Transcript Technical Meeting Uganda 2008 Summary

Containment of artemisinin resistance at the
Cambodia-Thailand border
Sylvia Meek, Technical Director, Malaria Consortium,
CMWG Meeting 8 July 2009
Drug Resistance in Southeast Asia
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Asia fought resistance to one drug after another from 1970s to 90s
Often first found in the same area on Thailand / Cambodia border
Moved from cheap and simple to costly and complex treatments
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 towards elimination could be threatened if resistance to
artemisinin derivatives appears
The Greater Mekong Subregion
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
Distribution of confirmed malaria cases in the
Greater Mekong Subregion, 2007*
Cambodia,
Viet Nam, 14,581 42,518
China-Yunnan,
6,085
Thailand, 33,178
Lao PDR, 19,037
Myanmar,
200,679
Source: National Malaria Control Programmes & WHO
*2006 data for Myanmar
The containment strategy
 Remove selection pressure
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Reduce and ultimately eliminate
falciparum malaria
Three Phases of the Response
Phase 1:
January to
December 2008
Phase 2:
January 2009 to
December 2010
Phase 3:
January 2011 to
December 2015
Phase 3 - the medium-term strategy
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
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
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
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
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)
Challenges
• Need 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
Challenges (2)
• We cannot be complacent and rely on current tools
lasting for ever
– Investment in R&D is essential
– How much to invest in protecting drugs versus
deploying them and moving on to next ones
• We shall continue to lose good tools if we do not take
systems strengthening and regulation seriously
– Re-emphasise quality, delivery, diagnosis
• Deciding when to act then raising support is a challenge
– If we saw the same amount of evidence in Nigeria or
Ethiopia, what scale of response could we mount?
Priority Partnership Activities
• Gain consensus on strategy components
• Plan for contingencies – response scenarios for different
regions
• Communicate issues realistically
• Review relevant experiences
• Multidisciplinary task force proposed