Civilian-military malaria outbreak response in Thailand: an example of multi-stakeholder engagement for malaria elimination

Abstract

Background In April 2017, the Thai Ministry of Public Health (MoPH) was alerted to a potential malaria outbreak among civilians and military personnel in Sisaket Province, a highly forested area bordering Cambodia. The objective of this study was to present findings from the joint civilian-military outbreak response. Methods A mixed-methods approach was used to assess risk factors among cases reported during the 2017 Sisaket malaria outbreak. Routine malaria surveillance data from January 2013 to March 2018 obtained from public and military medical reporting systems and key informant interviews (KIIs) (n = 72) were used to develop hypotheses about potential factors contributing to the outbreak. Joint civilian-military response activities included entomological surveys, mass screen and treat (MSAT) and vector control campaigns, and scale-up of the “1–3–7” reactive case detection approach among civilians alongside a pilot “1–3–7” study conducted by the Royal Thai Army (RTA). Results Between May–July 2017, the monthly number of MoPH-reported cases surpassed the epidemic threshold. Outbreak cases detected through the MoPH mainly consisted of Thai males (87%), working as rubber tappers (62%) or military/border police (15%), and Plasmodium vivax infections (73%). Compared to cases from the previous year (May–July 2016), outbreak cases were more likely to be rubber tappers (OR = 14.89 [95% CI: 5.79–38.29]; p < 0.001) and infected with P. vivax (OR=2.32 [1.27–4.22]; p = 0.006). Themes from KIIs were congruent with findings from routine surveillance data. Though limited risk factor information was available from military cases, findings from RTA’s “1–3–7” study indicated transmission was likely occurring outside military bases. Data from entomological surveys and MSAT campaigns support this hypothesis, as vectors were mostly exophagic and parasite prevalence from MSAT campaigns was very low (range: 0-0.7% by PCR/microscopy). Conclusions In 2017, an outbreak of mainly P. vivax occurred in Sisaket Province, affecting mainly military and rubber tappers. Vector control use was limited to the home/military barracks, indicating that additional interventions were needed during high-risk forest travel periods. Importantly, this outbreak catalyzed joint civilian-military collaborations and integration of the RTA into the national malaria elimination strategy (NMES). The Sisaket outbreak response serves as an example of how civilian and military public health systems can collaborate to advance national malaria elimination goals in Southeast Asia and beyond.

Assessing Thailand’s 1-3-7 surveillance strategy in accelerating malaria elimination

“…Continuation of the close partnership among GMS countries will help support regional goals and address some of the most challenging border hot spots identified by the spatial analysis. There is also historical success of cross-border and civilian-military cooperation in Sisaket province [ 34 ]. A starting point for expanded programming could be cross-border notification and foci response, utilizing the networks of community health workers that are acutely familiar with local populations, and providing additional training to boost 1-3-7 adherence in those areas.…”

“…The DVBD has been intensifying its strategies to ensure appropriate surveillance for very low-transmission settings [ 41 , 42 ]. Such strategies include enhancements to foci response and active surveillance protocols, advocacy for policy legislation, resources for additional staff trainings on accurate case management, support for improved data recording and reporting, and involvement of the private sector and military to ensure that the surveillance system is capturing all cases [ 34 , 43 ]. Effectively reaching marginalized populations may require innovative solutions, particularly as malaria burden and risk perception falls [ 5 , 44 ].…”

Modelling malaria in southernmost provinces of Thailand: a two-step process for analysis of highly right-skewed data with a large proportion of zeros

“…Since the majority of the people in this age group are of working age, they generally work in the agricultural and labor-force sectors which spend time outdoors more than other age groups [14,26]. They have a higher chance to be bitten by a mosquito, especially for those who work in forestry, agriculture, or social services, as well as in plantations or agriculture resulting in a higher occurrence of malaria [27,28]. Other risks may arise from the improper use of insecticide-treated nets or long-lasting insecticidal nets [29][30][31].…”

Modelling malaria in southernmost provinces of Thailand: a two-step process for analysis of highly right-skewed data with a large proportion of zeros

“…Since the majority of the people in this age group are of working age, they generally work in the agricultural and labor-force sectors which spend time outdoors more than other age groups [26][27]. They have a higher chance to be bitten by a mosquito, especially for those who work in forestry, agriculture, or social services, as well as in plantations or agriculture resulting in a higher occurrence of malaria [28][29]. Other risks may arise from the improper use of insecticide-treated nets or long-lasting insecticidal nets [30][31][32].…”