Obstacles on the road to malaria elimination - How can we make sure drug resistance does not take us backwards Dr. Sylv

1. 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

2. 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

3. 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

4. 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

5. The Greater Mekong Subregion

6. 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

7. Distribution of confirmed malaria cases in the Greater Mekong Subregion, 2007*

8. Distribution of malaria deaths in the Greater Mekong Subregion, 2007*

9. How do you contain resistance?

10. Three Phases of the Response

12. 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.

13. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. Private clinic, Komrieng DistrictBattambang Province (source: Kim Sedara, MC/CDC)

21. Inside a private drug shop, Promoy (the district capital)Veal Veng District, Pursat Province (source: Kim Sedara, MC/CDC)

22. 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 A+M2 box.)

23. 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

24. Conclusions (2) We cannot be complacent and rely on current tools lasting for ever Investment in R&D 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