Progress report: the National LF and STH programme in MYANMAR Dr. Ni Ni Aye, Program Manager (ELF) LF and STH program Mangers Meeting,Jakarta (23-24 sept,2014)

Background Information Geography and Population – Total population – (2014 Census) – Ecological zones - Myanmar,the largest country in mainland in South East Asia with a total land area of 676,578 square kilometer Political & Health Administrative Divisions: -First level (7 States and 7 Regions) -Second level (69 Districts, 330 townships, 82 sub townships and 396 towns) -Third level (3045 wards, village tracts and Villages)

Historical Perspective First case of elephantiasis -Indian man, Thayet tsp Dr Nandy, a surgeon of RGH – found out the relation between hydrocoele and presence of Mf 1959, Municipal Council of Rangoon - Anti- filarial campaign - vector control Division of Health Dep; - NMBS & treatment of (+)ve cases , Filariasis Research project (WHO)in Rangoon Pilot vector control programme - using 50% EC fenthion larvicide in 16 tsp; of Rangoon by health department (D.O.H )Directorate of Health - Filariasis control project -

Historical Perspective (Cont;) integrated with Malaria, DHF and J-B Encephalitis control Programme into VBDC Program 1983, Culex larval control was stopped because of vector resistant to insecticide, although case finding with NMBS and treatment of positive cases , the Global Strategy for Elimination of Lymphatic Filariasis (ELF) has been adopted.

National programme overview IndicatorLFSTH Year of inception of the national programme Target date for elimination2020 Name of administrative unit for implementation of PC District Total # administrative units requiring PC at the start of the programme 4567 Total population requiring PC in the country Total pop in endemic IUs (40,014,402) Sum of preSAC & SAC requiring PC (14,634,198)

PC Programme Financing Contributors to the 2013 programme costs (and rough estimate of contributions by each if available): ContributorFunding (US$) National governmentTravel allowance Sub-national governmentTransport cost for drug Internal donors External donors (GNNTD)27000 Others (WHO)7500 Others (JICA)IEC

PC programme achievements 2013 IndicatorTargetedAchieved M&E Total # sentinel and spot check sites surveyed (LF) 13 Total # sentinel sites surveyed (STH) 80 Total # IUs where stopping-MDA TAS implemented (LF) 00 Total # IUs which passed TAS and stopped MDA (LF) 00 Total # IUs where surveillance TAS implemented (LF) 30 MMDP # IUs where hydrocele surgeries performed 65 # IUs where lymphedema and ADLA management provided 45 Activities TargetedAchieved # administrative units for PC # people # administrative units for PC # people PC MDA2 (DEC + ALB) T3 (ALB/MBD) for STH 1 st round T3 (ALB/MBD) for STH 2 nd round

Progress Towards LF Elimination Definitions Started MDA≥5 MDA roundsSurveillanceMMDP access

Progress Towards LF Elimination

Progress Towards STH scale up *Coverage =

Progress Towards STH scale up *Coverage =

PC coverage, 2013 *65% for LF and 75% for STH **reported coverage was verified by coverage survey or similar independent activity PC type # administrative units receiving PC # administrative units with reported coverage above target* # administrative units where coverage was verified** MDA2 (DEC + ALB) 36 T3 (ALB/MBD) for STH 1 st round 67 T3 (ALB/MBD) for STH 2 nd round 67

Impacts of MDA in Sentinel Sites (LF) # SS/SC sites Sentinel Sites <1% mf Sentinel Sites ≥1% mf Spot Check sites <1% mf Spot Check sites ≥1% mf Baseline surveys Latest surveys (post-MDA)

PC Monitoring and Evaluation Describe how coverage is monitored Post MDA survey, Area coverage survey, Pop coverage

SAE protocol (Severely affected Event) Detection, Management, Reporting For <5 children and the ones who has problem to swallow the drug - Tablets should be crushed and given with sufficient water to prevent choking To exclude those people - who were taking other drugs for treatment of other diseases from MDA - who were suffering from other chronic diseases like, TB, Hypertension, Heart / renal / liver diseases (with evidence of taking treatment from any health facility) - who were ill or bed ridden during the time of MDA - < 2 year age group and pregnant women from MDA

# # administrative units currently eligible for surveys to stop mass treatment5 # administrative units where surveys to stop mass treatment were conducted 0 # administrative units where criteria was passed and mass treatment stopped Justification for stopping MDA without TAS in the above IU s Integrated assessment of STH considered? LF Transmission Assessment Survey to stop MDA

LF Transmission Assessment: Forecasting Year Number of IUs to be covered TAS1 TAS2 TAS3 Total number of EUs ICT/LF ST Required* * * * * * * *24 *sum of the total sample size required for each EU assessed;

Integrated Vector Management (LF) Describe any activities targeted to control LF vectors (including those conducted by other programmes) Training, Entomology survey (Malaria,JE and DHF) Describe monitoring and evaluation of such activities

LF MMDP – Strategy LF National policy exist?Morbidity Mx as in strategy Organizational placement within the government (who is responsible?) National ELF program PM is responsible How integrated with the health service?National LF programme and Public health division at various level Training of service providers conducted (by who? How frequent?) RO and TL from Reginal VBDC team are already trained and they give training to VBDC staff and BHS annually before MDA conduct. Patient mobilization and registration (by who? How?) VBDC staff register patient who come to VBDC clinic

LF MMDP – monitoring and evaluation LF Describe how MMDP services are currently monitored and reported to the national programme Monitored at regional level and reported to National program,but it need to be strengthen How is “access” determined?Determined by Regional RO and TL as clinically and also mf positive cases. Is there any quality assessment of provided services? Not yet, need to be done quality assessment

Best Practices Describe interventions and/or M&E activities that worked well i.Integrated activities with STH program,Nutrition program,Basic Health under umbrella of DOH ii.Disease-specific activities – as VBDC include malaria,DHF,Chikungunya and JE diseases, So that manpower work together for all diseases. iii.Voluntarily participated – VHW as drug distributors are voluntarily participate and BHS monitor them at grass root level iv.In spite of no incentives- incentive like materials can not be given since MDA was conducted, most of VHW are still participating during MDA. It is most important weakness to raise drug coverage. It must be fulfil by all partners as well as by goverment.

Issue and Challenges during the preparation of MDA in 2013 Micro-planning- Region and State,Township population register were distributed all Tsps,but it were not enough and copied during population data collection Due to planned for MDA in 2012 training for TMO and SMO and VBDC staff were trained since early month of 2012, but late arrival of DEC,we could not conduct MDA in 2012 BHS guide line for MDA were distributed to all BHS before MDA start Some of the trained TMO and BHS transfer to non LF endemic township

Issue and Challenges during the preparation of MDA in 2013 distribution of drug and IEC and arrived to RHC before MDA started Transportation cost of Drug and IEC were borne by ELF porgram with the support of GNNTD, WHO and government Drug distribution Team were not well formed in some of the township both existing and New IU Distribution of pamphlet were not received by each household before MDA Advoccay on MDA at central,State/region and township level

Issue and Challenges during MDA in 2013 No death due to drug, only one child death due to chocking of drug in 2013 Deaths case were reported during MDA are co incidental death during MDA conducted Most s/e are Dizziness, Head ache,vomiting MDA was implemented during I week without discontinuation even rumors on MDA Although some of township has low population coverage of ingestion of drug,more than 65 % of coverage was achieve in district

During the implementation of MDA Drug distributers team could not explain about drug and about LF to household member. They left drug for some person who were not at home and they marked as ingested drug People were not ready to ingest drug because they did not know that drug distributor will come and people refused to ingest when they heard rumors on SE of drug starting 2days of implementation weak supervision and monitoring during MDA by central, Regional and state,even in Township level

after the implementation of MDA Post MDA survey were mainly done by central and some TMOs But weak supervision and monitoring post/after MDA by central, Regional and state,even in Township level Post MDA survey did not conduct in every township Still rumors came out even after the MDA was finished in some state and Region especially Thai border

Out of 45 Endemic Districts (IU), Myanmar has covered 43 IU from Within 13 years, 3 IUs have reached the elimination target, Now 36 out of 43 IU was conducted in 2013 only new 21 district could be started MDA in 2013 (2 IU from Kachin state left) Total pop 35.3 M were covered,85% of total pop,90.9 % of eligible pop in 2013 Previously the main threat of the program is availability of DEC and late arrival of DEC. Integrated NTD of Joint request for Preventive chemotherapy, it will be regular availability of drug of LF and STH Issues and challenges

Availability of resources Now DEC tablets are donated through WHO & Albendazole is donated by the GSK company, IUs of high baseline Mf rate may need more rounds of MDA which in turn need more resource WHO ( )RB –10800 USD only No external or internal financial support previously Funding from GNNTD support US$ for operational cost in 2011,27000 US$ will support for operational cost for implementation of MDA (2013) Government support – in terms of staff, salary, traveling allowances, warehouses, transportation cost at township level and provision of IEC,training cost for BHS and VHW will be supported in 2014 ( request budget for MDA to government- 400,000 USD CNTD will support for TAS in 2014 and find to continue support for more activities.

ActivitiesYear 1Year 2Year 3Year 4Year 55-Year Total Coordination and training$702,240$350,000 $2,102,240 Mapping$0 Drug distribution$263,000 $1,315,000 Social mobilization$199,030 $995,150 Monitoring and evaluation$328,636$60,836$417,636$19,136$680,636$1,506,880 Morbidity control$10,500$3,500 $24,500 Total (USD)$1,503,406$876,366$1,233,166$834,666$1,496,166$5,943,770 Budget for NTD control and elimination in Myanmar ( ) 30 Myanmar’s national NTD program aims to treat 41 million people for at least one NTD at an estimated cost of less than US$0.04 per person per year, underscoring the cost-effectiveness of NTD control and elimination programs.

Programme Plan Activities 2014 target2015 target # administrative units for PC # people # administrative units for PC # people PC MDA2 (DEC + ALB) M T3 (ALB/MBD) for STH 1 st round T3 (ALB/MBD) for STH 2 nd round Activities2014 Target2015 Target M&E # districts/IUs where coverage surveys are planned for any PC diseases 36 IU/205 tsp40 # IUs where pre-TAS sentinel site and spot checks planned (LF) 6 IU12 # IUs where TAS for stopping MDA is planned (LF)5 IU10 # IUs where STH survey integrated with LF TAS planned # IUs where MMDP is to be evaluated (LF)2IU10 IU # IUs where surveillance activities are to be carried out (LF) 3 IU5 IU MMDP# IUs where MMDP services newly initiated (LF)10 IU IVM# IUs where IVM coordinated to target LF vectors10IU

PC medicine request for 2015 ALB (LF)ALB (STH)MBDDEC required in stock in pipeline requested to WHO requested to MDP (IVM) or ITI (AZI) Procured from other sources (source, # tablets and target age group)

Thank You for Attention