Malaria 2025: Accelerate t Eliminate The Glbal Technical Strategy fr Malaria: 2016-2025 Setting glbal targets Azra Ghani, GTS Steering Cmmittee Geneva, 12 March 2014 1
Visin and Gals Purpse f Visin and Gals sectin This sectin is cre t the GTS, by setting the directin and prviding cncrete targets that the malaria cmmunity shuld aim fr in the cming decade Visin and Gals prvide the strategic frame t reginal and lcal level prgrammes when develping their wn strategies Key questins Are the prpsed visin / gals sufficiently aggressive and ambitius t drive change and accelerate impact in the cming decade? Is the verall strategic frame clear, cnsistent, and cmprehensive? 2
Visin and Gals Lngterm Visin A single visin: a wrld free f malaria GTS Visin T accelerate prgress t a wrld free f malaria Gal 1 t reduce malaria mrtality rates glbally by 75% cmpared t 2015 Gals Gal 2 t reduce malaria case incidence glbally by 75% cmpared t 2015 Gal 3 t eliminate* malaria frm 20** cuntries that had nging transmissin f malaria in 2015 *eliminate refers t n indigenus transmissin f malaria; nt certificatin ** 20 cuntries t be cnfirmed 3
Fcus n malaria targets Three cmbined appraches t define apprpriate target levels 1 Reginal / Cuntry level targets Imperial Cllege malaria transmissin mdel GTS targets 2 3 GMP malaria eliminatin trend analysis Target setting methdlgy t be detailed in a separate Annex f the GTS dcument 4
Eliminatin gals & targets 2016-2030 as stated by cuntries 2015 Zer indigenus cases: Btswana Swaziland Indnesia (337 districts) Ethipia (specific gegraphical areas) 2017 Zer indigenus cases: China Zanzibar 2025: Zer indigenus cases: Cambdia Iran India (5-10 States) 2030: Zer indigenus cases in Indnesia 2016 Zer indigenus cases: Bhutan Thailand (60% f districts) Slmn Islands (Temtu Prvince) Vanuatu (1 Prvince) 2018: Zer indigenus cases: Suth Africa 2020: Zer indigenus cases: China Djibuti Malaysia Suriname Yemen Philippines (pst 2020) Thailand (80% f districts) Indnesia (459 districts) 2026: Zer indigenus cases in Nepal 5
Trend Analysis What have cuntries achieved t date? Hw des this match the resurces that have been input? Data cmpiled frm 2013 Wrld Malaria Reprt Trends in P.falciparum and P.vivax case reprts frm 2000 nwards Changing cverage f LLINs and IRS Increase in access t first-line treatment with ACTs Predictins fr 2016-2025: Statistical trend extraplatin (all cases) Mathematical mdel fitting (P.falciparum nly) 6
P.f cases P.v cases Example Trends: Bhutan Prgram Gals: T achieve zer indigenus case f malaria in Bhutan by 2016 100% 80% 60% 40% LLIN cverage IRS cverage 20% 0% 25,000 20,000 2000 2005 2010 25,000 20,000 15,000 10,000 15,000 10,000 Data falciparum Data vivax 5,000 5,000-2000 2005 2010 7 -
P.f cases P.v cases Example Trends: India Prgram Gals: substantial and sustained reductin in the burden f malaria in the near and mid-term; eliminatin f malaria in the lng term 30% 25% 20% 15% 10% LLIN cverage IRS cverage 5% 0% 1,400 2000 2005 2010 1,400 1,200 1,200 1,000 1,000 800 600 400 800 600 400 Data falciparum Data vivax 200 200-2000 2005 2010-8
P.f cases P.v cases Example Trends: Brazil Prgram Gals: Reductin in mrtality, cases and transmissin 100% 80% 60% 40% LLIN cverage IRS cverage 20% 0% 3,500 2000 2005 2010 12,000 3,000 2,500 2,000 1,500 1,000 500 10,000 8,000 6,000 4,000 2,000 Data falciparum Data vivax - 2000 2005 2010-9
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Number f cases Prjecting Frwards: Statistical Mdels Statistical mdels assume a cntinued trend Difficult t knw which functin is mst apprpriate Different functins give very different predictins 9,000 8,000 7,000 Observed Expnential decay Hlt-Winters Quadratic functin Linear (Observed) 6,000 5,000 (Bhutan) 4,000 3,000 2,000 1,000-10
Prjected decreases fr cuntries in which it is pssible t assess trends 12 12 10 10 8 8 6 6 4 4 2 2 0 0 African African Regin f the Americas Regin Eastern f Mediterranean the Americas Eastern Eurpean Mediterranean Eurpean Suth-East Asia Suth-East Western Pacific Asia Western Pacific % reductin 2016-2025 % reductin 2016-2025 Median decrease 82% (IQR 59%-99%) r 73% (IQR 55%-89%) excluding Eurpean Regin 11
P.f cases P.f cases Prjecting Frwards: Mathematical Mdels Can predict varied trends depending n cverage f interventins Less easy t match past trends P.falciparum nly Bhutan India 25,000 1,600 20,000 1,400 1,200 15,000 1,000 10,000 800 600 Data falciparum Mdeled falciparum 5,000 400 200-2000 2005 2010 2015 2020 2025-2000 2005 2010 2015 2020 2025 12
Mdelling scenaris fr P.falciparum (Wrk in Prgress) Aim t use mathematical mdel f malaria transmissin t assess what impact cmbinatins f currently recmmended interventins culd have if implemented between 2016 and 2025 Mdel inputs: Endemicity in 2010 (MAP prevalence and WMR 2013 case reprts) Cverage f interventins (treatment, ACT use, LLINs and IRS) up t 2012 (WMR 2013 & DHS/MIS surveys) Vectr species & their binmics fr 3 mst cmmnly reprted species in a cuntry (MAP estimates) Mdel utputs: Estimates f percentage change in cases and deaths between 2016 and 2025 Prprtin f cuntries achieving different reductin threshlds Prprtin f cuntries mved int pre-eliminatin status (<1 case per 1000 ppulatin per year) 13
Scenaris Scenari Descriptin 1 Cntinue the current cverage f LLINs, IRS and access t treatment 2 Increase universal cverage f LLINs t 80%, access t treatment t 80% f all cases (r existing cuntry levels if greater), all cases accessing care are treated with an apprpriate ACT 3 Scenari 2 plus SMC t children aged 3 mnths t 5 years with SP plus amdiaquine in recmmended areas in the Sahel regin f Africa at 80% cverage 3a Scenari 2 plus IPTi t infants with SP in Africa at 80% cverage where the EIR is abve 10 ibpppy 4 Scenari 3 plus treatment f severe disease with IV artesunate (assumed t reduce mrtality in cases wh reach hspital by a further 20%) 5 Scenari 4 plus yearly IRS with DDT (at 80% cverage) in thse cuntries in which a 90% reductin in cases r a mrtality rate less than 1 death per 1000 ppulatin per year was nt achievable by 2025 with Scenari 4 6 Scenari 5 with increased cverage f LLINs t 90%, access t treatment t 90% f all cases, all cases accessing care are treated with an apprpriate ACT 14
Case incidence per persn per year Glbal Prjectins: Cases (A) 0.3 1. Cntinue as in 2012 0.25 0.2 0.15 0.1 0.05 0 2000 2005 2010 2015 2020 2025 2. Increase t 80% cverage f LLINs and treatment 3. Plus SMC at 80% cverage in recmmended areas 3a. Plus IPTi t infants with 80% cverage in Africa 5. Plus yearly IRS at 80% cverage in areas nt achieving gals 6. All interventins at 90% cverage Past scale-up (B) 1 1. Cntinue as in 2012 15
Deaths per 1000 peple per year Case 0.05 Glbal Prjectins: Deaths 0 2000 2005 2010 2015 2020 2025 achieving gals 6. All interventins at 90% cverage Past scale-up (B) 1 1. Cntinue as in 2012 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 2000 2005 2010 2015 2020 2025 2. Increase t 80% cverage f LLINs and treatment 3. Plus SMC at 80% cverage in recmmended areas 3a. Plus IPTi t infants with 80% cverage in Africa 4. Plus treatment f severe disease with IV artesunate 5. Plus yearly IRS at 80% cverage in areas nt achieving gals 6. All interventins at 90% cverage Past scale-up 16
Predicted Glbal Reductins t 2025 Scenari % Reductin in Cases % Reductin in Deaths 2. Increase t 80% 44.6% 53.4% 3. Scenari 2 plus SMC 45.7% 54.6% 3a. Scenari 2 plus IPTi 44.6% 53.4% 4. Scenari 3 plus treatment f severe disease with IV artesunate 45.7% 57.2% 5. Scenari 4 plus yearly IRS (currently with DDT at 80% cverage) 82.5% 81.7% 6. Scenari 5 with increased cverage t 90% 88.6% 88.5% 38 ut f 80 cuntries predicted >90% reductin in cases under Scenari 5 Substantial reginal variatins: >95% reductin in cases and deaths under Scenari 5 in EMRO, SEARO and PAHO 27 cuntries at pre-eliminatin by 2025 under current cverage Additinal 16 cuntries predicted t reach this under Scenari 5 17
Resurce Needs Mdel tracks resurces utilised, taking int accunt ppulatin distributins in at-risk areas and ppulatin grwth Includes interventin resurces and healthcare utility (assuming n change in health-seeking behaviur) DHS/MIS surveys used t estimate rates f NMFI in children under 5 t calculate RDT resurces (ther methds will be cnsidered) IPTp csts nt currently incrprated (but can be) Financial and prgramme csts based n recent reviews Additinal malaria cntrl prgram csts (training/cmmunicatin, CHWs, peratinal research/m&e, infrastructure/institutinal strengthening) currently added using previus GMAP methdlgy 18
Resurce Csts Cst (USD 2010)* GMAP assumptins LLIN (per net) $7.03 $6.41 IRS (per persn) $3.60 $7.50 SMC (per curse) $1.50 - ACT treatment fr uncmplicated malaria at health centre / utpatient Nn-ACT treatment fr uncmplicated malaria at health centre / utpatient $1.00 (ACT cst) $0.60 (RDT cst) $1.40 (healthcare visit cst) $0.30 (drug cst) $0.60 (RDT cst) $1.40 (healthcare visit cst) $1.08 (paediatric) $2.025 (adult) $0.30 RDTs used fr NMFI (per fever) $0.60 $0.78 Hspital csts assciated with treatment f severe disease (assumed t be the same fr quinine and artesunate) $30.26 $29.50 19
Preliminary Estimates Scenari Estimated Cst per Year (2010 US$) including healthcare csts Estimated Cst per Year (2010 US$) excluding healthcare csts 1. Remain at current levels 2.0 billin 1.7 billin 2. Increase t 80% 3.1 billin 2.7 billin 3. Scenari 2 plus SMC 3.2 billin 2.9 billin 4. Scenari 3 plus treatment f severe disease with IV artesunate 3.2 billin 2.9 billin 5. Scenari 4 plus yearly IRS with DDT (at 80% cverage) 5.5 billin 5.4 billin 6. Scenari 5 with increased cverage t 90% 6.1 billin 6.0 billin Cmparative Figures: 2013 internatinal disbursements: US$ 1.97 billin (WMR 2013) 2012 dmestic spend: US$ 522 millin (WMR 2013) Original GMAP estimates:* $5.1 billin per year frm 2011 t 2020 *Includes LLINs, IRS, IPTp and treatment and management f cases assuming 100% cverage 20
Summary Gal 1 t reduce malaria mrtality rates glbally by 75% cmpared t 2015 Natinal Plan Review: 50%, 70%, 75%, 90% reductins Mdelling: 55%-90% reductin Gal 2 t reduce malaria case incidence glbally by 75% cmpared t 2015 Gals Natinal Plan Review: 50%, 70%, 75%, 90% reductins r threshld incidence Trend Analysis: 73% / 82% reductin Mdelling: 45%-88% reductin Gal 3 t eliminate* malaria frm 20** cuntries that had nging transmissin f malaria in 2015 Natinal Plan Review: 15 cuntries have cmplete r partial eliminatin currently in plan Mdelling: 27 cuntries at pre-eliminatin threshld by 2025, additinal 16 culd reach this with intensive scenari 21