Robert Newman - Science of Eradication: Malaria 2012


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Robert Newman - Science of Eradication: Malaria 2012

  1. 1. Malaria Elimination: Global PictureThe Science of Eradication: MalariaBoston8 June 2012Robert D. Newman, MD, MPHDirector, Global Malaria Programme
  2. 2. WHO Global Malaria Programme: four key roles I II Set, communicate and Keep independent scorepromote the adoption of of global progressevidence-based norms, Istandards, policies, and II guidelines Chart the course for malaria control IV & elimination III IVIdentify threats to malaria Develop approachescontrol and elimination as III for capacity-building,well as new opportunities systems strengthening, for action and surveillance
  3. 3. MPAC Background●  Scale up of malaria control and major investments in research = rapidly evolving policy environment for new tools and technologies (and end of one-size-fits-all approach)●  Setting policy, norms and guidance on malaria control is primary role of WHO Global Malaria Programme (GMP)●  MPAC provides independent strategic advice and technical input to WHO for development of policies related to malaria control & elimination●  GMP dedicated to a policy setting process that is more: §  Timely, transparent, and accountable●  2011 was a critical year in the redesign, launch and implementation of a strengthened policy setting process
  4. 4. Designing and Launching MPAC●  March 2011 - GMP Advisory Group on policy setting convened to review previous and existing processes, consider successful models, propose draft ToR●  April-June 2011 - Draft ToR (based on SAGE) received extensive input from over 40 external stakeholders●  August 2011 – ToR approved by WHO Director General●  September-October 2011 – Open call for nominations, 100 applications received & reviewed by independent selection panel●  November 2011 – 15 nominees appointed as MPAC members, selected for their experience and broad expertise●  December 2011 – all MPAC related information available online●  January/February 2102 – Inaugural meeting●  April 2012 – MPAC report published in Malaria Journal
  5. 5. MPAC: organogram Evidence Review Groups ERG a ERG c ERG b Standing TEG on chemotherapy WHO COs WHO malaria policySAGE MPAC WHO DG recommendations and guidelines MoH and NMCPs JTEG (with IVB) Other WHO WHO GMP WHO ROs RBM: Secretariat,departments Secretariat WGs and SRNs VCAG (Proposed, with NTD)
  6. 6. Interface between Roll Back Malaria Partnership (RBM) and WHO-GMP●  RBM Secretariat is hosted at WHO●  RBM Roles §  Advocacy §  Resource mobilization §  Partner harmonization●  Important to optimize interface between RBM mechanisms and WHO-GMP §  Example: MPAC meetings are offset from RBM Board meetings by 3 months to allow for dissemination of new policies and input into next agenda
  7. 7. World Malaria Report 2011 •  2011  Report  released  on  13  December  2011   •   Annual  reference  on  the  status  of  global  malaria   control  &  elimina<on.    Data  to  2010  and  2011   •   Principal  data  source  is  na<onal  programs  in  106   endemic  countries  with  support  from:  WHO  Regional   offices,  ACT  Watch,  AMFm,  ALMA,  CDC,  CHAI,  Columbia   University,  DFID,  DHS/  Measure,  FIND,  GHG  UCSF,   Global  Fund,  IHME,  ISGlobal,  JHU,  PATH,  R4D,  RBM,   Tulane  University,  UNICEF,  UNSE,  USAID   •   Summarizes  key  malaria  targets  &  goals   •   Documents  trends  in  financing,  interven<on  coverage   and  malaria  cases  and  deaths   •   Updates  malaria  burden  es<mates  for  decade:   2000-­‐2010     •   NEW:  Profiles  for  each  of  the  99  countries  with   ongoing  transmission  
  8. 8. Past and projected international funding for malaria control
  9. 9. Number of LLINs delivered by manufacturers to countries in sub-Saharan Africa294 million LLINs procured for distribution in Africa between 2008 and end 2010More than 50% of households in sub-Saharan Africa owned at least 1 ITN as of 2011
  10. 10. Proportion of population at malaria risk protected by IRS
  11. 11. Malaria RDT salesSales  to  public  and  private  sectors   Sales  by  panel  detec3on  score  (PDS)    
  12. 12. Proportion of suspected malaria cases atpublic health facilities receiving a parasitological test 100% 90% 80% 70% Africa 60% Americas Eastern Mediterranean 50% Europe 40% South-East Asia 30% Western Pacific 20% 10% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Despite improvements, long way to go to reach universal access to diagnostic testing, especially in Africa (currently 45%)
  13. 13. Current classification of 193 countries and 2 territories by the malaria programme that is implemented in the worst affected part of the country control 9 8 8 pre-elimination 29 elimination 89 prevention of 60 reintroduction 81 certified malaria-free supplementary list
  14. 14. Malaria Elimination: 2011
  15. 15. 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, 102 locally acquired malaria cases were reported in only five countries: Azerbaijan (4), Georgia (1), Tajikistan (53), Turkey (4) and Greece (40)●  Turkmenistan was certified malaria-free by WHO in 2010 and Armenia – in 2011●  Kazakhstan was added to supplementary list of malaria free countries in 2012
  16. 16. Progress with malaria elimination in WHO European Region Indigenous malaria cases in WHO EURO, 2000-2011 25000 20000 Cases number 15000 10000 5000 0 00 01 02 03 04 05 06 07 08 09 10 11 20 20 20 20 20 20 20 20 20 20 20 20 Azerbaijan Georgia Kyrgyzstan Russian Federation Tajikistan Turkey Turkmenistan Uzbekistan
  17. 17. Number of autochthonous cases of malaria in EURO, 1990-2011 2011 100000 90000 80000 70000 600001996 50000 40000 30000 20000 10000 0 1990 1993 1996 1999 2002 2005 2008 2011
  18. 18. Autochthonous malaria, Central Asia 2011 30000 25000 20000 15000 10000 5000 0 1992 1995 1998 2001 2004 2007 2010 KAZAKHSTAN UZBEKISTAN KYRGYZSTAN AREAS AFFECTED BY MALARIA TAJIKISTAN TURKMENISTAN
  19. 19. Progress with malaria elimination in WHO Eastern Mediterranean Region●  Twelve out of 20 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
  20. 20. Elimination in Morocco Monitoring & surveillance Malaria has been eliminated in Morocco remain high priorityTotal cases(log scale) Map of entomological surveillance100,000 sites in Morocco today 10,000 1,000 100 10 Local cases Permanent breeding sites for Total cases entomological surveillance 0 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2 0
  21. 21. Elimination in Iraq Last Local cases in Cases of vivax malaria Local cases in Iraq, 2008 - Iraq 1990-2008 2005-2008Local cases Total cases100,000 98,222 50 3 Imported cases Local cases 40 49,836 40,000 30 1 20 20,000 9,684 10 1,860 44 2 0 1 4 1 7 0 Sulaimania was the last 0 2 2 1990 1995 2000 2005 2010 region with malaria in Iraq 2005 2006 2007 2008 2009 2010 2 1
  22. 22. Elimination in Saudi Arabia Reported malaria Strong political cases in Saudi Arabia, 1990-2010 commitment 100,000   Total cases Local cases 10,000   1941   1,000   100   Coordination with 29   Yemen for cross-borderSouthwestern Saudi IRS activities to reduceArabia (including Jazan, transmission 10  Aseer & Qunfuda) is theprimary malaria focusfor P. falciparum, 1  transmitted via An. 1990   1992   1994   1996   1998   2000   2002   2004   2006   2008   2010  arabiensis
  23. 23. Progress in Republic of Iran•  Iran has had gradual Trend of Total and Local Cases- Iran (Islamic Republic of ) 25000 reduction of malaria 20000 Total Reported Cases Local Cases cases 15000•  Only 1847 local cases 10000 recorded in 2010 5000 (85% reduction compared to 2000) 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010•  Both Pf & Pv exist; close to Pf elimination•  Transmission is focal mainly in areas bordering Pakistan
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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.
  29. 29. Major challenges ahead●  Political commitment●  Financial resources●  Global health architecture●  Procurement and supply chain management●  Health system capacity; human resource capacity●  Delivering quality case management in the private sector●  Antimalarial drug resistance●  Insecticide resistance●  Inadequate surveillance and controversies over burden estimation●  Delivering results in highest burden countries
  30. 30. 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
  31. 31. 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)
  32. 32. 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
  33. 33. Tashkent   declara3on  WHO/ Northern  Africa   EURO  2005   WHO/EMRO  1997   The  Hispaniola   APMEN   Ini3a3ve     2009   Carter  Center   2008   Suriname   West  Africa   ini3a3ve?   Professor  Lis   2009   FEMSE  projects   2003-­‐2005-­‐2007  Mesoamerican  Ini3a3ve  for  Public    Health  2008   Southern  Cone     ini3a3ve     Arabian  Peninsula     malaria  free  2006            SADC  2007    Elimina3on  8  2009   GLOBAL MALARIA PROGRAMME
  34. 34. 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
  35. 35. Malaria Surveillance Manuals – Worldwide launch: Namibia, 24 April 2012
  36. 36. Surveillance Manuals: Objective and Rationale●  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
  37. 37. Three WHO Manuals as pillars of T3 Test Treat Track
  38. 38. T3: Test. Treat. Track.Worldwide Launch: Namibia, World Malaria Day 2012
  39. 39. Keep our eye on the prizes● First: near zero deaths from malaria § Today, no one should die from malaria for lack of a 5 dollar bednet, a 50 cent diagnostic test, and a 1 dollar antimalarial treatment● Ultimately: a world free of malaria