malaria elimination in the north eastern thailand 2014-2019

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Malaria elimination in the North Eastern Thailand 2014-2019

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Page 1: Malaria elimination in the North Eastern Thailand 2014-2019

Malaria elimination in the North Eastern Thailand

2014-2019

Page 2: Malaria elimination in the North Eastern Thailand 2014-2019

To interrupt malaria transmission (no indigenous cases

of malaria for three years) in the North Eastern

Thailand by 2018

Goal

Page 3: Malaria elimination in the North Eastern Thailand 2014-2019

0

2

4

6

8

10

12

14

16

0

2

4

6

8

10

2000 2003 2006 2009 2012

ABER SPR API

ABER & SPR / 100 pop. API / 1,000 pop.

Annual Blood Examination Rate (ABER), Slide PositivityRate (SPR) and

Annual Parasite Incidence (API/1,000), Thailand FY 2000 - 2013

Fiscal Year

0.31.6

2.1

Page 4: Malaria elimination in the North Eastern Thailand 2014-2019

41.2

58.8

0

20

40

60

80

100

1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

P.falciparum P.vivax

Percentage

Fiscal Year

Proportion of malaria parasite species, Thailand, FY 1965-2013

P. falciparum

P. vivax

Page 5: Malaria elimination in the North Eastern Thailand 2014-2019

All cases in 2013 Indigenous Cases, 2013

Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%)

PCD = 2,755 (TPR=18%)ACD = 3,294 (TPR=0%)API = 0.02 per 1,000Total case = 477 (Pf.= 26)Indigenous cases = 1Infected outside villages=2

Page 6: Malaria elimination in the North Eastern Thailand 2014-2019

Malaria foci, 2013% of case investigated, 2013

Page 7: Malaria elimination in the North Eastern Thailand 2014-2019

Technical feasibility

Page 8: Malaria elimination in the North Eastern Thailand 2014-2019

Vectorial capacity and receptivityEntomology

Is vectorial capacity low at the outset?

In the most part of Thailand, Vectorial capacity is relative low, especially in plain areas. Although, the main vectors in Thailand are An.dirus and An.minimus, high coverage of vector control measures result in vectors short-lived. In transmission areas (border and forest areas), Anophelline are still anthropophilic, but low vector density.

Can it be reduced to a level compatible with elimination?

Entomology

Main vectors are rather endophilic, endophagic and night-biting. Vectors tend to be endophilic and exophagic where are high coverage of vector control. Most breeding sites are able to be identified, but forest areas where transmission occurs. Vectors are still sensitive to insecticide (Pyrethroid). Malaria transmission is seasonal, but high coverage of vector control result in significant reduction of malaria cases.

Page 9: Malaria elimination in the North Eastern Thailand 2014-2019

Physical environment

Malaria is very low transmission in this region. Houses in endemic areas are sprayable walls with high acceptability.

Human ecology

Houses are made from wood and bamboo with sprayable wall. IRS and LLINs are highly accepted and used. Personal protection such as sleep under bed-net and mosquito repellent are common practices. Villagers in endemic areas practice outside activities in the evening such as wood cutting, and hunting.

Control effectiveness

Vector controls and personal protection are the main strategies for anti-malaria program. The action plan is adjusted annually to ensure the coverage and maintain high effectiveness in targeted areas. Case management is free of charge for everyone. There are collaboration of all affected communities and potential partners (inter-sectoral).

Page 10: Malaria elimination in the North Eastern Thailand 2014-2019

Can it thereafter be maintained below a threshold?

Environment, development

There is absence of natural or man-made disasters. There is no ongoing or expected changes in natural or human ecology favouring lower vectorial capacity, depending on zoo-geographic region and local vector bionomics (e.g. deforestation, desertification, pollution, urbanization).

Page 11: Malaria elimination in the North Eastern Thailand 2014-2019

(2) Duration of infectivity

Can duration of infectivity be reduced to and maintained at very low level?About 60 % of the total cases are P. vivax and resistance to ACT is reported in some provinces but the country targets to contain and eliminate resistant parasite with well collaboration with other inter-sectoral partners. Most at risk population seek treatment at public health facilities due to universal health coverage. Radical treatment and DOTs is applied for all species. Migrants are also able to access health services with free of charges.

(3) VulnerabilityCan importation of infections be reduced or maintained at low level?

Movement of population in these regions in common, which may increase importation of malaria cases. However, Health services such as treatment and prevention are high coverage and strong surveillance is in place.

Page 12: Malaria elimination in the North Eastern Thailand 2014-2019

Surveillance system in targeted areas

Passive case detection

• Hospitals

• Malaria posts

• Malaria clinics

Active case detection

• Mobile malaria clinics

• Proactive case finding in malaria transmission areas

• Reactive case finding

12

Case investigation and follow up

Page 13: Malaria elimination in the North Eastern Thailand 2014-2019

Case definition All positive malaria cases diagnosed with laboratory

confirmed including symptomatic and asymptomatic cases are included in the surveillance system.

Criteria for malaria testing Malaria clinics: all suspected malaria cases who

visit malaria clinics. Hospitals:

Patients whom have history of traveling to endemic areas.????

Page 14: Malaria elimination in the North Eastern Thailand 2014-2019

Methods of confirmation and Quality control

All suspected cases of malaria are diagnosed with microscopy or RDT (use in village malaria posts, for every RDT, a blood smear will be sent to malaria clinics).

A case investigation form will be completed for all confirmed cases

Confirmed cases will be followed Pf: 3, 7, 14, 21, 28day

Pv: 7, 14, 60, 90day

QA diagnosis

All positive slides and 10% negative slides are rechecked by expert microscopists

Page 15: Malaria elimination in the North Eastern Thailand 2014-2019

Department of Disease Control

Vector Borne Disease• Malaria • Filariasis• Dengue Fever

Office for Disease Prevention and Control

CENTRAL LEVEL

DISTRICT LEVEL

PROVINCIAL LEVEL

CANTON LEVEL

Provincial Public Health

• Provincial Hospital Vector Borne Diseases Control Center

Vector Borne Diseases Control Unit

Malaria Clinic

District Public Health• District Hospital

Health Center

REGIONAL LEVEL

Epidemiology

Coordination

Command

Malaria Post 15

Real-time web-based

Private clinics and hospitals??

Page 16: Malaria elimination in the North Eastern Thailand 2014-2019

Technologies• Web-based synchronization technology • capable of switching between offline / online mode of data entry. This

terminology is benefit for the low resources area. Users can still operate in case of internet link has difficulties. Then data can be later transferred when internet is back to normal.

• Mobile Computing • simply disseminated or received information to/from different devices

in other platforms i.e. Mobile/ Tablet

• Geographical Information System (GIS) ready• ability to toggle GIS in key elements of indicators for better

understanding of the situation in short term

Page 17: Malaria elimination in the North Eastern Thailand 2014-2019

Case investigation

All confirmed cases are investigated Data recorded

Date of symptom onsetLocation where the patient is living and had

visitedHistory of any previous malaria episodeCurrent treatmentBed-net use

Case classified as to likely mechanism of infection acquisition

indigenous, imported, etc.

17

Investigation rate is inadequate in the targeted areas

Page 18: Malaria elimination in the North Eastern Thailand 2014-2019

Case classification

Classification Description

A Indigenous (acquired in village)

Bx Outside village but inside canton

By

Outside canton, but inside

district

Bz

Outside district, but inside

province

Bo

Outside province, but inside

country

Bf Outside country

F Unclassified 18

Page 19: Malaria elimination in the North Eastern Thailand 2014-2019

Transmission areas (A): A1 - perennial transmission area (transmission reported for at least 6

months per year).

A2 - periodic transmission area (transmission reported but for less than 6 months per year

Non Transmission areas (B): B1 - high and moderate receptivity (transmission not reported within

the last 3 years but primary and secondary vectors present).

B2 - low and no receptivity (transmission not reported within the last 3 years and primary and secondary vectors absent, suspected vector may be present).

Malaria area stratification in Thailand

Page 20: Malaria elimination in the North Eastern Thailand 2014-2019

Residual active foci (1)+ residual non active foci

Malaria foci in targeted areas

New potential foci (B1+imported case) and Clear up foci (B1-Receptive)

Pseudo Foci (B2 areas with imported case- non-receptive)

Page 21: Malaria elimination in the North Eastern Thailand 2014-2019

All cases in 2013 Indigenous Cases, 2013

Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%)

PCD = 2,755 (TPR=18%)ACD = 3,294 (TPR=0%)API = 0.02 per 1,000Total case = 477 (Pf.= 26)Indigenous cases = 1Infected outside villages=3

Page 22: Malaria elimination in the North Eastern Thailand 2014-2019

5,338

2013

Malaria foci, 2013 % of case investigated, 2013

Page 23: Malaria elimination in the North Eastern Thailand 2014-2019

Areas for Surveillance system improvement

• Suspected case definition for hospitals• Case reporting from private hospitals and clinics• Case investigation and response (foci elimination)

Page 24: Malaria elimination in the North Eastern Thailand 2014-2019

Suspected case definition for hospitals

Criteria for malaria testing in hospitals: patients whom have history of traveling to endemic areas. Increase awareness of medical doctors

All positive malaria cases diagnosed with laboratory confirmed including symptomatic and asymptomatic cases are included in the surveillance system.

Page 25: Malaria elimination in the North Eastern Thailand 2014-2019

Improve case reporting from private hospitals and clinics

Enforce private sector to report a malaria case though regulation at policy level and implementing level

Introduce malaria online system for private sector

Page 26: Malaria elimination in the North Eastern Thailand 2014-2019

Strengthen case investigation and response (foci elimination)

Organize refreshing training for local staff including vertical and general health services

Involve stakeholders such as community, local administrative organization in receptive areas to inform any population migration from endemic areas.

Close supervision at all level, especially at the implementing level.

Page 27: Malaria elimination in the North Eastern Thailand 2014-2019

Operational Implications of different types of foci

Page 28: Malaria elimination in the North Eastern Thailand 2014-2019

Ineffective

Effective

Present

Absent

Present

Absent (For 3 years)

EndemicActive foci

Clean up

Residual non active

Active fociResidual

active

New potential

Cont

rol

Tran

smis

sion

Case

A1+A2With indigenous every year

B1 areas with no case

B areas with 1st indigenous case

B1 areas with imported cases

A1+A2 with indigenous case in any year during 3 years

A1+A2 no indigenous case in 3 consecutive years

Classification of Malaria foci in Thailand

Pseudo Foci

B1 areas with case infected outside village

B2 areas with imported case

Page 29: Malaria elimination in the North Eastern Thailand 2014-2019

Active and residual foci1. Indoor residual spraying (IRS)• Active foci =2 rounds • Residual foci (A2) 1 round

2. Insecticide-treated nets (ITN)

3. Long Lasting Insecticide-treated nets (LLINs) • LLIN+LLIHN = 1 net/ 2 person

VECTOR CONTROL

Page 30: Malaria elimination in the North Eastern Thailand 2014-2019

Active and residual foci• Proactive case finding • Reactive case finding

Case Detection

New potential foci (B1+imported case) and Clean up foci (B1-Receptive) Reactive case detection when reported case is identified

Pseudo Foci (B2 areas with imported case- non-receptive)

Passive case detection

Page 31: Malaria elimination in the North Eastern Thailand 2014-2019

THANK YOU