Malaria habitat in Central Vietnam

Central Vietnam is the hardest hit region by malaria in the country for many decades with high rates of malaria morbidity and mortality. This region is characterized by its geographical location with long borderlines adjacent to Laos and Cambodia, along with the presence of nature reservations and national forests. This region is also inhabited by many ethnic minorities whose livelihoods are closely linked to  logging and forest products exploitation.Despite the decrease in malaria indicators, the malaria control programme has been faced the challenges and difficulties such as ineffective management of malaria cases at health facilities of communes and villages, limited vector control measures, insecticide and multi-drug resistance with high risk of spreading to many areas and provinces. These are main obstacles o­n the path to malaria elimination in Viet Nam by 2030.

Institute of Malariology, Parasitology, and Entomology Quy Nhon (IMPE-QN) and the localities' healthcare sector have indefatigably worked and consolidated efforts towards achieving malaria elimination in the region as well as the whole country by 2030, as directed by the Ministry of Health. In Central Vietnam, Da Nang city was the first locality being certified to be free from malaria in 2019, and Thua Thien Hue province has just been declared malaria-free in December 2022. Other provinces in the region are leveraging the subnational verification exercise to prepare for their localities' certification according to the approved roadmap by the Ministry of Health.

Despite many difficulties and challenges, the malaria prevention and elimination in the region has reaped remarkable achievements. Specifically, the number of malaria cases detected in 2022 decreased compared to that in 2021, and no severe malaria, deaths from malaria, and malaria outbreaks reported, which increasingly reinforce sustainable factors against the risk of malaria recurrence. Thanks to the concern, investment, and direction from the Ministry of Health, the National Malaria Control and Elimination Program (NMCEP), and efforts of the healthcare sector, the damages by malaria have been reduced to the minimum.

The disease management work and main activities of IMPE-QN in the region in December 2022 and 12 months of 2022 as follows:

MALARIA AND HELMINTHIASIS

1. Malaria indexes in December 2022 against the same period of 2021:

Malaria cases

The number of malaria cases in December 2022 across the region compared to the same period last year decreased by 3 (13.64% - 19/22), of which the Central Coastal region increased by 8 (8/0), Central Highlands reduced by 11 (50.0% - 11/22).

- There were 05/15 provinces in the region with increased number of malaria cases: Phu Yen increased by 2 cases (2/0); Khanh Hoa by 2 cases (2/0); Ninh Thuan by 4 cases (4/0); Kon Tum by 1 case (1/0); Dak Nong by 1 case (1/0);

- There are 02/15 provinces in the region with decreased number of malaria cases: Gia Lai reduced by 11 cases (9/20); Dak Lak by 2 cases (0/2);

- There are 08/15 provinces without malaria cases: Quang Binh (0/0); Quang Tri (0/0); Thua Thien Hue (0/0); Da Nang (0/0); Quang Nam (0/0); Quang Ngai (0/0); Binh Dinh (0/0); and Binh Thuan (0/0).

Malaria parasites

The parasitemia o­n the peripheral blood smears in the whole Central Vietnam compared with the same period last year decreased by 25.00% (0.03/0.04), of which the Central Coastal region increased (0.02/0.0); Central Highlands decreased by 50.00% (0.05/0.10).

- There were 05/15 provinces with increased malaria parasitemia/blood smear, including Phu Yen (0.03/0.0); Khanh Hoa (0.06/0.0); Ninh Thuan (0,12/0,0); Kon Tum (0.06/0.0); Dak Nong (0.03/0,0);

- 02/15 provinces were reported with reduced malaria parasitemia/blood smear, including Gia Lai (0.25/0.23); Dak Lak (0.02/0.01);

- There are 08/15 provinces with absent malaria parasites including Quang Binh, Quang Tri, Thua Thien Hue, Da Nang, Quang Nam, Quang Ngai, Binh Dinh and Binh Thuan.

Severe and complicated malaria: No.

Malaria mortality: No.

2. Malaria indexes in 2022 compared to those of 2021:

Malaria cases

The number of malaria cases in 2022 across the region compared to that of last year decreased by 20 (6,33% - 296/316), of which the Central Coastal region by 19.35% (75/93), Central Highlands reduced by 0.90% (221/223).

- There are 05/15 provinces in the region with raised number of malaria cases including Quang Binh increased by 2 cases (6/4); Quang Tri by 17 (18/1); Da Nang by 1 THB (1/0); Khanh Hoa by 9 (12/3); Ninh Thuan by 8 (9/1);

- There are 07/15 provinces in the region with decreased number of malaria cases: Quang Nam reduced by 15 cases (1/16); Quang Ngai by 10 (0/10); Binh Dinh by 2 (2/4); Phu Yen by 19 (24/43); Binh Thuan by 9 (2/11); Gia Lai by 1 (196/197); Dak Lak by 1(11/12);

- There are 02/15 provinces with the stable number of malaria cases (remains unchanged compared to the previous year) including Kon Tum (5/5); Dak Nong (9/9). Additionally, there is o­ne province - Thua Thien Hue - that hasnot have any cases of malaria (0/0).

Malaria parasites:

The parasitemia o­n the peripheral blood smears in the whole Central Vietnam compared with the same period last year decreased by 20.00% (0.04/0.05). Specifically, in the Central Coastal region, the parasitemia remains unchanged (0.02/0.02), while in Central Highlands, it has decreased by 22.22% (0.07/0.09).

- There are 04/15 provinces with increased malaria parasitemia, including Quang Tri (0.05/0.0); Da Nang (0.04/0.0); Khanh Hoa (0.04/0.01); Ninh Thuan (0.02/0,0);

- There are 06/15 provinces with decreased malaria parasitemia, including Quang Nam (0.0/0.04); Quang Ngai (0.0/0.03); Binh Dinh (0.0/0.01); Phu Yen (0.04/0.10); Binh Thuan (0.0/0.02); Gia Lai (0.19/0.26);

- There are 04/15 with no increase or decrease in malaria parasitemia, including Quang Binh (0.01/0.01); Kon Tum (0.02/0.02); Dak Lak (0.01/0.01); Dak Nong (0.02/0.02). Particularly, Thua Thien Hue is the o­nly province with no malaria parasites reported.

Severe and complicated malaria: no.

Malaria mortality: no.

3. Assessment of malaria control in Central Vietnam in 2022:

The malaria morbidity in 2022 in the whole Central Vietnam compared to that of last year decreased by 6.33% (296/316), with the Central Coastal region decreasing by 19.35% (75/93) and the Central Highlands decreasing by 0.90% (221/223). There were 5 out of 15 provinces with an increase in malaria cases over the same period of 2021. Quang Binh had a 50.00% increase (6/4), with all 6 out of 6 incident cases being detected as imported cases from Africa. Da Nang (1/0) had o­ne new malaria case classified as imported cases. Quang Tri had a 1,700.00% increase (18/1) and Ninh Thuan had an 800.00% increase (9/1), with malaria patients mainly found among individuals engaging in forest activities and border interactions. Khanh Hoa had a 300.00% increase (12/3) with incident cases predominantly among people going into the forest and sleeping overnight in the field-huts, mostly distributed in Son Thai commune; many of these cases were of P. malariae infections and classified as indigenous malaria. There were no cases of severe and complicated malaria and malaria-related deaths in 2022. The number of cases caused by P. falciparum was 236 (accounting for 79.7%), by P. vivax 46 (accounting for 15.6%), by P. malariae 13 (accounting for 4.4%), and mixed infections 1 (accounting for 0.3%). During October to December, the peak season for malaria transmission in Central Vietnam, localities actively strengthened malaria surveillance in key areas and disease foci, and proactively detect cases in the community, particularly in areas with drug-resistant malaria. Thua Thien Hue province was recognized achievement of malaria elimination criteria in 2022. Activities related to prevention and control of malaria in the region were well implemented by IMPE-QN and local authorities.

4. Assessment of helminthiases control in Central Vienam in 2022:

In 2022, the Covid-19 pandemic was still complex. The total number of people coming to the clinic for diagnosis, testing and treatment in 2022 was 77,076. The majority of seropositive cases were involved in toxocariasis, strongyloidiasis, cysticercosis, fascioliasis, and gnathostomiasis. In addition, a small percentage of the cases was positive for amoeba and dipylidium caninum (dog tapeworm). The deworming program for primary school students, sponsored by the World Health Organization (WHO), showed that in some provinces of Central Vietnam, the deworming rate in each province reached over 96%. Some provinces achieved high results in deworming, such as Thua Thien Hue (100%), Kon Tum (99.9%), Gia Lai (99.95%), Dak Lak (99.19%), and Khanh Hoa (99%). In addition to deworming efforts, education and communication activities o­n preventing soil-transmitted helminthiasis have also been conducted in schools, healthcare facilities, and communities. These activities include distributing leaflets, posters, comics, banners, videos, and learning tools such as notebooks, rulers, etc. Propaganda information is disseminated through lectures in classrooms, and by public address systems in local areas.

IMPE-QN organized the "Workshop to update guidelines of Ministry of Health for diagnosis and treatment of some parasitic diseases in 2022" with participation of all staff members. Additionally, it also collaborated with OUCRU (Oxford University Clinical Research Unit) to conduct a multicenter, open-label, Phase IV study to determine the safety, tolerability, and clinical efficacy of oral EGATEN^TM (Triclabendazole) in patients infected with Fascioliasis (6 years old and above) at the Institute's specialised clinic.

Furthermore, with the spirit of patient satisfaction, the Clinic's doctors, nurses, and technicians thoughtfully welcome, give dedicated advice, assign reasonable tests and provide effective treatment. The clinic?s customer care department is always o­n the line to answer questions from patients and their family members. In addition, the Department of Parasitology in conjunction with the Clinic conducts medical examination, testing and treatment of parasitic protozoan and fungal infections.

SOME DIFFICULTIES AND CHALLENGES IN MALARIA CONTROL & ELIMINATION IN 2022

- In terms of composition of malaria parasite species, it is evident that P. falciparum is dominant, accounting for 79.42%. This poses difficulties and challenges in the plan to eliminate P. falciparum in Viet Nam by 2025.

- High-risk population groups entering the forest also lack appropriate protective equipment and proper prevention measures. Furthermore, they are not willing to undergo malaria diagnosis and testing at malaria posts or healthcare facilities when returning.

- The village health workers (VHWs) are often trained, but the quality of the VHWs network operations is still not effective. In some areas where malaria is prevalent, there is low involvement of VHWs in detecting and encouraging patients to seek prompt diagnosis and treatment from health facilities, especially in reaching out to groups that go into the forest or sleep in temporary shelters.

- Human resources for malaria control and elimination are currently not guaranteed. Many staff serving malaria programs at the grassroots level are not proficient in using computers, resulting in difficulties in reporting malaria cases o­n the eCDS-MMS software. In addition, these personnel are routinely burdened with other programs, that may sometimes affect the amount of time required to conduct timely and effective malaria reporting;

- The equipment for malaria control and elimination work is still limited. Some commune-level units o­nly have o­ne computer prioritized for serving healthcare insurance examination and treatment tasks. The internet connection is not stable, and the software requires frequent updates and bug fixes, which have affected the reporting of malaria cases. Additionally, supplies and equipment for microscopic points at some units have run out and yet been replenished.

The national budget allocated for malaria control and elimination activities has been decreasing. Some communes, after several years without detecting any cases of malaria, are no longer supported by funded projects and have to integrate malaria control and elimination activities into other programs for deployment.

From the aforementioned difficulties and challenges, IMPE-QN has proposed appropriate solutions for each locality to enhance epidemiological surveillance of high burden hotpot areas, unstable malaria areas with resurgence of main malaria vectors, long-term non-intervention communes, high-risk malaria outbreak areas, and areas with dynamic population movements, as follows:

- Enhance the capacity of grassroots medical staff by regularly organizing training and refresher courses for personnel in charge of the malaria program, malaria focal persons, VHWs, and private healthcare facilities to ensure a workforce for malaria control and elimination.

- Regularly monitor, inspect, and evaluate equipment and supplies for anti-malarial work to ensure the proper functioning of malaria reporting, microscopic points, epidemiological surveillance, and communication and education for malaria control and elimination.

- Coordinate with related units to leverage budget and funding for malaria control and elimination, ensuring that malaria surveillance activities are fully implemented by localities according to regulations.

- Strengthen malaria epidemiological surveillance, implement active malaria control measures, with a particular focus o­n areas with high malaria prevalence and dynamic malaria situation;

- Expand proactive case investigation and screening, provide treatment for all malaria cases and respond promptly to newly detected malaria foci;

- Monitor mobile and migrant populations (such as those engaged in farming, forestry, and natural resource exploitation). Pay special attention to areas where drug-resistant malaria has been recorded.

- Minimize the number of severe and complicated malaria cases and deaths among high-risk populations, including mobile and migrant populations, through communication o­n malaria risk and behavior change in malaria prevention and control, and early detection and timely treatment of malaria cases;

- Improve the operation quality of microscopic points; conduct inspections, and provide guidance to address ineffective points.

- Improve the detection, diagnosis and treatment of malaria cases through the evaluation of the upper levels in terms of the quality of diagnosis and treatment. Additionally, regular checks and reviews of essential antimalarial drugs should be conducted at all levels of healthcare facilities to prevent drug shortages and ensure availability of anti-malarial drugs at health facilities from commune to central level;

- Strengthen inspection of blood sampling for microscopic examination or rapid diagnostic testing for malaria; verify the records and reports of malaria cases by month at regional clinics and commune health stations for effective case follow-up and management; assess the reality of malaria situation in localities. This serves as the fundamental database for reporting to district, provincial, and central levels to assess data and monitor malaria situation most accurately.

- Strengthen civilian-military health collaboration in malaria control; particularly military health facilities and medical personnel may be situated along the border areas so as to provide malaria services to both military and civilian patients;

- Specify the malaria control and prevention activities in accordance with the proposed malaria elimination roadmap.

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