Dr.Merita Monteiro Head of CDC Ministry of Health Timor Leste Progress, Challenges and Way Foreword of National Malaria Programme Timor Leste Dr.Merita Monteiro Head of CDC Ministry of Health Timor Leste

Malaria situation Malaria was the leading cause of morbidity across the country in the past. The predominant malaria parasites are P. falciparum and P. vivax Vectors of Malaria –An barbirostris and An subpictus Dramatic decline in the incidence of malaria from 2006 number of malaria cases decreased from 223,002 (incidence 220/1000 Population) to 30 cases in 2017 (incidence <1 /1000 population). Significant reduction of malaria attributed deaths from 58 in 2006 no deaths due to malaria since 2015 up to today

VISION A “malaria-free” Timor-Leste by end 2020 to enable the people of DRTL to achieve their full potential.

MISSION Plan and implement a comprehensive malaria elimination programme to interrupt malaria transmission in Timor-Leste.

To eliminate malaria transmission in Timor-Leste by end 2020. GOAL To eliminate malaria transmission in Timor-Leste by end 2020.  

Objective 1: To interrupt malaria transmission by the end of 2020 Re-orient public and private health sector staff towards malaria elimination. Re-orient National Malaria Programme towards malaria elimination. Provide universal access to malaria diagnostic and treatment services free of charge Detect all infections early and treat all patients with quality assured antimalarials based on national treatment guidelines to ensure radical cure and prevention of secondary transmission.  

Objective 1: continue……… Objective 1: continue……….. To interrupt malaria transmission by the end of 2020 Ensure all suspected cases are tested for malaria (microscopy or RDT). Notification of all positive infections within 24 hours. Investigate all cases and foci within 2 days of notification. Protect vulnerable populations and residents in foci within 10 days of report of case Respond quickly to prevent spread of malaria and containment of outbreaks Quality assurance of malaria diagnostic services

Objective 2: To maintain zero mortality due to indigenous malaria Provide universal access to malaria diagnostic and treatment services free of charge. Detect all infections early and to treat all patients with quality assured antimalarials based on national treatment guidelines to prevent complications and secondary transmission. Ensure all suspected cases are tested for malaria (microscopy or RDT). Ensure availability of antimalarial medicines at all diagnostic and treatment facilities at all hospitals and treatment centres with in-ward facilities for treatment before referral. Ensure availability of adequate intensive care facilities in all referral hospitals and in the National Hospital.

Intensify surveillance in all municipalities. Objective 3: To prevent reintroduction of malaria in municipalities that have already interrupted malaria transmission. Intensify surveillance in all municipalities. Establish web based real time surveillance system. Notify all cases immediately. Investigate cases and foci within 2 days, entomological surveillance and reactive ACD within 5 days of notification. Establish response teams for quick and effective response within 10 days of notification. (IRS and LLINs within 1 KM radius of the reported case)

Objective 3: continue………………… To prevent reintroduction of malaria in municipalities that have already interrupted malaria transmission. Have adequate buffer stocks of LLINs, insecticides, diagnostics and antimalarial medicines. Protect vulnerable populations with LLINs and IRS where necessary. Strengthen cross border collaboration with Timor province of Indonesia and facilitate sharing of sub-national data. Establish diagnostic and treatment centres at border crossings

Malaria cases and milestones of malaria programme in Timor Leste from 2016 to 2017 (per month) GF 7 malaria 2009-2010 IRS in 3 districts & mono valent RDT

No of malaria cases reported from 2009 to 2018 Q1 Year No exam. slide No exam. RDT Presumed Confirm Pf Pv Mix Total deaths API (/1000) Indigenous Imported 2009 85,538 34,152 85,799 40,999 34517 12,246 567 133,129 56 37 2010 110,494 85,751 78,882 40,250 28,350 11,432 154 119,072 58 35 2011 81,172 127,272 16,418 19,740 14,261 3,759 1720 36,153 16 18 2012 64,318 117,180 940 5,208 1,962 2,288 958 6,148 4 5 2013 56,251 121,991 17 1,028 373 512 140 1,042 3 0.9 2014 25,421 70,618 342 118 139 85 347 1 0.3 2015 30,253 90,818 80 33 24 23 0.1 2016 12,241 108397 94 51 10 2017 24,225 115,029 30 11 14 0.03 13 2018 Q1 12,003 47,421

Distribution of the malaria cases in 2017

Progress of National Malaria Programme 2017 Indicator target achievement N D % Proportion of suspected malaria cases tested by RDT or microscopy at Public Health Sector 100% 115,029 Proportion of suspected malaria cases tested by RDT or microscopy at the community (35 CHV) 23,545 Proportion of suspected malaria cases tested by RDT or microscopy at the Private Health Sector (Q1 2018) 819 Proportion of confirm malaria cases that received first line antimalaria treatment public health sector 20 Proportion of confirm malaria cases that received first line antimalaria treatment in the community 10 Proportion of confirm malaria cases that received first line antimalaria treatment in the private health Sector (Q1 2018) No cases Percentage of confirmed cases fully investigated and classified (within 2 days of report) 30 Percentage of confirmed malaria foci fully investigated and classified ( within 2 days of report)

Progress of NMP 2017 continue……. Indicator target achievement % N D Number of LLINs distributed to at risk population through mass campaigns 289,247 287314 103% Number of LLINs distribute to target risk groups (PW) 45,324 37,157 82% Number of households in targeted areas that received Indoor Residual Spraying during the reported period 31,201 31,419 101%

Progress of NMP……………….. No stock out of anti malarials and RDT at all levels Improved Monitoring and Evaluation at all level Implementation of evidence based malaria control Programme Monitoring of effect and safety of malaria first line treatment Artemether/Lumefantrin and Chloroquine for treatment of uncomplicated Pf and Pv malaria Monitoring of insecticide resistance and persistence of insecticides on the surface during IRS and LLINs Availability of funds specially from GF and RAM Strong Technical Guidance Active malaria team

Addressing Challenges and way foreword Category Descriptions of issue Action taken/ proposed Cross border Collaboration >95% of the cases are reported in the border areas first cross border collaboration was conduced in January 2017. Need to carry foreword in 2018 Migrant, mobile and hard to reach population 13 out of 30 cases reported in 2017 from Timorese fisherman who did fishing in Indonesian island Positive cases reported from slash and burning cultivation farmers Migrant workers from private companies and migrants Distribution of LLIN to all malaria risk groups live in the border areas and migrant workers Mass Blood survey of the fisherman after return, farmers and workers BCC Strengthen surveillance at the entry points Private sector diagnosis and reporting 23 out od 30 private sector facilities reported Advocacy meeting was conducted to the private sector and faith based medical facilities from early November 2017. Preparation of Guide lines Training of the private sector for recording and reporting , use of malaria microscopy and RDT on progress Epidemic preparedness Sometimes- Delay in response Rapid response teams established and refresher training given Use of DIHS2 platform for reporting case base data and categorized data The special situations mentioned in column one under ‘category’ are situations that may pose challenges to elimination and you may be working on it currently. Please describe them, action taken and technical assistance needed eg WHO

Addressing Challenges and way foreword Category Descriptions of issue Action taken/ proposed Vector Control 1.Distribution of LLINs to the Pregnant women in the country -GF funded LLINs are available only for distribution of LLINS who live in border areas and malaria high risk areas for year 1 only -As per the GAP analysis and discussion with RAM in 2017 -NMP expect that the RAM will provide LLINs to PW through anti natal clinics in 2019 and 2020 -Training of midwives and malaria officers for distribution of LLINs and educate the PW 2. Carry out IRS in the malaria risk border areas and Atauro Island -80 Hudson Compression hand Held sprayers will be procured by RAM to replace old Sprayers to carry out IRS 3. LLINS usage monitoring It is important to use LLINs >80% of the malaria risk population for mass killing effect of malaria vectors after distribution of LLINS. Seeking for funds from RAM to monitor usage of LLINs and to encourage the risk population to use LLINs who are not using LLINs The special situations mentioned in column one under ‘category’ are situations that may pose challenges to elimination and you may be working on it currently. Please describe them, action taken and technical assistance needed eg WHO

Funding Gaps Long Lasting Insecticides treated nets Distribution (LLINs) -to Pregnant Women (PW) live in Risk areas: Procurement of LLINs Training of midwives for LLINs distribution to PW -Mass Distribution to the population in malaria risk areas: Funds for distribution Monitoring of usage of LLINs after distribution Procurement of 80 spray machines and spare parts to carry out Indoor Residual Spraying in the border areas

No of LLINs /Nets & Sprayers Funds needed, 2018-2020 activity No of LLINs /Nets & Sprayers Estimated budget US$ 2019 2020 Total   Total LLINs distribution to Pregnant women live in high risk areas only -Procurement of LLINs 40,058 45,315 85,373 160,232 181,260 341,492 Training of midwives for distribution of LLINs   18,662 37,324 Distribution of 43,093 LLINs to malaria Risk population in 2019 21,547 Distribution of 138,510 LLINs to malaria Risk population in 2020 69,255 Monitoring of 43.093 LLINs usage and assist for hanging up who are not using in 2019 17,237 Monitoring of 138,510 LLINs usage and assist for hanging up who are not using in 2020 55,404 Procurement of hand held Hudson Compression sprayers for IRS 80 31,300 248,978 324,581 573,559