Cambodia: From Control to Elimination Ministry of Health National Centre for Parasitology, Entomology and Malaria Control (CNM) Dr. Kheng Sim Presentation at APMEN Meeting, 8 May 212
History of Malaria Control in Cambodia Malaria Control Programme was started by the Ministry of Health (MoH) with support from WHO in 1951. Malaria activities were reduced during the civil war (197- April 1975) There were no malaria control activities at all during the Khmer Rouge regime, the period between April 1975 to 1978. CNM was reorganized in November/December 1995 with added responsibilities for the control of schistosomiasis, soil transmitted helminths as well as dengue control activities. Subsequently filariasis elimination programme was added to its remit.
History of Malaria Control (contd.) By May 2, CNM evolved as the nodal department of the MOH responsible for the control of vector borne and parasitic diseases Implementation of the artemisinin resistance containment project from 29-211 supported by BMGF. The NMCP is currently undergoing a reorientation to an elimination program with the launching of the National Strategic Plan for Malaria Elimination in March 211.
Overview of the NMCP Central CNM PHD 2 provincial health departments* OD 44 operational districts* Health Center 9* Village Malaria Workers The National Center for Parasitology, Entomology and Malaria Control (CNM) sets policies that are implemented by decentralized provincial and operational district health departments. CNM is also the Principal Recipient of GF SSF grant. *In malaria endemic areas 15 villages*
Significant long-term reduction observed in malaria incidence in Cambodia (HIS Data) since 2.
Significant long-term reductions observed in malaria mortality rate.
Number of Severe and Death 7 6 5 4 3 2 Malaria Severe Cases, Deaths and Case Fatality Rate of Severe Malaria from referral hospitals, 2 to 211, Cambodia 627 9.8 5453 8.7 4214 1.8 4936 8.8 3719 9.1 256 1.4 4392 Source: Epidemiology Unit,CNM, 31 Jan 212 1.4 2648 8.3 2755 7.1 445 6.4 2484 5.3 2727 3. 12 1 8 6 4 Case Fatality rate(%) 1 68 476 457 433 339 267 347 219 195 259 132 81 2 21 22 23 24 25 26 27 28 29 21 211 2 Severe Cases Death Case Fatality Rate A steady declining secular trend is being observed since 2 with regard to malaria severe cases, malaria deaths and severe malaria case fatality reported by referral hospitals
1. A reduction in Plasmodium falciparum incidence and some evidence of increasing Plasmodium vivax incidence observed in the HIS data. 2. The P.falciparum/P.vivax ratio has gradually reversed over the period since 2.
PV 16% Mix 3% Pf 81% Mix 9% PV 34% Pf 57% The Pf : Pv Ratio has been gradually reversing as Pf cases decline.
Age-Sex Distribution of Malaria Cases Positive >49 Male, 3% Positive 15 49 Female, 16% Positive >49 Female, 2% Positive 4 Yr, 7% Positive 5 14 Yr, 22% Positive 15 49 Male, 5% Malaria is mostly occupational (forest-related) among males aged 15-49 years (5%). Children aged 5-14 years (22%) and females aged 15-49 years (16%) are also at-risk when in the forest.
Epidemiological Data from VMW villages # of VMW villages by year Total Population Total RDT Tested Total Positive Malaria death case Incidence rate Mortality rate Positivity rate 24(235village) 7722 18771 11998 33 17 4.67 64 25(3v) 114687 5885 28443 29 248 2.53 56 26(3v) 124841 84917 43437 34 348 2.72 51 27(3v) 127837 634 2433 6 19.47 4 28(4v) 186186 57882 24439 5 131.27 42 29(1255v) 864525 12295 53568 19 62.22 44 21(1394v) 142995 13291 47222 3 45.3 36 211(1528v) 182971 1387 4875 2 45.2 35 Data Source: VMW Project,CNM The VMW project has demonstrated significant reductions in positivity rates, malaria incidence and mortality.
Scale-upVMWs A significant long-term reduction has also been observed in malaria incidence in the VMW villages since 24
Malaria Mortality in VMW villages 4 35 348 3 Per 1 population 25 2 15 17 248 19 131 1 5 62 45 45 Source VMW project/cnm 24 25 26 27 28 29 21 211 A significant long-term reduction has also been observed in malaria mortality in the VMW villages since 24 Year
(%) 3 2 1 Failure rates after treatment with an artemisinin based combination therapy, Cambodia (21 211) Battambang 21 22 24 25 27 (%) Pailin 3 2 1 22 24 29 21 211 (%) 3 2 1 Artemether-lumefantrine Artesunate-mefloquine Pursat 22 24 25 27 29 211 Dihydroartemisinin-piperaquine (%) 3 2 1 artemisinin resistance containment project zone 1 Odder Meanchey 23 (%) 3 2 1 Kampot 28 (%) 3 2 1 Preah Vihear 25 26 28 21 (%) 3 2 1 3 2 1 (%) 3 2 1 (%) Ratanakiri 23 25 26 21 211 23 Kratie 21 23 26 Kampong Speu
(%) 5 4 3 2 1 Day-3 positivity rate after treatment with an artemisininbased combination therapy, Cambodia (21 211) (%) 4 3 2 1 Battambang 21 22 24 25 27 Pailin 22 24 29 21 211 (%) 3 2 1 Artemether-lumefantrine Artesunate-mefloquine Pursat Dihydroartemisinin-piperaquine 2 4 5 7 9 11 artemisinin resistance containment project zone 1 (%) 3 2 1 23 (%) 3 2 1 Odder Meanchey 23 (%) 3 2 1 Kampong Speu (%) 3 2 1 Ratanakiri Preah Vihear 25 26 28 21 23 25 26 21 211 (%) 3 2 1 (%) 3 2 1 Kratie 21 23 26 Kampot 28
P.f cases 15 1 5 1 14 135 139 112 99 12 121 13 74 6 63 63 43 43 5 23 3 31 25 12 31 14 26 12 2 5 14 14 8 21 18 9 17 8 4 5 12 6 23 Sep-11 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan-1 Feb-1 Mar-1 Apr-1 May-1 Jun-1 Jul-1 Aug-1 Sep-1 Oct-1 Nov-1 Dec-1 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 29 13 11 Cases diagnosed in Pailin province P.f cases diagnosed by microscopy and RDT at health facilities in Pailin province (Z1), Jan 28-Jun 211 LLIN and EDAT interventions start 15 1 Jan-8 Feb-8
2.5 CAMBODIA: malaria mortality in public health facilities per 1, population, by zone and 6 month period, 28 211 Malaria Mortality per 1, Population 2. 1.5 1..5 Zone 1 ODs Zone 2 ODs Zone 3 ODs Non target ODs. Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun 28 29 21 211 Source: HIS OD data
1.%.9% Cambodia Containment Surveys 29 21: Prevalence of Malaria positive Slides.9%.8% Prevalence of positive blood slides.7%.6%.5%.4%.3%.6%.4%.6% Zone 1 Zone 2.2%.1%.% CS 29 CS 21
5.% Cambodia Malaria Surveys 24 21: Prevalence of Malaria positive Slides 4.5% 4.4% 4.% Prevalence of positive blood slides 3.5% 3.% 2.5% 2.% 1.5% 2.6% 1.3% Total Domain 1 (1 containment provinces) Domain 2 (1 other at risk provinces) 1.%.9%.5%.5%.% CMS 24 CMS 27 CMS 21
Political Support: the Prime Minister of Cambodia Let our people not suffer from the scourge of Malaria any more. Please prepare and implement a plan to wipe out the disease from our country Samdech Hun Sen, Prime Minister, Cambodia (while speaking on the occasion of the inauguration of the new building of the Referral Hospital, Kampong Cham Province on 2 January 211)
LONG TERM STRATEGY FOR MALARIA ELIMINATION IN CAMBODIA
STRATEGIC OBJECTIVES 1. To ensure universal access to early malaria diagnosis and treatment services with an emphasis on detection of all malaria cases (incl. among mobile/ migrant populations) and ensure effective treatment including clearance of P. falciparum gametocytes and dormant liver stage of P. vivax. 2. To halt drug pressure for selection of artemisinin resistant malaria parasites by improving access to appropriate treatment and preventing use of monotherapies and substandard drugs in both public and private sectors. 3. To ensure universal access to preventive measures and specifically prevent transmission of artemisinin resistant malaria parasites among target populations (including mobile/migrant populations) by mosquito control, personal protection and environmental manipulation. 4. To ensure universal community awareness and behavior change among the population at risk and support the containment of artemisinin resistant parasites and eliminate all forms of malaria through comprehensive behavior change communication (BCC), community mobilization, and advocacy. 5. To provide effective management (including information systems and surveillance) and coordination to enable rapid and high quality implementation of the elimination strategy.
Malaria Intervention Packages Over Next 15 Years Malaria Intervention Packages Vector Control and Malaria Prevention Case Management Behaviour Change Communication (BCC) Artemisinin Resistance Containment and Elimination Research Surveillance
Vector Control & Malaria Prevention Package Provision of Insecticide Treated Bednets (IBNs) is one of the main measures utilized to prevent malaria transmission. 1% LLIN/LLIHN Coverage for all population at risk (including mobile population & military/police). Re stratification and village level risk mapping based on health center level data. IRS an additional prevention tool to use in foci of transmission detected through active case investigation The IBN Unit conducts monitoring and research to inform policy decisions: Monitor residual effect of LLINs at sentinel sites Research & monitor the longevity of LLINs in Cambodia Define efficacy of repellents use in Cambodia Define residual efficacy of IRS.
Vector Control & Malaria Prevention Package (contd.) Mobile populations pose a new challenge by moving from non endemic to highly endemic forested areas. Free LLINs to mobile/migrant groups (incl. cross border, seasonal & new settlers) Introduction of LLIHN loaning scheme in Pailin to cover mobile populations Focus on 1% coverage. Malaria Information Database (MIS) Used to improve Data Management capacity and leverage data for implementation and policy development. MIS has been set up in 2 provinces (44 ODs).
BCC Package Emphasis on correct diagnosis & proper treatment and referral as well as prevention of malaria ITNs/LLINs are the main primary prevention tool in Cambodia and hence Health Education Unit focuses on proper use of this intervention Emphasis is on the local vernacular and practices in response to address the risk behavior representations in order to empower people Health behaviour contributes to and confounds the malaria problems in the country.
Case Management Package Access to affordable ACTs and RDTs: Free diagnosis & treatment: Public health facilities including Military and Police Health Facilities VMWs in high risk villages MMWs targeting mobile & migrant populations Subsidized diagnosis & treatment Private sector via PSI s social marketing of Malacheck and Malarine Ensuring Quality Service Delivery: Training, Monitoring & Supportive Supervision for health care providers.
Case Management Role of Private Sector CNM has developed a Public Private Mix Strategy to guide all PPM activities within the elimination context. Private Sector Engagement CNM led PPM initiatives underway in SR, BMC, Kampot & RTK Focus on appropriate Diagnosis, Treatment & Referral Encouraging reporting & recording of case information Initial feedback suggests private sector are very willing to collaborate with public sector.
Case Management Ban of artemisinin monotherapy Regulatory measures: Ban on oral artemisinin monotherapy Enforcement of ban by Department of Drugs and Food (DDF) & Ministry of Interior, Anti Economic Police (MoIE) Investigation of counterfeit and substandard drugs. Results (ACT Watch Surveys 29, 211): Total removal of monotherapy from public sector Dramatic drop of monotherapy in private sector
Program Management Package Includes planning, resource management and overall coordination of the program to support decentralization and integration within the health sector Adoption of a multisectoral approach, through the establishment of provincial and operational district coordinating committees/task Forces. Establishment and convening of a National Malaria Steering Committee to provide strategic direction and oversight to the NMCP. Updating and implementation of National Malaria Strategic Plan and National M&E Plan
Research Package Research conducted by CNM contributes to implementation and policy development, constantly improving CNM s response to malaria control. Entomological survey Insecticide monitoring Serological surveys Therapeutic drug efficacy studies Private sector use of RDTs (GUARD) Cambodia Malaria Surveys (CMS)
Surveillance Package Routine data collection, analysis and interpretation through the coordinated efforts of the epidemiology and M&E units contributes to CNM s understanding of the nationwide malaria situation and informs policy makers and key stakeholders. As case incidence is reduced, case investigation (source of infection and possibility of secondary cases) becomes primary activity.
Questions? Artemisinin Resistant Malaria Parasites Artemisinin Resistant Malaria Parasites Falciparum Malaria Parasites Vivax Malaria Parasites