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 Malariology Epidemiology
Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030) (Part 1)

Over the past 15 years the greatly improved malaria situation in the Greater Mekong Subregion (GMS) is reflected in the steady decline in annual malaria incidence and deaths. However, GMS nations still face daunting challenges as malaria epidemiology in this region exhibits enormous complexity and the disease is concentrated mainly in remote areas.

 

Plasmodium falciparum is the species of malaria parasite that accounts for 55% of cases and most malaria deaths in the GMS. Resistance of P. falciparum to several antimalarial medicines, including resistance to ACTs, has reached alarming levels in several areas of the GMS. In the area straddling the Cambodia-Thailand border, P. falciparum malaria could become untreatable with currently available drugs within a few years. Multidrug resistance is both an impediment to elimination and a reason for pursuing it. Therefore, it is imperative that efforts are based o­n evidence, and are coordinated and monitored.

 

Background

The Greater Mekong Subregion (GMS) countries are Cambodia, the People's Republic of China (specifically Yunnan Province and Guangxi Zhuang Autonomous Region), the Lao People's Democratic Republic, Myanmar, Thailand and Viet Nam.

The GMS is bound together by the Mekong River, and is characterized by important commonalities in social and economic development, and extensive population mobility within and across national borders. The area considered covers 2.4 million km2 and has a population of about 278 million (1).

Over the past 15 years the malaria situation in the Greater Mekong Subregion (GMS) has greatly improved and is reflected in the steady decline in annual malaria incidence and deaths (see Annex 2). However, GMS nations still face daunting challenges as malaria epidemiology in this region exhibits enormous geographical heterogeneity (2). Within each country, malaria distribution is uneven, exemplified by high transmission occurring along international borders, and in forests and forest fringes.

Furthermore, resistance of P. falciparum to artemisinin and other antimalarial medicines has reached alarming levels in certain areas of the GMS. In the area straddling the Cambodia-Thailand border, P. falciparum is becoming resistant to o­ne medicine after another, and it could become untreatable within a few years. The o­nly solution is to eliminate P. falciparum from the GMS. The quandary is that multidrug resistance is both an impediment to elimination and a reason for pursuing it. Therefore, it is imperative that efforts are based o­n evidence, and are effectively coordinated and monitored.
 

In September 2014, the Malaria Policy Advisory Committee of WHO (MPAC) reviewed the situation and a malaria elimination feasibility study. It recommended that the affected countries in the GMS adopt the goal of elimination of P. falciparum in the GMS by 2030, to counter the threat of multidrug resistance. MPAC further recommended the establishment of an effective joint subregional governance structure, noting that success will also require greater involvement of the private sector, o­ngoing operational research, and trialling and validation of novel interventions.

Following this recommendation, a draft strategy paper o­n the elimination of P. falciparum in the GMS was prepared by WHO. The paper was presented and discussed among representatives of the ministries of health of GMS countries, as well as partners, at a workshop in Phnom Penh, Cambodia, in November 2014. There was consensus at the workshop that time-bound elimination of not o­nly P. falciparum, but of all species of human malaria, is feasible and should be pursued by all GMS countries, with coordinated support from interested partners. Staff from national malaria programmes worked together to propose specific time-bound targets for each country as well as for shared regions straddling borders. As a result, a second draft of the strategy was prepared and discussed at national consultations during December 2014.

This led to a third draft, which was reviewed at an informal consultation with partners o­n the emergency response to artemisinin resistance, held in Bangkok, Thailand, in February 2015.

The version revised o­n the basis of this consultation was reviewed by MPAC in March 2015.

This final version of the strategy incorporates feedback from all of the consultations described above. It is designed to serve as a framework for revising or developing national level malaria elimination strategies and action plans adapted to local realities, which will then be consolidated and supplemented with regional activities to form a comprehensive GMS malaria elimination action plan. This process should proceed urgently at both country and regional levels.

As well as serving to guide national planning, this strategy will provide countries with an opportunity to apply for funding, both domestic and external, based o­n a WHO-recommended region-specific strategy. This GMS malaria elimination strategy has been developed in line with the principles of the Global technical strategy for malaria 2016-2030 (GTS, see Annex 1). The objectives of the GTS are o­nly achievable if the problem of multidrug resistance, including resistance to ACTs, is vigorously addressed in the GMS.

 

Strategy at a glance

Vision

- A region free of malaria and the continual threat posed by antimalarial drug resistance.

Goals

- The ultimate goal of the regional strategy is to eliminate malaria by 2030 in all Greater Mekong Subregion countries and, considering the urgent action required against multidrug resistance in the GMS, to eliminate Plasmodium falciparum malaria by 2025.

- In areas where malaria transmission has been interrupted, the goal is to maintain malaria-free status and prevent reintroduction.

 

Principles

- All countries can accelerate efforts towards elimination through combinations of interventions tailored to local contexts.

- Country ownership and leadership, with participation of communities, are essential to accelerate progress through a multisectoral approach.

- Improved malaria case1 and entomological surveillance, monitoring and evaluation, and stratification by malaria disease burden are required to optimize implementation of malaria interventions.

- Equity in access to services is essential, especially for the most vulnerable and hard-to-reach populations.

- Innovation in tools and implementation approaches will enable countries to maximize progress.

Objectives

1. Interrupt transmission of P. falciparum in areas of multidrug resistance, including artemisinin-based combination therapy (ACT) resistance, by no later than 20202,and in all areas of the GMS by 2025.

2. Reduce malaria in all high-transmission areas to less than 1 case per 1000 population at risk and initiate elimination activities by 2020.

3. Prevent the reintroduction of malaria in areas where it has been interrupted.

 

Priorities

At regional level

- Eliminate malaria in areas with multidrug resistance, including ACT resistance, surrounding the Cambodia-Thailand border.

- Reduce transmission in high-transmission areas in Myanmar.

- Prevent and respond to the resurgence of malaria.

At country level

- Eliminate malaria in areas of multidrug resistance, including ACT resistance.

- Flatten the epidemiological landscape by reducing transmission in highly endemic areas.

Milestones and targets

By end of 2015

- GMS countries have updated their malaria policies and included malaria elimination in their broader national health policies and planning framework.

- All countries have updated their national malaria strategic plans and action plans based o­n the strategy for malaria elimination in the GMS.

By end of 2016

- Transmission of malaria in Thailand interrupted in 60% of districts.

By 2017

- Each country has an established system at national level to implement elimination-phase surveillance in areas with low burden and has substantially strengthened malaria case and entomological surveillance in areas of high burden (including case reporting by the smallest administrative unit).

- Universal coverage with long-lasting insecticidal nets (LLINs) achieved for all populations in areas of malaria transmission.

By 2020 or earlier

- Transmission of P. falciparum malaria interrupted in all areas of multidrug resistance, including ACT resistance.

By 2020

P. falciparum malaria eliminated in Cambodia.

- Malaria eliminated in Yunnan Province, China.

- All first subnational level administrative units (provinces, states and regions) where malaria has not yet been eliminated are in the elimination phase (with malaria case surveillance meeting WHO standards and annual parasite incidence below 1/1000).

By 2025

P. falciparum malaria eliminated in all GMS countries.

- Malaria eliminated in Cambodia and Thailand.

By 2030

- Malaria eliminated in all GMS countries.

 

Key interventions

- Key intervention 1: Case detection and management

- Key intervention 2: Disease prevention in transmission areas

- Key intervention 3: Malaria case and entomological surveillance.

Supporting elements

- Supporting element 1: Expanding research for innovation and improved delivery of services

+ Development of novel tools and approaches to respond to existing and new challenges, such as insecticide resistance, outdoor biting and varying patterns of population mobility.

+ Operational research to optimize impact and cost-effectiveness of existing and new tools, interventions and strategies.

+ Action to facilitate rapid uptake of new tools, interventions and strategies.

- Supporting element 2: Strengthening the enabling environment

+ Strong political commitment and adequate financial support for elimination.

+ Capacity development appropriate to the implementing strategy.

+ Health systems strengthening to facilitate elimination.

+ Policies for delivery of services to meet the needs of mobile and migrant populations.

+ Intersectoral collaboration and community involvement.

+ Advocacy to support collective action.

+ GMS regional functions (including coordination, technical support, capacity-building, cross-border or regional collaboration, monitoring progress, priority research and information sharing).

The Strategy for malaria elimination in the Greater Mekong Subregion 2015-2030 was developed based o­n the new WHO Global technical strategy for malaria 2016-2030 (GTS). It was further refined through a series of consultations that involved the GMS national malaria programmes and their partners, WHO consultants, and staff from WHO?s Global Malaria Programme, the WHO Regional Offices for South-East Asia and the Western Pacific, and the WHO Emergency Response to Artemisinin Resistance in the GMS Regional Hub. The strategy also benefited from inputs from the WHO Malaria Policy Advisory Committee. In further articulating the strategy, targets adopted in the national malaria strategic plans in the GMS countries, and the East Asia Summit leaders' agreement to the goal of an Asia Pacific free of malaria by 2030, were taken into consideration.

 

The ultimate goal of this strategy is to eliminate malaria by 2030 in all GMS countries and, considering the urgent action required against multidrug resistance in the GMS, to eliminate P. falciparum by 2025. In areas and countries where transmission has been interrupted, the goal will be to maintain malaria-free status and prevent reintroduction, with particular emphasis o­n tackling the growing problem associated with imported malaria.

The proposed strategy emphasizes the progression from burden reduction, which needs to be pursued in high transmission areas, and the elimination phase with rigorous norms for surveillance and management of active foci. In addition, the rapid interruption of transmission in areas affected by multidrug resistance, including resistance to ACTs, is prioritized. In every country and setting, design of operations will be based o­n a careful assessment of technical and operational factors.

The strategy highlights the necessity of a conducive policy environment both in countries and the subregion. All GMS countries need to seek support from the highest level of state to ensure effective multisectoral engagement; address human resources requirements for malaria centrally and at all levels; ensure effective national leadership and governance, including stakeholder coordination; expand health services to provide full access for people in remote areas; and determine appropriate approaches to sustain community-level services beyond malaria specific services. Malaria programmes must possess a broad range of capabilities and be supported by an enabling environment.

To succeed, the GMS malaria elimination strategy has to be backed by effective national policies in which a high-level intersectoral national malaria committee is established and functional and political commitments are translated into adequate and sustained financing of malaria elimination.

Under the Strategy, in all areas of the GMS:

- the health system is strengthened and able to deliver basic health services, including interventions for malaria elimination;

- universal coverage of disease management is rapidly achieved and maintained;

- universal coverage of appropriate vector control in transmission areas is rapidly achieved and maintained;

- mobile and migrant populations have full access to services; and

- systems for adequate case-based malaria surveillance and collection of entomological data are established and fully functional.

In GMS areas already in the elimination phase and those with no transmission:

- notification of each case of malaria is mandatory;

- operations are based o­n epidemiological investigation and classification of each malaria case and focus;

- there is total and effective coverage of all active foci with proven vector control measures based o­n entomological data; and

- a national malaria elimination database is established and operational.

At the GMS level, there is ample scope for a number of functions including training and technical collaboration, collaboration in border areas, ensuring quality of antimalarial medicines, management of high-priority research, monitoring and evaluation, and governance and coordination.

A study to assess the feasibility of eliminating P. falciparum malaria in the GMS estimated a total malaria programme cost of US$ 3.2-3.9 billion over 15 years. The costs including elimination of P. vivax have not yet been estimated, but are expected to be o­nly marginally higher. Specific and detailed costing for each country is planned in 2015.

 

The need for a GMS malaria elimination strategy

Various factors have converged to create an urgent need for action to eliminate malaria in the GMS: the magnitude of the global threat of drug resistance, the substantial impact of the scaled-up interventions currently being applied, the commitment of governments, the keen interest of partners, and the momentum of recent scientific advances.

The rationale for undertaking malaria elimination in the subregion is based o­n the following observations:

- scaled-up interventions o­n malaria have had a marked impact, particularly o­n P. falciparum, bringing malaria incidence down to such low levels that interruption of transmission appears to be a realistic objective in the subregion;

- further delay in addressing the problem of multidrug resistance could lead to the emergence of untreatable P. falciparum malaria;

- affected countries and partners have reaffirmed their political and financial commitments to achieving a greater impact and eliminating malaria; and

- there is a need to establish an effective mechanism to ensure proper intercountry coordination of malaria elimination activities, particularly where movement across international boundaries occurs.

The international attention and political commitments given to malaria elimination in recent years are now being translated into real action, and should be leveraged for the planning and implementation of elimination interventions across the GMS.

The initial draft of this strategy document was developed by a team of consultants (Mikhail Ejov, Sean Hewitt, Kamini Mendis, Kevin Palmer and Allan Schapira). The document was later reviewed and enriched by the following staff from WHO's Global Malaria Programme, the WHO Regional Offices for South-East Asia and the Western Pacific, and the WHO Emergency Response to Artemisinin Resistance (ERAR) in the Greater Mekong Subregion (GMS) Regional Hub: Pedro Alonso, Dorina Bustos, Jane Cunningham, Eva Christophel, Rabindra Abeyasinghe, Bayo Fatunmbi, Deyer Gopinath, Mark Jacobs, Klara Tisocki, Tessa Knox, Gawrie Lokugalappaththy, Noura Maalaoui, Leonard Ortega, Charlotte Rasmussen, Pascal Ringwald, Richard Cibulskis, Krongthong Thimasarn and Walter Kazadi. Subsequent drafts were extensively revised based o­n contributions from the national malaria programmes, the GMS countries and their partners during national consultations, and the ERAR annual partners' forum, and based o­n suggestions from the WHO Malaria Policy Advisory Committee.

 

The strategy for malaria elimination in the Greater Mekong Subregion (2015-2030)

Vision

- A region free of malaria and the continual threat posed by antimalarial drug resistance.

Goals

- The ultimate goal of the regional strategy is to eliminate malaria by 2030 in all GMS countries and, considering the urgent action required against multidrug resistance in the GMS, to eliminate P. falciparum by 2025.

- In areas where malaria transmission has been interrupted, the goal is to maintain malaria-free status and prevent reintroduction.

Principles

In line with the GTS, this GMS malaria elimination strategy adopts the following principles:

- all countries can accelerate efforts towards elimination through combinations of interventions tailored to local contexts;

- country ownership and leadership, with participation of communities, are essential to accelerate progress through a multisectoral approach;

- improved malaria case and entomological surveillance, monitoring and evaluation, and stratification by malaria disease burden are required to optimize implementation of malaria interventions;

- equity in access to services is essential, especially for the most vulnerable and hard-to-reach populations; and

- innovation in tools and implementation approaches will enable countries to maximize progress.

Objectives

The strategy has three objectives:

1. To interrupt transmission of P. falciparum in areas of multidrug resistance, including ACT resistance, by no later than 20203, and in all areas of the GMS by 2025.

2. To reduce malaria in all high-transmission areas to less than 1 case per 1000 population at risk and initiate elimination activities by 2020.

3. To prevent reintroduction of malaria transmission in areas where it has been interrupted.

These three objectives will be achieved through the implementation of a number of key activities, presented below. 

Objective 1. To interrupt transmission of P. falciparum in areas of multidrug resistance, including ACT resistance, by no later than 2020, and in all areas of the GMS by 2025

Deterioration in the efficacy of ACTs in specific areas and the risk of malaria becoming untreatable in the GMS with the currently available drugs calls for urgent and aggressive measures.

Key activities should include:

- Reduce transmission rates through:

+ universal coverage of at-risk populations with LLINs or IRS and supplementary measures where appropriate;

+ reduction of the parasite reservoir through effective treatment and use of low-dose primaquine for P. falciparum;

+ deploying newly recommended transmission reduction tools.

- Apply universal parasitological confirmation of malaria through:

+ reinforcing quality microscopy and increasing access to quality assured RDTs;

+ using diagnostics correctly also in the private sector;

+ adhering to results of microscopy or RDTs.

- Supervise drug administration where possible to help to ensure adherence.

Ensure efficacious treatment is recommended in national treatment policy by:

+ performing routine monitoring of therapeutic efficacy of first- and second-line medicines;

+ timely change of antimalarial treatment policy.

- Eliminate foci of P. falciparum malaria by:

+ rapid detection and full treatment of cases through intensified surveillance and response;

+ detection and treatment of asymptomatic parasite carriers by screening appropriate populations using rapid and highly sensitive diagnostic tools with appropriate WHO recommended tests;

+ full vector control coverage (100%) of all populations in active foci of malaria;

+ adopting measures to prevent the export of parasites to other areas where possible.

- Strengthen malaria case and entomological surveillance.

- Focus o­n detecting, protecting and providing access to diagnosis and treatment for priority population groups (e.g. mobile and migrant populations).

Objective 2. To reduce malaria in all high-transmission areas to less than 1 case per 1000 population at risk and initiate elimination activities by 2020

In high-burden areas, massive and rapid scale-up of existing disease prevention and management interventions, aimed at achieving a significant reduction in malaria burden, should form a transitional stage o­n the path to elimination, reducing the risk of spread of malaria to areas approaching elimination.

Key activities should include:

- strengthen malaria programme management, to ensure that it is operating optimally at all levels of the health system;

- strengthen the malaria case and entomological surveillance system, to efficiently gather, use and disseminate data;

- deliver preventive measures appropriate to local vector biology, transmission settings and populations characteristics to accelerate the impact o­n transmission, morbidity and mortality;

- provide diagnosis and treatment in health facilities and at community level;

- ensure delivery of a comprehensive package of interventions to hard-to-reach, at-riskpopulations;

- empower at-risk populations by ensuring they understand the disease through culturally appropriate and gender sensitive communication;

- rapidly roll out newly recommended tools and interventions, where locally appropriate, to accelerate progress towards elimination; and

- initiate programme reorientation towards malaria elimination.

Objective 3. To prevent reintroduction of malaria transmission in areas where it has been interrupted

As areas and countries achieve interruption of transmission, programmatic focus needs to shift to prevention of reintroduction. The probability of malaria becoming re-established in a malaria-free area varies according to the area's receptivity and vulnerability. When importation of malaria (e.g. due to the arrival of refugees, soldiers or migrant workers from a malaria-endemic area) coincides with high receptivity (e.g. as a result of halting anti-malaria measures or of socioeconomic changes) re-establishment of malaria transmission can occur.

The following activities should be implemented:

- establish an early warning system to monitor malaria risk factors in terms of vulnerability and receptivity in order to predict and prevent re-establishment of malaria transmission;

- establish a reliable malaria case and entomological surveillance system with full coverage of malaria risk areas;

- maintain adequate epidemiological and entomological capabilities with an effective operational research component, to determine risk and underlying causes of transmission resumption;

- ensure easy access to reliable laboratory diagnosis, and effective and radical treatment for every individual;

- establish an epidemic preparedness and alert system; and

- ensure participation of at-risk communities and population groups in malaria prevention activities.

When malaria-free status is achieved, travel-associated and imported malaria will become a growing medical and health issue in all GMS countries. This situation will pose a hazard to the individuals who acquire malaria, because the disease may remain undiagnosed or be incorrectly diagnosed, resulting in high case-fatality rates.

Health systems should be strengthened to:

- improve early diagnosis of all cases of imported malaria and strengthen case-notification systems;

- treat promptly and adequately all imported malaria cases within the public and private health sectors, and prevent o­nward transmission and risk of death from imported malaria; and

- improve preventive practices among travellers through effective and evidence-based pre-travel health advice.

Once an elimination programme has been successfully implemented, the national government may officially proclaim that nationwide elimination of malaria has been achieved. To obtain international recognition of such a declaration, WHO certification is required.

 

Approach

Prioritization

This strategy aims for an accelerated scale-up of appropriate interventions in all endemic areas, tailored to the local epidemiology. Nevertheless, there is a need to prioritize at both regional and country level, at least initially.

Factors to be considered include the past and current intensity of transmission in an area, the degree of resistance to different antimalarial drugs and the size and mobility of affected populations. If a high-burden area is located near a low-burden area, then early reduction of transmission in the high-burden area will likely make it easier to achieve elimination in both.

Based o­n these considerations, the priorities at regional level must be:

- eliminating malaria in areas with multidrug resistance, including ACT resistance, around the Cambodia-Thailand border;

- reducing transmission in high-transmission areas in Myanmar; and

- preventing and responding to the resurgence of malaria.

The priorities at country level must be:

- eliminating malaria in areas of multidrug resistance, including ACT resistance; and

- flattening the epidemiological landscape by reducing transmission in highly endemic areas.

Local analysis may identify additional priorities.

This prioritization does not mean that efforts to eliminate malaria in low-transmission areas should be put o­n hold, o­nly that such efforts must not take precedence over addressing severe drug resistance and burden reduction. In most countries, certain areas should be eligible for the elimination phase as soon as the necessary systems have been developed. o­nce the epidemiological landscape has been flattened, and all major areas achieve malaria incidence below 1 case per 1000 people at risk per year, then the entire country should be eligible for the elimination phase, which will simplify operations.

 

Programme Phasing

Successful malaria elimination requires a distinction between a transmission-reduction phase, where a combination of interventions is applied in all endemic areas, and an elimination phase, where these measures can be targeted to remaining foci and surveillance intensified with measures to rapidly detect and cure every case. Phasing is necessary, because premature application of the elimination-phase approach would be prohibitively demanding. Thus, the malaria burden must be lowered before it is possible (and rational) to investigate and treat every case. Programme phasing o­n the path to malaria elimination has two components:

- The transmission-reduction phase aims to bring malaria incidence down to a level at which elimination can be considered (below 1 case per 1000 people at risk per year4). Interventions aim to reduce transmission and have an impact o­n morbidity and mortality. This involves aggressive scaling up of effective preventive and curative interventions to achieve universal coverage in transmission areas.

- The elimination phase aims to reduce incidence to zero. Malaria case and entomological surveillance become the core interventions - every case is investigated and managed to avoid o­nward transmission. Based o­n the investigated foci of transmission identified, appropriate vector control and antimalarial drug-based interventions are deployed to rapidly interrupt transmission.

Although different parts of a country may belong to different programme phases, phasing should normally be applied to large areas (provinces, counties in the case of China and states or regions in Myanmar). Countries that are not yet in the elimination phase should focus o­n assessing when each target area will reach the threshold for entering the elimination phase. In all GMS countries, incidence has already fallen below this threshold in at least some provinces, and elimination-phase surveillance and other activities should be implemented in those areas.

Establishing an elimination-phase surveillance system must start immediately as it can take several years, because it includes setting up databases and quality assurance (QA) systems, preparing and testing standard operating procedures at central level and training various staff at all levels (3).

The objectives of the national elimination programme have been achieved when:

- locally acquired malaria cases have been reduced to zero; and

- health services and malaria case and entomological surveillance operations are fully capable of preventing re-establishment of malaria transmission.

Once elimination has been achieved, the maintenance of malaria-free status should be the responsibility of general health services, as part of their normal function in communicable disease control, in collaboration with other relevant sectors.

There is consensus that for the elimination of malaria in the GMS, P. falciparum is a priority. However, the prioritization of P. falciparum is not of great operational importance, because in most endemic districts, both P. falciparum and P. vivax are found, and the same vector control strategies are applied. The key difference is in the treatment, where ensuring radical cure for all P. vivax cases poses a challenge.

 

Milestones and targets

The following timetable, with milestones and targets, is proposed for implementation of the GMS malaria elimination strategy. All of the country-specific elimination targets have been identified by the respective ministries of health.

By end of 2015

- GMS countries have updated their malaria policies, and included malaria elimination in the broader national health policies and planning framework.

- All countries have updated their national malaria strategic plans and action plans based o­n the strategy for malaria elimination in the GMS.

By end of 2016

- Transmission of malaria in Thailand interrupted in 60% of districts.

By 2017

- Each country has an established system at national level to implement elimination-phase surveillance in areas with low burden, and has substantially strengthened malaria case and entomological surveillance in areas of high burden (including case reporting by the smallest administrative unit).

- Universal coverage with LLINs achieved for all populations in areas of malaria transmission.

By 2020 or earlier

- Transmission of P. falciparum malaria interrupted in all areas of multidrug resistance, including ACT resistance.

By 2020

P. falciparum malaria eliminated in Cambodia.

- Malaria eliminated in Yunnan Province, China.

- All first subnational level administrative units (provinces, states and regions) where malaria has not yet been eliminated are in the elimination phase (with malaria case and entomological surveillance meeting WHO standards and annual parasite incidence is below about 1/1000).

By 2025

P. falciparum malaria eliminated in all GMS countries.

- Malaria eliminated in Cambodia and Thailand.

By 2030

- Malaria eliminated in all GMS countries.

01/19/2016
(Source: wpro.who.int)  

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