Planning for malaria elimination


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Planning for malaria elimination

  1. 1. Planning for Malaria Elimination Najibullah Safi, MD, MSc. HPM
  2. 2. Learning objectives• Describe the malaria elimination strategy and how it differs from malaria control• List the programmatic milestones for malaria elimination• Plan for malaria elimination• Identify the systems needed for malaria elimination and how they should be strengthen• Identify, estimate, and mobilize the resources needed for develop the capacity to eliminate malaria• Describe the malaria elimination certification requirement and processThursday, March 29, 2012 2
  3. 3. Introduction• The fundamental planning process applicable to malaria control also apply for malaria elimination• For elimination, the program and health services should be in advance stage: – Current achievements – Well established system in place – Trained staff, active community participation – Intersectoral collaboration – Political will• Re-planningThursday, March 29, 2012 3
  4. 4. Evolution of the malaria control strategy• 1970s malaria eradication• 1978, four general approach (tactical variant) to malaria control• 1985, reviewed of the four tactical approach• Two different strategies for malaria control – Improvement in general health services – Strengthening the capability for long term control of malaria transmissionThursday, March 29, 2012 4
  5. 5. Definition of malaria elimination• Cessation of local transmission of malaria parasites from person to person by anopheline mosquitoes – Does not require the elimination of disease vectors – Imported cases will continue to be detected – Elimination cover all Plasmodium species that infect humanThursday, March 29, 2012 5
  6. 6. Differences between malaria control and eliminatio• Elimination programs: – Detect and cure malaria patients – Interrupt local mosquito-born malaria transmission – Identify and eliminate residual foci of malaria transmission – Develop and implement special surveillance system for maintaining the malaria free status – Prevent re-establishment of transmission despite continuing importation of parasites – Collaborate with neighboring endemic countries to reduce malaria transmission in the regionThursday, March 29, 2012 6
  7. 7. • Control programs: – Precise objectives, strategies and targets – Selection of appropriate intervention – Access to malaria treatment – Surveillance – Facilities for diagnosis and curative activities – Prevention – Epidemiological services with component of applied research and training – Response to emergency situation – Community involvementThursday, March 29, 2012 7
  8. 8. Programmatic milestones for malaria elimination• Transition from malaria control to elimination – High transmission areas • Prim objective is to reduce malaria mortality and morbidity and transmission intensity • Reduce the burden of malaria to less than 5% of all patients with fibril disease – Low transmission areas • First aim at pre-elimination stage, reduce the incidence of malaria to less than 1 case per 1000 people at risk • Strong surveillance system is required – Areas where transmission has been interrupted • Prevent re-establishmentThursday, March 29, 2012 8
  9. 9. Malaria program phases and milestones WHO CertificationSPR < 5% in fever cases < 1 case/1000 0 locally acquired cases 3 years population at risk/year Control Pre-elimination Elimination Prevention of reintroduction 1st program reorientation 2nd program reorientation Thursday, March 29, 2012 9
  10. 10. Planning for malaria elimination• Malaria case definition in elimination program – A malaria case is a person in whom, regardless of the presence or absence of clinical symptoms, malaria parasites have been confirmed by quality controlled laboratory diagnosisThursday, March 29, 2012 10
  11. 11. Classification of malaria cases by origin of infection Malaria Infection Due to mosquito-born Not due to mosquito- transmission born transmissionAcquired locally Acquired abroad Imported Introduced Indigenous Induced First generation local All cases without e.g. due to blood transmission; evidence of a direct transmission, congenital epidemiologically link to an imported malaria limited to proven case imported case Relapsing History of PV or PO infection within past 3 years; no epidemiological Thursday, March 29, 2012 11 linked cases in vicinity
  12. 12. Classification of malaria foci for elimination purpose• A focus is defined situated in a currently or formerly malarious area and containing the continuous or intermittent epidemiological factors necessary for malaria transmissionThursday, March 29, 2012 12
  13. 13. Shared commonalities between the countries successfully eliminated malaria• Political stability• Good infrastructure• High quality of training and personnel• Developed and functional health system• Absence of internal or external conflict• Absence of major population movement from neighboring malaria endemic countries• Malaria originally unstable or of low grade intermediate stabilityThursday, March 29, 2012 13
  14. 14. Program system needs for malaria elimination• Malaria elimination evolves from a successful country wide malaria control program• At the initial phases elimination program become a specialized vertical program focuses: – Spatial distribution of malaria – Vector control – Case finding and case investigation• Once elimination achieved, focus shifts to general health services, which are vital to a good surveillance systemThursday, March 29, 2012 14
  15. 15. Feasibility of malaria elimination• Assess the feasibility of elimination – Political will supported by adequate fund allocation – Are legislation, environmental codes, and regulation in place? – Coverage of health system (including private sector) – Is malaria elimination part of countrys socioeconomic development plan? – Effective government administration at central and periphery – Good communication system and infrastructure – Established national malaria elimination monitoring committee – Adequate knowledge of local malaria epidemiology – Documentation of the impact of currently applied interventions – Malaria control program in bordering countriesThursday, March 29, 2012 15
  16. 16. Resource needs for malaria elimination• Considerable additional resources will be required• The most imported resources include: – Well trained and motivated staff at all level and each category – Active and knowledgeable managers – Long term training plan (must include continuing education) – Adequate financial resources for operation, supplies and equipment, monitoring and evaluation, education and training, operational research – Cost will change in different phases of eliminationThursday, March 29, 2012 16
  17. 17. Certification of malaria elimination• Has economic benefits• Country is the minimum geographical area for certification• Criteria for local malaria transmission by mosquitoes: – “cluster of 3 or more cases of malaria infection that can be traced with high likelihood to one source of mosquito transmitted infection within the territory”• A country is consider malaria free when there is no case of locally transmitted malaria for three consecutive yearsThursday, March 29, 2012 17
  18. 18. Requirement for certification• Good surveillance• Case register, mandatory immediate reporting (both in public and private sector)• Adequate facilities for the detection, treatment and follow-up of imported cases• Quality microscopy• Epidemiological investigation of every case• National comprehensive plan with adequate financial allocation for the prevention of re-establishmentThursday, March 29, 2012 18
  19. 19. Requirement for certification cont.• A system for awareness, prevention of mosquito bites and chemoprophylaxis for travelers to prevent imported cases• A central computerized geo-referenced database of cases and latest foci• Entomological surveillance and monitoring insecticide resistance• Functional border coordination system• Capacity for early detection and response to epidemics• Sero-epidemiological surveysThursday, March 29, 2012 19
  20. 20. Procedures for certification• General principle of certification: – Certification is for a country – Certification is for all four species – Inspection and evaluation are carried out by a team led by WHO – If appropriate, evaluation team recommend certification – The final decision is made by WHO Director General – Certification is published in the WHO weekly Epidemiological RecordThursday, March 29, 2012 20
  21. 21. Procedures for certification cont.• Established procedure for certification: – Government request – WHO secretariat, external experts and national government jointly formulate a certification action plan – The government implement the action plan, prepare supporting documentation and submits it to WHO – A WHO led team of experts conduct the external evaluation – External evaluation team submit its report with recommendation to WHO for wider reviewThursday, March 29, 2012 21
  22. 22. Procedures for certification cont.• WHO expert committee on malaria makes the final review and submits the final recommendation to Director General of WHO• DG WHO makes the final decision based on the recommendations• Certification of malaria elimination in the country is published in the WHO Weekly Epidemiological RecordThursday, March 29, 2012 22
  23. 23. Maintenance of malaria free status• Health system must remain vigilant to possible reintroduction of the disease• Countries are requested to report the malaria free status annually to WHO• PF outbreak should be reported immediately• Indication of the reestablishment of the transmission: – Occurrence of 3 or more introduced and/or indigenous malaria infections linked in space and time to local mosquito born transmission in the same geographical focus, for two consecutive years for PF, and for three consecutive years for PVThursday, March 29, 2012 23
  24. 24. Thursday, March 29, 2012 24