MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF MARIOLOGY PARASITOLOGY AND ENTOMOLOGY TRAN QUANG HAO SITUATION RESEARCH OF INFECTION OF MALARIA PARASITE AND
Trang 1MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH
NATIONAL INSTITUTE OF MARIOLOGY PARASITOLOGY AND ENTOMOLOGY
TRAN QUANG HAO
SITUATION RESEARCH OF INFECTION OF MALARIA PARASITE AND CIVIL-MILITARY COORDINATION IN MALARIA PREVENTION FOR CIVILS IN THE BORDER OF DAK
NONG PROVINCE (2016-2018)
Major: Parasitology Code: 62 72 01 16
ABSTRACT OF DOCTORAL DISSERTATION
HANOI - 2019
Trang 2THE DISSERTATION PRESENTED IN NATIONAL INSTITUTE OF MARIOLOGY PARASITOLOGY
AND ENTOMOLOGY
Advisors
1 Assoc.Prof.Dr Ho Van Hoang
2 Assoc.Prof.Dr Nguyen Van Ba
Committee member 1:
Committee member 2:
Committee member 3:
The dissertation will be defended in National Institute Of Mariology Parasitology And Entomology
At hour Date month Year 2019
The thesis can be found at:
1 National Library
2 Military Medical Library
Trang 31
INTRODUCTION
Malaria is still a common disease in many parts of the world and tropical countries like Vietnam, greatly affecting human health and causing great economic and social losses
In Vietnam, central region - Central Highlands (MT-TN) has seen the highest prevalence of malaria nationwide: accounting for nearly 50% number of malaria patients each year, 75%, malaria parasites (malaria parasites) ), 80% total cases of malignant malaria and malaria deaths of the country’s Most provinces with communes and districts bordering Laos or Cambodia have a higher proportion of patients with malaria than other localities in the country
Dak Nong is a province in the Central Highlands region Although the malaria situation in the province has improved a lot in recent years, the incidence and risk of malaria remains high The rate of malaria patients and parasites per 1,000 people; Malaria mortality per 100,000 people has been still among the provinces with the highest malaria incidence in the country Epidemiological situation of malaria in border areas of Dak Nong and Cambodia is often complicated, parasites often spread easily between villages on both sides of the border
Up to now, research on malaria in our country and the Central Highlands has focused on malaria epidemiology, vector prevention, drug resistance, knowledge-attitude-practice There are no studies on managing and monitoring models, early detection and treatment of malaria patients in border areas Therefore,
we implemented the project "Studying the actual situation of infection of malaria parasite and civil-military
coordination in malaria prevention for civils in the border of dak nong province
1 Research objectives:
1 Describe the current situation of infection with malaria parasites, species composition and transmission
role of Anopheles in the border region of Dak Nong province (2016)
2 Assess the effectiveness of civil-military coordination in malaria prevention for people in the border region of Dak Nong province
- Describe the current situation of malaria parasite infection of the community in the border areas of Dak Nong province (2016)
- Describe the species composition, density and rate of Anophenes mosquitoes infected with malaria
parasites and some risk factors for malaria in the Vietnam-Cambodia border
- Evaluate the effectiveness of civil-military coordination in malaria prevention for people in the border area
3 Outline: The thesis includes 122 pages and 4 chapters:
Introduction: 02 pages
Chapter 1 Literature review: 28 pages
Chapter 2 Research subjects and methods: 28 pages
Chapter 3 Research results: 32 pages
Chapter 4 Discussion: 29 pages
Conclusion: 02 page
Suggestion: 01 page
References: 126 documents (98 Vietnamese papers, 32 English papers)
CHAPTER 1
LITERATURE REVIEW 1.1 Epidemiology of malaria
In 2016, around 3.2 billion people in the world and nearly 50% of the population were at risk of malaria Migrant laborers traveling to endemic areas, children <5 years old, and pregnant women are high-risk groups that are affected by the high burden of malaria
Trang 42 According to WHO reports, malaria prevalence in Southeast Asia is about 7% and accounts for 6% of all malaria deaths in 2016, concentrated mainly in remote mountainous areas and along the borders of Laos, Myanmar, and Cambodia , Thailand and Vietnam In particular, the Greater Mekong Subregion (GMS) is facing the emergence and spread of artemisinin resistance, despite having used artemisinin-based combination therapies (ACTs) - the first-line drug to treat malaria at present
The 2015 Report on malaria prevention and control showed that the total number of malaria patients nationwide decreased by 30.9% in 2015, the prevalence of malaria per 1,000 people decreased by 31.2% compared to the same period in 2014 The number of patients with malignant malaria decreased by 56.16% and only found 3 death cases due to this disease
Anually, the number of patients infected and dead from malaria in border provinces is higher than other provinces in the country, of which the highest incidence of malaria is in provinces adjacent to Cambodia, followed by provinces bordering Laos According to statistics for the period 2006-2010, the number of malaria patients in border provinces accounted for 63.7% of the total number of malaria patients in the whole country (45,191 / 70,910) The number of malaria deaths in these provinces accounted for about 70% of all malaria deaths nationwide (14/20)
1.2 Current situation of malaria prevention
Difficulties in technical expertise: Since 1960 when chloroquine-resistant P.falciparum was found in South America (Brazil), Thailand, Vietnam the phenomenon of chloroquine-resistant P.falciparum was spreading
rapidly By 2000, there were 100 species resistant to this drug
Economic, social and financial constraints: natural disasters, epidemics, wars, and underdeveloped production in countries with malaria, especially in under-developing and developing countries
The health system, especially the grassroots health care system is inadequate and weak, local personnel responsible for malaria control are not sufficient in number and are still unqualified
Border areas are often underdeveloped and encouters a lot of contrainst in accessing due to the characteristics of hilly areas, underdeveloped infrastructure and far from administrative centers Malaria situation in Southeast Asian countries is often related to remote and mountainous areas, which is a reason that malaria incidence is often higher and more difficult to control, especially in border areas where ethnic minorities inhabit Especially in recent years, drug-resistant parasites have emeged in many provinces with different levels of resistance but most commonly in the Central - Highlands and Southeast regions
1.3 Civil-military coordination in malaria prevention:
In 2001, according to Decision No 1026 / QD-TTg, the Prime Minister approved the project on
Civil-military coordination to protect and care for civil’s health and serve national defense and security in the
2001-2010 period The specific objective of the project is to build and consolidate civil and military medical stations and centers in border areas and islands, fulfil the needs of protection, care civil's and soldiers’ health; improve the capability of qualified medical personnels to react in time in urgent cases: natural disasters and emergency situations; and propose to the Government about mechanisms and policies for civil and military cooperation in health sector and develop health human resources in extremely remote areas
In order to enhance the effectiveness of malaria prevention, the Ministry of Health and the Ministry of Defense issued Joint Circular No 05/2003 / TTLT-BYT-BQP on April 29th , 2003, guiding the work of civil and military cooperation for malaria prevention The Ministry of Health issued Decision No 246 / QD-BYT of February 2, 2004 on the establishment of a Subcommittee on civil and military cooperation in malaria prevention
Cvil and military medical coordination in Dak Nong province has been implemented since May 2005with many practical activities, which has contributed significantly to the accompaniment with the health sector in caring and protecting the health of the citizens, laying a solid foundation of community healthcare system in remote and border areas
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3
CHAPTER 2 RESEARCH SUBJECTS AND METHODS 2.1 Research subject, time and place
2.1.1 Research subjects
- People living in 4 communes bordering with Cambodia in Dak Nong province regardless of gender, age,
or ethnicity
- Malaria patients
- Plasmodium
- Mosquitoes transmitting malaria collected at research sites
- Medical system of civil- military cooperation: military medical outpost, the 16th Corps infirmary, the village and commune health stations
2.1.2 Research place:
- Field sites: The study was conducted in 4 communes bordering Cambodia, including: Quang Truc commune (Tuy Duc district); Thuan Hanh commune (Dak Song district); Dak Lao (Dak Mil) and Dak Wil (Cu Jut District)
- Labo research location: (1) Dak Nong Preventive Medicine Center: Performing techniques for malaria parasite by optical microscopy and mosquito identification; (2) Military Medical Research Institute - Military Medical University implementing ELISA technique
2.1.3 Research time:
The study was conducted over 3 years from 2016 to 2018
- The study describes the characteristics of Plasmodium infection in the border area of Dak Nong province
in 2016 Investigation of indicators of malaria: Conducted in 4 rounds at 4 different times of the year: Dry season (April / 2016), at the beginning of the rainy season (June 2016), mid- rainy season (August 2016) and the end of the rainy season (October 2016) Survey and assessment of KAP: April 2016 Investigation of
Anopheles mosquito: mid-rainy season (August 2016).)
- Intervention study: conducted from 1/2017 - 6/2018, including the following stages: (1) Preparation stage: 11/2016 - 12/2016; (2) Implementation and intervention stage: 1/2017 - 3/2017; (3) Maintenance stage: From 4/2017 - 6/2018; (4) Evaluation of malaria indicators stage (4 rounds): August 2017, October 2017, April 2018 and June 2018 Survey and assessment of KAP: 4/2018
2.2 Research desgin:
- Descriptive cross-sectional study (2016): Investigate and evaluate characteristics of Plasmodium in the community and species composition, density, and proportion of malaria vectors Investigate and evaluate knowledge and practices of civils from border areas in malaria prevention and control The study conducted surveyed 4 times a year
- Intervention study (January 2017 - June 2018): Controlled community intervention: Implementing civil-military cooperation in medical sector in Quang Truc commune of Tuy Duc district and Dak Lao commune of Dak Wil district (control) In the intervention commune, implementing civil-military cooperation measure in malaria control, in the control commune, carrying out routine malaria prevention activities Results of pre- and post comparisons between intervention commune and control commune The intervention results were investigated at 4 times of the year as pre-intervention
2.3 Content and data collection methods
2.3.1 Descriptive study
2.3.1.1 Sample size
- Sample size of the malaria prevalence survey (sample size for the cross-sectional survey district): Apply
of the sample size calculation formula for a prevalence of malaria
n =Z 1 / 2
2
) 1 (
p p
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n: Minimum sample size;
p: Percentage of malaria patients choosing p = 0,15;
Z1- /2: Reliability coefficient, for 95% confidence interval Z1- /2 = 1,96;
ε: Relative error chossing ε = 0,13
With the values selected, sample size calculated as 1289 In fact, it was conducted on 1320 people in April 2016 Because malaria is a seasonal disease, the study conducted three additional surveys in 2016: June 2016 surveyed 1300 people, August 2016 surveyed 1320 people and October 2016 surveyed 1310 people
- Sample size of Knowledge, Attitudes and Practices of malaria prevention (KAP):
Conduct community-based malaria knowledge and practice surveys in April 2016, with households surveyed for malaria incidence in dry season Determine the number of households surveyed = sample size of the number of people surveyed / average population size (provided by local authorities) Household size in 4 studied communes is 4.1 person / household Total number of households chosen to do KAP research in malaria prevention = 1320 / 4.1 = 322 households At each household, one representative will be selected for the interview, the sample size of the interviewee corresponds to the sample size of the household to be surveyed
- Sample size of insect surveyed: conducted in 3 villages with the highest number of malaria patients in each commune and conducted in the middle of the rainy season (8/2016)
- Sample size for Anopheles species composition: All collected adult Anopheles mosquitoes were collected to identify Anopheles species at the study sites
- Sample size for the ELISA technique to determine the role of vectors: All adult mosquitoes after identification will have themselves dried, stored in Eppendoft tube for ELISA testing in the laboratory to determine the rate of plasmodium infection of vectors
2.3.1.2 Indicators and data collection methods
a, Indicators for evaluation:
- Indicators of clinical malaria:
+ Percentage of patients having fever (%)
+ Percentage of patients with enlarged spleen (%)
- Indicators of characteristics of Plasmodium infection in the community
+ Indicators of clinical malaria: Percentage of clinical malaria cases by total number of people examined + Slide Positive Rate: Total positive for Plasmodium(+) x 100 / Total slides examined (total number of people surveyed for blood tests)
+ Plasmodium specification: percentage of each type of plasmodium over the total
+ Gametocyte rate: The percentage of gametocyte of each species over total slide positive
+ Ratio of plasmodium by gender, age, farming practices, border exchanges
- Indicators in Anopheles mosquito research
+ Composition and ratio of Anopheles species
+ Anopheles mosquito collected by trap
+ Percentage of mosquitoes infected with malaria parasites by ELISA test
+ Species composition in 3 habitats: In forest, forest edge and in village
+ Mosquito density by these methods: outdoor light trap; Indoor light trap; each person indoor; each person outdoor; daylight house inspection; nighttime house inspection; livestock inspection
- - Indicators of knowledge - attitude - practice on malaria prevention in the community:
+ Ratio of people who know mosquitoes is the cause of malaria transmission
+ Ratio of people who know Plasmodium is the cause of malaria
+ Ratio of people who know malaria is life-threatening
Trang 75 + Ratio of people who know to sleep with mosquito net to prevent malaria
+ Ratio of people who go to medical center when they have malaria
+ Ratio of people sleeping the forests
+ Ratio of people who have regular cross-border exchanges
+ Ratio of people sleeping with mosquito nets near mountainous or forested areas
+ Ratio of people who have regular cross-border exchanges sleeping with mosquito nets
+ Ratio of people who have regular cross-border exchanges using hammocks with net mosquito
b, Techniques used in the study
- Clinical examination discovering fever and malaria patients
- Technique of thick blood smear test to find malaria parasites: Blood smear slide test to discover malaria parasites by finger pricking, using Giemsa stain technique and microsopy
- Direct interview technique
- Anopheles mosquito discovering technique: The method of collecting mosquitoes follows the procedures
of the World Health Organization (1994) and National Institute of Malariology, Parasitology and Entomology
(NIMPE) (2011)
- Discovering Anopheles mosquito by habitats: 3 habitats including: in the forest, in the edge of the forest,
in the village
- Anopheles mosquito and larvae identification technique: Use Keys to Identify the Anopheles Mosquitoes (Adults-Pupae-Lavae) of National Institute of Malariology, Parasitology and Entomology (NIMPE) (2016)
- ELISA technique to identify mosquitoes infected with malaria parasites: according to SOP of the National Institute of Malariology, Parasitology and Entomology (2016)
2.3.2 Intervention research:
2.3.2.1 Sample size
- Sample size of Community-based vector control intervention research:
This is a community-based intervention study The intervention results were assessed by comparing before and after the intervention Therefore, the sample size for this intervention study was estimated by using the formula of estimating the sample size for the intervention study comparing 2 ratios as follows:
n = ( , )
2
2 1
2 2
1 1
) (
) 1 ( )
1 (
p p
p p
p p
Therein:
n: minimum sample size
p1: estimated percentage of people with malaria p1 = 0,15 [80]
q1 = 1-p1 = 1- 0,15 = 0,85
p2: The assumption is that interventions may reduce the proportion of malaria patients in the commune after the intervention, estimated to be 0,1% (reduced by 5% compared to before the intervention) So, choose p2 = 0,1 q2 = 1-p2 = 1- 0,1 = 0,9
Z1-α/2 = 1,96 (value of the normal distribution for confidence level α =5%)
)
,
(
2
Z = 3,8
Substituting the figures in the above formula, we have: n = 330 people Actual sample size investigated:
Research commune
8/2017 10/2017
4/2018 6/2018 Number of
examination
Trang 86 Sample size of the survey, assessment of knowledge, attitudes and practices of malaria prevention of people post-intervention: The sample size of KAP survey is equal to the sample size of KAP survey pre- intervention, Quang Truc commune: 82 households, Dak Lao commune: 82 households
2.3.2.2 Assessing the effectiveness of civil-military coordination in malaria prevention and control
* Indicators of Assessing the effectiveness of civil-military coordination in malaria prevention and control in border areas:
- Management Evaluation Index
Number of people with malaria symptoms in household
Number of family members sleeping with mosquito nets
Number of households with a fire stove
Number of households with livestock barn under the floor
Number of households moving cattle sheds 50 metres far from home
Number of households without bushes 50m far from the house
Number of people who go to and sleep in Cambodia
Number of people come back from Cambodia with malaria
Number of Cambodians who sleep at home, some have malaria
Number of people sleep in forest areas
- Indicator to evaluate the effectiveness of detection and treatment in the community
Number and percentage of malaria patients and malaria parasites detected and examined in the community
Number and percentage of people with fever and malaria parasite are consulted, monitored, treated for malaria
Number and percentage of people suffering from malaria due to border exchanges (to Cambodia) are detected, treated and managed
Number and incidence of malaria caused by going to forest and sleeping here are detected and managed in the community
- Indicators on communication and health education about malaria prevention:
Rate of people who have thorough knowledge about malaria prevention; Rate of people who have right attitude for malaria prevention; Rate of people who have good practice in malaria prevention
- Indicators for coordination of malaria prevention in border areas
Number of people, number of times, number of nights staying in Cambodia
Number and prevalence of malaria (%)
Number of Cambodians suffering from malaria, the number of people being treated for malaria at health facility, at Vietnamese families
Number and prevalence of malaria (%)
Prevalence of malaria in villages located in both sides of the border
Number of malaria patients and parasites detected and treated in villages located in both sides of the border
* Indicator to evaluate the results of interventions:
- Prevalence of malaria and plasmodium
- Ratio of correct response about knowledge, attitude, practice, prevention of malaria vectors
- Calculating effectiveness index of interventions
Intervention effectiveness index of intervention group
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Effectiveness of intervention
EI = CSHQ PCT- CSHQ PCh
Figure 2.1 Research design diagram
Descriptive study of the current
status of malaria parasites infection
Quang Truc
commune, Tuy
Duc district
- Cross-sectional survey and evaluation of malaria indicators (April, June, August and
October)
- KAP investigation
- Mosquitoes investigation
- Determining the rate of mosquitoes infected with malaria parasites
Evaluation of intervention effectiveness (in 1 year of intervention, 2017-2018):
- Compare survey results 1 year ago and 1-year survey results during the intervention
- Comparison of intervention commune - control commune
- Describe and analyze the indicators of malaria: malaria patients, malaria parasites by
age, gender, geography, farming practices, border exchanges
- Assess knowledge, attitudes and practices of malaria control in border areas
- Description of species composition, mosquito density
- Determining the rate of mosquitoes vectors
- Civil-military cooperation in health sector in detection and treatment of malaria, management
of malaria patients, management of migrants moving across borders
- Health education communication
- Civil-military cooperation in implementing malaria control measures according to the approved plan
Thuan Hanh commune, Dak Song district
Dak Lao commune, Dak Mil district
Dak Wil commune, Cu Jut district
Quang Truc commune, Tuy Duc district (Intervention)
Dak Lao commune, Dak Mil district (Control)
Implementing malaria control measures according to the approved plan
Study on the current situation of malaria parasite infection and the civil-military medical coordination in the malaria control in Dak
Nong province
Intervention study of the coordination of civil-military medical coordination in malaria
control
Trang 108 CHAPTER 3
RESEARCH RESULT 3.1 ACTUAL SITUATION OF PLASMODIUM INFECTION IN THE COMMUNITY IN THE BORDER AREAS OF DAKNONG PROVINCE:
3.1.1 Actual situation of malaria infection in the community in the border area of Daknong province
Table 3.1 Ratio of Malaria prevalence and enlarged spleen (n=1320)
Research Communes
Number
of patients examined
Malaria patients (Clinical malaria + M.Parasite)
Enlarged Spleen (Level 1)
NUmber Percentage
(%) Number
Percentage (%)
Thuận
Research conducted to detect malaria patients in the community in the dry season (April 2016) showed that, with 1320 people examined in 4 border communes, 24/1320 people were diagnosed with malaria, accounting for 1, 82%
Table 3.2 The percent of people testing positive for the malaria parasite (n=1320)
Commune Number of tests Positive
According to the survey in the dry season in 2016 (4/2016), the percent of people living in the border areas
of Dak Nong province positive for malaria parasite (+) accounted for 1.52% In particular, the highest (+) rate
is in Quang Truc and Dak Lao communes
Bảng 3.3 Distribution of malaria parasites for people who sleep at the forests (n=1320)
Communes Number of
patients examined
Number of who sleep at the forests
Number of Plasmodium (+)
Rate of Plassmodium Quảng
Thuận
The rate of malaria parasites among who sleep at the forests is 1.66% In particular, the highest rate is in Quang Truc commune (2.49%) and the lowest is Dak Wil commune (0.92%)
Table 3.4 Distribution of malaria parasites among cross-border people (n=1320)
Communes Number of
patients examined
Number of who do not have cross-border exchange
Number of who have have cross-border exchange Number Rate of parasite
(+) (%) Number
Rate of parasite (+)
(%)