1. Containment of artemisinin resistance at the Cambodia-Thailand border Sylvia Meek, Technical Director, Malaria Consortium, CMWG Meeting 8 July 2009

2. Drug Resistance in Southeast Asia Asia fought resistance to one drug after another from 1970s to 90s Often first found in the same area on Thailand / Cambodia border Moved from cheap and simple to costly and complex treatments After years of research and debate most countries now use Artemisinin-based Combination Therapies (ACTs) –Debates on choice of drug overrode efforts to improve delivery and access –Now these are being addressed –Results look good Progress towards elimination could be threatened if resistance to artemisinin derivatives appears

3. The Greater Mekong Subregion

4. Artemisinin derivative resistance has been detected in Thailand and Cambodia Research over last two years has confirmed increased time for parasites to be cleared Biggest problem is knowing how far it has spread In the meantime we cannot wait so a special containment programme is underway in the areas where there is evidence

5. Distribution of confirmed malaria cases in the Greater Mekong Subregion, 2007* Source: National Malaria Control Programmes & WHO *2006 data for Myanmar

6. The containment strategy  Remove selection pressure Reduce and ultimately eliminate falciparum malaria

7. Three Phases of the Response Phase 1: January to December 2008 Phase 2: January 2009 to December 2010 Phase 3: January 2011 to December 2015

9. Phase 3 - the medium-term strategy Re-defining the goal –Continue containment of artemisinin resistance –Commence elimination of malaria parasites countrywide during this time period pre-elimination status for Plasmodium vivax is unlikely to be completed but strategy will begin the process Expanding activities from current containment zones to other malaria areas of the country Testing, implementing and scaling up innovative “packages” of activities –Several of these will be piloted and refined during Phase 2 supported by WHO, BMGF, USAID and others, so evidence for key decisions is expected in 2010

11. Objectives Objective 1: To detect all malaria cases (including among mobile/migrant populations) and ensure effective treatment and Pf gametocyte clearance (through single dose primaquine). Objective 2: To decrease drug pressure for selection of artemisinin resistant malaria parasites by improving access to appropriate treatment and preventing use of monotherapy and substandard drugs in both public and private sectors

12. Objectives (2) Objective 3: To prevent transmission of artemisinin resistant malaria parasites among target populations (including mobile/migrant populations) by mosquito control and personal protection Objective 4: To support containment of artemisinin resistant parasites through comprehensive behavior change communication (BCC), community mobilization, and advocacy Objective 5: To provide effective management (including information systems and surveillance) and coordination to enable rapid and high quality implementation of the strategy

13. Key areas of focus Mobile and migrant populations –How to reach, what about new economic migrants? Surveillance and information systems Suppression of using monotherapies –Private sector issues –Understanding patient behaviour Joint action by Thailand and Cambodia Planning for sustainability

14. Female migrant workers in Komrieng District, Battambang Province. The plastic sheet at the back is used as shelter for sleeping at night and for keeping their belongings and in case of rain. (source: Kim Sedara, MC/CDC)

15. Challenges Need extraordinary efforts to control malaria even where it is less common –Link between resource allocation and disease burden is less clear There are beneficial side-effects –improving surveillance –improving private sector strategies –Learning to work with mobile populations –Learning for elimination Are we missing the main target? –How to determine routes of spread –How to support malaria control in Myanmar/Burma

16. Challenges (2) We cannot be complacent and rely on current tools lasting for ever –Investment in R&D is essential –How much to invest in protecting drugs versus deploying them and moving on to next ones We shall continue to lose good tools if we do not take systems strengthening and regulation seriously –Re-emphasise quality, delivery, diagnosis Deciding when to act then raising support is a challenge –If we saw the same amount of evidence in Nigeria or Ethiopia, what scale of response could we mount?

17. Priority Partnership Activities Gain consensus on strategy components Plan for contingencies – response scenarios for different regions Communicate issues realistically Review relevant experiences Multidisciplinary task force proposed