Post on 24-Dec-2015
transcript
1
Local resistance management and containment response
Dr Wichai Satimai: Director, Bureau of Vector Borne Diseases, Department of Disease Control, Ministry of Public Health, Thailand
15th RBM Partnership Board Meeting
November 10-11, 2008
New Delhi, India
2
Goal•To reduce malaria morbidity and mortality
Objectives
•To prevent transmission of drug resistance Malaria
•To develop the network of all partners for malaria control
3
Myanmar
Lao PDR
Cambodia
Malaysia
N
Source: Malaria Cluster, Department of Disease Control, MoPH
Integrated Provinces
Pre- integrated Provinces
Vertical Program
4
0
2
4
6
8
10
12
14
16
18API/1,000
API per 1,000 MMR per 100,000
Annual parasite incidence (per 1,000) and malaria mortality rate (per 100,000)
0.57
0.18
5
6
Fiscal Year
Malaria Cluster, Department of Disease Control, Ministry of Public Health.Fiscal Year :Oct - Sep * Preliminary data
91,703
57,883
67,749
58,846
47,948
33,983
38,902
32,38530,482
27,110
27,381
27,539
30,338
36,31335,587
27,767
25,700
25,368
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2000 2001 2002 2003 2004 2005 2006 2007 2008
THAI Non-Thai
Fisc al Ye ar
Number of c ases
Thai and Non-Thai malaria casesFiscal Year 2000-2008
7
0
100,000
200,000
300,000
400,000
500,000
1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007
no of cases
P. falciparum
P.vivax
Fiscal Year
Number of cases
Source: Malaria Cluster, Department of Disease Control, Thai MoPH
CQ ’45-‘73
SP’73-’82
QT’82-’85
MSP’85-’90
M, MSP’90-’95 M,
M+ATS (2 days)’95-’05
’05-07M+ATS2 days;
From ’08 3 days
No. of Malaria Cases by Parasite Species and 1st Line Drug Regimens for P. falciparum, Thailand, 1965-2008
8
Local resistance management
9
MYANMAR
THAILAND
LAOSVIETNAM
VIETNAM
MALAYSIAINDONESIA
CAMBODIA
GULF OF THAILAND
ANDAMON
SEA
TUNGIA GULF1.Chiang Mai
2. Mae Hong Son
3. Tak
4. Kanchanaburi
5. Ratchaburi9. Trat
8. Chanthaburi
7. Ubonratchathani
6. Ranong
Activities
• Routine follow-up• In vivo testing• In vitro testing• Drug Quality Assurance
Monitoring Malaria Drug ResistanceMonitoring Malaria Drug Resistance in Thailand in Thailand
10
Refs.Study site, Year
DoseSubjects (N)
Follow-up duration Efficacy
Mey Bouth et al, Siem Reap Conf.,2002.
Pailin Cambodia
2002
AM4,AM3, AM2
3 days
Children and adults
(70)
28 days 87.0%(PCR-
corrected)
Vijaykadga et al, TMIH 2006.
Trat Thailand
2003
ATS (600
mg) + MFQ 1,250 mg) in 2 days
Mostly adults
(>=10 yrs) (44)
28 days 78.6%
Mey Bouth et al, TMIH 2006.
Pailin Cambodia
2004
ATS 12 mg/kg in 3 days + MFQ 25 mg/kg.
Children and adults
(81)
42 days 79.3%(PCR-
corrected)
Increasing Evidence of ATS-MFQ Failures on the Thai-Cambodian Border
1111
Mef 25 mg/kg + Art 12 mg/kg + Pri 30 mg; two days regimen
** PCR corrected
N ACPR% LPF% LCF% ETF%
MHS 2006: 28d 191 94.8 2.09 3.66 0
TAK 2006: 28d 46 89.1 2.17 8.7 0
KB 2005: 28d 29 96.7 0 3.3 0
RB 2006**: 42d 48 97.9 0 2.1 0
RN 2004: 28d 40 90 2.5 5.0 2.5
TR 2006: 28d 29 86.2 13.8 0 0
Treatment Efficacy of Mefloquine and Artesunate against falciparum malaria at seven areas in Thailand, 2004 - 2006
13
Prevalence of parasitemia on D2 postRx has significantly increased over the past decade on Thai-Camb border, but not on Thai-Burmese border.
Source: Thai MOPH
Thai NMCP’s ATS-MFQ in vivo monitoring of 1,267 Pf patients 1997-2007.
OR(adj.)* for each year: - Cambodian border 1.40 (95% CI: 1.2, 1.7, p<0.0001)* - Burmese border 0.98 (95% CI: 0.8, 1.2, p=0.83)
*The odds of D2 parasitemia increases, on average, 40% per year on the Cambodian border but not increasing on the Burmese border.
Sensitivity of P. falciparum to Artesunate?
14
Tak
Ranong
KanchanaburiRatchabur
i Trat
Artesunate 12mg/kg + Mefloquine 25 mg/kg
Divided dose given
for 2 days
Antimalarial efficacy in the treatment of
falciparum malaria patients in the year 2007
Mae Hong Son
Antimalarial efficacy in the treatment offalciparum malaria in the Year 2007
ARS+MQ (1,250), 2D0
10
20
30
40
50
60
70
80
90
100
93.5
82.891.8
92.9
91.7
RN TK RN RB TR
15
Tak
Ranong
Ratchaburi
Yala
Artesunate 12mg/kg + Mefloquine 25 mg/kg
Divided dose given for 3 days
Efficacy of ARS-MQ in the treatment of falciparum malaria patients in the year 2008
Mae Hong Son
Ubonratchathani
Efficacy of ARS-MQ in the treatment offalciparum malaria in the Year 2008
0
10
20
30
40
50
60
70
80
90
10097.1
100
98.5
100 100
93.5
MH RB TK UB Yala RN
16
Constraints and key challengesConstraints and key challenges
• Multi-drug resistant of falciparum malaria.
• High proportion of reported foreign malaria cases, thus scaling up the effective interventions in all endemic villages focusing on both Thai and Non-Thai population is essential.
• Increase of cases in the unrest areas along the southern border provinces, thus scaling up the effective interventions in this area is needed.
• The program is being decentralized resulting in decrease of specialized field staff, thus capacity building of local health personnel on malaria control is needed
17
Why multi-drug resistance was constraint to
Malaria Control in Thailand? • A large number of migrant laborers coming from
different malarious areas import different strains/genotypes of P.falciparum and over a period of time mixed population of different strains/genotypes infect individuals.
• High population movement along the border still happened from both side, especially during harvesting and agriculture season.
• Unknown factors influence to multi drug resistance, more further research are needed.
18
Containment response
Phase 1: Containment of artemisinin-tolerant Containment of artemisinin-tolerant P. falciparumP. falciparum parasitesparasites in 7 provinces in Thailand in 2009 – 2010. in 7 provinces in Thailand in 2009 – 2010. Request fund from Bill- Milinda Gate FoundationRequest fund from Bill- Milinda Gate Foundation
Phase 2: Containment of artemisinin-tolerant Phase 2: Containment of artemisinin-tolerant P. falciparumP. falciparum parasitesparasites in 7 provinces in Thailandin 7 provinces in Thailand Request fund from GFM R9Request fund from GFM R9
1919
GoalGoal
Containment of artemisinin-tolerant Containment of artemisinin-tolerant Plasmodium falciparumPlasmodium falciparum parasites parasites
in 7 provinces in Thailand in 7 provinces in Thailand
in 2009 - 2010in 2009 - 2010
20
0
1000
2000
3000
4000
5000
6000
7000
8000Trat
Chanthaburi
Sakaeo
Surin
Srisaket
Ubonratchatani
Malaria cases in Thai-Cambodian Border, 1995-2007
No cases
21
Containment Implementation
Areas in Zone 1 and Zone 1 and 22
Containment Implementation
Areas in Zone 1 and Zone 1 and 22
Myanmar
Lao PDR
Cambodia
Malaysia
N
1
5432
6 7 1. Trat
2. Chanthaburi
3. Sakaeo
4. Burirum
5. Surin
6. Srisaket
7. Ubonratchathani
2222
ChantaburiChantaburi
Containment Implementation Areas in Zone 1 (2008)
Tambon vill pop
PongNamron 5 45
38,652
Soidao 4 5262,634
Borai 2 1110,871
Total 11 108112,157
23
Mass ScreeningPatients
Biometric Reader
Application
Disease Clinic Post
Vectorborne Disease Control Center VBDCOffice of Disease Prevention and Control ODPCVector Borne Disease Control Unit VBDUMinistry of Public Health MOPH
SMS Server
GIS Server
Malaria database Web Server
Server Farm at BioPHICSFac . of Trop . Med ., MAHIDOL Univ .
Remote Areas BIOPHICSMahidol University
Malaria Center
HealthVolunteers equipped with loaded Malaria Application
PDA
GIS MappingSMS Drug
Resistance Alert /FU treatment monitoring
Malaria Reports andWarning System
Internet
Internet
Drug Resistance Action Team
24
1. To eliminate artemisinin tolerant parasites by detecting all malaria cases in target areas and ensuring effective treatment and gametocyte clearance using zone specific combination therapies.
• Change the first line treatment for uncomplicated falciparum malaria in Zone 1 to a non artemisinin containing combination
• Improve coverage of passive case detection: MC and MP
• Conduct active case detection: mass screening of migrants and focus investigation.
• Implement directly observed treatment and conduct 28 day follow up of all confirmed falciparum malaria cases.
• Establish management system for treatment failure cases
Objectives and activities
25
Objectives and activities
2. To prevent transmission of artemisinin tolerant parasites by mosquito control and personal protection.
Increase coverage of LLINs to 1 per person (residents, migrants and military)
Distribute LLI hammock nets for personal protection for local residents, migrants and military spending nights in the forest
Distribute repellents for personal protection for plantation workers and soldiers patroling at night.
Conduct IRS in foci of transmission detected as a result of case investigation.
26
Objectives and activities
3. To support containment/elimination of artemisinin tolerant parasites through comprehensive BCC, community mobilisation and advocacy
Review communication/BCC strategy and develop strategy for containment (harmonized with that of Cambodia) targeting all risk groups.
Implement BCC/IEC, including massive health promotion & community mobilization to ensure high turnout for ITN campaign and to promote appropriate use.
27
Objectives and activities
4. To undertake basic and operational research to fill knowledge gaps and ensure that strategies are evidence-based
Characterization of artemisinin tolerant parasites through: clinical trials (including PK studies); development of an in vitro test and molecular markers
Mapping of artemisinin tolerant parasites in 8 sentinel sites using a simplified in vivo test and molecular markers; assessment of effectiveness of Malaria Posts.
Monitoring residual effect of LLIN/LLIHN in sentinel sites; acceptability of all net types; entomological study in areas of changing forest ecology; assess additional protection of using repellents.
Studies to characterize mobile/migrants population movement and behavior; Assessment of feasibility and impact of mass screening and treatment to eliminate artemisinin
Assess the effectiveness of mass screening and treatment of positive cases to detect and treat asymptomatic Pf. infections
28
5. Provide effective management system to enable rapid and high quality implementation of the strategy
Establish and maintain comprehensive malaria surveillance and active case investigation system in 13 Provinces bordering with Cambodia and Myanmar.
Hold cross-border coordination meetings.
Establish migrant networks to improve information sharing on malaria in source, transit and destination communities and at work sites
Strengthen human resources at all levels for management and implementation related to containment efforts
Increase supervision capacity to cope with containment associated increase in workload.
Strengthen collection of routine M&E data.
Objectives and activities
29
ขอบคุ�ณ