Obstacles on the road to malaria elimination How can we make sure drug resistance does not take us b

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Obstacles on the road to malaria elimination-
How can we make sure drug resistance does not
take us backwards?Dr. Sylvia Meek, Technical
Director, Malaria Consortium, APPMG 24 June 2009
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Status at 2009

• Progress in controlling malaria is at an all-time
  high
• We have excellent tools to prevent and treat
  malaria
• Political will is strong
• Funding is getting better
• Still major obstacles in systems to deliver and
  reaching remotest populations
• Funding is fragile
• First warnings that tools may not last

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Drug Resistance

• A major bottleneck in controlling malaria
• First reports of chloroquine resistance in late
  1950s
• Asia fought resistance to one drug after another
  from the 1970s to the 1990s
• Often it was first found in the same area on the
  border of Thaland and Cambodia
• Moved from cheap and simple to costly and complex
  treatments
• 1980s a 7 day course of quinine and
  tetracycline was 84 tablets in 21 doses for an
  adult

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Africa followed Asia

• Chloroquine resistance first reported in 1978
• Only became a real operational problem in late
  80s
• Increasing chloroquine resistance coincided with
  increasing child mortality
• After years of research and debate most countries
  now use Artemisinin-based Combination Therapies
  (ACTs)
• Debates on choice of drug overrode efforts to
  improve delivery and access
• Now these are being addressed
• Results look good
• Progress could be threatened if resistance to
  artemisinin derivatives appears

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The Greater Mekong Subregion
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Artemisinin derivative resistance has been
detected in Thailand and Cambodia

• Research over last two years has confirmed
  increased time for parasites to be cleared
• Biggest problem is knowing how far it has spread
• In the meantime we cannot wait so a special
  containment programme is underway in the areas
  where there is evidence

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Distribution of confirmed malaria cases in the
Greater Mekong Subregion, 2007
Source National Malaria Control Programmes
WHO 2006 data for Myanmar
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Distribution of malaria deaths in the Greater
Mekong Subregion, 2007
Source National Malaria Control Programmes
WHO 2006 data for Myanmar
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How do you contain resistance?

• Remove selection pressure
• Reduce and ultimately eliminate falciparum
  malaria

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Three Phases of the Response
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Phase 2 of the Containment Project, Cambodia
(Bill Melinda Gates Foundation supported)

• The containment implementation area includes
• 10 provinces in Cambodia along the border with
  Thailand.

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Phase 3 - the medium-term strategy in Cambodia

• Re-defining the goal
• Continue containment of artemisinin resistance
• Commence elimination of malaria parasites
  countrywide
• during this time period pre-elimination status
  for Plasmodium vivax is unlikely to be completed
  but strategy will begin the process
• Expanding activities from current containment
  zones to other malaria areas of the country
• Testing, implementing and scaling up innovative
  packages of activities
• Several of these will be piloted and refined
  during Phase 2 supported by WHO, BMGF, USAID and
  others, so evidence for key decisions is expected
  in 2010

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Where do we want to be in 2015?

• No artemisinin resistant malaria parasites are
  detected in Thailand and Cambodia by 2015
• Countries move toward pre-elimination status
• For P. falciparum
• In process for P. vivax

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Objectives

• Objective 1 To detect all malaria cases
  (including among mobile/migrant populations) and
  ensure effective treatment and Pf gametocyte
  clearance (through single dose primaquine).
• Objective 2 To decrease drug pressure for
  selection of artemisinin resistant malaria
  parasites by improving access to appropriate
  treatment and preventing use of monotherapy and
  substandard drugs in both public and private
  sectors

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Objectives (2)

• Objective 3 To prevent transmission of
  artemisinin resistant malaria parasites among
  target populations (including mobile/migrant
  populations) by mosquito control and personal
  protection
• Objective 4 To support containment of
  artemisinin resistant parasites through
  comprehensive behavior change communication
  (BCC), community mobilization, and advocacy
• Objective 5 To provide effective management
  (including information systems and surveillance)
  and coordination to enable rapid and high quality
  implementation of the strategy

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Key areas of focus

• Mobile and migrant populations
• How to reach, what about new economic migrants?
• Surveillance and information systems
• Suppression of using monotherapies
• Private sector issues
• Understanding patient behaviour
• Joint action by Thailand and Cambodia
• Planning for sustainability

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Female migrant workers in Komrieng District,
Battambang Province. The plastic sheet at the
back is used as shelter for sleeping at night and
for keeping their belongings and in case of rain.
(source Kim Sedara, MC/CDC)
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Private clinic, Komrieng DistrictBattambang
Province (source Kim Sedara, MC/CDC)
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Inside a private drug shop, Promoy (the district
capital)Veal Veng District, Pursat Province
(source Kim Sedara, MC/CDC)
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Assorted antimalarials and RDTs. This picture was
taken at a private clinic in Veal Veng. (N.B.
Although the fixed price on the Malarine box says
2500 the handwritten-price says 3500. There
is also a handwritten- (source Kim Sedara,
MC/CDC) price on the AM2 box.)
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Conclusions

• We need to make extraordinary efforts to control
  malaria even where it is less common
• Link between resource allocation and disease
  burden is less clear
• There are beneficial side-effects
• improving surveillance
• improving private sector strategies
• Learning to work with mobile populations
• Learning for elimination
• Are we missing the main target
• How to determine routes of spread
• How to support malaria control in Myanmar/Burma

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Conclusions (2)

• We cannot be complacent and rely on current tools
  lasting for ever
• Investment in RD is essential
• We shall continue to lose good tools if we do not
  take systems strengthening and regulation
  seriously
• Deciding when to act then raising support is a
  challenge