Key Gaps in Malaria and Emerging Infectious Disease Control -

Priorities for a Regional Response

Dr Eva Christophel, in collaboration with relevant units and the SEARO

WHO Regional Office for the Western Pacific, Manila, Philippines

APLMA Regional Financing for Malaria Task Force (RFMTF), Hong Kong, May 12, 2014

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Outline of Presentation

Burden of major communicable diseases in the Region, key gaps

Malaria: Threats to controlling and eliminating malaria in Asia Pacific, and opportunities.

Priorities for a Regional Response

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Malaria: 20 Endemic countries in WP and SEA Regions

SEAR countries

WPR countries

2012 (WMR 2013)

SEAR WPR Afghanistan,Pakistan

Total

Estimated # malaria cases

26.8 mio(21.7-32.5)

1.4 mio(1.2-1.7 mio)

376,7683,485,366

32.1 mio

Estimated # malaria deaths

42 000(25 000-60

000)

3 500(2 100 – 5

200)

261970

47,496

Population at risk (high and low transmission areas)

1.6 billion 711 million 16,030,688102,121,263

2.4 billion

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Tuberculosis: Distribution of Prevalent TB Patients, by Region

Source: Global Tuberculosis Control 2013, WHO

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2012 Estimates SEAR WPR

TB Cases (all forms) 3.4 mio 1.6 mio

TB Deaths 450,000 110,000

Multi-drug resistant TB 90,000 74,000

HIV-associated TB 170,000 24,000

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1. Current diagnostic algorithms are not

sensitive enough to detect TB patients early;

2. TB concentrates among high-risk and socially

vulnerable populations who are difficult to

reach;

3. Multi-drug resistant TB: only a small fraction

of MDR-TB patients are diagnosed, ensuring

treatment is also a challenge;

4. High percentage of external funding, esp

through the Global Fund. Donor investment is

shrinking in the Region, which threatens

sustainability of programmes.

Tuberculosis: Challenges

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Tuberculosis: Financial Gap WPR

In the WPR, national TB programmes report a funding gap of over USD 200 million per year.

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Source: Prepared by www.aidsdatahub.org based on UNAIDS HIV Estimates 2012 for UNAIDS.(2013). Global Report: UNAIDS Report on the Global AIDS Epidemic 2013.

HIV: Burden and Trends in Asia Pacific

People living with HIV4.9 million

Women living with HIV

1.7 million

New HIV Infection

s350,000

Deaths270,00

0

2012 “zoom-in”

Children living with HIV210,000

HIV and AIDS in Asia Pacific 1990-2012

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HIV: Increase in Domestic funding to make up for the Levelling off of International Financing

Source: UNAIDS estimates 2012

Resources available for AIDS response in Asia and the Pacific, low-and middle-income countries (LMIC)

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HIV: Challenges in Financing HIV programmes

Heavily reliant on donor funding for low and middle income countries, particularly Cambodia (89%), Lao PDR (93%) and Viet Nam (83%). Government should increase their domestic public HIV spending as GDP per capita rises;

Not enough is spent on key populations prevention programmes, e.g. spending on prevention for key populations accounts for only 24% of AIDS spending in Asia and the Pacific (2009-2012).

Moreover, prevention spending on key populations is heavily dependent on international financing sources.

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Hepatitis B: Distribution of estimated Number of annual Deaths, by Region

Courtesy of IHME – Global Burden of Disease Study

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The Global Hepatitis Action Plan

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Axis 2: Data for policy and action

Axis 1: Partnerships, resource mobilization and communication

Axis 3: Prevention of virus transmission

Axis 4: Screening, care and treatment

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Hepatitis: Gaps and Challenges

• Low levels of awareness, advocacy, and financial engagement from national governments

• Lack of data is a barrier to country-level dialogue and engagement

• Progress made in prevention, especially HBV immunization, but high coverage of birth dose vaccination remains a challenge in many countries

• Remarkable advances in hepatitis treatment options, but equitable access to quality and affordable diagnostics and medicines still far for many countries.

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Diseases Prevented by Vaccination

Traditional EPI?

Vaccine Global/RegionalEradication/Elimination/Control Goal

Funding Source

Traditional BCG (childhood TB)

Traditional Polio Global eradication GAVI for inactivated polio vaccine (IPV)

Traditional Diphtheria-Pertussis-Tetanus (DPT)

Traditional Measles Regional elimination

New Hepatitis B Regional control GAVI*

New Hemophilus influenzae type b (Hib)

GAVI*

New Human Papillomavirus (HPV)

GAVI*

New Japanese encephalitis Regional control (proposed) GAVI*

New Pneumococcal GAVI*

New Rotavirus GAVI*

New Rubella Regional control(Regional elimination proposed)

GAVI*

Support available to GAVI eligible countries and GAVI graduating countries*GAVI eligible countries in the Western Pacific: Cambodia, Lao People’s Democratic Republic, Solomon Islands, Viet Nam

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Measles: Disease Burden and Trends

Measles Cases by Month and Year, WPR, 2008–2013

Progress towards 2012 Measles Elimination Goal:94% reduction in reported measles cases in the Region between 2000 and 2012 when historic low incidence was achieved;

A relative resurgence in measles occurred in the Region in 2013 and 2014 with recent outbreaks in China, Papua New Guinea, the Philippines, and Viet Nam.

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Measles: Strategies and Challenges

Reported measles cases and coverage with first and second dose of measles vaccine, 1980-2012 An important strategy to

achieve measles elimination is high (>95%) coverage with two doses of measles vaccine.

Immunity gaps (pockets of susceptible persons, especially among migrants) allows measles virus to continue spreading

4 (of 37) countries and areas have not yet introduced routine second dose:•Lao People’s Democratic Republic •Papua New Guinea•Solomon Islands•Vanuatu

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Measles: Financial Gaps

Year Country Budget (USD) Source Gap (USD)

2014 Lao People’s Democratic Republic

1,161,800 Measles & Rubella Initiative

0

2014 Philippines 17,102,127 Self + partners ~1,000,000

2014 Viet Nam 32,003,878 GAVI 0

2015 Papua New Guinea 4,872,549 GAVI 0

2015 Solomon Islands 487,530 GAVI 0

Not scheduled Vanuatu 496,000 496,000

Supplemental mass immunization campaigns are an important strategy to increase population immunity

Planned measles mass vaccination campaigns, Western Pacific Region, 2014-2016

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Estimated Japanese Encephalitis incidence

among children <15 years old in the Western Pacific

Region, 2011 (cases/100,000)

Note: Estimated incidences calculated from Campbell et al, Bull World Health Organ 2011;89:766-774E

No known risk of JE

<0.5

LEGEND:

5.5 – 12.7

2.5 – 5.3

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Neglected Tropical Diseases: Dengue Trends

- Currently 24 countries are affected- Reactive approach, little specific prevention or outbreak preparedness- Severe lack of funding

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Neglected Tropical Diseases

Over 1 billion people affected, 39 countries with at least one of 17 priority NTDs. We have effective interventions & global targets to control/eliminate.

Funding gap for lymphatic filariasis, schistosomiasis, soil-transmitted helminths, trachoma, leprosy, yaws, food-borne trematodes control, WPR:

Source: ADB/WHO: Addressing Diseases of Poverty, 2014

YearObjective

1: Advocacy

Objective 2:

Programme

Management

Objective 3: Access

Objective 4: M&E

Objective 5:

Research

Regional Costs

Total

2012 92704 898744 5466414 1242388 250000 15443729,494,62

2

2013 77704 879804 8373184 966555 250000 192750912,474,7

56

2014 77704 947491 7915684 721268 250000 207726011,989,4

07

2015 77704 856731 7744052 1374057 250000 224198612,544,5

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2016 72304 336531 5543002 383769 50000 24231858,808,79

1

Total 398,1203,919,30

135,042,3

364,688,03

71,050,00

010,214,3

1255,312,1

06

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Emerging Infectious Diseases (EIDs): Hotspot Asia-Pacific

Zoonosisfrom wildlife

Figure 3: Global distribution of relative risk of an EID event.

Drug-resistantpathogens

Zoonosis fromnon-wildlife

Vector-borne pathogens

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Influenza A/H1N1 2009Cholera

SARS

WPR, a hotspot for EIDs

E. coli O157

Influenza A/H7N9

Dengue

Influenza A/H5N1

HFMD

Nipah

Typhoid

SFTSV

Chikungunya

Anthrax

Streptococcus Suis

Severe HFMD EV-71

Leptospirosis

Plague

Continuing Emergence…!

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EID: Avian Influenza A(H5N1) – Human Cases

Since 2013, the Western Pacific Region accounted for over 80% of

all H5N1 human cases

• Cambodia: – Overall 56 cases (37 deaths, CFR

66%). – In 2014, 9 cases reported.

• China:– Overall 47 cases (30 deaths, CFR 64%)– In 2014, 2 cases reported.

• Lao PDR:– Overall 2 cases ( 2 deaths) were reported in 2007– Since then, no case has been reported to date

• Viet Nam:– Overall 127 cases ( 64 deaths, CFR 50%) – In 2014, two fatal cases reported

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EID: Avian Influenza A(H7N9) –Human Cases

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EID: Distribution of Human Infections with Avian Influenza A(H7N9)

Number of cases

"The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement."

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EID: Arboviral Disease Outbreaks in Pacific Island Countries and Areas (May 2014)

CHIKV

DENV-?

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EID: Economic Impact

• SARS

• MERS-CoV, Philippines: o Testing all passengers

on-board a plane carrying a MERS-CoV positive case ~ 2 million pesos1

• H7N9 in mainland China:o Outbreaks estimated to

have caused 60 billion yuan loss to the poultry industry (I/II 2013) and at least 40 billion yuan in 20142

1. http://www.malaya.com.ph/business-news/news/doh-has-spent-p2m-keep-mers-cov-bay

2. Ministry of Agriculture

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EID: International Health Regulations 2005

• Legally binding international instrument for global public health security, for preventing international spread of disease, enforced 2007

• International commitment for shared responsibilities and collective defence against diseases information sharing!

• Network of national IHR focal points and WHO contact points, 24/7

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EID: Challenges

• Health security threats continue to occur in unexpected way, if not managed well, resulting in significant health, economic, social and political consequences

• Strong national and international capacities are a MUST for managing unpredictable/uncertain threats

• The Region is NOT sufficiently prepared to cope with severe public health emergencies and disasters

• Investing in health security essential, AND sustaining it equally vital

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EID: The way forward

• Continue to support to countries in meeting the IHR core capacity requirements through implementation of the Asia Pacific Strategy for Emerging Diseases/APSED (2010). This includes capacity building in surveillance, laboratory, zoonoses, risk communication, PH emergency planning

• Regional strategies, especially APSED, have proven to be valuable tools to support countries to meet IHR core capacity requirements.

• Promote cross-cutting capacities that serve as foundation for all emergency risk management

• Foster regional partnerships for emergency risk management • Respond to major emerging disease outbreaks and

emergencies swiftly and in coordinated way (WHO Emergency Response Framework)

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Malaria: Progress in the WPR, 2000-2012

Source: World Malaria Report 2013

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Malaria: Countries projected to achieve >75% decrease in incidence of microscopically confirmed cases by 2015

SEAR WPR

Source: World Malaria Report 2013

• India, Indonesia and Myanmar (SEAR), Papua New Guinea (WPR), Pakistan (EMR) cannot be projected to achieve the 75% decrease by 2015

• In the SEAR, 3/10 countries, and in the WPR, 2/10 are in pre-/elimination phase

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Malaria: Threats & Opportunities

THREATS

Losing the gains and investments made, malaria resurgenceo Shrinking financingo Limited/declining programme capacityo Decreasing government commitment once cases decreaseo Unregulated economic development

Artemisinin resistanceo Health systems issues, e.g pharmaceutical issues (OAMTs,

counterfeit/substand medicines, stockouts, irrational drug use)o Malaria control and elimination services, eg insufficient reach to

migrant/mobile populationso Insufficient engagement of the non-health sector

OPPORTUNITIES

Regional collaboration: ERAR, ASEAN, APMEN, APLMA,Pacific Malaria Initiative, IHR, RBM, Interpol, WHO, ADB

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, Lao PDR

Malaria: Resurgence in Lao PDR

Source: Lao PDR National Malaria Programme

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Malaria: The Global Challenge of Artemisinin Resistance

• Foci identified in five countries in the Greater Mekong Subregion, mainly along international borders

• Artemisinin resistance so far only confirmed in this region

• Containment efforts ongoing since 2008

• Number of detected foci increasing

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Malaria: Emergency Response Framework

• Emergency response based on strategic recommendations of a joint assessment by development partners

• Aim is to increase coordination, quality and coverage of interventions

• Launched in 2013 in Phnom Penh, Cambodia, where WHO has opened a Regional Hub to coordinate ERAR (supported by the Gates Foundation and Australia)

• Global Fund has committed 100 million USD to combat artemisinin resistance in GMS

• Funding gap was estimated at USD 450 mio/3 years, but will be higher due to recent TEG recommendation to expand Tier 2 throughout GMS

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Malaria Financing: Domestic Funding for Malaria Control, 2005-2012

Source: World Malaria Report 2013

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Malaria Financing:Trends in Domestic Funding, Philippines

Increasing government contribution to disease program

*Estimates for 2015 and 2016 are based on a modest anticipated increase of 1% in the annual program budget after 2014. Figures refer to national government funds only.

Source: Philippines Vectorborne Diseases National Programme

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Malaria Financing: USD per Person at Risk, by WHO Region and Funding Source, 2005–2012

Source: World Malaria Report 2013

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Malaria Financing: Global Fund Allocations to WPR Countries under New Funding Model

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Malaria Financing: Malaria Programme Funding Gaps in Solomon Islands, Vanuatu, PNG, based on costed National Strategic Plans

LLINS required to maintain 100% coverage: 5,707,530 Cost (including delivery to end user): $46,202,717Anticipated GF funding (including existing funds - $1,707,841) $23,740,745Anticipated GF funding as % of LLIN component requirement: 51%

Papua New Guinea – LLIN requirements, 2015-2017

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Conclusions

• Major improvements have been achieved across a range of communicable diseases in the Region, but the CD burden remains significant, disproportionately affecting the poor. Much remains to be done.

• We have effective tools for most diseases. These cannot be sufficiently rolled out, largely because of significant funding gaps, which are increasing due to shrinking external funding to the Region. Despite most of the countries in the Region having moved to middle-income status, these funding gaps currently cannot all be shouldered by national budgets, except in a few.

• Malaria is especially vulnerable to losing the enormous gains and investments made, as it can resurge rapidly once interventions are scaled back prematurely.

• There are many opportunities for regional collaboration (e.g ERAR, ASEAN, IHR/APSED, Interpol) which should be intensified.

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Priorities for a regional response

1. Mobilize funds to fill the programme gaps. o Prioritize high incidence countries. o Artemisinin resistance containment/elimination, as a regional and global

public good, should receive international financingo Malaria elimination should have significant domestic funds.

2. Use the opportunity of the current revision and costing of National Malaria Strategic Plans in most countries to get detailed analyses of malaria programme requirements (eg commodities, funds), which should be used at regional and global levels.

3. Foster greater collaboration between malaria and other national and regional initiatives, for synergies and cost saving, and document and evaluate this. Including on cross cutting issues such as migrant health.

4. Initiate innovative funding models and pilot and evaluate them. o

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THANK YOU