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Malaria elimination in the North Eastern Thailand
2014-2019
To interrupt malaria transmission (no indigenous cases
of malaria for three years) in the North Eastern
Thailand by 2018
Goal
0
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8
10
12
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16
0
2
4
6
8
10
2000 2003 2006 2009 2012
ABER SPR API
ABER & SPR / 100 pop. API / 1,000 pop.
Annual Blood Examination Rate (ABER), Slide PositivityRate (SPR) and
Annual Parasite Incidence (API/1,000), Thailand FY 2000 - 2013
Fiscal Year
0.31.6
2.1
41.2
58.8
0
20
40
60
80
100
1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
P.falciparum P.vivax
Percentage
Fiscal Year
Proportion of malaria parasite species, Thailand, FY 1965-2013
P. falciparum
P. vivax
All cases in 2013 Indigenous Cases, 2013
Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%)
PCD = 2,755 (TPR=18%)ACD = 3,294 (TPR=0%)API = 0.02 per 1,000Total case = 477 (Pf.= 26)Indigenous cases = 1Infected outside villages=2
Malaria foci, 2013% of case investigated, 2013
Technical feasibility
Vectorial capacity and receptivityEntomology
Is vectorial capacity low at the outset?
In the most part of Thailand, Vectorial capacity is relative low, especially in plain areas. Although, the main vectors in Thailand are An.dirus and An.minimus, high coverage of vector control measures result in vectors short-lived. In transmission areas (border and forest areas), Anophelline are still anthropophilic, but low vector density.
Can it be reduced to a level compatible with elimination?
Entomology
Main vectors are rather endophilic, endophagic and night-biting. Vectors tend to be endophilic and exophagic where are high coverage of vector control. Most breeding sites are able to be identified, but forest areas where transmission occurs. Vectors are still sensitive to insecticide (Pyrethroid). Malaria transmission is seasonal, but high coverage of vector control result in significant reduction of malaria cases.
Physical environment
Malaria is very low transmission in this region. Houses in endemic areas are sprayable walls with high acceptability.
Human ecology
Houses are made from wood and bamboo with sprayable wall. IRS and LLINs are highly accepted and used. Personal protection such as sleep under bed-net and mosquito repellent are common practices. Villagers in endemic areas practice outside activities in the evening such as wood cutting, and hunting.
Control effectiveness
Vector controls and personal protection are the main strategies for anti-malaria program. The action plan is adjusted annually to ensure the coverage and maintain high effectiveness in targeted areas. Case management is free of charge for everyone. There are collaboration of all affected communities and potential partners (inter-sectoral).
Can it thereafter be maintained below a threshold?
Environment, development
There is absence of natural or man-made disasters. There is no ongoing or expected changes in natural or human ecology favouring lower vectorial capacity, depending on zoo-geographic region and local vector bionomics (e.g. deforestation, desertification, pollution, urbanization).
(2) Duration of infectivity
Can duration of infectivity be reduced to and maintained at very low level?About 60 % of the total cases are P. vivax and resistance to ACT is reported in some provinces but the country targets to contain and eliminate resistant parasite with well collaboration with other inter-sectoral partners. Most at risk population seek treatment at public health facilities due to universal health coverage. Radical treatment and DOTs is applied for all species. Migrants are also able to access health services with free of charges.
(3) VulnerabilityCan importation of infections be reduced or maintained at low level?
Movement of population in these regions in common, which may increase importation of malaria cases. However, Health services such as treatment and prevention are high coverage and strong surveillance is in place.
Surveillance system in targeted areas
Passive case detection
• Hospitals
• Malaria posts
• Malaria clinics
Active case detection
• Mobile malaria clinics
• Proactive case finding in malaria transmission areas
• Reactive case finding
12
Case investigation and follow up
Case definition All positive malaria cases diagnosed with laboratory
confirmed including symptomatic and asymptomatic cases are included in the surveillance system.
Criteria for malaria testing Malaria clinics: all suspected malaria cases who
visit malaria clinics. Hospitals:
Patients whom have history of traveling to endemic areas.????
Methods of confirmation and Quality control
All suspected cases of malaria are diagnosed with microscopy or RDT (use in village malaria posts, for every RDT, a blood smear will be sent to malaria clinics).
A case investigation form will be completed for all confirmed cases
Confirmed cases will be followed Pf: 3, 7, 14, 21, 28day
Pv: 7, 14, 60, 90day
QA diagnosis
All positive slides and 10% negative slides are rechecked by expert microscopists
Department of Disease Control
Vector Borne Disease• Malaria • Filariasis• Dengue Fever
Office for Disease Prevention and Control
CENTRAL LEVEL
DISTRICT LEVEL
PROVINCIAL LEVEL
CANTON LEVEL
Provincial Public Health
• Provincial Hospital Vector Borne Diseases Control Center
Vector Borne Diseases Control Unit
Malaria Clinic
District Public Health• District Hospital
Health Center
REGIONAL LEVEL
Epidemiology
Coordination
Command
Malaria Post 15
Real-time web-based
Private clinics and hospitals??
Technologies• Web-based synchronization technology • capable of switching between offline / online mode of data entry. This
terminology is benefit for the low resources area. Users can still operate in case of internet link has difficulties. Then data can be later transferred when internet is back to normal.
• Mobile Computing • simply disseminated or received information to/from different devices
in other platforms i.e. Mobile/ Tablet
• Geographical Information System (GIS) ready• ability to toggle GIS in key elements of indicators for better
understanding of the situation in short term
Case investigation
All confirmed cases are investigated Data recorded
Date of symptom onsetLocation where the patient is living and had
visitedHistory of any previous malaria episodeCurrent treatmentBed-net use
Case classified as to likely mechanism of infection acquisition
indigenous, imported, etc.
17
Investigation rate is inadequate in the targeted areas
Case classification
Classification Description
A Indigenous (acquired in village)
Bx Outside village but inside canton
By
Outside canton, but inside
district
Bz
Outside district, but inside
province
Bo
Outside province, but inside
country
Bf Outside country
F Unclassified 18
Transmission areas (A): A1 - perennial transmission area (transmission reported for at least 6
months per year).
A2 - periodic transmission area (transmission reported but for less than 6 months per year
Non Transmission areas (B): B1 - high and moderate receptivity (transmission not reported within
the last 3 years but primary and secondary vectors present).
B2 - low and no receptivity (transmission not reported within the last 3 years and primary and secondary vectors absent, suspected vector may be present).
Malaria area stratification in Thailand
Residual active foci (1)+ residual non active foci
Malaria foci in targeted areas
New potential foci (B1+imported case) and Clear up foci (B1-Receptive)
Pseudo Foci (B2 areas with imported case- non-receptive)
All cases in 2013 Indigenous Cases, 2013
Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%)
PCD = 2,755 (TPR=18%)ACD = 3,294 (TPR=0%)API = 0.02 per 1,000Total case = 477 (Pf.= 26)Indigenous cases = 1Infected outside villages=3
5,338
2013
Malaria foci, 2013 % of case investigated, 2013
Areas for Surveillance system improvement
• Suspected case definition for hospitals• Case reporting from private hospitals and clinics• Case investigation and response (foci elimination)
Suspected case definition for hospitals
Criteria for malaria testing in hospitals: patients whom have history of traveling to endemic areas. Increase awareness of medical doctors
All positive malaria cases diagnosed with laboratory confirmed including symptomatic and asymptomatic cases are included in the surveillance system.
Improve case reporting from private hospitals and clinics
Enforce private sector to report a malaria case though regulation at policy level and implementing level
Introduce malaria online system for private sector
Strengthen case investigation and response (foci elimination)
Organize refreshing training for local staff including vertical and general health services
Involve stakeholders such as community, local administrative organization in receptive areas to inform any population migration from endemic areas.
Close supervision at all level, especially at the implementing level.
Operational Implications of different types of foci
Ineffective
Effective
Present
Absent
Present
Absent (For 3 years)
EndemicActive foci
Clean up
Residual non active
Active fociResidual
active
New potential
Cont
rol
Tran
smis
sion
Case
A1+A2With indigenous every year
B1 areas with no case
B areas with 1st indigenous case
B1 areas with imported cases
A1+A2 with indigenous case in any year during 3 years
A1+A2 no indigenous case in 3 consecutive years
Classification of Malaria foci in Thailand
Pseudo Foci
B1 areas with case infected outside village
B2 areas with imported case
Active and residual foci1. Indoor residual spraying (IRS)• Active foci =2 rounds • Residual foci (A2) 1 round
2. Insecticide-treated nets (ITN)
3. Long Lasting Insecticide-treated nets (LLINs) • LLIN+LLIHN = 1 net/ 2 person
VECTOR CONTROL
Active and residual foci• Proactive case finding • Reactive case finding
Case Detection
New potential foci (B1+imported case) and Clean up foci (B1-Receptive) Reactive case detection when reported case is identified
Pseudo Foci (B2 areas with imported case- non-receptive)
Passive case detection
THANK YOU
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