Nghiên cứu thực trạng nhiễm ký sinh trùng sốt rét và biện pháp kết hợp quân dân y trong phòng chống bệnh sốt rét cho người dân vùng biên giới tỉnh đắk nông (2016 2018

MINISTRY OF EDUCATION AND TRAINING
MINISTRY OF HEALTH
NATIONAL INSTITUTE OF MARIOLOGY PARASITOLOGY AND ENTOMOLOGY

TRAN QUANG HAO

SITUATION RESEARCH OF INFECTION OF MALARIA PARASITE AND CIVIL-MILITARY
COORDINATION IN MALARIA PREVENTION FOR CIVILS IN THE BORDER OF DAK
NONG PROVINCE
(2016-2018)

Major: Parasitology
Code: 62 72 01 16

ABSTRACT OF DOCTORAL DISSERTATION

HANOI - 2019


THE DISSERTATION PRESENTED IN NATIONAL INSTITUTE OF MARIOLOGY PARASITOLOGY
AND ENTOMOLOGY

Advisors
1. Assoc.Prof.Dr. Ho Van Hoang
2. Assoc.Prof.Dr. Nguyen Van Ba

Committee member 1:
Committee member 2:
Committee member 3:

The dissertation will be defended in National Institute Of Mariology Parasitology And Entomology

At

hour

Date month

Year 2019

The thesis can be found at:
1. National Library
2. Military Medical Library


1

INTRODUCTION
Malaria is still a common disease in many parts of the world and tropical countries like Vietnam, greatly
affecting human health and causing great economic and social losses.
In Vietnam, central region - Central Highlands (MT-TN) has seen the highest prevalence of malaria
nationwide: accounting for nearly 50% number of malaria patients each year, 75%, malaria parasites (malaria
parasites) ), 80% total cases of malignant malaria and malaria deaths of the country’s. Most provinces with
communes and districts bordering Laos or Cambodia have a higher proportion of patients with malaria than
other localities in the country.
Dak Nong is a province in the Central Highlands region. Although the malaria situation in the province has
improved a lot in recent years, the incidence and risk of malaria remains high. The rate of malaria patients and
parasites per 1,000 people; Malaria mortality per 100,000 people has been still among the provinces with the
highest malaria incidence in the country. Epidemiological situation of malaria in border areas of Dak Nong and
Cambodia is often complicated, parasites often spread easily between villages on both sides of the border..
Up to now, research on malaria in our country and the Central Highlands has focused on malaria
epidemiology, vector prevention, drug resistance, knowledge-attitude-practice. There are no studies on

managing and monitoring models, early detection and treatment of malaria patients in border areas. Therefore,
we implemented the project "Studying the actual situation of infection of malaria parasite and civil-military
coordination in malaria prevention for civils in the border of dak nong province.
1. Research objectives:
1. Describe the current situation of infection with malaria parasites, species composition and transmission
role of Anopheles in the border region of Dak Nong province (2016).
2. Assess the effectiveness of civil-military coordination in malaria prevention for people in the border
region of Dak Nong province.

2. New contributions of the thesis
- Describe the current situation of malaria parasite infection of the community in the border areas of Dak
Nong province (2016).
- Describe the species composition, density and rate of Anophenes mosquitoes infected with malaria
parasites and some risk factors for malaria in the Vietnam-Cambodia border.
- Evaluate the effectiveness of civil-military coordination in malaria prevention for people in the border
area.
3. Outline: The thesis includes 122 pages and 4 chapters:
Introduction: 02 pages
Chapter 1. Literature review: 28 pages
Chapter 2 Research subjects and methods: 28 pages
Chapter 3 Research results: 32 pages
Chapter 4 Discussion: 29 pages
Conclusion: 02 page
Suggestion: 01 page
References: 126 documents (98 Vietnamese papers, 32 English papers).
CHAPTER 1
LITERATURE REVIEW
1.1. Epidemiology of malaria
In 2016, around 3.2 billion people in the world and nearly 50% of the population were at risk of malaria.
Migrant laborers traveling to endemic areas, children <5 years old, and pregnant women are high-risk groups

that are affected by the high burden of malaria.


2

According to WHO reports, malaria prevalence in Southeast Asia is about 7% and accounts for 6% of all
malaria deaths in 2016, concentrated mainly in remote mountainous areas and along the borders of Laos,
Myanmar, and Cambodia. , Thailand and Vietnam. In particular, the Greater Mekong Subregion (GMS) is
facing the emergence and spread of artemisinin resistance, despite having used artemisinin-based combination
therapies (ACTs) - the first-line drug to treat malaria at present.
The 2015 Report on malaria prevention and control showed that the total number of malaria patients
nationwide decreased by 30.9% in 2015, the prevalence of malaria per 1,000 people decreased by 31.2%
compared to the same period in 2014. The number of patients with malignant malaria decreased by 56.16% and
only found 3 death cases due to this disease.

Anually, the number of patients infected and dead from malaria in border provinces is higher than other
provinces in the country, of which the highest incidence of malaria is in provinces adjacent to Cambodia,
followed by provinces bordering Laos. According to statistics for the period 2006-2010, the number of malaria
patients in border provinces accounted for 63.7% of the total number of malaria patients in the whole country
(45,191 / 70,910). The number of malaria deaths in these provinces accounted for about 70% of all malaria
deaths nationwide (14/20).
1.2. Current situation of malaria prevention
Difficulties in technical expertise: Since 1960 when chloroquine-resistant P.falciparum was found in South
America (Brazil), Thailand, Vietnam ... the phenomenon of chloroquine-resistant P.falciparum was spreading
rapidly. By 2000, there were 100 species resistant to this drug..
Economic, social and financial constraints: natural disasters, epidemics, wars, and underdeveloped
production in countries with malaria, especially in under-developing and developing countries.
The health system, especially the grassroots health care system is inadequate and weak, local personnel
responsible for malaria control are not sufficient in number and are still unqualified.
Border areas are often underdeveloped and encouters a lot of contrainst in accessing due to the

characteristics of hilly areas, underdeveloped infrastructure and far from administrative centers. Malaria
situation in Southeast Asian countries is often related to remote and mountainous areas, which is a reason that
malaria incidence is often higher and more difficult to control, especially in border areas where ethnic
minorities inhabit. Especially in recent years, drug-resistant parasites have emeged in many provinces with
different levels of resistance but most commonly in the Central - Highlands and Southeast regions.
1.3. Civil-military coordination in malaria prevention:
In 2001, according to Decision No. 1026 / QD-TTg, the Prime Minister approved the project on Civilmilitary coordination to protect and care for civil’s health and serve national defense and security in the 20012010 period. The specific objective of the project is to build and consolidate civil and military medical stations
and centers in border areas and islands, fulfil the needs of protection, care civil's and soldiers’ health; improve
the capability of qualified medical personnels to react in time in urgent cases: natural disasters and emergency
situations; and propose to the Government about mechanisms and policies for civil and military cooperation in
health sector and develop health human resources in extremely remote areas.
In order to enhance the effectiveness of malaria prevention, the Ministry of Health and the Ministry of
Defense issued Joint Circular No. 05/2003 / TTLT-BYT-BQP on April 29th , 2003, guiding the work of civil
and military cooperation for malaria prevention The Ministry of Health issued Decision No. 246 / QD-BYT of
February 2, 2004 on the establishment of a Subcommittee on civil and military cooperation in malaria
prevention.
Cvil and military medical coordination in Dak Nong province has been implemented since May 2005with
many practical activities, which has contributed significantly to the accompaniment with the health sector in
caring and protecting the health of the citizens, laying a solid foundation of community healthcare system in
remote and border areas.


3

CHAPTER 2
RESEARCH SUBJECTS AND METHODS
2.1. Research subject, time and place
2.1.1. Research subjects
- People living in 4 communes bordering with Cambodia in Dak Nong province regardless of gender, age,
or ethnicity.

- Malaria patients.
- Plasmodium.
- Mosquitoes transmitting malaria collected at research sites.
- Medical system of civil- military cooperation: military medical outpost, the 16th Corps infirmary, the
village and commune health stations.
2.1.2. Research place:
- Field sites: The study was conducted in 4 communes bordering Cambodia, including: Quang Truc
commune (Tuy Duc district); Thuan Hanh commune (Dak Song district); Dak Lao (Dak Mil) and Dak Wil (Cu
Jut District).
- Labo research location: (1) Dak Nong Preventive Medicine Center: Performing techniques for malaria
parasite by optical microscopy and mosquito identification; (2) Military Medical Research Institute - Military
Medical University implementing ELISA technique.
2.1.3. Research time:
The study was conducted over 3 years from 2016 to 2018..
- The study describes the characteristics of Plasmodium infection in the border area of Dak Nong province
in 2016. Investigation of indicators of malaria: Conducted in 4 rounds at 4 different times of the year: Dry
season (April / 2016), at the beginning of the rainy season (June 2016), mid- rainy season (August 2016) and
the end of the rainy season (October 2016). Survey and assessment of KAP: April 2016. Investigation of
Anopheles mosquito: mid-rainy season (August 2016).).
- Intervention study: conducted from 1/2017 - 6/2018, including the following stages: (1) Preparation stage:
11/2016 - 12/2016; (2) Implementation and intervention stage: 1/2017 - 3/2017; (3) Maintenance stage: From
4/2017 - 6/2018; (4) Evaluation of malaria indicators stage (4 rounds): August 2017, October 2017, April 2018
and June 2018. Survey and assessment of KAP: 4/2018
2.2. Research desgin:
- Descriptive cross-sectional study (2016): Investigate and evaluate characteristics of Plasmodium in the
community and species composition, density, and proportion of malaria vectors. Investigate and evaluate
knowledge and practices of civils from border areas in malaria prevention and control. The study conducted
surveyed 4 times a year
- Intervention study (January 2017 - June 2018): Controlled community intervention: Implementing civilmilitary cooperation in medical sector in Quang Truc commune of Tuy Duc district and Dak Lao commune of
Dak Wil district (control). In the intervention commune, implementing civil-military cooperation measure in

malaria control, in the control commune, carrying out routine malaria prevention activities. Results of pre- and
post comparisons between intervention commune and control commune. The intervention results were
investigated at 4 times of the year as pre-intervention.
2.3. Content and data collection methods
2.3.1. Descriptive study
2.3.1.1. Sample size
- Sample size of the malaria prevalence survey (sample size for the cross-sectional survey district): Apply
of the sample size calculation formula for a prevalence of malaria.
n =Z

2
1 / 2

(1  p )
p 2


4

n: Minimum sample size;
p: Percentage of malaria patients choosing p = 0,15;
Z1-/2: Reliability coefficient, for 95% confidence interval Z1-/2 = 1,96;
ε: Relative error chossing ε = 0,13.
With the values selected, sample size calculated as 1289. In fact, it was conducted on 1320 people in April 2016.
Because malaria is a seasonal disease, the study conducted three additional surveys in 2016: June 2016
surveyed 1300 people, August 2016 surveyed 1320 people and October 2016 surveyed 1310 people
- Sample size of Knowledge, Attitudes and Practices of malaria prevention (KAP):
Conduct community-based malaria knowledge and practice surveys in April 2016, with households
surveyed for malaria incidence in dry season. Determine the number of households surveyed = sample size of
the number of people surveyed / average population size (provided by local authorities). Household size in 4

studied communes is 4.1 person / household. Total number of households chosen to do KAP research in
malaria prevention = 1320 / 4.1 = 322 households. At each household, one representative will be selected for
the interview, the sample size of the interviewee corresponds to the sample size of the household to be
surveyed.
- Sample size of insect surveyed: conducted in 3 villages with the highest number of malaria patients in
each commune and conducted in the middle of the rainy season. (8/2016).
- Sample size for Anopheles species composition: All collected adult Anopheles mosquitoes were collected to
identify Anopheles species at the study sites..
- Sample size for the ELISA technique to determine the role of vectors: All adult mosquitoes after
identification will have themselves dried, stored in Eppendoft tube for ELISA testing in the laboratory to
determine the rate of plasmodium infection of vectors..
2.3.1.2. Indicators and data collection methods
a, Indicators for evaluation:
- Indicators of clinical malaria:
+ Percentage of patients having fever (%).
+ Percentage of patients with enlarged spleen (%).
- Indicators of characteristics of Plasmodium infection in the community
+ Indicators of clinical malaria: Percentage of clinical malaria cases by total number of people examined.
+ Slide Positive Rate: Total positive for Plasmodium(+) x 100 / Total slides examined (total number of
people surveyed for blood tests).
+ Plasmodium specification: percentage of each type of plasmodium over the total
+ Gametocyte rate: The percentage of gametocyte of each species over total slide positive.
+ Ratio of plasmodium by gender, age, farming practices, border exchanges.
- Indicators in Anopheles mosquito research.
+ Composition and ratio of Anopheles species.
+ Anopheles mosquito collected by trap.
+ Percentage of mosquitoes infected with malaria parasites by ELISA test.
+ Species composition in 3 habitats: In forest, forest edge and in village.
+ Mosquito density by these methods: outdoor light trap; Indoor light trap; each person indoor; each person
outdoor; daylight house inspection; nighttime house inspection; livestock inspection.

- - Indicators of knowledge - attitude - practice on malaria prevention in the community:
+ Ratio of people who know mosquitoes is the cause of malaria transmission..
+ Ratio of people who know Plasmodium is the cause of malaria.
+ Ratio of people who know malaria is life-threatening.


5

+ Ratio of people who know to sleep with mosquito net to prevent malaria.
+ Ratio of people who go to medical center when they have malaria.
+ Ratio of people sleeping the forests.
+ Ratio of people who have regular cross-border exchanges.
+ Ratio of people sleeping with mosquito nets near mountainous or forested areas.
+ Ratio of people who have regular cross-border exchanges sleeping with mosquito nets.
+ Ratio of people who have regular cross-border exchanges using hammocks with net mosquito.
b, Techniques used in the study
- Clinical examination discovering fever and malaria patients.
- Technique of thick blood smear test to find malaria parasites: Blood smear slide test to discover malaria
parasites by finger pricking, using Giemsa stain technique and microsopy.
- Direct interview technique.
- Anopheles mosquito discovering technique: The method of collecting mosquitoes follows the procedures
of the World Health Organization (1994) and National Institute of Malariology, Parasitology and Entomology
(NIMPE) (2011).
- Discovering Anopheles mosquito by habitats: 3 habitats including: in the forest, in the edge of the forest,
in the village
- Anopheles mosquito and larvae identification technique: Use Keys to Identify the Anopheles Mosquitoes
(Adults-Pupae-Lavae) of National Institute of Malariology, Parasitology and Entomology (NIMPE) (2016).
- ELISA technique to identify mosquitoes infected with malaria parasites: according to SOP of the National
Institute of Malariology, Parasitology and Entomology (2016)
2.3.2. Intervention research:

2.3.2.1. Sample size
- Sample size of Community-based vector control intervention research:
This is a community-based intervention study. The intervention results were assessed by comparing before
and after the intervention. Therefore, the sample size for this intervention study was estimated by using the
formula of estimating the sample size for the intervention study comparing 2 ratios as follows:

Z 2 ( ,  )

n=

p1 (1  p1 )  p2 (1  p2 )
( p1  p2 ) 2

Therein:
n: minimum sample size
p1: estimated percentage of people with malaria. p1 = 0,15 [80].
q1 = 1-p1 = 1- 0,15 = 0,85
p2: The assumption is that interventions may reduce the proportion of malaria patients in the commune after
the intervention, estimated to be 0,1% (reduced by 5% compared to before the intervention). So, choose p2 =
0,1. q2 = 1-p2 = 1- 0,1 = 0,9
Z1-α/2 = 1,96 (value of the normal distribution for confidence level α =5%)

Z 2 ( ,  ) = 3,8
Substituting the figures in the above formula, we have: n = 330 people. Actual sample size investigated:
Research
commune
Quang Truc
Dak Lao

8/2017

10/2017

332
332

332
332

4/2018

6/2018

338
338

328
326

Number of
examination
1330
1328


6

Sample size of the survey, assessment of knowledge, attitudes and practices of malaria prevention of people
post-intervention: The sample size of KAP survey is equal to the sample size of KAP survey pre- intervention,
Quang Truc commune: 82 households, Dak Lao commune: 82 households.

2.3.2.2. Assessing the effectiveness of civil-military coordination in malaria prevention and control
* Indicators of Assessing the effectiveness of civil-military coordination in malaria prevention and
control in border areas:
- Management Evaluation Index
Number of people with malaria symptoms in household.
Number of family members sleeping with mosquito nets.
Number of households with a fire stove.
Number of households with livestock barn under the floor.
Number of households moving cattle sheds 50 metres far from home
Number of households without bushes 50m far from the house.
Number of people who go to and sleep in Cambodia.
Number of people come back from Cambodia with malaria.
Number of Cambodians who sleep at home, some have malaria.
Number of people sleep in forest areas.
- Indicator to evaluate the effectiveness of detection and treatment in the community
Number and percentage of malaria patients and malaria parasites detected and examined in the
community.
Number and percentage of people with fever and malaria parasite are consulted, monitored, treated for
malaria.
Number and percentage of people suffering from malaria due to border exchanges (to Cambodia) are
detected, treated and managed.
Number and incidence of malaria caused by going to forest and sleeping here are detected and managed in
the community.
- Indicators on communication and health education about malaria prevention:
Rate of people who have thorough knowledge about malaria prevention; Rate of people who have right
attitude for malaria prevention; Rate of people who have good practice in malaria prevention.
- Indicators for coordination of malaria prevention in border areas
Number of people, number of times, number of nights staying in Cambodia.
Number and prevalence of malaria (%).
Number of Cambodians suffering from malaria, the number of people being treated for malaria at

health facility, at Vietnamese families.
Number and prevalence of malaria (%).
Prevalence of malaria in villages located in both sides of the border.
Number of malaria patients and parasites detected and treated in villages located in both sides of the
border.
* Indicator to evaluate the results of interventions:
- Prevalence of malaria and plasmodium.
- Ratio of correct response about knowledge, attitude, practice, prevention of malaria vectors.
- Calculating effectiveness index of interventions

Intervention effectiveness index of intervention group


7

Effectiveness of intervention
EI = CSHQ PCT- CSHQ PCh
Study on the current situation of malaria parasite infection and the
civil-military medical coordination in the malaria control in Dak
Nong province
Intervention study of the
coordination of civil-military
medical coordination in malaria
control

Descriptive study of the current
status of malaria parasites infection

Quang Truc
commune, Tuy

Duc district

Thuan Hanh
commune, Dak
Song district

Dak Lao
commune, Dak
Mil district

Dak Wil
commune, Cu Jut
district

- Cross-sectional survey and evaluation of malaria indicators (April, June, August and
October).
- KAP investigation.
- Mosquitoes investigation.
- Determining the rate of mosquitoes infected with malaria parasites.

- Describe and analyze the indicators of malaria: malaria patients, malaria parasites by
age, gender, geography, farming practices, border exchanges.
- Assess knowledge, attitudes and practices of malaria control in border areas.
- Description of species composition, mosquito density
- Determining the rate of mosquitoes vectors.

Quang Truc
commune, Tuy
Duc district
(Intervention)

- Civil-military cooperation in
health sector in detection and
treatment of malaria, management
of malaria patients, management of
migrants moving across borders.
- Health education communication.
- Civil-military cooperation in
implementing malaria control
measures according to the
approved plan.

Dak Lao
commune, Dak
Mil district
(Control)

Implementing malaria
control measures
according to the
approved plan.

Evaluation of intervention effectiveness (in 1 year of
intervention, 2017-2018):
- Compare survey results 1 year ago and 1-year survey results
during the intervention.
- Comparison of intervention commune - control commune.

Figure 2.1. Research design diagram

8

CHAPTER 3
RESEARCH RESULT
3.1. ACTUAL SITUATION OF PLASMODIUM INFECTION IN THE COMMUNITY IN THE
BORDER AREAS OF DAKNONG PROVINCE:
3.1.1. Actual situation of malaria infection in the community in the border area of Daknong province
Table 3.1. Ratio of Malaria prevalence and enlarged spleen (n=1320)
Malaria patients
Enlarged Spleen
Number
(Clinical malaria +
(Level 1)
Research
of
M.Parasite)
Communes
patients
Percentage
Percentage
examined NUmber
Number
(%)
(%)
Quảng Trực
335
9
2,69
3

0,90
Thuận
325
5
1
0,31
Hạnh
1,54
Đắk Lao
335
6
1,79
2
0,60
Đắk Wil
325
4
1,23
2
0,62
Total
1320
24
1,82
8
0,61
Research conducted to detect malaria patients in the community in the dry season (April 2016) showed
that, with 1320 people examined in 4 border communes, 24/1320 people were diagnosed with malaria,
accounting for 1, 82%.
Table 3.2. The percent of people testing positive for the malaria parasite (n=1320)

Number of tests
Positive
Commune
n
%
Quảng Trực
335
8
2,39
Thuận Hạnh
325
4
1,23
Đắk Lao
335
5
1,49
Đắk Wil
325
3
0,92
Total
1320
20
1,52
According to the survey in the dry season in 2016 (4/2016), the percent of people living in the border areas
of Dak Nong province positive for malaria parasite (+) accounted for 1.52%. In particular, the highest (+) rate
is in Quang Truc and Dak Lao communes..
Bảng 3.3. Distribution of malaria parasites for people who sleep at the forests (n=1320)
Number of

Number of who
Number of
Rate of
Communes
patients examined sleep at the forests Plasmodium (+) Plassmodium
Quảng
335
321
8
2,49
Trực
Thuận
325
257
4
1,56
Hạnh
Đắk Lao
335
301
5
1,66
Đắk Wil
325
325
3
0,92
Cộng
1320
1204

20
1,66
The rate of malaria parasites among who sleep at the forests is 1.66%. In particular, the highest rate is in
Quang Truc commune (2.49%) and the lowest is Dak Wil commune (0.92%).
Table 3.4. Distribution of malaria parasites among cross-border people (n=1320)
Number of who do not have Number of who have have
Communes
Number of
cross-border exchange
cross-border exchange
patients
Rate of parasite
Rate of parasite (+)
examined Number
Number
(+) (%)
(%)
Quảng Trực
335
228
4 (1,76)
107
4(3,74)
Thuận Hạnh
325
122
1 (0,82)
203
3(1,48)
Đắk Lao

335
226
2 (0,88)
109
3(2,75)
Đắk Wil
325
247
2 (0,81)
78
1(1,28)
Tổng
1320
823
9 (1,10)
497
11(2,21)
p
<0,05


9

Tỷ lệ %

The rate of malaria parasites among people who have cross-border exchanges (2.21%) is much higher in
the group without border people (1.10%). The difference was statistically significant with p <0.05..
The highest rate of malaria parasites among border people is in Quang Truc commune (3.74%), followed
by Dak Lao commune (2.75%), the lowest is Dak Wil commune (1 , 28%).

8
7
6
5
4
3
2
1
0

7.58
6.67

6.46 6.67
5.45

5.76

4.62
3.38

6.15

5.15

3.69
3.08

2.39
1.23 1.49

0.92

Dry season

Early-wet season

Mid-wet season

Late-wet season

Mùa

Quảng Trực

Thuận Hạnh

Đắk Lao

Đắk Wil

Hình 3.1. Occurrence of malaria parasites by season (n=1320)
The results of cross-sectional survey at 4 seasonal points in 2016 demonstrated that the highest rate of
malaria parasites in the border areas of Dak Nong province was highest at the end of the rainy season (6.72%),
followed by the middle of the rainy season is 5.76% and the lowest is in the dry season with 1.52%. The overall
prevalence of malaria parasites in the whole border area of Dak Nong province is 4.42%. The difference
between seasons is statistically significant with p <0.05.
The percentage of Plasmodium in Quang Truc commune is higher than other border communes of Dak
Nong province in all seasons..
Table 3.5. Real situation of malaria infection along border lines after 4 surveys

Not going through
Controlled via
Plasemodium border gate (border
border gate
Communes
trade)
(+)
Number
%
Number
%
Quảng Trực
39
29
74,36
10
25,64
Thuận Hạnh
21
13
61,90
8
38,10
Đắk Lao
22
15
68,18
7
31,82

Đắk Wil
24
14
58,33
10
41,67
Total
106
71
66,98
35
33,02
p
<0,05
Analysis of the number of malaria parasites infection cases in people who have regular cross-border
exhcange indicated that the rate of malaria parasites infection among people who follow border trade (66.98%)
is much higher than that of people who follow border gate (33.02%). The difference was statistically significant
with p <0.05.
Table 3.6. Percentage of malaria parasites having gametocytes after 4 surveys
Communes
Total
parasites
Quảng Trực
Thuận Hạnh
Đắk Lao
Đắk Wil
Total

70
54

58
50
232

P.falciparum
Number of
TS gametocyte
(%)
35
20(57,14)
29
10(34,48)
30
16(53,33)
26
11(42,31)
120
57(47,50)

P.vivax
Number of

Coordination

TS

gametocyte

TS

31
23
24
21
99

(%)
31(100,00)
23(100,00)
24(100,00)
21(100,00)
99(100,00)

Number of gametocyte
(Frequency)

4
2
4
3
13

3/4
2/2
3/4
3/3
9/13

All patients infected with P.vivax parasites have gametes. The proportion of samples infected with P.
falciparum parasites with gametocytes accounted for 47.50%. This percentage is higher in Quang Truc and Dak

Lao communes.


10

3.1.2. Results of survey on species composition, density and proportion of Anopheles mosquitoes at the
fieldsites

Figure 3.2. Distribution of Anopheles species in 4 communes in the border area of Dak
Nong province
The total number of Anopheles species collected in the border region of Dak Nong Province is 21. In
Quang Truc, the highest number of Anopheles species is 19, and in Thuan Hanh, 18 species are collected. The
number of Anopheles species collected in Dak Lao is 16 and Dak Wil is 14.
In the Dak Nong border area, there are five species on the list of main and secondary vectors of malaria in
Vietnam: the two main malaria vectors are An. dirus and An. minimus. Besides, there are 3 secondary vector
species in mountainous areas: An. aconitus, An. jeyporiensis and An. maculatus. The highest proportion of
species composition is An. vagus (17.42%), followed by An. sinensis (15.91%) and An. peditaeniatus (15.97%).
18
An. aconitus

15.7

16

An. dirus
14

12.87

An. jeyporiensis

12

An. maculatus

10

An. minimus

9.12

8
6
4

2.86

2.33
2

0.85

2.8
0.12

2.33

2.07

1.43

0.12

0

0

0

0
In the forests

Forest edge

In the village

Figure 3.3. Anopheles distribution based on habitats in 4 communes in Dak Nong border
area
In the forest habitat, there are 13 species of Anopheles species, including 05 main and secondary malaria
vectors with the rate of An main vector. dirus is very high (15.70%); At the edge of the forest, the number of
Anopheles species is the highest among 03 habitats (21 species), including 05 main and secondary malaria
vectors with a small rate; In the village, 13 species of Anopheles are discovered, and only 02 secondary malaria
vectors are present with a slight ratio and there is no main vector An minimus, An. dirus.


11

Table 3.7. Number of batches of mosquitoes infected with malaria parasites in the study sites
Plasmodium
Infection rate
Number

Plus
(Number of batches (+))
of
(+)
batches (+)Pf (+)Pv210 (+)Pv247
An. aconitus
10
0
0,0
An. dirus
60
1
1
2
0,84
An. jeyporiensis
6
0
0,0
An. maculatus
44
0
0,0
An. minimus
12
4
4
14,28
Cộng
132

4
1
1
6
The secondary vector An. aconitus, An. Jeyporiensis, An. maculatus and An. harrisoni have not been detected
infection with malaria parasites; meanwhile, the two main vectors of malaria are An. dirus and An. minimus are
positive ELISA with both parasite species P. falciparum and P. vivax
Species

Number of
mosquitoes
examined
660
238
513
640
28

3.1.3. Knowledge and practice of malaria prevention and control border people in Dak Nong province
Table 3.8. The ratio of sleeping with and without mosquito nets in the community of field sites
Mosquito nets
Number of
Using mosquito nets
Communes
(duo)
households People
Sleep
Sleep
observed
%

%
Number Rate
with nets
without nets
82
335
182
238
71,0
97
1,84
28,96
Quảng Trực
4
79
325
183
1,78
232
71,3
93
28,62
Thuận Hạnh
8
82
335
179
247
73,7
88

26,27
1,87
Đắk Lao
3
79
325
172
233
71,6
92
1,89
28,31
Đắk Wil
9
Total
322
950
71,9
370
1320
717
1,84
28,03
7
Direct observation at night showed that the percentage of bed nets in border communes was low, accounting for
71.97%, non-sleeping nets accounted for 28.03%, the rate of people / mosquito netswas 1.84.
Table 3.9. Proportion of people using hammocks with mosquito nets when cross-border exchanges
Number of
Using hammocks with mosquito
Communes

households People
Hammock
nets
observed
Number Rate
Using hammocks
%
Quảng Trực
82
335
29
0,35
15
4,48
Thuận Hạnh
79
325
36
0,46
23
7,08
Đắk Lao
82
335
36
0,44
25
7,46
Đắk Wil
79

325
30
0,38
21
6,46
Tổng
322
1320
129
0,40
83
6,29
Direct observation: The results showed that the rate of using hammock covered with mosquito nets when
exchanging borders was 6.29%, the percentage of households with a hammock was 0.40..
3.2. EFFECTIVENESS OF CIVIL-MILITARY COOPERATION IN MALARIA CONTROL IN BORDER
AREAS
3.2.1. Results of developing solutions and training
The solution of military-civilian medical union of Quang Truc was established on the basis of
comprehensive integration of staffing, organization and tasks between the commune health station and the
Regimental Hospital 726 and Military Hospital of Border Patrol 769, 771 and 775. The commune health
station, Regimental hospital 726 and Military Hospital of Border Patrol 769, 771 and 775 are directly under the
management of Tuy Duc District Medical Center and the Military Medical Department at higher levels in terms
of their professional skills and expense. In addition to the function of medical examination and treatment at


12

commune health stations, the hospital also strengthens the activities of controlling, examining, detecting,
treating and monitoring malaria cases for soldiers and the whole community.

Provincial People's
Committee
- Military command post
of Dak Nong province
- Unit commander

Department of Health
of Dak Nong Province

People's Committee
of Tuy Duc district

Military - civil
medical department
of the province

- Medical unit of Millitary
command of Dak Nong
- Millitary medical of unit

Military command post of
Tuy Duc District

Tuy Duc district
health center

Military - civil
medical department
of Tuy Duc

Military Medical
Border Unit, economic
union

Civil- military cooperation in malaria
control in Tuy Duc

Quang Truc commune
health station

- Regimental Hospital 726
- Medical unit of Military
Border Post

Table 3.4. The solution of military-civilian medical union of Quang Truc commune
3.2.2. Effectiveness of civil-militarycooperation in malaria control in border areas of Dak Nong province
- Effectiveness of civil-military cooperation in reducing the prevalence of malaria
Table 3.10. Assess the effectiveness of interventions for malaria incidence
Number
of tests
Pre-intervention

1320

Post-intervention
EI
p

1328

Control group
Number of
Plasmodium
(+)
58
50
27,79%

Rate
%

Intervention Group
Number
Number of
Rate
of tests
Plasmodium
%
(+)

4,39

1320

3,17

1330

70
34

51,70%
<0,05

Intervention
Effectiveness

>0,05

5,30
2,56

p

23,91%

<0,05

The efficacy indicator of the proportion of malaria patients in the control group is 27.79%. This is the
effectiveness of routine malaria prevention activities..
EI on the proportion of malaria patients in the intervention group was 51.70%. This is the effectiveness of
the coordination of regular malaria prevention activities and the effectiveness of civil-military cooperation
solutions in the border areas.


13

- Effectiveness of civil-military cooperation in reducing the rate of vulnerability to malaria parasite
Table 3.11. Evaluate the effectiveness of intervention on the proportion of people with malaria parasites
before and after the intervention

Number
of tests
Pre-intervention

1320

Post-intervention
EI
p

1328

Control group
Number of
Plasmodium
(+)
58
50
14,12%

Rate
%

Intervention Group
Number
Number of
Rate
of tests
Plasmodium
%

(+)

4,39

1320

3,77

1330

70
34
51,70%
<0,05

Intervention
Effectiveness

>0,05

5,30
2,56

p

37,58%

<0,05

EI on the proportion of people with malaria parasites in the intervention group compared to before the

intervention: EI = 51.70%
EI on the proportion of people with malaria parasites in the control group compared to before the
intervention: EI = 14.12%.
Efficacy of the proportion of people with malaria parasites in the intervention group compared to the
control group is: EI = 51.70% - 14.12% = 37.58%
- Effectiveness of civil-military cooperation in malaria control due to cross border exchange.
Table 3.12. Assessment of reduction in incidence of malaria parasites in people who have cross-border
before and after the intervention
Number
of tests
Pre-intervention

435

Post-intervention
EI
p

543

Control group
Number of
Plasmodium
(+)
22
32
-16,40%

Rate
%

Intervention Group
Number
Number of
Rate
of tests
Plasmodium
%
(+)

5,06

655

5,89

712

39
22
48,07%
<0,05

Intervention
Effectiveness

>0,05

5,95
3,09

p

64,47%

<0,05

Before the intervention: The rate of infection with malaria parasites in the group of people crossing the
border has no difference between the intervention group and the control group (p> 0.05)
After the intervention: In the control group, the prevalence of malaria parasites among people who have
regular border exchange tended to increase, the effectiveness index was -16.40%. In the intervention group, the
rate of infection with malaria parasites in the group of people crossing the border decreased significantly, the
effectiveness index was 48.07%.
Efficacy of civil-military cooperation in controlling incidence of malaria parasites due to border exchanges
reached 64.47%.
Table 3.13. Evaluation of reduction in malaria parasite incidence in people having free cross-border
exchanges (by border trade) before and after the intervention
Number
of tests

Control group
Number of
Plasmodium
(+)

Rate
%

Intervention Group
Number

Number of
Rate
of tests
Plasmodium
%
(+)

Pre-intervention

22

15

68,18

39

Post-intervention
EI
p

32

22
-0,84%

68,75

22

29
12
26,64%
<0,05

Intervention
Effectiveness

>0,05

74,36
54,55

p

27,48%

<0,05


14

Before the intervention: The rate of malaria parasites among people who exchange freely across borders
did not differ between the intervention and control groups (p> 0.05)
After the intervention: In the control group, the rate of malaria parasites among people who freely exchange
cross-border increased, the effectiveness index was -0.84%. In the intervention group, the rate of malaria
parasite infection among the group of people who exchange freely via borders decreased significantly, the
efficiency index was 26.64%.
Efficacy of civil-military cooperation in controlling the incidence of malaria parasites due to free crossborder exchanges reaches 27.48%
- Effectiveness of civil-military cooperation solutions in improving the capacity of malaria prevention

and control practices of the community
Table 3.14. Evaluate the effectiveness of interventions to improve people's thorough knowledge about
malaria prevention after intervention
Intervie
w

Control group
Correct answer

%

Intervie
w

Intervention Group
Correct answer

%

Pre-intervention

82

43

52,44

82

42

51,22

Post-intervention
EI
p

82

67

81,71

82

80

97,56

55,82%

Intervention
Effectiveness

p
>0,05

34,66%

<0,05

90,47%
<0,05

EI on improving community knowledge in the control of malaria in the control group (the effectiveness of
regular malaria prevention activities) is 55,82%.
EI on improving the knowledge of the community in malaria prevention in the intervention group (the
effectiveness of the combination of routine malaria prevention activities and the effectiveness of civil-military
coordination solutions in the border areas) is 90,47%
EI on improving knowledge in the intervention group compared to the control group: = 90,47% - 55,82% =
34,66%.
Table 3.15. Assess the effectiveness of intervention on the rate of good malaria prevention and control
practices for the people after the intervention
Intervie
w
Pre-intervention

82

Post-intervention
EI
p

82

Control group
Correct
answer
41
67

63,42%

%

Intervie
w

50,00

82

81,71

82

Intervention Group
Correct answer
41
78
90,24%
<0,05

%

Intervention
Effectiveness

>0,05

50,00

95,12

p

26,82%

<0,05

EI on improving the community's practice in preventing and fighting malaria in the control group (the
effectiveness of regular malaria prevention activities) was 63.42%
EI on improving community practices in malaria prevention in the intervention group (effectiveness of
coordination of regular malaria prevention activities and effectiveness of civil-military coordination solutions
in border areas) was 90.24%.
Intervention Effectiveness of the rate of good practices was 26.82%


15

CHAPTER 4
DISCUSSION
4.1. CHARACTERISTICS OF PLASMODIUM INFECTION IN THE COMMUNITY IN THE
BORDER AREA OF DAKNONG PROVINCE:
4.1.1. Regarding the prevalence of malaria parasites
The results of cross-sectional surveys at 4 seasonal points in 2016 showed that the highest rate of malaria
parasites in the border areas of Dak Nong province was highest at the end of the rainy season (6.72%),
followed by in the middle of the rainy season with the rate of 5.76% and the lowest was in the dry season at
1.52%. The overall prevalence of malaria parasites in the whole border area of Dak Nong province was 4.42%.
This rate is quite high compared to the current severe malaria areas and the border areas.
The survey results in four rounds of this study showed that out of 232 malaria parasites, only 54.31% were
local infections, 45.69% were infected among Vietnamese returning from Cambodia..

4.1.2. Regarding species composition, density and proportion of Anopheles mosquitoes at the field sites
The total number of Anopheles species collected in the border area of Dak Nong Province was 21 species.
In Quang Truc, the highest number of Anopheles species was 19, and in Thuan Hanh, 18 species were
discovered. The number of Anopheles species collected in Dak Lao was 16 and that in Dak Wil was 14. In the
Dak Nong border area, five species are listed in the list of major and minor malaria vectors in Vietnam's
mountainous forests, of which An. dirus and An. Minimus are the main vector, there are 3 sub-vector species in
mountainous areas including: An. aconitus, An. jeyporiensis and An. maculatus. The highest proportion of
species composition is An. vagus (17.42%), followed by An. sinensis (15.91%), An. peditaeniatus (15.97%).
The ELISA test results showed that the secondary vectors: An. aconitus, An. Jeyporiensis, An. maculatus
and An. harrisoni have not detected infection with malaria parasites; meanwhile, the two main vectors of
malaria: An. dirus and An. minimus have been proved to be ELISA positive for with both parasite species P.
falciparum and P. vivax. Rate of An. dirus mosquito prone to P. vivax infection with 0.84% and that of An.
minimus prone to P. falciparum infection was 14.28%..
4.1.3. Current situation of malaria prevention knowledge and practice of people in border areas of Dak
Nong province
The initial survey showed that the percentage of mosquito nets in these 4 communes is 1.85 people / 1
double curtain. However, the percentage of people sleeping nets in the community has not met standard at 80%
and only reached 71.96%. Among the people who regularly cross the border, the rate of sleeping in hammock
with mosquito nets was only 6.34%..

These factors may be due to the limited knowledge, attitudes and practices of people in the border
areas. The survey results in these 4 communes showed that knowledge and practice of malaria control
among the community was still low (50.31% -72.36%). Only 67.39% correctly understood mosquitoes as
the main vector of malaria. The ratio of people / mosquito net was 1.84. 71.97% of local people used mosquito
nets, the rate of using hammock with mosquito nets for cross-border exchange was 6.29%
4.2. EVALUATION OF CIVIL-MILITARY COOPERATION IN MALARIA CONTROL
4.2.1. Results of building and training military - civilian forces to coordinate in malaria control in Quang
Truc commune
The study has established a payroll organization, equipment and operational mechanism of military-civilian
forces to coordinate and prevent malaria in Quang Truc commune. Assign positions, functions of the three

parties involved. During 1 year of operation, with regular supervision of researchers and monthly meetings to
draw on experience, at the time of the survey to evaluate the output efficiency, basically the coordination of the
forces involved in was very rhythmic and effective. Based on the results of the intervention, the research team,
together with officials from the three participating units, had a meeting to learn from experience and come to an
agreement on some key characteristics to develop effective solutions.
4.2.2. Model effectiveness in preventing malaria due to border exchanges
The results show that Civil-military medical cooperation measure has significantly reduced the incidence of
malaria parasites due to border exchanges. The results of the pre-intervention survey showed that, the rate of
infection with malaria parasites in the group of people crossing the border did not differ between the


16

intervention group and the control group (p> 0.05). After the intervention: in the control group (the group
performing routine malaria prevention activities), the prevalence of malaria parasites among people who
regularly exchange borders tended to increase, efficiency index was -18.38%. In the intervention group, the rate
of infection with malaria parasites in the group of people crossing the border decreased significantly, the
effectiveness index was 48.07%. The intervention effectiveness of Civil-military medical cooperation measure
in malaria control due to border exchanges reached 64.47%
4.2.3. Model effectiveness in proactive detection and treatment of malaria patients in the community
The rate of detection and treatment of malaria in the community reached: 26.47%, which was different with
the control group, p <0.05
The results showed that the number of Vietnamese and malaria-infected people who went to Cambodia, the
number of Cambodian malaria patients who were monitored, detected and treated early was better than the
control group (p <0.05).
The prevalence of malaria through cross-sectional surveys before and after the intervention decreased
significantly, p <0.05. The incidence of malaria through vertical monitoring of the group pre and post the
intervention decreased, p <0.05.
4.2.4. The effectiveness of the model's communication, education and environmental sanitation plan to
prevent malaria:

- Regarding knowledge of the community in malaria control:In the control group, with the effectiveness of
the regular malaria prevention program, the effective index on improving the knowledge of the community in
malaria prevention in this group is 55,82%. In the intervention group, the effectiveness of the combination of
routine malaria prevention activities and that of civil-military medical cooperation in border areas improved the
community knowledge to 90,47%. The effiency of interventions on improving knowledge of civil-military
medical cooperation was 34,66%.
- Regarding community practices in malaria control: for the regular activities of the malaria control
program (control group), the EI was 63.42%. The effectiveness of improving community practice in malaria
prevention of civil-military medical cooperation measures in border areas was 90.24%. That of the rate of good
practice of civil-military medical cooperation measures is 26.82%.
4.2.5. Evaluate the overall effectiveness of Civil-military medical cooperation in malaria prevention for
people in border areas
An assessment of the overall effectiveness of the solutions demonstrates that Civil-military medical
cooperation in malaria prevention for people in border areas helped to reduce malaria incidence of the
community by 23.91%. It also decreased the rate of vulnerability to malaria parasite to 37.58%.
Compared with the previous solution ‘’model of malaria prevention at households in border areas’’, the
effectiveness of this solution was higher. The old solution only brought about the reduction in prevalence of
malaria by 16.3% and the rate of malaria infection to 28.9%.
4.2.6. Feasibility and sustainability of the solution
The above results show that the solution "Civil-military medical cooperation in malaria prevention for
people in border areas" was applied in this study to be effective, feasible and can be widely applied in many
localities, It is considered as a supplement to the national programs for malaria prevention. This solution can be
applied to many provinces of Vietnam sharing borders with China, Cambodia, Laos and other countries.


17

CONCLUSIONS
Research in 4 border communes of Dak Nong province on the situation of malaria parasite infection and the
effectiveness of civil-military medical cooperation in malaria control showed that:

1. Actual situation of malarial infection within border communities in Dak Nong province
- The prevalence of malaria in the border communities in Dak Nong province in 2016 was 1.82%, the
percentage of enlarged spleen cases was 0.61%, 1.52 percent of patients were positive for Plasmodium. These
ratios were higher in Quang Truc and Dak Lao communes. The percentage of carrying malaria parasites was
highest in the age group of> 15 years old (60.00%), the rate of carrying parasites in Kinh people is 70.00%,
followed by M’Nong people with 20.00%. 1,66 percentage of people who practice milpa farming suffered from
malaria infection and that of immigrants was 2.21%. In particular, the proportion of malaria parasites infection
cases related to border exchanges accounted for 45.69% and mainly due to border trade (accounting for 67.92%
of the total number of cases due to border exchanges)..
- Structure of malaria parasites, P.falciparum species accounted for 55,00% and combined species
accounted for 15,00%. 100% of patients infected with P.vivax parasite had gametes. Infection with
P.falciparum parasites having gametocyte accountedfor 47.50%.
- Malaria occurrence: The highest rate of malaria parasites occurred at the end of the rainy season (6.72%),
followed by the middle of the rainy season (5.76%) and the lowest was found in the dry season (1.52%). The
average rate of having malaria parasites all year was 4.42%.
- The number of Anopheles species collected was 21, the most in Quang Truc with 19 species. There are 5
main and secondary vector species of malaria: the main malaria vector is An. dirus and An. minimus, secondary
vector are: An. aconitus, An. jeyporiensis and An. maculatus. The secondary vectors have not detected infection
with parasites, the two main malaria vectors are infected with parasites, the rate of An. P. vivax dirus infected
with 0.84% and An. P. falciparum infection minimus was 14.28%.
- People 's knowledge and practice of malaria control was still low (50.31% -72.36%). Only 67.39%
correctly understood mosquitoes as the main vector of malaria. The ratio of people / mosquito net was 1.84.
71.97% of local people used mosquito nets, the rate of using hammock with mosquito nets for cross-border
exchange was 6.29%.
2. Effectiveness of civil-military medical cooperation in malaria prevention for people in border
areas
- Owing to civil-military coordination measures, a lot of activities undertook to control malaria (compared
to the control group). In particular: strengthening management and case detection techniques in the community
(the rate of detection and treatment of malaria in the community after the intervention reached 26.47%),
increase the provision of supervised medicine and cross-border surveillance, 100% of households were

monitored vectors, increase the number of households sprayed with chemicals and impregnated mosquito nets,
boost communication activities to educate and prevent malaria among the locals, mobilize the Armed force and
military medical personnel to participate in malaria prevention and surveillance in the community, mobilize
- Assessing the effectiveness of intervention (compared to the control group):
+ The effectiveness of intervention reduced the incidence of malaria patients in the community by 23.91%.
It also cut down the prevalence of Plasmodium in the community by 37.58%.
+ The effectiveness of intervention measures in controlling the incidence of Plasmodium due to border
exchanges reached 64.47%. EI in controlling the prevalence of malaria parasites due to free cross-border
exchanges reached 27.48%.
- Assess the effectiveness in the health education center after intervention (compared to the control group):
Knowledge raising awareness for the community about anti-malaria for the community is 34,66%. EFF
enhances anti-malarial practices for the community is 26.82%.
SUGGESTIONS
1. Deploying and deploying measures of civil-military medical cooperation in malaria control in the border
areas where armed forces units stand. It is recommended to apply the solution to other border areas of Dak
Nong and Central Highlands provinces.
2. Healthcare network at the grass roots level and Military medical forces in border areas have strengthened
the management of migrants to pay attention to detecting malaria parasite infection after the cross-border


18

exchange to control acute malaria and death cases.
3. It is necessary to have a mechanism for medical coordination between the two border provinces as well
as the assistance of Armed force to effectively manage border crossings..
CONTRIBUTIONS OF THE THESIS
Up to now, malaria control has only been fully implemented in commune health stations, there is no
solution for malaria surveillance in remote and border areas and there is hardly any effort to manage malaria
because of border exchanges, especially free cross-border exchanges.
Within this topic, in addition to strengthening the Ministry of Health's routine malaria surveillance and

management measures, this study also carried out measures to monitor and control malaria that are specific to
remote areas, mountainous areas and border areas with regular border exchanges of people, including:
- To promote the role of village health services, military medical units based in the locality in managing
people at high risk of malaria due to cross-border exchanges, forests, and sleeping in the forest. Early diagnosis
and treatment for malaria patients at home contributes to reducing the spread to the community.
- Military medical forces in border areas strengthens the management and supervision of border exchange
migrants, especially those who have regular border trade to promptly detect, diagnose and monitor suspected
malaria patients.
- Enhance the role of military health clinics and commune health stations in the diagnosis and treatment of
malaria patients, including those who are local residents and immigrants.
LIMITATIONS OF THE THESIS
1. Limitations in the interview process: Due to the low educational level of ethnic minorities in the area and
language differences, it is difficult to avoid mistakes in the interview process even though there are local people
who helped to guide the way and translate
2. Limitation in identifying evidence to confirm that a patient caught malaria due to the cross-border
exchange because the incubation period of malaria parasites (P.falciparum) is at least 8 days (P.falciparum), so
it is possible that he or she was infected on either side of the border.
LIST OF WORKS PUBLISHING THE RESULTS OF THE THESIS
1. Composition and role of malaria vector in the border area of Dak Nong province
Vietnamese Medicine Journal, August, No. 1/2019, p. 29 - 34.
2. Situation of malaria in the community in the border area of Dak Nong province
Journal of Malaria and Parasite Diseas Control, No. 3 (111)/2019, p. 03-09.