Malaria Burden and Strategies for Control and Elimination.

Malaria Burden and Strategies for Control and Elimination

Outline

● Global situation of malaria elimination in 2011

● Lessons on malaria elimination – WHO regions by region

● Recent WHO activities on malaria elimination

● Major challenges/opportunities ahead

● Conclusions

Current classification of 193 countries and 2 territories by the malaria programme that is implemented in the worst affected part of the country

Malaria Elimination: 2011

Progress with malaria elimination in the WHO European Region

● Ten out of 53 countries in the European Region were affected by malaria in 2000

● As of 2011, locally acquired malaria cases were reported in only four countries: Azerbaijan, Greece, Tajikistan and 1 case in Georgia

● Turkmenistan was certified malaria-free by WHO in 2010, Armenia – in 2011

Indigenous malaria cases in WHO EURO, 2000-2011

0

5000

10000

15000

20000

25000

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Cas

es n

um

ber

Azerbaijan Georgia Kyrgyzstan

Russian Federation Tajikistan Turkey

Turkmenistan Uzbekistan

Progress with malaria elimination in WHO European Region

Number of autochthonous cases of malaria in EURO, 1990-2011

1996

2011

0100002000030000400005000060000700008000090000100000

1990 1993 1996 1999 2002 2005 2008 2011

AREAS AFFECTED BY MALARIA AREAS AFFECTED BY MALARIA

Autochthonous malaria, Central Asia 2011

0

5000

10000

15000

20000

25000

30000

1992 1995 1998 2001 2004 2007 2010

TAJIKISTAN

KYRGYZSTAN

TURKMENISTAN

KAZAKHSTAN

UZBEKISTAN

Similarities & Differences between North Afghanistan and South

Tajikistan SIMILARITIES:● P. vivax malaria is predominant● Areas susceptible to P. falciparum outbreaks/epidemics● The same malariogenic landscapes with the same malaria vectors ● High level of commitment to control and eliminate malaria

DIFFERENCES:● Malaria is more prevalent in Afghanistan● Health infrastructure is in the process of being rebuilt in Afghanistan● Malaria control and elimination policies are uniform in Tajikistan but they are variable in

Afghanistan● Quality control and assurance of anti-malaria measures are absent in Afghanistan but

present to some extent in Tajikistan● Insecure , but relatively safe in North Afghanistan and safe in South Tajikistan

Progress with malaria elimination in WHO Eastern Mediterranean Region

● Twelve out of 22 countries in the Eastern Mediterranean Region reported local malaria transmission in 2000

● During subsequent decade, six countries embarked on nationwide elimination programmes (Islamic Republic of Iran, Iraq, Morocco, Oman, Saudi Arabia and Syria), resulting in 10-fold reduction in malaria cases

● Three others (Pakistan, Sudan and Yemen) developed sub-national malaria-elimination initiatives

● The United Arab Emirates and Morocco were certified malaria-free in 2007 and 2010, respectively

Elimination in Morocco

11

Malaria has been eliminated in MoroccoMalaria has been eliminated in Morocco

Total cases(log scale)

100,000

10,000

1,000

100

10

0

20102005200019951990198519801975197019651960

Total cases

Local cases

Monitoring & surveillance remain high priority

Monitoring & surveillance remain high priority

Map of entomological surveillance sites in Morocco today

Permanent breeding sites for entomological surveillance

Elimination in Iraq

12

Cases of vivax malaria - Iraq 1990-2008

Cases of vivax malaria - Iraq 1990-2008

Sulaimania was the last region with malaria in Iraq

Local cases in Iraq, 2005-2008

Local cases in Iraq, 2005-2008

50

40

30

20

10

0

2010

7

2009

1

2008

2

4

2007

2

1

2006

1

2005

3

Last Local cases in 2008

Last Local cases in 2008

Local cases 

Imported cases

Local cases

100,000

40,000

20,000

0

20102005200019951990

02441,860

9,684

49,836

98,222Total cases

Iran - gradual reduction of malaria cases (1710 cases in 2011 compared to 14396 in 2005)

Close to falciparum elimination only 463 local cases in 2011

Saudi Arabia reported 29 local cases in 2010 ( 99% decrease compared to 2000) However, local cases have increased to 79 in 2011

Elimination in Saudi Arabia and IR Iran

Bilateral coordination - Border units for screening, diagnosis and treatment

قائم قائم الالصصيايابب

المكندراتالمكندرات

سمسرةسمسرة

المجدعةالمجدعة

العرةالعرة المظبرالمظبربتولبتول

السودةالسودة

القرقاعيالقرقاعيالخوبةالخوبة

المصفقالمصفق

Border units

Border screening clinics between Saudi Arabia and YemenSaudi-Yemen border

Saudi Arabia

Yemen

Challenges in malaria elimination/free countriesIncreased Vulnerability

● Considerable increase in population movement (legal and illegal)

● Increase in imported malaria esp. in Gulf countries

● Several outbreaks in Oman ● Increase in local cases in KSA

69 in 2011compared to 69 in 2010

● Mostly imported cases from India and Pakistan

● Majority P. vivax

Challenges: ● Decrease political support ● Border problems● Relaxation● More attention to non-CDs

Country NameImported local

% increase of imported compared to 2010

Bahrain 186 0 107Kuwait 476 0 39Oman 1519 13 28Qatar 673 0 53Saudi Arabia 2719 69 44

UAE 5242 0 61Total 10815 82 50

Source of importation

Imported cases % PV

Pakistan 5514 91

India 2541 95

Unknown 2491 98

Yemen 920 15

Afghanistan 714 91

Progress with malaria elimination in WHO Region of the Americas (PAHO)

● Local malaria transmission in 23 out of 47 countries in 2000

● Four have since progressed to the pre-elimination phase (Argentina, El Salvador, Paraguay and Mexico)

● Two have initiated an elimination programme at sub-national level (Dominican Republic and Haiti)

● Two other countries (Bahamas and Jamaica) suffered a temporary reintroduction of malaria transmission in 2006 that has since been controlled

Progress with malaria elimination in WHO Southeast Asia Region (SEARO)

● With exception of the Maldives, which is preventing reintroduction following its successful elimination efforts in the 1980s, all 11 countries affected by malaria during last decade

● Two countries progressing with nationwide elimination (Sri Lanka and Democratic People’s Republic of Korea)

● Indonesia has adopted a sub-national elimination strategy for Java and Bali

● Bhutan and Thailand, where large areas with no malaria transmission are found, have expressed their intention to proceed with elimination

Progress with malaria elimination in WHO Western Pacific Region (WPRO)

● Malaria is still endemic in 10 of 37 countries● Malaysia and Republic of Korea implementing

nationwide malaria elimination programmes ● Sub-national elimination on-going in Philippines,

Solomon Islands, and Vanuatu ● Cambodia, China, Viet Nam and Lao People’s

Democratic Republic have included elimination in their national strategies.

● In 2010, China made a government commitment to eliminate malaria

Progress with malaria elimination in WHO African Region (AFRO)

● All but four of 46 countries have on-going transmission● Lesotho, Mauritius, and the Seychelles not endemic for

malaria ● Algeria is in the elimination phase; Cape Verde entered the

pre-elimination phase in 2010● Four countries of southern Africa (Botswana, Namibia, South

Africa and Swaziland) share a common goal of eliminating malaria by 2015; joined by four northern neighbours (Angola, Mozambique, Zambia and Zimbabwe) in 2009, to form sub-regional malaria elimination initiative known as Elimination Eight (E8)

● Another four countries in Africa (Gambia, Rwanda, Sao Tome and Principe, and Madagascar) have secured grants to prepare for elimination

Recent WHO activities on malaria elimination

● Community Based Reduction of Malaria Transmission (with malERA)

● Eliminating Malaria: Learning from the Past and Looking Ahead

● Malaria Elimination Case Studies Series (together with UCSF Global Health Group)

● Elimination Scenario Planning (ESP) tool (together with Clinton Health Access Initiative)

● Launch of Disease Surveillance for Malaria Elimination

● Launch of T3: Test. Treat. Track.

Major challenges ahead

● Political commitment

● Financial resources

● Procurement and supply chain management

● Health system capacity

● Delivering quality case management in the private sector

● Human resource capacity

● Antimalarial drug resistance

● Insecticide resistance

● Inadequate surveillance and controversies over burden estimation

● Delivering results in highest burden countries

Challenge: Global political commitment

● Context Major shift towards non-communicable diseases Sense that malaria has already made significant progress, therefore

needs less support going forward Fatigue (this is a long fight)

● Potential solutions Consistent evidence-based policy setting (WHO Malaria Policy

Advisory Committee) Careful and consistent documenting of impact Link to wider health & development efforts Resolutions from major organizations (e.g. UN, WHO) Organizational support (e.g. ALMA) Helping countries cross the finish line (malaria elimination)

● Risks Advocacy sometimes out ahead of reality: a fine line

Continued global political commitment

● Creation of African Leaders Malaria Alliance (ALMA): 2009

● United Nations General Assembly resolution on malaria: April 2011

● World Health Assembly (WHA) resolution on malaria: May 2011

● Roll Back Malaria (RBM) Partnership revised objectives, targets, and priorities: June 2011

● malERA (2009-2011) & MESA (2012 & beyond)

Challenge: Financial

● Context Well short of estimated 6 billion USD per year required Concerning data to suggest that funds could decline by 2015 Global financial crisis and competing priorities with potential to

worsen the situation Global Fund Continuity of Services policy does not include

malaria● Potential solutions

Increased efficiency and value for money Increased domestic funding for malaria Innovative financing mechanisms

● Risks Worsening financial crisis; continued financial challenges at

Global Fund

Major opportunities ahead

● Malaria elimination: crossing the finish line

● Trans-border collaboration

● New uses for existing tools. Example: Seasonal Malaria Chemoprevention (WHO policy for Sahel sub-Region as of 2012)

● New tools: malaria vaccine in 2015?

● Integrated community case management (iCCM)

● Improving efficiency and value for money. Example: a 5-year LLIN

● Universal diagnostic testing, improved case management, and strengthened surveillance (T3: Test, Treat, Track)

● Stratification: Using data for decision making Determining the optimal intervention mix for different

epidemiological settings

Malaria Surveillance Manuals – Worldwide launch: Namibia, 24 April 2012

● Objective To provide guidance to malaria-endemic countries on the operation of

malaria surveillance systems for malaria control and elimination● Rationale

Updated malaria surveillance guidance has not been issued by WHO since the Global Malaria Eradication Programme era

Scale-up of malaria interventions increases need for timely and accurate information on malaria occurrence for program management

Increasing availability of malaria diagnostic tests allows for tracking confirmed malaria cases and better targeting of resources

New manuals focus on program implementation and complement other existing guidance on malaria indicators

Surveillance Manuals: Objective and Rationale

Surveillance Manual Content

• Developed by WHO with help from members of the Roll Back Malaria Monitoring and Evaluation Reference Group and other partners in global malaria community

• Focus on routine information systems, decentralized analysis, interpretation and use of surveillance data

• Structure: two volumes: (i) programs in control phase; (ii) programs in elimination phase

1. Overview of Malaria Surveillance in Different Phases of Malaria Control

2. Key Concepts in Malaria Surveillance

3. Data Recording, Reporting, Analysis and Use

4. Establishing Surveillance Systems

• Annexes

• Diagnostic tests/ quality assurance

• Core surveillance indicators

• Registers, case investigation forms, report forms, sample analyses

Three WHO Manuals as pillars of T3

Test Treat Track

T3: Test. Treat. Track.Worldwide Launch: Namibia, World Malaria Day 2012

Conclusions

● Experiences in countries of EMR – provide important lessons for Rwanda i.e. cross-border and vulnerability

● Complacency and lack of political commitment

● Tendency to withdraw resources for malaria following successful elimination. There is a need to strengthen: Capacity on surveillance so that cases are picked

up, treated and reported rapidly (T3) Capacity for entomological and insecticide

resistance monitoring Capacity to respond to malaria outbreaks through

appropriate vector control interventions

I thank you for your attention