robert newman - science of eradication: malaria 2012
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Malaria Elimination: Global Picture
Robert D. Newman, MD, MPH Director, Global Malaria Programme
The Science of Eradication: Malaria Boston 8 June 2012
WHO Global Malaria Programme: four key roles
I
II
III
IV
Set, communicate and promote the adoption of evidence-based norms, standards, policies, and
guidelines
I
Develop approaches for capacity-building,
systems strengthening, and surveillance
Keep independent score of global progress
Identify threats to malaria control and elimination as well as new opportunities
for action
IV
II
III
Chart the course for malaria control
& elimination
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
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
Evidence Review Groups
MPAC
RBM: Secretariat, WGs and SRNs
WHO malaria policy recommendations and
guidelines WHO DG MoH and
NMCPs SAGE JTEG
(with IVB)
VCAG (Proposed, with NTD)
Standing TEG on chemotherapy
ERG a
ERG b
ERG c
WHO GMP Secretariat
WHO ROs
WHO COs
MPAC: organogram
Other WHO departments
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
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
Past and projected international funding for malaria control
Number of LLINs delivered by manufacturers to countries in sub-Saharan Africa
294 million LLINs procured for distribution in Africa between 2008 and end 2010 More than 50% of households in sub-Saharan Africa owned at least 1 ITN as of 2011
Proportion of population at malaria risk protected by IRS
Malaria RDT sales
Sales to public and private sectors Sales by panel detec3on score (PDS)
Proportion of suspected malaria cases at public health facilities receiving a parasitological test
Despite improvements, long way to go to reach universal access to diagnostic testing, especially in Africa (currently 45%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
AfricaAmericasEastern MediterraneanEuropeSouth-East AsiaWestern Pacific
Current classification of 193 countries and 2 territories by the malaria programme that is implemented in the worst affected part of the country
81
89 8
29
60
89
control
pre-elimination
elimination
prevention ofreintroduction
certified malaria-free
supplementary list
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, 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
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
Case
s nu
mbe
r
Azerbaijan Georgia KyrgyzstanRussian Federation Tajikistan TurkeyTurkmenistan 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
Autochthonous malaria, Central Asia 2011
0
5000
10000
15000
20000
25000
30000
1992 1995 1998 2001 2004 2007 2010
TAJIKISTAN
KYRGYZSTAN
TURKMENISTAN
KAZAKHSTAN
UZBEKISTAN
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
Elimination in Morocco
20
Malaria has been eliminated in Morocco
Total cases (log scale) 100,000
10,000
1,000
100
10
0 2010 2005 2000 1995 1990 1985 1980 1975 1970 1965 1960
Total cases Local cases
Monitoring & surveillance remain high priority
Map of entomological surveillance sites in Morocco today
Permanent breeding sites for entomological surveillance
Elimination in Iraq
21
Cases of vivax malaria - Iraq 1990-2008
Sulaimania was the last region with malaria in Iraq
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
Local cases Imported cases
Local cases
100,000
40,000
20,000
0 2010 2005 2000 1995 1990
0 2 44 1,860
9,684
49,836
98,222 Total cases
29
1941
1
10
100
1,000
10,000
100,000
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Elimination in Saudi Arabia
Reported malaria cases in Saudi Arabia, 1990-2010
Coordination with Yemen for cross-border IRS activities to reduce
transmission
Strong political commitment
Total cases Local cases
Southwestern Saudi Arabia (including Jazan, Aseer & Qunfuda) is the primary malaria focus for P. falciparum, transmitted via An. arabiensis
Trend of Total and Local Cases- Iran (Islamic Republic of )
0
5000
10000
15000
20000
25000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Total Reported CasesLocal Cases
• Iran has had gradual reduction of malaria cases
• Only 1847 local cases recorded in 2010 (85% reduction compared to 2000)
• Both Pf & Pv exist; close to Pf elimination
• Transmission is focal mainly in areas bordering Pakistan
Progress in Republic of Iran
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 ● 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
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
GLOBAL MALARIA PROGRAMME
APMEN 2009
Mesoamerican Ini3a3ve for Public Health 2008
The Hispaniola Ini3a3ve Carter Center 2008
Northern Africa WHO/EMRO 1997
SADC 2007 Elimina3on 8 2009
Tashkent declara3on WHO/EURO 2005
Arabian Peninsula malaria free 2006
Professor Li's FEMSE projects 2003-‐2005-‐2007
West Africa 2009
Suriname ini3a3ve?
Southern Cone ini3a3ve
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
Three WHO Manuals as pillars of T3
Test Treat Track
T3: Test. Treat. Track. Worldwide Launch: Namibia, World Malaria Day 2012
● 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
Keep our eye on the prizes