Learning Unit 8. Feasibility Biregional Training Course on Malaria Elimination Lipa City, Philippines, February 2014 Allan Schapira

Purpose of feasibility study Can transmission be interrupted? Can malaria- free status then be maintained? Can transmi ssion be reduced to very low? Can the system to interrupt transmiss ion be built?

Learning objectives Describe the purpose of a feasibility assessment; Describe the technical, operational and financial factors that should be considered in assessment of feasibility of malaria elimination; Formulate a clear problem definition for a malaria programme feasibility assessment in own country; Carry out a feasibility analysis based on technical and operational data from own country; Formulate interim targets for malaria elimination based on the analysis; Analyse financial feasibility for a given area and explain how cost-effectiveness of elimination and control may be compared.

3-way analysis Technical: Is elimination possible with existing tools (but not necessarily limited to tools currently used in the country), assuming that there are no operational or financial constraints? If yes, proceed: Operational are there significant obstacles in the health system including the malaria programme, or in broader contextual determinants? If so, can they be overcome? If yes, proceed: Financial and economic: Would the costs be reasonable and justified? How they could be covered? It is most useful, if information is presented to compare various options. ……………… If yes, eliminate……..

So there is a bit of work Advanced controlPre-eliminationEliminationPrevention of reintroduction Technical Operational Financial

Time is of the essence There must be a time-limited objective Time-frame (to reach 0 cases) could be 5 – 15 years Timing of feasibility analysis: When SPR/TPR approaches 5% in the most affected region/province may be a sensible point to do feasibility study. I.e. the 5% threshold is a good time to do analysis. Depending on it, a programme may enter pre-elimination phase and set time-bound objectives, or decide to continue in control mode.

Why do we have to do it? Why WE? What are the risks of embarking on elimination and failing? What are the risks of not embarking on elimination, if it is feasible? The decision is political, but the issues are too serious and too complicated to be left to the politicians.

Strategic variants Elimination of falciparum malaria only – or first Local elimination in a unit of suitable size, which is not too vulnerable – i.e. it is relatively isolated, unless its receptivity is very low. It should not be an area, where malaria is disappearing by itself. Aim for controlled non-endemic malaria: corresponds to remaining in WHO’s “prevention of reintroduction” category, but not 100% malaria-free. Proceed to pre-elimination, but without an elimination plan. Not ideal, but may be sensible.

Local elimination In a State, region, province, island A national process An independent national body must validate (not certify) that local health authority has eliminated malaria and can maintain malaria-free status. Responsibility for maintenance must rest with local authority. WHO takes no responsibility, but may provide technical cooperation and may report on the reported achievement in ITH. (WHO Malaria Policy Advisory Committee and Secretariat Malaria Journal 2013, 12:456.

TECHNICAL FEASIBILITY in elimination + prevention of reintroduction phases (1) vectorial capacity/receptivity, (2) duration of infectivity, which depends on the surveillance system and, (3) risk of importation/vulnerability.

Elimination phase: Can we get R<1? R 0 =C 0 x D 0 Before control, we have: Ex.: 100 = 5/day x 20 days R c =C c x D c Under best possible control, we get: Transmission will be interrupted, if R c < 1 Vectorial capacity Duration of infection in humans

Maintenance Phase: Can we prevent reintroduction? R c =C c x D c Recep tivity Surveillance => D Vulnerability !!!

R c and vulnerability If R c =1 and 100 cases are imported, we expect 100 introduced cases; in the next generation 100 indigenous cases and in the next generation…. If R c =1 and there are 3 imported cases… If R c =0.5 and100 cases are imported and, then we expect 50 introduced cases; in the next generation….

Local/imported ratio In steady state, after apparent interruption of transmission An ratio local/imported of 1/1, indicates that R c = 0.5. In the face of frequent importation, small outbreaks will continue to occur. This corresponds to controllled non-endemic malaria (Cohen et al. How absolute is zero. Mal.J. 2010)

Technical + operational feasibility Review the list on p in learners

Empiricist approach to feasibility: Plot log incidence by year and extrapolate Within 2-3 years, all 5 of these provinces should reach incidence rate of 0.001/ 1000 = 1 /million, malaria will disappear (as population of each province is about 1 million).

Extrapolation in the frontier islands Extrapolation indicates that Occidental Mindoro will get to 10 per million in 3-4 years, but Palawan only by With such a long time horizon, there is considerable uncertainty.

¿Será posible el sur?

Exercise 8. Select a country or a region, which is sufficiently homogenous, sufficiently large and sufficiently advanced to make a feasibility assessment rational Go through the main technical and operational determinants. Note if favourable, unfavourable, neutral or unknown For operational, note to what extent the situation can realistically be ameliorated. Assess vulnerability Assess feasibility of elimination and timeline

8. continued For the area under consideration, present case number by year for latest 4-8 years. Graph case number by year with logarithmic y-axis If it is approximately linear, compute the least square regression slope, using the SLOPE function in Excel Through linear extrapolation, find the years, when the number reaches 10 and 1.