On 7 November, the Royal Government of Cambodia (RGC), the World Health Organization (WHO) and health partners committed to targeted and aggressive action to reach a goal which has been years in the making: the elimination of Plasmodium falciparum by 2023 and all strains of human malaria by 2025.
The ‘last mile’ elimination approach is the culmination of years of hard work to control and eliminate malaria in Cambodia, the epicentre of malaria multidrug resistance. It outlines a comprehensive plan to reach the unreached and interrupt P. falciparum transmission. The plan brings together the Ministry of Health (MOH), including the National Center for Parasitology, Entomology, and Malaria Control (CNM), WHO, provincial health authorities, the United Nations Office for Project Services and all malaria partners to reach this ambitious goal.
“The Royal Government of Cambodia has shown great leadership in setting this elimination goal,” said Dr Li Ailan, WHO Representative to Cambodia. “Because of the innovative and targeted approach in Cambodia, the country is in the last mile toward elimination.”
WHO will support the CNM and partners in ensuring an effective technical strategy and will also provide operational and financial support to achieve the elimination goal.
The double challenge of malaria and COVID-19
At the beginning of 2020, years of hard work to control and eliminate malaria in Cambodia had paid off. In 2011, the government committed to eliminating malaria in the country by 2025. With WHO’s support and under the leadership of the WHO Regional Director, Dr Takeshi Kasai, the CNM had taken decisive action to reduce the risk of malaria, most recently through the second phase of its Malaria Intensification Plan to Reach the Unreached, which was first launched in 2018.
As a result, P. falciparum and mixed malaria cases decreased to historically low levels, from 3761 cases reported in November 2017 to 47 cases in November 2020, three years later.
Then COVID-19 hit. In Cambodia, the coronavirus threatened to disrupt health services and prompted massive population movements in Cambodia, with more than 100 000 migrant workers returning from Thailand, some of them to malaria hotspots in the country. These developments had the potential to derail Cambodia’s progress towards reducing the risk of antimalarial multidrug resistance and reducing malaria incidence and mortality.
WHO urgently called on countries to maintain core malaria control services while protecting health workers and communities from COVID-19 infection. Cambodia continued to prioritize malaria elimination despite the pandemic, and put steps in motion to adopt more aggressive approaches to eliminate the parasite.
A group of men receive malaria prevention supplies including ASMQ (malaria medication) which is part of Cambodia’s aggressive approach.
© WHO/Chor Sokunthea
At the central level, WHO worked with the national malaria control programme to assess the risks that COVID-19 posed towards malaria elimination and ensure that malaria activities continued throughout the pandemic. Cambodia quickly reacted to formalize an operational plan to ensure malaria services throughout the pandemic. The CNM launched the plan in April 2020 before the country had registered even 200 COVID-19 cases.
“Malaria elimination and COVID-19 response go hand in hand,” said Dr Li, who visited numerous provinces with malaria hotspots as part of joint MOH-WHO missions earlier this year. “Together, the government, WHO and partners were able to continue more aggressive malaria interventions despite the coronavirus pandemic.”
In communities, WHO epidemiologists met with healthcare workers, village chiefs, health authorities, malaria partners and community members to hear their needs and concerns. Throughout the process, the WHO Cambodia country office supported Cambodia to implement its plan and avoid any disruptions to malaria activities during the COVID-19 pandemic.
“Having a field team of WHO epidemiologists allows us to have a deeper and live understanding of the epidemiological situation, which is constantly changing,” said Dr Luciano Tuseo, Hub Coordinator of the regional Mekong Malaria Elimination Programme. “With this understanding, we can take quick action.”
With WHO support, provincial health departments and health-care providers sprang into action to ensure people knew how to protect themselves from both COVID-19 and malaria, and to ensure malaria diagnosis and treatment did not fall through the cracks. It was a true “grounds-up” approach where local solutions where applied in local contexts.
These efforts not only successfully prevented a malaria resurgence – they also contributed to the lowest-ever numbers of malaria in Cambodia. By November 2020, P. falciparum and mixed cases reduced by 83% compared to the same period in 2019. Remarkably, malaria testing increased by 40% over the same timeframe.
A mobile malaria worker conducts a blood test to check for the presence of malaria parasites in a patient from Kampong Speu, Cambodia.
© WHO/Chor Sokunthea
Cambodia’s progress mirrors malaria success stories emerging across other countries in the subregion. The remarkable achievements have attracted notice on the world stage. At the 73rd World Health Assembly on 9 November, WHO Director-General Dr Tedros Adhanom Ghebreyesus congratulated the subregion and noted that, "On communicable diseases, there is cause for optimism. In the Greater Mekong, cases and deaths from malaria are falling and the threat of antimalarial resistance spreading around the world has eased."
The final push to eliminate malaria in Cambodia
With case numbers so low, Cambodia is ahead of the game to eliminate P. falciparum by 2023, which is the shared target for malaria elimination in the subregion. The country also remains on track to meet its own goal to eliminate all species of human malaria by 2025.
To achieve this, village and mobile malaria workers and health-care professionals will distribute treated mosquito nets; conduct weekly house-to-house fever screening to test every person with a fever for malaria and provide treatment if positive; and administer Intermittent Preventive Treatment for travellers to malaria-risk areas. As many malaria health workers in Cambodia are women, the project will ensure they are able to do this work safely and fully supported, as part of a commitment to gender, equity and rights.
Meeting these goals will contribute to a broader initiative supported by WHO’s Mekong Malaria Elimination programme to eliminate malaria in all countries of the Greater Mekong Subregion by 2030.
“Malaria elimination in Cambodia is critical to malaria elimination throughout the Greater Mekong Subregion,” said Dr Tuseo. “The experience in Cambodia will help to provide a path for other countries pursuing elimination.”