Third meeting of the Vector Control Technical Expert Group (VCTEG): meeting report, 15-17 March 2015, Geneva, Switzerland

Third meeting of the Vector Control Technical Expert Group (VCTEG) Global Malaria Programme Framework for a national insecticide resistance monitoring and management plan for malaria vectors Global Malaria Programme World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland Meeting report, 15–17 March 2015, Geneva, Switzerland © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). 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WHO/HTM/GMP/2015.13 Third meeting of the Vector Control Technical Expert Group (VCTEG) | 1 TABLE OF CONTENTS TABLE OF CONTENTS 1 BACKGROUND 2 OBJECTIVES 2 OPENING REMARKS 2 ITEMS REVIEWED AND ARISING RECOMMENDATIONS 3 When can malaria control and elimination program safely reduce vector control efforts? 3 Modelling background and assumptions - description of OpenMalaria and scenario assumptions - preliminary results and final simulation set 5 Deployment of combination nets, the evidence 6 Draft insecticide resistance response plan 8 New areas for policy guidance for VCTEG and MPAC consideration 10 CONCLUSIONS AND RECOMMENDATIONS 11 Deployment of pyrethroid + PBO LLINs: the evidence and Operation requirement 12 Insecticide Resistance Response plan 13 Proposed TOR for Country/Regional IR response plan 13 OTHER ORDERS OF BUSINESS 14 Update on VCAG recommendation 14 VCTEG recommendations on how various TEG and ERG committees converge to come up with unified strategic agreement. 15 Plans for next meetings 15 LIST OF PARTICIPANTS 16 Third meeting of the Vector Control Technical Expert Group (VCTEG) | 2 BACKGROUND The Technical Expert Group on Malaria Vector Control (VCTEG) is tasked with reviewing and providing guidance and making draft recommendations to the Malaria Policy Advisory Committee on the implementation of malaria vector control including issues related to programme management. The VCTEG is constituted by and reports to the MPAC. The responsibilities of the TEG on malaria vector control are to:  Review and recommend to MPAC on the predicted effectiveness and appropriate mix of vector control interventions for particular situations – including the adoption of new forms of vector control following recognition of “proof of principle” from the Vector Control Advisory Group (VCAG)1;  Formulate and propose to MPAC evidence-based norms, standards and guidelines for the implementation and management of malaria vector control;  Address policy issues related to building capacity for entomological monitoring and optimization of vector control investments; and  Identify gaps in evidence and suggest specific areas of priority research to improve management and implementation of malaria vector control. The third meeting of the VCTEG was convened on 17 – 19 March 2015 at WHO Headquarters in Geneva, Switzerland. OBJECTIVES The specific objectives of the meeting were to:  Review technical paper on Better targeting “graduation” of malaria vector control interventions: Background to topic and literature review.’ for MPAC consideration  Review Modelling background and assumptions - description of OpenMalaria and scenario assumptions - preliminary results and final simulation set.  Review Simulation results and recommendations - including Monte Carlo simulations  Review ‘Deployment of combination nets: the evidence’  Identify new areas for policy guidance for VCTEG and MPAC consideration OPENING REMARKS Dr Pedro Alonso, Director of the WHO Global Malaria Programme, opened the meeting. He acknowledged the contributions of the group in compiling and reviewing technical overviews on challenges facing vector control, and providing policy recommendations and technical guidance for further reducing the burden of malaria. An update on the status of the Global Technical Strategy for Malaria: 2016-2030, GMP strategic refresh and proposed adjustment to improve GMP policy making was provided. The group was informed that GMP strategic refresh emphasize the need to strengthen entomology and vector control capacity for malaria control. Such capacity is also essential during elimination and when program transition from malaria control to vector borne diseases control. 1 A group managed jointly by the Global Malaria Programme (GMP) and the department of Neglected Tropical Diseases (NTD) Third meeting of the Vector Control Technical Expert Group (VCTEG) | 3 Pedro indicated that, currently MPAC act as a validating body from all technical committees so as to provide advice to WHO on policies formulation. Adjustment on policy setting process aim to ensure GMP (WHO Secretariat), in consultation with chairs of various technical committees, act as clearing house for MPAC and repositioning MPAC as an advisor on most critical topics. This changes reinforce the importance of Technical Expert Groups TEG and ERGs on tasks to provide technical recommendations on critical topics to MPAC and when necessary provide specific advice directly to GMP for policy consideration by WHO. This implies TEG will therefore be required to take some function of MPAC to make bold policy advice to WHO. In addition WHO secretariat will play a role of linking various TEGs and ERGs when it involved making decision on converging strategic advice for policy recommendation. Dr Melanie Renshaw, the chairperson of the VCTEG, reminded the meeting of the responsibilities and process of the meeting and gave an overview of the agenda. She indicated that the meeting would be reviewing technical papers prepared by members, technical advisors and resource persons to generate guidance and recommendations for policy decision by WHO. All meeting participants were requested to introduce themselves. Dr Abraham Mnzava, coordinator GMP Vector Control Unit, read DOI as per requirement of WHO legal unit. Declared interest did not preclude anyone from participating in decision making. Also introduce the objectives and expected outcomes of the meeting. Abraham introduced key topics for discussion and decision. This include confusion on definition of universal coverage and interpretation at program level, the request for advice by Member States on when to withdraw vector control and the evidence needed to guide deployment of PBO nets. Abraham informed the meeting on the following: 1) Recent update of VCAG to MPAC particularly the review of intervention targeting resistance and advice to GMP to provide guideline on where such tools can be deployed. To deliver on this task will require establishment of an expert group to review existing data and provide advice on deployment of resistance targeting interventions; 2) Update of GPIRM to MPAC lead to advice for full situation analysis and development of global response plan as well as provide technical recommendations to what countries should do to implement GPRIM. Draft response document will be centre for discussion and TEG is expected to provide suggestions for further development; 3) Brief highlight on changes in policy setting whereby MPAC will make decision on major issues while TEG will provide technical advice to GMP as well as MPAC for policy recommendation. ITEMS REVIEWED AND ARISING RECOMMENDATIONS When can malaria control and elimination program safely reduce vector control efforts? This work originated following requests from countries on practical consideration for graduation or scaling back, and eventual withdrawal of vector control interventions while minimising the risk of resurgence. In order to provide answer to this question, VCTEG review is presented into 3 sub- headings as follows: Better targeting “graduation” of malaria vector control interventions: Background to topic and literature review, description of OpenMalaria and scenario assumptions: preliminary results and final simulation set A background document by Joshua Yukich attempt to answer the question when it is safe for malaria control and elimination programs to scale back vector control was the subject of review by VCTEG. There are several reasons to consider scale back of vector control, these include, 1) high cost of maintaining universal coverage of interventions; 2) when transmission and burden reductions is maintained, even in the absence, or reduction, of vector control, 3) in response to changes in epidemiology of malaria following decades of intervention and 4) consultations during Global Technical Strategy development made clear the need for guidance to countries. To the contrary, scale back of vector control might have cost implication such as 1) investment to support transition from a Third meeting of the Vector Control Technical Expert Group (VCTEG) | 4 malaria control to control of vector borne diseases and 2) enhance surveillance which is important for detection of malaria outbreak or resurgence. Methodology involved included literature review to look at evidence on scaling back vector control and resurgence as well as model scenario to identify key factors and indicator to monitor success of scaling back vector control and risk of resurgence. There are many observation studies demonstrating positive and negative consequence of vector scale back, and no trials but one underway on IRS targeting in South Africa. A review by Cohen et al2 associated causes of malaria resurgence with weakening of the control program, largely due to reduction in the level of vector control effort or outright vector control withdrawal. Also withdrawal of vector control can lead to resurgence of other vector borne diseases. Caribbean, for example, maintained elimination for decades but there have been event of malaria importation during mining operations. Vector control brought about elimination and high insecticide resistance but now there is treatment of cases and space spray for outbreak (emerging cases) control. Monte Carlo simulation was used to identify indicators to monitor vector withdrawal and risk of resurgence. Key indicators were EIR, infection importation rate (IIR) as tracked in surveillance, human (annual) blood examination (H-A-BER). Based on preliminary results of simulation, draft recommendations were made on what should be considered in view of scaling back control. Discussions: The meeting highlighted the need for using common definition of key terms such as API or SPR as thresholds of malaria transmission required to stratify different level of transmission, clear description of target areas for scaling back vector control, consideration for changing or adding new parameters on the modelling approach, clarity on definition of risk of resurgence, requirement of entomological surveillance, programmatic consideration and cost implication of scaling back vector control. It was agreed the definition of resurgence should capture an event of public health importance instead of using thresholds of probability. Model validation should include EIR and case management data for high and low transmission settings, acquired and inert immunity which is important indication for receptivity of a population, and consideration for both long and short term climate changes which can influence malaria transmission. This goes hand in hand assuming spatial heterogeneity / patchiness of malaria and variation in levels of receptivity. VCTEG felt that greater emphasis was needed to give clear message on the risk of scaling back vector control in high malaria burden and the risk of resurgence, need to include case studies with example of programs which have successfully scale back vector control and sustained elimination. The group stressed that the aim of this work is to give practical information useful to programs particularly:  Clear message on risk of graduation VC in high malaria burden and risk of resurgence  Modelling backed up with real life experience case studies is useful to inform recommendation  Vector control as a tool for both insecticide and drug resistance and implication on graduation.  Economic development and reduction in transmission as well as drawing attention to secondary vector.  Consequence of scale back of vector control are many this include: 1) Program resisting to scale back from routine control activities due to political and economic implication, for example vector control commodities are associated with large sum of money; 2) programmatic and cost implication of managing these changes. 2 J. COHEN, D. SMITH, C. COTTER, A. WARD, G. YAMEY, O. SABOT, AND B. MOONEN, “Malaria resurgence: a systematic review and assessment of its causes”, Malaria Journal 11(1), 122 (2012). Third meeting of the Vector Control Technical Expert Group (VCTEG) | 5  Stages necessary to move program from universal control to elimination. Clear description of activities undertaken during transition stages, with clear indication on when to scale down universal coverage and start targeting control.  Acknowledgement that scaling back VC is a challenging undertaking with operational and cost implications, which require more thinking to determine when withdrawal is strategic and cost effective, and identification of thresholds which are likely to be analysed case by case. Considerable efforts are needed to guide vector control scale back to avoid situation where high transmission countries embark in scaling back control effort which might eventually increase the risk of malaria, and a summary of VC scale back case studies will be useful.  All issues around cost effectiveness and feasibility for vector control withdrawal should be explored, this include: re-planning, prioritisation and budget which might affect availability of supplies needed to sustain case management, surveillance and targeting. Actual vector control targeting is a complex and difficult to implement programmatically. Modelling background and assumptions - description of OpenMalaria and scenario assumptions - preliminary results and final simulation set Technical document developed by Nakul Chitnis describe scenario assumptions to model planning scale back of interventions. OpenMalaria, a simulation platform, consisting of models of malaria epidemiology and immunology was used to predict malaria specific outcomes after withdrawing of interventions calculated under various assumptions. Simulation results were then analysed using logistic regression in order to derive predicted probabilities of resurgence under various scenarios defined by baseline EIR, case management coverage, vector control coverage and other parameters. Precision and bias associated with metrics to measure the important parameters necessary to determine if a situation meets the criteria for safe vector control graduate were examined using Monte Carlo simulation. It on the basis of this background information that VCTEG discussed and raised several points which should be considered in the model assumptions:  Since number of imported infection is modelled as Poisson and actual detection rate is modelled as binomial (logistic), the concern was raised on what will happen to model prediction when case detection is low.  Given the possibility that H(A)BET will include cases resulting from repeated testing of same people and how this is handled in the modelling.  Consideration to include the following parameters in the model: 1) vectorial capacity, 2) stratification by age group to include infant parasite rate, 3) likelihood of effective treatment, 4) different forms of targeting e.g. geographic versus targeting vulnerable groups or migrant populations, 5) Inclusion of focal vector control as opposed to geographical targeting in the long term  Model validation using prevalence data from both high and low transmission settings, as well as vector species from Asia and South, and animal settings with zoophilic vectors. Simulation results and recommendations - including Monte Carlo simulations: Nakul Chitnis present preliminary simulation results on the pitfalls and potential for the safe graduation or relaxation of universal coverage of vector control intervention before and after local elimination of malaria transmission. Simulation provide answers to the question ‘is it possible (or advisable), after successful vector control has been achieved and malaria disease burden reductions realized, to “graduate” from universally applied vector control measures to more focal approaches, or can transmission and burden reductions be maintained, even in the absence of vector control?’ A simulation model of malaria epidemiology and immunology was used to predict malaria specific outcomes after withdrawing vector control interventions under various assumptions. These results were then analysed using logistic regression to derive predicted probabilities of resurgence under Third meeting of the Vector Control Technical Expert Group (VCTEG) | 6 various scenarios defined by baseline entomological inoculation rate, case management coverage, vector control coverage and several other parameters. The Monte Carlo simulation was used to examine the precision and bias associated with metrics to measure the important system parameters necessary to determine if a situation meets the criteria for safe vector control scaling back. Preliminary results presented indicate that, in absence of changes in malaria receptivity, there are few scenarios under which vector control can be reduced without strong expectation of resurgence. These, potentially safe, scenarios are characterized by low historic EIRs, successful control with vector control reaching elimination or near elimination, and effective surveillance systems with high coverage and effective treatment. Based on this review, VCTEG made a number of suggestions for consideration before full scale model simulation is completed.  Consideration that historical EIR can be estimated from a combination of parasite rate and net coverage.  Current model assumes low levels of MSAT but this is an unlikely to be done in practice and therefore should be removed.  Geographical targeting to be emphasised, this can be done in mid-term.  Regression model should report in odds ratios and not logit coefficients. Conclusions: Review of historical evidence and preliminary results of mathematical simulations based on a number of scenarios to determine the impact of ‘scale-back’ of malaria vector control indicate that for the vast majority of scenarios, the probability of malaria resurgence is high. The authors will revise model input based on feedback provided and new prediction generated, and results of final simulation will be circulated to the VCTEG for further comments. Conversely, WHO received considerable requests from countries and donors on guidance on when to scale back vector control. This is prompted by observations in some settings where epidemiology of malaria changed after years of effective vector control and expectation that it might be possible to scale-back intervention in certain areas. As consequence, VCTEG drafted an interim guide to support countries deciding when it is safe to scale back interventions. A draft guidance is provided at section 3.1 of this report. Deployment of combination nets, the evidence Recently VCAG reviewed evidence on Pyrethroid + PBO LLIN, the first in class of a new paradigm resistance targeting product, and concluded that such net has public health value in areas with substantive pyrethroid resistance. Responding to VCAG recommendation on LLIN addressing insecticide resistance as a new paradigm, countries have requested an operational guideline on where to deploy such nets. Due to complexity of resistance there is need to guide program on areas where these nets can be used to overcome resistance. Identification of geographical areas of moderate resistance intensity where such nets may have added benefit is crucial in order to estimate the likely market size of these nets and use this information to guide procurement. In order to establish conditions under which Pyrethroid + PBO nets are likely to provide greater protection than convention LLINs and estimate the magnitude of this effect on malaria disease, evidence review and modelling work was commission to LSTM. The proposed evidence review and modelling work aim to find out at what level of resistance do PBO nets provide most advantage, whether resistance mechanism is important and identify geographical areas where such LLINs may be more effective than pyrethroid alone LLIN. Dr Hilary Ranson presented a draft concept note on guidance where Pyrethroid + BPO LLIN may be more effective than convention LLINs. Third meeting of the Vector Control Technical Expert Group (VCTEG) | 7 Background: LLINs are the most widely used vector control intervention against malaria, and their use has contributed toward the global reduction in the malaria burden over the last decade. However, an increase and spread of pyrethroid resistance in mosquitoes over the last decades may compromise the effectiveness of LLINs and of pyrethroid formulations used for IRS. While there are a limited number of alternative insecticides available for use in IRS, none of these have been approved for use on nets. The potential stop-gap solution is to temporarily restore the efficacy of LLINs through the use of a pyrethroid + PBO combination net. Piperonyl butoxide (PBO) is a ‘synergist’ that, despite having no insecticidal activity, enhances the potency of certain insecticides. PBO inhibits the natural defence mechanisms of the insect, the most important being the mixed function oxidase system (MFOs). The MFO system is the primary route of detoxification in insects, causing the oxidative breakdown of insecticides like pyrethroids. Pyrethroid resistant mosquitoes have elevated levels of MFOs. Discussion and decision: VCTEG discussed the approach to follow in order to understand the benefit of combination LLIN and issues to address in order to determine operation condition for deployment, this will require review of evidence in short term and long term fashion. The short term topics to address include evidence on whether PBO nets are more effective than pyrethroid alone LLIN and can reduce malaria cases under specific scenario and pyrethroid resistance. This can be done through validated model and use of data from ongoing epidemiological trials, review existing insecticide resistance data with a view to identify geographical areas where PBO LLIN can be deployed as well as looking at cost effectiveness of deploying PBO LLIN versus standard LLIN. Spatial modelling, validated with data from epidemiological trial, will be used to model epidemiological impact of PBO nets to determine where these nets are needed using experimental hut trial data and interpolation with few actual data.The long term topics to understand include evidence from epidemiological trials to determine whether PBO LLIN reduce malaria, the interaction of PBO synergist with different AIs used for vector control, and its effect on insecticide resistance and disease outcome. VCTEG agreed that the evidence review and modelling to determine operation condition for deployment of PBO LLIN should be based on the following source of data and approach:  Data on wash resistance to determine bio-availability of pyrethroid and PBO following a number of washes is available. This is important because effectiveness of combination net will depend on bio-availability of both pyrethroid and synergist.  Data comparing PBO nets with conventional LLINs in experimental huts. This should include review of WHOPES data on wash resistance to determine bio-availability of pyrethroid and PBO following a number of washes. Also consideration to review evidence on possible negative interaction between PBO and OP which might likely have operational implication considering an increase in number of countries using pirimiphos methyl and for IRS and other OPs as a strategy for managing insecticide resistance.  Use of mathematical modelling of malaria transmission, validated with data from epidemiological trials, to estimate 1) public health benefit of PBO nets under different transmission seasons stratified by pyrethroid resistance level and 2) cost effectiveness of PBO nets compared with pyrethroid only LLIN.  Use data in IRmapper and WHO IR database to predict regions where PBO nets may have result in fewer malaria events  Cost effectiveness analysis of deploying PBO LLINs versus conventional LLINs. The LSTM team will finalise a report of evidence review and modelling work by July 2015. This report will be discussed by an evidence review group (ERG) with a view to provide advice to VCTEG on operational requirement for deployment of PBO nets. The ERG constituted by WHO secretariat will include members with expertise in insecticide resistance, population genetics, health economics, epidemiology, biostatistics, experimental hut trial, program management and modelling. MPAC and Third meeting of the Vector Control Technical Expert Group (VCTEG) | 8 VCTEG should be included in the ERG membership, and relevant donors will be invited as observers. VCTEG agreed the proposed ERG will operate under the following terms of reference (TOR). TOR for ERG on PBO combination nets:  Review evidence that PBO LLINs can reduce malaria cases under specific scenarios of transmission and pyrethroid resistance. This evidence will be based on data on wash resistance and bio-availability of PBO and pyrethroid as well as experimental hut trial comparing PBO nets with pyrethroid alone LLIN.  Define transmission and resistance scenarios under which PBO LLINs are predicted to be more cost effective alternative to conventional LLINS  Make recommendations on practical and informative measurements of insecticide resistance that will inform decisions on where to deploy PBO LLINs  Identify process for validating the predictions based wash resistance and experiment hut trials and data from ongoing epidemiological trials  Guidance on how to evaluate and monitor the impact/effectiveness of PBO LLINs under routine deployment with a view to inform revision of ongoing intervention.  Document lessons learnt from evidence review of PBO LLINs that will guide evaluations and targeting of future combination net products. ERG will meet toward the end of July 2015 to discuss the report by LSTM team on evidence review and modelling work and provide recommendations to VCTEG on operation consideration for deployment of Pyrethroid + PBO LLINs. Based on this discussion, ERG will produce a report and initial recommendations to guide deployment of Pyrethroid + PBO LLINs. ERG report will be a subject for discussion in the next VCTEG. The final output of this review is expected to provide initial/interim recommendation on where to deploy PBO LLIN based on existing evidence and identify geographical area where PBO LLIN could be useful. For some question new evidence is likely to be available at later stage which will be essential to inform deployment of PBO LN and provide full recommendation Draft insecticide resistance response plan GPIRM, a five pillar strategy with short-term, medium-term and long-term plan for insecticide resistance management plan was launched in 2012. This was a response to an increase in insecticide resistance, particularly to pyrethroid. Status of GPRIM implementation was presented at VCTEG meeting. Overall some progress has been made in implementing GPIRM technical recommendations. But adoption to policy and operational implementation at country level have generally been poor due to a lack of political will coupled with major financial, human and infrastructural resources. As a consequence, urgent efforts are needed to ensure correct use of existing interventions and availability of new tools. Update on progress of GPIRM implementation was reviewed by MPAC in September 2014. MPAC requested WHO-GMP to conduct a comprehensive situation analysis and in consultation with malaria endemic countries and their partners prepare a global response plan in order to improve GPIRM implementation, particularly at country level. In response to MPAC request, GMP prepared a draft “Global response against biological threats to effective malaria vector control: framework for urgent national action, 2016-2020” which was reviewed by VCTEG with a view to deliberate on the way forward and provide suggestions on the goal and purpose of such a plan. Discussions: The Chair indicated that the priority was to address shortfall of the Global Fund TRP. When a country wish to conduct IRS with a non-pyrethroid in areas with LLINs in order to address insecticide resistance, the TRP have indicated that a) there is no WHO guidance to support this strategy, and b) there is no clear indication of when and where this should be done and its cost- effectiveness. IR management should be conducted in the context of maintaining the effectiveness of Third meeting of the Vector Control Technical Expert Group (VCTEG) | 9 current vector control (mostly pyrethroids based intervention), phasing in new classes (AIs) of insecticides, and ensuring their continued efficacy. Normative guidance is required not only on how to implement LLINs and IRS together, but also how to use the new AIs and non-chemical interventions. Such clear implementation guidance will be needed for guiding forecasting in order to influence prices of new AIs. At present there are limited options for IR management, limited understanding on the extent of the problem and impact of existing efforts to manage resistance. Still there is a lack of evidence on the impact of insecticide resistance and the outcomes of IR management i.e., demonstration of a reversion to pyrethroid susceptibility. The inability to document the impact means that countries also don’t know how to proceed. Necessary documentation is critical to gain and maintain momentum.The above limitations contribute to confusion amongst countries and implementing partners on how to manage IR and roll out GPIRM. Strategies for managing resistant mosquitoes need to be more clearly articulated. Focus should be on what is actionable and what can be done at present. Countries require 1) a generic action plan on how to move forward, after which countries can adapt the resulting plan based on their local situation; 2) practical guidance that includes operational details for example the frequency for rotating the AIs with different mode of action and application of non-chemical intervention for resistance management; 3) specific operational guidance that would include cost justification for IRM in order to drive action. An action- oriented and well-publicised plan is required, that includes preparedness for new evidence and new tools, that is, outlining the process for establishing the evidence-base and capacity to be able to implement once the new tools are available. This should include how to rotate in new tools, recognise gaps and plan for filling that data gaps and forward thinking around how to deploy the new tools that will come out. The main areas to focus now are: a) capacity building including teaching materials b) development of new tools, and c) research to develop the evidence base required. Capacity building will be key to derive necessary information and support decision making. The guidance should be flexible, practical and may give situation-specific advice. It should be a live document that can be updated frequently considering rapidly changing environment (e.g. new technology) and need for new evidence to improve understanding of current limitations. Considering current serious technical constraints and while GPIRM does provides guidance, this may not be clear enough to donors or countries. As a consequence clarification on the normative guidance to target specific audiences is needed. Donors and countries need to know under which circumstances is it justified to spend more money i.e. on overlapping interventions, improved or new tools? Cost-effectiveness should consider preserving the gains and also incorporating the previous investments made. It is obvious a clear justification for buying fewer higher cost products is needed, but without the field data, it is difficult to provide that justification.Donors like Global Fund require clear guidance from malaria community, this is necessary to trigger internal mechanisms to follow that guidance. But, the GF procurement team lack the necessary guidance for supporting those changes. It is possible that formulating TPPs for a set of resistance management tools may aide the discussions between Global Fund and industry. Overall VCTEG felt that the subject IR and residual transmission should be kept separate. Combining the two will dilute urgency for each subject and make it more difficult to communicate the issues therefore limiting opportunities for influencing the agenda. There was general agreement that the main aim of this IR response plan will be to roll out GPIRM and will constitute operational plan which is feasible at global and regional/country level. This action plan should have mid-term and long-term plan for partnership at country, regional and global level to implement IRM with a focus to: 1) Build capacity at regional and country level, 2) Gather more evidence on impact of IR on vector control, 3) Deal with high cost of new tools as well as mechanism to guide deployment and procurement. The plan should clarify technical specifications and practical description of what country should do to manage IR, advocate for more awareness and funding. The IRM plan should be a living document to allow for regular update to include new evidence, providing guidance on what and how interventions should be deployed and inform on evidence needed in order to inform future deployment of new tools. This plan should be as practical as possible with guidance to support adaptation to suit local context and specificity. Third meeting of the Vector Control Technical Expert Group (VCTEG) | 10 VCTEG advised two guidance should be developed as follows:  High level global IR response strategy: Focus on global coordination and advocacy for resource mobilisation to implement GPIRM, with a preamble on current status of IR, geographical distribution and implication for vector control. It will define who is doing what, what need to be achieved and identify the gaps. Consideration for global coordination to ensure countries have the capacity to collect and analyse data and that operational plans are linked to GPIRM, with greater technical support provided for interpretation of data to inform policies at the global level. Should include subregional capacity building for countries and consideration for capacity strengthening urgently required in WHO.  Regional/Country level IR operation plan: will focus on understanding country perspectives on what pillars of GPIRM will be useful to the country or sub-region, identifying current resistance situation, what are the prospects for new tools and plans for deployment and the technical recommendations for countries with guidance for specific sub-regions. As a way forward, additional and significant resources will be required to support the development of the documents. It was decided that the TOR and consultant profiles should be completed by 31 May 2015 in consultation with VCTEG. The products should be reviewed at the next VCTEG. However, there was no discussion on how best to plan and fund development of two documents; this is considered a key requirement to determine the way forward. As such WHO-GMP will work on a feasibility plan in order to determine the way forward given the considerable resources and time required to develop such practical IRM guidance’s for member states. New areas for policy guidance for VCTEG and MPAC consideration The meeting proposed new topics for future consideration as follows: Net durability and fabric strength with a view to inform programming and procurement decisions A written status update on Insecticide Treated Net (ITN/LLINs) durability was proposed. This will be a status update on issues related to measuring of net durability, acceptability of LLIN products and consequence to the country. The review should aim to capture interest of countries where nets will be used. A concept note on desk review compilation on status of ITN durability should focus on the following TOR.  An update on the current implementation status and relevance of existing ITN durability monitoring guidance and its effect on programmatic and procurement decisions;  An overview of ongoing and planned work to characterize ITN durability;  A review of Resistance to Damage (RD) scores and their potential relevance to ITN implementation decisions;  A summary of the current evidence -base on the persistence of insecticide treatment on ITNs, with specific emphasis on identifying whether it can be assumed that current treatments are sufficiently long-lasting to persist up to and beyond a three year useful life of an ITN under field conditions  Recommendations on future developments in ITN durability assessment (both physical and chemical), potential impacts on procurement and programmatic practices and areas of focus for normative guidance. Stratification and prioritization of vector control intervention.  Guidance on prioritization of vector control in terms of interventions (LLINs, IRS, larvicing etc) and geography in the context of stratification, consideration for long term plan for malaria control, special (prison, army, emergency) settings etc.  Prioritization beyond vector control, such as iCCM vs RDT, role of MDA or FSAT. Third meeting of the Vector Control Technical Expert Group (VCTEG) | 11  GMP EVC and TEG (Joe Lines) to develop concept note and statement on issues around prioritization and need for guidance on prioritization Entomological monitoring and vector controls decision in elimination. Guidance for entomological monitoring and vector control decision in elimination is needed. This should include consideration for outbreak investigation, investigation of a malaria index house and cross border activities. Such guidance should describe consideration for entomological outbreak investigation, decision around deficiency in entomological surveillance methods and foci response including vector control. GMP-EVC and TEG (Sylvia Meek) will develop a concept note with statement of issues around the subject. Emerging interest in LSM and the way forward Recent interest in LSM for malaria control manifested in terms of huge political interest, investment in facilities to produce larvicides and large scale trial evaluation (e.g. Burkina Faso larviciding project) as well as potential for new tools (such acoustic sonar larval control). Through BGMF, there are plans to fund a pilot IVM project with aim to demonstrate role of integrated approach, including LSM, for malaria control. More important LSM is main intervention in urban areas in several countries. Renewed interest and investment will provide a good learning opportunity but there is also a concern on negative consequence if LSM is not implemented properly. TEG agree, in order to guide implementation of LSM it will require:  Strong message stressing the fact that LSM is useful but misusing it will have consequence. In the meantime there is a need to provide guidance on how to conduct larvae surveillance and evaluate LSM  Need to develop strategy to support countries and guide monitoring of vector interventions in general, and specifically LSM.  Interim statement and operational manual available but there is no clear guidance and where larval control should or should not be implemented. Countries need support to develop practical guidance for implementation and evaluation of LSM. AFRO is currently developing a regional vector surveillance framework with a detailed section on monitoring and evaluation of LSM. The main target of the framework is to build or strengthen the capacity and system required for informed planning and implementation, and regular monitoring and evaluation of vector control interventions including LSM, which has been given a special emphasis. The first draft is currently undergoing technical review. The revised version will be reviewed by VCTEG and provide recommendations on how to advocate for update and implementation, resource mobilisation for technical capacity/system strengthening and best approach to introduce this framework to the countries. Overall TEG agrees on a need to develop guidance a entomological surveillance for monitoring and evaluation of vector control. CONCLUSIONS AND RECOMMENDATIONS When can malaria control and elimination program safely reduce vector control efforts? A review of historical evidence and mathematic simulations based a number of scenarios were undertaken to determine the impact of deviations from universal coverage or ‘scale-back’ of malaria vector control. Preliminary results indicate that for the vast majority of scenarios, the probability of malaria resurgence is high. Those limited scenarios with low probability for resurgence included situations with low historic EIRs, low case importation rates, highly successful vector control Third meeting of the Vector Control Technical Expert Group (VCTEG) | 12 interventions and high case management and surveillance coverage – including entomological surveillance. Significant gains in malaria control have been achieved in the past decade. With this achievement in mind, countries and donors have been asking for guidance on the circumstances in which it may be appropriate to stop or scale back vector control in areas where malaria transmission have been successfully reduced. Based on this review, VCTEG drafted interim guidance with 3 recommendations on how to determine areas considered unsuitable for scale back of malaria vector control, while further guidance is under development on identification of areas where such scale back carries a low risk of resurgence. Draft recommendations to be finalized in consultation with TEG  In areas 3 with ongoing local malaria transmission (API of local cases ≥ 0.1 per 1,000 over the past three years), the scale back of vector control is not recommended. In such areas, scaling back is likely to result in resurgence and a return to pre-intervention levels of malaria parasite transmission and disease.  In areas where local malaria transmission has been reduced to an API of local cases < 0.1 per 1,000, the scaling back of vector control is not recommended unless key criteria are met. The decision to scale back therefore requires a careful assessment of local receptivity 4 and vulnerability, as well as the existence of comprehensive disease surveillance – including the capacity to track residual asymptomatic parasite carriers and the ability to respond rapidly to outbreaks.5  Countries with areas approaching interruption of malaria transmission should maintain vector control, as well as strengthening surveillance and health system capability. Such system strengthening is an essential pre-condition to any scale back of vector control and is an essential consideration in cost-benefit evaluations. GMP will further work on the revised version of these documents and finalise recommendations in consultation with VCTEG members. Deployment of pyrethroid + PBO LLINs: the evidence and Operation requirement A concept on the public health benefit of PBO nets in areas with substantive pyrethroid resistance with a view to develop operation guidance on where to deploy such nets was discussed. VCTEG recommend establishment of an ERG to review evidence of effectiveness of PBO nets in areas with substantive pyrethroid resistance. This work will include review of evidence based on entomological experimental hut trials, geographical distribution of metabolic resistance mechanisms and modelling with a view to develop operational guidance for deployment of PBO nets. It was agreed the ERG to be established will operate under the following TOR.  Review evidence that PBO LLINs can reduce malaria cases under specific scenarios of transmission and pyrethroid resistance. This review will involve the following: 3 The minimum size of an area is determined by availability of reliable disaggregated disease surveillance data and feasibility for decisions on vector control implementation. 4 For the purpose of these recommendations receptivity needs to be determined from local information on the situation before the scale up of vector control. This information may come in a variety of forms. In some cases there may be records of pre-vector control observation of entomological parameters, including entomological inoculation rate (EIR) or vectorial capacity. In many cases, however, the most relevant information about pre-control transmission will be derived from parasite prevalence including asymptomatic parasite carriers through active case detection and / or cross sectional population surveys using PCR and/or case incidence of locally contracted cases. Current measurements of these parameters combined with measures of the duration of deployment and coverage of malaria control interventions may also be helpful. 5 The risk of resurgence following the scale back of vector control is higher in contexts of relatively higher receptivity in the absence of vector control, higher rates of imported infections, lower surveillance coverage and lower coverage of effective case management. Third meeting of the Vector Control Technical Expert Group (VCTEG) | 13 o Data on wash resistance which determines bio-availability of pyrethroid and PBO following a number of washes. This is important because the residual effectiveness of PBO net will depend on bio-availability of pyrethroid and synergist. Wash resistance data is available for all LLIN products which have undergone WHOPES evaluation. o Data comparing pyrethroid pyrethroid + PBO LLINs with Pyrethroid only LLIN in experimental hut trial.  Define transmission and resistance scenarios under which PBO LLINs are predicted to be more cost effective alternative to conventional LLINS  Make recommendations on practical and informative measurements of insecticide resistance that will inform decisions on where to deploy PBO LLINs  Identify process for validating the predictions using data from ongoing epidemiological trials  Guidance on how to evaluate and monitor the impact/effectiveness of PBO LLINs under routine deployment with a view to inform revision of ongoing intervention.  Document lessons learnt from evidence review of PBO LLINs that will guide evaluations and targeting of future combination net products. The evidence review and further modelling work will be conducted by LSTM team, addressing main topics covered in the TOR for ERG provided above. Insecticide Resistance Response plan VCTEG agreed to two technical documents: 1) High level global IR response plan to focus on global coordination, advocacy for resource mobilization and capacity building: 2) Country / regional IR operation plan (IOP) linked with GPIRM which will provide practical requirement for implementation of IR management at country and regional level. The development of these documents will be guided by the following TORs. Proposed TOR for High level global IR response plan  Background on what has changed to include: a) Resistance situation at regional level, b) Testing methods, what is there and what is needed to assess the level of IR, c) Intervention options, what is there and what’s needed.  Implementers’ Guide to the Practical elements of GPIRM – practical guide for implementation of GPIRM technical recommendations  Situation and need analysis will include: a) Review obstacles in implementation of GPIRM & key issues (Pathway to market for new molecules, new formats – review of new structures & systems, Funding envelope - Procurement mechanisms – issues in intervention & product choice, Capacity needs & building, evidence gaps, Issues in country guidance); b) Identify, for each of those elements, what partners are and are not doing, identify gaps and functions that are necessary but not yet supported, and c) Roadmap for implementation of plan to mitigate impact of IR. Proposed TOR for Country/Regional IR response plan The following tasks will need to be conducted in order to develop country IR response plan:  Situation analysis which will involve consultation with GMP and regions as well as country consultation on needs with a view to info management (linked a meetings e.g. EMRO June, W Africa May/June),  Draft Table of Contents (2 days)  Developing guide (2 weeks plus 1 week feedback time) Third meeting of the Vector Control Technical Expert Group (VCTEG) | 14  Annexes on subregional settings (epidemiology, entomology, maps) (included above) This document will address the following issues and topics  Decision making on insecticide resistance plans as part of national strategies, to include template for national action plan highlighting technical support needs.  Planning and implementation of human capacity building including data management (training, job description, work environment, recruitment)  Allocation of resources  Entomological and resistance monitoring plans to cover a) Criteria for selection of sentinel sites, b) Minimum requirements of a sentinel site (e.g. materials), c) Requirements for central referral entomology laboratory, d) Vector surveillance – numbers of sites and frequency of data collection, e) Methodologies for insecticide resistance monitoring – e.g. bioassays, intensity assays and biochemical analysis  Collaboration to implement IRM which should include a) cross-border initiatives, b) intersectoral collaboration between MOH and key partners such as research institution, academic etc  Decision making process from results interpretation and action  Annexes with various tools needed to implement the plan Development of regional/country IR response plan will require candidates with field operational vector control experience, expertise in entomology, planning, health systems skills, programme management and interview skills. At least two candidates, a technical person and another from programme management, will be needed to develop this document. WHO-GMP will work on a feasibility plan in order to determine the way forward given the considerable resources and time required to develop such practical IRM guidance’s for member states. OTHER ORDERS OF BUSINESS Update on VCAG recommendation Upon review of evidence for the first in line Pyrethroid + PBO prototype product of this paradigm, VCAG made the following recommendations for consideration by MPAC.  Considers combination/mixture LLINs that are designed to have increased effectiveness in areas of high pyrethroid resistance be established as a new paradigm with potential public health value in the face of rising insecticide resistance. Based on VCAG update, MPAC made the following decision on a paradigm for tools for use in areas of high insecticide resistance:  Recognised and appreciate the work of VCAG, that in less than two years the group has reviewed 16 submissions of which 8 are considered new paradigms. This is a huge accomplishment despite the challenges on the burden of evidence needed, either entomological vs epidemiological outcome, for product efficacy evaluation. Endpoints for proof of paradigm, particularly consideration for entomological proxies with epidemiological outcome, needs to be resolved to speed up products to market.  Encourages innovation for new tools given the huge problem of insecticide resistance and residual transmission Third meeting of the Vector Control Technical Expert Group (VCTEG) | 15  Advises GMP to review additional data for an eventual guidance on the use of Pyrethroid + PBO LLINs. VCTEG recommendations on how various TEG and ERG committees converge to come up with unified strategic agreement.  Cross fertilization of different TEGs to address cross cutting issues such as use of MDA for malaria and vector control, prioritisation and targeting of interventions  Since there are only 4 TEGs then decisions on cross cutting issues should involve members from different TEGs.  Secretariat should track what goes to MPAC for policy advice and what goes to GMP for policy recommendation with a view to ensure vector control agenda is represented. Distinction of what goes to MPAC should be categorised on issues for information, update and or recommendations. Plans for next meetings ERG on PBO-LLINs to review evidence on pyrethroid + PBO combination nets in July 2015 and next VCTEG meeting expected in August 2015. Third meeting of the Vector Control Technical Expert Group (VCTEG) | 16 LIST OF PARTICIPANTS TECHNICAL EXPERTS GROUP Dr Chioma N. AMAJOH Director, Community Vision Initiative, Abuja, Nigeria Dr Pierre CARNEVALE Directeur de Recherches C.E., Portiragnes, France Dr John CHIMUMBWA International Malaria Consultant, Lusaka, Zambia Professor Maureen COETZEE Director, Wits Research Institute for Malaria, University of Witwatersrand Johannesburg, South Africa Professor Marc COOSEMANS Head, Entomology and Vector Control, Prince Leopold Institute of Tropical Medicine Antwerp, Belgium Dr Josiane D. ETANG Senior Lecturer, Organization de Coordination pour la Lutte Contre les Endémies en Afrique Centrale (OCEAC), Yaoundé, Cameroun Dr Patricia GRAVES * Senior Principal Research Fellow, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Cairns, Australia Dr Jeffrey HII Senior Vector Control Specialist Malaria Consortium (Regional Asia), Bangkok, Thailand Dr Christian LENGELER* Professor of Epidemiology, Swiss Tropical and Public Health Institute Basel, Switzerland Dr Jonathan LINES Reader in Vector Biology and Malaria Control, London School of Hygiene and Tropical Medicine, London, United Kingdom Dr Sylvia MEEK Programme Director, Malaria Consortium, London, United Kingdom Dr Martha L. QUINONES Profesor Asociado DE Grupo de Investigación en Entomología, Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional de Colombia Bogotà, Colombia Dr Melanie RENSHAW (Chair VCTEG) Chief Technical Advisor ALMA, Nairobi, Kenya Dr Mark ROWLAND Professor in Medical Entomology and Malaria London School of Hygiene and Tropical Medicine, Department of Disease Control London, United Kingdom Dr Sharma Rajander SINGH Director of Entomology, National Vector-Borne Disease Control Programme Haryana, New Delhi, India Dr Robert WIRTZ * Chief, Entomology Unit Centers for Disease Control and Prevention, Atlanta, USA Dr Joshua YUKICH Research Assistant Professor, Tulane University, School of Public Health, Department of Global Health Systems and Development, New Orleans, USA TEMPORARY ADVISERS Dr Immo KLEINSCHMIDT Professor, London School of Hygiene and Tropical Medicine, London, United Kingdom Dr Nakul CHITNIS Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland Third meeting of the Vector Control Technical Expert Group (VCTEG) | 1 Dr Hmooda KAFY IVM Department Manager & Deputy Manager of NMCP / FMOH Khartoum, Sudan Dr Hilary RANSON Liverpool School of Tropical Medicine, Liverpool, United Kingdom OBSERVERS Dr Jan KOLACZINSKI Technical Advisor, Malaria: Global Fund to Fight AIDS, Tuberculosis and Malaria Geneva, Switzerland Dr Mike REDDY Gates Fellow/Programme Officer, Malaria Global Health Programme, Bill and Melinda Gates Foundation, Seattle, USA Dr Christen FORNADEL Entomologist/Senior Malaria Vector Control Specialist, President’s Malaria Initiative USAID, USA Dr Angus SPIERS Malaria Adviser, President’s Malaria Initiative, USAID, USA WHO SECRETARIAT Dr Pedro ALONSO Director, Global Malaria Programme, WHO Geneva Dr Birkinesh AMENESHEWA Scientist, Protection of the Human Environment, WHO AFRO Dr Florence FOUQUE Leader, Vectors Environment and Society Unit, Special Programme for Research and Training in Tropical Diseases, WHO Geneva Dr Stephane HOYER Medical Officer, Vector Control Unit, Global Malaria Programme, WHO Geneva Dr Tessa KNOX Technical Officer, Vector Control Unit, Global Malaria Programme, WHO Geneva Dr Abraham MNZAVA Coordinator, Vector Control Unit, Global Malaria Programme, WHO Geneva Dr Emmanuel TEMU# Consultant, Vector Control Unit, Global Malaria Programme, WHO Geneva Dr Raman VELAYUDHAN Scientist Control of Neglected Tropical Diseases, Vector Ecology and Management Unit, WHO Geneva Dr Rajpal S. YADAV Scientist-in-Charge WHO Pesticide Evaluation Scheme, Vector Ecology and Management Department of Control of Neglected Tropical Diseases WHO Geneva * Unable to attend # Rapporteur AGENDA Meeting Objectives  Review and establish whether current guidance and ongoing work on LLIN durability are adequate to inform procurement decisions  Discuss and provide input on community preferences on LLINs size, shape and colour and how these could be used to guide procurement decisions  Review potential perceptions on the effectiveness of IRS compared to LLINs with the view of developing an advocacy document  Discuss the scope and content of the guideline for vector control  Review and finalize test procedures for monitoring insecticide resistance to include key data essential for managing insecticide resistance with new vector control tools  Review and provide input on a monitoring and evaluation guidance to support countries to deploy PBO nets Outcomes/deliverables 1. Update on the current status of LLIN durability efforts and identification of next steps 2. Guidance document on procurement of LLINs updated to reflect the latest information on durability and community preferences 3. Test procedures for monitoring insecticide resistance updated 4. An advocacy/communication document on the perceptions on the effectiveness of IRS and LLINs developed 5. Guidance document on standardized methods for monitoring and evaluating deployed PBO nets WEDNESDAY 22 JUNE 2016 08:30 – 09:00 Registration GMP 09:00 – 09:10 Opening remarks and welcome 09:15 - 09:30 Declaration of Conflict of Interests 09:30 – 09:45 Objectives and expected outcomes 09:45 – 10:05 Coffee /Tea Break 10:05 – 11:20 Testing and monitoring the physical durability of LLIN: A review of current guidance and ongoing work Albert Kilian / Kate Kolaczinski 11:20 – 13:00 Discussions 13:00 – 14:00 Lunch Break Third meeting of the Vector Control Technical Expert Group (VCTEG) | 1 14:00 – 14:20 LLIN preferences (size, shape and colour) and how they influence procurement decisions Hannah Koenker 14:20 – 15:30 Discussions 15:30 – 16:00 Coffee/Tea Break 16:00 – 16:20 Potential perceptions on the effectiveness of IRS compared to LLINs Helen Prytherch 16:20 – 17:30 Discussions 18:00 Cocktail THURSDAY 23 JUNE 2016 08:30 – 10:15 Discussions 10:15 – 10:30 Coffee/Tea Break 10:30 – 12:00 Update on test procedures for monitoring insecticide resistance Maureen Coetzee /Basil Brooke 12:00 – 13:00 Discussions 13:00 – 14:00 Lunch break 14:00 – 15:00 Discussions 15:00 – 16:00 Monitoring and evaluation guidance to support countries in deploying PBO nets: Monitoring framework and mapping tool Mike Lynch / Joshua Yukich 16:00 – 16:20 Coffee/Tea break 16:20 – 17:30 Discussions FRIDAY 24 JUNE 2016 08:30 – 10:15 Discussions 10:15 – 10.30 Coffee/Tea Break 10:30 – 11:30 Guideline for vector control 11:30 – 13:00 Discussions 13:00 – 14:00 Lunch Break 14:00 – 15:40 Discussions 15:40 – 16:00 Coffee/Tea Break 16:00 – 17:00 Areas for further guidance, conclusions and general recommendations 17:00 Closure of the meeting