REGIONAL ARTEMISININ MALARIA INITIATIVE (RAI) IMPLEMENTATION, ACHIEVEMENT AND LESSONS LEARNT REGIONAL TRAINING WORKSHOP ON ANTIMICROBIAL RESISTANCE (AMR) 15-18 NOVEMBER 2016 BANGKOK, THAILAND
Background Situation of ACT failures in the GMS Countries Delayed parasite clearance following treatment with an artesunate monotherapy or with ACT. This could facilitate the selection of partner drug resistance. In April 2013, WHO launched the Emergency response to artemisinin resistance in the GMS: Regional framework for action 2013 2015 (ERAR) (1). Concern that falciparum malaria in the GMS is becoming increasingly resistant to antimalarial medicines including ACTs. In addition Molecular studies have confirmed that artemisinin resistance has emerged independently in many areas of the GMS. In September 2014, the MPAC of WHO recommended the adoption of the goal to eliminate P. falciparum in the GMS by 2030
Background The Regional GFATM Grant ( RAI) In line with the ERAR s call to action and recommendations, the Global Fund to Fight AIDS, Tuberculosis and Malaria has allocated US$ 100 million to a regional artemisinin initiative (RAI), funding activities to contain and eliminate artemisinin resistance in Cambodia, Lao PDR, Myanmar, Thailand and Vietnam. Funds split between country components (85m USD) and the Inter-Country Component (15m USD). Split by country and ICC are shown in next slide UNOPS was selected as regional Principal Recipient (PR) Oversight by a Regional Steering Committee (RSC)
RAI Grant component Component Country Components Intercountry Components in Million USD Cambodia 15 Lao 5 Myanmar 40 Thailand 10 Vietnam 15 Sub-total 85 ICC Projects by CSOs* 14.1 Pharma - WHO 0.4 Regional Data Sharing - WHO 0.5 Sub-total 15 Grant Total 100
Key Programmatic Achievements - Country Components Expansion of coverage/range of malaria interventions through national programs Jan 2014 June2016 > 3.5 M LLINs DISTRIBUTED TO RISK POPULATION 22,000 8.2 M VMWs / MALARIA POST WORKERs SUPPORTED TO v PROVIDE COMMUNITY CASE MANAGEMENT SUSPECTED MALARIA CASES RECEIVED PARASITOLOGICAL TEST 155,000 CONFIRMED MALARIA CASES WERE TREATED > 52% Pf CASES IN LOW ENDEMIC AREAS INVESTIGATED* > 39 % TRANSMISSION FOCI INVESTIGATED**
Key Programmatic Achievements Inter-country Component 1 (ICC1) Expanding Malaria Posts: 1,436 MPs established and functional. CPI: 83 MAM: 299 SMRU; 1,054 MDA Pilot: Completed in 43 hot spot village (8,375 person completed full MDA ). CPI: 3 MAM: 10 SMRU: 30 M12 post MDA surveys are ongoing. Sustaining community engagement through advocacy events and health education activities.
ICC 1: Summary of MDA Protocol
ICC 1: MDA Results Results M12 from SMRU and CPI are being finalized MAM results from intervention and control villages under MAM showed that prevalence rates for P.falciparum dropped rapidly after MDA in the MDA villages. In control villages the qpcr prevalence also dropped but is was less and less rapid than in the MDA villages.
ICC 1: MDA and Selection for artemisinin resistance. The proportion of P.falciparum malaria with K13 mutations were similar before and after MDA and there is no indication that selection for artemisinin resistance occurred during the MDA.
Key Programmatic Achievements Inter-country Component 2 (ICC2) HPA NIMPE (VTN CAM border) MAM (MYN INDIA border) HPA PEDA- CMPE (LAO CAM THA border) MC PSK -RTF (CAM THA VTN border) WHO ERAR WHO ERAR Expanding malaria to remote and ethnic regions through stablishing MPs Strengthening surveillance and local malaria elimination capacities Expanding malaria to remote and ethnic regions through stablishing MPs Expanding malaria posts and support VMWs. mobile malaria team activities in the targeted areas. BCC/IEC Expanding malaria to remote and ethnic regions through stablishing MPs Strengthening surveillance and local malaria elimination capacities Working Manufacturers Strengthening FDAs Strengthening regional supply chains Establishing regional Database Sharing using DHIS2 platform Strengthening Surveillance and Monitoring and Evaluation
Impact to date ANNUAL PARASITE INCIDENCE: CONFIRMED FALCIPARUM MALARIA (cases per 1,000 persons/year) COUNTRY Baseline 2012 Result 2015 % change CAMBODIA 3.99 2.82-30% LAOS 32.00 9.75-70% MYANMAR 8.50 4.04-52% THAILAND 0.30 0.18-40% VIETNAM 0.40 0.15-62%
Additional epidemiological information BLOOD EXAMINATION RATE: 2014 June 2016 20% 15% 10% 5% 0% 17% 15% 16% 14% 13% 14% 11% 9% 8% 8% 7% 6% 3% 3% 2% Cambodia Lao, PDR Myanmar Thailand Vietnam SLIDE POSITIVITY RATE: 2014 June 2016 2014 2015 2016 Desirable ABER for impact 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 20.9% 20.3% 16.6% 10.2% 10.5% 11.5% 8.7% 7.6% 5.3% 1.9% 1.0% 1.1% 1.0% 0.6% 0.4% Cambodia Lao, PDR Myanmar Thailand Vietnam 2014 2015 2016
Additional epidemiological information PF : PV Ratio Annual 2015 Cambodia Lao, PDR Myanmar Pv 44% Pf 56% Pv 59% Pf 41% Pv 39% Pf 61% Thailand Vietnam Pv 66% Pf 34% Pv 57% Pf 43%
Lessons and Achievements Realistic ambitions to achieve elimination. Increased coordination and dialogue between countries of the GMS. RAI is aligned with coherent national strategies and responses in the GMS countries good complementarity. Coordination. Critical to bring services to all communities, hence the key role of functioning Malaria Posts/Volunteers in all communities. CSOs are an important implementer towards elimination, as part of the health system. Well positioned to serve hard to reach populations. Increasingly MOHs view on CSOs as partners and service providers, as demonstrated by increased budget allocations and inclusion of new partners. 14
Coordination and knowledge sharing High Level inter-country meeting for Directors General of Health in the GMSs. The meeting will be held in Nay Pyi Taw, Myanmar on 5 October Regional MMP workshops twice since 2015 Study tour to MDA villages Kayin State Myanmar Jul 2016 for all the 5 countries to see and interact with the communities where MDA was successfully implemented Special meeting on MDA under ICC1 in June 2016 in BKK 58 participants from Cambodia, Lao PDR, Myanmar, Thailand and Vietnam joined the study tour Including ICC-1 SRs, EHPs and UNOPS. Participants from WHO HQ, ERAR, GFATM, NGOS at the special meeting on MDA in June 2016 in BKK 15
Challenges Difficult Terrains with limited access to telecommunication. The time taken for approvals of CSOs projects was considerably long, resulting in late start of implementation Border area security affects implementation and monitoring of programme. Attrition of Malaria volunteers due to very tough nature of field work Delays in receiving prior import clearance, tax exemption certificates, custom clearance.
Challenges related to MDA Pilot Difficult to convince people to take MDA drugs when they are not sick. People do not care much about the high malaria positivity rate in their village, because they do not realize how it affects their lives. Traditional beliefs. Suspicion of external agencies coming to the village. Villagers just had vaccination and filariasis campaigns. But in general the population was cooperative and friendly. 17
Way Forward RSC initiated the CN writing process a committee from 5 GMS countries including CSO Country-level consultations (starting Nov/Dec) Technical assistance request (ongoing) RAI Current grant (end Dec 2016) 1-year costed extension (Jan-Dec 2017) New grant (2018-2020) Process start: Oct 2016 Concept Note submission: April/May 2017 New grant start: 1 January 2018
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