost effectiveness of malaria CHW programmes will be vital to persuade donors and countries to invest in malaria CHWs to sustain malaria services, and strengthen community-based health care.Item Metadata only Expanding the roles of malaria post workers in Thailand: A qualitative study of stakeholder perspectives(2024-09-17) Jongdeepaisal M.; Khonputsa P.; Prasert O.; Maneenate S.; Sirimatayanant M.; Sopa P.; Saisong A.; Charoensup I.; Kamsri T.; Tipmontree R.; Sudathip P.; Liverani M.; Maude R.J.; Pell C.; Jongdeepaisal M.; Mahidol UniversityIn Thailand, since the 2000s, malaria post (MP) workers have been tasked with promptly detecting and treating all malaria cases to prevent onward transmission in the communities. Expanding their roles to provide health services beyond malaria has been proposed as a strategy to sustain their activities until elimination is reached. This article examines the perspectives of stakeholders on community-based malaria care to assess prospects for expanding the role of MPs. The study incorporated in-depth interviews (IDIs) and focus group discussions (FGDs). In forested communities and local health facilities in northeast Thailand bordering Lao PDR and Cambodia, where malaria transmission is low, IDIs were conducted with 13 MPs and 23 community members. An additional 14 policymakers and implementers across the health sector in Thailand were interviewed. The respondents highlighted how in these border areas population groups most at risk of malaria, namely forest goers and migrants, are reluctant to visit public health facilities. In these areas, MP workers are well integrated in their communities and remain relevant although the communities no longer see malaria as spriority. Common conditions such as dengue, diabetes, insect bites, diarrhea, mental illness and substance abuse, were identified as local health concerns needing potential add-on services from MP workers. Although challenges in terms of training, supervision, and financing were raised, opportunities included additional funds from local administrative offices to maintain and integrate malaria activities with other health programmes. Changes to the roles of MPs should be adapted to changing local needs, some of which were identified in this study, should avoid duplication and potential tensions with other local health programmes, and need to build on the capacity of the community and primary care system. These enabling factors are worthy of consideration by any malaria programmes looking into maintaining their village malaria workers in the Greater Mekong Subregion.Item Metadata only Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Lao PDR(2022-12-01) Jongdeepaisal M.; Inthasone S.; Khonputsa P.; Malaphone V.; Pongsoipetch K.; Pongvongsa T.; Mayxay M.; Chindavongsa K.; Pell C.; Maude R.J.; Mahidol UniversityBackground: Despite significant decline in malarial incidence and mortality in countries across the Greater Mekong Subregion, the disease remains a public health challenge in the region; transmission continues mainly among people who visit forests in remote areas, often along international borders, where access to primary healthcare is limited. In the absence of effective vector-control measures and limited exposure periods, malaria chemoprophylaxis has been proposed as a strategy to protect forest goers. As a rarely used approach for indigenous populations, questions remain about its feasibility and acceptability. Drawing on in-depth interviews with forest goers and stakeholders, this article examines opportunities and challenges for implementation of anti-malarial chemoprophylaxis for forest goers in Lao PDR. Methods: In-depth interviews were conducted with 16 forest goers and 15 stakeholders in Savannakhet province, Lao PDR. Interview topics included experience of malaria prevention and health services, and perceptions of prophylaxis as a potential component of malaria elimination strategy. The interviews were transcribed and coded using inductive and deductive approaches for qualitative thematic analysis. Results: In ethnically and geographically diverse villages, awareness of malaria risk prompts forest goers to protect themselves, albeit sub-optimally using available preventive measures. Stakeholders highlighted challenges for targeting at-risk populations and approaches to address forest malaria in southern Lao PDR. Among policymakers, choice and cost of anti-malarials, particularly their efficacy and source of funding, were key considerations for the feasibility of malaria prophylaxis. Acceptability of prophylaxis among forest goers was also influenced by the complexity of the regimen, including the number of tablets and timing of doses. Implementation of prophylaxis may be affected by a lack of transportation and communication barriers in remote communities. Conclusion: Adding prophylaxis to existing malaria control activities requires strengthening the capacity of local health workers in Lao PDR. Ideally, this would be part of an integrated approach that includes strategies to address the other febrile illnesses that forest goers describe as priority health concerns. The prophylactic regimen also requires careful consideration in terms of effectiveness and simplicity of dosing.Item Metadata only Forest malaria and prospects for anti-malarial chemoprophylaxis among forest goers: findings from a qualitative study in Thailand(2022-12-01) Jongdeepaisal M.; Khonputsa P.; Prasert O.; Maneenet S.; Pongsoipetch K.; Jatapai A.; Rotejanaprasert C.; Sudathip P.; Maude R.J.; Pell C.; Mahidol UniversityBackground: Across the Greater Mekong Subregion, malaria remains a dangerous infectious disease, particularly for people who visit forested areas where residual transmission continues. Because vector control measures offer incomplete protection to forest goers, chemoprophylaxis has been suggested as a potential supplementary measure for malaria prevention and control. To implement prophylaxis effectively, additional information is needed to understand forest goers’ activities and their willingness to use malaria prevention measures, including prophylaxis, and how it could be delivered in communities. Drawing on in-depth interviews with forest goers and stakeholders, this article examines the potential acceptability and implementation challenges of malaria prophylaxis for forest goers in northeast Thailand. Methods: In-depth interviews were conducted with forest goers (n = 11) and stakeholders (n = 16) including healthcare workers, community leaders, and policymakers. Interviews were audio-recorded, transcribed and coded using NVivo, employing an inductive and deductive approach, for thematic analysis. Results: Forest goers were well aware of their (elevated) malaria risk and reported seeking care for malaria from local health care providers. Forest goers and community members have a close relationship with the forest but are not a homogenous group: their place and time-at-risk varied according to their activities and length of stay in the forest. Among stakeholders, the choice and cost of anti-malarial prophylactic regimen—its efficacy, length and complexity, number of tablets, potential side effects, and long-term impact on users—were key considerations for its feasibility. They also expressed concern about adherence to the preventive therapy and potential difficulty treating malaria patients with the same regimen. Prophylaxis was considered a low priority in areas with perceived accessible health system and approaching malaria elimination. Conclusions: In the context of multi-drug resistance, there are several considerations for implementing malaria prophylaxis: the need to target forest goers who are at-risk with a clear period of exposure, to ensure continued use of vector control measures and adherence to prophylactic anti-malarials, and to adopt an evidence-based approach to determine an appropriate regimen. Beyond addressing current intervention challenges and managing malaria incidence in low-transmission setting, it is crucial to keep malaria services available and accessible at the village level especially in areas home to highly mobile populations.Item Metadata only Rethinking village malaria workers in Cambodia: Perspectives from the communities, programme managers, and international stakeholders(2024-12-11) Orng L.H.; Jongdeepaisal M.; Khonputsa P.; Dysoley L.; Sovannaroth S.; Peto T.J.; Callery J.J.; Pell C.; Maude R.J.; Liverani M.; Orng L.H.; Mahidol UniversitySince the early 2000s, malaria cases in Cambodia have declined steadily. Village malaria workers (VMWs) have played a critical role in reducing malaria transmission and progress towards malaria elimination. To prevent malaria re-establishment, however, implementation strategies need to consider carefully the changing healthcare needs in the communities as well as challenges to, and opportunities for, programme adaptation. We conducted in-depth interviews with a diverse range of stakeholders involved in the planning or implementation of the VMW programme in Cambodia, to elicit their views and experiences about health priorities in the communities, the public health value of VMWs and community-based care, and prospects for future programme development. Respondents included managers and implementers involved in the VMW programme at the central and provincial level (n = 9), technical officers at international agencies in Cambodia (n = 7), international stakeholders in non-governmental and research organisations based in Cambodia or other countries in the region (n = 5), as well as VMWs (n = 10), and community members (n = 16) in six endemic communes of Kravanh District, Pursat Province. In Kravanh, we also conducted four focus group discussions with 19 community members who had previous experience of malaria. The qualitative dataset was analysed using a thematic approach. VMWs, particularly mobile malaria workers tasked with active case detection among forest workers, were deemed necessary to maintain effective malaria control. However, there was a clear demand in the communities for additional services including treatment for common illnesses, monitoring of blood pressure and blood sugar levels, and relief of general symptoms through medication, such as for fever, headache, and stomach pain. Programme managers and international stakeholders agreed that the VMW programme needs a rethinking of the current implementation model to ensure continued uptake, relevance, and motivation of VMWs. Suggestions for add-on activities included adoption of new tests for febrile illnesses such as dengue and chikungunya, and screening for the prevention and monitoring of non-communicable diseases. There was emphasis on the needs for more sustainable financing mechanisms and integration with the existing community health infrastructure. The potential expansion of VMW services will benefit from the continued involvement of external donors and partners for technical and financial support. However, the implementation strategy should consider since the outset opportunities for enhanced local ownership and health system integration. To maintain domestic political momentum and access new potential sources of domestic funding, further programme development should align with national health priorities and the ongoing process of administrative decentralisation, while being responsive to changing public health needs within the communities.Item Metadata only Sustaining village malaria worker programmes with expanded roles: Perspectives of communities, healthcare workers, policymakers, and implementers in Vietnam(2024-08-06) Nguyen H.; Jongdeepaisal M.; Tuan D.A.; Khonputsa P.; Ngo T.; Pell C.; Liverani M.; Maude R.J.; Nguyen H.; Mahidol UniversityBackground In Vietnam, multiple types of community-based malaria workers are recruited to promote access to malaria testing and treatment for at-risk mobile and migrant populations. However, as the country approaches elimination, these roles are at risk from declining investment. This article characterises the different types of workers and relevant health policy in Vietnam, and explores stakeholder perspectives on sustaining and expanding the roles of these workers in the malaria elimination context. Methods We conducted a rapid policy document review to describe the policy background of community-based health care in Vietnam and identify key informants. In-depth interviews were conducted with policymakers and implementers (n = 11) in different government sectors, international, and civil society organizations. We also conducted interviews (n = 8) and two focus group discussions with community members (n = 12), and interviews with health workers (n = 9) in 18 communities in Phu Yen and Binh Thuan provinces in the central region. Results Our study identified three main types of malaria workers: village health workers (VHWs), malaria post workers (MPWs) and other groups of workers supported by civil society organisations (CSO). Workers reported being willing to maintain their current roles and potentially provide additional services that respond to community needs, although they were concerned about excess workload and inadequate income. Besides working in a variety of jobs to secure their incomes, mainly in agriculture, VHWs in particular were primarily tasked with supporting the delivery of a wide range of health services from commune health stations. Faced with reduced patients, MPWs and CSO-supported workers could be tasked with the following potential roles: case notification for infectious diseases, real-time data collection and reporting, and screening for non-malaria illnesses using other rapid test kits. There was agreement that the community-based health network is crucial to health care delivery in remote communities and to ensure comprehensive access to care among vulnerable populations. However, policymakers and implementers stressed concerns about their limited skillsets, the inadequate budget to support these workers, and the regulation constraining them from performing diagnosis and treatment activities, highlighting the priority to maintain the capacity of workers and funding allocation through provincial advocacy and multi-programme collaboration. Conclusions This study highlights the crucial role of community-based health workers in eliminating malaria in Vietnam. Sustained efforts are needed to maintain accessible case detection and treatment while addressing local health concerns beyond malaria. Implementing these strategies requires prioritizing the mapping of groups most in need and developing enablers to raise community awareness and maintain the capacity of these workers. Ensuring political advocacy, financial resources, and coordination between multiple groups are key to maximizing impact and integrating malaria activities into the broader health system.
