ENSURE: Enhanced surveillance for control and elimination of malaria in the Philippines

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Infectious and Tropical Diseases

Abstract

Malaria remains a problem in many parts of the world. Even in countries where the level of infection is low, malaria can still cause death and there is the constant threat that drug and insecticide resistance may undermine any ongoing control attempts such that malaria comes back.

A major complication for control programmes when infections are rare is identifying where transmission is actually occurring. This is because the current methods used to diagnose malaria are not sensitive enough to detect all infections and miss a substantial proportion. Although these infections that are missed may not cause illness, they can still lead to infections in mosquitoes and therefore maintain malaria transmission in the area. It is an expensive process for many poorer countries to try and actively find all these cases, and so more flexible approaches need to be used to identify where infections are happening so that they can be targeted effectively.

The Philippines is a prime example of a low transmission setting. The country has recently experienced a reduction in annual malaria cases (from over 36,000 local cases in 2000 to fewer than 5,000 in 2014), but despite this progress, 54 out of the 81 provinces remain endemic of malaria, putting 14 million people at risk of the disease. Novel approaches and more sensitive methods are needed to detect if and where any remaining transmission might occur. With drug resistant parasites circulating in some countries in South East Asia, targeting transmission in the Philippines through an integrated surveillance system is particularly important and probably the most effective approach to address this issue.

In this project, we will combine existing systems that monitor malaria in people who attend local clinics in the Philippines with more sensitive diagnostic methods to see who is infected and who has recently been exposed to malaria. We will use the data from the clinics and cutting edge mapping techniques with tablet computers to identify where people live, so that we can see where infections are occurring. We will give this information to the Philippines National Malaria Control Programme so that they can target the area for control. We will perform these activities regularly at health facilities and continually update the maps. This will allow us to identify new areas of infection and check that targeted areas remain low.

We will work closely and continually with the control programme and health facility staff to see if the approach we are promoting is acceptable and how it might be improved. The goal is to develop an approach that can be easily absorbed into the existing health system using more modern approaches, and ultimately to help the Philippines eliminate a deadly and costly disease - and potentially to help other countries and regions achieve the same.

The project also aims to build human capacity in the Philippines in serological and molecular surveillance, data analysis, epidemiology, spatial studies and health systems research. The international collaboration provides a unique opportunity to develop and evaluate malaria burden measurement tools, allowing for novel strategies in a region of diverse and complex epidemiology, in which the rapid advances being made on elimination require great input in research and innovation.

Technical Summary

Malaria surveillance in low transmission settings is hampered by poor diagnostics. Whilst the majority of infections missed are probably of little consequence clinically, being asymptomatic and low parasite density, they can infect mosquitoes and maintain transmission. This is of concern in areas of southeast Asia where there is the threat of artemisinin drug resistance; elimination of all parasites is widely considered the best way to stop the spread of resistance. Sensitive molecular methods can identify low density infections and, when combined with serological approaches, detect antibodies in those who have been exposed to infection. Together these two methods can more accurately identify areas where active transmission is ongoing and/or specific groups most at risk, such as migrant workers.

Collection of samples through large scale community surveys is not practicable for most control programmes; sensible operational approaches are needed. One option is through health facilities which represent an ideal source of contact with local populations. We have previously demonstrated that facility-based surveys generate malariometric data that correlate well with data collected from the local community and schools.

In this study we will use molecular and serological analysis of samples collected from regular surveys of facility attendees in three areas of the Philippines to generate data on infection and exposure in the community. We will combine these data with routinely collected epidemiological data, which we will embellish using enhanced tablet computer-based maps to create iteratively improved maps of areas where transmission is occurring.

We will work closely with the malaria control programme on laboratory and facility aspects to ensure successful implementation, training and include improvements or changes identified as work progresses. The ultimate goal is to develop an approach that can be easily absorbed into the existing health system.

Planned Impact

Malaria remains one of the most important global health challenges. The economic and societal burden of malaria is great, and malaria and poverty are closely linked. In countries such as the Philippines, where persistent and coordinated control methods have achieved remarkable success in reducing the prevalence of malaria, there still exists a reservoir of subpatent and residual infections which continues to drive transmission and undermine progress made.

In the short term, participants in the study (health facility attendees) and indirect participants (health facilities staff) will benefit from increased awareness of malaria via their exposure to the study and consent procedures, despite the decreasing number of cases. This is important for Bataan and Occidental Mindoro, two of the three study sites, which were once priority provinces for malaria control. This will encourage them to use control methods (e.g. bed net). If found to be infected, in addition to being treated at the health facility, they will also benefit from enhanced interventions in and around their home. The community will benefit from better understanding and planning for malaria control including any emergence of drug resistance.

In the medium term, beneficiaries of the research will be the Philippines national public health officials, policy makers and malaria control programmes, and their counterparts in other countries/regions at similar stages of pre-elimination. The outcomes of the research will be used directly by these groups in developing national and regional policy and guidelines for disease surveillance and targeted control activities, and will help them to reach new targets of disease/transmission reduction. In addition, people working on the project will develop technical skills: laboratory, integrating data across disciplines, communication, advocacy, analysis and management, which could be transferred to other sectors, thus creating a highly competent and skilled workforce with the potential to provide economic gains for the country beyond the scientific research community.

In the longer term, the beneficiaries of the research will ultimately be the Philippines general population. In addition to malaria, filiariasis, schistosomiasis and leprosy are other diseases targeted for elimination in the Philippines. If the methods are shown to be effective at targeting reservoirs of infection and eliminating these pockets of transmission, they can be rolled out nationally and used to reduce and ultimately eliminate disease transmission in the Philippines. The Philippines population could be 'free' of a life threatening and debilitating disease, enhancing the health, well-being and quality of life of the nation. Reducing the burden of malaria could contribute to economic prosperity via the improved health and productivity of its population, and potentially through increased tourism and national mobility. If the study results can be generalised to other settings, then these long term impacts could be realised on a much wider, global scale.

Publications

10 25 50
 
Description Simple adjustments to surveillance at health facilities can improve knowledge of risk factors for malaria
Exploitation Route By examining all attendees at health facilities rather than just those seeking care and adding detailed molecular testing alongside geographical information allows relatively inexpensive improvements in identification of malaria foci
Sectors Education,Healthcare

 
Description Malaria remains one of the most important global health challenges. The economic and societal burden of malaria is great, and malaria and poverty are closely linked (SDG 1 & 3). In countries such as the Philippines, where persistent and coordinated control methods have achieved remarkable success in reducing the prevalence of malaria, our project provided further evidence that enhanced surveillance can capture reservoirs of sub-patent and residual infections that have the potential to drive transmission and undermine progress made. Our project made it as a finalist for the Newton Prize 2019. Through this Philippine-UK partnership, participants in the study (health facility attendees) and indirect participants (health facilities staff) benefited from increased awareness of malaria via their engagement with the study and consent procedures. When found to be infected, in addition to being treated at the health facility, the participants benefited from enhanced interventions in and around their homes. Beneficiaries of the research include the Philippines national public health officials, policy makers and malaria control programmes (SDG 11 and 17). We have conducted several stakeholder meetings in the Philippines in order to have an impact in the development of national and regional policy and guidelines for disease surveillance and targeted control activities. We have promoted local development and capacity building, through technology training and exchange of researchers (both UK and the Philippines). UK-based MSc students have been trained on geospatial mapping and drug-resistance monitoring. We are providing opportunities for young UK-based scientists to be part of a sustainable partnership with the Philippines. Similarly, Filipino researchers have visited the UK to train on serological and molecular analysis, genomics and geospatial mapping. In addition, we have conducted workshops on geospatial mapping (funded by the UKRI) and have participated in genetic epidemiology workshops (funded by the British Council). Our goal is to better enable Filipino scientists to undertake and disseminate malaria research using given tools, which will maximise the Philippines' impact on its own public health issues, development and economic growth. We have also promoted gender equality (SDG 5). Many of our health facility workers and laboratory researchers are females. Notably, our Philippines PI (FEE) was seconded for 1-year as Director of Research Support and Country Engagement of Asia Pacific Malaria Elimination Network (APMEN). The long-term beneficiaries of the research are the Philippine general population. As an extension, we are working on projects to extend our studies to other diseases targeted for elimination in the Philippines.
First Year Of Impact 2019
Sector Education,Healthcare
Impact Types Societal,Policy & public services

 
Description Challenge Grant
Amount £99,725 (GBP)
Funding ID CH160018 
Organisation The Royal Society 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2016 
End 11/2018
 
Description Challenge Grants
Amount £99,657 (GBP)
Organisation The Royal Society 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2017 
End 11/2018
 
Description Developing an Integrated and Enhanced Surveillance for Malaria and Lymphatic Filariasis for National Program Decision-Making to Accelerate their Elimination
Amount $200,000 (USD)
Organisation Global Solutions for Infectious Disease 
Sector Charity/Non Profit
Country United States
Start 01/2022 
End 01/2023
 
Description Immunological Memory to Malaria
Amount ¥1 (JPY)
Organisation Japan Society for the Promotion of Science (JSPS) 
Sector Public
Country Japan
Start 09/2019 
End 03/2023
 
Description Intensified surveillance for the control of soil-transmitted helminthiases in the Philippines
Amount £89,192 (GBP)
Funding ID 414710036 
Organisation British Council 
Sector Charity/Non Profit
Country United Kingdom
Start 02/2019 
End 02/2020
 
Title GeoODK for health facility-based survey data collection 
Description First time to introduce the GeoODK software for use in local surveillance activities: Tablet devices containing the Android application GeoODK was used for recording data in the health facility-based survey for ENSURE. The electronic form included the routinely collected patient data and spatial data (location of residence) was also collected. 
Type Of Material Biological samples 
Year Produced 2017 
Provided To Others? Yes  
Impact GeoODK makes spatial data collection possible for use in disease surveillance. This novel strategy has a potential to be integrated into health data management systems. 
 
Title Geospatial information for Malaria in Palawan 
Description Geospatial information for malaria in Palawan, and STH and schistosomiasis in 11 other provinces in the Philippines 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? Yes  
Impact NA 
 
Description LSHTM/ Nagasaki PhD funding funding awarded to Maria Lourdes Macalinao 
Organisation Nagasaki University
Country Japan 
Sector Academic/University 
PI Contribution LSHTM/ Nagasaki PhD funding awarded to Maria Lourdes Macalinao on malaria immunology (start date 2019)
Collaborator Contribution LSHTM/ Nagasaki PhD funding awarded to Maria Lourdes Macalinao on malaria immunology (start date 2019)
Impact PhD funding
Start Year 2019
 
Description Monitoring for HRP2 deletions 
Organisation QIMR Berghofer Medical Research Institute
Country Australia 
Sector Academic/University 
PI Contribution Provision of clinical malaria samples with detailed provenance
Collaborator Contribution Provision of standardised methodology
Impact None yet
Start Year 2017
 
Description 3. Workshop on Geospatial Data Management and Analysis 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Workshop on Geospatial Data Management and Analysis, including members of National Malaria Control Programmes from Asia, the Pacific and Africa, Manila 2019
Year(s) Of Engagement Activity 2019
URL https://healthgeolab.net/resources/workshops_trainings/malaria-gdmt-training-mnl-2019/
 
Description ENSURE feedback meetings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Purpose: to regularly give updates on the status of ENSURE activities to about 50 main stakeholders whose jurisdiction include all those at risk of malaria in the Philippines. ENSURE team made regular visits to health officers and other stakeholders to feedback the results of the data collection for ENSURE
Year(s) Of Engagement Activity 2016,2017,2018
 
Description Engagement with A-level students to consider careers in STEM 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Schools
Results and Impact Engagement with A-level students to consider careers in STEM.
I have been a mentor for 3 years.
Year(s) Of Engagement Activity 2017,2018,2019
URL https://www.windsor-fellowship.org
 
Description Geospatial mapping for infectious disease control 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The main focus was building research capacity to use open-source technology platforms and methods developed during the Newton Funded ENSURE project. During these activities, individuals from a range of institutions and countries were trained on the collection and analysis of geospatial data. Training materials developed were further publicised and made available online as part of a course on geo-enabling health information systems.
Year(s) Of Engagement Activity 2019
 
Description Interview by local newspaper 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Media (as a channel to the public)
Results and Impact Interview by local newspaper
Year(s) Of Engagement Activity 2019
 
Description LSHTM-UPD-PCHRD 2021 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Linking LSHTM with the University of the Philippines and the Philippine Council for Health Research and Development
Year(s) Of Engagement Activity 2021
 
Description Malaria Centre Webinar on Vaccines 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact This is a Malaria Centre-sponsored Webinar on Malaria Vaccines and Immune Responses
Year(s) Of Engagement Activity 2020
 
Description Participation in the Genetic Epidemiology of Infectious Diseases Workshop, July 2017, Philippines 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact This five-day Workshop will be held at the National Science Complex, University of the Philippines, Diliman, Quezon City, Philippines, aimed at early career researchers from the UK and the Philippines. This Workshop will bring together global experts on the study of genomic epidemiology of infectious diseases, particularly those affecting the Philippines. The Workshops aims to promote collaborations that will enhance the use of tools in bioinformatics, population genetics and statistics in infectious disease research.
Year(s) Of Engagement Activity 2018
URL https://pgc.up.edu.ph/index.php/2017/05/30/geid-philippines-2017-2/
 
Description Participation in the Genetic Epidemiology of Infectious Diseases Workshop, November 2018, Philippines 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact This Workshop was held at the National Science Complex, University of the Philippines, Diliman, Quezon City, Philippines, aimed at early career researchers from the UK and the Philippines. This Workshop will bring together global experts on the study of genomic epidemiology of infectious diseases, particularly those affecting the Philippines. The Workshops aims to promote collaborations that will enhance the use of tools in bioinformatics, population genetics and statistics in infectious disease research.
Year(s) Of Engagement Activity 2018
URL https://www.britishcouncil.ph/about/press/geid-omics-in-infectious-diseases
 
Description Participation in the Genetic Epidemiology of Infectious Diseases Workshop, October 2018, Malaysia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact This Workshop was held in Penang, Malaysia, and aimed at early career researchers from the UK and the Philippines. This Workshop will bring together global experts on the study of genomic epidemiology of infectious diseases, particularly those affecting the Philippines. The Workshops aims to promote collaborations that will enhance the use of tools in bioinformatics, population genetics and statistics in infectious disease research.
Year(s) Of Engagement Activity 2018
 
Description Participation in the Research Symposium of the Research Institute for Tropical Medicine, Philippines - December 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Research symposium aimed at presenting new data/outputs for the staff of the Research Institute for Tropical Medicine
Year(s) Of Engagement Activity 2018
 
Description Participation in the WISE Kick-off Meeting, Nagasaki University, Japan - March 2019 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact WISE kick-off meeting for the collaboration between LSHTM and Nagasaki University
Year(s) Of Engagement Activity 2019
 
Description Presentations 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact - Supargiyono, Asia-Pacific Malaria Elimination Network, Bangkok, September 2018
- Ralph Reyes, First Malaria World Congress, Melbourne, Australia 2018
- Maria Lourdes Macalinao, American Society for Tropical Medicine and Hygiene, New Orleans, October 2018
- Henry Surendra, American Society for Tropical Medicine and Hygiene, New Orleans, October 2018
- Julius Hafalla, Genetic Epidemiology of Infectious Diseases Workshop, Philippine Genome Centre, November 2018
- Chris Drakeley, Research Institute for Tropical Medicine Symposium, Manila, Philippines, December 2018
- Julius Hafalla, WISE Kick-off Meeting, Nagasaki University, March 2019
Year(s) Of Engagement Activity 2018,2019
 
Description Speaker - University of Sao Paolo 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Gave a talk to students at the University of Sao Paolo (online)
Year(s) Of Engagement Activity 2021
 
Description Speaking engagement with local TV station 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Media (as a channel to the public)
Results and Impact Speaking engagement with local TV station
Year(s) Of Engagement Activity 2019