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Preventing Cross Border Transmission of Malaria

Posted: 09 Nov, 2015   Recommendations: 16   Replies: 44

Despite increase in funding for malaria control in the last decade and some significant achievements in treatment, we are still a long way from meeting global eradication goals. In December 2014, WHO reported that almost half of the world’s population (3.5 billion) is at risk of malaria. In 2013, there were approximately 198 million malaria cases, and an estimated 584,000 malaria deaths, mostly in Africa. One of the biggest challenges in malaria control is the cross border transmission of the infection.

In recent years, large population movements across countries in many continents have affected control measures and contributed to the spread of the disease. For example, a study shows that between 2001 and 2009, almost half of the malaria cases reported in northern South African province of Mpumalanga were acquired from Mozambique (Gueye, 2012). There are estimates that anywhere between 50 to 70% of all Argentinian malaria cases are linked to migration, especially cross border movements from Bolivia (PAHO, 2005; UCSF, 2012). Similar challenges exist in Asia as well. For example, in 2009, Yunnan Province of China saw 98.8% of its malaria cases imported from neighboring countries (Xu, 2012). Such spread presents significant challenges to human health by introducing the infection to areas with history of no infection, re-introducing it to areas that achieved infection control or eradication, and by importing drug resistant malaria strains. In order to control malaria infection and to completely eradicate it, cross border collaboration among countries is vital. There also needs to be training and operational research that supports these control measures.

To discuss this significant challenge of cross border malaria transmission, and current as well as past efforts for control, GHDonline is pleased to welcome the following group of panelists:

• Susan Lily Mutambu, PhD, Director, National Institute of Health Research, Zimbabwe
• Timothy Freeman, Project Manager, Rotarians Against Malaria, Papua New Guinea
• Jerome Ngundue, MHSA, BSc. Nuc Med.CNMT, Public Health Preparedness Planner, SNS Warehouse Manager, Preparedness & Response Branch, Center for Health Protection, Arkansas Department of Health
• David Zinyengere, Malaria Vector Control Consultant, Heded Consulting, Zimbabwe

Our panelists will offer insight into the following questions:

1) What are the biggest challenges for controlling cross border malaria transmission?
2) What measures are currently in practice to address these challenges? How successful are these measures?
3) How do we ensure that current work in cross border transmission is sustainable? What challenges the sustainability of control measures?
4) What lessons can we learn from these efforts to scale up control measures? Can these measures be applied to different settings?
5) Is there anything we can learn from the HIV and TB communities regarding the trans-border control of infection?

We look forward to a rich discussion – please join the conversation and share your questions or comments.



Marie Teichman Replied at 9:33 AM, 9 Nov 2015

In preparation for next week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address next week. Looking forward to a great discussion!

Attached resources:

Bamou Roland Replied at 9:56 AM, 9 Nov 2015

Dear Dr
I wish to congratulate the new pannel from Zimbabwe.
I think screening of travallers at airport will be the first thing to do to dimisnih or control transborder malaria infection. So, training and recruitmemt of clinician at airport will help to achive that. Sometimes, medical booklet and medical record should be obligatory for travallers.

Judith Thermidor Replied at 10:13 AM, 9 Nov 2015

Dear Rebecca,
Thank you so much for this colossal topic. Malaria is the real disease of poverty.

John Banda Replied at 10:23 AM, 9 Nov 2015

Dear Rebecca,

Zambia and Zimbabwe have come together to control malaria across the common border. The topic you have introduced has come at the appropriate time when the two countries are preparing the modalities of cross border control. I am looking forward to the discussion.

Murali Ramachandran Replied at 10:01 PM, 9 Nov 2015

Dear All,
The suggestions if applicable can be included in he discussion.

What are the biggest challenges for controlling cross border malaria
The issue is how successful we are in line listing cases
Efficient in Diagnosis and treatment and follow up.
2) What measures are currently in practice to address these challenges? How
successful are these measures?
Challenges as i perceive is follow up including treatment protocol.
3) How do we ensure that current work in cross border transmission is
sustainable? What challenges the sustainability of control measures?
Integrating Entomology and Medicine and also all stakeholders
4) What lessons can we learn from these efforts to scale up control
measures? Can these measures be applied to different settings?
Scale up after consolidating over at least three years and sustainability
can be applied with modification of strategy
5) Is there anything we can learn from the HIV and TB communities regarding
the trans-border control of infection?\
Identifying Transmission cycle- Source of infection.

Byamukama Agaba Replied at 1:38 AM, 10 Nov 2015

Am pleased to be part of this but i would like  some to  discuss about the role of surveillance on cross border transmission of malariaThank you

LIZZY N IGBINE Replied at 11:25 AM, 10 Nov 2015

Before we go into next weeks discussion, I will like to remnd us of the nessasary things we have forgoten to do.
Our prevention of Mosquito bites or prevention of the causes, should this be the focus for the upcoming discussion.
Lets ponder on this till we meet.

Elizabeth Glaser Replied at 4:33 PM, 10 Nov 2015

The combination of migrants and those with asymptomatic malaria present a challenge to identification and treatment of disease creating hotspots in previously clear areas. Sounds like an interesting panel.


Samuel Tesema Replied at 11:19 PM, 10 Nov 2015

An Important topic, and thanks for the invitation

Mary Murugami Replied at 1:00 AM, 11 Nov 2015

Very interesting. im glad to be part of the panel this week. I agree, prevention of causes should be one of the key areas we focus on as it plays a big role in reducing cross border transmission.

Roger Paul Kamugasha/Maridadi Replied at 1:18 AM, 11 Nov 2015

Dear allits interesting to discuss crossborder controlling of malaria. As it's on record that mosquitoes have no borders. The world has had mixed reactions on the prevention of malaria.  Some looking at indoor residual spraying others vector control where the focus is on mosquito breeding places or their attacking base. Other have focused on larviciding.To me all these can work towards the prevention and control of malaria but what is important is to come up with crossborder guidelines that clearly spell out how countries can come up with a harmonised strategy.Cheers Roger Paul Kamugasha Uganda 
Sent from Yahoo Mail on Android

Simon Onsongo Replied at 5:04 AM, 11 Nov 2015

Bamou Roland: You recommend screening at the airports. What methods can be used for screening that are sensitive enough to pick malaria cases, considering most cases of travellers will have low parasitemia and most likely asymptomatic.
Would use of RDTs help?

Monique Germain Replied at 3:31 PM, 13 Nov 2015

Very interesting. I am curious to learn more as I am a frequent traveller.

David Zinyengere Panelist Replied at 10:13 PM, 16 Nov 2015

work is Greetings to all My Name is David Zinyengere and based in Harare Zimbabwe. My main focus of activities have been in the line of Malaria and Tsetse Control Vector activities within the Sub Saharan Countries. Currently working as a public health consultant in championing malaria and other vector borne disease control activities under the organisation HEDEC(Health Environment and Development Consulting)

Coming to the discussion in question i would like to begin by highlighting in bullet point form some of what i believe are critical areas of concern that need consideration as they may pose challenges in Cross border Malaria Control and Prevention
I feel that in Cross Border Malaria Control and Prevention the following must be considered not necessarily in order of preference:
# All Stakeholder Identification, mobilisation,sensitisation and proactive involvement
#Program Strategies- problem definition and prioritisation -How is each country prioritising the problem and relating its prioritisation to its neighbour
#What are the intervention strategies and how are they related to the neighbouring country strategies?
#Border Population dynamics- both human and vector
#Competing activities in both countries and how can these be reconciled
#Political Commitment of leadership
#Capacity -Both Human and Material and Facilities
#Information Management- Data acquiring , synthesising, and appropriate strategic use.
# Borders not the only control focal areas but all ports of entry including airports.
#Macro social, cultural and economic issues across borders -
#Geographical features -nature of barriers between countries- how easy is it for cross border movements especially informal or unofficial entry points?
#Monitoring and Evaluation activities
#Financial resources and their allocation

These issues may bring challenges to the issue of cross border malaria control initiatives and would in many ways require a broad view in mapping out successful outcomes.

Monique Germain Replied at 12:23 AM, 17 Nov 2015

Thanks for exposing these challenging issues as we need to dialog on the topic. I grew up in a country-Haiti- where malaria was and still is prevalent taking the lives of so many people. As a matter of fact, I lost a brother at a tender age of 10 years due to malaria and my family had never been able to comprehend what actuaaly happened because my family thought to be "cleaner" than those living in some other areas of the country (macro social, cultural and economic and as well as geographical issues). I also cross borders that are potential transmitters or conduits for malaria when I travel.
The question of "capacity" is real and relevant for progress to continue.
The question of strategies is crucial in order to achieve established outcomes.
The question of interventions must be specific and achievable.
So, let's hear from you and others and let's engage in a productive dialog!.

Tim Freeman Panelist Replied at 2:22 AM, 17 Nov 2015

Greetings. My name is Tim Freeman. I am the project manager of Rotarians Against Malaria who coordinate the distribution of LLINs to every village in Papua New Guinea (PNG) on a three year basis. We have distributed seven million nets in PNG in the last six year. I also have experience in LLIN distribution and malaria epidemiology with a particular interest in community based malaria control in Southern Africa , Afghanistan, West Africa and lastly in PNG since 2010.

In addressing the topic of discussion, "What are the biggest challenges for controlling cross border malaria transmission?" I can add the following:

Whatever measures are put into place, unless they are religiously adhered to malaria will get through borders. From my own experience I am often reminded of my several visits to Mauritius where a blood slide should have been taken to screen that I did not have malaria. Not once did the authorities catch me as they were worried that they would upset tourists if they did this on arrival so consequently went around the island trying to find tourists at a later time. In my case they never did.

Cross border malaria control only makes financial and practical sense in a scenario where a country has a potential for malaria transmission but has already largely controlled or eradicated malaria within its borders and is threatened by surrounding countries with a greater malaria burden e.g. South Africa and Mauritius respectively. The challenge is controlling the importation of external malaria through borders including airports and ports in a systematic way which includes screening of visitors, screening of transport for vector mosquitoes, and funding cross border initiatives in the bordering countries where malaria is worse to create a buffer e.g. malaria initiatives in Mozambique to protect South Africa and Swaziland.

yves visangi Replied at 4:32 AM, 17 Nov 2015


i am glad to see this topic because in our country (DRC mainly in eastern )malaria is ill by missing some tablet and moisture


Sungano Mharakurwa Replied at 4:33 AM, 17 Nov 2015

Many thanks for these thought-provoking perspectives. I was talking with a medical and public health colleague who said often blaming the other side of the border may also be a current challenge to galvanizing collaborative cross-border malaria prevention. One wonders whether this is prevalent or is starting to be overcome through systematic regional initiatives for example.

Susan Mutambu Panelist Replied at 1:20 PM, 17 Nov 2015

My name is Susan Lily Mutambu and below is a brief write up about myself.
Susan L Mutambu is the current director of the National Institute of Health Research (NIHR), a research wing of the Ministry of Health and Child Care, Zimbabwe. Her role is to provide research leadership and training, collaboration with provincial and district teams and other departments in the Ministry of Health and Child Care, collaboration with other research institutes, NGOs and private sector, and represent the Ministry of Health and Child Care at international and global fora such as World Health Assembly and SADC.

She participates in both the national and SADC region malaria activities including the development of malaria plans and programme reviews (MIM) and malaria indicator surveys. Susan has been involved in capacity building in terms of short courses as well as MSc/Mphil and PhD programmes with special emphasis on malaria. She is the coordinator of antimalarial therapeutic efficacy monitoring at 8 sentinel sites and her work has contributed to policy formulation on antimalarial treatment in Zimbabwe.
She has participated in Global fund proposal writing and serves on various malaria committees.

The biggest challenges for controlling cross border malaria transmission are the porous borders that we have between countries eg my country shares a border of more than 750 km with another country. Monitoring the exchange of any commodities, let alone malaria parasites and mosquito border jumpers is virtually impossible. Communities that reside within the vicinity of either side of our borders are very closely knit to each other, most likely as families. Country borders to these communities are imaginary and not a reality, especially where there is no river along the border to clearly demarcate the countries.

This being the case, what should we do to make sure that cross border malaria transmission is controlled? I believe that this issue needs to be tackled at the local level and involve the community on either side of the border in malaria interventions. This calls for adjacent districts on either side of the border to collaborate and reduce the burden of malaria. By so doing, the same malaria interventions can be implemented on either side of the border, simultaneously. One of our provinces that shares the biggest chunk of the over 750 km border with another country has not done well in establishing functional links with the adjacent province across the border. It has also been difficult to establish these collaborative links at the national level (National Malaria Control Programme to National Malaria Control Programme) because malaria is not considered a priority along this border.

Malaria transmission may be considered as a priority along the shared border by one country and not by the other country. In the country where malaria transmission is a priority, control interventions should continue to be implemented and Indoor Residual Spraying should be considered to create a buffer zone along the border in the country where no interventions are taking place. The question is which of the two countries funds the spraying of the buffer zone? Will this reduce cross border malaria transmission and will this intervention be sustainable?

Maimunat Alex-Adeomi Replied at 3:41 PM, 17 Nov 2015

Interesting discuss so far.

I will like to add on the shared border differences.
As Susan implied, one country might have a better national control program and stronger political will to tackle these issues while the other lacks either or both thereby creating an imbalance in efforts which should ideally be a shared responsibility of both countries.

Pierre Bush, PhD Replied at 6:53 PM, 17 Nov 2015

Dear colleagues,
Thank you for these good points. The measures already implemented, and the ones to be put in place will require a strong political will from leaders at all levels and community mobilization across borders. South Africa& Mozambique have implemented a good program that can serve as a model for the control of the malaria transmission across their borders. Other countries in the Southern African region are putting together their efforts to implement the measures required for this great program.

Monique Germain Replied at 9:55 PM, 17 Nov 2015

What other interventions are available besides spraying? I like the idea of taking a blood smear to verify but what else could it be?

FUH PRINCEWILL Replied at 6:13 AM, 18 Nov 2015

what is it that the government, health personnels and public is suppose to
do that hey are not doing there by makiong it difficult for malaria to be
eradicated in my country cameroon

Manuel Lluberas Replied at 9:11 AM, 18 Nov 2015

The only way to keep the borders safe is to reduce the numbers of mosquitoes trying to cross them. The only way to do that is to implement an Integrated Vector Control program that actively targets the vector(s). One that starts with source reduction and includes active population suppression methods tailored to the local conditions while expanding local net and IRS coverage -if there is no insecticide resistance in the target vectors. What has been done during the past dozen years or so falls way short of that. Vector control goes far beyond net distribution and IRS. Unfortunately, there seems to be little understanding about what true IVC is and what it can do and many continue to promote nets and IRS as THE solution. This limited understanding of active vector control results in limited will going all the way up "the chain" to the highest levels of agencies and organizations providing recommendations and results in even less political will at the local government level.

Unfortunately, this concept is not popular and will require significant effort and funding. The good news is that funding should not be an issue. The world has spent about US$1 Billion annually during the past dozen years in malaria control. All we need to do is reconfigure how that funding is allocated and place vector control in the hands of mosquito control professionals. However, many public health entomologists like myself are under no illusion this will happen in our lifetimes.

Fiona Davidson Replied at 10:11 AM, 18 Nov 2015

Resources from Malaria Consortium's experience in Cambodia:

In September, Malaria Consortium launched the second phase of its cross-border project in Stung Treng province, Cambodia. This new study will build on the work of a project that ended last year, which investigated the impact of mobile and migrant populations on the spread of artemisinin resistant malaria by screening people both at formal checkpoints and informal border posts.

You can find resources about these new project here:

You can find the journal article which was one of the outputs from the previous project here:

Feel free to get in contact with me if you have any further questions.

Tim Freeman Panelist Replied at 11:58 PM, 18 Nov 2015

For any border control or initiative to take place there must be strong and sustained political will. Mauritius has eradicated malaria at least twice and then been re-infected with malaria. I guess that one of the reasons is that the authorities in Mauritius were scared to hassle tourists when they arrived in the country and consequently did not screen effectively for malaria on arrival. Therefore, unless there is a consensus on what needs to be done, and political muscle to support it, all forms of malaria screening at borders and other interventions may fail. The same goes with financing. Malaria was successfully controlled in southern Mozambique before 2010 with the LSDI programme which was a joint Mozambican, South African and Swaziland initiative. Political will and financial support was lost, and malaria returned uncontrolled after 2010. It is only now that the cross border initiative is once again active between South Africa, Swaziland and Mozambique but one can only wonder for how long this might continue this time around.

Tim France Replied at 6:58 AM, 19 Nov 2015

As a first contribution to this panel, it is worth taking the opportunity to point out some of the specific ways the nature of malaria in Asia and the Pacific differs from that in other parts of the world, and highlight why mobile and migrant population are such a critical population.
Currently, an estimated 61% of the Asia Pacific population lives in areas that are at risk of malaria. Outdoor transmission is a leading cause of malaria infection, and so protection of rural workers in the forestry, agricultural and mining sectors is critically important.

Asia Pacific has historically been a global epicentre of emerging infectious diseases and drug resistance. This is due to various factors including climate, proximity of humans to animals, rapid economic development and – central to this panel discussion – the extensive movement of migrant workers, traders and tourists.

As the region continues to evolve rapidly, our countries are becoming even more interconnected due to trade and investment, further accelerating risks. For example, the enactment of the ASEAN Free Trade Agreement will lead to a more integrated ASEAN Economic Community, an enhanced ASEAN Highway Network, and vastly increased movement of migrant and mobile workers through already porous borders.

And at this very time of rapid change, Asia is facing a silent malaria emergency that could have a disastrous impact on our own people and on global health security. Having halved deaths from malaria in the past 15 years, the failure of the most effective antimalarial drugs in the Greater Mekong Subregion threatens those hard-won gains for all of us.

In most countries of the region, malaria has been controlled sufficiently to largely pin it back to the confines of high risk and hard-to-reach populations, which in many places include border communities, mobile and migrant populations. The communities at risk are not air travellers (as mentioned already in this discussion) – they are often ethnic minorities in remote areas, including seasonal migrant workers who move frequently, often across borders. They typically have very limited or no access to health care services.

Inadequate health systems in many hard-to-reach areas frequently share common weaknesses: lack of surveillance data; lack of health infrastructure and staffing; and insufficient supply of key commodities. Together these lead to critical gaps in access to malaria prevention, diagnosis and care for the most vulnerable populations. This can also be made worse by the simple geographic difficulty in reaching some populations.

Given its cross-border nature, tackling malaria in Asia Pacific depends on the collective ability to monitor, reach and protect these populations. Strong regional coordination is therefore a key enabler of progress towards greater control of the disease and, ultimately, its elimination.

At last year’s East Asia Summit, 18 Heads of Government – representing 55% of the global population – made an historic commitment to achieve an Asia Pacific free of malaria by 2030. At this year’s summit, taking place this coming weekend (22nd November 2015), Leaders will consider the Malaria Elimination Roadmap prepared by the Asia Pacific Leaders Malaria Alliance (APLMA). Based on wide consultation across the region, the roadmap provides a detailed plan for specific steps countries may take to accelerate defeat of this disease. If endorsed and fully implemented, the roadmap will save more than a million lives over the next 15 years, and will generate over US$ 300 billion in cost savings.

Participants in this panel can follow news of the Summit on the website of the Asia Pacific Leaders Malaria Alliance, mentioned below.

Attached resource:

Sara Canavati Replied at 9:14 AM, 19 Nov 2015

Dear all,

To follow up on Tim's discussion, I would like to share four publications conducted in Cambodia published in 2015 that are very much related to your above discussion:

1. Malaria and the mobile and migrant population in Cambodia: a population movement framework to inform strategies for malaria control and elimination
2. Novel Cross-Border Approaches to Optimise Identification of Asymptomatic and Artemisinin-Resistant Plasmodium Infection in Mobile Populations Crossing Cambodian Borders
3. Re-imagining malaria: heterogeneity of human and mosquito behaviour in relation to residual malaria transmission in Cambodia
4. Characterizing Types of Human Mobility to Inform Differential and Targeted Malaria Elimination Strategies in Northeast Cambodia

I am also sharing a link on an oral presentation from ASTMH in 2014 on 'Targeting high-risk groups: Experience from the Greater Mekong Subregion'.

I would to share with you my personal experience working in Cambodia with migrant groups; instead of that we have already published.
I have seen that three main issues have been somehow overlooked in scientific publications but are of high relevance when it comes to malaria elimination and reaching the last mile:

1) high heterogenity among migrant groups
2) how to implement prevention, test, treat and track (P+T3) amongst migrants
3) migrant and mobile populations are common barriers to inclusion of study participants in Cambodia

1) high heterogenity among migrant groups

Leanings from regional and cross-border collaborations it is very evident that Migrant groups are key to reaching the current goal of elimination. The Heterogenity that we have found among migrant groups at risk of malaria in Cambodia is very high. This heterogeneity is very much overlooked. It is indeed, this local heterogeneity, including social and cultural barriers and vector behaviour, which prevented success in the past elimination efforts, must not be forgotten as this is once again in light of commitment to achieve an Asia Pacific free of malaria by 2030.

We have found out that standard control programmes and measures seldom consider human heterogeneity such as local sociocultural variability, examples of which are mobility, the lower than expected uptake of preventive measures in certain vulnerable populations and difficulties achieving optimal adherence to anti-malarial treatment. In low malaria transmission in pre-elimination contexts in Cambodia (i.e. Pailin) might additionally cause a decreasing perception of risk, potentially leading to a lower use of malaria preventive measures.

2) how to implement prevention, test, treat and track (P+T3) amongst migrants

We have been also looking at how to implement prevention, test, treat and track (P+T3) amongst migrants. Cambodia has set itself pre-elimination goal by 2015. In Cambodia (and in most malaria elimination settings), as transmission reduces, malaria increasingly becomes a disease of certain demographic groups. Amongst these are mobile, migrant and groups with limited access to services. We have studied used in the Programme to Prevent, Test, Treat and Track (T3) malaria in these populations and evaluated the effectiveness in this context – we believe that lessons learned from Cambodia may provide guidance to other elimination settings.

The strategies used in the various interventions have been classified as:
a) Prevention: interactive voice response (IVR) technology, taxi scheme, LLIN- lending scheme, mass media, mobile broadcasting units, listener viewer clubs,
focus group discussions, IEC and BCC materials, positive deviance.
b) Test/Treat: cross-border screening, active case detection, village malaria
workers, mobile malaria workers, plantation malaria workers.
c) Track: respondent driven sampling, multiple cross-sectional surveys, movement
mapping, farm and plantation mapping and MMP-information system.
Various levels of effectiveness and factors influencing success has been used to inform the Programme.

Targeting these groups is a priority in both malaria eliminating and drug resistance settings. We have found out that some solutions exist to these problems and that village malaria workers are the backbone of all above described interventions. However, factors such as dark media zones, low-literacy, low exposure to intervention, high mobility affect the effectiveness of the strategies in some contexts and need to be accounted for in Programming.

3) migrant and mobile populations are common barriers to inclusion of study participants in Cambodia

I would also like to share my experience in conducting clinical studies and operational research in Western Cambodia.

In order to eliminate malaria in the context of artemisinin resistance and multi-drug resistance we need to find the right combination therapies for infected individuals to clear parasites and stop the spread of disease. However, exclusion of migrant workers is a commonly accepted criterion for drug trials, due to obvious difficulties of follow-up.

It can't be overlooked that migrant workers could be important subjects to include in malaria elimination related research as they may have different environmental (e.g.: living and working in forest areas); exposure (e.g. movement between areas of low and high endemicity) and other factors that may be important to consider.

Additionally the role of people living in these environments , with often-poor health care access , to the spread of drug resistant parasites has been identified. The importance of outreaching to mobile and migrant populations is critical in the endgame.

As noted in the Artemisinin Resistance Containment (ARCE) project by the WHO, innovative means to reach mobile populations are required. However, these methods of reaching and retaining mobile populations is often not logistically possible within projects without placing considerable strain on staff and resources. Understanding what is required to include a mobile patient in a study in terms of time, human resources, funding is important to make explicit to ensure the right and quality research is done .

In Western Cambodia migrant and mobile populations are common barriers to inclusion of study participants.
This is especially common in drug efficacy studies as many screened patients are migrants; hence not included in the study due to follow up issues.

If migrants are not included in clinical studies due to their mobility, then these studies might be missing out key effective populations that must be studied. However, an efficacy study requires 28-42 day follow up. The inability to reach the sample size required is an ever-present issue in malaria studies.

Looking forward to contributing to more discussions. Best wishes from Cambodia!
Sara Canavati

Attached resources:

Pierre Bush, PhD Replied at 7:50 PM, 19 Nov 2015

Dear Tim Freeman, Tim France, and Sara Canavati,
Thank you for these great contributions to this panel! You demonstrated that the concerted effort between countries is the cornerstone in the prevention, testing, treatment and tracking of cases of malaria across borders. You also highlighted the challenges faced especially to be able to include hard to reach populations who are in fact the most vulnerable to the problem of cross borders transmission. Other malaria endemic regions of the world should emulate the South East Asia model. It is especially striking on how 18 prominent political leaders from this region came together to define a common goal and strategy to follow!
Once again thank you very much.

Sara Canavati Replied at 5:37 AM, 20 Nov 2015

Dear all,
Following Pierre Bush's comment on South East Asia's Approach to addressing Cross Border Transmission of Malaria, I would like to add to this discussion the Emergency Response to Artemisinin Resistance (ERAR) in the Greater Mekong subregion (GMS) project (attached link) which has brought together 6 countries: Cambodia, Thailand, Vietnam, Yunnan(China), Laos PDR, and Myanmar.

One strong aspect of the ERAR project is cross-border collaborations as well as cross-border initiatives especially focusing on cross-border surveillance.

Following containment efforts and in light of the spread of artemisinin resistance in Vietnam, Myanmar and Thailand, the ERAR framework was developed as a follow-up to the containment project and the Joint Assessment of the Response to Artemisinin Resistance in the Greater Mekong Subregion in 2012.

The ERAR framework highlight a need to focus on MMPs; Action 2 of the ERAR framework is to “engage health and non-health sectors to reach high-risk populations,” including communicating with local employers of workers at high risk of contracting malaria (e.g. plantations, construction sites) to ensure access to appropriate prevention, diagnostic testing and treatment of malaria, and managing initiatives to target high-risk populations by using volunteers and behaviour change communication (BCC).

The ERAR project in close consultation with partners have produced several regional documents. Most importantly the Strategy for malaria elimination in the Greater Mekong Subregion: 2015-2030 (link attached).

Much work has been invested in producing regional materials on how to tailor malaria interventions for mobile and migrant populations, such as:
1. Improving access to malaria control services for migrant and mobile populations in the context of the emergency response to artemisinin resistance in the Greater Mekong Subregion (attached link)
2. Technical consultation on improving access to malaria control services for migrants and mobile populations in the context of the emergency response to artemisinin resistance in the Greater Mekong Subregion (GMS) (attached link)
3. Mobile and migrant populations and malaria information systems(attached link)
4. Decision-tree framework for selecting study methods for malaria interventions in mobile and migrant populations(attached link)
5. Vector control and personal protection of migrant and mobile populations in the Greater Mekong subregion: A matrix guidance on the best options and methodologies(attached link)

All the above documents have been carefully drafted with high participation from GMS malaria control programmes and their partners.

Hope you find them useful.
Best wishes

Attached resources:

Sungano Mharakurwa Replied at 8:24 AM, 20 Nov 2015

What a rich and instructive sharing of expertise and experiences on the challenges of cross-border malaria and its prevention. The SE Asia is one impressive multi-prong, multi-sector, multi-country model from which to draw lessons for other areas and growing initiatives. The last question in our discussion is: “Is there anything we can also learn from the HIV and TB communities regarding the trans-border control of infection?” Thoughts on this on any ongoing discussion material are most welcome. Thank you.

Dr Shanta Ghatak Replied at 8:52 AM, 20 Nov 2015

In the Western African context in recent months - my experience has been in cross border control of EVD suspects and was amazed at the numbers that crossed the check points each day .....and yes political will and repeated trainings for the grass root level workers in identifying suspects ..and giving treatment cases of malaria this needs to be done I believe .....with ample political will and advocacy

The hard to reach communities - even they travel a lot and suffer from malaria get more funding must be there for malaria control in these areas .....crossing borders and migration ( seasonal ) needs to be tracked well too. Trained human resource will be required .

Sungano Mharakurwa Replied at 4:42 PM, 20 Nov 2015

Many thanks Dr. Ghatak. Indeed one can imagine the likely scale with malaria which is even more prevalent with abundant long-duration asymptomatic carriers.
The panel has been really captivating and informative, with generous sharing of resources and inspiration for the fight against malaria. Thanks to our panelists and many community members who contributed.

Sara Canavati Replied at 3:51 AM, 21 Nov 2015

Thank you Sungano Mharakurwa- I have been following up cross-border tuberculosis projects at the Mexico-USA border.

Regarding your question:
“Is there anything we can also learn from the HIV and TB communities regarding the trans-border control of infection?”

I have always found the paper by Carla DeSisto et al: "Border Lookout: Enhancing Tuberculosis Control on the United States–Mexico Border" as a very useful example on trans-border control of tuberculosis where they evaluate the US programme: "Do Not Board and Border Lookout". This is a surveillance project for active case finding and referral of tuberculosis infected individuals crossing the borders.

We evaluated the use of federal public health intervention tools known as the Do Not Board and Border Lookout (BL) for detecting and referring infectious or potentially infectious land border travelers with tuberculosis (TB) back to treatment. We used data about the issuance of BL from April 2007 to September 2013 to examine demo- graphics and TB laboratory results for persons on the list (N = 66) and time on the list before being located and achieving noninfectious status. The majority of case-patients were Hispanic and male, with a median age of 39 years. Most were citizens of the United States or Mexico, and 30.3% were undocumented migrants. One-fifth had multidrug- resistant TB. Nearly two-thirds of case-patients were located and treated as a result of being placed on the list. However, 25.8% of case-patients, primarily undocumented migrants, remain lost to follow-up and remain on the list. For this highly mobile patient population, the use of this novel federal travel intervention tool facilitated the detection and treatment of infectious TB cases that were lost to follow-up.

Kindly find attached paper for further reading.

Attached resource:

Menyanga Abu Replied at 3:44 PM, 21 Nov 2015

Malaria elimination in any country or region requires cooperationwith the neighburing country’s malaria control programs to address the issuesof cross border transmission. This is so because a number of challenges couldarise from the facts that each bordering country may have different healthagenda, different malaria control strategies, different malaria prevalence,different mosquitoe species and malaria parasite. Malaria along theinternational border is an important public health problem and one of theborder health concerns that need serious attention in malaria eliminationprogramme. There is the need to reconcile all the competing issues andapproaches to prevent cross-border malaria transmission. The occupational andbehavioural risk of the people along the border sometimes tends to increase thesusceptibility resulting from vector combination. To address the issues ofcross-border malaria transmission one needs to identify the factors that arelinked to the complex border malaria settings and vulnerability in bordermalaria transmission dynamics.   The border crossing of the vulnerable groupand local border people are epidemiolocally linked with transmission dynamicsof border malaria by P.palciparum and P. vivax. The following vulnerabilities influence border malariatransmission dynamics:-a)    -- Malaria infected persons who cross the borderare likely to have delay treatment.b)     --Some border people may have improper healthseeking behaviour   or self medicationespecially with counterfeit drug leading to emergency of multi-drug resistanceto anti-malariac)      --Surveillance and monitoring of P. palciparumand P. vivax drug resistant malaria  maynot be intensified  in high transmissionareasd)      --Thereare limits to which surveillance, control and monitoring of vector carryingresistant malaria parasite on the border can be carried out.Border movement activities of malaria-developing cross-borderpersons have the potential of transmitting drug resistant malaria if there isdrug resistance in the neighbouring country. This is epidemiologically linkedthrough multiple bites of mosquitoes at multiple locations. It is important tounderstand the generic basis of drug resistant malaria parasite in the complexborder malaria as this will help the public health professionals andresearchers to standardize data format.Suggestedstrategies to prevent cross-border malaria transmission    ·        --Identify the various stakeholders in malariaelimination programme/ activities. This should be accompanied by capacitybuilding both facilities, materials and human.·       -- Reconciliation of border populationactivities, malaria elimination strategies as well as the vector behaviours.Competing border activities in both countries  should be reconciled ·        --Information synthesis and sharing byneighbouring countries will help in synchronizing the elimination strategiesand activities.·        --Development of sentinel surveillance,monitoring and evaluation points for tracking imported malaria cases. ·       -- Sustainable elimination activities should beensured.·        --Identifying and understanding thesocio-cultural and economic issues across the border will no doubt help inreducing trans-border malaria cases. The rate of cross border movementespecially informal and unofficial entry points most times influences theincidences of cross-border malaria.·       -- Strong political commitments of theleaderships of the neighbouring countries which is translated into concreteactions for positive result.           Menyanga Abu


Marie Teichman Replied at 9:06 AM, 23 Nov 2015

Thank you again to all of our exceptional panelists and community members who participated in this rich discussion. We greatly appreciate the insights everyone has shared, and look forward to continuing to discuss these important topics.

We will be working on a Discussion Brief to summarize the key points from this Expert Panel, and will share details as soon as that is available on the website.

Sungano Mharakurwa Replied at 9:37 AM, 23 Nov 2015

Many thanks again All. It has been a great discussion with so many lessons to learn.

Kavitha Simpson Replied at 2:55 PM, 14 Dec 2015

I wanted to say thank you for all the wisdom you have shared through this discussion! I am a relatively new doctor to less developed countries and I appreciate learning more about Malaria eradication and prevention of spread across borders.

Sungano Mharakurwa Replied at 10:09 AM, 15 Dec 2015

Thank you Dr. Simpson. As we gear towards malaria elimination, cross-border transmission is one key area that needs particular attention, concerted efforts and the sharing of expertise and success as well as challenge experiences. Thanks again all for great contributions. A Discussion brief will follow.

Pierre Bush, PhD Replied at 11:17 PM, 17 Dec 2015

Dear Colleagues,
Thank you for your contribution to the discussion panel: Preventing Cross Border Transmission of Malaria. Please find attached the discussion brief. It is also posted as a new discussion for this week.

Attached resources:

Pierre Bush, PhD Replied at 12:14 PM, 25 Jul 2016

Dear Colleagues,
Thank you for participating in this expert panel discussion: Preventing cross border transmission of malaria. The GHDonline team has posted the discussion brief. You can access it by going to the discussion briefs. Also, you are welcome to continue to post your comments . It is very well part of the malaria control and elimination topic that we have been discussing during this month.
Thank you

Pierre Bush, PhD Replied at 12:26 PM, 25 Jul 2016

Dear Colleagues for those of you who use GHDonline via email, here is the link to access the discussion briefs:

Menyanga Abu Replied at 5:37 PM, 25 Jul 2016

Thanks Pierre Bush for mailing me the discussion briefs .
Menyanga Abu

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Nderitu Joshua Replied at 12:15 PM, 26 Jul 2016

Quite interesting

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