DHA piperaquine as an eradication tool in Myanmar Myaing Myaing Nyunt MD PhD Celebrating 15 years of MMV Siam Reap, Cambodia 25 February 2015
Evidence and action for malaria elimination in Myanmar Evidence: To collect baseline data to support elimination & to gather buy in from country leadership and local malaria communities Action: Targeted Mass Treatment of malaria To test an intervention based on evidence collected DHA piperaquine ± primaquine and/or others
A question from Myanmar leader Does it pop or jump?
Justification for malaria elimination in Myanmar Vietnam Cambodia Myanmar High asymptomatic infections Presence of artemisinin resistant P. falciparum in Myanmar Independent emergence of artemisinin resistant falciparum Urgency of need to eliminate malaria in GMS by scientific communities Leadership?? Communities?? Takala Harrison et al JID 2014
University of Maryland Baltimore in Myanmar Atypical track of UMB collaboration in Myanmar since 2009 Began as technical assistance supported by USAID and WHO, followed by NIH Fogarty & Open Society Foundation Technical assistance to Myanmar Laboratory support for civilian & military malaria research institutions Intellectual support to researchers & academic communities Optimization of Ethics Review Committees of MoH & MoD Explicit teaching of ethics and professionalism in medical schools Faculty development in civilian and military research institutions and medical schools
Research follows capacity development
New surveillance tools for malaria elimination Gathering of Myanmar malaria communities on 18 January 2014 Need for systematic and large scale baseline evaluations Evidence Prevalence & distribution of asymptomatic infection Prevalence & distribution of drug resistant markers Map parasite migration pattern Malaria research and training as a catalyst to build trust and to initiate a culture of meaningful collaboration Leadership & malaria communities Media & public acceptance & interest
Partners for Gates Project Governmental NMCP DMR DSMRC Non governmental MMA CPI PSI Burnet Institute China CDC Clinton Health Access Initiative Role Lead, coordinate; Field support Field work & lab analysis Field & lab analysis Role Field work Field work Field work Field work & M&E Field work & lab analysis Coordination & data translation to policy Close communication with WHO, USAID/PMI, regional partners
Meaningful collaboration in every steps Protocol review with all partners on 18 January 2015 in Nay Pyi Taw: Exactly one year after Myanmar malaria community gathering
Initial study sites Region/ State Site Partner Ayerwaddy Ingapu MMA Bago East Shwe Kyin DMR/UMB Chin Paletwa MMA / DSMRC Kachin Myitkyina DSMRC Kachin Nabang China CDC Kayah Hpruso Burnet Mandalay Madaya DMR/UMB Rachine Ann MMA Rachine Buthidaung DMR / DSMRC Sagaing Ye Oo PSI Shan Menglian China CDC Yangon Taik kyee DSMRC / MMA
Identification of low parasitemia Ability to identify parasites in standard diagnostic methods Thick blood smear or RDT: ~50 200 parasites per ul Polymerase chain reaction (PCR) method as surveillance tool Standard diagnosis and PCR may be missing significant parasites in low parasite density setting Standard PCR: 1 2 parasites/ul Quantitative PCR (qpcr): <0.02 parasites/ul (<16 parasites/ml) Optimized qpcr methods at UMB High blood volume PCR used on Thai Burma border: Challenges in implementation Blood volume only 0.3 ml (finger or ear prick) & no refrigeration needed for 14 days
Future work & long term success Depending on results of this study: Where? How? When? With whom? Evaluate Targeted Mass Treatment Improve qpcr test: Smaller blood volume; Dried blood spots? Develop minimal surveillance tool for elimination Political complexity has effective impact on success or failure of malaria elimination in Myanmar Sense of ownership & sense of urgency MUST be felt by local communities and leadership Critical for sustained political and community support
Thank you for your attention!