Dr Hoda Atta

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Implementation of anti-malarial drug Policy in EMR
Dr Hoda Atta WHO/EMRO
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Malaria burden in the Eastern Mediterranean
Region

• 15 million clinical cases per year
• 47 thousand deaths per year
• 287 million live under risk (60 of EMR
  population)

Estimated number of cases in EMR countries
(million/year)
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Current operational situation

• Group 1 Malaria free countries 7 of the
  population
• Lebanon, Palestine, Jordan, Qatar Libya ,
  Bahrain, Tunisia, Kuwait, UAE,
• Group 2 Countries with very limited foci and
  targeting malaria eradication, 24 of the
  population
• SYR, MOR, OMA, EGY
• Group 3 low/moderate endemicity, 53 of the
  population
• IRA, IRAQ, SAA, PAK
• Group 4 intense malaria transmission and
  complex situations, 16 of population
• SOM, SUD, AFG, YEM, DJI

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Transmission of P. falciparum in EMR

• still ongoing in 8 countries
• Sudan, Djibouti, Somalia
• Yemen and the adjoining part of Saudi Arabia
• South-eastern part of Iran ( PF 10)
• Pakistan ( PF 40) and Afghanistan ( PF 20)

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(No Transcript)
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Surveillance system is still weak
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The objectives of the regional programme

• Dissimilar in member states
• to bring down morbidity and mortality
• ( SUD, SOM, DJI, YEM, AFG)
• to control malaria transmission
• decrease ( IRA, PAK, IRQ, SAA)
• interrupt ( MOR , SYR , EGY, OMA)
• to maintain the malaria-free status in countries
  or areas where it has been already achieved

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Drug policy change in malaria free countries

• GPI and GP2 are receiving imported cases
• Policy is use most effective drugs ( ACT, for PF
  and CQ 14 d PMQ for PV)
• Drug policy was updated in MOR 2003 ( Coartem for
  imported PF cases, 14 d PMQ instead of 5 d
• UAE (2004) MEF ART (3d)
• MEF for chemoprophylaxis???

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Resistance/monitoring antimalarials -1

• Sudan
• Continuous monitoring
• Started in a number of sentinel posts 5 sites
  established in 1997 as part of TDR project. The
  network was expanded in 2000 (RB and JICA funds)
  and then in 2002
• Somalia
• Surveys supported by IX fund in 1998 , sites in
  2002
• Yemen
• POA for continuous monitoring and training was
  conducted in January 1999, 12 sentinel sites was
  selected

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Resistance/monitoring antimalarials -2

• Afghanistan
• A survey supported by WRO in 1999, 2003( Merlin)
• Pakistan
• sulfa-pyrimethamine combination low
• POA, training for continuous monitoring and a
  national workshop in August 1998, 2003
• Iran (south eastern part only)
• National surveillance since 1990
• WHO technical support in 2003, MM study in 2003

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Resistance/monitoring antimalarials -3

• Saudi Arabia (south western part only)
• A survey supported through TDR SGS in 1998 , TF
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• Djibouti
• No i vivo test
• Last invitro 1990

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Results of CQ 2003 from 3 Sentinel sites in Iran
ACPR ranges between 25-31

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• Afghanistan Pakistan
• Pf 20 31
• ACPR
• CQ 11 30
• SP 77
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• Merlin study 2003

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Drug policy for PF in EMR countries
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Policy change Uncomplicated P.falciparum malaria

• AFG changed the policy by using ACT (2003)
• SP CQ for unconfirmed
• SPAS for confirmed cases and during the outbreak
• Sudan adopted ACT (SPAST) in 2003, will be
  implemented, 2004
• Somalia will change soon possibly SPAST
• Iran is in process of change, TS in 2004

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Primaquine

• Primaquine is recommended for
• Antirelapse treatment (14 day course ) in
  confirmed infection with P.vivax and P.ovale
• Radical treatment (gametcytocidal therapy) is
  given in a single dose of 0.75mg/kg
• (not in area with intense transmission in Sudan,
  Somalia , Djibouti, AFG)
• Challenges
• Compliance with 14 day course is a problem
• - Pakistan is recommending PQ for 5days
• - Morocco changed from 5 d to 14 d in 2002
• Not to be used for children lt 4 years and
  pregnant women
• 14 day course cannot be used in patients with
  G6PD deficiency
• - Updated policy in Saudi Arabia (2003)
  recommend use of primaquine 0.75mg/kg weekly
  for 8 weeks to patients with G6PD deficiency

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Mass Drug Administration

• NOT USUALLY RECOMMENDED
• Mass treatment of fever cases is recommended
  during outbreak.
• Only fever cases are treated with full curative
  dose, usually SP
• Exceptionally
• Updated drug policy in AFG (2003) recommend Mass
  treatment
• in defined geographical area, where mortality is
  high (gt1/10000 cases/day) gt80 fever cases
  detected at health facilities are confirmed to be
  infected with Pf and an efficacious antimalarial
  drug is used (SP AS).

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Challenges

• Resistance to CQ is observed resistance to SP is
  emerging
• No sentinel sites in PAK, DJI, SAA, AFG
• updating the policy yet to be done in Yemen,
  Pakistan, Dji, SAA     

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Challenges

• Limited diagnostic facilities and lack of quality
  assurance system for ACT implementation
• Ensuring access and affordability is a problem
• Compliance of private sector , (formal and
  informal )
• Drugs for home management

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Recommendations

• Maintain/Strengthen the sentinel sites for
  monitoring drug efficacy, testing possible CT
• Develop Networks for information transfer
• HOA (in process)
• PAK, IRA, AFG (needed)
• Policy update and ensuring access to ACT in
  countries with resistance

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Recommendations

• Quality assurance of laboratory diagnosis and
  expand the coverage by diagnostic facilities
• Capacity building of staff on case treatment at
  all level including the community using COMBI
  approach
• Develop strategies to address the private and
  informal sectors

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Thank you for your attention