Malaria Symposia Myanmar Medical Association Dr Aung Thi National Malaria Control Program 04 March 2017
OUTLINE OF THE PRESENTATION Country profile Programmatic achievements Challenges Lessons learnt Way forward
COUNTRY PROFILE Total population Population at risk Administrative structure Neighboring countries Economy Malaria endemic townships ~ 52 million ~ 43.9 million 15 States and Regions 330 Townships 13,619 Village tracts 64,134 Villages Bangladesh, China, India, Laos, Thailand Agriculture, mining, industries, plantations, forestry, fishing, etc., 291 % of MMPs 7%
Species-wise Yearly Malaria Cases (Pf and Pv) 35000 30000 67% is Pf in 2016 25000 20000 Cases 15000 10000 5000 0 Pf Pv
ABER, API & TPR (2015_2016) 70.00 7.00 60.00 6.00 50.00 5.00 API, TPR 40.00 30.00 4.00 3.00 ABER 20.00 2.00 10.00 1.00 0.00 0.00 *2016(NMCP-Not complete) ABER API(All) Test Positivity Rate ABER 2.3 % in 2016. API (0.95 in 2016) and TPR (4.1 in 2016) going down
14.00 API (Pf, Pv, All species) 2005_2016 12.00 10.00 8.00 6.00 4.00 2.00 0.00 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 *2016(NMCP-Not complete) AFI(Pf) API(All Sp) API(Pv) Downwards trend of API (all), AFI (pf) and API (pv) from 2012
Incidence of malaria cases by age and sex 2015 Incidence of malaria is higher in male than female
MALARIA MICROSTRATIFICATION (2015) Stratum Transmission status Subcenter Population (2015) % of Pop: 3a High 1,026 3,542,647 7% 3b Moderate 1,461 6,328,845 12% 3c Low 2,062 12,664,333 24% 2 Potential 4,439 21,354,063 41% 1 Malaria free 1,531 8,116,373 16% Total 10,519 52,006,261 100%
NUMBER OF IP PER TOWNSHIP VHV MAPPING 20 IMPLEMENTING PARTNERS 15,000 VILLAGE VOLUNTEERS
ANTIMALARIAL RESISTANCE Therapeutic Efficacy Studies: 10 sentinel sites P. falciparum P. vivax All ACTs are effective more 95% except Artesunate-Sulfadoxine- Pyrimethamine Chloroquine and Sulphadoxine-Pyrimethamine recorded over 25% Mefloquine less than 10% Chloroquine is still effective
Susceptibility of Anopheline species to different insecticides in Myanmar Species Organophosph ate (malathion) Insecticide Organochlori ne (DDT) Pyrethroi ds (Various) An. minimus - S S An. dirus S S S An. maculatus S S S An. philippinensis - - S An. aconitus S T S An. sundaicus - - - An. annularis S T S An. sinensis S S R An. hyrcanus T T R An. minimus and An. dirus distribution Courtesy JICA S= susceptible; T= tolerant; R=resistant
KEY PROGRAMMATIC ACHIEVEMENTS Malaria epidemiological situation analysis in 2015 External Programme Review in 2016 Malaria endemicity mapping (micro-stratification) in 2016 Key programme documents in 2016 National Malaria Strategic Plan 2016-2020 National Malaria Elimination Plan 2016-2030 Monitoring and Evaluation Plan Other programme supporting documents related to case management, vector control and surveillance Malaria Global Fund Concept Note (2017-2020): US$124 M National Malaria Elimination Committee
SUMMARY OF ACHIEVEMENTS Malaria related MDG achieved in 2004 well before the target year of 2015 The goal of National Strategic Plan (2010-2016) achieved well before target year 2016 Malaria cases and deaths reduced by 62% and 91% respectively in 2015 compared to 2012 The incidence malaria reduced by 49% in 2015 compared to 2012. No reported outbreaks of malaria since 2012
SUMMARY OF ACHIEVEMENTS ACTs more than 95% effective Primary vectors are susceptible to insecticides tested National Strategic Plan 2016-2020 and Malaria Elimination Plan 2016-2030 in place Funding secured for 2017-2020
4 Objectives MALARIA NATIONAL STRATEGIC PLAN (2016-2020) 1. To reduce reported incidence of malaria to less than 1 case per 1,000 population in all states/regions by 2020. 2. To interrupt transmission of falciparum malaria in at least 5 states/regions by 2020. 3. To prevent the re-establishment of malaria in areas where transmission has been interrupted. 4. To prevent the emergence of multi-act resistant P. falciparum in Myanmar. 3 Key interventions 1. Case detection and management 2. Disease prevention 3. Malaria case and entomological surveillance 2 Supporting elements 1. Expanding research for innovation and improved delivery of services 2. Strengthening enabling environment
NATIONAL MALARIA ELIMINATION PLAN (2016-2030) Vision Myanmar free from malaria by 2030 Mission Achieving the vision of Malaria Free Myanmar will contribute significantly to saving lives and poverty alleviation as malaria is most prevalent in the poorest segment of the population Goals Interrupt transmission and eliminate indigenous malaria by 2030 Maintain malaria-free status in areas where malaria transmission has been interrupted and prevent reestablishment of local transmission
CHALLENGES Orientation of the malaria control programme to elimination Capacity building of the programme staff and partners in elimination To eliminate and prevent the emergence and spread of artemisinin resistant malaria parasite; availability of oral artemisinin-based monotherapy Increase accessibility of diagnosis and treatment, mapping and targeting, providing additional LLINs, IEC/BCC to mobile and migrant population
CHALLENGES (cont d.) Limited malaria prevention and control in non-government control areas Prevention and control outdoor malaria transmission Filling the vacant position at different levels Engaging the private sectors in malaria elimination efforts Strengthen coordination and collaboration among the many implementing partners Further strengthening of malaria information system by incorporating e-health (DHIS2)/m-health/LMIS
LESSONS LEARNT High level political commitment driving the programme Improved case detection by RDT and effective treatment by ACT through the network of 15,000 village health volunteers Targeted LLIN distribution Engagement of CSOs and Ethnic Health Organizations to provide malaria treatment and prevention services in hard to reach areas and non-governmental control areas Malaria TSG as a platform for technical guidance and partner coordination
WAY FORWARD Programme & IPs orientation & capacity building on elimination Functioning of national malaria elimination committee, working group & executive working group Scaling up of malaria elimination activities without delay: case investigation, foci investigation & response in elimination townships. Initiate case based DHIS2 Strengthen law enforcement and initiate activities to eliminate oral artimisinin-based monotherapry Continuous distribution of LLINs, production & distribution of MMP sensitive IEC/BCC materials to address MMPs Engage private sector for malaria elimination
SHRINKING MALARIA MAP 2015 2018 2020 2025
MALARAI FREE MYANMAR BY 2030
National Malaria Treatment Guidelines 2016
Objectives of the guidelines To provide information on the diagnosis and treatment of uncomplicated malaria, including disease in special risk groups, and in epidemics and complex emergency situations; and severe malaria including its management
Diagnosis of malaria at peripheral level Diagnosis of uncomplicated malaria by community workers including VHVs by Simple history taking Temperature measurement Blood test by RDT Referral of severe malaria with pre-referral treatment to nearest hospital with facilities for management Patients who fail to treatment will also be referred
Diagnosis at intermediate level without a laboratory Staffed with health assistant (HA) and other trained health workers (LHV/ PHS-I/ MW/PHS- II) Diagnosis based on clinical signs and symptoms blood examination with RDT better possibility of diagnosing other diseases which are not malaria.
Diagnosis at intermediate level with a laboratory Institutions staffed with health assistant and other trained health workers Permitted to administer antimalarial drugs intramuscularly Able to carry out parasitological examination of blood by microscopy
Diagnosis at Hospital level Trained physician and laboratory with malaria microscopy facilities available Parasitological diagnosis of malaria with microscopy (species identification, sexual and asexual forms, and quantitative parasite counts). Other laboratory tests: blood for haemoglobin, total & differential count, urine analysis and basic biochemical tests are available.
Use of Rapid Diagnostic Test (COMBO Test) RDT for P. falciparum has been used since 2002 at community level, sub-rural health centers and RHCs that have no microscopy services Since 2011, RDT for both Pf and Pv are being used. Use of RDT should not replace the microscopy. It should be used only where microscopy is not available when the patient condition is severe and no time to wait for microscopy result.
Treatment of uncomplicated malaria (due to Pf) (1) 1 st choice Artemether (20 mg) plus lumefantrine (120 mg) Others Artesunate plus Mefloquine (AS+MQ) Dihydroartemisinin plus Piperaquine (DHA+PPQ) With single dose of PQ Management of treatment failures (due to Pf) Antimalarial treatments for failure within 28 days An alternative ACT such as AS+MQ (or) DHA+PPQ for 3 days (+PQ at Day 0) Antimalarial treatments for failure after 28 days Considered as new infection and it can be treated with AL (+PQ at Day 0)
Treatment in pregnancy (Uncomplicated Pf) First trimester of pregnancy: Quinine plus Clindamycin for 7 days AL for 3 days is indicated when this is the only treatment immediately available, or if treatment with 7-day Quinine plus Clindamycin fails, or if there is uncertainty of compliance with a 7-day treatment Second and third trimester of pregnancy: AL for 3 days Lactating mothers AL for 3 days Primaquine should not be given to breast feeding mothers of infants <6 months of age
Infant and young children (Uncomplicated due to Pf) AL as first line treatment Infants weighting <5kg should be treated with AL dosed at the same mg/kg target as for children weighing 5kg Careful attention should be paid to accurate dosing and ensuring the administered dose is retained Referral to a health center or hospital is indicated for young children who cannot swallow antimalarial medicines reliably Pre-referral treatment with rectal artesunate is indicated Primaquine should be avoided in the first 6 month of age Tetracyclines must be avoided throughout infancy and in children < 8 years of age
Mixed malaria infection (Uncomplicated) AL+PQ as follows: By BHS/ Hospital staff: AL for 3 days and PQ (0.25mg/kg) daily (starting from Day 0) up to 14 days By Volunteers: AL for 3 days and PQ (0.75mg/kg on Day 0) followed by weekly for 7 weeks (total 8 weeks)
Treatment of uncomplicated malaria (P. vivax, P. ovale and P. malariae) Chloroquine (total dose of 25mg base/kg) Plasmodium vivax and Plasmodium ovale: radical curative treatment with Primaquine from last day of Chloroquine For health staffs: Primaquine 0.25mg base/kg/day for 14 days Volunteers: Primaquine 0.75mg/kg once weekly for 8 weeks Primaquine contraindicated during pregnancy, breast feeding mothers of <6 month, infancy (<6 months) and severe G6PD deficiency.
Pre-referral treatment of severe malaria Pre-referral treatment with IM injection Artesunate or Artemether or intramuscular Quinine (600 mg for adult), or Artesunate suppository Should be accompanied by blood film/rdt result referral notes that includes history of treatment given.
Algorithm for management of severe falciparum malaria in small hospitals
Principle of treatment of Sever Malaria Treat children and adults with severe malaria with intravenous or intramuscular artesunate for at least 24 hours and until able to tolerate oral medication. Once the patient is able to tolerate oral therapy, complete treatment with three-days of an ACT Children weighing <20 kg should receive a higher dose of artesunate (3 mg/kg/dose) than larger children and adults (2.4 mg/kg/dose). If parenteral artesunate is not available, use artemether in preference to Quinine for treating children and adults
END MALARIA FOR GOOD We shouldn t feel complacent with the remarkable achievement of malaria control in Myanmar, rather we need to build strong partnerships to provide malaria services to atrisk population and effectively use resources to sustain the past achievements and move aggressively to eliminate malaria in Myanmar by 2030. Dr. Aung Thi Programme Manager, NMCP
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