Designing malaria surveillance strategies for mobile and
migrant populations in Nepal: a mixed-methods study
Full text: https://malariajournal.biomedcentral.com/track/pdf/10.1186/s12936-019-2791-1
Jennifer L. Smith†, Prakash Ghimire†, Komal Raj Rijal,
Alysse Maglior, Sara Hollis, Ricardo Andrade-Pacheco, Garib Das Thakur,
Nabaraj Adhikari, Upendra Thapa Shrestha, Megha Raj Banjara,
Bibek Kumar Lal, Jerry O. Jacobson and Adam Bennett
†Contributed
equally
Malaria Journal201918:158 https://doi.org/10.1186/s12936-019-2791-1
© The
Author(s) 2019
Received: 18 January 2019 Accepted: 23 April 2019 Published: 3 May 2019
ABSTRACT
Background
As malaria cases have
declined throughout Nepal, imported cases comprise an increasing share of the
remaining malaria caseload, yet how to effectively target mobile and migrant
populations (MMPs) at greatest risk is not well understood. This formative
research aimed to confirm the link between imported and indigenous cases,
characterize high-risk MMPs, and identify opportunities to adapt surveillance
and intervention strategies to them.
Methods
The study used a
mixed-methods approach in three districts in far and mid-western Nepal,
including (i) a retrospective analysis of passive surveillance data, (ii) a
quantitative health facility-based survey of imported cases and their MMP
social contacts recruited by peer-referral, and (iii) focus group (FG)
discussions and key informant interviews (KIIs) with a subset of survey
participants. Retrospective case data were summarised and the association
between monthly indigenous case counts and importation rates in the previous
month was investigated using Bayesian spatio-temporal regression models.
Quantitative data from structured interviews were summarised to develop
profiles of imported cases and MMP contacts, including travel characteristics
and malaria knowledge, attitudes and practice. Descriptive statistics of the
size of cases’ MMP social networks are presented as a measure of potential
programme reach. To explore opportunities and barriers for targeted malaria
surveillance, data from FGs and KIIs were formally analysed using a thematic
content analysis approach.
Results
More than half (54.1%)
of malaria cases between 2013 and 2016 were classified as imported and there
was a positive association between monthly indigenous cases (incidence rate
ratio (IRR) 1.02 95% CI 1.01–1.03) and the previous month’s case importation rate.
High-risk MMPs were identified as predominantly adult male labourers, who
travel to malaria endemic areas of India, often lack a basic understanding of
malaria transmission and prevention, rarely use ITNs while travelling and tend
not to seek treatment when ill or prefer informal private providers. Important
obstacles were identified to accessing Nepali MMPs at border crossings and at
workplaces within India. However, strong social connectivity during travel and
while in India, as well as return to Nepal for large seasonal festivals,
provide opportunities for peer-referral-based and venue-based surveillance and
intervention approaches, respectively.
Conclusions
Population mobility
and imported malaria cases from India may help to drive local transmission in
border areas of far and mid-western Nepal. Enhanced surveillance targeting
high-risk MMP subgroups would improve early malaria diagnosis and treatment, as
well as provide a platform for education and intervention campaigns. A
combination of community-based approaches is likely necessary to achieve
malaria elimination in Nepal.
Keywords
Imported malaria cases, Mobile migrant
populations (MMPs), Focus group discussion, Key informants’ interview, Malaria
elimination, Nepal
