DHA‐piperaquine as an eradication tool in Myanmar Myaing Myaing Nyunt MD PhD Celebrating 15 years of MMV Siam Reap, Cambodia 25 February 2015
DHA‐piperaquine as an eradication tool in Myanmar
Myaing Myaing Nyunt MD PhD
Celebrating 15 years of MMVSiam Reap, Cambodia25 February 2015
Evidence and action for malaria elimination in Myanmar
• Evidence: • To collect baseline data to support elimination & to gather buy‐in from
country leadership and local malaria communities
• Action: Targeted Mass Treatment of malaria ‒ To test an intervention based on evidence collected‒ DHA‐piperaquine ± primaquine and/or others
A question from Myanmar leader
Does it pop or jump?
Justification for malaria elimination in Myanmar • High asymptomatic infections• Presence of artemisinin resistant
P. falciparum in Myanmar• Independent emergence of
artemisinin resistant falciparum • Urgency of need to eliminate
malaria in GMS by scientific communities – Leadership?? – Communities??
VietnamCambodiaMyanmar
Takala‐Harrison et al JID 2014
University of Maryland Baltimore in Myanmar
• Atypical track of UMB collaboration in Myanmar since 2009– Began as technical assistance supported by USAID and WHO, followed
by NIH Fogarty & Open Society Foundation
• Technical assistance to Myanmar – Laboratory support for civilian & military malaria research institutions
– Intellectual support to researchers & academic communities• Optimization of Ethics Review Committees of MoH & MoD• Explicit teaching of ethics and professionalism in medical schools • Faculty development in civilian and military research institutions and medical schools
Research follows capacity development
New surveillance tools for malaria elimination
• Gathering of Myanmar malaria communities on 18 January 2014• Need for systematic and large scale baseline evaluations
• Evidence• Prevalence & distribution of asymptomatic infection • Prevalence & distribution of drug resistant markers• Map parasite migration pattern
• Malaria research and training as a “catalyst” to build trust and to initiate a culture of meaningful collaboration • Leadership & malaria communities • Media & public acceptance & interest
Partners for “Gates Project”
Governmental Role NMCP Lead, coordinate; Field support DMR Field work & lab analysis DSMRC Field & lab analysis Non‐governmental RoleMMA Field work CPI Field work
PSI Field work Burnet Institute Field work & M&EChina CDC Field work & lab analysis Clinton Health Access Initiative Coordination & data translation to policy
Close communication with WHO, USAID/PMI, regional partners
Meaningful collaboration in every steps • Protocol review with all partners on 18 January 2015 in Nay Pyi Taw: Exactly one year after Myanmar malaria community gathering
Region/ State Site Partner
Ayerwaddy Ingapu MMA
Bago East Shwe Kyin DMR/UMB
Chin Paletwa MMA / DSMRC
Kachin Myitkyina DSMRC
Kachin Nabang China CDC
Kayah Hpruso Burnet
Mandalay Madaya DMR/UMB
Rachine Ann MMA
Rachine Buthidaung DMR / DSMRC
Sagaing Ye Oo PSI
Shan Menglian China CDC
Yangon Taik‐kyee DSMRC / MMA
Initial study sites
Identification of low parasitemia• Ability to identify parasites in standard diagnostic methods
– Thick blood smear or RDT: ~50‐200 parasites per uL
• Polymerase chain reaction (PCR) method as surveillance tool• Standard diagnosis and PCR may be missing significant parasites
in low parasite density setting – Standard PCR: 1‐2 parasites/uL– Quantitative PCR (qPCR): <0.02 parasites/uL (<16 parasites/mL)
• Optimized qPCR methods at UMB– High blood volume PCR used on Thai‐Burma border: Challenges in
implementation – Blood volume only 0.3 mL (finger or ear prick) & no refrigeration needed
for 14 days
Future work & long‐term success• Depending on results of this study:
– Where? How? When? With whom?– Evaluate “Targeted Mass Treatment” – Improve qPCR test: Smaller blood volume; Dried blood spots?– Develop minimal surveillance tool for elimination
• Political complexity has effective impact on success or failure of malaria elimination in Myanmar
• Sense of ownership & sense of urgency MUST be felt by local communities and leadership
– Critical for sustained political and community support
Thank you for your attention!