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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