Vector Control Updates and
Issues in the WPR region
Session 2: APMEN Vector Control
Working Group meeting
APMEN III, 8 May 2011
Dr Jeffrey Hii
WHO PHL and WHO Regional Office for the
Western Pacific, Manila, Philippines
1
Western Pacific Region
Overview – Updates & Issues
1.
2.
3.
4.
5.
Moving from control to elimination
LLIN/ITNs and universal coverage
IRS and elimination
Insecticide resistance monitoring network
Sound management of pesticides of public
health importance
6. Integrated vector management
7. Durability of LLIN monitoring guideline
8. Interim recommendations on LLIN packaging
2
Western Pacific Region
Phases and Milestones in Malaria Programme Evolution
WHO certification
SPR < 5%
< 1 case / 1000
pop. at risk
zero local cases
Effective
insecticides
Better
monitoring
Resistance
3 years
monitoring
Novel
Vector id &
Appropriate
Prevention of
approaches,
Control
Pre-elimination
Elimination
IVM
incrimination
re-introduction
eg
GMM
Targeted
interventions
outdoor
biting
1st
programme
re-orientation
Effective
consumer
products
2nd
programme
re-orientation
“…aim at interrupting malaria transmission, where feasible” WHA 60.18 (5/2007).
3
Western Pacific Region
% IRS coverage
Source:
WMR
No. Issues
offor
people
Adoption
of policies
IRS programmes,
2010
by Report
•Both IRSStates,
& LNs protected
highly
on pyrethroids,
Member
Worlddependent
Malaria
2010
(in 2009)
•widespread use ofIRS
a single
insecticide class increases
Policy
Number
of endemic
risk that mosquitoes
will develop
resistance
Malaysia
400,007
36.4
countries
•Changes
in
species
distribution
China
8,768,609
1.3
IRS is recommended
by NMCP changes
6
•Behavioral
17,809
Papua
New
•Documenting
evidence-based7IRS0.3
IRS
is used
for preventionfor
and
Guinea
control
of epidemics •Spray quality
•Spray
coverage
Philippines
239,605
IRS
and ITNs used together
for
6 86.6%
•Building
IRS capacity
malaria
control
in at
least 170,941
some
Solomon
Islands
areas
Viet Nam
1,544,329
DDT is used for IRS
Insecticide resistance
monitoring is undertaken
4
0
6
-
Western Pacific Region
Adoption of policies for ITN programme, 10
Member States, World Malaria Report 2010
Policy
5
No. of endemic
countries (5E)
ITNs distributed free of charge
9
ITNs/LLINs sold at subsidized prices
2
ITNs/LLINs distributed to all age groups
9
ITNs/LLINs distributed through mass
campaigns to all age groups
7
ITNs/LLINs distributed through mass
campaigns to <5 only
ITNs/LLINs distributed through antenatal
clinics
0
ITNs/LLINs distributed through EPI clinics
2
3
Western Pacific Region
100
8.0
Lao PDR
7.0
7.0
80
6.0
70
5.0
4.4
60
3.6
4.0
50
3.0
3.8
4.1
4.0
3.3
2.9
2.6
6.0 Nam
Viet
Philippines
5.2
3.0
2.0
1.0
1.0
20
0.0
0.0
Southern
Highlands
Momase
Islands
Country-wide
Region
members/Net
% of HH withNo.
≥ 1HH%
of HH with ≥ 1
any net LLIN distribution
ITNratio
6
4.0
2.0
30
0
5.0
3.0
40
10
Average housheold size
No. of household members/net
8.0
Cambodia
90
No.<5HH members/LLIN
% of children
% of pregnant
years who slept
Averagewomen
HH size who slept
under an ITN
under an ITN
Western Pacific Region
Lao PDR
Universal Coverage (UC) and Continuous
CambodiaSteps to meet UC target:
Distributions Systems
for ITNs
Measles Vaccine
coverage %, 2009
1. ITN
programmes
need
to have sufficient
Solomon Is
• UC targets whole communities, not only vulnerable subgeographical
reach
to provide ITNs to all hhs
groupsMalaysia
with these
communities
•2.Aim
– equitable
protection
& be
“community
effect”
Sufficient
nets
need
to
provided
to
hhs
PNG
• Mass campaigns best to rapidly scale up LLIN coverage,
tobut
cover
all
people
living
in
ANCthem,
Coverage %,
notVanuatu
good enough to sustainLatest
UC
Year
(source:
ADB 2010;
People
within
hhstoneed
to
use
the
available
•3.WHO
 higher
priority
routine
services
such
as ANC
WHO)
China
&
EPI
as
a means to sustain UC
nets.
• In WPR,
ANC & EPI coverage is variable; not enough
VietNam
to sustain full UC.
Philippines
• Additional
flexible systems for continuous LLIN delivery
• Innovative solutions are needed where access and
Brunei
quality of these services are low
0
7
20
40
60
80
100
120
Western Pacific Region
Background of IR Network
•
•
•
•
•
•
8
Need for region-wide comparable resistance data to
Insecticide
concentrations
that a decade
encourage the
correct use of insecticides
in VC.
Aug
2008
VCM kill
meeting
– patchy
ago
would
100Siem
% ofReap
a mosquito
information
on R
status.
Requested
for capacity
population
are
now
readily
achieving
building & strengthening entomological services.
much
much
lower levels
of mortality
ITM
Antwerp
established
a cross-country
IR monitoring
network in 4 Mekong countries.
MALVECASIA:
regional network
IR monitoring:
Spread
of resistance
may beforaccelerating
– To define the insecticide status of the major malaria
in in
areas
withdifferent
high coverage
of
vectors
indifferent
physio-geographical
regionsinsecticide
in Southeast Asia
treated bednets
Extension ofor
thisindoor
networkspraying.
to the rest of the ACTMalaria
countries to gain better insight into the problem of IR
Western Pacific Region
Bi-regional IR workshop, Hanoi, Nov 2009
From 2009
to 2011……..
General – to improve
knowledge
on insecticide
Workshop
recommendations
resistance status ofLittle
adultprogress
mosquitoes, vector of
and
changing
by increasing
the dengue
1. Adiseases,
network to
monitor
IR intrends
vectors
of malaria and
Fewcapacity
new insecticide
resistanceIRdata
generated from the countries
for
appropriate
monitoring.
2. Strengthen
entomology
skills among
country staff.
&
posted
in
the
ACTMalaria
website
• Specific objectives
3.
ff-up workshops
M&E
of monitoring
LLIN,
IRS,the
vector
control
etc
Participants
at the
2009on
workshop
all from
program.
1. To set up
a network
for thenot
of national
insecticide
4. Introduce
strategy
(emphasis
in capacity
Notvector
empowered
to make
decisions
resistanceIVM
of
mosquito
species
in the building)
ACTMalaria
countries
Cambodia,
Country at
programme
mangers
not levels
well
informed, PR
regional(Bangladesh,
& country
China,did
Republic
of Indonesia,
Laoresistance
PDR, Malaysia,
hence
not
support
the
insecticide
monitoring
5. Myanmar,
WHO test Philippines,
kits to be sent
to the ,Vietnam
participating
countries
Thailand
and
East
Lack of funds to purchase WHO test kits, papers
Timor)
6. Provide technical support to countries
to staff
conduct
the testin
especially
for dengue
vectors.
2. Toand
train
of
NMCP
bioassays,
data
entry
and
7.
Review
progress
on
insecticide
resistance
management
3. To set up a web based data base for data
management and analyses of the bioassay data
•
9
Western Pacific Region
Actions to be taken
1. Request this Group to support the IR Network in Member
countries
2. Combine insecticide resistance monitoring for both malaria and
dengue vectors.
3. Formalize the tools for data collection
4. Joint WHO Expert panel to provide technical advice to interpret
resistance data
5. Capacity building plan
6. Website to rapidly access data on insecticide resistance
7. Assess impact of IR on program performance – control failure
10
Western Pacific Region
Sound management of pesticides
of public health importance
• refers to the regulatory control, proper handling, import,
•inadequate
capacity
foruse
pesticide
resistance
prevention
supply, transport,
storage,
and disposal
of pesticide
waste
to minimize
adverse environmental effects and human
and
management;
exposure.
•general lack of capacity for monitoring pesticide
• WHO Resolutions 2010 related to the strategic approach to
exposure
andchemicals
poisoning;
international
management including the
management
pesticides
•low
capacityoffor
disposal of pesticides and pesticide•related
Report waste;
of 2010 survey
••low
weakcapacity
legislationof
& regulation;
managers of vector control programmes
•forinadequate
mechanisms
and capacity forof
procurement
and QC
IVM and
sound management
pesticides.
• challenges in implementation of IVM and application of pesticides;
11
Western Pacific Region
Problems in vector control
Role of IVM in elimination
• Sub-optimal targeting and lack of adaptation
Need
tools to resolve
deficiencies
in elimination and for
of methods
to local
circumstances
sustaining the achievements made in malaria
•Malaria
Missed
opportunities for integrating diseases
& LF elimination programs (particularly for AnophIVM
• Other
sectors
transmitted
LF) and communities unaware of
theirWHO
role products
in increasing
riskreleased:
of VBD
Three
will be
• 1.
Insecticide
will increase with
overGuidanceresistance
on Policy Development
for IVM
reliance
on chemical
2.
Handbook
on IVM methods
100
90
80
Malaria burden
70
60
50
40
Attack
30
Consolidation
Elimination
Maintenance
20
Certification
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Indicative time line
22
years
3.FullCore
coverage structure for training curriculum on
IVMIVM
as management strategy to tackleIRS these
Residual foci
Low receptivity
LLINs or IRS
(or both)
LLINs or IRS
problems
(not as a separate parallel programme but through
Preparation
Implementation
transformation
of the existing system)
ITMs - Larvicides
Environmental management, larvivorous fish, house
proofing/improvement, social/economic development
12
Western Pacific Region
Between-year
variation in rate
physical
150 denier
polyethylene
andof 100
denier
Multi-country
show
unexpectedly
large
damagestudies
of LLINs,
Palawan,
Philippines
polyester
nets, in a durability study
(source: RITM, CHD-4B, RHU)
No. of LNs with varying hole indexes
variation in effective life between locations –
70
How long do
LNscm
even more variation between locations
than
<0.5
really last?
between brands
0.5-2 cm
60
1) survivorship/
2-10 cm
Evidence that the relative lifespan
of different
50
attrition
(includes
brandsAis not constantBbut varies
in different
>10 cm
retention)
40
contexts
2) Physical integrity
So
a global “top five” ranking is not realistic
30
(holes)
(and would not be good for market)
3) bio-efficacy –
20
C
D
interaction between
Figure 3. 10
Damage and repairs made on retrieved LLINs: (A) knotted
insecticide & holes
/ tied failed seams on DawaPlus, (B) rips and burns on Permanet
2.0, (C) burned holes on Permanet 2.0, and (D) repair on long rip on
Olyset.
0
Year 4 Olyset
13
Year 3 Olyset
Year 2 Olyset
Year 2 Permanet Year 1 DawaPlus
Western Pacific Region
Draft standard durability monitoring guidelines
now being finalised (J Lines, GMP)
• Retrospective monitoring limited by:
– Unreliable recall / records to estimate net-age
– Attrition cannot be reliably estimated
– significant fractions of the population moved in/out of
the area
– Fade out of labels of nets
– Remaining nets may represent a biased sample
• However, can provide immediate info about
previously distribution as long as the net rosters
& time of distribution are kept.
14
Western Pacific Region
Monitoring LLIN Durability (J Lines GMP)
• Method Involves
• A Mixture of Brands / Products used together
– (why this is new and important)
•
Exactly equal and recorded numbers of each brand
– (why this is new and important)
•
Emphasis on attrition and holes – insecticide
optional
• A Hole Index - quantification of physical wear
– (not just % with holes) (but need to calibrate this)
•
Procedures can be openly & critically scrutinised
– – so demonstrably free of external influence / bias
•
15
User preference data that is guaranteed from
manufacturers’ influence
Western Pacific Region
Monitoring LLIN Durability (J Lines GMP)
• Need constant flow of location-specific data, not
some large set-piece trials from WHO. This
monitoring will be recommended as "good practice"
in all large-scale procurements/deployments, for all
implementation agencies, and all donors, especially
GFATM.
• Estimated Cost: depends on scale and outcomes
measured. Typical ballpark might be (excluding
nets): $100k - $300k
• So – how often?
– ? should normally be part of every procurement over $2m ?
– ? Where each procurement is smaller, then after every
cumulative $2m.
– So then cost of monitoring would be an extra 1%.
– Expected to save >>10% !
16
Western Pacific Region
WHO Toolkit on Sustainable management of
LLINs (work in progress, GMP)
• Objective – to identify and assess the feasibility of
environmentally sound and cost-effective options for
end-of-life management of nets used for malaria
control.
• Community surveys
• What factors influenced the selection of a
geographical area believed to contain an adequate
quantity of nets? How accurate were these
predictions?
• Were collections organized around a distribution
programme or independent of a distribution?
17
Western Pacific Region
Do:
Do:...............
...............
INTERIM
RECOMMENDATIONS
ON
LLIN
1.
IfWHO
recycling
Recycle
LLINs
or incineration
packaging
isonly
not possible
through recyclers
and
if the
manufacturers
that understand
provide
the
necessity
directionsofonrecycling
methodsnonfor
PACKAGING
safe
biodegradable
disposal, follow
pesticide-tainted
these.
residues only
into
non-consumer products and that work in an
• Do
Not:
industrial
environment
that
poses little
risk to
If
not,
bury
any
potentially
insecticide
treated
• DO
NOTor
burn
LLIN bags in open air;
workers
the
environment.
plastics in soils with low permeability, away from
•2.
DO
NOT incinerate
LLIN
unless
the
Incinerate
LLIN
bags ONLY
ifbags
specified
high
any
residences,
preferably
down
gradient
from
any
proper
incineration
conditions
be
temperature
incineration
conditions
for pesticideknown
domestic
water sources
but at can
least
100
tainted
plastic
can
be guaranteed
FAO/WHO
guaranteed
and
forand
the
whole
meters
from
wells
or maintained
other
domestic
water
intakes or
and
Basel
Convention
guidelines
can
strictly
high
water
marks
lakes-wetlands,
to a be
depth
not
duration
of
theofbags
incineration
and
follow
followed;
tostrictly
exceed
one
meter above
highest
annual water
FAO/WHO
and the
Basel
Convention
3.
table.
Store LLIN packaging only if future safe
guidelines;
incineration
recycling
is the
expected:
storage
Compacted
soilorshould
cover
buried the
plastic
to a
•depth
DO
NOT
re-use
LLIN
for any purpose
facility
must
be dry
and bags
secure;
of one
meter
or
more.
18
Western Pacific Region
Thank you
19
Western Pacific Region