Malaria elimination in the North Eastern Thailand

To interrupt malaria transmission (no indigenous cases of malaria for three years) in the North Eastern Thailand by 2018 Goal

ABER & SPR / 100 pop. API / 1,000 pop. Annual Blood Examination Rate (ABER), Slide PositivityRate (SPR) and Annual Parasite Incidence (API/1,000), Thailand FY Fiscal Year

Percentage Fiscal Year Proportion of malaria parasite species, Thailand, FY P. falciparum P. vivax

All cases in 2013 Indigenous Cases, 2013 Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%) PCD = 2,755 (TPR=18%) ACD = 3,294 (TPR=0%) API = 0.02 per 1,000 Total case = 477 (Pf.= 26) Indigenous cases = 1 Infected outside villages=2

Malaria foci, 2013 % of case investigated, 2013

Technical feasibility

Vectorial capacity and receptivity Entomology Is vectorial capacity low at the outset? In the most part of Thailand, Vectorial capacity is relative low, especially in plain areas. Although, the main vectors in Thailand are An.dirus and An.minimus, high coverage of vector control measures result in vectors short-lived. In transmission areas (border and forest areas), Anophelline are still anthropophilic, but low vector density. Can it be reduced to a level compatible with elimination? Entomology Main vectors are rather endophilic, endophagic and night-biting. Vectors tend to be endophilic and exophagic where are high coverage of vector control. Most breeding sites are able to be identified, but forest areas where transmission occurs. Vectors are still sensitive to insecticide (Pyrethroid). Malaria transmission is seasonal, but high coverage of vector control result in significant reduction of malaria cases.

Physical environment Malaria is very low transmission in this region. Houses in endemic areas are sprayable walls with high acceptability. Human ecology Houses are made from wood and bamboo with sprayable wall. IRS and LLINs are highly accepted and used. Personal protection such as sleep under bed- net and mosquito repellent are common practices. Villagers in endemic areas practice outside activities in the evening such as wood cutting, and hunting. Control effectiveness Vector controls and personal protection are the main strategies for anti- malaria program. The action plan is adjusted annually to ensure the coverage and maintain high effectiveness in targeted areas. Case management is free of charge for everyone. There are collaboration of all affected communities and potential partners (inter-sectoral).

Can it thereafter be maintained below a threshold? Environment, development There is absence of natural or man-made disasters. There is no ongoing or expected changes in natural or human ecology favouring lower vectorial capacity, depending on zoo-geographic region and local vector bionomics (e.g. deforestation, desertification, pollution, urbanization).

(2) Duration of infectivity Can duration of infectivity be reduced to and maintained at very low level? About 60 % of the total cases are P. vivax and resistance to ACT is reported in some provinces but the country targets to contain and eliminate resistant parasite with well collaboration with other inter-sectoral partners. Most at risk population seek treatment at public health facilities due to universal health coverage. Radical treatment and DOTs is applied for all species. Migrants are also able to access health services with free of charges. (3) Vulnerability Can importation of infections be reduced or maintained at low level? Movement of population in these regions in common, which may increase importation of malaria cases. However, Health services such as treatment and prevention are high coverage and strong surveillance is in place.

Surveillance system in targeted areas Passive case detection Hospitals Malaria posts Malaria clinics Active case detection Mobile malaria clinics Proactive case finding in malaria transmission areas Reactive case finding 12 Case investigation and follow up

Case definition  All positive malaria cases diagnosed with laboratory confirmed including symptomatic and asymptomatic cases are included in the surveillance system.  Criteria for malaria testing  Malaria clinics: all suspected malaria cases who visit malaria clinics.  Hospitals:  Patients whom have history of traveling to endemic areas.????

Methods of confirmation and Quality control  All suspected cases of malaria are diagnosed with microscopy or RDT (use in village malaria posts, for every RDT, a blood smear will be sent to malaria clinics).  A case investigation form will be completed for all confirmed cases  Confirmed cases will be followed  Pf: 3, 7, 14, 21, 28day  Pv: 7, 14, 60, 90day  QA diagnosis  All positive slides and 10% negative slides are rechecked by expert microscopists

Department of Disease Control Vector Borne Disease Malaria Filariasis Dengue Fever Office for Disease Prevention and Control CENTRAL LEVEL DISTRICT LEVEL PROVINCIAL LEVEL CANTON LEVEL Provincial Public Health Provincial Hospital Vector Borne Diseases Control Center Vector Borne Diseases Control Unit Malaria Clinic District Public Health District Hospital Health Center REGIONAL LEVEL Epidemiology Coordination Command Malaria Post 15 Real-time web-based Private clinics and hospitals??

Technologies Web-based synchronization technology capable of switching between offline / online mode of data entry. This terminology is benefit for the low resources area. Users can still operate in case of internet link has difficulties. Then data can be later transferred when internet is back to normal. Mobile Computing simply disseminated or received information to/from different devices in other platforms i.e. Mobile/ Tablet Geographical Information System (GIS) ready ability to toggle GIS in key elements of indicators for better understanding of the situation in short term

Case investigation  All confirmed cases are investigated  Data recorded  Date of symptom onset  Location where the patient is living and had visited  History of any previous malaria episode  Current treatment  Bed-net use  Case classified as to likely mechanism of infection acquisition  indigenous, imported, etc. 17 Investigation rate is inadequate in the targeted areas

Case classification ClassificationDescription A Indigenous (acquired in village) Bx Outside village but inside canton By Outside canton, but inside district Bz Outside district, but inside province Bo Outside province, but inside country Bf Outside country F Unclassified 18

Transmission areas (A):  A1 - perennial transmission area (transmission reported for at least 6 months per year).  A2 - periodic transmission area (transmission reported but for less than 6 months per year Non Transmission areas (B):  B1 - high and moderate receptivity (transmission not reported within the last 3 years but primary and secondary vectors present).  B2 - low and no receptivity (transmission not reported within the last 3 years and primary and secondary vectors absent, suspected vector may be present). Malaria area stratification in Thailand

Residual active foci (1)+ residual non active foci Malaria foci in targeted areas New potential foci (B1+imported case) and Clear up foci (B1-Receptive) Pseudo Foci (B2 areas with imported case- non-receptive)

All cases in 2013 Indigenous Cases, 2013 Total Pop. = 17,002,113 Pop. At risk = 86,311 ABER = 0.04 % (At risk pop. = 6.9%) PCD = 2,755 (TPR=18%) ACD = 3,294 (TPR=0%) API = 0.02 per 1,000 Total case = 477 (Pf.= 26) Indigenous cases = 1 Infected outside villages=3

5, Malaria foci, 2013 % of case investigated, 2013

Areas for Surveillance system improvement Suspected case definition for hospitals Case reporting from private hospitals and clinics Case investigation and response (foci elimination)

Suspected case definition for hospitals  Criteria for malaria testing in hospitals: patients whom have history of traveling to endemic areas.  Increase awareness of medical doctors  All positive malaria cases diagnosed with laboratory confirmed including symptomatic and asymptomatic cases are included in the surveillance system.

Improve case reporting from private hospitals and clinics  Enforce private sector to report a malaria case though regulation at policy level and implementing level  Introduce malaria online system for private sector

Strengthen case investigation and response (foci elimination)  Organize refreshing training for local staff including vertical and general health services  Involve stakeholders such as community, local administrative organization in receptive areas to inform any population migration from endemic areas.  Close supervision at all level, especially at the implementing level.

Operational Implications of different types of foci

Ineffective Effective Present Absent Present Absent (For 3 years) Endemic Active foci Clean up Residual non active Active foci Residual active New potential Control Transmission Case A1+A2 With indigenous every year B1 areas with no case B areas with 1 st indigenous case B1 areas with imported cases A1+A2 with indigenous case in any year during 3 years A1+A2 no indigenous case in 3 consecutive years Classification of Malaria foci in Thailand Pseudo Foci B1 areas with case infected outside village B2 areas with imported case

Active and residual foci 1.Indoor residual spraying (IRS) Active foci =2 rounds Residual foci (A2) 1 round 2.Insecticide-treated nets (ITN) 3.Long Lasting Insecticide-treated nets (LLINs) LLIN+LLIHN = 1 net/ 2 person VECTOR CONTROL

Active and residual foci Proactive case finding Reactive case finding Case Detection New potential foci (B1+imported case) and Clean up foci (B1- Receptive)  Reactive case detection when reported case is identified Pseudo Foci (B2 areas with imported case- non-receptive)  Passive case detection Passive case detection

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