DHA‐piperaquine as an eradication tool in Myanmar
Myaing Myaing Nyunt MD PhD
Celebrating 15 years of MMVSiam Reap, Cambodia25 February 2015
Evidence and action for malaria elimination in Myanmar
• Evidence: • To collect baseline data to support elimination & to gather buy‐in from
country leadership and local malaria communities
• Action: Targeted Mass Treatment of malaria ‒ To test an intervention based on evidence collected‒ DHA‐piperaquine ± primaquine and/or others
A question from Myanmar leader
Does it pop or jump?
Justification for malaria elimination in Myanmar • High asymptomatic infections• Presence of artemisinin resistant
P. falciparum in Myanmar• Independent emergence of
artemisinin resistant falciparum • Urgency of need to eliminate
malaria in GMS by scientific communities – Leadership?? – Communities??
VietnamCambodiaMyanmar
Takala‐Harrison et al JID 2014
University of Maryland Baltimore in Myanmar
• Atypical track of UMB collaboration in Myanmar since 2009– Began as technical assistance supported by USAID and WHO, followed
by NIH Fogarty & Open Society Foundation
• Technical assistance to Myanmar – Laboratory support for civilian & military malaria research institutions
– Intellectual support to researchers & academic communities• Optimization of Ethics Review Committees of MoH & MoD• Explicit teaching of ethics and professionalism in medical schools • Faculty development in civilian and military research institutions and medical schools
Research follows capacity development
New surveillance tools for malaria elimination
• Gathering of Myanmar malaria communities on 18 January 2014• Need for systematic and large scale baseline evaluations
• Evidence• Prevalence & distribution of asymptomatic infection • Prevalence & distribution of drug resistant markers• Map parasite migration pattern
• Malaria research and training as a “catalyst” to build trust and to initiate a culture of meaningful collaboration • Leadership & malaria communities • Media & public acceptance & interest
Partners for “Gates Project”
Governmental Role NMCP Lead, coordinate; Field support DMR Field work & lab analysis DSMRC Field & lab analysis Non‐governmental RoleMMA Field work CPI Field work
PSI Field work Burnet Institute Field work & M&EChina CDC Field work & lab analysis Clinton Health Access Initiative Coordination & data translation to policy
Close communication with WHO, USAID/PMI, regional partners
Meaningful collaboration in every steps • Protocol review with all partners on 18 January 2015 in Nay Pyi Taw: Exactly one year after Myanmar malaria community gathering
Region/ State Site Partner
Ayerwaddy Ingapu MMA
Bago East Shwe Kyin DMR/UMB
Chin Paletwa MMA / DSMRC
Kachin Myitkyina DSMRC
Kachin Nabang China CDC
Kayah Hpruso Burnet
Mandalay Madaya DMR/UMB
Rachine Ann MMA
Rachine Buthidaung DMR / DSMRC
Sagaing Ye Oo PSI
Shan Menglian China CDC
Yangon Taik‐kyee DSMRC / MMA
Initial study sites
Identification of low parasitemia• Ability to identify parasites in standard diagnostic methods
– Thick blood smear or RDT: ~50‐200 parasites per uL
• Polymerase chain reaction (PCR) method as surveillance tool• Standard diagnosis and PCR may be missing significant parasites
in low parasite density setting – Standard PCR: 1‐2 parasites/uL– Quantitative PCR (qPCR): <0.02 parasites/uL (<16 parasites/mL)
• Optimized qPCR methods at UMB– High blood volume PCR used on Thai‐Burma border: Challenges in
implementation – Blood volume only 0.3 mL (finger or ear prick) & no refrigeration needed
for 14 days
Future work & long‐term success• Depending on results of this study:
– Where? How? When? With whom?– Evaluate “Targeted Mass Treatment” – Improve qPCR test: Smaller blood volume; Dried blood spots?– Develop minimal surveillance tool for elimination
• Political complexity has effective impact on success or failure of malaria elimination in Myanmar
• Sense of ownership & sense of urgency MUST be felt by local communities and leadership
– Critical for sustained political and community support
Thank you for your attention!