PLENARY: Monday, May 11 Session 1. Welcome and objectives Chairs: Professor Gao Qi and Professor Roly Gosling [See Presentation] Summary Objective 1: To work together on a minimum set of indicators for elimination and prevention of reintroduction. Objective 2: To encourage countries to plan for changing from control programs to elimination programs and to understand the changes in activities and indicators that are required. Session 2. Indicators for elimination and prevention of reintroduction Chair: Professor Gao Qi and Professor Roly Gosling [See Presentations] Indicators: What are they good for? Presenter: Roly Gosling (on behalf of Richard Cibulskis) What exists and what is the gap? Presenters: Adam Bennett, Josh Yukich Discussion Some indicators might be easier to standardize across a region or at a global level, and some will not be possible and will need to remain country-specific. However it is hoped that standard indicators can be a reasonable number and are useful for each country. It is a balance between what is suitable for countries and ideal for global entities, such as international organizations and donors. The foci classification system should be discussed and adapted to suit country context. Some countries have defined indicators based on their strategic framework, some are not yet finished. There are differences in how countries and donors measure progress district level progress vs. the Global Fund Key Performance Indicators. Along with the creation of indicators is the need for a reliable system to collect and report the data. Drivers of malaria are often socio-economic factors, so there might be a way to capture the data outside of the malaria program, such as migration in the region, perhaps through the Sustainable Development Goals. Some countries wish to include indicators from historical period, so that they can compare over time (e.g. SPR or API), also the timing is important to measure (e.g. an action within a certain number of days). Is receptivity a good way to measure progress in POR? Session 3. Examples from APMEN Countries Chair: Dr. Christina Rundi Performance indicators in elimination context. Presenter: Dr. Rose Nani Mudin [See Presentation] Discussion SOPs are based on stratification system Districts are important in data collection, so the goal is to increase internet access at district level. There are 47 indicators used, some are monitored daily. Indicators in POR context. Presenter: Dr. Risintha Premaratne [See Presentation] Discussion There is no local transmission, therefore no parasites in the vector, hence there is no vector control applied. However, if there is delayed diagnosis and treatment of imported cases in a receptive area, could lead to the re-establishment of malaria. 1
1,3,7 in China. Presenter: Professor Gao Qi [See Presentation] Discussion For monitoring and identifying sub-clinical infections, some countries collaborate with different groups and for different activities. China works with several different agencies. In Sri Lanka, there is a collaboration with the armed forces and there is starting a collaboration under the South Asian Association for Regional Cooperation (SAARC) that could increase the ability to contact people infected with malaria. Malaysia collaborates with immigration teams, involves employers in high burden areas, and invites the armed forces to their technical meetings to discuss current issues. What are the required actions for imported cases? The unit of foci in China is the natural village of the index case even though mosquitoes are able to fly within a range of 2 km. Estimated cost of surveillance in China was 2,000 Yuan per foci. Session 4. ERAR-GMS Regional GMS Malaria Database Chair: Dr. Prayuth Sudathip Presenter: Dr. Bayo Fatunmbi [See Presentation] Summary Given the issue of artemisinin resistance in the GMS, there is an increased need for information sharing across the region on a real-time basis. With a goal of malaria elimination by 2030 there is a need to provide better information sharing for artemisinin resistance containment and malaria elimination through strengthened surveillance, monitoring and evaluation. To facilitate greater information sharing in the GMS, a regional database was created with the support of ERAR: http://gmsmalaria.org (password protected). It includes 6 countries for reporting, 5 modules and reporting at the district level. Discussion The intention is to include countries outside of the GMS in the regional database platform, to all 22 malariaendemic countries in the Asia Pacific region. However, before we can scale up the platform to additional countries, additional indicators need to be included in the database, such as on vectors and finance. Currently, approximately four program staff in each of the GMS countries have access to the reporting platform: program manager, data manager, surveillance and M&E officers. In the future, different partners and then stakeholders will be able to access the database. There is progress being made in the fight against artemisinin resistance. The strategy is to go after all parasites, including P. vivax. WHO has the password and administration rights to the regional database. The platform was designed to be open source (Microsoft) and a bottom-up system to meet country needs. The quality of the data is supported by APMEN and other partners feeding in to it. In order to integrate the regional database with country systems, there will have to be retraining and building of QA systems. Data verification is absolutely needed, and data managers are needed to do this full time. Countries will provide updates and validation. There are challenges to creating this database: financial resources, supporting countries to aggregate data, and developing a border module which should help to monitor cases. Session 5. Group Work: Activities across interventions and across the spectrum 10 Facilitators Five groups filled in priority activities for the 6 activity headings along the spectrum. What program is currently doing and aspirations of what it aims to do. Activities were consolidated by facilitator teams for 2
discussion the next day. PLENARY: Tuesday, May 12 Agenda and objectives for the day Chairs: Professor Gao Qi and Professor Roly Gosling Session 6. Consolidated report-back from Day 1 Chairs: Professor Gao Qi and Professor Roly Gosling [See Activities List tables, by intervention category, below] Session 7. World Café: Identification of indicators Chairs: Professor Gao Qi and Professor Roly Gosling [See Indicators List tables, by intervention category, below] Six groups were formed and participants circulated to visit each of the six intervention categories, filling in the indicators for each activity across the intervention categories: what are programs currently measuring and what they aim to do. Session 8. World Café Report back & Summary of next steps Facilitators: Professor Gao Qi and Professor Roly Gosling [See Activities and Indicators tables, below] Session 9. APMEN SRWG Business Meeting Facilitators: Professor Gao Qi and Professor Roly Gosling [See Presentation} Discussion Prioritization exercise was led to define the workplan activities for the 2015-2016 year. Ten work areas were identified that were prioritized by some partners: Foci identification, MMHR groups, rapid reporting technologies, minimal essential data/indicators, surveillance and response operational research, translate and sharing of Standard Operating Procedures (SOPs), mentor networks for analysis, regional resources in QA, capacity building, and private sector reporting methods. The top three activities identified as priorities for the 2015-2016 workplan were (in order of importance): 1) Rapid reporting technologies; 2) Surveillance and response operational research; and 3) Translation and sharing of SOPs. A toolkit on mobile messaging is available for programs and will be shared with the SRWG. The topic and location for the 2016 SRWG meeting was discussed. The topic of foci definition and action was discussed as an important topic for consideration. Location and date for the meeting to be determined. 3
CASE MANAGEMENT ACTIVITIES CONTROL All fever cases to be confirmed by microscopy or rapid diagnostic test (RDT) in the first 48 hours Increase access to diagnosis and treatment through village malaria/volunteer workers/post and mobile clinics Procurement of and supply chain management to ensure availability of drugs, RDTs, and equipment Vulnerable populations receive proper screening/treatment/prophylaxis/presumptive treatment (e.g. pregnant women, outbreak response) Therapeutic drug efficacy studies carried out Aggregate monthly case reporting (or case-based reporting where possible) Develop policies/sops and conduct training on diagnosis and treatment including monitoring and evaluation Establish referral network for severe cases with pre-referral protocol Enforcement of non-use of monotherapy Incentives for community/village-based health or malaria workers Commodities: push model to prevent stock outs Maintain drug availability/ buffer (in case of outbreak/disaster) Behavior Change Communication (BCC) for timely treatment seeking Standby treatment for those traveling to places where diagnosis and treatment are not available PRE-ELIMINATION Weekly online logistic/commodities reporting Directly observed treatment with follow up to assess treatment outcome, adherence and adverse events Establish lab QA/QC including accreditation of lab cross-checking, ensure SOPs Case-based, weekly reporting (by SMS system or other rapid system) Develop policies and guidelines for case-finding (through ACD, RACD, PACD and presumptive treatment where indicated) Training on new diagnosis and treatment protocols for all health workers Microscopy refresher courses/training for laboratory staff ELIMINATION Diagnosis and treatment in the first 24 hours from contact/consultation with health worker Web-based, real-time reporting (plus high resolution mapping where possible) Engagement of private sector in diagnosis, treatment and reporting (including potential positive/negative incentives reinforcement) Use of molecular or other sensitive tests for parasite confirmation/speciation Radical treatment using primaquine with G6PD testing for P. vivax Clinical and parasitological follow up (day 0,3,7,14,21,28,42) for all malaria (then monthly up to one full year for P vivax) Screening and treatment for accessible, high risk populations (e.g. migrant workers) Presumptive treatment for high risk, hard-to-reach populations Training for all hospitals on diagnosis, treatment and reporting PREVENTION OF REINTRODUCTION (POR) Continued, regular training on diagnosis, treatment and reporting Establish referral network and referral protocols for all health facilities on diagnosis and treatment RDT availability for all health facilities (as necessary) Ensure drug stocks and trained personnel in preparation for outbreaks 4
CASE MANAGEMENT INDICATORS # of confirmed cases (by species) # of imported, indigenous, introduced, relapse cases by species (classify) % of suspected cases receive laboratory diagnosis (microscopy, RDT, PCR) % of confirmed cases receive radical treatment (Pf, Pv included) % of cases followed up (locally defined) # of clinical/confirmed cases received ACT treatment # of cases reported within 24 hours # of cases notified within locally defined timeframe. % of hospitals that maintain laboratory diagnosis capacity on malaria % of microscopists trained on malaria annually # of malaria deaths % of malaria death cases reviewed 5
EPIDEMIOLOGY ACTIVITIES CONTROL Cross-sectional surveys to determine burden of disease, implementation progress and outcomes Defining and determining the population at risk (stratification process) Aggregate surveillance data collection, analysis, feedback and use Health systems, human resources & surveillance strengthening Malaria Program Reviews and use for program strengthening and/or re-orientation Mortality tracking (using verbal autopsy) PRE-ELIMINATION Micro-stratification (at commune or village level) and mapping Case based surveillance & follow-up (line listing) + follow-up (up to 28, 42 days) (level + timing appropriate) Case classification based on adapting standard methods to local situation Foci investigation Feasibility study for elimination ELIMINATION Reporting by high risk groups Long term case follow-up Line listing (case registry) + classification Mortality review Receptivity + vulnerability assessment PREVENTION OF REINTRODUCTION (POR) Molecular epidemiology (cases + vectors) Monitor importation rate (introduced cases) Investigation of imported cases Border screening + other sites of entry (maintain parasite-free areas) Serology 6
EPIDEMIOLOGY INDICATORS Presence of updated national case register API classified by species, local cases, introduced cases and imported cases Number of cases by species, local cases, introduced cases and imported cases ABER (annual blood examination rate) (number of persons receiving malaria parasitological tests per 100 at risk population per year) # of deaths (proportion of malaria deaths investigated) Proportion of administrative areas with zero local cases in previous 3 years Proportion of administrative areas with capacity to conduct epidemiological investigations Stratification (Y/N) see stratification section under Surveillance and Response, below, for more details 7
PRIVATE SECTOR ENGAGEMENT ACTIVITIES CONTROL Public-private collaboration (including NGOs) for: (1) strategy & guidelines, (2) implementation (corporate social responsibility funding, hotel owners, and Principal Recipients (PRs) of GFATM grants) Oral artemisinin monotherapy ban in private sector Registration of private clinics and pharmacies Provision of free RDTs and treatment to private sector clinics and pharmacies Mandatory referral to public sector facilities Mandatory reporting by private sector PRE-ELIMINATION Public-Private Mix (PPM) for: o Training on case management and microscopy o Provide ACT and RDT (for all species), diagnostic tools o Forms for reporting/mandatory reporting o Support for vector control (funding, implementation support) o Survey of pharmacies on RDTs, treatment, stock and quality o Mapping of private sector pharmacies and clinics ELIMINATION Rx guidelines shared with private sector Private sector provides financial and policy support (e.g. mega projects) Provide training: private sector lab and Rx staff Awareness campaign for all providers (e.g. general practitioners, midwives) Engage private sector to reach mobile, migrant and hard to reach populations (MMHR) Antimalarial drugs only provided by government (policy) PREVENTION OF REINTRODUCTION (POR) Competency assessment of private sector laboratory technicians Work with private sector (associations) for reporting of imported cases Availability of registered local supplier of quality antimalarials (QC for ACT) 8
PRIVATE SECTOR ENGAGEMENT INDICATORS # of coordination meetings between public and private sector with output of progress (e.g. meeting report) Oral artemisinin monotherapy ban (Y/N) + enforcement (Gap: how to measure enforcement) # of private sector clinics & pharmacies (Gap: most countries do not have this information) # of private sector facilities reporting/# of private sector facilities registered and capable of malaria diagnosis and treatment (or # known/identified private sector facilities) M&E system in place for private sector reporting (Y/N) Identify number of labs that meet diagnosis and treatment competencies/targeted (e.g. targeted labs may be areas where imported cases increase transmission potential) % of private sector facilities following national treatment guidelines (survey of registered private providers) # of formal private sector practitioners + technicians trained per year (Gap: no denominator for most countries) # of private clinics sending slides (and possibly RDT) for QA 9
POLICY FRAMEWORK ACTIVITIES CONTROL Regional collaboration + coordination mechanism (e.g. regional malaria elimination committee) Inter-sectorial collaboration + coordination mechanism (including private sector) National political commitment to elimination Financing plan that includes government funding + other resources Strategic plan for elimination adequately budgeted including HR and resource plan Specific surveillance, monitoring and evaluation (SM&E) strategy for elimination including budget (including training capacity) Operational plans + standard operating procedures (SOPs) Technical working groups PRE-ELIMINATION Regional collaboration that specifically addresses data-sharing Subnational malaria elimination goals ELIMINATION Strategic plans for elimination Specific SM&E Plans (notifiable disease, case-based reporting, national case register) Regulation of availability of antimalarials and insecticides Specific measures to improve access to diagnosis and treatment (e.g. free diagnosis and treatment for all migrants) PREVENTION OF REINTRODUCTION (POR) Policy for integration into health system Elimination certification Regulatory and legal framework/policies Regional collaboration (cross border plans) Inter-sectorial collaboration (screening migrant labor) Political commitment (advocacy) Government funding to maintain readiness for outbreaks, continuing surveillance, monitoring and response of receptivity and vulnerability Strategic plans for sustained in during POR Specific SM&E strategy for POR 10
POLICY FRAMEWORK INDICATORS Functional inter-sectoral coordination mechanism in place (Y/N, # of meetings, # of reports) Adequate level of financial support of the national costed elimination plan (X% to be determined by country, Y/N) Political commitment reflected by official declaration (at national and subnational levels) of malaria elimination as a national goal (Y/N) National and subnational committee (or similar technical mechanism) functioning (Y/N, # of meetings/reports) National Strategic Plan for malaria elimination (Y/N) National Surveillance, Monitoring and Evaluation (SM&E) Plan for malaria elimination (Y/N) Defined strategy for human resource development to support malaria elimination (Y/N) Mandatory malaria notification within 48 hours (Y/N) Regulations in place to enforce ban on oral artemisinin monotherapy (Y/N) Regulations in place for use of insecticides (Y/N) Case reporting from private sector is mandatory (Y/N) Process indicator measuring budgetary systems/processes for domestic resources for POR (Gap) Process indicator to measure progress towards certification (Gap: Indicator could include key documents among the 13 required) 11
SURVEILLANCE & RESPONSE ACTIVITIES CONTROL Mass treatment Active surveillance campaigns Basic monthly (aggregated to village) passive reporting of confirmed cases Establish risk mapping/stratification Training and inclusion of community health workers (CHWs)/Community-based awareness Drug resistance/tes surveillance Improved data management PRE-ELIMINATION Establish reactive case detection (RACD), targeting high risk groups Foci registration/classification Linking of surveillance databases into unified framework Case investigation/classification Targeted mass drug administration (MDA) Establish early warning system Establish real-time reporting systems (e.g. SMS-based) ELIMINATION Village-level micro-stratification Case investigation Case reporting within 24 hours Mapping of individual cases Targeted response to foci vector control mobile and migrant populations reactive case detection Early warning systems Active surveillance on high risk pops/movement Use of sensitive diagnostics to detect asymptomatic infection Transmission metrics to assess interruption PREVENTION OF REINTRODUCTION (POR) Fever screening in ports/airports Screening migrant workers (at borders) RRT outbreaks Collaboration other sectors (armed forces) Community engagement 12
SURVEILLANCE & RESPONSE INDICATORS Microstratification o API disaggregated by village o Case-based stratification at village level past year o Receptivity and vulnerability (Gap: how to identify receptive and vulnerable areas; mobile clinics may help to monitor and target interventions) Case Reporting o Proportion of confirmed cases reported to surveillance system within 24 hrs o Completeness of reporting and timeliness Case investigation o Proportion of confirmed cases investigated within XX days (3 days suggested, however must be appropriate to country context) o Proportion of confirmed cases classified as local/imported Mapping o Proportion of cases geo-located to locality, GIS Targeted response o Proportion of active foci that received intervention package (IRS, RACD, FMDA, BCC) o Proportion of cases with targeted response within XX days (must be appropriate to country context) High risk group surveillance o Proportion of districts where rapid assessment of high risk groups conducted o Proportion of high risk groups identified that received intervention package Percentage of community health workers (CHWs)/health facilities receiving refresher/awareness training, percentage of health facilities with adequate diagnostic and treatment capacity Percentage of outbreaks (defined locally) that received rapid response in areas in Prevention of Reintroduction Foci definition. For interventions see vector control, above 13
VECTOR CONTROL ACTIVITIES CONTROL Vector survey (species, bionomics, density etc.) Vector mapping + stratification Vector control including integrated vector management (IVM), larval source management (LSM) (map breeding sites, larviciding), IRS, LLIN, ITN, PPE + personal protection (repellents, insecticide-treated jackets, insecticide-treated hammocks especially for high risk groups/areas) Monitor insecticide resistance monitoring, bio-efficacy Training Health education & community participation Management of vector control (e.g. insecticides, LLINs) Training of entomologists Health education/communication (e.g. bednet usage) PRE-ELIMINATION All of the above + foci management IRS ELIMINATION All of the above, focus on foci Vector survey focus on foci Vector mapping focus on foci Vector control focus on foci (e.g. IRS, IVM, LSM) Insecticide resistance monitoring Training of entomologists Health education/communication focus on foci PREVENTION OF REINTRODUCTION (POR) All of the above in receptive areas only (classify receptive areas), receptive and vulnerable Vector survey (receptive areas and classify risk of re-introduction) Insecticide resistance monitoring Vector control in receptive areas (e.g. larval source management/reduction especially when imported cases are reported) 14
VECTOR CONTROL INDICATORS In areas that are at high risk for malaria transmission, such as those that are known to be receptive, have a changing epidemiology, increased human movement due to displacement, or economic activity (e.g. construction sites), the following indicators should be collected (with overall indicator being annual reports from vector control program): Vector surveillance in foci (# of active foci receiving vector survey/# active foci) and in sentinel sites (# of annual reports from sentinel sites), target 100% Document with written criteria for intervention following vector survey (Y/N) Proportion of foci that receive appropriate vector control, target 100%. # of foci receiving vector control / # of foci targeted for vector control Proportion of households targeted for vector control (coverage 100%). # of foci that received adequate vector control intervention coverage (>80% of target households or breeding sites, depending on interventions chosen)/ # of foci targeted for vector control; # of larvivorous fish introduced into breeding sites/# of breeding sites targeted Community participation in larval source management (# of breeding sites "closed"/# of breeding sites identified for "closing") Number of foci classified according to individual country definitions (e.g. active foci, potential and pseudo) with annual update # of personnel trained in vector control (per year) Proportion of rapid response team trained in vector control (>90%) (per year) # of imported cases that receive vector survey/# of imported cases at risk of transmission 15