Session 2: APMEN Vector Control Working Group meeting APMEN III, 8 May 2011 Dr Jeffrey Hii

1. Vector Control Updates and Issues in the WPR region Session 2: APMEN Vector Control Working Group meeting APMEN III, 8 May 2011 Dr Jeffrey Hii WHO PHL and WHO Regional Office for the Western Pacific, Manila, Philippines

2. Overview – Updates & Issues • Moving from control to elimination • LLIN/ITNs and universal coverage • IRS and elimination • Insecticide resistance monitoring network • Sound management of pesticides of public health importance • Integrated vector management • Durability of LLIN monitoring guideline • Interim recommendations on LLIN packaging

3. Phases and Milestones in Malaria Programme Evolution WHO certification < 1 case / 1000 pop. at risk zero local cases SPR < 5% 3 years Control Pre-elimination Elimination Prevention of re-introduction 1st programme re-orientation 2nd programme re-orientation “…aim at interrupting malaria transmission, where feasible” WHA 60.18 (5/2007).

4. Issues • Both IRS & LNs highly dependent on pyrethroids, • widespread use of a single insecticide class increases • risk that mosquitoes will develop resistance • Changes in species distribution • Behavioral changes • Documenting for evidence-based IRS • Spray quality • Spray coverage • Building IRS capacity Adoption of policies for IRS programmes, Member States, World Malaria Report 2010

5. Adoption of policies for ITN programme, 10 Member States, World Malaria Report 2010

7. Steps to meet UC target: • ITN programmes need to have sufficient • geographical reach to provide ITNs to all hhs • 2. Sufficient nets need to be provided to hhs • to cover all people living in them, • People within hhs need to use the available • nets. Universal Coverage (UC) and Continuous Distributions Systems for ITNs • UC targets whole communities, not only vulnerable sub-groups with these communities • Aim – equitable protection & “community effect” • Mass campaigns best to rapidly scale up LLIN coverage, but not good enough to sustain UC • WHO  higher priority to routine services such as ANC & EPI as a means to sustain UC • In WPR, ANC & EPI coverage is variable; not enough to sustain full UC. • Additional flexible systems for continuous LLIN delivery • Innovative solutions are needed where access and quality of these services are low

8. Insecticide concentrations that a decade ago would kill 100 % of a mosquito population are now readily achieving much much lower levels of mortality Spread of resistance may be accelerating in areas with high coverage of insecticide treated bednets or indoor spraying. Background of IR Network • Need for region-wide comparable resistance data to encourage the correct use of insecticides in VC. • Aug 2008 VCM meeting Siem Reap – patchy information on R status. Requested for capacity building & strengthening entomological services. • ITM Antwerp established a cross-country IR monitoring network in 4 Mekong countries. • MALVECASIA: regional network for IR monitoring: • – To define the insecticide status of the major malaria vectors in indifferent different physio-geographical regions in Southeast Asia • Extension of this network to the rest of the ACTMalaria countries to gain better insight into the problem of IR

9. Bi-regional IR workshop, Hanoi, Nov 2009 • Workshop recommendations • A network to monitor IR in vectors of malaria and dengue • Strengthen entomology skills among country staff. • ff-up workshops on M&E of LLIN, IRS, vector control etc • Introduce IVM strategy (emphasis in capacity building) • at regional & country levels • 5. WHO test kits to be sent to the participating countries • 6. Provide technical support to countries • 7. Review progress on insecticide resistance • From 2009 to 2011…….. • Little progress • Few new insecticide resistance data generated from the countries • & posted in the ACTMalaria website • Participants at the 2009 workshop not all from the national program. • Not empowered to make decisions • Country programme mangers not well informed, • hence did not support the insecticide resistance monitoring • Lack of funds to purchase WHO test kits, papers • and to conduct the test especially for dengue vectors. • General – to improve knowledge on insecticide resistance status of adult mosquitoes, vector of diseases, and changing trends by increasing the capacity for appropriate IR monitoring. • Specific objectives • To set up a network for the monitoring of insecticide resistance of vector mosquito species in the ACTMalaria countries (Bangladesh, Cambodia, PR China, Republic of Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Thailand ,Vietnam and East Timor) • To train staff of NMCP in bioassays, data entry and management • To set up a web based data base for data management and analyses of the bioassay data

10. Actions to be taken • Request this Group to support the IR Network in Member countries • Combine insecticide resistance monitoring for both malaria and dengue vectors. • Formalize the tools for data collection • Joint WHO Expert panel to provide technical advice to interpret resistance data • Capacity building plan • Website to rapidly access data on insecticide resistance • Assess impact of IR on program performance – control failure

11. refers to the regulatory control, proper handling, import, supply, transport, storage, use and disposal of pesticide waste to minimize adverse environmental effects and human exposure. WHO Resolutions 2010 related to the strategic approach to international chemicals management including the management of pesticides Report of 2010 survey weak legislation & regulation; inadequate mechanisms and capacity for procurement and QC challenges in implementation of IVM and application of pesticides; Sound management of pesticides of public health importance • inadequate capacity for pesticide resistance prevention • and management; • general lack of capacity for monitoring pesticide • exposure and poisoning; • low capacity for disposal of pesticides and pesticide- • related waste; • low capacity of managers of vector control programmes • for IVM and sound management of pesticides.

12. Problems in vector control • Sub-optimal targeting and lack of adaptation of methods to local circumstances • Missed opportunities for integrating diseases • Other sectors and communities unaware of their role in increasing risk of VBD • Insecticide resistance will increase with over-reliance on chemical methods • IVM as management strategy to tackle these problems • (not as a separate parallel programme but through transformation of the existing system) Role of IVM in elimination • Need tools to resolve deficiencies in elimination and for sustaining the achievements made in malaria • Malaria & LF elimination programs (particularly for Anoph-transmitted LF) • Three WHO products will be released: • Guidance on Policy Development for IVM • Handbook on IVM • Core structure for training curriculum on IVM IVM Malariaburden Attack Consolidation Elimination Maintenance Indicative time line Certification years Full coverage Residual foci Low receptivity IRS LLINs or IRS (or both) LLINs or IRS ITMs - Larvicides Preparation Implementation Environmental management, larvivorous fish, house proofing/improvement, social/economic development

13. A B C D • Figure 3. Damage and repairs made on retrieved LLINs: (A) knotted / tied failed seams on DawaPlus, (B) rips and burns on Permanet 2.0, (C) burned holes on Permanet 2.0, and (D) repair on long rip on Olyset. 150 denier polyethylene and 100 denier polyester nets, in a durability study • Multi-country studies show unexpectedly large variation in effective life between locations – even more variation between locations than between brands • Evidence that the relative lifespan of different brands is not constant but varies in different contexts • So a global “top five” ranking is not realistic (and would not be good for market) • How long do LNs • really last? • survivorship/ • attrition (includes • retention) • 2) Physical integrity • (holes) • 3) bio-efficacy – • interaction between • insecticide & holes

14. Draft standard durability monitoring guidelines now being finalised (J Lines, GMP) • Retrospective monitoring limited by: • Unreliable recall / records to estimate net-age • Attrition cannot be reliably estimated • significant fractions of the population moved in/out of the area • Fade out of labels of nets • Remaining nets may represent a biased sample • However, can provide immediate info about previously distribution as long as the net rosters & time of distribution are kept.

15. Monitoring LLIN Durability (J Lines GMP) • Method Involves • A Mixture of Brands / Products used together • (why this is new and important) • Exactly equal and recorded numbers of each brand • (why this is new and important) • Emphasis on attrition and holes – insecticide optional • A Hole Index - quantification of physical wear • (not just % with holes) (but need to calibrate this) • Procedures can be openly & critically scrutinised • – so demonstrably free of external influence / bias • User preference data that is guaranteed from manufacturers’ influence

16. Monitoring LLIN Durability (J Lines GMP) • Need constant flow of location-specific data, not some large set-piece trials from WHO. This monitoring will be recommended as "good practice" in all large-scale procurements/deployments, for all implementation agencies, and all donors, especially GFATM. • Estimated Cost: depends on scale and outcomes measured. Typical ballpark might be (excluding nets): $100k - $300k • So – how often? • ? should normally be part of every procurement over $2m ? • ? Where each procurement is smaller, then after every cumulative $2m. • So then cost of monitoring would be an extra 1%. • Expected to save >>10% !

17. WHO Toolkit on Sustainable management of LLINs (work in progress, GMP) • Objective – to identify and assess the feasibility of environmentally sound and cost-effective options for end-of-life management of nets used for malaria control. • Community surveys • What factors influenced the selection of a geographical area believed to contain an adequate quantity of nets? How accurate were these predictions? • Were collections organized around a distribution programme or independent of a distribution?

18. Do: ............... Recycle LLINs packaging only through recyclers that understand the necessity of recycling non-biodegradable pesticide-tainted residues only into non-consumer products and that work in an industrial environment that poses little risk to workers or the environment. Incinerate LLIN bags ONLY if specified high temperature incineration conditions for pesticide-tainted plastic can be guaranteed and FAO/WHO and Basel Convention guidelines can be strictly followed; Store LLIN packaging only if future safe incineration or recycling is expected: the storage facility must be dry and secure; Do:............... If recycling or incineration is not possible and if the manufacturers provide directions on methods for safe disposal, follow these. If not, bury any potentially insecticide treated plastics in soils with low permeability, away from any residences, preferably down gradient from any known domestic water sources but at least 100 meters from wells or other domestic water intakes or high water marks of lakes-wetlands, to a depth not to exceed one meter above the highest annual water table. Compacted soil should cover the buried plastic to a depth of one meter or more. WHO INTERIM RECOMMENDATIONS ON LLIN PACKAGING • Do Not: • DO NOT burn LLIN bags in open air; • DO NOT incinerate LLIN bags unless the proper incineration conditions can be guaranteed and maintained for the whole duration of the bags incineration and follow strictly FAO/WHO and Basel Convention guidelines; • DO NOT re-use LLIN bags for any purpose

19. Thank you