As many as 90 percent of malaria deaths in Cambodia may go uncounted, Dr Stefan Hoyer, the World Health Organization’s coordinator for infectious disease control in Cambodia, told a team of visiting malaria experts last week.
National Malaria Center statistics show that 418 people died of malaria in 2001, but that number includes only those who died in public hospitals—not those who died at private clinics or at home.
“We estimate the number could be as much as 10 times more because of [lack of] access to treatment” and because many people don’t trust state-run medical centers, Hoyer said in a workshop at the National Malaria Center.
The number of hospital deaths from malaria has declined in recent years, from more than 880 in 1999 to 620 in 2000 and 418 in 2001. Malaria workers hope the decrease is linked to the use of drug combinations rather than single-drug therapy.
But data on the true number of people who die of malaria are difficult to collect, and officials know that nationwide, the number is much too low, making it hard to draw conclusions about the progress of anti-malaria efforts, Sean Hewitt, adviser to the European Commission’s malaria control project in Cambodia, told the workshop.
Six international malaria experts spent last week in Cambodia, led by Dr Richard Feachem, director of the Institute for Global Health at the University of California in the US. Feachem is a former World Bank health adviser and former dean of the London School of Hygiene and Tropical Medicine.
Cambodia is one of three countries the experts are visiting to evaluate the Roll Back Malaria program, a 3-year-old worldwide effort supported by the WHO, the World Bank, Unicef and other international organizations. The other countries are Tanzania and Cameroon.
The team spent three days in Ratanakkiri province visiting hill tribe villages, which are at high risk for malaria. They watched enthusiastic minority villagers line up to get their mosquito nets reimpregnated with insect repellent. The experts then returned to Phnom Penh for briefings, discussions and workshops.
The difficulty of collecting mortality rate information was one of the points the experts discussed. On the whole, Feachem said the team was impressed with Cambodia’s innovative methods and substantial progress in attacking the mosquito-borne parasite.
The National Malaria Center has distributed 541,000 mosquito nets and begun commercial production of a combination drug therapy to be launched nationally in March.
“I suppose the message I would give is, ‘Well done, Cambodia,’” Feachem said. He said one of the team’s recommendations would be for Cambodia to share more of its ideas with Africa, where the problem is much more severe.
Cambodian malaria workers have wholeheartedly adopted the dipstick method of diagnosis, wherein a drop of blood on an absorbent stick makes two dark bands appear if the person is infected. Some 66,025 dipsticks were distributed in 2000. The number was only 25,000 in 2001 due to a faulty order from the manufacturer.
African countries still use cumbersome and inaccurate blood tests, which require samples to be sent to a lab, where a scientist must judge whether the parasite is present—a guess that is frequently wrong.
Cambodia was also quick to adapt to the new theory that a combination of malaria drugs is more effective than a single drug because the parasite develops a resistance to combination therapy much slower, if at all.
In Africa, combination therapy has yet to catch on. When a particular drug fails, Feachem said, health workers simply panic and wait for a new drug to come out.
Cambodia’s approach to diagnosis and treatment is due to “the Cambodian openness to innovation and new ideas,” Hoyer said. “There’s not much red tape here.”
Dr Doung Socheat, director of the National Malaria Center, said he was pleased with the international experts’ visit. “We were very proud that we could show them our malaria efforts [in Ratanakkiri], and they were happy to see how we have helped the minority ethnic groups,” he said.