Evaluation of the Global Fund-supported National Malaria Control Program in Papua New Guinea, 2009-2014.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is the major funaer Of the National Malaria Control Program in Papua New Guinea (PNG). One of the requirements of a Global Fund grant is the regular and accurate reporting of program outcomes and impact. Under-performance as well as failure to report can result in reduction or discontinuation of program funding. While national information systems should be in a position to provide accurate and comprehensive information for program evaluation, systems in developing countries are often insufficient. This paper describes the five-year plan for the evaluation of the Global Fund Round 8 malaria grant to PNG (2009-2014) developed by the Papua New Guinea Institute of Medical Research (PNGIMR). It builds on a complementary set of studies including national surveys and sentinel site surveillance for the assessment of program outcomes and impact. The PNGIMR evaluation plan is an integral part of the Global Fund grant. The evaluation program assesses intervention coverage (at individual, household and health facility levels), antimalarial drug efficacy, indicators of malaria transmission and morbidity (prevalence, incidence), and all-cause mortality. Operational research studies generate complementary information for improving the control program. Through the evaluation, PNGIMR provides scientific expertise to the PNG National Malaria Control Program and contributes to building local capacity in monitoring and evaluation. While a better integration of evaluation activities into routine systems would be desirable, it is unlikely that sufficient capacity for data analysis and reporting could be established at the National Department of Health (NDoH) within a short period of time. Long-term approaches should aim at strengthening the national health information system and building sufficient capacity at NDoH for routine analysis and reporting, while more complex scientific tasks can be supported by the PNGIMR as the de facto research arm of NDoH.

Epidemiology of malaria in the Papua New Guinean highlands.

OBJECTIVES: To conduct an in-depth investigation of the epidemiology of malaria in the Papua New Guinea (PNG) highlands and provide a basis for evidence-based planning and monitoring of intensified malaria control activities. METHODS: Between December 2000 and July 2005, 153 household-based, rapid malaria population surveys were conducted in 112 villages throughout the central PNG highlands. The presence of malaria infections was determined by light microscopy and risk factors assessed using a structured questionnaire.The combined dataset from all individually published surveys was reanalysed. RESULTS: The prevalence of malaria infections in the different surveys ranged from 0.0% to 41.8%(median 4.3%) in non-epidemic surveys and 6.6% to 63.2% (median 21.2%, P < 0.001) during epidemics. Plasmodium falciparum was the predominant infection below 1400 m and during epidemics, Plasmodium vivax at altitudes >1600 m. Outside epidemics, prevalence decreased significantly with altitude, was reduced in people using bed nets [odds ratio (OR) = 0.8, P < 0.001] but increased in those sleeping in garden houses (OR = 1.34, P < 0.001) and travelling to highly endemic lowlands (OR = 1.80, P < 0.001). Below 1400 m, malaria was a significant source of febrile illness. At higher altitudes, malaria was only a significant source of febrile illness during epidemic outbreaks, but asymptomatic malaria infections were common in non-epidemic times. CONCLUSIONS: Malaria is once again endemic throughout the PNG highlands in areas below 1400­1500 m of altitude with a significant risk of seasonal malaria outbreaks in most area between 1400­1650 m. Ongoing control efforts are likely to result in a substantial reduction in malaria transmission and may even result in local elimination of malaria in higher lying areas.

Epidemic malaria in the highlands of Papua New Guinea.

As part of a larger study into the epidemiology of malaria in the highlands of Papua New Guinea, outbreak investigations were carried out at the end of the 2002 rainy season in 11 villages situated between 1,400 and 1,700 meters above sea level that had reported epidemics. Locations and timing of these epidemics corresponded largely to those reported in the pre-control era of the 1960s and 1970s. On average, 28.8% (range = 10.3-63.2%) of people in each of the 11 villages were found to be infected with malaria. Plasmodium falciparum accounted for 59% of all identified infections and P. vivax for 34%. The majority (53%) of infections were symptomatic. Although symptomatic infections were most common in children 2-9 years of age (36%), even in adults a prevalence of 20% was observed. A comparison with earlier non-epidemic data in three of the villages without easy access to health care showed markedly increased levels of morbidity, with 6-10-fold increases in parasite prevalence, a 3-fold increase in both measured and reported fevers, and a 12-fold increase in enlarged spleens. The average hemoglobin levels were reduced by 2.3-3.5 g/dL, with a concurrent increase in moderate to severe anemia (hemoglobin level < 7.5 g/dL) from 0.0-3.3% to 3.8-18.4%. These massive increases in morbidity have devastating impact on the affected communities and highlight that malaria epidemics are a serious and increasing public health problem in the highlands of Papua New Guinea.

The epidemiology of malaria in the Papua New Guinea highlands: 2. Eastern Highlands Province.

The epidemiology of malaria in Eastern Highlands Province (EHP) is characterized by generally very low-level or no local malaria transmission but a considerable risk of epidemics. In non-epidemic situations, parasite prevalence was under 5% in all but one area, Lufa Valley, where P. vivax was the most common parasite (prevalence rate of 58%). During epidemics, however, 23% (range 8-63%) of people were infected, with P. falciparum the predominant parasite. Mixed infections were very common (12%) but P. malariae and P. ovale were rare. Outside epidemics, malaria was only a minor source of febrile illness and enlarged spleens and anaemia (haemoglobin level < 7.5 g/dl) were virtually absent. However, epidemics were associated with a high incidence of relatively severe morbidity, both in terms of fevers and moderate to severe anaemia. Epidemic prevention, surveillance and response therefore are priorities in malaria control in EHP.