Standard Operating Procedures of activities

for
Intensification Plan and Acceleration Strategies

National Malaria Control Programme

Department of Public Health
Ministry of Health
 National Malaria Control Programme

Department of Public Health

Ministry of Health

Standard Operating Procedures of activities for

Intensification Plan and Acceleration Strategies

(Version 1)

February 2023
Contents

Introduction .................................................................................................................................... 3

Intensification and Acceleration interventions and activities by Stratum ..................................... 5

SOP for stratification of villages to dictate implementation of Malaria Intensification Plans and
Acceleration Strategies ................................................................................................................. 11

SOP for Village Census for villages ................................................................................................ 16

SOP for MDA in Stratum A ............................................................................................................ 19

SOP for TDA in Stratum B.............................................................................................................. 23

SOP for Intermittent Preventive Therapy for Pf (IPTf) for forest goers and high-risk travellers in
Stratum A and B ............................................................................................................................ 27

SOP for Active Case Detection (ACD) ............................................................................................ 31

SOP for Passive Case Detection (PCD) .......................................................................................... 33

SOP for Indoor Residual Spraying (IRS) ......................................................................................... 35

SOP for Reactive Indoor Residual Spraying (rIRS) ......................................................................... 37

SOP for House-to-house Active Fever Screening (AFS) in Strata A, B, C and D ............................ 39
2
Introduction

Malaria is a disease that imposes a localized burden which varies geographically and socio-
demographically. The intensity of malaria transmission of an area depends on ecology and climate
condition suitable for vector habitats, risk of importation of malaria cases to the area, and behavior
of the population to get malaria infection. According to WHO, all countries can accelerate progress
towards elimination regardless of the current intensity of transmission through combinations of
interventions tailored to the local contexts (WHO- a framework for malaria elimination-2017).
National Malaria Control Programme has been implementing malaria prevention and control
activities by stratifying the risk of malaria transmission since 2006-2007. The interventions have
been implemented based on stratification and available resources. National Strategic Plan 2021-
2025 also highlights key interventions in different transmission intensity.

Myanmar targets to eliminate Plasmodium falciparum malaria by 2025 and all human malaria
species by 2030. In 2017, the National Plan for Malaria Elimination (2016-2030) was launched and
National Strategic Plans (2016-2020) and (2021-205) were developed. Activities were implemented
for intensifying malaria control and accelerating the progress towards malaria elimination.
Elimination activities started in townships with low API since 2016 and areas were expanded in
years. “Malaria Elimination Execution” was re-energized by Malaria elimination launching
ceremony on 16 December 2019. The country showed marked declination in cases up to 2019.
However, resurgence of malaria cases has been seen in some townships with outbreaks in 2019,
although nation showed decline in cases. The cases increased in many townships in 2020, 2021 and
2022 amid COVID-19 and political development. High burden townships contribute over 80% of
cases in the country and, resurgence of cases occur in townships with no or few indigenous cases
in previous years. Although Myanmar aims to achieve malaria elimination by the year 2030,
implementation is now not on the right track to achieve the goal due to various reasons.

It is imperative to revise the strategies depending on the disease burden and current context.
Routine case detection, vector control and surveillance activities are to be intensified to reduce the
burden in hot spot area, and acceleration strategies like MDA (Mass Drug Administration), TDA
(Targeted Drug Administration) and IPTf (Intermittent Preventive Treatment for forest goers and
travelers to high-risk areas) are needed for elimination in low burden area and to maintain the
elimination status in previously eliminated areas. During 2022, WHO provides new
recommendations for chemoprevention like MDA, TDA, IPTf, etc. under different transmission
intensity. Now data information is available up to village level and microstratification criteria are
revised based on current situation- which is suitable for implementation of the new strategies. The
intensification and acceleration activities are also updated based on newly revised stratum.

The National Strategic Plan (2021-2025) aims to reduce 95% malaria cases by 2025 and eliminate
P. falciparum by 2025. High-burden townships contribute over 80% of total cases of the country for

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more than four years. Cases have recurred in previously eliminated areas, indicating the need for
intensified and accelerated strategies. The intensification and acceleration strategies implemented
in other GMS countries, such as Laos and Cambodia, have been able to reduce the malaria burden
and eliminate P. falciparum. The objectives of the intensification plan and acceleration strategies
are to reduce malaria morbidity 67% in 2026 (target set in amended NSP (2021-2026) and to
eliminate P. falciparum by 2025 and all malaria species by 2030.

4
Intensification and Acceleration interventions and activities by Stratum

Stratum A- Intensification Plans

➢ Case Management

• ICMVs: PCD in village (1 ICMV), ACD to fill the gap from PCD (forest farms,
plantations etc.) (ACD may not be feasible when transmission intensity is high, but
it is advisable for identifying cases in areas or population for whom health care
services are not available or under-used- Source – A framework for malaria
elimination, WHO, 2017)

• Test, treat, report every case; DOT, adherence support (DOT strategy) for Pv
radical cure

➢ Surveillance

• Ensure rigorous and systematic data collection at village and HF levels

• Ensure complete monthly reports at HF and township levels, and monthly data
analyses to guide implementation

➢ Vector Control

• Regular, routine IRS in high burden villages (at least 3 years) – especially before
transmission season (priority if it is operable)

• LLINs for villagers

• LLIHNs for at-risk travelers

➢ CE/IEC/BCC tailored to high burden settings

➢ Monthly coordination meetings, monthly M&E of activities

Stratum A- Acceleration Strategies

➢ MDA for burden reduction (for Pf+mix and Pv- with CQ in certain areas)

• 3 rounds at minimum, at full therapeutic dose, required to bring down the

parasite burden (1 round can last 5-7 days/village)

• Starting before the peak transmission season

• MDA needs to be supported by and followed up with all Intensification Plan

activities conducted rigorously and effectively -> any lapse in case management
and surveillance will negate the impact of MDA

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 • Requires availability of HR for the first round of MDA and a solid ICMV system in
place

➢ IPTf for at-risk population

• ICMVs can implement IPTf with only initial support from HF staff or IP staff -> may
require hiring additional ICMVs

• IPTf can continue on a monthly basis for the first year from start of Acceleration
Strategies

➢ Weekly Active Fever Screening (Testing of groups returning from at-risk areas, after MDA
and alongside with IPTf)

Stratum B- intensification plans

➢ Case Management

• ICMVs: PCD in village (1 ICMV) + ACD to high-risk group (forests, worksites near
village) (ACD should be done only when there are very few cases and foci of
transmission- Source: Malaria surveillance, monitoring & evaluation – WHO,
2018.)

• Test, treat, report every case; DOT, adherence support for Pv radical cure by DOT
strategy

➢ Surveillance

• CIFIR

• Ensure rigorous and systematic data collection at village and HF levels

• Ensure complete monthly reports at HF and township levels, and monthly data
analyses to guide implementation

➢ Vector Control

• LLINs; LLIHNs for at-risk travelers

• Reactive IRS following indigenous case as foci response- if necessary, number of

HH can expend

➢ CE/IEC/BCC targeted at increasing awareness of risk factors and protection

➢ Monthly coordination meetings, monthly M&E of activities

6
Stratum B- Acceleration Strategies

➢ TDA to reduce Pf transmission among highest risk groups (targeted group must be
considered based on village data, age group proportion, male and female proportion etc.
(eg- 10-50 years old + migrant workers)

• 3 rounds at minimum required to bring down the parasite burden (1 round can
last 5-7 days/village), starting 1 month before peak transmission season to ensure
ICMVs have support before rainy season makes access impossible

• TDA needs to be supported by and followed up with all Intensification Plan

activities conducted rigorously and effectively -> any lapse in case management
and surveillance will negate the impact of TDA

• Requires availability of HR and a solid ICMV system in place

➢ IPTf for at-risk population – including Migrant Workers, irrespective of age and gender

• ICMVs can implement IPTf with only initial support from HF staff or IP staff -> may
require hiring additional ICMVs

• IPTf can continue on a monthly basis for the first year from start of Acceleration
Strategies

➢ Weekly Active Fever Screening (Testing of groups returning from at-risk areas –after TDA
and alongside with IPTf)

Stratum C – Intensification Plan

➢ Case Management

• ICMVs: PCD in village (1 ICMV)

• Test, treat, report every case

• Pv radical cure for all Pv cases by DOT strategy

➢ Surveillance

• CIFIR

• Ensure rigorous and systematic data collection at village and HF levels

7
 • Ensure complete monthly reports at HF and township levels, and monthly data
analyses to guide implementation

➢ Vector Control

• LLIN/ LLIHNs for at-risk travelers (forest goers)

• Reactive IRS following indigenous case as foci response- if necessary, no. of HH

can expand.

➢ CE/IEC/BCC targeting at Prevention of Reintroduction: keeping the community aware of

malaria + protection methods

➢ Monthly coordination meetings, monthly M&E of activities

Stratum C - Acceleration strategies

➢ Weekly Active Fever Screening - Testing of groups returning from at-risk areas

Stratum D- Intensification Plans

➢ Case Management

• ICMVs: PCD in village (1 ICMV)

• Test, treat, report every case

• Radical cure for all Pv cases by DOT strategy

➢ Surveillance

• CIFIR

• Ensure rigorous and systematic data collection at village and HF levels

• Ensure complete monthly reports at HF and township levels, and monthly data
analyses to guide implementation

➢ Vector Control

• LLINs/ LLIHNs for at-risk travelers (forest goers)

• Reactive IRS following indigenous case as foci response- if necessary, no. of HH

can expand

➢ CE/IEC/BCC targeted at keeping malaria knowledge fresh despite no cases

➢ Monthly coordination meetings, monthly M&E of activities

8
Stratum D- Acceleration strategies

➢ Weekly Active Fever Screening - Testing of groups returning from at-risk areas

Stratum E- Intensification Plans

➢ Case Management

• Test, treat, report every case – based at HF

• Pv radical cure for all Pv cases by DOT strategy

➢ Surveillance

• Case Investigation and Response (CIR) (Response- reactive case detection to co-
travellers, information sharing to responsible persons from S/R &township of
source of infection)

• Ensure rigorous and systematic data collection at village and HF levels

• Ensure complete monthly reports at HF and township levels, and monthly data
analyses to guide implementation

➢ CE/IEC/BCC targeted at keeping malaria knowledge fresh despite no cases

➢ Monthly coordination meetings, monthly M&E of activities

Stratum E- Acceleration Strategies

➢ No acceleration strategy

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The activities are summarized as follows

Intensification Plans Acceleration Strategies

Stratum A • PCD • MDA for Pf burden reduction (needs

• ACD (to high-risk group, worksites near
village- gap not covered by PCD)
• Routine IRS (at least 3 years) (or) LLINs +
LLIHNs
• IEC/BCC/CE
• Pv (DOT strategy) where possible
to be supported by and followed up
with all Intensification Plan activities
conducted rigorously and effectively)
• IPTf for at-risk population, to
maintain gains of MDA
• weekly Active Fever Screening (after
MDA and alongside with IPTf)

Stratum B • PCD • TDA to reduce Pf transmission

• ACD (to high-risk group, worksites near
village)
• CIFIR - LLINs + LLIHNs, Reactive IRS
(following indigenous case as foci
response- if necessary, no. of HH
can expend)
• Pv (DOT strategy) for all Pv cases
• IEC/BCC/CE
among highest-risk groups (need to
be supported by and followed up
with all Intensification Plan activities
conducted rigorously and effectively)
• IPTf for at-risk population, to
maintain gains of TDA
• weekly Active Fever Screening (after
TDA and alongside with IPTf)

Stratum C • PCD
• CIFIR (Reactive IRS as foci response)
• Active Fever Screening (biweekly to
• LLIN/LLIHNs (risk travellers)
risk groups)
• Pv Radical Cure by DOT strategy for all
Stratum D Pv cases
• IEC/BCC/CE

Stratum E • Test and treat at HF

• Case investigation and Response • No acceleration activities
(reactive case detection to co-
travellers, information sharing to
responsible persons from S/R
&township of source of infection)
• Pv Radical Cure by DOT strategy for all
Pv cases
• IEC/BCC/CE

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SOP for stratification of villages to dictate implementation of Malaria Intensification Plans and
Acceleration Strategies

PURPOSE

In anticipation of the goal to eliminate malaria and, the purpose is to assign a stratum to the villages
in Myanmar based on the malaria transmission patterns, the receptivity, the vulnerability, and the
caseload, in the villages. This stratification will be applied to both Pf and Pv and all villages/
worksites.

Given the heterogeneity in transmission and caseload between villages even in close proximity to
each other, it is important for the stratification to happen at the village level.

This stratification will guide the implementation of activities as part of the Intensification Plan for
malaria control and burden reduction, and the strategies for accelerating malaria elimination in
Myanmar.

The Stratum-specific activities comprised in Myanmar’s Intensification Plan and Accelerator

Strategies have been designed specifically to address the needs of the villages in each Stratum,
and the success of the interventions depends on the correct classification of the villages.

OBJECTIVE

Objectives of village-wise microstratification are to:

1) delineate the area according to area malariogenic potential and local transmission status
2) clearly define the appropriate interventions for each stratum and to be specific for each
stratum
3) allocate the limited resources effectively

OPERATOR, LOGISTICS, & TIMING

The stratification is coordinated by the Malaria Elimination Management Team (MEMT) including
NMCP and Implementing Partners at the Township level.

The stratification is operated by the MEMT health staff at the Township level, possibly assisted by
the Basic Health Staffs together with the implementing partners of concerned, supervised by the
Township-level Medical Officer, for the Health Facility overseeing the different villages.

The MEMT at the Township level should re-stratify the villages by the end of every calendar year.

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REQUIRED INFORMATION

1) Village-resolution malaria data as to the number of Pf and Pv cases;

2) the number of indigenous cases (cases with no travel history);
3) receptivity;
4) vulnerability; and
5) the manageability of the caseload.

DEFINITONS FOR STRATIFICATION

Local transmission:

a. at least 1 indigenous (case with no travel history in the last 30 days prior to
diagnosis), or

b. presence of malaria positive cases in the village without travelling history within
one month

1) Receptivity:

a. Physical, environmental and climatic condition of village are favourable for

breeding and surviving of anopheles vectors for malaria parasites (high, moderate,
low, no)
b. Season when number of malaria cases increase without travel (Rainy, winter,
summer, not occur if there is no travel)
c. Season when number of malaria cases increase in children in the village who are
not going to forest (Rainy, winter, summer, not occur without going forest)
2) Vulnerability:

a. Is there any migrant peoples from other villages (Yes/No)

b. Malaria cases in migrant population from risk areas (No, Few, Many)
c. Malaria cases in villagers coming back from risk areas (No, Few, Many)
3) Pf/Pv burden: number of Pf +mix cases/ Pv in the village within one year

4) Manageability of caseload: a village’s caseload is defined as unmanageable if the number

of cases is more than 2 cases per month per village (>24 cases/year/village). If the average
number of cases per month is fewer than 2 per village (≤24 cases/year/village), the case
load is defined as manageable.

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STEPS FOR STRATIFYING VILLAGES

Synchronized collective efforts of NMCP, BHS, partners, EHOs, other ministries, private sectors,
volunteers, informal private providers, etc. are required for village-wise microstratification.

Collect all the necessary information of each village for stratification by annex A (Village wise basic
data, Receptivity status, Vulnerablity, Total annual positive cases and species wise data, etc.).

1) Each and every village should be stratified whether receptive area or not. If the village/ ward
is non-receptive- stratify as Stratum E.
2) If the area is receptive, check ABER.
3) If the area is receptive and case load is unmanageable- stratify as stratum A irrespective of
ABER
4) If ABER is <10 % (or) 8% (8% for urban, very low transmission areas) and case load is
manageable (≤24 cases/village/year) or ABER>10% but CIFIR was not conducted to all cases
in previous calendar year- stratify as stratum B.
5) If ABER is >10% and CIFI was conducted to all cases and there is strong evidence of
interruption of local transmission (no indigenous case) for 1-2 consecutive calendar year (s)-
stratify as stratum C.
6) If ABER is >10% and CIFI was conducted to all cases and there is strong evidence of
interruption of local transmission (no indigenous case) for at least three consecutive calendar
years – stratify as stratum D.

See the summary table for village stratification.

Local CIFIR for all
transmission Receptivity Vulnerability Burden Pf Burden Pv Caseload (Pf+Pv)
ongoing cases
Stratum A Yes Yes Yes High High Unmanageabl No
e (>24 cases
/year/village)
Stratum B Yes, variable Yes Yes Low to Low to Manageable Yes
moderate moderate (≤24
cases/year/vill
age)
Stratum C No (1-2 Yes Yes No No Manageable Yes
calendar indigenous indigenous c
years) case ase
Stratum D No (3 calendar Yes Yes No No Manageable Yes
years) indigenous indigenous
case case
Stratum E None No Yes No No Manageable Yes
historically indigenous indigenous
case case

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RECORDING AND REPORTING

1) The stratification of all villages should be recorded at the Township level

The stratification will inform the planning and preparation for the intensification and acceleration
activities, so the Township should keep a running record of the number of villages in each stratum
and monitor the number and stratification of villages and the interventions running.

2) The Township-level staff should communicate the stratification to the State, Regional,
and Central NMCP for mapping of the villages based on stratum

The NMCP should keep an up-to-date map of stratified villages on a regular basis, based on
information provided by the Townships.

3) The Township should share the stratification of their villages with the Health Facilities
so the HFs can prepare to plan the interventions accordingly

Once the stratification is complete for the villages within a Township, the Township health staff
should share this with the HF staff, so the BHS and IPs’ staff to know how many villages are in each
stratum: this will help them to prepare the planning and logistics for implementation.

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 Sr. No.

Village name
Existing strata
RHC name
General information
Sub-center name
No. of HHs
Population
Type of health care provider present for Test, Treat & Track.
Physical, environmental and climatic condition of village are favourable for breeding
and surviving of anopheles vectors for malaria parasites (high, moderate, low, no)
Season when number of malaria cases increase without travel (Rainy, winter, summer,

15
not occur if there is no travel)
OF THE VILLAGE

Season when number of malaria cases increase in children in the village who are not
RECEPTIVITY STATUS

going to forest (Rainy, winter, summer, not occur without going forest)

Is there any migrant peoples from other villages (Yes/No)

Annex A – Format to collect the data for village wise stratification

Malaria cases in migrant population from risk areas (no, few, many)
OF PARASITE
IMPORTATION

Malaria cases in villagers coming back from risk areas (no, few, many)
(VULNERABILITY)

Number of cases tested for malaria in previous year

Pv + Mixed cases
Pv cases
High caseload
parasite species

Total Positive
SOP for Village Census for villages

PURPOSE

Household (HH) enumeration, population census and at-risk population assessment consists of
visiting every selected household, interviewing household head on demography and occupation of
each member of the household. Census is the reference to guide and monitor interventions
specifically targeting at risk population to interrupt transmission in a focus.

OBJECTIVE

The objective is to gather information for each member of each HH in the village and annexes,
worksites, and forest settlements to be able define the target populations for implementation of
acceleration strategies like below:

1. Mass Drug Administration (MDA)

2. Targeted Drug administration (TDA)

3. Intermittent Preventive Treatment for forest goers and travelers to high-risk areas (IPTf)

4. Active house to house Fever Screening (AFS)

OPERATOR, LOGISTICS, TIMING

This activity is coordinated by the MEMT at the Township level with guidance and support from the
central and State/Regional Public Health Department.

The activity is operated by the Health Facility-level BHS and Implementing Partners’ staff, as well as
by ICMVs.

The activity should last 7 days and should happen in time to ensure the start of MDA (in stratum A)
or TDA (in stratum B) before the beginning of the peak transmission season.

In stratum C & D, Active Fever Screening is done only for targeted high-risk groups returning from
malaria risk areas.

REQUIRED RESOURCES AND MATERIAL

One Census Form per household

One Census Summary Form per village

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PLANNING AND PREPARATION

Census should occur as soon as possible after the community engagement in the village. The
dates of the census – 7 days – will be communicated to the community during the community
engagement event to ensure that family members are most likely to be at home during the
census activity. The objective of the census should be communicated to the household members.

OPERATION STEP BY STEP

1) Recruitment of full-time ICMV assistants and their expectations:

• Select one ICMV for 50 households (if ICMV is not in the village) depending on the
geography of the village and the distance between houses and
annex/worksite/settlements houses: if an annex or permanent settlement belonging
to the village is far and/or difficult to reach, an extra ICMV should be recruited for that
site

• Discussion needs to happen with village chief and community leaders on the census
(demographic and the geographical extension of the village) to identify the total
number of households in the village including belonging worksites where villagers
spend nights for seasonal activities or permanent forest settlements

• Each ICMV will be assigned to his/her block of HHs (~50 HHs) in the village accordingly
for the census. Each ICMV will implement the activities by visiting door-to-door all the
assigned houses in the village. 1 ICMV will be appointed as focal point and he/she will
be responsible for centralizing all information on a weekly basis during the entire
duration of the activities

2) Mapping and numbering every house in the village

• Every house must be mapped and should have a number, which will correspond to the
same number reported in the forms
• Note: ICMVs should take the time to walk into the village, verify that all houses in the
village are mapped and have a number in the map

3) Planning and coordination with the team to schedule the door-to-door visits of every house
in the village along the 5 days activity.

• Create at least 2 teams among the people present during the activity (ICMVs, Township
staff, BHS, Village Leaders).

• Plan and schedule of the 5 days activity to visit door-to-door every house in the village,
including surrounding worksites and forest settlements if any.

17
4) Census of each house: door-to-door visit of every house. Please note that in one house there
might be more than one household: in this case the households will be referred to one house
only.

Presentation of the context and explanation of the activity in the village by using a
prepared script.

RECORDING AND REPORTING

1. Record the Census information for each household in the Census form

Household census form

Name of the village/ worksite----------------------------------

Name of the volunteer-------------------------------------------
Date of census collection ----------------------------------------
Name of HH head ----------------------------------------------- Ph number ----------------------------------
HH- Name Age Sex Forest MDA TDA

No of forest
pack top up
need to top
Usable LLIN
Total No of

No of LLIN

No of LLIN
Number -goer target target
received
Bet nets

within 3

(Y/N) No of
years

up
1

2. record the summary of census for the whole village in the Census Summary Form

Total HHs in the village Total Male Female <5 yr. Main occupation of the villagers
Population

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SOP for MDA in Stratum A

PURPOSE

To bring down the high number of malaria cases i.e., to reduce the parasite reservoir in the villages
classified as Stratum A. Depleting the parasite reservoir will decrease the pool of parasites
circulating in the village, bringing the parasite load to a more manageable level that can be targeted
by other interventions.

Depleting the parasite reservoir before the peak transmission season decreases the transmission
potential within the village, while further 2 rounds of MDA ensure any imported or locally
transmitted cases cannot contribute to the transmission.

OBJECTIVE

To aim for ≥80% coverage of the population in village by 3 rounds of MDA (one month apart)

OPERATOR, LOGISTICS, TIMING

This activity is coordinated by the MEMT at the Township or village-level

The first round should be led by MEMT staff at the Township level; thereafter the second and third
round are operated by ICMVs, assisted by the Basic Health Staff and Implementing Partners from
the closest HF for the first round, and by community leaders and NGO staff for all rounds.

1 round of MDA lasts 7 days, depending on the size and accessibility of the village.

The 1st round of MDA to start at the end of March, the two following rounds to be conducted at a
1-month interval.

REQUIRED RESOURCES AND MATERIAL

ACT [Artesunate- Pyronaridine: long half-life + few side-effects]. Sufficient medication stockpiled
within country, to be distributed to the HF level for 3 rounds of MDA per village

1 ICMV per 50 households

One MDA Form per household

One MDA Summary Form per village

PLANNING AND PREPARATION

1) Quantification of required ACTs

Once a village has been classified as belonging in Stratum A, the first step is the quantification of
required drugs, based on the population of village, for MDA (and IPTf, refer to IPTf SOP)

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Perform Census to determine the number of people in the village (including annexes and worksites
where necessary) to whom the ACT can be given

If the number of visits to the village is limited by the security and safety related inaccessibility
situations, Township-level Health Staff communicate with the BHS and village leaders to establish
village population and number of households according to local knowledge (including migrant and
mobile population)

Every HF should base their expected needs of ACTs on the number of Stratum A villages in their
catchment area and the population of these villages

Ensure a count of 1 full therapeutic dose of ACT per inhabitant per village, plus 20% buffer

Expect 9-12 months between quantification and start of MDA

2) Recruitment of additional ICMVs

Based on the number of households in the village, recruit additional ICMVs to support giving the
MDA throughout the village: 1 ICMV for 50 households.

The ICMVs will be trained during the first round of MDA by the BHS and IP staff.

3) Logistics for distributing ACTs to HF

Based on the quantity of ACTs needed per village, the MEMT Township should mobilize the required
stock from the central level to the HF, and plan for logistic arrangements to the village with the
support of the BHS.

Ensure the required ACTs for a full round of MDA are delivered to the village at the start of each
round of MDA, or if access to the village is expected to be difficult, ensure the required ACTs for 3
full rounds of MDA are delivered at the start of the first round.

4) Planning and coordination at village level

The first round of MDA should be coordinated by the Township or BHS with the ICMV and ICMV
assistants, and the community leaders.

The planning phase should start one month before the first round of MDA, and should consider any
relevant annexes, settlements, worksites, or fields/plantations according to the epidemiology of
malaria in the village and the movement of community.

The BHS, ICMV, and community leaders should plan for Community Engagement (CE) to happen
before the start of MDA and set the dates for the 3 rounds of MDA with one month-intervals.

20
Certain population groups to be excluded from the campaign, depending on the medicine chosen
for MDA:

• pregnant women in the first trimester: a decision to use pregnancy tests or self-reported
pregnancy to exclude pregnant women should be guided by the health authorities and local
context.
• infants and <6 months of age or weighing <5 kg;
• severely ill people

OPERATION STEP BY STEP

1) MDA plan according to workforce

Most efficient deployment of teams is decided according to available workforce.

The BHS and any MEMT Township-level staff should participate in the first round of MDA and
perform a refresher on-the-job training for ICMVs and ICMV assistants.

2) Door-to-door visit of all households, including in annexes, worksites, and settlements

Every household should be visited, door by door, and the ICMVs should offer ACTs to all inhabitants
according to the therapeutic dose prescribed according to their weight/age.

This will include:

a. Every household is visited door-to-door

b. ACTs are provided to all eligible household members.
c. Every household should receive detailed information (already mentioned during
Community Engagement) on the benefits of MDA

3) Second and third round to be repeated 30 and 60 days respectively after the first round

Every household should be visited, door by door, and the ICMVs should offer ACTs to all inhabitants
according to the therapeutic dose prescribed according to their weight/age.

This will include:

a. Every household is visited door-to-door

b. ACTs are provided to all eligible household members

c. Every household should receive detailed information (already mentioned during CE) on the
benefits of MDA

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RECORDING AND REPORTING

Record the number of people who took MDA

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SOP for TDA in Stratum B

PURPOSE

To reduce the parasite reservoir in Stratum B-classified villages in the highest risk group, men and
women 10-50 years old. Depleting the parasite reservoir in this highest risk group will decrease the
largest portion of the pool of parasites circulating in the villages, bringing the parasite load to a
more manageable level that can be targeted by other interventions.

Depleting the parasite reservoir before the peak transmission season decreases the transmission
potential within the village, while further 2 rounds of TDA ensure any imported or locally
transmitted cases cannot contribute to the transmission.

A strong surveillance system based on weekly house to house fever screening and pre-exposure
chemoprevention for forest goers is essential to prevent reinfection during the period of post-
treatment TDA.

OBJECTIVE

To quickly reduce the parasite biomass in the highest risk populations to interrupt the transmission
of Plasmodium falciparum malaria.

To aim for ≥80% coverage of the high-risk men and women aged 10-50 years old in the village in all
3 rounds of TDA (one month apart)

OPERATOR, LOGISTICS, TIMING

This activity is coordinated by the MEMT at the Township or village-level

The first round should be led by MEMT staff at the Township level; thereafter the second and third
round are operated by ICMVs, assisted by the Basic Health Staff and Implementing Partners from
the closest HF for the first round, and by community leaders and NGO staff for all rounds.

1 round of TDA lasts 7 days, depending on the size and accessibility of the village.

The 1st round of TDA to start before the peak transmission season, the two following rounds to be
conducted at a 1-month interval.

REQUIRED RESOURCES AND MATERIAL

ACT [Artesunate+ Pyronaridine] Sufficient medication stockpiled within country, to be distributed

to the HF level for 3 rounds of TDA per village

1 ICMV per 50 households

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One TDA Form per household

One TDA Summary Form per village

PLANNING AND PREPARATION

1) Quantification of required ACTs

Once a village has been classified as belonging in Stratum B, the first step is the quantification of
required drugs, based on the population of village, for TDA and IPTf

Perform census to determine the number of people in the village (including annexes and worksites
where necessary) to whom the ACT can be given.

Every HF should base their expected needs of ACTs on the number of Stratum B villages in their
catchment area and the population of these villages

Ensure a count of 1 full therapeutic dose of ACT per inhabitant per village, plus 20% buffer

Expect 9-12 months between quantification and start of TDA

2) Recruitment of ICMV assistants

Based on the number of households in the village, the BHS and/or IPs should recruit additional
ICMVs to support the giving the TDA throughout the village: 1 ICMV for 50 households.

The ICMV assistants will be trained during the first round of TDA by the BHS and IP staff.

3) Logistics for distributing ACTs to HF

Based on the quantity of ACTs needed per village, the Township should mobilize the required stock
from the central level to the HF, and plan for logistic arrangements to the village with the support
of the BHS.

Ensure the required ACTs for a full round of TDA are delivered to the village at the start of each
round of TDA, or if access to the village is expected to be difficult, ensure the required ACTs for 3
full rounds of TDA are delivered at the start of the first round.

4) Planning and coordination at village level

The first round of TDA should be coordinated by the MEMT Township or IPs/BHS with the ICMV and
ICMV assistants, and the community leaders.

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The planning phase should start one month before the first round of TDA, and should consider any
relevant annexes, settlements, worksites, or fields/plantations according to the epidemiology of
malaria in the village and the movement of community.

The BHS/IPs, ICMV, and community leaders should plan for Community Engagement to happen
before the start of TDA and set the dates for the 3 rounds of TDA with one-month intervals.

Certain population groups to be excluded from the campaign, depending on the medicine chosen
for TDA:

• pregnant women in the first trimester: a decision to use pregnancy tests or self-reported
pregnancy to exclude pregnant women should be guided by the health authorities and local
context
• severely ill people

OPERATION STEP BY STEP

1) TDA plan according to workforce

Most efficient deployment of teams is decided according to available workforce.

The BHS/IPs and any MEMT staff from the Township level should participate in the first round of
TDA, and perform a refresher on-the-job training for ICMVs and ICMV assistants

2) Door-to-door visit of all households, including in annexes, worksites, and settlements

Every household should be visited, door by door, and the ICMVs should offer ACTs to all eligible
population according to the therapeutic dose prescribed according to their weight/age.

This will include:

a. Every household is visited door-to-door

b. ACTs are provided to all eligible household members

c. Every household should receive detailed information (already mentioned during

Community Engagement) on the benefits of TDA

3) Second and third round to be repeated 30 and 60 days respectively after the first round

Every household should be visited, door by door, and the ICMVs should offer ACTs to all eligible
population according to the therapeutic dose prescribed according to their weight/age.

This will include:

25
 a. Every household is visited door-to-door

b. ACTs are provided to all eligible household members

c. Every household should receive detailed information (already mentioned during CE) on the
benefits of TDA

RECORDING AND REPORTING

Record the number of people who took TDA

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SOP for Intermittent Preventive Therapy for Pf (IPTf) for forest goers and high-risk travellers in
Stratum A and B

PURPOSE

To protect people who routinely travel to the highest risk places, get exposed and infected with Pf
malaria parasite. Intermittent Preventive Treatment is for forest goers and other travellers to high-
risk areas (IPTf) is a course of malaria drugs to prevent infection, regardless of whether the
recipients are parasitaemic.

Offering a course of ACTs to people who intend to spend time in the pre-defined malaria high-risk
areas in Myanmar (forests, mines, plantations, worksites, etc) will ensure they are protected from
infection during the travel, and therefore will minimize the risk of bringing back a parasite reservoir
to their village when they return.

Note: IPTf need to be considered carefully in high receptivity and vulnerability areas with limited
resources, uncontrolled movements of migrants depending on the nature of jobs, the possibility of
increasing drug-resistant levels, and considering for sub-national elimination in low caseload areas.

OBJECTIVE

The objective of pre-exposure chemoprevention is to reduce the risk of getting malaria for all
travelers to high-risk areas residing in active foci.

To aim for ≥40% coverage (aim should be 100%) of the men and women aged 10-50 years in the
village every month.

Each IPTf-target person should be offered a course of IPTf every month they intend to travel to
high-risk areas.

OPERATOR, LOGISTICS, TIMING

This activity is coordinated by the ICMV at the village level with the support of the Village
Leaders/Community Leaders

The ICMVs should canvas the whole village once a week, 5 days per week: this will require recruiting
additional ICMVs in some villages to enable the ICMV network to cover the whole village within the
given timeframe.

IPTf should start immediately after MDA or TDA, in case anyone who is eligible missed MDA or TDA.

27
REQUIRED RESOURCES AND MATERIAL

ACT [Artesunate-Pyronaridine] Sufficient medication stockpiled within country, to be distributed to

the HF level for 3 months per village

1 ICMV per 50 households

One IPTf Form per household

One IPTf Summary Form per village

PLANNING AND PREPARATION

1. Quantification of required ACTs

Once a village has been classified as belonging in Stratum A or B, the first step is the quantification
of required drugs, based on the population of village, IPTf (and for MDA/TDA, see SOP).

Perform Census to determine the number of high-risk people in the village (including annexes and
worksites where necessary) to whom the ACT can be given.

Every HF should base their expected needs of ACTs on the number of Stratum A and B villages in
their catchment area and the population of these villages.

Ensure a count of 1 full therapeutic course (3 doses) of ACT per inhabitant per village, plus 20%
buffer.

Expect 9-12 months between quantification and start of IPTf.

2. ICMV to be assigned their blocks of 50 households

Additional ICMVs already recruited for MDA or TDA.

Once MDA or TDA have been completed in villages in Strata A or B, the ICMVs will include the offer
of IPTf in their weekly screening of the whole village as part of AFS.

The canvasing of the households should take place when family members are most likely to be at
home (early morning/late afternoon/as per the local context).

Certain population groups to be excluded from the campaign, depending on the medicine chosen:

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 • pregnant women in the first trimester: a decision to use pregnancy tests or self-reported
pregnancy to exclude pregnant women should be guided by the health authorities and local
context
• infants and <6 months of age or weighing <5 kg
• severely ill people

OPERATION STEP BY STEP

1) Door-to-door visit of every house in the village, including annexes, worksites, forest
settlements:

• Each ICMV will be responsible for their block of houses within the village, as designated
during the planning and preparation phase, and as initiated for AFS

• An average of ~10 houses should be daily visited by each ICMV, 5 days per week

2) Implementation of IPTf to men and women aged 10-50 years who plan to go to the forest
or other high-risk areas in the following 4 weeks

• An average of ~ 10 houses should be daily visited by every ICMV, 5 days per week, every
week for 12 months.

• Every house where men or women aged 10-50 years who regularly visit high-risk areas
reside must be visited door-to-door every week as part of the active house-to-house
fever screening

3) Information must be given to the residents according to a prepared script IPTf can be
administered monthly, when an IPTf target plans to go to the forest or other high-risk
areas, as follows:

a. The first dose to be given as DOT according to the National Guidelines

b. Give the other doses to the person to take on Day 2 and Day 3 at the same time as
Dose 1 (DOT to be provided where possible)

c. If a person is staying in the forest/farms for more than 1 month (or far away from
ICMV’s travel distance) then he/she should be given additional course of IPTf.

4) The ICMV will complete the information for each member in the house by filling the IPTf
Household Form daily, and the Summary IPTf Form on a monthly basis.

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RECORDING AND REPORTING

1) Record the number of people who were given IPTf by the ICMV during their
weekly/monthly rounds (use carbonless form)

2) Record the summary of the number of people who received IPTf during the previous
month in the monthly Summary Form

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SOP for Active Case Detection (ACD)

PURPOSE

To detect malaria cases by health workers at the community or household level, or in population
groups that are at high risk which are uncovered by PCD in stratum A & B.

ACD is important to fill gaps in the PCD system, to detect both asymptomatic and symptomatic
malaria infections as early as possible and provide prompt and effective treatment and immediate
response to prevent secondary cases.

OBJECTIVE

To detect symptomatic or asymptomatic malaria cases at community and household levels that are
not detected through passive case detection

OPERATOR, LOGISTICS, TIMING

The activity is conducted by the ICMVs in vulnerable and at-risk communities, annexes, forested
areas, development projects, people living in areas with poor accessibility to health care services,
and areas identified as malaria hot spots through PCD.

All ICMVs within the catchment area of one HF should be supervised by a BHS or IP staff, and
monthly/regular meetings should happen at the HF for all ICMVs under the catchment area of that
HF.

ACD must be conducted before, during and after transmission season.

REQUIRED RESOURCES AND MATERIAL

Each ICMV should have a monthly (or quarterly, where monthly re-supplying is not feasible) supply
of ACTs, CQs and PQs

RDTs

Malaria carbonless register for entering the tests and the cases

Materials for health education on malaria

31
PLANNING AND PREPARATION

1) Recruitment of ICMVs

Villages with [worksites/ forest farms / mines/ plantations/ huge number of migrants and mobile)
nearby should have 1 ICMV recruited by community consensus: the BHS or IP staff should ask advice
from the Village or Community Leader as to who should be chosen to be ICMV, or ICMVs should be
voted on by the community.

2) Logistics for ICMVs

Once a month, or once a quarter for hard-to-reach areas, a meeting should be held at the HF to be
attended by the ICMVs of all the villages under that HF. Alternatively, a BHS or IP staff will make
monthly or quarterly rounds to all ICMVs in their catchment area.

During these meetings, each ICMV should receive 2 courses of ACT/CQ, PQ, RDT 25 tests, and other
commodities as outlined in the National Treatment Guidelines to be able to test and treat any
patient who comes to them for testing.

During the meetings, the ICMVs will also hand in their monthly register of malaria cases.

3) Definition of ICMVs’ outreach area

The Township-level health staff and/or BHS, and the IP staff supervising the ICMVs, should work
with the ICMVs and the community to define which areas (forests, annexes, worksites, etc.) should
be visited, and at what frequency, based on the risk factors and the local epidemiology.

OPERATION STEP BY STEP

Test and treat every person with risk factors or symptoms in pre-defined areas

The ICMVs who perform ACD should perform outreaches to the pre-defined areas at a frequency
decided with the BHS and IP staff, using RDT kits for diagnosis of any person presenting with any
malaria signs and symptoms or having had any risk exposure in the last 14 days, and to treat any
positive cases according to the National Malaria Treatment Guidelines.

In addition, the ICMVs should use the opportunity of the outreaches to perform malaria-related
health education.

RECORDING AND REPORTING

Record all tests and positive cases

All tests and positive cases to be recorded in the ICMVs’ malaria carbonless register as usual.

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SOP for Passive Case Detection (PCD)

PURPOSE

To set a framework within which the Integrated Community Malaria Volunteers (ICMVs) can ensure
regular, reliable, adequate malaria services are provided at the village level.

PCD is the detection of malaria cases among the people who based on their own initiative visit a
health facility or health care provider to get treatment, usually with febrile illness.

OBJECTIVE

To identify malaria cases and provide complete treatment for clearance of infection as soon as
possible in order to alleviate symptoms and progression of disease. This will also help reduce the
parasite reservoir and prevent secondary cases.

OPERATOR, LOGISTICS, TIMING

The activity is conducted by the ICMVs in villages which have ICMVs, or by BHS from the nearest HF
for villages which do not have their own ICMV.

All ICMVs within the catchment area of one HF should be supervised by a BHS or IP staff, and
monthly/regular meetings should happen at the HF for all ICMVs under the catchment area of that
HF.

REQUIRED RESOURCES AND MATERIAL

ACTs, CQs and PQs: each ICMV should have a monthly (or quarterly, where monthly re-supplying is
not feasible) supply of ACTs, CQs and PQs.

RDTs

Malaria carbonless register for entering the tests and the cases

Materials for health education on malaria

PLANNING AND PREPARATION

1) Recruitment of ICMVs

33
ICMV must be recruited for all villages under stratum A, B, C and D if there is no health facility within
the village. ICMV must be recruited by community consensus: the BHS or IP staff should ask advice
from the Village or Community Leader as to who should be chosen to be ICMV, or ICMVs should be
voted on by the community.

2) Logistics for distributing ACTs to ICMVs

Once a month, or once a quarter for hard-to-reach areas, a meeting should be held at the HF to be
attended by the ICMVs of all the villages under that HF. Alternatively, a BHS or IP staff will make
monthly or quarterly rounds to all ICMVs in their catchment area.

During these meetings, each ICMV should receive 2 courses of ACT, CQ, PQ, RDT 25 tests, and other
commodities as outlined in the National Treatment Guidelines to be able to test and treat any
patient who comes to them for testing.

During the meetings, the ICMVs will also hand in their monthly carbonless register of malaria cases.

OPERATION STEP BY STEP

Test and treat every person visiting the ICMV

The ICMVs should test any person coming to them, and treat any positive cases, according to the
criteria outlined in the National Treatment Guidelines.

RECORDING AND REPORTING

1) Record all tests and positive cases

All tests and positive cases to be recorded in the ICMVs’ malaria carbonless register as
usual.

2) Reporting

First, second and third copies of Malaria carbonless register must be reported to HF/IP staff
or VBDC at the end of each month.

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SOP for Indoor Residual Spraying (IRS)

PURPOSE

To reduce the probability of indigenous transmission of malaria in receptive active foci (defined as
villages with the malaria vector with local transmission of malaria cases), by repelling mosquitoes
from entering households, and by reducing the lifespan of the vector.

OBJECTIVE

To reduce the vector’s lifespan to less than the time it takes for the malaria sporozoites to develop.
In this way the vector can no longer transmit malaria parasites from one person to another.

To reduce vector density by immediate killing, and to reduce human–vector contact through a
repellent effect, thereby reducing the number of mosquitoes that enter sprayed rooms.

OPERATOR, LOGISTICS, TIMING

The activity is conducted by the township VBDC staffs and IP staff, with support from MEMT, the
BHS, and the ICMVs in high-burden and/or high-transmission villages one month before
transmission season.

REQUIRED RESOURCES AND MATERIAL

Sufficient [long-lasting, residual insecticide] supplies and spray equipment. Material for health
education on malaria

PLANNING AND PREPARATION

1) Mapping/survey of the village

The geographical layout of the village should be mapped out (where a focus investigation has been
conducted, the map drawn up during the focus investigation can be used). The highest-risk houses
should be identified.

2) Planning/ensuring sufficient stock of long-lasting insecticide

The MEMT, BHS, and IP staff should ensure sufficient supplies are available to cover all households
in the village.

35
OPERATION STEP BY STEP

1) Spraying of 80-85% of the households in the village (target 100%)

The MEMT, BHS, VBDC staffs and IP staff should aim to spray the interior of 80-85% of the
households in the village, to ensure critical coverage of the village by IRS.

2) Malaria-related health education

While BHS, VBDC staffs and IP staff are spraying the houses, the ICMV should conduct health
education, to remind the community of the risk of malaria and to seek PCD in case of any malaria
risk exposure, or signs or symptoms, or to encourage the community to participate in MDA or TDA
as planned.

36
SOP for Reactive Indoor Residual Spraying (rIRS)

PURPOSE

To spray the households identified as at-risk following an index case, to prevent onward
transmission of malaria from an index case, whether imported or indigenous, in a receptive residual
or cleared focus (defined as a village with the malaria vector with no indigenous P falciparum cases
for at least 12 months), by repelling mosquitoes from entering households, or killing the mosquitoes
resting indoors and by reducing the lifespan of the vector in the household of the index case and
the households around the case.

This will reduce the likelihood of mosquitoes that may have fed on the index case surviving to infect
other humans.

OBJECTIVE

To reduce the vector’s lifespan to less than the time it takes for the malaria sporozoites to develop.
In this way the vector can no longer transmit malaria parasites from one person to another.

To reduce vector density by immediate killing, and to reduce human–vector contact through a
repellent effect, thereby reducing the number of mosquitoes that enter sprayed rooms.

OPERATOR, LOGISTICS, TIMING

The activity is conducted by the Township MEMT, with support from the BHS, the IP staff, and the
ICMVs, following the detection of a malaria case in stratum B, C and D.

REQUIRED RESOURCES AND MATERIAL

Sufficient [long-lasting, residual insecticide] supplies, spray equipment.

Materials for health education on malaria

PLANNING AND PREPARATION

1) Identification of the index case’s house

When a case has been identified in a residual or cleared focus in which the presence of malaria
vectors has been established, the house in which the index case lives should be identified, as well
as the layout of the nearest 25-50 houses.

2) Ensure sufficient long-lasting insecticide supplies are available for spraying

37
The MEMT, BHS, and IP staff should ensure sufficient supplies are available to cover the 25-50
households surrounding the index case’s house.

OPERATION STEP BY STEP

1) Spraying of 25-50 households around the index case household

Depending on the layout of the village, the BHS and IP staff should aim to spray the interior of 25-
50 households in the immediate vicinity of the household of the index case, within 1 week of the
index case being identified.

2) Malaria-related health education

While the MEMT, BHS, and IP staff are spraying the houses, the ICMV should conduct health
education, to remind the community of the risk of malaria and to seek PCD in case of any malaria
risk exposure, or signs or symptoms.

Recording and reporting

To use the IRS reporting format.

38
SOP for House-to-house Active Fever Screening (AFS) in Strata A, B, C and D

PURPOSE

House-to-house Active Fever Screening (AFS) is to reinforce early case detection and treat malaria
cases accordingly as soon as possible.

OBJECTIVE

The objective of house-to-house fever screening is to detect malaria cases early. This SOP is to
provide guidance for ICMVs conducting routine door-to-door screening.

OPERATOR, LOGISTICS, TIMING

This activity is coordinated by the ICMV at the village level.

The ICMVs should canvas the whole village once a week in Strata A and B, and biweekly in Stratum
C and D: this will require hiring additional ICMV in some villages to enable the ICMV network to
cover the whole village within the given timeframe.

AFS should start immediately after MDA or TDA for villages in Strata A and B, alongside with IPTf
and immediately after the training of the ICMVs for villages in Stratum C and D.

REQUIRED RESOURCES AND MATERIAL

Rapid Diagnostic Tests: Sufficient RDTs stockpiled within the country, to be distributed to the HF
level to cover the needs of all villages for 2-3 months
ACT (Artemether Lumefantrine) + CQ, PQ: the first-line drugs for the treatment
1 ICMV per 50 households
One AFS Form per household
One AFS Summary Form per village
Malaria carbonless register as usual
Mask, hand sanitizer, gloves, Timer
PLANNING AND PREPARATION

1) ICMV to be assigned their blocks of 50 households

Once MDA or TDA have been completed in villages in Strata A or B, the ICMVs will begin to screen
the whole village 5 days per weeks for 12 full calendar months. In Stratum C and D, the ICMVs
should start screening the whole village 5 days biweekly for 12 full calendar months.

The canvasing of the households should take place when family members are most likely to be at
home (early morning/late afternoon).

39
2) Quantification of necessary RDTs and Antimalarials

ICMVs should always have a stock of RDTs and ACTs, CQs and PQs in hand

OPERATION STEP BY STEP

1) Door-to-door visit of every house in the village, including annexes, worksites, forest
settlements:

a. Each ICMV will be responsible for their block of houses within the village, as
designated during the planning and preparation phase

b. An average of ~5 houses should be daily visited by each ICMV, 5 days per week for
villages in Strata A and B, or 5 days biweekly for villages in Stratum C and D for a
full 12 calendar months

2) The ICMVs will use standard malaria RDTs to test all individuals as follows:

a. The ICMVs will offer testing to:

i. any individuals with one or more of any of the following malaria symptoms:
fever, chills, sweats, headache, nausea, vomiting, diarrhoea

ii. any individuals who have been to high-risk areas (forests, mines, worksites,
etc.) or

iii. any individuals wishing to be tested

b. The ICMV will read the test result 15 minutes after testing

c. The ICMV will interpret the test result

3) The ICMV will treat individuals tested positive for malaria according to the national
treatment guidelines and job aids

4) All ICMVs will complete the test and treat activities in the malaria carbonless register and
/smartphone application as usual, on a daily basis

5) The ICMV will complete the information for each member in the house by filling the AFS
Household Form daily, and the Summary AFS Form on a monthly basis.

RECORDING AND REPORTING

1) Record the number of people who were tested by the ICMV during their weekly/monthly
rounds

2) Record the summary of villages AFS in the monthly Summary Form

40