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

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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.