Prevention of Indigenous Malaria Cases by Strengthening Migration Surveillance at Village Level in Purbalingga Regency, Central Java Province, Indonesia

Abstract

Purbalingga Regency had achieved zero indigenous malaria cases in April 2016, 3 years before the targeted deadline for elimination. Currently, the biggest threat to elimination efforts is the risk of local malaria reintroduction due to imported cases in the receptive areas. The aim of this study was to describe the implementation of village level migration surveillance and identify the areas for improvement in it. We performed the study in four malaria-free focus villages in Purbalingga Regency, i.e., Pengadegan, Sidareja, Panusupan, and Rembang, from March to October 2019. A total of 108 participants were involved in the processes. Data on malaria vector species, community mobility from malaria-endemic areas, and implementation of malaria migration surveillance (MMS) were collected. We use descriptive analysis for quantitative data and thematic content for qualitative data. Socialization of migration surveillance in Pengadegan and Sidareja villages has been carried out to the wider community, whereas in Panusupan and Tunjungmuli villages, it is still limited to neighbors. Communities in Pengadegan and Sidareja villages have participated in reporting the arrivals of migrant workers, and the village malaria interpreter conducts blood tests on all migrants. Community participation in reporting migrant workers arriving in Panusupan and Tunjungmuli villages is still low. Recording of migrant data reporting has been carried out by MMS officers, but malaria checks are only carried out before Eid al-Fitr to prevent importation of malaria cases. The program needs to strengthen the community mobilization and case-finding efforts.

Introduction

Malaria is one of the diseases that is a global and national priority in accordance with the global commitment of the World Health Assembly in 2007 and the regional commitment of the Asia Pacific Malaria Elimination Network in 2014.[¹] Indonesia is one of the malaria-endemic countries.[²] Of the 514 districts/cities in Indonesia, 197 districts were malaria-endemic areas in 2019.[³] The malaria control program is focused on achieving comprehensive and integrated malaria elimination. As of April 2017, 251 districts/cities have received malaria elimination certificates.[¹]

Purbalingga Regency is one of the malaria-endemic areas in Central Java Province. Malaria cases from 1996 to 2016 fluctuated and there were outbreaks in 2002 and 2010. Malaria elimination in Purbalingga Regency is targeted for 2020. District criteria that can be proposed to obtain malaria elimination certification are no cases of local transmission of malaria for the last 3 years and annual parasite incidence (API) <1 per 1000 population.[¹] From April 2016 to 2019, no indigenous cases were found and API <1 per 1000 population. Imported cases are still being reported in Purbalingga Regency, especially from the 406^th Infantry Battalion Candra Kusuma of the Army in 2021.

Currently, the biggest threat of elimination efforts is the risk of local malaria reintroduction due to imported malaria and the continuing receptivity due to the presence of malaria vectors.[^4,5] Population mobility and malaria importation are the key challenges to malaria elimination.[⁶]

Migrant workers and traveling outside the region in the short term are the risk factors for malaria transmission in Ethiopia and China.[^5,7] The majority of imported cases of malaria are caused by travelers becoming infected while traveling through endemic regions, depending in the malaria endemicity of the destination.[⁸] In each receptive area with high community mobility, stricter supervision is required. One of the efforts that can be made is through the implementation of migration surveillance at the village level. The village is an entry point border screening that can be used as an active surveillance strategy for detecting imported infections. Efforts that have been made by the Purbalingga Health Office and related sectors in controlling malaria include the issuance of a Village Regulation on Malaria Migration Surveillance (MMS) in; routine vector surveillance, screening of imported cases in the 406^th Infantry Battalion Candra Kusuma; and vector control with long-lasting insecticidal nets and indoor residual spraying. The purpose of this study is to describe the implementation of village level migration surveillance to prevent the reintroduction of local transmission and identify the areas for improvement ongoing malaria surveillance program.

Subjects and Methods

Design and setting

The study was conducted in free focus villages of malaria in Purbalingga Regency i.e., Pengadegan village, Pengadegan subdistrict; Sidareja village, Kaligondang subdistrict; Panusupan village, Rembang subdistrict; and Tunjungmuli village, Karangmoncol subdistrict.

This study used mixed methods with a concurrent nested strategy. Data collection was carried out between March and October 2019. This study was approved by the Health Research Ethics Committee, National Institute of Health Research and Development (LB.02.01/2/KE.329/2018).

Mapping of malaria receptive areas

The information needed to map the receptivity was malaria vector data and population mobility from malaria-endemic areas. Mosquito surveys were conducted using the human landing collection method from 18.00 to 06.00 h. Mosquito catching was carried out in March, August, and October 2019. The mobility of the community to and from malaria-endemic areas was recorded in a form by the MMS officer at the village level. Secondary data, such as imported malaria cases and history of mobility information, were obtained from the Health Office of Purbalingga and Public Health Center.

Focus group discussions and key informant interviews

There were 80 informants for the focus group discussion from four research locations, each location consisting of 10 informants (health cadres, village officials, and community leaders) and 10 informants (community groups: Fathers and mothers). A total of 28 key informant interviews, consisting of malaria program officer at the Purbalingga District Health Office, a malaria program officer from the public health center, 21 MMS officers, and two village malaria interpreters from Sidareja and Pengadegan.

Thematic analysis identified three main areas of discovery: (1) socialization of MMS to the community; (2) case finding; and (3) community participation in supporting MMS. Implementation of MMS was rated based on the following three criteria: (1) implemented optimally if migration surveillance is socialized to the wider community, case finding is carried out anytime migrant workers return home, and many people (>75%) have participated in reporting if there are migrant workers returning home; (2) suboptimal if migration surveillance is still limited to neighbors, case finding has only been done at specific times (such as before Eid al-Fitr), and not many people (50%) have reported on whether any migrant workers returned home.

Data analysis

Malaria case data were analyzed descriptively in the form of graphs and narrated. Information on malaria vector data and population mobility from malaria-endemic areas was made in the form of a receptive area map. Indonesian transcripts were then translated into English and formally analyzed using a thematic content analysis approach.

Results

There were 229 individual malaria case records reported through passive and active health facility-based surveillance data between 2016 and 2019. The last indigenous case was reported in Purbalingga in March 2016 from Sidareja and Pengadegan villages (10 cases). Overall, approximately 95.6% of malaria cases were classified as imported by district health officers based on their travel history.

During 2016–2019, the most imported malaria cases in Purbalingga Regency were reported in 2016, which was dominated by Infantry Battalion 406 Candra Kusuma, who finished their mission from Papua. The travel profile of imported cases shows that the overwhelming majority had traveled to Papua and Kalimantan for work [Table 1].

Table 1: Imported malaria cases in Purbalingga Regency in 2016–2019

Malaria vectors (Anopheles balabacensis and Anopheles maculatus) were still found in the four study sites [Figure 1] and there was the mobility of people from the malaria-endemic areas. An. balabacensis has been found both indoors and outdoors (0.04/man-h, respectively), while An. maculatus was mostly found resting in the cattle pens of Pengadegan village (14.71/man-h). MMS officers recorded the migrant workers who had just returned home, especially from malaria-endemic areas. Migrant workers came from various regions, especially outside Java, such as Sumatra, Riau Islands, Jambi, Kalimantan, Papua, Sulawesi, and West Nusa Tenggara [Figure 2].

Figure 1: Anopheles mosquito densities (per man-hour) in Pengadegan, Sidareja, Panusupan, and Tunjungmuli villages

Figure 2: Malaria vector map and population migration in Pengadegan, Sidareja, Panusupan and Tunjungmuli villages

MMS at the village level is carried out by MMS officers and village malaria interpreters/juru malaria desa (JMD) from the local community appointed by the village. The key findings are highlighted in Table 2.

Table 2: Results from key informant interview and focus group discussions

The implementation of MMS in Pengadegan and Sidareja villages has been going well. Socialization has been carried out to the wider community through the meetings in the community.

“…in the Neighborhood Association/Rukun Tetangga (RT) meeting, we have Muslim recitations (Muslims meeting called pengajian) around each subdistrict. I will socialize about malaria and continue to carry out surveillance so that I know when I go home, who should I report to…(MMS Sidareja officers).”

Many people (86%) have participated in reporting if there are relatives or neighbors who have just returned from wandering. The village malaria interpreter took blood preparations from all migrant workers who arrived from outside the Purbalingga Regency region, especially from endemic malaria areas, to detect the presence of Plasmodium.

“…People already know that when they come home they will be checked. Remind each other. I often travel in those areas. In each RT, there is a health cadre, also often tell. Please short message service… usually through WhatsApp group and I came to his house to pick up the ball to take a blood sample...(JMD Sidareja and Pengadegan).”

Socialization of MMS in Panusupan and Tunjungmuli villages has not yet reached the wider community; information is still limited to neighbors. MMS officers and village malaria interpreters socialize about the requirement to report for all migrant workers and their blood samples are taken, notably those from the malaria endemic areas. Not many people (47%) have participated in reporting the return of the migrant workers. Blood sampling at Panusupan was carried out by health cadres who were part of the MMS team. The implementation of MMS in Panusupan so far has only been carried out before the Eid al-Fitr. Meanwhile in Tunjungmuli, there has been no follow-up to the examination of blood preparations, only reporting the arrivals of migrant workers. Blood collection is carried out by public health center officers ahead of Eid al-Fitr.

“…All I do is share information with people through word-of-mouth… When I encountered my neighbors after returning from the malaria area, I visited them and encouraged them − at the very least − to check. Usually, a program to check blood samples is often only carried out for Eid al-Fitr., beyond that just noted. So I'm likewise confused if someone returns home following Eid al-Fitr…(MMS Panusupan Officer).”

“…Not just note migrant workers who just arrived back from endemic malaria…ideally, the blood sample should be taken immediately… just that the decision regarding who will take the blood sample has not yet been made… MMS officers or told to go to the Puskesmas… if the person has gone home, don't go home first, but go to the public health center first. But people who have recently arrived oppose to being told to go to the public health center. They say it's far away…(MMS Tunjungmuli officer).”

Discussion

Imported malaria cases in the Purbalingga Regency are inseparable from population mobility. This is related to the work of the community in Pengadegan, Sidareja, Panusupan, and Tunjungmuli villages, most of whom are migrant workers in malaria endemic areas in Java (Purworejo) and Outside Java., including Indonesian national army personnel from the 406^th Infantry Battalion Candra Kusuma who returned from a mission to maintain defense and security at the Indonesian border. Several districts in the province are malaria endemic areas. Even in Papua, a high malaria endemic area, no district has yet obtained a malaria elimination certificate.[³] The results of Prastiawan's research show that high mobility (≥3 times outside Java) has a 16,670 times greater risk of contracting malaria.[⁹] Population movements cannot be restricted, but it must be monitored, particularly in malaria-endemic areas.

The four villages we vulnerable to local malaria reintroduction due to the mobility of the population from and to endemic areas that can be the carriers of malaria parasites (Plasmodium sp.) into areas where malaria vectors are still found. As a result of these findings, an integrated vector intervention can be implemented, including increasing coverage for long-lasting insecticide-treated net and use of repellents to provide indoor protection, outdoor residual spraying to reduce Anopheles density in cattle pens, predatory fish, and larviciding.

Migration workers are vulnerable to malaria transmission factors because migrants who visit endemic areas have a greater risk of contracting malaria as compared to residents who live in these areas.[¹⁰] Population movements can increase the risk of transmission, reintroduction of malaria, and the spread of drug-resistant parasites to areas that are already free of malaria.[¹¹]

Migration surveillance at the village level is important to get prompt diagnosis and appropriate treatment. This activity is carried out mainly in malaria-endemic and receptive villages and the population migrates to malaria-endemic areas.[¹²] This is similar to the policy carried out in Sri Lanka.[⁴] The long-term success of any intervention or the adoption of fresh approaches to health improvement depends on community involvement. Communities must define, commit to, and believe in an attempt to eliminate malaria transmission.[¹³]

Malaria screening in Pengadegan and Sidareja villages was carried out all the time, but screening in Panusupan and Tunjungmuli villages are only carried out at certain times, such as before Eid al-Fitr. Furthermore, geographically, Anopheles breeding sites are still to be found, as well as the community culture of Takbir (the night before Eid al-Fitr) from the night to morning, which increases transmission.

MMS activities were also carried out in other places, including Bulukumba Regency, South Sulawesi Province,[¹⁴] Banjarnegara, Jawa Tengah,[¹²] Sabang, Aceh province, and Jembrana regency, Bali.[¹⁵] Malaria has been eradicated in Purbalingga since November 2019. Of particular concern are the threats to the health of individuals in Purbalingga who travel from or work to malaria-endemic areas, and the potential for local transmission to reintroduction in malaria-free areas when migrant workers return.

The implementation of MMS in Pengadegan and Sidareja villages was still ongoing in 2021. The village malaria interpreter received information about returning migrant workers from the migrants themselves and MMS officers, then taking a blood sample. Meanwhile, Panusupan village has progressed significantly, as shown by the recording of departing migrant workers and taking a blood sample by MMS officers every time. In Tunjungmuli village, there are now more malaria migratory surveillance officers, but only before Eid al-Fitr are migrant workers being recorded by MMS officers and taking a blood samples by public health center officers.

Conclusions

Based on indicators socialization, case finding, and community participation, we conclude that MMS in Pengadegan and Sidareja villages has been well implemented. Meanwhile, the implementation of migration surveillance in Panusupan and Tunjungmuli villages have not been optimal; socialization needs to be carried out to the wider community; case finding is carried out at anytime; and it motivates the community to participate in reporting of returning migrant workers.

Authors' contributions

NP and SPMW as main contributors in charge of concepts, designed the manuscript, literature search, and manuscript preparation. APK and LP, as member contributors performed data analysis and manuscript editing. All authors read and approved the final manuscript.

Financial support and sponsorship

This work was financially supported by District Health Office of Purbalingga, Central Java, Indonesia.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

Our sincere thanks to the Purbalingga District Health Office for providing the opportunity to conduct research collaborations. We would like to thank Pengadegan, Kaligondang, Karangmoncol, and Rembang Public Health Centers for assisting with the research. Our thanks to the migration surveillance officers and village malaria interpreters for supporting data collection.