Malaria Elimination Project Quarterly Report (FY19 Q2)

CAMBODIA MALARIA ELIMINATION PROJECT

Cambodia Malaria Elimination Project

Quarterly Progress Report - Year 3, Quarter 2 January - March 2019

Submission Date: April 30, 2019

Contract Number: AID-442-C-17-00001 Contract Period: October 26, 2016 to October 25, 2021 COR: Rida Slot Alternate COR: Noah Sprafkin

Submitted by: Sharon Thangadurai, Chief of Party University of Research Co., LLC. #31, St 352, Sangkat Beugkengkang 1, Khan Chankamon, , Email: [email protected]

This document was produced by University Research Co., LLC (URC) for review and approval by the United States Agency for International Development (USAID).

Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

TABLE OF CONTENTS

Acronyms ...... iv

1. Introduction ...... 1

2. Progress Toward achieving CMEP OBJECTIVES ...... 3 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia...... 3 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist...... 8 2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities ...... 12 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level ...... 14

3. Project Management ...... 15 Oversight and Coordination ...... 15 Procurement ...... 19 Financial Management ...... 19

4. Resolving challenges from FY19 Q1 ...... 20

5. Challenges and actions taken or proposed ...... 20

6. Plans for next Quarter and upcoming events ...... 20 ANNEX 1 CSO FY19 Q1 RESULTS TABLES ...... 22 ANNEX 2 - LAB QA/MICROSCOPY TRAINING TABLES ...... 26

i Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

ACRONYMS

ACT Artemisinin-based Combination Therapies AOP Annual Operational Plan BKN Bakan BTB CMEP Cambodia Malaria Elimination Project CBO / CSO Community Based Organization / Civil Society Organization CDC Centers for Disease Control and Prevention CN Concept Note CNM Cambodia National Malaria Center COP / DCOP Chief of Party /Deputy Chief of Party COR Contracting Officer’s Representative EDAT Early Diagnosis and Treatment GUC Grants Under Contract HC Health Centre HF Health Facility HP Health Post IDQA Internal Data Quality Assessment IPC Interpersonal Communication IRB Institutional Review Board ITN Insecticide-Treated Net KRK Krakor LLIN / LLIHN Long Lasting Insecticidal Net / Hammock Net M&E Monitoring and Evaluation MEAF Malaria Elimination Action Framework 2016-2020 MMP Mobile and Migrant Populations MMW Mobile Malaria Worker MoH Ministry of Health MOP Malaria Operational Plan MRS Maung Russey OD / ODMS Operational Health District / OD Malaria Supervisor ODTL/ODTLA Operational District Team Leader / OD Assistant TL OEC Operation Enfant Cambodge PHD / PMS Provincial Health Department / Provincial Malaria Supervisor PKV Phnom Kravanh PLN Pailin PMI President’s Malaria Initiative PP Private Provider PPM Private Public Mix PMP Performance Management Plan RDT Rapid Diagnostic Tests SBCC Social and Behavior Change Communication SLDPQ Single Low Dose Primaquine SOP Standard Operating Procedure SPL Sampov Loun STA Senior Technical Advisor TMK Thmar Kaul UNOPS United Nations Office for Project Services URC University Research Co., LLC USAID United States Agency for International Development VMW Village Malaria Worker WHO World Health Organization

i Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

1. INTRODUCTION The USAID | PMI Cambodia Malaria Elimination Project (CMEP), 2016-2021, was launched on October 26, 2016 to support the Cambodian National Center for Malaria Control, Parasitology and Entomology (CNM) to reduce malaria morbidity and mortality and contribute towards malaria elimination goals nationwide by 2025. To reach this goal, the project has set up four strategic objectives to: 1. Develop a scalable, evidence-based elimination model in Sampov Loun OD and support its dissemination & replication for malaria elimination in Cambodia. 2. Support scale-up of high-quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist. 3. Strengthen national malaria surveillance systems and monitoring and evaluation (M&E) appropriate for malaria elimination and control activities. 4. Build capacity of malaria program to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level. Until Year 2 Quarter 2, CMEP implemented activities in four ODs in (Sampov Loun (SPL), Battambang (BTB), Maung Russey (MRS), Thmar Kaul (TMK)) and two ODs in Province (Phnom Kravanh (PKV) and Krakor (KKR)). During Year 2 Quarter 3 (April to June 2018), CMEP expanded to three additional ODs (two ODs in : Bakan and Sampov Meas, and 1 OD in Pailin Province: Pailin OD). Three transitional ODs graduated to elimination ODs (BTB, MRS and TMK), and Pailin was selected as an elimination OD. See Figure 1 for a summary of activity progress in FY19 Q2. In all 9 ODs, CMEP conducted the following activities in FY19 Q2: . 18,838 of suspected cases tested with 2,281 positive cases confirmed and all cases received appropriate treatment according to National Treatment Guidelines . Among the 5 elimination ODs in Battambang and Pailin province, 89% of all cases were notified within 1 day, 76% investigated within 3 days, and 73% responded to within 7 days (for SPL OD, 100% were notified within 1 day, 100% investigated within 3 days, and 100% respnded to within 7 days) . CMEP response to the increase in cases in Pursat ODs in FY19 Q2 continued and included monitoring daily/weekly cases, intensifying services at all points of care, and the continued setup and support of touchpoint/peer educator volunteers (there are now 6 touch point volunteers in KRK, 8 in PKV ODs, 5 touch point volunteers in KRK, 11 in PKV ODs) . Despite the changes due to the Private Provider ‘PRAKAS’, CMEP continued to support PPs in the areas of SBCC and referrals of suspected malaria patients . In the 5 elimination ODs, CMEP deployed 24,731 ITNs as buffer stock to VMWs in Q2 (target=14,600). Through VMW outreach activities, 14,977 ITNs were distributed (target=12,950) to local recidents and 3,031 ITNs (target=775) were distributed to PPMs through MMWs at big farms and MMP locations . In the 4 transitional ODs, 16,893 ITNs were deployed as buffer stock (target was 23,440) to the VMW level. 9,323 ITNs were distributed to local residents (target=13,425) and 330 ITNs were distributed (target was 480) to MMPs at big farms and MMP locations during outreach and response activities . Conducted systematic administration of single low dose primaquine for confirmed P. falciparum (Pf)/mixed cases (154 cases in all 9 target ODS). . Supported CNM technical units to conduct 52 planned supervision visits (target=49).

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

CMEPpittFY19Q2.xlsx Progress against each performance indicator is presented in the file attached.

Figure 1. CMEP Summary of Activity Progress (January-March 2019)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

2. PROGRESS TOWARD ACHIEVING CMEP OBJECTIVES 2.1 Objective 1: Develop a scalable, evidence-based elimination model in SPL OD and support its dissemination and replication for malaria elimination in Cambodia. Task 1. Pre-implementation situational analysis of current malaria elimination operations in SPL: Rapid Situational Analysis and Needs Assessment Report1: Task 2. Sustain universal long-lasting insecticidal net (LLIN) coverage: Mass distribution: There was no mass distribution activity in FY19 Q2 for Objective 1. Ensure continuous distribution of LLINs: In line with the updated list of villages for ITN distribution, CMEP’s target for continuous LLIN distribution was 201 villages in the 5 elimination ODs (partially due to an overall reduction of VMWs in elimination ODs in Q2) [Act 1.2.3]. Of these 5 elimination ODs, CMEP deployed 24,731 ITNs as buffer stock to VMWs in Q2 (14,600 planned). CMEP will further deploy ITNs in Q3, using USG-purchased ITNs. CMEP distributed 14,977 ITNs (12,950 planned) to target populations during outreach and response activities [Act 1.2.5] and another 3,031 ITNs (target=775) were distributed to MMPs at big farms and MMP locations [Act 1.2.5.a]. Net top up and malaria education to households: In the 5 elimination ODs, VMWs conducted 2,560 visits (target=1,110) to households/farms for net use monitoring, net top-up and health education [Act 1.2.6]. The number of supervision visits increased significantly as the number of VMW visits increased to up to 5 visits per month. Visits to household members and farm workers included health education for malaria prevention and LLIN use. The CNM ITN Unit conducted all 5 monitoring & supervision visits for all 5 elimination ODs in Q2 [Act 1.2.7]. Task 3. Ensure Early Diagnosis and Treatment (EDAT) and follow up: For the 5 elimination ODs, CMEP activities covered 374 points of care in Q2 (82 public health facilities and 292 VMWs/MMWs) in Q2 (this figure does not include private providers as they are now not allowed to perform malaria tests and treatment) [Act. 1.3.1]. 9,969 of 10,409 (96%) suspected malaria cases received a parasitological test. 76.03% of individuals were tested by VMWs and 23.97% by HFs. Out of all the individuals tested, 160 cases (1.60%) were confirmed positive. All 160 cases were enrolled in the system and 128 have travel history information. (See Figure 2 for a table of case classification and a case distribution map for Q2). Further analysis showed that 35 cases (27%) were imported from Pursat, 15 (12 %) from and the remaining 78 cases (61%) from other provinces in Cambodia.There were no local cases (L1, L2, L3) for Pf/Mix identified in this quarter in the 5 elimination ODs. Figure 2. Map of case classification in table for 5 ODs and reported malaria cases by origin and, Jan-Mar 2018

1 Activity 1,1.1. was completed in Year 1 and Year 2 is not applicable to the FY19 Q2 reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Out of 160 positive cases reported in FY19 Q2, 6 (3.75%) were Pf/mixed and 154 (96.25%) were Pv. Figure 3 provides the cases breakdown for Q2 and the cases trend since 2017.

Figure 3. Number of confirmed malaria cases in 5 ODs per species in Oct-2016-Mar 2019 (source MIS/PMIS)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Of the total 160 cases, 6 were Pf/mixed. All 6 Pf/mixed cases were reached through reminder messages via the mHealth application and were automatically transferred to a response team to conduct 28-day follow up. 3 patients out of 6 (50%) received 28-day follow-up. 3 of the cases missed 28-day follow up (mainly due to patient movements and not being able to return for day 28) [Act. 1.3.3]. Figure 4 summarizes the implementation of DOT for PF/mixed cases in the 5 CMEP elimination ODs. Figure 4. Implementation of DOT in 5 ODs per species (*data fully Pf/Mixed)

In FY19 Q2, no patients were hospitalized for second line treatment in the 5 elimination ODs. [Act 1.3.6]. CMEP provided orientation training to government staff and continued emphasizing the use of single low dose primaquine (SLD-PQ) in monthly meetings with VMWs and HF staff since FY18. All 6 Pf/mixed cases diagnosed in the 5 ODs in Q2 are eligible for SLDPQ (weight ≥ 50kg) and received SLDPQ 100%, and 4 cases received 7-day follow up no significant SLD-PQ adverse events were notified. CNM Pharmacy, Lab and Diagnosis and Treatment units completed 4 supervision visits (5 visits planned) during FY19 Q2. [Act. 1.3.10]. 1 visit is planned for Q3. Task 4. Malaria case reporting, investigation, and response For 5 ODs, in Q2, 142 out of 160 cases (89 %) were notified within 1 day via the SMS Day-0 mHealth system, 121 (76%) were investigated within 3 days, and for 117 (73%), the response was provided within 7 days [Act.1.4.1-1.4.3]. All HFs and VMWs followed the established 1- 3-7 surveillance practice. Among all 160 confirmed cases, 18 cases (11%) were not notified within 24 hours. This late notification was mainly due to limitations of internet connection, tablets and smartphones (which were not functioning well) and to HF staff/VMWs being busy. For the investigation within 3 days, 39 cases (24%) were investigated later than 3 days or were not investigated due too late notification or no notification being done or due to patient movements. For response within 7 days, 43 cases out of 160 cases (27%) were not responded too or were responded too later than 7 days, mainly due to no or late notification or HF staff being busy [Act.1.4.1-1.4.3]. Task 5. Strengthen case management, reporting, and response to all malaria cases in the private sector CMEP is proposing a contract modification to be submitted in May regarding private sector non involvement in testing and treatment. In Q2 53% of PPs (133/250) attended the PP meetings [Act 1.5.3]. PPs who were absent from quarterly meetings were either busy with other tasks or did not consider the meetings relevant as they realize PPs are no longer able to test or treat. Those PPs who were absent received data collection visits from PHD/OD or from CMEP staff to ensure all PPs were continuing to provide health education and referrals for suspected malaria patients for all target populations. Semesterly supervision visits were also conducted to provide technical feedback on referrals and to improve SBCC initiatives.

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Although no supervision visits were planned, 23 visits to 104 PPs were accomplished in Q2 [Act 1.5.4]. Supervision visits in Q2 served to compliment those visits missed in Q1. Five supervision visits (target=5) from CNM’s PPM unit were conducted in Q2 [Act 1.5.6]. Task 6: Build capacity and strengthen systems to manage elimination activities Supporting VMW monthly meetings: Monthly meetings continued in Q2 to support capacity building of VMWs and HF staff. Meetings were held during the fourth week of January, February and March. In Q2, for the 5 ODs, 949 VMWs attended meetings versus 1,240 planned (76.5%) [Act 1.6.1]. The VMWs who did not attend the meeting were notified as first time absent, and CMEP along with HF staff will now monitor the VMWs for the 2nd and 3rd month, and if found consecutively not attending for 3 months, CMEP and the OD will ensure the replacement of VMWs as per CNM guidance. CMEP OD teams visited 20 absent VMWs at their homes to review progress and provide mentoring [Act 1.6.2]. Reasons mentioned for the VMWs being absent included attending to economic activites and travel to other provinces. Integrated supervision from ODs to HFs: 43 supervision visits were conducted to 79 HFs in the 5 elimination ODs using the CNM supervision checklist (target=51) [Act 1.6.3]. No artemisinin-based combination (ACT) stock outs or potential stock outs were detected at the time of supervision (data verification confirmed the accuracy of this). Also, data verification on total tests, total confirmed cases and total treated cases was performed during the visits. Stock monitoring: CMEP continued to provide monthly RDT and ACT (ASMQ & Pyramax) stock status reports to CNM and all partners including UNOPS and updates from all HFs in the 9 target ODs. Overall, stocks of tests and drugs in CMEP areas was secured for the period of January-March 2019; there was no stockout while the few places that did identify any potential stockout were immediately fixed. There was no reallocation of drugs between Elimination ODs during Q2. CMEP staff also visited key HCs, reviewed/monitored the stock levels and verified the consumption against the allocation. Visit to selected VMW’s from CNM VMW Unit 5 visits were made by the CNM VMW unit for quality assurance during Q2 [Act 1.6.6]. District Special Working Group for Malaria Elimination: 3 meetings were conducted in Q2 (2 in TMK and 1 in BTB ODs). The meetings facilitated updates of the malaria situation for participants and the common challenges were discussed [Act 1.6.7]. Provincial Special Working Group for Malaria Elimination 1 meeting was conducted in PLN province in Q2 (February 18th, 2019). [Act 1.6.8].The meeting was chaired by the Provincial Governer. The current situation and efforts taken by CMEP/CNM/PHD/OD/HFs/VMWs was discussed. The provincial working group assured that all possible support will be provided for elimination activities by all sectors. They also promised to follow up on relevant elimination activities and to try to increase VMW attendance at VMW meetings. Task 7. Social and Behavior Change Communication (SBCC) for malaria elimination2 In the 5 elimination ODs, 9,969 individuals tested for malaria received IPC for malaria education (target=4,735 – over target mainly due to VMWs/HFs increasing their number of tests and increased CSO activity) [Act 1.7.1]. In addition to malaria patients, IPC was provided to 5216 people (170 sessions were carried out at SPL, BTB, TMK, MRS & PLN) from high- risk groups during case response activities [Act 1.7.2]. At the farms, VMWs organized small group education sessions to deliver key malaria messages. As a result, 7,939 MMPs were reached at farms with malaria outreach educational activities. CNM Health Education Unit

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) made 5 visits to the elimination ODs in Q2 (target 5) [Act 1.7.3]. In Q2, CMEP continued to support the public service announcements (PSA’s) and radio call- in show program in BTB Province. The PSA’s continue 4 times a day in BTB (see under Objective 2, Task 6 on how PSA’s may be considered as being effective similar to Pursat ODs). Task 8. Support civil society organizations (CSOs/CBOs) to complement malaria elimination activities During Q2, CMEP conducted 2 field visits (January and March) to review the implementation of AHEAD (who work in BTB, TMK, SPL and PLN ODs) and OEC (who work in MRS OD). During the January field visits, CMEP noted that both sub-grantees had succeeded in engaging all relevant stakeholders (including HF staff, volunteers and local authorities). However, it was observed that some implementing approaches demonstrated were not well standardized. CMEP organized a technical training for AHEAD/OEC staff on February 7th 2019. The aim of the training was to improve the technical capacity and quality of sub-grantee and CMEP staff on implementation. The training included standardizing activity implementing approaches, understanding CMEP project indicators, sub-grantee management, branding and marketing. During the March field visits, CMEP observed improvement in the implementation approach of AHEAD and OEC, and were particularly impressed with OEC who demonstrated an interesting MMP mapping exercise/health education campaign in remote villages where individuals have been isolated from public health services for a considerable time. On March 29, 2019, CMEP organized a Q2 CSO review meeting in Pursat where AHEAD and OEC presented their progress, challenges and solutions. Overall, during Q2, AHEAD and OEC accomplished good results in organizing the HE campaign, ITN distribution, MMP mapping, and suspected malaria patient referrals and follow-up. For AHEAD, all key indicators were achieved above target due to their committed staff and successful collaboration with partners. For OEC, most key indicators were achieved. AHEAD results for Q2 are provided in Annex 1. Task 9. Conduct operational research in the context of malaria elimination CMEP prepared a summary report of the hsRDT study for PMI/CDC following their template. By 31st March 2019, 9 Pf cases were enrolled and 47 people (including index cases) were screened through Re-ACD with 4 testing tools (cRDT, 2 types of hsRDT-Alere & Global Good, and PCR DBS). None of the screened individuals tested positive for malaria. Importantly, CMEP continues to discuss with CNM, implementing partners and donors for additional priority OR subjects in line with the national malaria elimination framework. The meeting on HsRDT was held in Battambang on March 26, 2019 with CDC HQ, IPC and CMEP. During the meeting it was agreed that the modification of the HsRDT study protocol is required to expand coverage areas (in Pursat) to ensure completeness of 150 Pf sample cases and 1000 screenings from populations surrounding those index cases. Task 10. Refine existing malaria elimination tools, SOPs, and guidelines The remaining tool to be developed for malaria elimination is the foci investigation form and work on this continued in Q2. CMEP actively joined with CNM, WHO and CHAI to review and develop an SOP for foci investigation and management along with the foci investigation form itself and conducted a field testing excercise in February 2019 for selected L1 cases reported in BTB and MRS areas during 2018. CMEP actively participated and took the lead in entomological monitoring, mapping and house enumeration and field survey as part of the activity. The outcome of this were discussed in 3 separate meetings at CNM and the finalization of the SOP and investigation forms will be completed on April 30, 2019. The foci investigation

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) form itself will be ready to be implemented in late Q3 or starting from Q4. 2.2 Objective 2: Support scale-up of high quality malaria control and prevention interventions in five to eight ODs, where gaps in coverage or quality exist Task 1. Rapid Situational Analysis and Needs Assessment Report - There was no activity on this task during FY19 Q2. Task 2. Ensure universal coverage with LLINs Mass distribution: There was no mass distribution activity in FY19 Q2 for Objective 2. Continuous LLIN distribution and top up monitoring: Initially, there was no plan to deploy ITNs to VMWs/MMWs in Q2 given the mass distribution campaign. However, since CNM revised targets for ITN mass distribution for only villages with an API ≥5, CMEP deployed ITNs to villages that were not covered by the mass campaign. Therefore, 16,893 (72%) ITNs were deployed as buffer stock at the health center and VMW level (23,440 planned). During Q2, CMEP distributed 9,323 (69%) ITNs (13,425 planned) to target populations during outreach and response activities in January - March 2019. The actual result was lower than planned due to a relatively low need for ITNs after the mass distribution event [Act 2.2.5]. MMWs distributed 330 ITNs at big farms and MMP locations in Q2 (480 targeted) [2.2.6]. VMWs/MMWs conducted outreach visits to households and farms to top up ITNs using remaining nets from the previous deployment, along with providing SBCC activities and EDAT services, when required. 1,807 visits were accomplished (570 planned) by VMWs to households for ‘use monitoring’ and health education [Act 2.2.7]. 24,948 individuals received malaria education through IPC (target=5,700, increase due to more VMW visits) [Act 2.2.8]. Task 3. Ensure EDAT and follow up Provide ongoing support in malaria diagnosis and treatment: CMEP activities covered 354 Point of Care units in Jan-March 2019 for 4 transitional ODs (53 HFs and 301 VMWs). PPs are now excluded as they are not allowed to test and treat [Act 2.3.1]. In the 4 transitional ODs, 8,869 individuals were tested, 2,121 were confirmed with malaria and 2,119 cases were treated in Q2 (see Figure 5). For confirmed cases, 248 cases (12%) were Pf/mixed and 1,873 cases (88%) were Pv. Three-day DOT was provided to 176 Pf/mixed cases by VMWs (97% of total, 181 Pf/Mix cases) [Act. 2.3.2]. 150 Pf/mix cases received SLD-PQ treatment by VMWs [Act 2.3.3]. During Q2, there were no severe malaria cases [Act. 2.3.4]. Figure 5. Confirmed malaria cases in 4 ODs (January 2017 to March 2019)

Table 1 provides a breakdown of the confirmed malaria cases by species in the 4 transitional ODs. Overall, there has been a significant increase in Pf and Pv cases from 2017 onwards (especially in Phnom Kravanh and Krakor ODs – see Figure 6).

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Figure 6. Monthly malaria cases in Kravanh and Krakor ODs

Table 1. Breakdown of confirmed malaria cases by species in 4 ODs

OD Name Species Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Pf 434 345 238 198 179 208 321 347 418 380 242 196 157 128 67 54 77 39 Kravanh Pv 336 478 377 343 382 465 574 861 945 928 853 740 669 644 545 517 415 365 Mix 26 39 29 24 19 49 28 33 31 26 7 18 11 15 10 11 6 2 Pf 145 119 57 56 67 47 72 82 115 73 81 47 47 48 26 25 16 9 Krakor Pv 139 165 159 167 138 167 215 196 317 246 308 205 231 216 165 195 137 120 Mix 21 10 6 6 3 10 5 2 1211 7 4 3 2 2 4 1 0 Pf 13 8 6 3 61311 3 312 8 0 1 2 0 0 0 0 Bakan Pv 6 16 6 4 8 9 16 30 24 23 26 21 30 23 21 18 14 13 Mix 1520002 30200100000 Pf 21 15 7 7 11 0 14 7 1710 12 15 8 4 10 2 2 0 Sampov Meas Pv 19 19 18 15 9 19 37 23 55 56 45 47 40 43 34 33 26 20 Mix 3010000 02222200000 Outreach activities: Among all confirmed malaria cases, 1,486 cases (70%) were in PKV, 507 cases (24 %) were in KRK ODs, and the remaining 128 cases (6 %) were in BKN and SPM ODs. See Figure 7 for maps showing village incidence in Kravanh and Krakor ODs. Although there were some changes in the number of cases identified in individual villages, the general areas of concern remain the same, with most representing areas near the forest. For 9 selected high incidence villages in PKV, there were 103 cases in January 2019 and 64 cases in March 2019. For 12 selected high incidence villages in KRK, there were 30 cases in January 2019 and only 15 cases in March 2019. Jan-19 until Mar-19. See Figure 7 for maps showing variation of these village incidence by month in the Kravanh and Krakor ODs. Figure 7. Map of villages with high number of malaria cases in PKV and KRK

Forest interventions: In response to the high caseload in Pursat province remaining from 2018, CMEP continued supporting forest interventions along with an intensification plan (IP) introduced by CNM since October 2018. The interventions aim at increasing malaria services coverage for forest workers, particularly in PKV and KRK ODs where population movement into the forest areas is still very dynamic. In Q2, the interventions were managed through 68 MMWs, which included 14 touch point volunteers (6 in KRK and 8 in PKV), 16 peer educators (5 in KRK and 11 in PKV), 7 ‘MMWs at big farms’ (4 in KRK and 3 in PKV), and 31 Forest Rangers (3 in KRK and 28 in PKV). The Forest Rangers MMWs became active during Q2 after reciveing training from CMEP. The MMWs (touch point/peer educator volunteers) contacted forest goers/workers to conduct malaria testing, provide treatment for confirmed cases, provide health education via IPC, and distribute treated nets and SBCC materials (as the touch points are entry points, they come into contact with forest goers while they pass through the touch points into the forests, the peer educators get into contact with the forest goers when

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) visiting the work sites). The MMWs regularly joined monthly meetings with VMWs (under the same catchment areas of relevant HFs). Results showed the touch point and peer volunteers conducted site visits to meet with forest workers and tested 1,620 suspected malaria patients. 241 patients (221 Pv and 20 Pf/Mx) or 15% tested positive. 719 ITNs were distributed (many of the forest goers already have nets from previous distribution events) and 1,689 health education sessions were conducted (which reached 2,531 forest workers). Capacity building: In Q2, there was 38 Case Management trainings conducted for newly recruited touch point volunteers and peer educators. Technical supervisions were conducted by technical units from CNM, as well as PHDs/ODs to respective target ODs and HFs/VMWs. CNM supervision: There were 6 supervision visits from the laboratory unit of CNM to the transitional ODs conducted as a follow up from Q1 against the 4 planned. 4 supervision visits from pharmacy unit were made to transitional ODs against 4 planned[Act 2.3.10]. Task 4. Strengthen case management and reporting in the private sector: Private Provider Mapping: CMEP is proposing for a modification due to be submitted in May regarding private sector non involvement in testing an treatment. However, 2 quarterly meetings (4 planned) were held in the 4 ODs (PPM tasks are no longer a priority for the Government functionaries and PPMs are not motivated to attend the meeting. [Act 2.4.3]. 88 PPs attended (target=122) the quarterly meeting (during which the main question being asked is why the PPs were stopped to test and treat and when will this ban be lifted). Supervision visits: During this reporting period, there were no supervision visits from CNM PPM unit to CMEP transitional ODs [Act. 2.4.5]. Task 5. Build capacity and strengthen systems to manage malaria control activities: CMEP Support to VMWs/MMWs: In total, 650 (274-KRK; 214-PKV; 65-SPM; 97-BKN) VMWs/MMWs (target 542) attended monthly meetings from January to March 2019 (120%) [Act 2.5.1]. During these meetings, VMWs reported information on malaria cases; received RDTs/ACTs from health center staff; and, received on the job training for case management, SBCC, case registration/reporting, and ITN monitoring/top-up reports. VMWs also shared challenges which included difficulties with DOT completion among MMPs and forest-related workers, poor road conditions, long distances to travel and unnecessary demands of topping up ITNs among the residents. During Q3, CMEP teams at OD level will continue to work with VMWs to encourage them to attend meetings to share experiences and build knowledge, and will work with ODMS to ensure that the attendance of VMWs in meetings increases. Integrated supervision from OD to HFs [Act 2.5.3]: 39 supervisory visits were accomplished during Q2 (103% - 38 planned). Build capacity and strengthen systems to manage malaria commodities: CMEP provided support in stock monitoring and management to the nine target ODs during Q2. CMEP used the mHealth application (via laptops) [Act 2.5.4-2.5.5] which automatically geotags facilities and locations to allow close monitoring of places visited. ACT distribution:1 actual ACT stock out and 1 actual stockout of RDTs were reported in the 9 ODs (for BKN OD which was due to one 1 non-endemic HF having Pyramax drugs in stock rather than ASMQ – the situation was quickly rectified). Otherwise, the routine supply of commodities from MOH/CMS was sufficient for all CMEP target ODs. Table 2 provides a summary of the OD level stock monitoring. Table 2. Q2 ACT and RDT stock monitoring in all ODs

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Operational # of HFs ACT RDT District monitored Potential Stock Out Potential Stock Out SPL 10 0 0 0 0 BTB 28 0 0 0 0 PKV 8 0 0 0 0 KRK 8 0 0 0 0 TMK 18 0 0 0 0 MRS 15 0 0 0 0 PLN 6 0 0 0 0 BKN 11 0 1 0 1 SPM 12 0 0 0 0 TOTAL 116 0 1 0 1 Visits to selected VMWs from CNM VMW Unit: In Q2, 4 visits from CNM’s VMW Unit to CMEP areas were undertaken (target=4) [Act. 2.5.6]. Provincial special working group for malaria elimination [Act 2.5.7]: There was one planned provincial special working group meeting for malaria elimination in the transitional areas. A meeting was held in Pursat province on March 29th 2019 and was chaired by PHD director and one CNM deputy director (the provincial governor/vice governor’s were not available). Task 6. Strengthen BCC interventions for intensified malaria control IPC to tested malaria cases and high-risk groups: From January to March 2019, 8,869 (target 12701) suspected malaria patients were tested and received IPC through VMWs and HCs [Act 2.6.1]. For the high risk groups in KRK and PKV ODs, 16 peer educators and 14 touch points provided 1,689 health education sessions to 2531 MMPs (target=1,231sessions) [Act 2.6.2]. Public Service announcement broadcasting: CMEP has continued to support Pursat PHD to broadcast public service announcements on the radio (broadcasting 4 times per day to alert malaria vulnerable persons using ‘radio 98.50 MHz’). The broadcasting includes a one-hour radio call-in show. According to the CAP-Malaria project endline survey conducted in September 2016, 40% of the MMP’s on the project received malaria messages through radio channels. This evidence supported the request of the Pursat PHD Director to CMEP to support the radio call-in show program and PSA broadcasting as part of the malaria case increased response activities in Pursat Province. CMEP has supported the PSA’s since August 2018. CMEP team followed up on the PSA progress and understood that the broadcasted programs reached the target location quite well. It has been noted that awareness building through mass media campaigns (talk/radio shows) have been the channel of some behavior change and CMEP belives that the PSA’s may have influenced the target audience behaviors. Malaria education campaigns at schools: In Q2, CMEP supported Pursat provincial and district education staff to assess the ability of previously CMEP trained teachers in delivering key malaria messages to students and to then assess the knowledge of students in relation to malaria knowledge. For the 32 targeted primary schools in Veal Veng Administrative District, 2,097 (female:927) students received malaria messages from their teachers. Of these students, 1,895 (female:867) students were interviewed by POE/DOE to assess their knowledge and it was observed that, for most of these, they responded well to the checklist questions. In Q2, CMEP supported similar activities in 12 primary schools in KRK OD. In total, 1,781 (female:904) students recieved malaria messages from their teachers. 825 of these (female: 425) were interviewed to assess their malaria knowledge and nearly all could answer correctly the 6 questions relating to malaria causes, prevention and treatment. Task 7. Support civil society and community-based organizations (CBOs) to implement Provide support to selected CSO partners & Implement sub-grant activities [Act 2.7.2]:In FY19, CMEP contracted PFDA to work in its 4 transitional ODs (PKV, KRK, SPM, BKN).

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

The PFDA activities supplement the role of CMEP. PFDA field activities were monitored on a monthly basis by CMEP OD teams, and have been visited twice by CMEP central team with similar objectives for sub-grantees as mentioned in Objective 1 task 8. According to the visits, CMEP observed that, although PFDA has been able to collaborate well with all partners, counterparts, community volunteers and local authorities to implement its activities, there were some issues identified including challenges around selecting target locations/populations and the methodology being used for conducting health education campaigns. These issues were addressed at the technical training organized by CMEP on February 7th in Pursat Province (together with AHEAD and OEC). PFDA achieved reasonable results for its indicator targets with shortfalls on suspected patient referrals, number of reported cases and number of counterpart meetings. The PFDA Q2 results by indicator are provided in Annex 1, Table 2. Sub-grant oversight and management: CMEP team at the central level continues providing ongoing technical and financial support to PFDA through conducting field visits and phone call support. At the OD level, CMEP works closely with PFDA to conduct monthly field visits and organize feedback meetings. CMEP central team continues to conduct the quarterly progress review for PFDA aiming to review how effectively PFDA executed their activities. Task 8. Operational research- CMEP OR activity is covered under Objective 1.

2.3 Objective 3: Strengthen national malaria surveillance systems and M&E appropriate for malaria elimination and control activities

Task 1. Refine and harmonize M&E reporting forms and support consistent use by public and private healthcare providers Work with CNM and partners to harmonize M&E reporting forms: Technical supervision procedures were revised for HF/RH/ODs in March 2019. [Act 3.1.1] Support consistent use of the harmonized forms by providers: CMEP regularly ensures consistency of the forms (including recent visits/spot checks from key staff that check for this) Some inconsistent Elimination forms were identified in the ODs in Q2 by the CMEP team. OD teams were urged to always use the required correct forms [Act 3.1.2.] Overall, 92% of providers submitted surveillance data on time(100% from HFs and 91% from VMWs). See Figure 8 for percentages per OD. Figure 8: Percentage of HFs, VMWs/MMWs, and private providers in target transitional ODs submitting surveillance data on time per national guidelines.

Task 2. Provide technical assistance on data management and use Conduct IDQA at OD and selected HFs by ODMS/PMS and CMEP [Act 3.2.2]: The CMEP IDQA exercise was conducted in FY19 Q1 (December 2018). It was carried out for 2 ODs, 1 elimination OD (MRS) and 1 transitional OD (KRK). The exercise was carried out successfully using an updated IDQA tool (similar to what USAID uses for its own DQA exercises). The

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) report was approved by COR in February 2019. Provide TA to CNM on village-based stratification and facilitate use of stratification tools [Act 3.2.3]: CMEP team (COP & STA) joined a meeting at CNM with partners to review the criteria for VMW scale down and setup at elimination and transitional areas. Two criteria in terms of village distance to HF and village API were recommended. Due to the unavailability and lack of village area information, CMEP has started developing the next administrative level/commune based stratification for all 9 ODs. Initial maps have been completed, and various parameters required for spatial analysis and stratification have been collected. Provide TA to CNM on data visualization and outbreak module development for MIS The distribution of the CMEP OD Bulletins for FY 18/FY19 has contributed to the TA to CNM on data visualization. The bulletins provide useful visual representations of OD cases and species and are provided in the local language. [Act 3.2.4] CNM supervision [Act 3.2.5]: During Q2, several visits were conducted by CNM technical units to CMEP target areas. Table 3 summarizes these visits. Table 3: Summary of CNM Technical Unit visits in Q2. Unit from CNM Q2 Planned Q2 Actual Percentage ITN unit 9 9 100% Pharmacy unit 4 4 100% Laboratory unit 5 7 140% PPM unit 5 6 120% VMW unit 8 9 112.5% Health Education Unit 9 6 66.7% M&E unit 9 6 66.7% Epidemiology unit 0 5 NA Entomology 2 2 100% Total 51 54 103% The reasons given for the M&E Unit and Health Education Unit not reaching their target number of visits were these units being busy with other donor activities during Q2 (they aim to catch up on these planned visits during Q3). Task 3. Support further development and implementation of electronic data reporting and use platform CMEP continues to monitor and follow up on the use of smartphones designated to VMWs and tablets designated to HF/OD staff that provide notification and reporting of malaria cases and stock status of malaria commodities. ODs are in the process of compiling the lists of phones (and those that are damaged etc). Task 4. Strengthen capacity to conduct entomologic monitoring 3 Conduct entomology training for OD and PHD staff [Act 3.4.1.]: No entomology training was provided during FY19 Q2. However, CMEP/CNM joint monthly vector surveillance was conducted at 2 sentinel sites in Pursat province in January and March 2019.[Act 3.4.4]. This activity was conducted by a team including CNM, PHD, OD, HC, VMWs and CMEP staff for 5 days per month and using 3 different collection methods.

3 No targets were set for activities 3.4.1-3.4.2 in Q2 FY 2019

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Tables 5 and 6 provide the results for the Q2 entomology monitoring visits (All of the data from the monthly collections was entered into a database developed by CMEP, which will be handed over to the CNM entomologist after the completion of the work by CMEP).

Table 5 - Summary of Jan 2019 entomological sentinel site collections

Collection No. of Total Anopheles No. of different An. Culicines Method traps collected Spp.

CDC Light Traps 5 3 74 Cattle bait trap collections 2 596 16 1890 Human Landing collections 2 0 0 845

Table 6 - Summary of Mar 2019 entomological sentinel site collections

CDC light trap No. of Total Anopheles No. of different An. Culicines collections traps collected Spp. CDC Light Traps 5 0 0 0 Cattle bait trap collections 2 118 13 815

Human Landing collections 2 4 3 255 It was observed that there is a decresing trend in the number of Anopheles mosquitos collected during this peiod, which may be due to it being dry season. Cattle bait traps still show the highest number of Anopleles mosquitoes collected and the other 2 methods, CDC light traps and Human landing collections, were not that productive. All collected mosquitoes were identified, verified and stored. It was also noted that, despite the absence of An. Dirus, a few An. maculatis and An. minimus were collected primarily from the Cattle Bait Traps. To know the infective rates, species confirmation, resistance mechanism and status of the collected mosqitoes, necessary molecular tests should be carried out as early as possible. 2.4 Objective 4: Build capacity of Ministry of Health (MOH) to manage, intensify, and sustain malaria control and elimination efforts particularly at the OD level Task 1. Develop and implement a plan to strengthen technical and management capacity at National, PHD and OD levels4 OD AOP development [Act 4.1.4.]: All AOPs for 9 ODs were further reviewed during Q2 by CMEP. The main issues covered in the meetings included, a) all the ODs highlighted concerns regarding targeting, b) some activities required re-wording/re-phrasing c) OD Director/ODMS mentioned issues with PPMs, d) Some of the OD Directors mentioned it might be challenging to change the VMW setups in the ODs due to various political and historical reasons. Internal Competency Assessment (ICA) course for selected malaria microscopists [Act 4.1.7] Due to conflicting schedules/priorities of the CNM Lab team and the malaria annual meeting, this activity was not conducted during Q2. The course has been rescheduled for April 8-12, 2019 with confirmation from the CNM Lab unit chief, and therefore will be undertaken in Q3.

4 Activities 4.1.1-4.1.3 are not applicable to the reporting period

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Laboratory quality assurance [Act 4.1.8]: From January to March 2019, the CMEP Lab Supervisor conducted supervision visits to lab HCs for 5 elimination ODs with the BTB Provincial Lab Supervisor (BTB, SPL, TMK, MRS ODs) and for Pailin province. Crosschecking for lab QA was carried out in PLN, BTB, SPL, TMK and MRS ODs. Annex 2, table 1 provides a summary of the crosscheck results. From March 25 – 29, 2019, ICA conducted training for malaria microscopists, which was organized by the CNM team (Lab unit) for the 12 lab staff from Battambang, Pursat and Pailin provinces. Annex 2, Table 2 provides the results of the training. Provide on the job training and mentoring by CNM units [Act 4.1.9]: There was no specific training provided on entomology in Q2. As previously mentioned under activity 3.4.4, there were foci investigation testing exercises conducted in Q2 (1 in January and 1 in March). Whilst a few persons were trained during these exercises, this was not a formal training. E-Payment [Act 4.1.10]:The e-payment system is used to pay per diems, transportation and other allowances through mobile payments. During Q2, CMEP further implemented e- payments for VMWs at SPL, PLN, BTB and MRS (scale up in hard to reach locations remains a challenge, as there are no financial centres, MFIs /banks in these locations). Task 2. Support CNM and MOH to develop and maintain a system for on-going technical and management capacity development Provide technical assistance to CNM [Act 4.2.1]: There were 52 technical assistance feedback sessions provided by CMEP to CNM in Q2. CMEP progress review [Act 4.2.2.]: The CMEP central progress review meeting took place in Battambang on March 13th. 57 participants joined the meeting and it was presided over by the CNM Deputy Director, BTB PHD Deputy Director and the CMEP COP. The highlights of the review included discussions on PPMs, VMW attendance and 28 day follow-up. CNM clarification and guidance focused on PPM-VMW management, CSO focus, capacity building, system strengthening and surveillance.The participants included CNM staff, target PHDs, ODs, CMEP and relevant NGO partners. Task 3: Improve malaria policies and guidelines [Act 4.3.1] In Q2, the CMEP team worked with CNM, WHO and other partners during several meetings to initiate Pv radical treatment, update SLDPQ dosing including for SLDPQ to cover patients from 20 Kg up, and regarding the development of SOP/tools for foci investigation and management. CNM SBCC strategy development: [Act 4.3.1] After receiving feedback from the CNM Director and discussions amongst the CNM team, CMEP decided to revise the BCC strategy book. The strategy book modification is under way and will be finalized in Q3 (CMEP has been part of the development process and CMEP has been at the forefront in developing and supporting CNM in drafting the strategy). 3. PROJECT MANAGEMENT Oversight and Coordination CMEP Field Visits: The CMEP team continues to conduct field visits to all project sites for routine monitoring and to attend significant activities and events. In Q2, the following key visits took place: A 2-day ODTL meeting in Pursat (February 5-6, 2019) was led by the COP, DCOP, STA and all 9 DTLs and 9 ODTLAs. The meeting agenda was altered due to an urgent exercise on revisiting OD AOP targets for Year 3 by adjusting them to align with the approved CMEP country Work Plan. Emphasis was also made for several specific activities to ensure set targets

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) are achievable for ODs (for example, ITN distribution through VMWs and CSOs, participation of VMWs at monthly meetings, HF/OD/PHD and CNM supervision) On February 8, 2019, the COP and DCOP visited 2 HCs (Pramoy and Thmar Da) in with PKV ODTL, Pursat CMEP Coordinator, Pursat Technical Chief. The focus of the visit was Pramoy HC (along with its 2 HP satellites) where malaria cases are still high (2,500 cases in 2018 and 150 cases in January 2019). Several issues were discussed with the HC teams including laboratory services, an increase of malaria testing, management of complicated/severe cases, repeated Pv cases, available RDTs and drugs, PPM activities (including discussions on whether they test/treat), MMPs and border crossing populations. On February 8, 2019, the DCOP and relevant ODTLs attended the Pursat Provincial Special Working Group on Malaria Elimination which was chaired by the Provincial Governor. The ODTLs provided a detailed presentation on CMEP activities. Mobile/migrant issues were discussed and the PHD also informed participants on the PRAKAS situation for PPs. On 12th and 13th of February, CMEP provided MMW training in Pursat for 32 Forest Rangers based in Pursat province. Impressive results were achieved during the training, and sets of relevant equipment, materials, RDT, ASMQ, PQ, LLIHNs and recording tools were delivered to 17 fixed locations within 3 administrative districts of Krakor, Phnom Kravanh and Veal Veng. The training was appreciated by CNM/Pursat PHD Directors and it could eventually be adopted as a standard training. Pictures of the training activities were displayed at the CNM annual conference in from February 20-21, 2019. On February 12th, a one day ‘device’ training event was provided by the CMEP team in Pursat for the Health Facility staff taking part in the ‘Round 2 LLIN Durability Monitoring Survey’. The participants were provided background on the ‘Round 2’ electronic based survey plans, specific training on using the devices to conduct the survey, and a schedule to conduct the survey in the field in February/March 2019 was agreed. On February 14th, 2019, an ODTL meeting was organized in Pursat to clarify remaining issues with AOP activities, targets and required procedures to ensure appropriate project implementation and monitoring (attended by COP, STA, M&E, ODTLs, ODTLAs, HFCs). From February 26-27, a 2 day field observation and spot check visit took place by CMEP M&E team and key technical staff in BTB and KRK ODs. The purpose of the visits were to ensure that the Health Facility Enumerators were carrying out the LLIN Durability monitoring survey as trained (and also using the devices to correctly collect the data). From March 19th-20, the COP, STA, CMEP SPM OD team, Chief of Technical Bureau of Pursat, PHD and ODMSs visited 10 HFs (5 in SPM and 5 in BKN). The purpose of the visits were to assess the malaria burden/situation and the potential readiness/preparedness of the facilities to be able to move to malaria elimination. A brief was provided to the HF at the start of the visit on malaria elimination. Malaria data was then checked via the various HF registers. Commodity stocks at the HF were also checked. Overall, the HF staff appeared committed to commence malaria elimination activities in their catchement areas. A follow-up meeting was held with CNM, Pursat PHD, SPM and BKN ODs and CMEP, which resulted in a general agreement to move SPM and BKN ODs to elimination within the next 4-6 months. Sub-grant oversight and management: CMEP conducted 2 field visits (January and March) to review the implementation of AHEAD (who work in BTB, TMK, SPL and PLN ODs) and OEC (who work in MRS OD). On February 7th, CMEP organized a technical training for sub-grantee staff and CMEP staff in Pursat Province. The training was conducted to improve technical capacity of CMEP and sub-

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) grantee staff on the sub-grantee implementation. In total, 31 (9 CMEP staff) participated in the meeting. On Friday March 29th, a similar meeting was held in Battambang OD. CMEP organized the Q2 CSO review meeting in Pursat on March 29, 2019. All 3 sub-grantees presented their results, challenges and possible solutions for improvement. A similar meeting will be held in Q3. Meetings with USAID, CNM, Implementing Partners, and Others: (1) Meetings with the USAID COR - During Q2, CMEP team met with the PMI-USAID team and the COR. On February 21, CMEP met with COR in Siem Reap to provide updates on various project activities including the CMEP support to the ongoing CNM annual conference; training of 32 forest rangers as MMWs; foci investigation testing; progress on the Concept Note for Pv radical cure; hsRDT study; PMI quarterly report; central progress review; Sri Lanka visit; World Malaria Day on April 25, 2019; review of PPMs as per contract deliverable; OR network coordination meeting; the interest expressed by the CNM director to pilot the distribution of sets of hammocks and nets to forest goers; moving Pursat to elimination (considering the 2 low burden of SPM and BKN); LLIN DM; and, the request from COR to share CMEP bi-weekly update reports. COR provided feedback to CMEP on revising the Pv radical cure Concept Note, PPM challenges in relation to the contract modification and deciding on whether 2 ODs (BKN & SPM) from Pursat province might move to elimination. CMEP joined the Cambodia ‘STEM’ festival in Phnom Penh from February 21-23 with other US funded projects. CMEP focused on project BCC activities, demonstrating the mobile app and entomological activities. Mainly school children and university students attended the festival. The CMEP booth was also visited by US Ambassador/USAID Mission Director. On March 25, 2019, CMEP COP and STA, along with CDC team from HQ, met IPC representative (Ms. Kim Nimul) for an update on the hsRDT study and to visit laboratory facilities in IPC, followed by field visits from March 25-27. At Prey Tralach HC (MRS OD), where 1 Pf case had been detected, the IPC team, along with CMEP/HC staff conducted a Re- ACD and interviewed participants who were eligible for malaria testing. As a result, the index case was found to be an imported case (L4 originally infected in Pursat province); therefore no one was detected positive by this Re-ACD. During the testing, it was observed that the ‘Global Good’ hsRDT tests were invalid, which required the team to perform new tests. This concern was raised by CDC who requested it be followed up. CDC, CMEP & IPC then discussed ways to amend the protocol factoring in the challenges of the index case and surrounding screening. It was agreed that a modification of the hsRDT study protocol is required to expand coverage areas to ensure completeness of the 150 Pf samples of index cases and for the 1,000 screened people surrounding these index cases. (2) Meetings with CNM and Other Partners Meeting with CNM on Prepration of CNM Conference: CMEP met CNM and partners at CMEP office on January 31, 2019 to prepare slides for the CNM Annual Conference CMEP Attendance at CNM Annual Conference: From February 20-21, CMEP COP, STA, and Senior BCC Advisor joined the CNM Annual Conference in Siem Reap. Over 360 participants attended the conference (CNM, MOH, military, police, donors, NGOs implementing partners and representatives of Municipality/PHDs, and malaria endemic ODs). The conference shared CNM progress/achievements in 2018, challenges, lessons learned and ways forward for 2019. CMEP presented on its continued support to the national program, key achievements, challenges, lessons learned, activities planned for 2019 and various SBCC

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) materials. At a separate meeting, CMEP shared with other research partners the CMEP elimination approaches and results achieved on CMEP elimination work. Meeting with CNM on Malaria OR Network Coordination: On February 22, 2019, the ‘Research Network’ meeting was called by CNM (on the request of CMEP). It was chaired by CNM Deputy Director (Professor Lek Dysoley), an additional CNM Deputy Director and CNM Technical Bureau, Epidemiology, VMW, Health Education Chiefs. Participants were from CNM, CMEP, MORU, NAMRU, AFRIM, NIH, Korean University, WHO, MSF, PSI, MC, HPA, HSD, Consortium for Health, as well as USAID/PMI (Dr. Rida Slot). CMEP shared progress on its current hsRDT study in BTB/PLN and discussed potential OR topics including: (i) Tafenoquine Single Dose for Pv radical cure; (ii) Ivermectin introduction to interrupt malaria transmission; and, (iii) Effective prevention tools/health seeking behavior with community engagement. It was agreed with PMI that CMEP should proceed with a selected research topic and that the research network meeting should be held twice a year. Meeting with CNM on Intensification Plan: On February 25, 2019, CMEP STA met CNM and other partners to receive feedback on the Intensification Plan (IP). The results were interesting as the MMWs were already being recruited/trained/equipped and providing services. CMEP was asked why they had not recruited any MMWs in the 4 recommended HCs by CNM (Pramoy, Prognil, Anlongreap and Chhoukmeas). In response, CMEP said that it agreed with the HCs/ODs, who had said that there were no apparent gaps and that it was not necessary to recruit more MMWs because no new hotspots had yet been identified. Participation in Foci Investigation field testing with CNM/Other Partners: From February 26 – March 1, DCOP and Dr. Narann participated in the Foci Investigation testing in BTB province with CNM and partners (WHO and CHAI), along with CMEP OD and PHD staff. The data verification and preparation was carried out at the BTB OD office. On February 28th, field activities were conducted in OtaTeung Village in Bueng Run HC area (BTB OD) and on February 29th in ‘Praly 18’ in Pray Talach HC area (MRS OD). Mapping, house enumeration and mobility assessments were carried out. All selected L1 cases were properly followed up. On March 1st, preliminary findings were presented by the team to the PHD/staff. On March 15, 2019, CMEP met CNM to discuss the field testing. It was agreed the results were impressive and, therefore, SOP/tools development (factoring in the local cases of L1) should be progressed so that the foci investigation could be initiated. CMEP Central Review Meeting (with CNM): On March 13 2019, CMEP held its central progress review in Battambang (57 particpants). It was chaired by the CNM Deputy Director, BTB PHD Deputy Director and COP (details of discussions provided under activity 4.2.2). Meeting with IPC/Partners: A meeting was held at the CMEP office with IPC in regard to the HsRDT progress and field visits. Through this meeting, CMEP learned that IPC was facing challenges getting the sample index cases, as the pf cases have been limited. Thus, IPC proposed an amendment to be able to move to Pursat. CMEP suggested setting up a meeting with Jimee from CDC to discuss and explore amendment possibilities. Meeting with WHO/Partners: The Malaria Elimination Partner Forum was held in Phnom Penh (March 28-29). CMEP presented its various efforts on forest interventions. Meeting with PSM: On March 4th, the COP met the Procurement & Supply Management (PSM) Managing Director to discuss ways forward and increased coordination (in absence of PSM Country Director). It was agreed bi-monthly meetings would be held to improve efforts around stocks review and procurement requirements until the PSM Country Director returns. Meeting with UNOPS: The COP met the UNOPS Program Coordinator after the CNM annual meeting to discuss procurement for radical cure intervention planning and the required support from CMEP. A proposal from the CNM Director on the piloting and procuring of

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2) hammock/nets for forest goers to study net preferences in forest locations was also shared with UNOPS who agreed that a meeting with CNM, UNOPS and CMEP should be held. Procurement During FY19 Q2, CMEP procured 1 Water Cooler to use at PNH office. It was not necessary to purchase any Equipment/Supplies in Q2 as various inventory had been transferred from the URC QHS/SHP projects. The summary of procured items for Q2 is provided in Table 7 below.

Table 7 CMEP Procured Items FY19 Q2 No. Item Unit Purchased date 1 Water Cooler 1 11 March 2019 Financial Management During Q2, CMEP spent 99% of its budgeted amount (see Table 8 for a summary of planned versus actual expenses during Q2). -CMEP over spent its budgeted line item for Salary and Wages by 26% due to the introduction of mandatory ‘seniority payments’ (based on an updated Prakas introduced in January 2019). -CMEP did not spend on any equipment or supplies because it used the inventory/equipment that was transferrred from URC ‘QHS/SHP’ projects -CMEP over spent on Travel, Transportation and Travel by 106%. This was because CMEP increased its monitoring visits, especially to Pursat, and also had extra meetings called by CNM and provincial stakeholders. CMEP also increased staff visits to CSO locations and VMWs. -CMEP over spent on Other Direct Costs by 82%. This was due to increased costs related to office moves in Phnom Penh and Battambang (more expensive rental agreements and CMEP offices no longer sharing with other URC projects), and rental of a warehouse in Battambang. In Q3, CMEP will continue to maintain the expenditure in program activities as already demonstrated during Q2. Table 8 provides a summary of Q2 expenditure with explanations. Table 8: CMEP planned vs. actual expenses FY19 Q2 Cost

TOTAL E

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Human Resource Management At the end of Q2, CMEP had 69 staff on board (with a target of 71 staff). 4 new staff joined CMEP and 2 staff resigned. This compares with Q2 where there were 64 staff on board, 1 new staff joined and zero resigned. The new staff joining included 1 Security Guard and 1 Finance Assistant (joined January 2019) and 2 OD Data Assistants (joined February/March 2019). 4. RESOLVING CHALLENGES FROM FY19 Q1 The major challenges that arose in FY19 Q1 were around the issues on agreeing and calling meetings to develop the foci investigation process and Pv radical cure intervention. In FY19 Q2, CMEP was able to influence and maneuver the process in coordination with WHO and CNM, who helped to organize the field testing visit to BTB province from February 26 – March 1. CNM, WHO and CHAI also participated in this visit. In regard to the PV radical cure process, CMEP, CNM and CHAI were able to decide on the process to be undertaken to get the job aids and other plans in place. CMEP provided the quantification and requirement of G6PD test assay and the required PQ 7.5 mg. CMEP made every efforts to follow-up on a regular basis and also involved the COR in the process of quantification. 5. CHALLENGES AND ACTIONS TAKEN OR PROPOSED The Research Network meeting, which had been postponed several times since year 2, was held on February 22, 2019 with support from CMEP. The members who attended the meeting appreciated CMEP’s efforts and suggested a meeting to be held twice a year. While taking into consideration efforts made so far on foci investigation and Pv radical cure, challenges exist around getting WHO and CNM to agree on job aids/materials required for both. CMEP also revised the Pv Radical cure intervention CN and is waiting for PMI approval (once approved, CMEP will share with WHO/CNM and will then execute the Pv intervention). CMEP asked CNM to organize another meeting to rapidly get all of the SOPs for the foci investigation completed so that a quick trial can then be done to assess the relevance of these foci investigation SOPs in the elimination ODs. 6. PLANS FOR NEXT QUARTER AND UPCOMING EVENTS The focus and strategic action in Q3 will be largely around: - Organizing and conducting the WMD in all CMEP 3 provinces on April 25th. CMEP staff will participate in the WMD in Mondulkiri on April 22, 2019. - Cross visit of CNM /PHD/OD and CMEP staff to Srilanka from May 5-11, 2019. - Put in place a robust action plan in Kravannh OD following the April 8-9 CNM visit. Further develop the action plan and increase the level of effort to target forest goers. - Prepare the CMEP contract dcuments for modification on i) moving SPM and BKN to eliminaton ODs; ii) PPM indicator revision; and, iii) budget realignments. - Ensure and support CNM and CHAI for procurement of G6PD tests and PQ supply. - Follow-up with PSM on PQ procurement. - Submit the HsRDT protocol ammendments to IRB Cambodia once approved by IRB CDC. - PV radical cure intervention concept note once approved by PMI will then be ready for execution, subject to supply of G6PD and PQ

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

- Support WHO and CNM in finalizing the Foci Investigation SOP. - Support WHO/CNM to finalize training materials/job aids for Pv radical cure intervention.

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

ANNEX 1 CSO FY19 Q1 RESULTS TABLES

Table 1 AHEAD Results FY19 Q2 Indicators Target Actual Target explanation 1. # of health education 147 147 Target 140 in Quarter 2 but reached campaigns organized in 147 (SPL 4, Thmar Kol 2 and PLN 1) high transmission villages Campaign educations due to carry over from Quarter 1 that had not been reached by 7 campaigns 2. # of mobile/migrant 3,500 4,520 More MMPs now work in the target and new settlers reached villages with BCC messages through IPC 3. # of LLINs distributed to 400 1,299 More MMPs now work in the target mobile/migrant villages populations 4. # of mobile/migrant 144 229 More MMPs now work in the target settlements mapped villages 5. # of suspected malaria 350 362 Battambang, Sampov Loun and Pailin patients referred to achieved above target. Thmar Kaul OD VMWs/HFs did not reach its target because it was hard to find the suspected malaria patients.

6.# of patients seeking 332 362 Achieved above target treatment at VMWs/HFs (referred suspected cases reached VMWs/HFs) 7.# of reports of any 2 2 Joined with CMEP and HC to conduct increase in malaria cases case response activities or outbreaks 8.# of meetings organized 5 5 Meeting and discussion with OD with OD and PHD by CSOs Director and ODMS at Thamar Koul and Sampov Loun OD 9. # of government 3 7 Attended Pro-TWGH, OD monthly meetings attended by meeting, health annual conference, CSOs (Pro-TWGH meeting) meeting with (PSWGME) and (DSWGME)

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

Table 2 OEC Results FY19 Q2 Indicators Target Actual Target explanation 1. # of health education campaigns 17 23 Achieved above target in the organized in high transmission quarter. OEC worked closely villages with ODMS, HC, CMEP OD team leader, focal persons, and village volunteers to accelerate health education campaigns in the remote annex villages. Due to harvest season/crop collection, it was possible to conduct many health education campaign and reach more migrants/mobile workers. 2. # of mobile/migrant and new 515 696 Achieved above target in the settlers reached with BCC messages quarter. OEC worked closely through IPC with ODMS, HC, CMEP OD team leader, focal persons, and village volunteers to accelerate health education campaigns in the remote annex villages. Due to harvest season/crop collection, it was possible to conduct many health education campaign and reach more migrants/mobile workers. 3. # of LLINs distributed to 429 1409 Achieved above target due to mobile/migrant population more settlements of MMPs for seasonal working on harvest/collecting crops 4. # of mobile/migrant settlements 12 22 Achieved above target due to mapped more settlements of MMPs for seasonal working on harvest/collecting crops 5. # of suspected malaria patients 360 88 Lack of focal people (9FPs referred to VMWs/HFs selected among 16 ps). OEC hopes that after selecting more FPs, this target will be reached. 6. # of patients seeking treatment at 360 88 It is linked to indicator # 5 VMWs/HFs (referred suspected cases reached VMWs/HFs) 7. # of report any increased malaria 4 0 Increase cases or an outbreak cases or outbreaks did not occur in this quarter

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

8. # of meetings organized with OD 3 4 Achieved above target and PHD by CSOs 9. # of government meetings 3 4 Achieved above target attended by CSOs (Pro-TWGH meeting)

Table 3 PFDA Results FY19 Q2

Indicators Target Actual Target explanation 1. # of health education 120 537 Achieved above target because campaigns organized in the number included small group high transmission villages health education sessions by contact points 2. # of mobile/migrant 1,200 6,322 Achieved above target because this and new settlers reached number included persons attending with BCC messages the small group education sessions through IPC 3. # of LLINs distributed to 1,036 3,982 Achieved above target because mobile/migrant identified people who needed ITN populations were more than estimated 4. # of mobile/migrant 21 42 Achieved above target, a total 23 settlements mapped mapped were found and a total 4,314 (2,025 female) in this include 3,499 (1,663 female) from local residents and a total 815 (362 female) are people who stay in these sites 5. # of suspected malaria 434 144 Under achieved because this is dry patients referred to season, so it was hard to find VMWs/HFs suspected patients. 6.# of patients seeking 95% 100% 100% of suspected patient referred treatment at VMWs/HFs reaching location of VMW/HC have (referred suspected cases been followed up in this month. reached VMWs/HFs) Among these cases, 66 cases were tested with 22 positive cases (breakdown by species, Pf:1, Pv:21) and these received treatment on time from VMWs/MMW/HCs. 7.# of reports of any 12 0 No reports of malaria increase, increased malaria cases or because no case increase in this outbreaks month compare with last months VMW records

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

8.# of meetings organized 3 3 Achieved the target with OD and PHD (Pro- TWGH meeting) 9. # of government 12 10 In February, PFDA did not have time meetings attended by to attend all meetings organized CSOs because their staff were busy selecting contact points to meet their deadline

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Cambodia Malaria Elimination Project Quarterly Report (FY19 Q2)

ANNEX 2 - LAB QA/MICROSCOPY TRAINING TABLES

Table 1 - Slides crosscheck for lab QA January-March 2019 in BTB and Pailin Provinces

HC Lab result HC Lab result QA Lab result QA Lab result OD Name of HC Negative Positive Negative Positive

Ou Chrar 0 0 Absence Lab PL Krachab 4 1 4 1 Phnom Spong 1 0 1 0 BR 11 (D28=1) 1 11 1 BTB Tasanh 15 4 15 4 Sdao 3 3 3 3 Plov Meas 0 1 0 1 Kompong Lpov 3 0 3 0 RH SPL 15 2 15 2 SPL Trang 3 (D28 =1) 1 3 1 Pichenda 8 1 8 1 TMK RH 9 0 9 0 TMK BV 3 0 2 1 MRS MRS RH 4 (D28) 0 4 0 Prey Trolach 4 10 4 10 Total 83 24 82 25 Accuracy 98% 96%

Table 2 – Q2 Malaria microscopist training

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