1. Learning Unit 3. Road Map to Elimination from Advanced Control to the Prevention of Reintroduction Phase Biregional Training Course on Malaria Elimination Lipa City, Philippines, February 2014 Allan Schapira

2. 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

3. Overview

5. 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  Introduce geographical reconnaissance  Concentrate vector control in foci, this includes: withdraw 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  New drug policy universally implemented  Routine quality assured microscopy QA (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

6. 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 emphasis on total coverage of vector control interventions. Pre-elimination denotes a dynamically changing programme, and 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) when the health workers are overloaded by the regular clinic work. It will have limited impact 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 every febrile patient who does not have other obvious causes of fever is tested for malaria; preventing stock-outs at clinic level; enhancing collaboration with the private sector, etc.

7. What is the priority in elimination? What needs to be perfect?

8. 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.

9. Epidemiology: look closely, but don’t be myopic

10. Bulacan Province Bgy.Kalawakan in Doña Remedios, with 5000 inhabitants and 20 cases, API = 2.51/1000 In the province of Bulacan, the municipality with the highest API was Doña Remedios Trinidad (API 2.51 per 1,000; 20 cases). The cases and API related to just one barangay – Kalawakan – with a population of about 5,000. Because of that API, the municipality had been assigned to “Control Phase”. However, the barangay had the last remaining focus in a province with a total of 22 or 23 cases. 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, and then stop the transmission. The absurdity of calculating API at too small a level is obvious – if one imagines that all the 20 cases had been found in 1 sitio with a population of 500, the API there would have been 40 per 1,000. And if all members of one household had had malaria within a year, the API there would be 1,000 per 1,000!

11. The focus

12. Prevention of reintroduction phase After strengthening the specialized system during pre-elimination to do the elimination, this 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

13. 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.

14. Groups 1 and 3: Table 3 Indicators by programme type Indicator Control programme Pre-elimination programme Elimination programme Prevention of reintroduction programme Outcome Impact Programme milestone

15. Groups 2 and 4 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?