1. Lessons Learned in Elimination Campaigns for Other Diseases Curso de actualización "Eliminación de la Malaria en Mesoamérica y la Española“ CC Campbell 17 February 2014

2. Onchocerciasis and Smallpox Smallpox o Successful program: global eradication o Geographic distribution at onset: global, with intensity in SE Asia and Africa o Highly effective vaccine o Eradication program last ~ 20yrs Onchocerciasis o A regional elimination program (OEPA) o Effort closing in on 20 yrs. o Program based on highly efficacious drug the kills parasite and sterilizes female worms

3. Lessons Learned, Big Picture Operational feasibility: Establish proof at onset in range of difficult settings Subnational leaders: Establish mechanisms to understand and engage them Research: Sustain intensive program throughout initiative Insecurity and conflict: Ensure program capacity to adapt over range of settings Weak health systems: Sustain gains by addressing system vulnerabilities

4. Onchocerciasis: the Basics Biology-Epidemiology o Filarial worm transmitted by a biting blood-sucking insect o Adults live for 8+ yrs. o Distribution around running water…small streams up to small rivers…generally remote areas and populations o Disease manifestations are skin and eye disease…..leading to blindness o 123 million persons at risk for infection in 38 endemic countries, 25.7 million are infected, and 1 million are blinded or have severe visual impairment Intervention o Ivermectin is unique drug: kills microfilariae, sterilizes adult females o No drug resistance to date

5. Onchocerciasis Global Distribution

6. Onchocerciasis Elimination in Middle America

7. Onchocerciasis The Worms and the Vector

8. Elimination Program Ivermectin killing microfilaria up to 6 months Adult worms produce mf for 5+ yrs. Program: surveillance for eye disease, skin biopsy o MDA, high coverage at 6 mo. interval o Stratification by prevalence intensity In 2013, only 4% (23,378) of the 560,911 persons originally at risk in the Americas will be under Ivermectin MDA

9. Lessons Being Learned Is the eradication program purposefully vertical Develop broad range of partnerships The importance of advocacy Keep investing in intervention science Involve community-based partners Fix target and dates, but be flexible The “end-game” will be most challenging

10. Smallpox Historical Lessons in Eradication

11. Smallpox History and Epidemiology Highly transmissible: human-human Major and minor variants: major high case fatality rate Vaccination highly efficacious in producing sterilizing immunity for multiple years Global outbreaks and endemic transmission up to 1950s WHO and CDC commitment to eradication in 1967

12. Vaccination: The Silver Bullet

13. Eradication Strategy Mass vaccination with high population coverage (> 90%) Quarantine Ring vaccination and containment

14. Eradication Strategy Favorable Factors Highly effective intervention Lag between exposure and disease onset: vaccination effective in interval Few competing global campaigns Interventions relatively inexpensive: lives saved, deaths averted Planning projected time-limited effort

15. Smallpox Eradication A 20-year Global Campaign

16. Smallpox Eradication Results are Clear Last case 1979….in Horn of Africa Lessons learned: o Highly efficacious vaccine and favorable epidemiology o Massive effort and team work o Sustaining resources “Begin where you will end up”

18. Lessons Learned from Earlier Malaria Eradication Campaigns Curso de actualización: "Eliminación de la Malaria en Mesoamérica y la Española“ CC Campbell 17 February 2014

19. Lessons Learned from Earlier Malaria Eradication Campaigns Eliminating or eradicating malaria transmission has long history o Draining Pontine swamps to rid Rome of malaria o Malaria naturally receded in many areas of northern Europe and the United States without direct interventions; due to improved housing, etc. o An understanding of transmission intensity evolved intuitively, leading to understanding of malaria at the fringes o By mid-1900s malaria distribution and burden at historical levels

20. Malaria Distribution as of 1950

21. Technology Infused Hope for Eradication Discovery of DDT and chloroquine and wide- spread deployment opened consideration of elimination Early successes in several areas with low transmission: IRS and various uses of chloroquine (ACD, MDA, etc.) By 1957 WHO launched malaria eradication effort using IRS with various insecticides: strategy “simple”….high population coverage sustained for multiple years though undefined

22. The Interventions

23. “Global” Malaria Eradication Program 1957-1972 Led by WHO Focus on Central America, SE Asia western Pacific, middle East IRS and drug use in various modalities Creation of national malaria eradication programs….vertical units in governments Funding USG, World Bank, and other bilaterals

24. Malaria Eradication: Outcomes In geographically isolated settings elimination achieved: e.g. Sri Lanka, Middle East Program named “global”, yet did not include Africa where 90% of burden exists In broader areas variable control achieved Resistance to insecticides and drugs evolved Political and financial support proved difficult to sustain Closed down 1972

25. District-based Action District engaged, responsible and supported A ‘Team’ approach from district to community System to map, identify coverage, gaps, & fill gaps, locate infections System to identify and treat all infections and aggressively reduce transmission Active case & infection detection Screen and treat (mass drug administration ?) Treatment for Transmission Reduction (reaching all infected people) Surveillance as an Intervention ­Identify & cure all infections (diagnosis is critical) ­Investigate and eliminate transmission (follow up is critical)

26. Focus on Central America, El Salvador A Personal Recounting

27. El Salvador …..a Malaria Success Story

28. Malaria El Salvador, 1974-mid 1980s Post eradication ~800,000/annually Largely focused around littoral, large-scale agriculture with irrigation(cotton, cane), and seasonal migrant labor ….the Perfect Storm Massive agricultural insecticide application Laborers from highlands; influx during rainy season Esteros filled with rain run-off…breeding sites Malaria program moved to more expensive and toxic insecticides

29. Malaria El Salvador 1980s-present The critical development: land reform and break up of hacienda system Combined with large projects to break up water impoundment, and dramatic drop in insecticide use No longer seasonal influx of labor 2012 reported cotton production and malaria cases….

30. Malaria El Salvador Cause and Effect

31. The Success of an Elimination Program Depends on Key Components….and Commitment and Financing TOOLS HEALTH SYSTEM ENVIRONMENT Drugs and Insecticides remain effective LLINs are used by > 80% even in the absence of malaria in the community Universal Access to High Quality Diagnosis and Treatment Near perfect surveillance (passive case detection) Strong political support Community Involvement and buy-in Resistance Monitoring and Entomological Surveillance IEC/BCC Existing plans to strengthen the health system are executed (free malaria treatment for all) QA/QC, training, health worker incentives (?), IEC/BCC High level political involvement IEC/BCC

32. Prevention of Reintroduction is the Challenge The Zanzibar Experience Before any prevention measures can be scaled back, surveillance must be (near) perfect! Surveys on the ferry boats and at “informal” landing sites: -Where are people coming from and where are they going? -How long are they staying for? -What is the Infection Prevalence in travelers? Border Screening? Prophylaxis in travelers/migrant workers? Screening of high risk groups?

33. Lessons to be Learned…..are we Listening? Elimination and eradication are serious long-term commitments Time is of the essence….resistance and boredom can eventually undo the effort A continuing portfolio of impressive successes is essential Financing will never be enough and will be required for longer that we can ever anticipate Technical contingencies and innovations must continue to evolve Start where you will end up!