WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIF.IC BUREAU RtGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirtieth session Singapore 2-8 Qctober 1979 Provisional agenda item 22
WPR/RC30/20 27 July 1979 ORIGINAL: ENGLISH
STATUS OF THE ANTIMALARIA PROGRAMME 1.
THE MALARIA SITUATION AND PROGRAMME SUPPORT
There was little change in the overall epidemiological situation. While some programmes progressed satisfactorily. others showed no marked progress, and a few showed some deterioration. In most countries or areas the antimalaria programme continued to receive considerable support from the national authorities. In a few, however. the budgetary outlay for controlling malaria remained. or slipped, below the level commensurate with the importance of the disease as a deterrent to health and socioeconomic development. In those countries the introduction of meaningful antimalaria measures was restricted and essential field operations became increasingly more difficult to maintain. 1.1 Australia
A trend, starting in 1977, towards a substantial increase in the number of imported cases continued into 1978. Papua New Guinea being the major source of importation. However, no indigenous infections were reported. About half the P. falciparum infections show reduced sensitivity to chloroquine. It is proposed that a field research station be established to strengthen vigilance activities on the highly receptive and vulnerable Torres Strait islands. The training component of such a station would be of particular value to students from South-West Pacific countries or areas. 1.2 Brunei
Malaria vigilance as a routine function of the general health services continues. The malaria-free status was maintained during 1977 -1978.
WPR/RC30/20 page 2 1.3 people's Republic of China
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In China, malaria has been brought uttder control in BOst areas where it was once endemic, and in some it has actually been eradicated. Determination on the part of the Government, entailing the coordinated support of the departments of health, agriculture, forestry, water conservation, education, industry and others, together with effective organization at the central and peripheral levels and the full participation of the population obtained through appropriate health education, appears to have been instrumental in achieving the present level of control. . There is, however, need for additional research, particularly in relation to the radical treatment of P. vivax infections, and to alternative measures for controlling the major vectors, including A. sinensis and A. ba1abacensis. Two scientists have been awarded WHO fellowships to study the continuous in vitro cultivation of P. fa1ciparum. In early 1979 a visit was paid to China by WHO staff members concerned with malaria and with the Special Programme for Research and Training in Tropical Diseases, to discuss further ,cooperation in the field of malaria research. 1. 4
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Hong Kong
Among the 85 cases detected during 1977 and 1978 the majority proved to be imported. Four were classified as induced, including one case of congenital malaria in 1978, and one, which occurred in late September 1977 in the New Territories, as indigenous (P. vivax). This was the only indigenous case confirmed since 1968; and should perhaps have been classified as introduced. Routine vector control measures in densely populated areas continue. 1.5 Japan
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With international travel becoming steadily more popular, the incidence of imported cases of malaria, particularly among returning residents, has increased in recent years. Some introduced cases have been recorded, although the exact mode of transmission remains obscure. Some fatalities have been experienced, due to delays in diagnosis and/or treatment. Radical cure is complicated by the fact that some antimalarial drugs are not readily available. 1.6 Macao
Preventive larviciding and house spraying operations at 6-month intervals continue in border areas, together with routine entomological observation for the possible breeding of anophelines. The situation remains well under control.
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1.7 Lao people's Democratic Republic
WPR/RC30/20 page 3
Some progress has been made with the antima1ariaprogramme, despite considerable operational and administrative impediment. With UNDP and WHO cooperation, the DDT spraying campaign in Vientlat:te province, interrupted in 1976, was resumed. Since 1976, overall malaria incidence has declined steadily. Sixty antimalaria technicians were trained during 1977 and 1978 for posting to provinces throughout the country. Chloroquine-resistant P. falciparum was confirmed in vivo in Vientiane, a high degree of resistance being manifested in some cases. Administration of combined sulfadoxine/pyrimethamine appeared to be effective for the treatment of chloroquine resistant falcipanim. The central malaria unit needs to be further strengthened and developed in order to carry out additional studies, including the in vitro assessment of chloroquine resistance. 1.8 Malaysia
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Considerable progress was made with the antimalaria programme in Peninsular Malaysia. At the end of 1978, 68.5% of the population was living in consolidation/pre-maintenance phase areas, and a substantial increase is expected in 1979 in the number entering the consolidation phase. The malaria problem among the security forces was largely resolved in 1977, through modification of the prophylactic regimen. Difficulties associated with land development schemes continued but several special teams, planned to deal with the problem, became operational during 1978 and results so far have been encouraging. Recruitment of suitable field staff to man the teams proved difficult due to administrative impediments. In Sabah the deterioration in the malaria situation which had continued since 1974, finally halted in 1978. Although in several areas it is still far from satisfactory, the incidence in the Interior Residency showed a 25-50% reduction compared to 1977. Strengthened supervision and management and increased cooperation from the public, supported by a change over from DDT wettable powder to emulsion, led to markedly improved field operations and coverage. It is antiCipated that additional short-term mass drug administration of a su1fadoxine/ pyrimethamine/primaquine combination, started in late 1978, will further improve the epidemiological situation. In vivo and in vitro assessment of the response of P. falciparum to chloroquine confirmed widespread chloroquine resistance. In Sarawak the gradual decline in malaria incidence reached 1133 cases in 1977, that is an annual parasite incidence (API) of 0.94 per thousand. The trend was not sustained in 1978 owing to an outbreak of partly chloroquine-resistant P. falciparum among the semi-nomadic Punans during the early part of the year and the growing number of
WPR/RC30/20 page 4 imported cases which caused some secondary transmission. As a result, there were 1548 cases in 1978, an API of 1.24 per thousand. The situation appeared to be under control towards the end of 1978. Overall prospects for the success of the programme, assisted by ever improving coordination in carrying out operations along the border with Indonesia ,and :,·in Sabah, where the gre&~ majorioy, of caaes occur, are good. 1.9 New Hebrides
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Following a trial in Malekula in which village san!tarians were actively involved in house spraying operations, active community participation in the antima1aria programme was introduced in all sprayed areas in 1978. Des.pite some technical imperfections because the spraymen did not receive adequate instruction, the approach resulted in improved acceptance and coverage. The new approach will permit a further expansion of operations in Central District II. United Kingdom Overseas Development aid became available for expansion of operations into the Southern District. Increased attention was paid to the possibility of instituting simple source reduction and larviciding operations. Shortage of manpower at the intermediate level, together with limitations in the inter-island transport system, remain major impediments to the further improvement and expansion of field operations. 1.10 Papua New Guinea
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Following critical review and assessment of the programme, a sub-committee of the national health planning committee developed a plan for reorientation of the programme strategy for the next fiveyear plan period. The strategy was formulated as a confirmation and consolidation of trends which became visible during 1978, and allows for greater flexibility, increased involvement of the general health services and the other services engaged in rural development, active community participation, applied field research inte) .technical problems, and relevant training activities. There was no appreciable change in the malaria situation in 1977 and 1978. Introduction of antilarva1 operations in urban and semi-urban areas progressed. WHO cooperated in developing a plan for carrying out those operations and in the training of personnel. Transfer of the malaria training centre from Yagaum and its integration into the College of Allied Health Sciences, Madang was completed. Following decentralization of the malaria programme in 1978, orientation seminars were conducted for provincial health officers and provincial health extension officers. Chloroquine resistance was confirmed in vitro in the Kiunga area. Western Province. While cases tested in Madang proved to be chloroquine sensitive, a resistant strain was found near the Sepik border.
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WPR/RC30/20 page 5
1.11
Philippines
At the end of 1978, of the total population of 14.4 million living in originally malarious areas, 6.0 million (421.) were living in areas virtually cleared of the disease, 2.5 million (171.) in areas where the disease had ceased to be a public health problem, and 5.9 million (411.) in areas where malaria still persisted and various ant!malaria operations were being carried out. Trials towards a functional integration of the malaria service into the general health services, started in 1975, have'now been extended to five provinces. With the cooperation of WHO, progress was reviewed in late 1978, and it was decided to extend integration, in 1979, to the pre-maintenance areas of other provinces. A trial similar to that in the Northern province of Papua New Guinea is planned for northern Pa1awan, Philippines and external resources are being sought. While gains could generally be preserved, and progress was made in involving the rural health services in the programme, particularly in areas where the disease had ceased to be endemic, the annual incidence of malaria has shown a gradual increase since the early 1970s. The inaccessibility of some operational areas, chloroquine resistance and administrative difficulties remain major constraints. 1.12 Singapore
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There were 184 cases of malaria (including 3 deaths) in 1977, comprising 174 imported, 9 introduced and one cryptic case. In 1978 there were 166 cases of which 159 were classified as imported and 7 as introduced. As the cases were detected early and focal remedial measures instituted without delay, it was possible to prevent any indigenous cases. 1.13 Solomon Islands
Despite efforts in 1977 to stem the imminent epidemic, the situation deteriorated further in 1978. The progranune was faced with~. serious technical, operational and administrative problems which might . require reexamination of strategies and possibly changed approaches. The manpower situation remained precarious. Decentralization, introduced in late 1976, resolved some of the transport problems, but did not improve operational performance or public cooperation. 1,
WHO cooperated in the implementation of emergency measures in 1978 and in a feasibility study for the introduction of more permanent control measures through water management in northern Guadalcanal in 1979. Additional support, made available by United Kingdom Overseas Development aid, should improve the situation in the near future. 1.14 Viet Nam
In the northern part of the country, where malaria incidence is limited to small foci, 3.9 million people remain under the protection of yearly DDT spraying. The annual parasite incidence showed a further
WPR/RC30/20 page 6 decline from 0.33 per thousand in 1977 to 0.30 per thousand in 1978. Particular attention is being paid to further strengthening surveUlance. In the southern part of the country six-monthly DDT spray cycles covered 6.5 million people by early 1979, compared to 4 million in 1977. Chemoprophylaxis and chemotherapy were made available to an additional 4 million people. During 1978 the malaria manpower situation showed considerable improvement. Additional persorine1, DDT and antimalarials will be required for further expansion of operations in the Southern provinces. 2. DEVELOPMENT OF THE RURAL HEALTH SERVICES ~
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In Papua New Guinea, involvement of the general health services in the antimalaria programme was actively pursued. With WHO cooperation, orientation seminars and workshops on malaria and the antimalaria programme were conducted for provincial health officers and provincial health extension officers. Malaria was also included, a~ appropriate, in newly developed curricula for the training of various categories of health personnel. Similar orientation seminars for general health services staff became an annual feature in Malaysia. The functional integration of the malaria and the general health services, undertaken in five provinces of the Philippines, was reviewed in November 1978 by an assessment team which included a WHO staff member. It was found that, although support from the malaria service remained indispensable for the present, in order to preserve the gains achieved, particularly in the more receptive areas, the malaria vigilance carried out in areas where the restructured health care delivery system had become fully operational had been succesful. Further development and expansion of the integrated services to other low endemicity areas was recommended. 3. ALTERNATIVE APPROACHES IN THE CONTROL OF MALARIA
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Alternative approaches within antimalaria programme operations were introduced in the South-West Pacific area. In New Hebrides, decentra lization of spraying operations, with active participation of the community, was introduced in 1978. In Papua New Guinea, a special project for urban and semi-urban vector control commenced. At the same time, areas to be covered by DDT spraying were redefined and, with WHO cooperation, a trial was initiated in Northern province on the application of antimalaria measures, including DDT indoor spraying by the members of the community themselves.
WPR/IlC30/20 pase, 7 As supplementary measures, 1arviciding and mass drug administration were introduced in the area where there is a persistent focus in northern Guada1canal, Solomon Islands. With WHO cooperation, a further trial will start in late 1979 in which DDT will be replaced by fenitrothion. 4. INTERCOUNTRY COOPERATION
Several programmes continued to enjoy external cooperation in support of antimalaria field operations. Besides the cooperation extended to the programmes in Papua New Guinea and Solomon Islands, UNDP contributed substantially to the programme in Lao People's Democratic Republic. UNICEF also participated in the latter programme. The Government of the United Kingdom increased its support to Solomon Islands for the implementation of supplementary measures in northern Guadalcanal. Similar support given by the Government of the United Kingdom to New Hebrides permitted the extension of operations into the Southern district. The Government of Australia continued its indirect support to the programme in Papua New Guinea. The Governments of several countries, including Malaysia, Malta, Netherlands, Republic of Korea, Switzerland and USSR provided commodity support to the programme in Viet Nam. A visiting UNDP/ESCAP mission recommended support for the establishment of an intercountry malaria training centre for senior technical personnel of the South-West Pacific area. The College for Allied Health Sciences in Madang, Papua New Guinea is considered a suitable location for such a centre. A joint mission of the Government of India, UNIDO and WHO visited Viet Nam in November 1978 to discuss technical details relating to the establishment of a DDT production and formulating plant, together with possible- sources and funding. 5.
WHO TECHNICAL COOPERATION WITH THE REGIONAL PROGRAMME General
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In 1978, in order to use limited WHO technical resources to the best advantage, cooperation through long-term staff was withdrawn from the antima1aria programmes in Malaysia and Philippines, where sufficient national technical expertise exists. At the same time, a regional antimalaria team was created, based in Kuala Lumpur with staff representing the basic disciplines of epidemiology, entomology, parasitology and sanitation. The team provides technical cooperation as required particularly to the antimalaria programmes in Malaysia, Philippines and the South-West Pacific. During 1978 a member of the team was stationed temporarily in Honiara, Solomon Islands to relieve the precarious national malaria manpower situation there. Apart from providing technical cooperation to individual programmes in Malaysia, New Hebrides, Papua New Guinea, Philippines and Solomon Islands, members of the Team cooperated in regional and national malaria training programmes and in the promotion of applied field research.
WPR/RC30/20 page 8 To support applied research activities on malaria and other tropical diseases, an intercountry post of epidemiologist was created in 1979, under the Special Programme for Research and Training in Tropical Diseases. 5.2 Training
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A combined course in parasitology, entomology and epidemiology for senior technical personnel was organized in September/October 1977 at the Malaria Eradication Service building in Manila. A regional course on the epidemiology and control of malaria for professional staff was conducted at the Public Health Institute, Kuaia Lumpur in September 1978. In September 1979 a regional workshop for directors of the antimalaria programme will be organized; the regional programme will be reviewed and areas identified where alternative approaches might be used and additional collaborative studies or technical problems initiated. At the same time, it is hoped further to promote collaboration in the coordination of antimalaria operations along common borders, particularly with a view to reducing the vulnerability of areas in the consolidation or maintenance phase. The Indonesia.Malaysia-Singapore border meeting held in Singapore in October 1978 contributed significantly to that endeavour. In 1978 a Joint WHO/USAID Task Force on the Malaria Training Programme for Asia gathered preliminary information for the establishment of an interregional malaria·training programme for Asia. The programme is aimed at developing the urgently needed manpower for control activities in malarious countries in Asia. The programme, which may become operational in late 1979 or early 1980, will involve the functional development of major training institutions. 5.3 Research
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Basic research activities have been undertaken with support from the Special Programme for Research and Training in Tropical Diseases, Individual research grants have been provided to workers from institutes in the Region with particular attention being paid to the promotion of studies on resistance to malaria drugs, as recommended by the Western Pacific Advisory Committee on Medical Research. At a workshop held in Manila in mid-1978 with the support of the Special Programme for Research and Training in Tropical Diseases, the problem of drug resistance was reviewed in depth and regional collaborative studies were developed. As a related development, an agreement was signed between the Special Programme for Research and Training in Tropical Diseases and the Government of the Philippines to initiate, in Manila, the production of in vitro test kLts for global use. In Sabah, WHO cooperated in training technicians in the technique. It was also introduced in Papua New Guinea. A study in the South-West Pacific on the A. punctulatus complex, of which A. farauti is 8 member. was initiated in Papua New Guinea.
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WPR/aC30/20 page 9
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RECOMMENDlTIONS
Progress in national antimalaria progra~es is intimately related to the provision of adequate and sustained government support. External resources enabled a number of governments to mai~tain effective degr.ees of control, thereby enhancing overall socioeconomic development in rural areas. Development of the manpower required at the higher echelons of the antimalaria organization must continue, as mustt~e orientation with regard to malaria of staff and personnel of the general health services, in particular those involved in rural health activities. Alternative operational approaches for attaining improved coverage in the remote rural areas, including active community participation in the application of antimalaria measures, deserve to be tested. Development of the health infrastructure at the periphery, should be considered,tegether ,with ·the."'.~lection of alternative methods for malaria control which might provide superior cost-benefit ratios when adapted to local circumstances. • Applied field research should be pursued. Apart from studies on a1 ternative operational approaches such research should includ,e further studies on multi-drug resistant strains of P. falciparum, on the effectiveness of alternative drugs or combinations of drugs, and on the vectors which are difficult to control by DDT house spraying, in particular A. balabacensis and A. farauti.
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