Towards zero: harnessing data to eliminate malaria in the Lao People’s Democratic Republic

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Lao People’s Democratic Republic (PDR) has made strides in reducing its malaria burden. The country has not recorded a malaria death in 2 years and 2020 saw an all-time low of 3505 cases. Such achievements are all the more notable given the country’s recent history of malaria outbreaks. This shift is largely thanks to a series of improvements in malaria data management systems which have ensured that the country can effectively identify and respond to malaria cases.

Following a period of immense progress between 2000 and 2010, during which the country slashed cases by 92%, the last major outbreak occurred from 2011 to 2014. Over 50 000 malaria cases were recorded in 2014 alone.

The 3-year outbreak served as a turning point for the National Center for Malariology, Parasitology, and Entomology’s (CMPE) malaria strategy. It exposed weaknesses in the country’s surveillance system, particularly when it came to identifying unusual spikes in cases.

These weaknesses are partly related to the complexity of tailoring malaria interventions in an ethnically and geographically diverse context. High-risk malaria areas host a broad range of ethnic minorities, and neighbouring villages often display very different trends of malaria transmission. At the height of the wet season, one village harvesting cassava can have little to no sign of malaria while a neighbouring village harvesting wild mushrooms can experience a cluster of cases. In settings like this, data driven approaches are essential for tracking and tracing cases.

From outbreaks to break-throughs in malaria control

Following the three-year outbreak, the CMPE launched a new electronic malaria information system in 2017. It was the first disease programme in the country to integrate its data into the existing online national health information system. For the first time, national, provincial and district malaria staff could easily view and use malaria data from all of Lao PDR’s health facilities. Most importantly, the database had an in-built warning system to detect and report any outbreaks.

With epidemiological maps and datasets at their fingertips, malaria staff found they could pick up on any unusual malaria trends which might indicate an emerging outbreak. The surveillance system also allowed them to analyze different factors which could indicate an increased risk of malaria in a given village. In doing so, the CMPE, WHO and partners were able to tailor packages of interventions for at-risk villages to drive down the number of cases.

Fine tuning surveillance systems for malaria elimination

As the burden of malaria on a public health system reduces, the focus of malaria work changes from preventing deaths and severe cases to preventing any cases at all. With this shift, more emphasis needs to be placed on tracking and investigating cases to determine their origin.

In preparation for this shift, the CMPE rolled out a complementary “elimination-focused” surveillance system in 2018. The complementary elimination surveillance system is optimal for collecting the type of data required for case investigations. This gives the CMPE access to crucial information needed to perform contact tracing and find the location where a patient could have contracted malaria.

With the old surveillance system, outbreaks used to take up to 6 months to detect. These days, malaria cases detected in 84% of all districts in the country are notified in near real time. The data from the surveillance systems ensure that village malaria workers can quickly perform an investigation and pinpoint the origin of a case. As technology and a proactive “learning by doing” approach has taken root in Lao PDR, outbreaks are now identified and responded to within days or weeks.

“In 2021 the CMPE discusses and analyzes cases at village level. This sort of granular information allows it to tease out what environmental and behavioral factors are specific to each high burden village, and to adapt and tailor the responses to suit very localized contexts. This is critical in a country that is as culturally and geographically diverse as Lao PDR” says Dr Matt Shortus, the WHO technical officer for the malaria programme in Lao PDR.

A data-driven “last mile” of malaria elimination

The steps that Lao PDR has put in place to prevent any future malaria outbreaks are having noticeable effects. Despite the impact of the global COVID-19 pandemic, malaria testing numbers continue to increase while the total number of cases fall. At the end of 2020 the country launched new Elimination Surveillance and Response Guidelines which further cement a commitment to proactively tracking, testing and treating every case.

Key malaria data are shared on a monthly basis with WHO’s Mekong Malaria Elimination (MME) programme’s Malaria Elimination Database. This database ensures that national malaria programmes from the Greater Mekong subregion can keep track of their own progress while monitoring the malaria situation in neighbouring countries.

The CMPE, WHO Country Office and MME programme and are now focused on implementing a package of “enhanced response strategies” that complement existing core interventions through focalized aggressive approaches which target high risk populations such as forest goers. Throughout this, data utilization will remain at the centre of the CMPE’s approach and will guide the country towards its 2030 malaria elimination target.

*In Lao PDR, WHO has been working with the National Center for Malariology, Parasitology, and Entomology’s **and partners to support the country’s malaria control and elimination efforts.*

WHO’s malaria work in Lao PDR and the Mekong Malaria Elimination programme are funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Bill & Melinda Gates Foundation.