Learning Unit 3. Road Map to Elimination from Advanced Control to the Prevention of Reintroduction Phase GMS Training Course on Malaria Elimination Chiang Mai, Thailand, 11 August 2015 Allan Schapira

By the end of this Unit, the Participant should be able to: Describe the malaria control to elimination continuum Explain the objectives of each programme phase Describe the major programme reorientations and approaches from malaria control to elimination to prevention of reintroduction Identify major programme transition milestones, interpret them, and discuss their limitations

Overview Pre-eradication/ConsolidationMaintenance Attack

Operational characteristics Pre-elimination  Drug policy change to radical  Set up QA for microscopy  Immediate notification of all cases; engage private sector, no OTC drugs  Concentrate vector control in foci,  Withdraw vector control from cleared- up areas with strong surveillance  Set up database on foci and cases  Train staff on case investigation, focus identification and management  Mobilise domestic funding  Set up national elimination commission Elimination  Asymptomatic carriers are cases and must be detected  New drug policy universally implemented  Routine quality assured microscopy (even if primary diagnosis is by RDT)  Universal access to free diagnosis and treatment  Cooperation of private sector is complete  All cases investigated, classified, databased, followed-up  All foci delimited, investigated, classified and databased, managed with V.C. and ACD according to class and local situation  Measures to control imported malaria including prevention of malaria in travellers, inter-country collaboration

What is pre-elimination? Pre-elimination indicates a transition: Phasing in elimination programme approaches, indicators and systems, Phasing out of the malaria control mode with its total coverage of vector control. Pre-elimination denotes a dynamically changing programme, not a static situation. Countries thus do not "achieve pre-elimination status", they go through it. The decision on when to change programme orientation is limited by operational constraints. It will not be possible to introduce key elimination approaches like individual case investigation (with house visits) if health workers are overloaded by the regular clinic work. It is useless to introduce close follow up and DOTS for OPD malaria cases if most patients obtain treatment from unregulated street pharmacies. Better in such situations to start gradually by improving the services of the OPD and the quality and timelines of diagnosis; ensuring that all suspected cases are tested for malaria; preventing stock-outs at clinic level; enhancing collaboration with the private sector, etc.

Stratification at the outset of pre- elimination 1 st stratum: No risk of transmission. Foci cannot occur (pseudofoci possible) 2 nd stratum: Risk of transmission but no current transmission. May include potential foci (cases only) and cleared up foci 3 rd stratum: Ongoing transmission. In elimination phase, 3 rd stratum = active foci Delimitation fixed, unless major environmental changes Delimitation on the move, until at the end of elimination, there is no longer a 3 rd stratum In GMS stratum 3 must be subdivided according to resistance

The focus

The focus classification simplified Cleared -up Risk of transmission, but 0 cases at present Potenti al Risk of transmission and case(s) present, but no transmission Active Ongoing transmission +

Meaning of 1/1000 threshold < 1 per 1000 per year Local case Persons at risk Data is reliable Does province & districts have HR to investigate, manage each case? To investigate each focus and apply ACD + VC as per guidelines? Yes Has national program set up surveillance system for elimination phase? Have province/district staff been trained in all procedures? Yes Province is in elimination phase!

Elimination is War! It should be declared, when your army is stronger than the enemy’s The elimination phase can be entered, when you have the work-force, which is sufficient to deal intelligently with every case and every focus The pre-elimination phase is, when that work- force is built. The epidemiological threshold values are for rough guidance; whether you declare war or not depends on whether you can build the required work-force, launch-pads and fortifications.

Example of malaria program workforce & infrastructure calculation for elimination phase A province Population: 1 million, at risk population: 400,000, Malaria cases (local and imported): 500 per year in 30 foci located in 4 of 10 districts. Each focus may need a mobile team for, on average, three five-day periods per year, i.e. for a total of 30 x 3 x 5 =450 days. Team members need to prepare reports, work with local health authorities and inter- sectorally and attend meetings and trainings. Thus, the province will need two mobile teams, working under a provincial malaria coordinator. One team could be based in the province capital, another in one of the most affected districts covering neighbouring districts. Administrative officer, supply officer, data entry clerk. Vehicles, storehouse at province level, where supplies and training materials are stocked for rapid deployment. Administrative provisions for rapid recruitment of workers for ACD and vector control.

Epidemiology: look closely, but don’t be myopic

Bulacan Province In the province of Bulacan, the municipality with the highest API was Doña Remedios Trinidad (API 4 per 1,000; 20 cases). Because of API>1/1000, the municipality had been assigned to “Control Phase”. Obviously, it should be the target of elimination efforts and not assigned to “control status”. The key challenge at that stage is not to calculate the API, but to map the cases down to household level, identify breeding sites, find out about population movement, identify the focus or foci and then stop the transmission. The absurdity of calculating API at too small a level is obvious –if all members of one household had had malaria within a year, the API there would be 1,000 per 1,000!

From 1/1000 to ZERO Local Imported Interval variable. typically : up to 5 year for Pf, up to 8 years for Pv

An approach to planning working backwards from the set objectives Determine for each “Province” the dates when – Pf transmission must be interrupted – Pv transmission must be interrupted When, then, must the “Province” enter elimination phase? What must be done at different levels to make that deadline?

CAN WE ACCELERATE? Time is short:

Addressing a Range of Transmission Intensity Transmission Intensity (measured as EIR) Infections/ 1000/year 10, Parasite Prevalence 2-9yr olds 30-60%10-30%1-10%<2% <0.3% 0 Health Facility* cases/week <1 0 * Health facility is assumed to serve ~5000 population and may include community health workers; numbers indicate confirmed malaria cases and include the notion that as infection rates are lower, an increasing proportion of infections become symptomatic. High MediumLow Very Low End GameZero

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO ACCELERATE SCALE UP for Impact OPTIMIZE PREVENTION and CASE MANAGEMENT

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO ACCELERATE SCALE UP for Impact OPTIMIZE PREVENTION and CASE MANAGEMENT BUILD INFORMATION Systems for Action QUALITY and TIMELY REPORTING of INFECTIONS

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO ACCELERATE SCALE UP for Impact OPTIMIZE PREVENTION and CASE MANAGEMENT BUILD INFORMATION Systems for Action QUALITY and TIMELY REPORTING of INFECTIONS COMMUNITY CLEARANCE of Malaria Parasites POPULATION-WIDE STRATEGIES to REDUCE TRANSMISSION

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO ACCELERATE SCALE UP for Impact OPTIMIZE PREVENTION and CASE MANAGEMENT BUILD INFORMATION Systems for Action QUALITY and TIMELY REPORTING of INFECTIONS COMMUNITY CLEARANCE of Malaria Parasites POPULATION-WIDE STRATEGIES to REDUCE TRANSMISSION DETECT & INVESTIGATE Individual Cases HOUSEHOLD and NEIGHBORHOOD STRATEGIES to STOP TRANSMISSION

Steps to Accelerate to Elimination: Steps A-to-E Parasite Prevalence 30-60%10-30%1-10%<2%<0.3%0 Health Facility* cases/week <10 Range of Transmission Intensity ELIMINATE DOCUMENT and MAINTAIN ZERO ACCELERATE SCALE UP for Impact OPTIMIZE PREVENTION and CASE MANAGEMENT BUILD INFORMATION Systems for Action QUALITY and TIMELY REPORTING of INFECTIONS COMMUNITY CLEARANCE of Malaria Parasites POPULATION-WIDE STRATEGIES to REDUCE TRANSMISSION DETECT & INVESTIGATE Individual Cases HOUSEHOLD and NEIGHBORHOOD STRATEGIES to STOP TRANSMISSION

Prevention of reintroduction phase After strengthening the specialized system during pre-elimination to achieve elimination, the work- force is sent back to the barracks, usually meaning: reoriented to VBDCP and other public health functions Responsibility for malaria prevention reverts to general health services Main challenge is to ensure that private health services comply with obligations Specialized services may be needed in areas of high receptivity and vulnerability

Receptivity and vulnerability Areas are receptive when the abundant presence of vector anophelines and the prevailing ecological and climatic factors favour malaria transmission. Areas are vulnerable when they are in proximity to malarious areas or are prone to the frequent influx of infected individuals or groups and/or infective anophelines.

Group 1. Table 2. Comparison of critical health systems and programmatic issues in the different programme phases Issue Control programme Pre-elimination programme Elimination programme Prevention of Reintroduction programme Health system issues Programmatic issues

Groups 2 and 3 Select one country in each group Let it be about to embark on pre-elimination at national level What kind of stratification system to apply? At what level will it be stratified? What data needs to be collected? What are the operational implications?