Basic Essential Package of Activities for Malaria Pre-elimination in Sampov Loun OD Siemreap, February 26 th, 2016

 Objectives  Essential Package of Activities –1-3-7 approach –Treatment follow up  Preliminary results  Challenges and way forwards Outline

Objectives  General objective: to develop and implement pre-elimination model based on approach and to document the feasibility of the model in SPL OD from July, 2015-September,  Specific objectives are to: –Strengthen malaria surveillance with case notification, investigation and responses to all malaria species –Optimize malaria case management with 28 days follow up –Understand cost of specific pre-elimination activities

Surveillance and response: approach Case management: 28 days FU Day-1 Case notification Case enrollment: All malaria species Case enrollment: All malaria species % of cases notified within one day or 24h (1) Basic Essential Package of Activities for Pre-Elimination Case investigation Day-3 % of cases investigated within 3 days (3) 3 days DOT: All malaria species 3 days DOT: All malaria species Case response Day-7 % of cases responded activities conducted within 7 days (7) Follow up signs: All malaria species MBF Day-7 (Pf/Mix) Follow up signs: All malaria species MBF Day-7 (Pf/Mix) Day-28 % of Pf/mix cases completed 28 days follow up Case follow up Follow up signs: All malaria species MBF Day-28 (Pf/Mix) Follow up signs: All malaria species MBF Day-28 (Pf/Mix)

Cambodia Implementing site: SPL OD o Total population: 158,680 o 3 Administrative districts, 127 villages o Service delivery points: 9 HCs, 1 FDH, 1 RH, 168 VMWs and 32 PPs

Elimination Structure in SPL OD CNM CAP-MALARIA PHD CAP-MALARIA WHO, PMI, UNOPS Other partners Provincial Special Working Group for Malaria Elimination (Pro. ME) OD Director, ODMS CAP-M Team leader District Special Working Group for Malaria Elimination (AD. ME) 11 HFs32 PPs 168 VMWs HFs Chief CAP-M Coordinator Cross border collaboration: -Patient investigation and follow up -Data sharing and Bi-lingual BCC materials

Practical Approach Strategy Case investigation and response often happen simultaneously by Day3 Day-7 Ç÷ Å HF or VMW Perform RDT & prepare slide Conduct case notification via SMS Conduct Case Investigation Conduct Case Response Case Follow-up Day-7 & Day-28 POSITIVE Day-1 DOT Day-2 DOT Day-3 DOT Refer slides for confirmation (Double reading) Interview & Test Co-travelers & HH members Education/IPC IRS & LLIN/LLIHN Refer patient for further investigation NEG Day-3 Day-1 PPs ÇÅÅ

Malaria Case Management  Treatment regimens: o First line regimen: DHA-PIP => ASMQ (from Feb 2016) (for 1 st trimester pregnancy: Quinine) o Second line: Quinine+/-Tetracycline  DOT and patient follow up: o Systematic DOT for all cases o Pv: follow up only for 3 days DOT o Pf/Mix: follow up till Day-28

Retrospective Case Investigation (July 2014-June 2015) * Patients were not met for interviewing

Preliminary Results (Jul 2015 – Jan 2016) Cases from PPs (Dec. 15-Jan 16) Suspected/tested: 193 Referred: 40 Reached: 40 (37 to HF & 3 to VMW) Positive: 16 (9 Pf, 7 Pv) Total cases: All cases: nd line cases: 20

Preliminary Results (Jul 2015 – Jan 2016)

2 nd line cases (20) were excluded as they stay in the hospital, already investigated

Preliminary Results (Conti…)

History of traveling the last 3 weeksCases ImportedIndigenous No 4623 Kamrieng 990 Phnom Proek Sampov Luon 1679 Yes ( week 2 and 3 before last) Battambang- other districts 10 0 Kampong Speu 22 0 Krati 880 Odomeanchey 12 0 Preahvihear 23 0 Pursat 57 0 Steung treng 880 Thaland 30 0 Others 34 0 Total Among 23 Imported cases In SPL OD had malaria history: 13 Pv and 8 Pf Among 30 Imported cases In Thailand OD had malaria history: 6 Pv and 2 Pf

70/127 villages have no reported cases

Response activities to 216 index cases: Screening index household members and co-travelers: o Index HH members: 554 => 1+ (Pf:1) o Co-travelers: 247 => 9+ (Pf: 7, Pv: 2) o Members of HHs surrounding index HH (suspected): 73=>0+ Health education and ITNs topping up: o 1,862 persons received HE through IPC o 70 ITNs distributed (50 LLINs & 20 LLIHNs) IRS: 48 HHs (17 Index HHs and 31 Surrounding HHs) Preliminary Results (Conti…)

CODEScreening Symptom (day ) Classificatio n OriginRelationIndexOrigin PfNoImportedPursat/Chheutom Family member PfPursat/Chheutom Pf1ImportedKg. Speu/ThbongCo-travelerPvKg. Speu/Thbong Pf1ImportedKg. Speu/ThbongCo-travelerPvKg. Speu/Thbong BT-112-5Pv2RelapsePursat/ChheutomCo-travelerPfPursat/Chheutom SM-80-01Pv2ImportedSTG/ThalaborivatCo-travelerPvSTG/Thalaborivat TC-64-01Pf2Imported Kg. Speu/Phnom Sruch Co-travelerPf Kg. Speu/Phnom Sruch TC-65-01Pf2Imported Kg. Speu/Phnom Sruch Co-travelerPf Kg. Speu/Phnom Sruch TC-71-01Pf1ImportedPursat/Veal VengCo-travelerPvPursat/Veal Veng TR-09-02PfNoImportedPursat/KravahnCo-travelerPfPursat/Kravahn TR-09-04PfNoImportedPursat/KravahnCo-travelerPfPursat/Kravahn Preliminary Results (Conti…)

Malaria Diagnosis and QA -Diagnostic tools: RDT (SD Malaria Ag Pf/Pv) & Microscope -Malaria Blood Films (MBF) by VMW/HF staff -First reading by HCs lab staff and second reading by RH Lab expert -Slides cross-checked and QA supervision by PHD & CNM Lab

1. Data collection -Real time notification by SMS/Phone: VMW/HF staff (Day-0 alert system) -Treatment FU forms (Day-0, 1, 2; Day-7 & Day-28): VMWs send them to HC -CIF & Response summary: performed by response team and sent to HF/OD 3. Data analysis and reporting -CAP-Malaria M&E prepares weekly reports -Daily tracking chart on case treatment follow up, case investigation and response displayed at each HC/OD 2. Data entry -Excel sheet of 1, 3, 7 data used by CAP-Malaria staff (Jul-Dec 15) -OD/CAP-Malaria staff enter 1, 3, 7 data into MIS on a daily basis (From Jan 16) -Double data entry Data Management

Challenges  HR: Limited quality staff and motivation  1, 3, 7 activities: required HF/OD working on holidays/weekends  Limited malaria case information from other sectors (Uniforms, PPs)  Treatment failure: required 7 days hospitalization (2 nd line treatment)  Treatment follow up: missed 28 days follow up of Pf/Mix cases  PQ: pending (Pf transmission blockage and Pv radical treatment)

Way Forwards  Refine tools of the 1, 3, 7 activities  Disseminate progress (Strengths, weaknesses) and final result  Advocate for model scaling up  Documentation and publication

THANK YOU Together eliminate malaria!

23,895 ITNs, (19,595LLINs/4,300 LLIHNs) were distributed 50,716 persons (27,655 MMPs) received HE through IPC on net use and proper service seeking behavior Monthly meeting has been conducted at HF between VMWs and HF staff with/without participation from OD and CAP-Malaria staff Supply and stock monitoring on malaria commodities, especially RDT, ACT and lab materials have been conducted on monthly basis Supervisions to HFs and by HF to VMWs/PPs, to HFs by OD staff Regular meeting of the AD-ME Other Activities in SPL