Malaria Elimination: Global Picture

Robert D. Newman, MD, MPH Director, Global Malaria Programme

The Science of Eradication: Malaria Boston 8 June 2012

WHO Global Malaria Programme: four key roles

I

II

III

IV

Set, communicate and promote the adoption of evidence-based norms, standards, policies, and

guidelines

I

Develop approaches for capacity-building,

systems strengthening, and surveillance

Keep independent score of global progress

Identify threats to malaria control and elimination as well as new opportunities

for action

IV

II

III

Chart the course for malaria control

& elimination

MPAC Background

●  Scale up of malaria control and major investments in research = rapidly evolving policy environment for new tools and technologies (and end of one-size-fits-all approach)

●  Setting policy, norms and guidance on malaria control is primary role of WHO Global Malaria Programme (GMP)

●  MPAC provides independent strategic advice and technical input to WHO for development of policies related to malaria control & elimination

●  GMP dedicated to a policy setting process that is more: §  Timely, transparent, and accountable

●  2011 was a critical year in the redesign, launch and implementation of a strengthened policy setting process

Designing and Launching MPAC

●  March 2011 - GMP Advisory Group on policy setting convened to review previous and existing processes, consider successful models, propose draft ToR

●  April-June 2011 - Draft ToR (based on SAGE) received extensive input from over 40 external stakeholders

●  August 2011 – ToR approved by WHO Director General ●  September-October 2011 – Open call for nominations, 100

applications received & reviewed by independent selection panel ●  November 2011 – 15 nominees appointed as MPAC members,

selected for their experience and broad expertise ●  December 2011 – all MPAC related information available online ●  January/February 2102 – Inaugural meeting ●  April 2012 – MPAC report published in Malaria Journal

Evidence Review Groups

MPAC

RBM: Secretariat, WGs and SRNs

WHO malaria policy recommendations and

guidelines WHO DG MoH and

NMCPs SAGE JTEG

(with IVB)

VCAG (Proposed, with NTD)

Standing TEG on chemotherapy

ERG a

ERG b

ERG c

WHO GMP Secretariat

WHO ROs

WHO COs

MPAC: organogram

Other WHO departments

Interface between Roll Back Malaria Partnership (RBM) and WHO-GMP

●  RBM Secretariat is hosted at WHO ●  RBM Roles

§  Advocacy §  Resource mobilization §  Partner harmonization

●  Important to optimize interface between RBM mechanisms and WHO-GMP §  Example: MPAC meetings are offset from RBM Board

meetings by 3 months to allow for dissemination of new policies and input into next agenda

World Malaria Report 2011 •  2011  Report  released  on  13  December  2011  

•   Annual  reference  on  the  status  of  global  malaria  control  &  elimina<on.    Data  to  2010  and  2011  

•   Principal  data  source  is  na<onal  programs  in  106  endemic  countries  with  support  from:  WHO  Regional  offices,  ACT  Watch,  AMFm,  ALMA,  CDC,  CHAI,  Columbia  University,  DFID,  DHS/  Measure,  FIND,  GHG  UCSF,  Global  Fund,  IHME,  ISGlobal,  JHU,  PATH,  R4D,  RBM,  Tulane  University,  UNICEF,  UNSE,  USAID  

•   Summarizes  key  malaria  targets  &  goals  

•   Documents  trends  in  financing,  interven<on  coverage  and  malaria  cases  and  deaths  

•   Updates  malaria  burden  es<mates  for  decade:  2000-­‐2010    

•   NEW:  Profiles  for  each  of  the  99  countries  with  ongoing  transmission  

Past and projected international funding for malaria control

Number of LLINs delivered by manufacturers to countries in sub-Saharan Africa

294 million LLINs procured for distribution in Africa between 2008 and end 2010 More than 50% of households in sub-Saharan Africa owned at least 1 ITN as of 2011

Proportion of population at malaria risk protected by IRS

Malaria RDT sales

Sales  to  public  and  private  sectors   Sales  by  panel  detec3on  score  (PDS)    

Proportion of suspected malaria cases at public health facilities receiving a parasitological test

Despite improvements, long way to go to reach universal access to diagnostic testing, especially in Africa (currently 45%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

AfricaAmericasEastern MediterraneanEuropeSouth-East AsiaWestern Pacific

Current classification of 193 countries and 2 territories by the malaria programme that is implemented in the worst affected part of the country

81

89 8

29

60

89

control

pre-elimination

elimination

prevention ofreintroduction

certified malaria-free

supplementary list

Malaria Elimination: 2011

Progress with malaria elimination in the WHO European Region

●  Ten out of 53 countries in the European Region were affected by malaria in 2000

●  As of 2011, 102 locally acquired malaria cases were reported in only five countries: Azerbaijan (4), Georgia (1), Tajikistan (53), Turkey (4) and Greece (40)

●  Turkmenistan was certified malaria-free by WHO in 2010 and Armenia – in 2011

●  Kazakhstan was added to supplementary list of malaria free countries in 2012

Indigenous malaria cases in WHO EURO, 2000-2011

0

5000

10000

15000

20000

25000

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Case

s nu

mbe

r

Azerbaijan Georgia KyrgyzstanRussian Federation Tajikistan TurkeyTurkmenistan Uzbekistan

Progress with malaria elimination in WHO European Region

Number of autochthonous cases of malaria in EURO, 1990-2011

1996

2011

0100002000030000400005000060000700008000090000100000

1990 1993 1996 1999 2002 2005 2008 2011

AREAS AFFECTED BY MALARIA

Autochthonous malaria, Central Asia 2011

0

5000

10000

15000

20000

25000

30000

1992 1995 1998 2001 2004 2007 2010

TAJIKISTAN

KYRGYZSTAN

TURKMENISTAN

KAZAKHSTAN

UZBEKISTAN

Progress with malaria elimination in WHO Eastern Mediterranean Region

●  Twelve out of 20 countries in the Eastern Mediterranean Region reported local malaria transmission in 2000

●  During subsequent decade, six countries embarked on nationwide elimination programmes (Islamic Republic of Iran, Iraq, Morocco, Oman, Saudi Arabia and Syria), resulting in 10-fold reduction in malaria cases

●  Three others (Pakistan, Sudan and Yemen) developed sub-national malaria-elimination initiatives

●  The United Arab Emirates and Morocco were certified malaria-free in 2007 and 2010, respectively

Elimination in Morocco

20

Malaria has been eliminated in Morocco

Total cases (log scale) 100,000

10,000

1,000

100

10

0 2010 2005 2000 1995 1990 1985 1980 1975 1970 1965 1960

Total cases Local cases

Monitoring & surveillance remain high priority

Map of entomological surveillance sites in Morocco today

Permanent breeding sites for entomological surveillance

Elimination in Iraq

21

Cases of vivax malaria - Iraq 1990-2008

Sulaimania was the last region with malaria in Iraq

Local cases in Iraq, 2005-2008

50

40

30

20

10

0

2010

7

2009

1

2008

2 4

2007

2

1

2006

1

2005

3

Last Local cases in 2008

Local cases Imported cases

Local cases

100,000

40,000

20,000

0 2010 2005 2000 1995 1990

0 2 44 1,860

9,684

49,836

98,222 Total cases

29  

1941  

1  

10  

100  

1,000  

10,000  

100,000  

1990   1992   1994   1996   1998   2000   2002   2004   2006   2008   2010  

Elimination in Saudi Arabia

Reported malaria cases in Saudi Arabia, 1990-2010

Coordination with Yemen for cross-border IRS activities to reduce

transmission

Strong political commitment

Total cases Local cases

Southwestern Saudi Arabia (including Jazan, Aseer & Qunfuda) is the primary malaria focus for P. falciparum, transmitted via An. arabiensis

Trend of Total and Local Cases- Iran (Islamic Republic of )

0

5000

10000

15000

20000

25000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Total Reported CasesLocal Cases

•  Iran has had gradual reduction of malaria cases

•  Only 1847 local cases recorded in 2010 (85% reduction compared to 2000)

•  Both Pf & Pv exist; close to Pf elimination

•  Transmission is focal mainly in areas bordering Pakistan

Progress in Republic of Iran

Progress with malaria elimination in WHO Region of the Americas (PAHO)

●  Local malaria transmission in 23 out of 47 countries in 2000

●  Four have since progressed to the pre-elimination phase (Argentina, El Salvador, Paraguay and Mexico)

●  Two have initiated an elimination programme at sub-national level (Dominican Republic and Haiti)

●  Two other countries (Bahamas and Jamaica) suffered a temporary reintroduction of malaria transmission in 2006 that has since been controlled

Progress with malaria elimination in WHO Southeast Asia Region (SEARO)

●  With exception of the Maldives, which is preventing reintroduction following its successful elimination efforts in the 1980s, all 11 countries affected by malaria during last decade

●  Two countries progressing with nationwide elimination (Sri Lanka and Democratic People’s Republic of Korea)

●  Indonesia has adopted a sub-national elimination strategy for Java and Bali

●  Bhutan and Thailand, where large areas with no malaria transmission are found, have expressed their intention to proceed with elimination

Progress with malaria elimination in WHO Western Pacific Region (WPRO)

●  Malaria is still endemic in 10 of 37 countries ●  Malaysia and Republic of Korea implementing

nationwide malaria elimination programmes ●  Sub-national elimination on-going in Philippines,

Solomon Islands, and Vanuatu ●  Cambodia, China, Viet Nam and Lao People’s

Democratic Republic have included elimination in their national strategies.

●  In 2010, China made a government commitment to eliminate malaria

Progress with malaria elimination in WHO African Region (AFRO)

●  All but four of 46 countries have on-going transmission ●  Lesotho, Mauritius, and the Seychelles not endemic for

malaria ●  Algeria is in the elimination phase; Cape Verde entered the

pre-elimination phase in 2010 ●  Four countries of southern Africa (Botswana, Namibia, South

Africa and Swaziland) share a common goal of eliminating malaria by 2015; joined by four northern neighbours (Angola, Mozambique, Zambia and Zimbabwe) in 2009, to form sub-regional malaria elimination initiative known as Elimination Eight (E8)

●  Another four countries in Africa (Gambia, Rwanda, Sao Tome and Principe, and Madagascar) have secured grants to prepare for elimination

Recent WHO activities on malaria elimination

●  Community Based Reduction of Malaria Transmission (with malERA)

●  Eliminating Malaria: Learning from the Past and Looking Ahead

●  Malaria Elimination Case Studies Series (together with UCSF Global Health Group)

●  Elimination Scenario Planning (ESP) tool (together with Clinton Health Access Initiative)

●  Launch of Disease Surveillance for Malaria Elimination

●  Launch of T3: Test. Treat. Track.

Major challenges ahead

●  Political commitment ●  Financial resources ●  Global health architecture ●  Procurement and supply chain management ●  Health system capacity; human resource capacity ●  Delivering quality case management in the private sector ●  Antimalarial drug resistance ●  Insecticide resistance ●  Inadequate surveillance and controversies over burden

estimation ●  Delivering results in highest burden countries

Challenge: Global political commitment ●  Context

§  Major shift towards non-communicable diseases §  Sense that malaria has already made significant progress, therefore

needs less support going forward §  Fatigue (this is a long fight)

●  Potential solutions §  Consistent evidence-based policy setting (WHO Malaria Policy

Advisory Committee) §  Careful and consistent documenting of impact §  Link to wider health & development efforts §  Resolutions from major organizations (e.g. UN, WHO) §  Organizational support (e.g. ALMA) §  Helping countries cross the finish line (malaria elimination)

●  Risks §  Advocacy sometimes out ahead of reality: a fine line

Continued global political commitment

● Creation of African Leaders Malaria Alliance (ALMA): 2009

● United Nations General Assembly resolution on malaria: April 2011

● World Health Assembly (WHA) resolution on malaria: May 2011

● Roll Back Malaria (RBM) Partnership revised objectives, targets, and priorities: June 2011

● malERA (2009-2011) & MESA (2012 & beyond)

Challenge: Financial

●  Context §  Well short of estimated 6 billion USD per year required §  Concerning data to suggest that funds could decline by 2015 §  Global financial crisis and competing priorities with potential to

worsen the situation §  Global Fund Continuity of Services policy does not include

malaria ●  Potential solutions

§  Increased efficiency and value for money §  Increased domestic funding for malaria §  Innovative financing mechanisms

●  Risks §  Worsening financial crisis; continued financial challenges at

Global Fund

GLOBAL MALARIA PROGRAMME

APMEN  2009  

Mesoamerican  Ini3a3ve  for  Public  Health  2008        

The  Hispaniola  Ini3a3ve    Carter  Center  2008  

Northern  Africa  WHO/EMRO  1997  

       SADC  2007    Elimina3on  8  2009  

Tashkent  declara3on  WHO/EURO  2005  

Arabian  Peninsula  malaria  free  2006  

Professor  Li's  FEMSE  projects  2003-­‐2005-­‐2007    

West  Africa  2009  

Suriname  ini3a3ve?  

Southern  Cone  ini3a3ve    

Major opportunities ahead ●  Malaria elimination: crossing the finish line ●  Trans-border collaboration ●  New uses for existing tools. Example: Seasonal Malaria

Chemoprevention (WHO policy for Sahel sub-Region as of 2012) ●  New tools: malaria vaccine in 2015? ●  Integrated community case management (iCCM) ●  Improving efficiency and value for money. Example: a 5-year LLIN ●  Universal diagnostic testing, improved case management, and

strengthened surveillance (T3: Test, Treat, Track) ●  Stratification:

§  Using data for decision making §  Determining the optimal intervention mix for different

epidemiological settings

Malaria Surveillance Manuals – Worldwide launch: Namibia, 24 April 2012

●  Objective §  To provide guidance to malaria-endemic countries on the operation of

malaria surveillance systems for malaria control and elimination

●  Rationale §  Updated malaria surveillance guidance has not been issued by WHO

since the Global Malaria Eradication Programme era

§  Scale-up of malaria interventions increases need for timely and accurate information on malaria occurrence for program management

§  Increasing availability of malaria diagnostic tests allows for tracking confirmed malaria cases and better targeting of resources

§  New manuals focus on program implementation and complement other existing guidance on malaria indicators

Surveillance Manuals: Objective and Rationale

Three WHO Manuals as pillars of T3

Test Treat Track

T3: Test. Treat. Track. Worldwide Launch: Namibia, World Malaria Day 2012

● First: near zero deaths from malaria

§ Today, no one should die from malaria for lack of a 5 dollar bednet, a 50 cent diagnostic test, and a 1 dollar antimalarial treatment

● Ultimately: a world free of malaria

Keep our eye on the prizes