Highlights from the second Annual Global Forum of Malaria-Eliminating Countries: Focusing on the Foci 11-13 June 2018, San Jose, Costa Rica
The 2nd Annual Global Forum of Malaria Eliminating Countries convened by WHO was held in San Jose, Costa Rica, from 11-13 June 2018. This was a 2.5 day meeting with approximately 100 participants from 20 out of 21 national programme managers (or representatives) of E2020 countries, additional national programme participants as observer (Panama, Guatemala, Argentina, Nicaragua and Honduras), 10 MEOC members, WHO staff and partners. Here we present highlights from this event:
Highlights from the 2nd Annual Global Forum of Malaria-Eliminating Countries: Focusing on the Foci
11-13 June 2018, San Jose, Costa Rica
Report from: Dr. Seyed Mehdi Tabatabaei, Vice Chancellor for Health, Zahedan University of Medical Sciences
Published: 24 June 2018
The 2nd Annual Global Forum of Malaria Eliminating Countries convened by WHO was held in San Jose, Costa Rica, from 11-13 June 2018. This was a 2.5 day meeting with approximately 100 participants from 20 out of 21 national programme managers (or representatives) of E2020 countries, additional national programme participants as observer (Panama, Guatemala, Argentina, Nicaragua and Honduras), 10 MEOC members, WHO staff and partners. Here we present highlights from this event:
The meeting objectives included:
• Review progress towards elimination in individual countries of the E-2020 along with the quality and coverage of their malaria elimination activities.
• Provide updates and clarifications on key WHO guidance to countries on malaria elimination strategies and processes.
• Share experiences and lessons learned by countries on implementation and impact of malaria elimination strategies and activities, particularly in the remaining foci of malaria transmission.
• Develop recommendations from the Malaria Elimination Oversight Committee on how malaria elimination can be accelerated in the E-2020 countries.
• Highlight successes in elimination with particular emphasis on the Americas and certification of one or more countries of the Americas as malaria-free.
• Two-and-a-half day meeting
• Combination of country presentations and technical briefings
• Country presentations are for 15 minutes followed by 15 minutes of discussions
• Discussion is meant to be a “peer” review
• First questions held for countries
• Subsequent questions by MEOC, WHO and others
• Questions during discussion are meant to provoke introspection, generation of new ideas and new approaches, to question the status quo and suggest new ways of thinking
• Introduction of MEOC and its role
Day 1 presentations
Welcoming addresses, opening remarks and introductions
· Dr Giselle Amador Muñoz, Minister of Health, Costa Rica
· Dr Pedro Alonso, Director, Global Malaria Programme, WHO
· Dr Carissa Etienne, Director, Pan American Health Organization (PAHO/WHO)
Malaria elimination: A regional priority in the Americas (Panel discussion)
· Dr Marcos Espinal, Director, Communicable Diseases and Environmental Determinant, PAHO/WHO
· Dr Alejandro Solis Martinez, COMISCA
· Dr Emma Iriarte, Inter-American Development Bank
· Dr Daniel Salas Peraza, Ministry of Health, Costa Rica
"Current Status of Malaria Control and Elimination, WHO (1948 – 2018), 7 decades supporting countries fight malaria"
Presented by Dr. Pedro Alonso, Director, Global Malaria Programme
In 1955, 8th World Health Assembly (WHA) held in Mexico, launched the first Global Malaria Eradication Program.
E – 2020 Initiative: E-2020 – Initiative launched in 2017, the 1st Annual Global Forum held in Geneva in March 2017 and the 2nd Annual Global Forum held in Costa Rica in June 2018. Regional focal points in five Regions participated in the forum.
Countries That Have Been Certified Malaria-Free
1995-1972: 14 countries, 1 subnational region and 1 territory (Bulgaria, Cyprus, Dominica, Grenada, Hungary, Italy, Jamaica, Netherlands, Poland, Romania, Saint Lucia, Spain, Taiwan, Trinidad and Tobago, United States of America, Venezuela)
1972-1987: 7 countries and 1 territory (Australia, Brunei, Cuba, Mauritius, Portugal, Réunion, Singapore, Yugoslavia (Bosnia Herzegovina, Croatia, The former Yugoslav Rep. of Macedonia, Montenegro and Serbia)
1987-2007: None
2007-2017: 7 countries (Armenia, Kyrgyzstan, Maldives, Morocco, Sri Lanka, Turkmenistan, and United Arab Emirates)
Countries submitted official request for certification: Argentina, Paraguay, Uzbekistan, Algeria
Eliminate malaria from countries in which malaria was transmitted in 2015 : At least 35 countries by 2030
"The fight against malaria is a problem to be solved, not simply a task to be performed"
"Introduction to the Malaria Elimination Oversight Committee (MEOC)” presented by Dr. Frank Richards, Chair, MEOC
•
In March 2017 the Malaria Program Advisory Committee (MPAC) endorsed creation of MEOC. MEOC is modelled on similar committees in polio, onchocerciasis and Guinea worm (dracunculiasis). The purpose of MEOC is to assist countries close to elimination. MEOC comprises 12 members, 10 member have a mix of high-level political, technical, public health, or disease elimination experience, and 2 adjunct members representing malaria-eliminating countries
• Meetings to be held 1-2 times per year, with one meeting to coincide with Global Forum of Malaria-Eliminating Countries.
• MEOC Terms of Reference included independent advice on:
1. Monitor and report on progress in eliminating countries
2. Provide technical advice to address programmatic or operational bottlenecks
3. Identify risks to elimination that need to be addressed
4. Question the status quo and confront difficult issues
• MEOC is working to help the global community achieve the elimination targets in the Global Technical Strategy (i.e. 10 countries by 2020 and 35 countries by 2030 )
• At minimum having reached zero indigenous malaria cases in 2020
• The scope of the MEOC is focused on countries actively pursuing elimination or close to achieving elimination
• MEOC is a new committee, and just beginning to determine how best to be useful
• An immediate goal for the MEOC in 2018 is to introduce itself as an ally to eliminating countries during the Global Forum
Malaria Elimination Certification Panel (MECP)
Criteria for Certification of Malaria Elimination includes:
• Indigenous malaria transmission by Anopheles mosquitoes has been fully interrupted
• Zero incidence of indigenous cases for at least the past three consecutive years
• Demonstration of an adequate and fully functional surveillance and response system for preventing reestablishment of indigenous transmission throughout the territory of the country
• Terms of Reference of the MECP: Recommend whether malaria elimination should be certified in applicant countries
1. Review country documents and national elimination reports
2. Conduct country assessments to verify findings
3. Develop an evaluation report and recommendation to WHO
"Border Malaria" presented by: Dr Li Xiao Hong, Malaria Elimination Unit
•
Persons who crossed uncontrolled land borders present the greatest threat of the re-introduction of malaria. Border malaria cannot be solved unilaterally ... in this context, regular meetings between neighbouring countries are essential.
• Border malaria is a frequently cited challenge to malaria elimination
• 1st Global Forum of malaria eliminating countries, mentioned by 15/20 E 2020 countries
• Countries nearing elimination often find their last cases occur along international borders with countries that have not achieved substantial reductions in malaria transmission.
• Political unrest, conflict (international or internal), social security.
• Social and economic development lags behind other areas.
• Remote, poor, difficult terrain
• Relatively weaker health system, low surveillance.
• Lack of access to health care (malaria service)
• Transmission differential
• Porous border, large population movement across border
• Difficulties in international coordination/border collaboration, border is not a priority for the country with higher transmission
• Implementation of strategies at the periphery is often suboptimal – but they hold the key to success. When planning an elimination program, think of the borders from the very beginning.
• More resources should be directed to border areas (financial, human resource, technical support).
• Without a functional surveillance system at border areas, elimination will not be achieved.
• Border malaria should not be recognized as a technical issue only; it is also a political, social and economic development issue.
• Information sharing and coordination at local level is essential (and often more efficient).
• Joint mapping and risk assessment
• Covering ecology, resources, high risk areas / populations, movement routes & timing, healthcare seeking behavior & health facilities, community leaders, etc, are needed to inform best suited interventions and how to optimize logistics, as well as to identify other institutions that can be engaged on both sides of the border.
• Surveillance & Vector control should be synchronized across the border.
• Case Management - Access to free diagnosis and treatment
• Border malaria posts can be a way to increase access to health care. However, there is lack of data or evidence to support its role in reducing importation.
• Community health workers test, search, treat, refer and supervise treatment adherence.
Country presentation from: Comoros, Belize, Costa Rica, El Salvador, Ecuador, Suriname, Mexico
Paraguay certified malaria-free at E-2020 global forum
On day one of the forum, Paraguay was officially certified free of malaria – the first among the E-2020 countries to attain elimination status. Dr Carlos Ignacio Morínigo, Minister of Health of Paraguay, accepted the certification on behalf of his government at a ceremony in honor of the country’s achievement.
Award ceremony
· Welcome – Walter Campos, Master of Ceremonies
· Opening remarks – Dr Pedro Alonso, Director, Global Malaria Programme, WHO
· Perspective from the Global Fund – Ms Annelise Hirschmann, Regional Manager for Latin America and the Caribbean, The Global Fund for HIV/AIDS, Tuberculosis and Malaria
· Video on elimination of malaria in Paraguay)
· Congratulatory message on the certification of malaria elimination in Paraguay – Dr Tedros Adhanom Ghebreyesus, Director, WHO
· Recognition of certification of malaria elimination in Paraguay – Dr Carissa Etienne, Director, PAHO/WHO (10’)
· Award of the certificate
· Remarks – Dr Carlos Ignacio Morínigo Aguilera, Minister of Health, Paraguay
· Closing remarks – Dr Giselle Amador Muñoz, Minister of Health, Costa Rica
· End of ceremony – Master of Ceremonies
Day 2 presentations
"Microplanning for elimination of malaria foci – experiences from countries in PAHO" presented by Dr Roberto Montoya, Regional Malaria Advisor, PAHO
• How to eliminate malaria
• Transform active foci to cleared foci
• Eliminate human reservoir of parasites and vectors
• How to eliminate asymptomatic reservoirs –through diagnose, treat, investigate and respond
• Micro-stratification and micro-planning – micro-epidemiology of localities
by number of cases, malaria cases by communities, health post
• Putting together epi and ento data to define focus and microareas
• Assess local contextual framework
• Generate hypothesis
•Micro-plan for each area –micro strategy for each area
What is M&E plan for this strategy?
• The importance of the distance between localities – see if they are the same / different
"Surveillance for elimination: A pragmatic approach” presented by: Dr. Kim Linblade, Malaria Elimination Unit, WHO
• New guideline is available in English currently
• High burden of malaria –rely on PCD, monthly reporting
• Moderate burden of malaria –Active case detection, weekly case notification
• Low burden of malaria – PCD, pro-active, reactive up to household level, immediate reporting (real time)
• Vector surveillance important for reduction; also need to do susceptibility testing and resistance monitoring – whole chapter in new guideline on vector surveillance
• MDA for vivax – there is no recommendation
• Issue of the radius for case investigation at household –no magic number, depends on country and setting
• Proactive case detection used for communities that do not have access to HF, hard to reach populations, highly mobile populations
• Surveillance, along with good case management and vector control, are the essential interventions in an elimination program
• By this point, all E-2020 countries should have surveillance systems capable of identifying, investigating and supervising treatment of all cases, conducting RACD and investigating foci of transmission to design appropriate response plans
• Documentation of all of these processes will be needed for certification
"Hot topics in malaria elimination" presented by: Dr. Pedro Alonso, Director, Global Malaria Programme, WHO
1.
Tafenoquine: Tafenoquine, a single-dose anti-relapse treatment alternative to primaquine has been submitted for registration
2. Pyrethroid insecticide-treated nets with PBO: PBO (piperonyl butoxide) is a synergist that ‘knocks out’ mono oxygenase mechanisms so they can’t detoxify insecticides. In theory, a net containing a combination of pyrethroid insecticide and PBO should have increased killing effect on mosquitoes with these metabolic mechanisms. WHO now recommends national malaria control programs should consider deployment of pyrethroid-PBO nets in areas where the main malaria vector(s) have: Confirmed pyrethroid resistance of at least an intermediate level* due to mono oxygenase-based metabolic mechanisms
3. Ivermectin : Ivermectin’s additional impact on biting insects such as lice was noted. Laboratory trials demonstrated that ivermectin in blood kills mosquitoes. Initial field studies also showed impact on mosquitoes and safety. Considered as a possible complementary tool for elimination – to the standard insecticide via bednets or indoor spraying
4. Highly sensitive point of contact diagnostics: WHO held a Technical Consultation 4-6 June on research requirements to support policy recommendations for highly sensitive malaria diagnostic tests. Priority research questions and recommended study designs were developed for specific transmission settings. Meeting report should be available on line by August 2018. Once sufficient research has been completed, an evidence review group will be convened.
Country Presentations from : China, Malaysia, Republic of Korea, Bhutan, Nepal, Timor Leste, Botswana, South Africa, Eswatini, Islamic Republic of Iran, and Saudi Arabia
Islamic Republic of Iran, presented by Dr. Seyed Mehdi Tabatabaie, Vice Chancellor for Health, Zahedan University of Medical Sciences on Behalf of Iranian Ministry of Health & Medical Education
• In 2017, a total of 57 indigenous cases, 871 imported, 6 introduced, down from 1800 indigenous cases in 2010
• Medical universities are focal points
• Programme integrated at district level
• Government funding and technical support by WHO
• The Independent National Malaria Elimination Advisory Committee has been established
• Border with Pakistan- cross border issues to be addressed
• Political support decreasing and funding shifted to NCDs
• Maintaining sensitivity of medical practitioner
• Strengthening of vigilance of surveillance system in line with prevention of reestablishment of local transmission
• Review and revision of criteria for case & foci classification with technical support from WHO
• Strengthening human capacity at central level specially in entomology/vector control (i.e. establishment of a Vector Control Unit at the central level
• Sustainable resource mobilization
• Explore potential modalities for scaling up cross border coordination/collaboration with neighboring countries from WHO and other international agencies
• Improvement and expansion of targeted mass treatment with primaquine to eliminate hypnozoites in parasitemic persons in selected high risk areas
Day 3 presentations
"WHO certification of malaria elimination" presented by: Dr Li Xiao Hong, Malaria Elimination Unit, WHO
The 13th world Health Assembly (1960), requests the Director-General to establish an official register listing areas where malaria eradication has been achieved, after inspection and certification by a WHO evaluation team -Resolution WHA 13.55
Criteria for certification
• Local malaria transmission by Anopheles mosquitoes has been fully interrupted, resulting in zero incidence of indigenous cases for at least the past three consecutive years, and
• An adequate surveillance and response system for preventing re-establishment of indigenous transmission is fully functional (in particular the curative and preventive services and the epidemiological service) throughout the territory of the country.
Key steps of WHO certification of Malaria Elimination
1. Country submits official request for certification after 3 past years with zero indigenous cases
2. WHO assessment missions: Country formulates a plan of action and timeline with WHO
3. Country submits National Elimination Report to WHO
4. Malaria Elimination Certification Panel reviews National Elimination Report
5. A subset of MECP visits the country to verify findings from National Elimination report, and develop the Certification mission Report (Certification Mission)
6. MECP reviews and discuss the Certification Report and reach a consensus on whether the country should be certified or postpone certification.
7. MPAC reviews the meeting report of MECP and gives concurrence to the recommendation to WHO Director-General
8. WHO Director-General makes final decision and officially informs the national government
· Publication in Weekly Epidemiological Record and others
· Country listed in WHO Official Register of areas where malaria elimination has been achieved
· Country prevents re-establishment and reports annually to WHO
A GUIDE FOR COUNTRIES
• Submission of a formal request to WHO
• National Elimination report
• Key documents to be prepared for certification
• Prevention of re-establishment of transmission
• Receive a certification mission
• Subnational verification
"MEOC Draft Conclusions”, presented by Dr. Frank Richards
Cross border issues were a major theme for almost all countries, each with unique characteristics. MEOC will continue to follow this complex and multi-faceted issue closely.
· All people and groups at risk must be able to access prevention, diagnosis and treatment.
· MEOC was concerned about the programs that appear frozen with same number of cases for many years. A program audits are urgently needed to end ͚"business as usual" processes.
· MEOC was concerned to see a number of the eliminating countries having resurgent cases/case buildups /outbreaks/epidemics of malaria. MEOC noted that operations research is important, and time should be set aside at the next GF to allow some countries to give short reports on their work to address and solve key problems identified by their malaria elimination programs.
· Governments have to keep malaria high on the political agenda.
· Information systems across borders and new technology to share information related to malaria importation, vulnerability and receptivity.
· WHO should do a better job at communicating the risks of failing to finish the last mile.
· MEOC noted that many eliminating countries have gotten out of the habit of conducting entomological surveillance. At minimum monitoring of insecticide resistance should be conducted.
· Private sector case reporting cannot be lost to the surveillance system in malaria eliminating countries. The private sector should be included in elimination training, diagnosis, treatment and surveillance.
· Work sites associated with agricultural plantations and other industries (mining) could be engaged by national committees or through regional advocacy approaches to contribute to the elimination by ensuring prevention diagnosis and treatment of their workers.
· Community involvement in malaria elimination efforts should be strengthened. MEOC noted that WHO is working on a community engagement framework specifically focused on elimination efforts.
· The WHO should develop, and the MEOC approve, the criteria for additional countries to be included in the E2020 initiative and attend the GF. MEOC also recommends WHO continue to invite countries that have recently been certified to the GF.
· MEOC recommends the GF continue to promote and celebrate intermediate milestones, such as dropping below 100 cases, dropping to single digits, reaching zero, and the ultimate celebration of WHO certification (as done at the second GF celebrating Paraguay"s malaria certification success)!
Country Presentations from: Algeria, Paraguay
"Next Steps” presented by Dr Gawrie Galappaththy, Global Malaria Programme
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National program representatives to reflect on the Global Forum, lessons learned from other countries and identify areas of improvement to their program
• Discuss strengthening surveillance systems, entomologic surveillance, capacity building, reorientation to elimination and advocacy for political commitment
• Evaluate access to prevention, diagnosis and treatment for at-risk groups, including migrant and mobile populations
• WHO at country, regional and headquarters levels remain ready to support in all these efforts
Related Links
- http://www.who.int/malaria/meetings/2018/second-global-forum-elimination/en/
- http://www.who.int/malaria/news/2018/second-global-forum-elimination/en/
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