Western Pacific Region 1

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

Vector Control Updates and Issues in the WPR region

Western Pacific Region 2

Overview – Updates & Issues

1. Moving from control to elimination2. LLIN/ITNs and universal coverage3. IRS and elimination4. Insecticide resistance monitoring network5. Sound management of pesticides of public

health importance6. Integrated vector management7. Durability of LLIN monitoring guideline8. Interim recommendations on LLIN packaging

Western Pacific Region 3

Control Pre-elimination EliminationPrevention of

re-introduction

1stprogramme

re-orientation

2nd programme

re-orientation

SPR < 5%

< 1 case / 1000pop. at risk zero local cases

WHO certification

3 years

Phases and Milestones in Malaria Programme EvolutionPhases and Milestones in Malaria Programme Evolution

“…“…aim at interrupting malaria transmission, where feasible” WHA 60.18 (5/2007).aim at interrupting malaria transmission, where feasible” WHA 60.18 (5/2007).

Western Pacific Region 4

Adoption of policies for IRS programmes, Member States, World Malaria Report 2010

Policy Number of endemic countries

IRS is recommended by NMCP 6

IRS is used for prevention and control of epidemics

7

IRS and ITNs used together for malaria control in at least some areas

6

DDT is used for IRS 0

Insecticide resistance monitoring is undertaken

6

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

Source: WMR 2010

No. of people protected by IRS (in 2009)

% IRS coverage

Malaysia 400,007 36.4

China 8,768,609 1.3

Papua New Guinea

17,809 0.3

Philippines 239,605 86.6%

Solomon Islands 170,941 -

Viet Nam 1,544,329 -

Western Pacific Region 5

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

Policy No. of endemic countries (5E)

ITNs distributed free of charge 9

ITNs/LLINs sold at subsidized prices 2

ITNs/LLINs distributed to all age groups 9

ITNs/LLINs distributed through mass campaigns to all age groups

7

ITNs/LLINs distributed through mass campaigns to <5 only

0

ITNs/LLINs distributed through antenatal clinics

3

ITNs/LLINs distributed through EPI clinics 2

Western Pacific Region 6

2.6

3.8

2.93.3 3.0

3.6

5.2

4.44.0 4.1

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Southern Highlands Momase Islands Country-wide

Region

No. o

f hou

seho

ld m

embe

rs/n

et

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Aver

age h

oush

eold

size

No. HH members/Net No. HH members/LLINLLIN distribution ratio Average HH size

Western Pacific Region 7

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

Steps to meet UC target:

1.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,

3.People within hhs need to use the available

nets.

Western Pacific Region 8

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

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.

Western Pacific Region 9

Bi-regional IR workshop, Hanoi, Nov 2009

• 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 objectives1. 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)

2. To train staff of NMCP in bioassays, data entry and management

3. To set up a web based data base for data management and analyses of the bioassay data

Workshop recommendations1. A network to monitor IR in vectors of malaria and dengue

2. Strengthen entomology skills among country staff.3. ff-up workshops on M&E of LLIN, IRS, vector control etc4. Introduce IVM strategy (emphasis in capacity building)

at regional & country levels5. WHO test kits to be sent to the participating countries

6. Provide technical support to countries7. 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.

Western Pacific Region 10

Actions to be taken1. Request this Group to support the IR Network in Member

countries2. Combine insecticide resistance monitoring for both malaria and

dengue vectors.3. Formalize the tools for data collection4. Joint WHO Expert panel to provide technical advice to interpret

resistance data5. Capacity building plan6. Website to rapidly access data on insecticide resistance7. Assess impact of IR on program performance – control failure

Western Pacific Region 11

Sound management of pesticides of public health importance

• 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;

•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.

Western Pacific Region 12

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

IRSLLINs or IRS

ITMs - Larvicides

Environmental management, larvivorous fish, house

proofing/improvement, social/economic development

Attack Consolidation Maintenance

LLINs or IRS

(or both)

Certification

Role of IVM in elimination

Full coverage

IVM

Mal

aria

bur

den

Low receptivityResidual foci

Indicative time line

Elimination

Preparation Implementation

years

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:

1. Guidance on Policy Development for IVM

2. Handbook on IVM

3. Core structure for training curriculum on IVM

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)

Western Pacific Region 13

150 denier polyethylene and 100 denier polyester nets, in a durability study

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.

How long do LNsreally last?

1) survivorship/attrition (includes

retention)2) Physical integrity

(holes)3) bio-efficacy –

interaction betweeninsecticide & holes

Multi-country studies show unexpectedly large variation in effective life between locations – even more variation between locations than between brandsEvidence that the relative lifespan of different brands is not constant but varies in different contextsSo a global “top five” ranking is not realistic (and would not be good for market)

Western Pacific Region 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.

Western Pacific Region 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

Western Pacific Region 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% !

Western Pacific Region 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?

Western Pacific Region 18

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

Do: ...............

1.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.

2.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;

3.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.

Western Pacific Region 19

Thank you