Abstract
Cambodia has seen a general decline in clinically diagnosed cases of malaria and case fatality over the past decade, coupled with a significant and steady decrease in overall malaria prevalence. A diverse range of interventions has been undertaken with the goal of achieving pre-elimination of malaria across Cambodia by 2015 and phased elimination of all forms of malaria in Cambodia by 2025. Resistance to artemisinins was identified and confirmed on the Cambodia–Thailand border in a series of studies conducted between 2001 and 2009. Delayed parasite clearance following treatment with ACTs has since been observed in some areas of Cambodia, Myanmar, Thailand and Vietnam, indicating the presence of artemisinin resistant malaria in the Greater Mekong Sub-Region.
Cambodia has recently designed and implemented policy and strategy changes to improve coverage of appropriate case management and address the threat of artemisinin drug resistance. The National Centre for Entomology, Parasitology and Malaria Control (CNM) has stratified the country into four zones: 1) Zone 1 – areas where artemisinin tolerance has been detected; 2) Zone 2 – areas with no evidence of drug tolerance but considered at risk (known as a ‘buffer’ area); 3) Zone 3 – malaria endemic provinces with relatively high malaria prevalence, but without evidence of resistance; and 4) ‘No zone’ – malaria endemic provinces with relatively low malaria prevalence. Significant policy changes include:
- A shift in the first-line therapy for Plasmodium falciparum (Pf) malaria from the artemisinin-based combination therapy (ACT) artesunate mefloquine (ASMQ) to ASMQ or dihydroartemisinin piperaquine (DHA-PPQ) occurred in 2012 following targeted use of DHA-PPQ since 2009 in artemisinin resistance containment areas. Malaria case management using ASMQ or DHA-PPQ also includes treatment with primaquine (PQ). Atovaquone proguanil (Malarone) is authorized for use in Zone 1. The first-line therapy for Plasmodium vivax changed from chloroquine to DHA-PPQ plus PQ in 2012.
- Malaria rapid diagnostic tests (RDT) have been scaled-up to facilitate confirmatory testing before antimalarial treatment.
- The Village Malaria Worker (VMW) program has been scaled-up to improve access to appropriate fever case management; blood testing and treatment are provided free-of-charge through VMWs.
- The sale of oral artemisinin monotherapy was banned in 2009.
- Increased regulation of private sector sale of antimalarials and RDTs has been enforced.
The ACTwatch outlet surveys conducted in 2009, 2011, 2013, and planned for 2015 are designed to monitor key antimalarial market indicators at national level and across three research domains defined by the CNM stratification: Zone 1, Zone 2, and Zone 3 plus ‘No zone.’ The objective of the outlet survey is to monitor levels and trends in the availability, volumes, price and use of antimalarials, as well as outlet providers’ perceptions and knowledge of antimalarial medicines.
This documents aims to present the main findings of the 2013 outlet survey, as well as trends across time using data from the 2009, 2011 and 2013 surveys.
