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In Lao PDR, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Lao PDR. The study relied on a literature review and 35 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. In Lao PDR, the HIV and TB programmes remain vertical and mostly weakly integrated with the general health system. However, Global Fund investments have extended the network of facilities delivering care at local level, resulting in greater integration with primary care and improved access for patients, particularly for TB. For HIV, as the prevalence remains low, services primarily target high-risk groups in urban areas. Less integrated functions include procurement and drug supply, and monitoring and evaluation. HIV and TB programmes are only starting to coordinate with each other. Global Fund-supported activities are generally integrated within the national disease programmes, except for monitoring and evaluation. Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building, improved family planning (with wider condom distribution through HIV/AIDS social marketing programmes), and the delivery of add-on interventions, such as vaccinations and health education, alongside Global Fund-supported interventions at community level. Unintended consequences concern the lack of alignment between national stated priorities (maternal and child health) and the strong focus of external partners, such as the Global Fund, on financing communicable disease programmes.
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PMID:Critical interactions between Global Fund-supported programmes and health systems: a case study in Lao People's Democratic Republic. 2096 7

The Greater Mekong Subregion (GMS), comprised of six countries including Cambodia, China's Yunnan Province, Lao PDR, Myanmar (Burma), Thailand and Vietnam, is one of the most threatening foci of malaria. Since the initiation of the WHO's Mekong Malaria Program a decade ago, malaria situation in the GMS has greatly improved, reflected in the continuous decline in annual malaria incidence and deaths. However, as many nations are moving towards malaria elimination, the GMS nations still face great challenges. Malaria epidemiology in this region exhibits enormous geographical heterogeneity with Myanmar and Cambodia remaining high-burden countries. Within each country, malaria distribution is also patchy, exemplified by 'border malaria' and 'forest malaria' with high transmission occurring along international borders and in forests or forest fringes, respectively. 'Border malaria' is extremely difficult to monitor, and frequent malaria introductions by migratory human populations constitute a major threat to neighboring, malaria-eliminating countries. Therefore, coordination between neighboring countries is essential for malaria elimination from the entire region. In addition to these operational difficulties, malaria control in the GMS also encounters several technological challenges. Contemporary malaria control measures rely heavily on effective chemotherapy and insecticide control of vector mosquitoes. However, the spread of multidrug resistance and potential emergence of artemisinin resistance in Plasmodium falciparum make resistance management a high priority in the GMS. This situation is further worsened by the circulation of counterfeit and substandard artemisinin-related drugs. In most endemic areas of the GMS, P. falciparum and Plasmodium vivax coexist, and in recent malaria control history, P. vivax has demonstrated remarkable resilience to control measures. Deployment of the only registered drug (primaquine) for the radical cure of vivax malaria is severely undermined due to high prevalence of glucose-6-phosphate dehydrogenase deficiency in target human populations. In the GMS, the dramatically different ecologies, diverse vector systems, and insecticide resistance render traditional mosquito control less efficient. Here we attempt to review the changing malaria epidemiology in the GMS, analyze the vector systems and patterns of malaria transmission, and identify the major challenges the malaria control community faces on its way to malaria elimination.
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PMID:Malaria in the Greater Mekong Subregion: heterogeneity and complexity. 2138 35

The Greater Mekong Subregion (GMS) has low transmission of Plasmodium falciparum and P. vivax and is a prime region for malaria elimination based on evidence. The extent of GMS based research is unknown. Pub Med-identified research articles from the GMS were selected based on defined criteria and classified into 24 research areas. A research questionnaire was sent to WHO country offices, national malaria control programs (NMCPs), national research institutes and non governmental organizations (NGOs). Two thousand eight hundred ninety of 3,319 identified publications were included, dating from 1933 to June 2012; 1,485 (51.8%) of 2,890 since 2000. Ten research areas accounted for 2,264 (78.3%) publications: drug resistance 12.8% (n=371), entomology 11.42% (n=330), clinical trials 10.45% (n=302), pathophysiology 9.34% (n=270), epidemiology 8.96% (n=259), pharmacology 6.06% (n=175), parasite biology 5.19% (n=150), malaria control 4.88% (n=141), diagnosis/diagnostics 4.6% (n=133) and clinical studies 4.6% (n=133). Thailand produced most publications, 1,684 (58.27%), followed by Viet Nam (365, 12.63%), Cambodia (139, 4.81%), Myanmar (132, 4.57%), Yunnan Province, China (124, 4.3%) and Lao PDR (79, 2.73%). Other publications were multicountry, including >or=1 GMS country (n=269), or reviews (n=98). Publication numbers increased significantly over time. Eleven questionnaires were received. Principal research areas were treatment seeking behavior, knowledge, attitude and practice surveys, bed net use, access to treatment by migrants, and malaria diagnostics. Research in GMS is broad. Biomedical research dominates peer reviewed publications. NMCP and NGOs focus more on downstream malaria implementation issues. The challenge is to engage GMS research capacity to build quality evidence for malaria elimination.
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PMID:Malaria research in the Greater Mekong Subregion: an overview. 2415 34

In Lao PDR, the National Malaria Control Program (NMCP) evaluates bednet coverage, often at the village level, using a coverage target of one net per 2.5 (or fewer) persons in a given population. However, in villages that meet the target, not all households necessarily meet the target or utilize all available bednets. This study explored households that fell short of the target and household utilization of bednets in villages that met the target of bednet coverage set by the NMCP. The person per net ratio (PPNR), which is defined as the population divided by the number of available bednets in a household/village, was used to determine whether a household/village met the NMCP target. Using a household survey, we collected and analyzed the data of 635 households in 17 villages in Xepon district in 2012. Households that fell short of the target (households with a PPNR of > 2.5 or no bednet) existed in every village. The proportion of these households differed greatly among the villages, ranging from 3.4-50%, with some households falling far short. Of the 635 households, 275 (43.5%) had at least one bednet that was not being used on the night preceding the survey and 131 (20.6%) had at least two. In conclusion, in villages that met the NMCP target, a considerable number of households fell short of the target, and the available bednets were not fully utilized in many of the surveyed households.
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PMID:Households with Insufficient Bednets in a Village with Sufficient Bednets: Evaluation of Household Bednet Coverage Using Bednet Distribution Index in Xepon District, Lao PDR. 2606 Apr 22

There has been a dramatic increase in the global movement of workers during the last few decades. As Thailand has developed rapidly over the past 20 years, it has attracted laborers (both authorized and unauthorized) from the neighboring countries of Myanmar, People's Democratic Republic of Lao (Lao PDR), and Cambodia. Given that agriculture has been Thailand's most important industry, its continued growth has been dependent on migrant workers. Both crop agriculture and animal-production agriculture have employed migrant labor. Migrants have been hired to plant, weed, fertilize, spray pesticides, and harvest crops such as rice, corn, sugar cane, and cassava. They have worked at rubber and coffee plantations, as well as in the production of ornamental crops. Also, migrants have labored on pig, beef, and duck farms. There have been numerous documented health problems among migrant workers, including acute diarrhea, malaria, and fever of unknown causes. Occupational illness and injury have been a significant concern, and there has been limited health and safety training. This article reviewed the demographic changes in Thailand, studied the agricultural crops and animal production that are dependent on migrant labor, discussed the health status and safety challenges pertaining to migrant workers in agriculture, and described several recommendations. Among the recommendations, the conclusions of this study have suggested that addressing the cost for health care and solutions to health care access for migrant labor are needed.
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PMID:Migrant Workers in Agriculture: A View from Thailand. 2647 89

Knowledge on insecticide resistance in Anopheles species is a basic requirement to guide malaria vector control programs. In Lao PDR, vector control relies on insecticide residual spraying (IRS) and impregnated bed-nets (ITNs) with the use of pyrethroids. Here, the susceptibility of Anopheles species, including several malaria vectors (An. maculatus and An. minimus), to various insecticides was investigated in ten provinces of Lao PDR through a north-south transect. Bioassays were performed on field caught female mosquitoes using the standard WHO susceptibility tests with DDT (4%), deltamethrin (0.05%) and permethrin (0.75%). In addition, the DIIS6 region of the para-type sodium channel gene was amplified and sequenced to identify knockdown resistance mutations (kdr). Resistance to DDT and permethrin was detected in suspected malaria vectors, such as An. nivipes and An. philippinensis in Lao PDR. Resistance to the formerly used DDT was found in a population of An. maculatus s.l. from Luang Prabang province. No resistance to pyrethroids was found in primary vectors, indicating that these insecticides are still adequate for malaria vector control. However, high resistance levels to pyrethroids was found in-vector species and reduced susceptibility to permethrin in An. minimus and An. maculatus was reported in specific localities which raises concerns for pyrethroid-based control in the future. No kdr mutation was found in any of the resistant populations tested hence suggesting a probable role detoxification enzymes in resistance. This study highlights the necessity to continue the monitoring of insecticide susceptibility to early detect potential occurrence and/or migration of insecticide resistance in malaria vectors in Lao PDR.
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PMID:Insecticide resistance status of malaria vectors in Lao PDR. 2843 49

Although the Lao People's Democratic Republic (Lao PDR) is comparatively small landlocked country with patterns of both in- and out-migration, its human migration situation has been poorly studied. This is despite all of the country's 18 provinces sharing both official and unofficial border checkpoints with neighboring countries. Economic reforms in the last decade have seen a gradual increase in the promotion of foreign investment, and main towns and transportation networks have been expanding thus offering new opportunities for livelihoods and economic activities.In the last decade, there has also been a significant reduction of reported malaria cases in Lao PDR and while this is an important prerequisite for eliminating malaria in the country, malaria outbreaks reported in the last four years suggest that population mobility, particularly in the south, is an important factor challenging current control efforts.Bolder investment in social sector spending should be geared towards improving health service provision and utilization, ensuring equitable access to primary health care (including malaria) through efforts to achieve universal health coverage targets. This should be extended to populations that are mobile and migrants. The local government plays a critical role in supporting policy and enforcement issues related to private sector project development in the provinces. Cross-border initiatives with neighboring countries, especially in terms of data sharing, surveillance, and response, is essential. Mechanisms to engage the private sector, especially the informal private sector, needs to be explored within the context of existing regulations and laws. Existing and new interventions for outdoor transmission of malaria, especially in forest settings, for high-risk groups including short- and long-term forest workers and their families, mobile and migrant populations, as well as the military must be combined into integrated packages with innovative delivery mechanisms through social marketing approaches. This should happen at multiple points in the mobility pathway and involve the private sector rather than being fully reliant on the national malaria vertical programThis article based on the review of existing literature from abstracts and full texts, includes published, peer-reviewed English language literature sourced through PubMed and grey literature sources through Google and Google Scholar. The review included also case reports, sector reports, conference proceedings, research reports, epidemiology studies, qualitative studies, and census reports in both Lao and English languages. The authors used the search terms: malaria and mobile populations, malaria control program and elimination, health system performance, malaria outbreak, Lao PDR; and included articles published until June 2015.
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PMID:Malaria elimination in Lao PDR: the challenges associated with population mobility. 2843 18

Climatic, sociological and environmental conditions are known to affect the spatial distribution of malaria vectors and disease transmission. Intensive use of insecticides in the agricultural and public health sectors exerts a strong selective pressure on resistance genes in malaria vectors. Spatio-temporal models of favorable conditions for Anopheles species' presence were developed to estimate the probability of presence of malaria vectors and insecticide resistance in Lao PDR. These models were based on environmental and meteorological conditions, and demographic factors. GIS software was used to build and manage a spatial database with data collected from various geographic information providers. GIS was also used to build and run the models. Results showed that potential insecticide use and therefore the probability of resistance to insecticide is greater in the southwestern part of the country, specifically in Champasack province and where malaria incidence is already known to be high. These findings can help national authorities to implement targeted and effective vector control strategies for malaria prevention and elimination among populations most at risk. Results can also be used to focus the insecticide resistance surveillance in Anopheles mosquito populations in more restricted area, reducing the area of surveys, and making the implementation of surveillance system for Anopheles mosquito insecticide resistance possible.
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PMID:Modeling spatial variation in risk of presence and insecticide resistance for malaria vectors in Laos. 2849 13

The impact of the rapid expansion of rubber plantations in South-East Asia on mosquito populations is uncertain. We compared the abundance and diversity of adult mosquitoes using human-baited traps in four typical rural habitats in northern Lao PDR: secondary forests, immature rubber plantations, mature rubber plantations, and villages. Generalized estimating equations were used to explore differences in mosquito abundance between habitats, and Simpson's diversity index was used to measure species diversity. Over nine months, 24,927 female mosquitoes were collected, including 51 species newly recorded in Lao PDR. A list of the 114 mosquito species identified is included. More mosquitoes, including vector species, were collected in the secondary forest than immature rubber plantations (rainy season, odds ratio [OR] 0.33, 95% confidence interval [CI] 0.31-0.36; dry season, 0.46, 95% CI 0.41-0.51), mature rubber plantations (rainy season, OR 0.25, 95% CI 0.23-0.27; dry season, OR 0.25, 95% CI 0.22-0.28), and villages (rainy season, OR 0.13, 95% CI 0.12-0.14; dry season, 0.20, 95% CI 0.18-0.23). All habitats showed high species diversity (Simpson's indexes between 0.82-0.86) with vectors of dengue, Japanese encephalitis (JE), lymphatic filariasis, and malaria. In the secondary forests and rubber plantations, Aedes albopictus (Skuse), a dengue vector, was the dominant mosquito species, while in the villages, Culex vishnui (Theobald), a JE vector, was most common. This study has increased the overall knowledge of mosquito fauna in Lao PDR. The high abundance of Ae. albopictus in natural and man-made forests warrants concern, with vector control measures currently only implemented in cities and villages.
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PMID:Diversity of Mosquitoes (Diptera: Culicidae) Attracted to Human Subjects in Rubber Plantations, Secondary Forests, and Villages in Luang Prabang Province, Northern Lao PDR. 2850 14

Introduction: Novel interventions are needed to accelerate malaria elimination, especially in areas where asymptomatic parasitemia is common, and where transmission generally occurs outside of village-based settings. Testing of community members linked to a person with clinical illness (reactive case detection, RACD) has not shown effectiveness in prior studies due to the limited sensitivity of current point-of-care tests. This study aims to assess the effectiveness of active case finding in village-based and forested-based settings using novel high-sensitivity rapid diagnostic tests in Lao People's Democratic Republic (Lao PDR). Methods and analysis: This study is a cluster-randomized split-plot design trial. The interventions include village-based mass test and treat (MTAT), focal test and treat in high-risk populations (FTAT), and the combination of these approaches, using high-sensitivity rapid diagnostic tests (HS-RDTs) to asses P. falciparum infection status. Within four districts in Champasak province, Lao PDR fourteen health center-catchment areas will be randomized to either FTAT or control; and within these HCCAs, 56 villages will be randomized to either MTAT or control. In intervention areas, FTAT will be conducted by community-based peer navigators on a routine basis, and three separate rounds of MTAT are planned. The primary study outcome will be PCR-based Plasmodium falciparum prevalence after one year of implementation. Secondary outcomes include malaria incidence; interventional coverage; operational feasibility and acceptability; and cost and cost- effectiveness. Ethics and dissemination: Findings will be reported on clinicaltrials.gov, in peer-reviewed publications and through stakeholder meetings with Ministry of Health and community leaders in Lao PDR and throughout the Greater Mekong Subregion. Trial registration: clinicaltrials.gov NCT03783299 (21/12/2018).
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PMID:Study protocol for a cluster-randomized split-plot design trial to assess the effectiveness of targeted active malaria case detection among high-risk populations in Southern Lao PDR (the AcME-Lao study). 3211 99


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