SEA/RC61/11 - Responding to emerging and re-emerging vector-borne diseases

REGIONAL COMMITTEE Sixty-first Session SEARO, New Delhi 8–11 September 2008

Provisional Agenda item 13 SEA/RC61/11 28 July 2008

RESPONDING TO EMERGING AND RE-EMERGING VECTOR-BORNE DISEASES

The paper outlines the growing burden of emerging and re-emerging vector-borne diseases in the South-East Asia (SEA) Region. To prevent the emergence of new vector-borne diseases and re-emergence of those already under control, it is essential to strengthen national vector control programmes. Regional guidelines and activities have been put in place to bring together measures to combat vector-borne diseases such as malaria, lymphatic filariasis, leishmaniasis, dengue, Japanese encephalitis and chikungunya, etc. Most Member countries of the SEA Region have appropriate surveillance systems for vector-borne diseases including monitoring of drug resistance in the case of malaria and kala-azar. However, given their epidemiological profile, prevention and control of all vector-borne diseases should be addressed comprehensively under an effective national programme. WHO has developed a regional integrated vector control strategy. Global climate changes, emerging drug resistance and development of paediatric dengue vaccine etc. are the main challenges of the future. WHO is playing a pivotal role in capacity building, advocacy, partnerships and operational research. This paper was submitted to the Meeting of the Advisory Committee (ACM) held in the Regional Office, New Delhi from 30 June–3 July 2008. The ACM made the following recommendations:

Action by Member States (1) To accelerate the development and implementation of national vector-borne disease control programmes that are consistent with the regional strategy for vector-borne disease control; To promote intersectoral collaboration and coordination with other ministries, such as environment, education, tourism, rural development and agriculture for the implementation of vector-borne disease control programmes; To enhance intercountry cooperation through multicountry activities (MCAs) to establish and strengthen linkages between researchers and academic institutions; To strengthen internal and cross-border surveillance to assess the burden of vector-borne diseases;

(2)

(3) (4)

(5) (6) (7) (8) (9)

To scale up effective interventions to prevent emergence of drug-resistant malaria in Member countries; To implement kala-azar and lymphatic filariasis elimination programmes to achieve the regional target; To incorporate Japanese encephalitis immunization programmes into the Expanded Programme on Immunization (EPI), where appropriate; To implement and monitor an effective integrated vector management programme; and To explore the use of global funds available for malaria for a collective response to other vector-borne diseases.

Action by WHO/SEARO (1) To provide educational training, technical support and advocacy for the mobilization of additional financial resources for strengthening the vector-borne disease control programme; To collaborate with the Regional Office for the Western Pacific in implementation of the strategic plan for the prevention and control of dengue in the Asia-Pacific region; To provide technical support to accelerate development of vaccine; paediatric dengue

(2)

(3) (4)

To support Member countries in assessing the disease burden and transmission pattern through disease and vector surveillance, including drug-resistance monitoring; To strengthen intersectoral collaboration between Member countries and stakeholders to share information concerning prevention and control of vectorborne diseases; To support Member countries in establishing pharmacovigilance for kala-azar and malaria; To promote operational research as a key priority in the area of vector-borne disease management; and To develop a regional strategic plan and guidelines for the management of chikungunya.

(5)

(6) (7) (8)

The paper is now submitted to the Sixty-first Session of the Regional Committee for its consideration.

Contents Page Introduction ................................................................................................................................ 1 The growing burden of vector-borne diseases in the SEA Region.................................................. 1 Strategies and responses .............................................................................................................. 4 Monitoring of drug resistance .......................................................................................................................6 Implementing integrated vector management ...............................................................................................7 Collaboration and partnership ......................................................................................................................7

Challenges and opportunities ahead ............................................................................................ 7 Low coverage and timely intervention...........................................................................................................7 Inadequate human resources and weak management ...................................................................................7 Emerging drug resistance ..............................................................................................................................8 Dengue vaccine ...........................................................................................................................................8 Climate change ............................................................................................................................................8 Community participation..............................................................................................................................9

Role of WHO .............................................................................................................................. 9 Issues for consideration at the national level ................................................................................ 9 Issues for consideration at the regional level .............................................................................. 10 Issues for consideration in the case of specific vector-borne diseases ........................................ 10 Conclusion ................................................................................................................................ 11 References ................................................................................................................................. 11

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Introduction 1. In the South-East Asia (SEA) Region of the World Health Organization, several vector-borne diseases, especially malaria, dengue/ dengue haemorrhagic fever, lymphatic filariasis, visceral leishmaniasis (kala-azar), Japanese encephalitis, plague, rodent-borne viruses and arboviruses pose serious threats to human health with considerable health and economic impact. Considerable attention has recently been drawn at a global level to the serious threat to humans by the new, emerging and re-emerging vector-borne infectious diseases. The SEA Region is burdened with diverse vector-borne human diseases. 2. The Region has experienced a gradual increase in outbreaks of dengue, malaria and other vector-borne diseases. These diseases are closely associated with climatic conditions, although response patterns vary between diseases. In areas with limited or deteriorating public health infrastructure, and where temperatures now or in the future are conducive for disease transmission, an increase in temperatures (along with adequate rainfall) will trigger certain vector-borne diseases (including malaria, dengue and leishmaniasis). The strong correlation between precipitation and malaria and between temperature and dengue, documented in different studies in the Region, suggests that these and other diseases may be more prevalent in the Region as a result of global warming and climate change. Higher temperatures, in combination with conducive patterns of rainfall and surface water, will prolong transmission seasons in some endemic locations. In other locations, climate change may decrease transmission via reductions in rainfall or temperatures. In all such situations, the actual health impacts of changes in potential vector-borne diseases transmission will be strongly determined by the effectiveness of the public health system. Deforestation, poor water management, migration and lifestyle changes are other important factors that are related to vector-borne disease transmission. WHO will continue to extend support to Member countries to strengthen their vector-borne disease control and elimination programmes that will culminate in the achievement of the Millennium Development Goals related to vector-borne disease control and elimination targets through implementation of a comprehensive regional strategy.

The growing burden of vector-borne diseases in the SEA Region 3. An estimated 1394 million people, or 84% of the total population of the SEA Region, are at risk of malaria. Malaria is endemic in all Member countries of the Region except Maldives. The burden of malaria in Asia equals 38% of the number of clinical cases in the world. On an estimate, more than 100 000 deaths are reported every year in the SEA Region. The reported number of deaths due to malaria had reduced by approximately 50% in 2005 as compared to that in 19951. Post 1998 Plasmodium falciparum cases had increased continuously over the years, which is mainly due to the spread of drug resistance of this species (Figure 1). There have been recent reports from the region of the Thailand-Cambodian border on the emergence of “tolerant” P falciparum to artemisinin-based combination therapy (ACT) which is the most efficacious. This implies enhanced threat of malaria to the Region and globally requires urgent action to contain the spread of this particular strain of parasite.

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Figure 1: Malaria: Trends in number of reported cases and proportion of P. falciparum in WHO SEA Region, 1981–2006 4500 4000

60.0

50.0 3500

Number of cases in thousands

3000 2500

40.0 Pf proportions

30.0 2000 1500 1000

20.0

10.0 500 0

0.0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Years

Number of cases in 1000

Pf proportions

Source: Country reports

4. Dengue continues to pose a major public health problem in Member countries of the SEA Region. Among an estimated 2.5 billion people at risk of dengue globally, about 1.8 billion (more than 70%) reside in the countries of the Asia-Pacific region. During the last five years more than 200 000 cases were reported every year. New outbreaks have been reported at an interval of every three to four years, showing an increasing trend. The case fatality rates in the region vary from 0.5% to 2.6 % which is recording an overall decline as a result of improved case management (Figure 2). The main factors for the recent re-emergence of dengue in the Region are related to the increased vector population attributed to urbanization, travel, migration, climatic change and unsatisfactory water management at the household and community level. 5. The epidemiological pattern and geographical distribution of Japanese Encephalitis (JE) has been changing throughout Asia. This has been possible through control efforts that integrate human vaccination, water management, immunization of amplifying animals, systematized piggery, and community awareness programmes. On the other hand, the incidence of JE has shown an increasing trend in India, Nepal, Sri Lanka and Thailand. Epidemics peak every three to five years. In the SEA Region JE cases in endemic areas have been reported throughout the year though epidemics occur only immediately after the rainy season, with 90% of cases reported between mid-July and October.

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Figure 2: Dengue: Trends in reported number of cases and case fatality rate in countries of the SEA REgion, 1985–2007 300 3

250

2.5

Number of cases in thousands

200

2 Case fatality rate %

150

1.5

100

1

50

0.5

0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

0

Years Number of cases Case fatality rate

Source: Country report

6. Chikungunya fever is re-emerging in previously unaffected areas with possibly changing epidemiology and severity of the disease. Chikungunya tends to cluster geographically and overlap with Dengue because they share also some common features. This disease has not been included in the ambit of routine communicable disease surveillance in most Member countries of the South-East Asia Region. There were major outbreaks reported in India, Sri Lanka and Maldives recently and the disease has been frequently reported as an outbreak phenomenon in different parts of India and other countries. Regional Strategy for Prevention and Control of Chikungunya has been developed. 7. Kala-azar, a re-emerging disease both globally and in the SEA Region, continues to be a public health concern in three countries-Bangladesh, India and Nepal. Cases of Visceral leishmaniasis (VL) have also been identified recently in Bhutan. More than 200 million people are at risk of VL in the SEA Region. Approximately 25 000 to 40 000 cases and 200-300 deaths are reported every year, but these are believed to be grossly underestimated (Figure 3). Recent multicentric studies identified the VL burden to be 21 cases per10 000 among the sampled population of Bangladesh, India and Nepal. The study estimated figure is 420 000 VL cases2. The factors responsible for the upsurge of VL include poor socioeconomic status, malnutrition and insufficient spraying of insecticide in affected areas that lead to vector proliferation.

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Figure 3: Kala-azar: Trends in reported cases and case fatality rate in endemic countries of the SEA Region (2001–2007) 45 40 35 Number of cases in thousand 1 30 25 20 15 0.4 10 5 0 2001 2002 2003 2004 2005 2006 2007

1.4

1.2

0.8

0.6

0.2

0 Bangladesh India Nepal Case fatality rate

Source: Country report

8. Lymphatic filariasis (LF) is one of the major public health problems in the South-East Asia Region. Nine out of 11 countries in the Region are known to be endemic for filariasis. It is estimated that there are about 700 million people living in endemic areas, 64% of the global population is at risk and 60 million people are either harbouring microfilaraemia or suffering from clinical manifestations which constitute about half of the global figure3. India alone has been estimated to lose US$ 1 billion per year on account of LF4.

Strategies and responses 9. A substantial progress has been made in achieving the vector-borne diseases control and elimination targets for South-East Asia through the implementation of the regional strategy and strategic framework and plan for different vector-borne diseases. The Regional Office recognized the urgency to revise the Malaria Control Strategy 2006-2010. The revised strategy for the SEA Region, 2006-2010 was disseminated and shared with Member countries, development partners and donors accordingly in several forums5. Member countries are revising their national strategic plan accordingly and incorporating the Regional Revised Strategy for implementation. The AsiaPacific Strategic Plan for the Prevention and Control of Dengue (2008-2015) has been

Case fatality rate %

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developed in collaboration with the Western Pacific Region. In addition, the Asia Pacific Dengue Partnership (APDP) has been established to undertake advocacy and resource mobilization to support implementation of national and regional operational plans6. 10. The Regional Strategic Framework for Kala-azar Elimination from the South-East Asia Region (2005-2015) has been developed7. Its goal is to improve the health status of vulnerable groups and at-risk populations in kala-azar endemic areas of Bangladesh, India and Nepal by reducing the annual incidence of disease to less than one per 10 000 population at the district or sub-district level (upazila in Bangladesh, Tehsil (Sub-district) in India and district in Nepal) by 2015. The strategies proposed by WHO to achieve the goal of LF elimination have two components: interruption of transmission of filarial infection in all endemic countries through reduction of the microfilariae prevalence levels by Mass Drug Administration (MDA) through diethylcarbamazine [DEC] and albednazole and prevention and alleviation of disability and suffering in individuals already affected by LF7. Sri Lanka and Thailand have made significant progress with five rounds of MDA and other Member countries are progressing with the MDA of the two drugs. Coverage; however, needs to be strengthened further. 11. The proposed strategic elements for control of vector-borne diseases are healthy public policy in developmental projects and implementing a multisectoral approach. The emphasis is on ecological, environmental and behavioural determinants that contribute to disease transmission. Reforms aimed at programme planning and management (including monitoring and evaluation), striking a balance between treatment and control interventions, and scaling up the coverage of preventive and treatment services are essential. Vector-borne disease control supportive strategies include advocacy for mobilization of additional resources, programme planning and management, information exchange, human resources development, behavioral change communication (BCC) and development of a monitoring and evaluation framework to track the progress of programme implementation. 12. WHO provided technical support to Member countries in advocacy for dengue, VL, malaria, JE and LF control in the SEA Region at the political level and to partners in the communities. The Member countries are committed to achieve the MDG targets by 2015. The enhanced visibility of emerging and re-emerging vector-borne disease control and application of strategies would require sustained high-level political commitment. 13. A resolution on the Revised Malaria Control Strategy was passed by the Regional Committee for SE Asia at its Sixtieth Session in Thimphu in 20075. Since this resolution, the WHO SEA Regional Office has been assisting Member States in implementing the Revised Malaria Control Strategy and providing technical support to strengthen national capacity in monitoring and evaluation in Bangladesh, Bhutan, Nepal, and Sri Lanka. 14. Based on the successes of immunization for JE in the Member countries, a carefully planned programme for control of JE has been developed and attempts are in progress to incorporate JE vaccine into the Expanded Programme on Immunization (EPI) Surveillance and response systems have been included as an integral part of the programme. Case management of JE has been improved and the sequilae and mortality from the disease has been reduced.

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15. A WHO mission to India’s Bihar state consisting of international and national experts reviewed the progress and identified the technical and operational challenges. Major gaps identified included the completion of treatment and information, education and communication (IEC) activities. Training guidelines and standard operating procedures have been developed and Member counties are using the same for the implementation of the programme. The procurement of drugs (Miltefosine); RDT (rk39 dipsticks); Deltamethrin (in Bangladesh), DDT (in India) and Lambda-cyhalothrin (in Nepal) has been completed. The community is suitably informed about the availability of drugs for the prevention and treatment of kala azar. Service packages available at different levels, of the health system according to the norms for the level and health facilities at different levels have the capacity to deliver effective services. Incentives regarding clients’ food, loss of compensation and housing are in place in India, and policy advocacy has been set in motion in Bangladesh and Nepal. WHO is providing technical support for all the activities, including adopting training of trainers curricula; conducting training; procuring drugs and diagnostics; updating training manuals; conducting Miltefosine Phase IV trials (in Bangladesh) and adopting integrated vector management strategies and plan. 16. To support the control and elimination of the vector-borne disease initiatives, a series of national and multicentric studies in the areas of diagnosis, case detection, treatment and vector control are in implementation with the support of the Global Fund, World Bank and other funding sources. The gaps are being identified for policy and effective implementation of interventions. The experts in the Regional Office have also developed research priorities in the area of vector-borne diseases. The following implementation research areas have been identified: (1) (2) (3) (4) (5) Identify the barriers to access care for patients and vulnerable groups (socio-economic, knowledge, cultural, gender issues, topographical). The scale-up proposal on “Towards More Cost-effective VL Case Detection and Case Management in Endemic Districts”. Explore different types of DOTS (including home-based DOTS). Efficacy and costs of alternative methods for VL active case finding. Usefulness, feasibility and cost of vector control monitoring in kala-azar endemic districts.

Monitoring of drug resistance 17. Drug resistance in both P. vivax and P. falciparum malaria has been reported in many Member countries. As multi-drug resistant P. falciparum has spread in these, almost all Member countries where P. falciparum is prevalent have revised their national treatment guidelines and adopted artemisinin-based combination therapy (ACT) in line with WHO recommendations. As part of the bi-regional collaboration between the Western Pacific and South-East Asian Region, drug resistance monitoring in sentinel sites and networking continues to be strengthened and Myanmar and Thailand have been included from the SEA Region. 18. Recently miltefosine has been introduced in Member countries as a first-line drug for the treatment of kala-azar. Pharmacovigilance guidelines have been developed to monitor VL drug use and its resistance.

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Implementing integrated vector management 19. A step-by-step approach to a regional framework for implementing integrated vector management (IVM) at the district level in the South-East Asia region was developed recently. It addresses the appropriateness of deploying an optimum mix of interventions. This framework will guide Member countries in selectively applying the various vector control tools available based on the epidemiological situation, vector bionomics and its behaviour, and the sociobehavioural characteristics of the community.

Collaboration and partnership 20. Partnership interest and engagement for the control of malaria, dengue and JE and for the elimination of VL and LF has been increasing since effective interventions and tools are available. International collaboration and partnerships are likely to influence the political commitment and help the mobilization of resources. The partners are the World Bank, Global Fund and the Bill and Melinda Gates Foundation. The Asia-Pacific Strategic Plan for the Prevention and Control of Dengue (2008-2015) has been developed to facilitate the development of national operational plans and undertake advocacy for resource mobilization. The APDP has been established in collaboration with the Western Pacific Region to assist Member countries to mobilize resources to support the implementation of the strategic plan.

Challenges and opportunities ahead Low coverage and timely intervention 21. For the control of vector-borne diseases reported coverage of insecticide-treated nets and extent of indoor spraying by the population-at-risk is low (10-20%). Though during past couple of years some progress has been made in improving the coverage of ITNs, the current degree of coverage is not likely to have a significant impact on arresting vector-borne disease transmission transmission. The reported LF drug coverage and consumption rate of MDA in many countries is low. High coverage of MDA is very crucial to achieve elimination of LF. There has been progress in improving the timeliness, completeness and quality of data for reporting and sharing the information within and among Member countries and WHO.

Inadequate human resources and weak management 22. Vector-borne disease control programmes in most Member countries are grappling with problems of inadequate trained personnel, weak programme management and insufficient financial resources. Programmatic innovation with well-designed plans, effective surveillance, and a competent monitoring and supervision system are needs that must be urgently addressed for better prevention and control of vector-borne diseases.

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Emerging drug resistance 23. The problem of multi-drug resistant P. falciparum is expanding geographically and countries of South-East Asia and the Mekong Basin are the new epicentres of such resistance. The nature of threat of P. vivax malaria has been largely ignored since the disease is non-fatal though disabling. Focal outbreaks of malaria are frequently reported in almost all the countries reflecting the unstable nature of malaria transmission in the region and inadequate epidemic preparedness of the control programme. For kala-azar, monitoring of the SAG drug resistance, found to be spreading from Bihar to other parts of the continent is inadequate. It has been recommended that this drug is going to be discontinued in the kala-azar elimination programme .The overlapping of the VL and HIV has lead to an emergence of the new entity leishmania HIV coinfection that is likely to worsen the problem of drug resistance.

Dengue vaccine 24. The development process of live attenuated tetravalent dengue vaccine by Mahidol University of Thailand was renewed a few years ago. These new sets of vaccine are called Mahidol set II. All dengue virus strains selected for using in attenuation attempts were recent dengue viruses isolated from patients within 4-10 years. After completion of preclinical evaluation, candidate dengue vaccines for DEN-1, DEN-2, DEN-3 and DEN-4 were selected. Mahidol University intends to scale up all the DEN vaccines at industrial scale using certified continuous Vero cells. Mahidol University and Thailand Center of Excellence for Life Sciences (TCELS) have committed to build a GMP vaccine pilot plant. Clinical batches of each monovalent dengue vaccine for phase I and II clinical trials will be prepared at this GMP plant in 2009. There are several key issues and challenges on pediatric dengue vaccine development which include affordability, availability, quality and competitiveness that must be considered. Technical, economic and political commitments are also important areas to carry forward WHO endeavours in this initiative.

Climate change 25. Global warming and climate change have taken malaria, dengue and other vector- borne diseases to new areas. Climatic factors, particularly temperature and rainfall, affect the ability of malaria parasites, viral propagation and potential mosquito vectors to coexist long enough to maintain and increase the rate of transmission. The suppression of Aedes aegypti using practical methods; strengthening of linkages between research and academic institutions; addressing issues related to unplanned poor housing, unsatisfactory living conditions, under-nutrition, migration and resettlement; organization of integrated vector management (IVM), behavioral change communication strategies; and implementation of targeted interventions along with improvement and implementation of community-based-vector-borne disease control programmes are other important challenges. Most of the vector-borne diseases are ecological diseases. Efforts, therefore, need to be made to adopt a community development approach and move beyond the realm of health.

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Community participation 26. The control of vector-borne diseases is generally undertaken by disposal of potential Aedes aegypti breeding sources and containers, and use of insecticide treated nets and insecticide, and environmental management. These benefit not only those who practice these control measures but others in the community as well. A broader perspective of the disease control strategy is required for a holistic interaction between economic and political factors with the social environment to enhance community participation and promote vector-control strategies. A high motivational level in the community along with sustained and continuous collaboration among community members and stakeholders will hasten the rate of success.

Role of WHO 27. WHO takes a lead role in response to vector-borne diseases and is strongly committed to work with national vector-borne diseases control/elimination/eradication programmes through the scaling up of different public health interventions. The role of WHO includes: •

Capacity building: WHO assists in strengthening health systems that support implementation of different control, elimination and eradication programmes on emerging and re-emerging vector-borne diseases. These include human resource development; service delivery; strategic information; and procurement and supply management. The training modules and standard operating procedures have been developed and intercountry, intracountry and local-level training courses have been conducted in the different areas of vector- borne disease. Advocacy and resource mobilization: WHO works with international development agencies and with the private sector and donors to advocate for evidence-based policies and mobilizing resources to support the implementation of national programmes. Programme review, surveillance, monitoring/evaluation and strategic planning: WHO supports national vector-borne disease control programme review, surveillance, monitoring and evaluation. This information helps in developing national strategic plans in the Member countries. Partnerships: It is critical to enhance the role of various sectors such as education, public works, tourism, industry, the private sector and nongovernmental organizations. WHO plays a leading role to ensure active participation of intersectoral partners in the prevention and control of vector- borne diseases. Research: Operational/implementation research on disease transmission, epidemiology, vector management, treatment as well as socio-economic and behavioural aspects of the disease is urgently needed. The results of such studies can be used to formulate revisions in policies and strategies.

•

•

•

•

Issues for consideration at the national level •

The development and implementation of national vector-borne control programmes that are consistent with the regional strategy for Vector-Borne Disease Control and that emphasize the improvement of the health system capacity including human resources.

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•

Optimum coordination with ministries such as environment, education, tourism, rural development and agriculture in the implementation of vector-borne disease control programmes as a part of the corpus of healthy public policies. The control of vector-borne diseases through multi-country activities (MCAs) within the gamut of cross border collaboration. Strengthening surveillance to assess the burden of vector-borne diseases. Advocacy for vector-borne diseases in national and international forums. Establishing and strengthening linkages between researchers and academic institutions. Effective implementation of an integrated vector control plan which has been developed.

• • • • •

Issues for consideration at the regional level • •

Provision of technical support and advocacy for the mobilization of additional financial resources to strengthen the vector-borne disease control programme. Promotion and implementation of evidence-based policies, standard tools for the improvement of the programme, and sharing useful information and country experiences with Member States. Collaboration among stakeholders–who include governments, development partners, NGOs, donors, academia and other relevant parties–to address the issues and challenges in preventing and controlling vector-borne diseases. Promoting and developing operational/implemention research as one of the priorities in the area of vector-borne disease control and to advocating complimentarity of research and programme implementation.

•

•

Issues for consideration in the case of specific vector-borne diseases • • •

Endorsement of the Asia-Pacific Strategic Plan for Dengue 2008-2015 and recommendations to Member countries for its implementation. Provision of technical support to facilitate and accelerate pediatric vaccine development. Incorporation of JE immunization programme into the Expanded Programme on Immunization in disease-endemic areas along with an active inbuilt surveillance and response system. Implementation of kala-azar and LF elimination programmes to achieve the global target. Development of a regional strategic plan and guidelines for the management of chikungunya.

• •

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Conclusion 28. Vector-borne diseases are re-emerging in the WHO South-East Asia Region due to a number of natural and man-made factors. Many of these diseases, particularly dengue, japanese encephalitis and malaria are now occurring in epidemic form and causing considerable morbidity and mortality. Dengue is spreading rapidly in newer areas and with more frequent outbreaks. It requires collaboration between Member countries in the Asia-Pacific to implement the Bi-regional Strategic Plan through Asia-Pacific Dengue Partnerships. Chikungunya has reemerged in most Member countries of the SEA Region and also needs a strategic plan for its control which could be implemented together with Dengue Prevention and Control Strategy. VL and LF pose a much higher burden and are a cause for public health concern. While the morbidity for most of the vector-borne diseases has increased during the period, the case fatality rate have been reduced. To prevent the emergence of new vector-borne diseases and the reemergence of those already under control, it is essential to have high political commitment, multisectoral collaboration and community participation. Though the health sector will continue to remain central to disease control activities, containment of VBD requires active support and commitment from many active partners to avert the factors that promote and facilitate the breeding of vectors, and the effective implementation of an integrated vector control plan that has been developed. The discovery and development of new dengue vaccine candidates needs to be accelerated in coordination with Member States. For JE a carefully planned immunization programme needs to be further incorporated into the Expanded Programme on Immunization in disease-endemic areas along with an active inbuilt surveillance and response system.

References 1. 2. 3. 4. 5. 6. 7. Kumar A, Valecha N, Jain T, Dash AP. Burden of malaria in India: retrospective and prospective view. Am J Trop Med Hyg. 2007 Dec;77(6 Suppl):69-78. A Joshi, J.P. Narain, C. Prasittisuk, R. Bhatia, Ghalib Hashim, Alvar Jorge, M. Banjara and A. Kroeger. Can visceral leishmaniasis be eliminated from Asia? J Vector-borne Dis 45, June 2008, pp. 105–111. WHO/SEARO. Burden of lymphatic filariasis in South-East Asia region. April, 2006. Ramaiah KD, Das PK, Michael E and Guyatt HL (2000). The economic burden of lymphatic filariasis in India. Parasitol Today. 16: 251-253. Resolution SEA/RC60/R6: Revised Malaria Control Strategy: focusing on a new paradigm Bi-regional Strategic Plan for the prevention and control of Dengue in Asia Pacific (2008-2015), SEARO/WPRO 2007. Regional strategic framework for elimination of kala-azar from SEA Region (2005–2015), World Health Organization, Regional Office for South-East Asia, New Delhi, SEA-VBC-85 (Rev.1) August 2005 . WHO/SEARO. Implementation status of ELF in the South-East Asia Region. Presentation at the 4th meeting of SEA, Pattaya, Thailand, July 2007. Country report and SEARO Website

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REGIONAL COMMITTEE Sixty-first Session SEARO, New Delhi 8–11 September 2008

Provisional Agenda item 13 SEA/RC61/11 Inf.Doc. 18 August 2008

ASIA-PACIFIC DENGUE STRATEGIC PLAN (2008-2015) The Asia-Pacific Dengue Strategic Plan (2008-2015) has been prepared by the WHO Regional Offices for South-East Asia and the Western Pacific to respond to the increasing threat from dengue, which is spreading to new geographical areas in Member countries of the South-East Asia and the Western Pacific regions. The development of this strategic plan is important to meet the requirements of the International Health Regulations (IHR) 2005. The goal is to reverse the rising trend of dengue in Member countries of both regions. The strategic plan has been developed through consultation with programme managers during the biregional Dengue Programme Managers, meetings held in Phuket, Thailand in September 2007 and Singapore in May 2008. It will be used as guidelines for the development of national strategic plans by Member countries of both regions.

Contents Page Executive summary ..................................................................................................................................................1 Introduction................................................................................................................................................................2 Guiding principles....................................................................................................................................................2 Constraints, opportunities and lessons learnt...............................................................................................3 Rationale for the strategy on prevention and control of dengue fever/DHF....................................4 Regional goal, vision, mission and objectives ...............................................................................................5 Objectives ..................................................................................................................................................................................................... 5 General objective ....................................................................................................................................................................................... 5 Specific objectives...................................................................................................................................................................................... 5

Components of the strategy................................................................................................................................6 Supportive strategies..............................................................................................................................................6 Mobilization of resources........................................................................................................................................................................ 6 Partnerships ................................................................................................................................................................................................. 7 Programme planning and management ........................................................................................................................................... 7 Monitoring and evaluation..................................................................................................................................................................... 8

Implementation of the Strategic Plan ..............................................................................................................8

Annex – The Log Frame Dengue Strategic Plan ..........................................................................................9

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Executive summary The Asia-Pacific Dengue Strategic Plan (2008-2015) has been prepared in response to the increasing threat from dengue, which is spreading to new geographical areas and causing high mortality during the early phase of the outbreaks. Among an estimated 2.5 billion people at risk globally, about 1.8 billion (more than 70%) reside in the Asia-Pacific region. The development of this Strategic Plan is also important to meet the requirements of the International Health Regulations (IHR) 2005. The goal is to reverse the rising trend of dengue in countries of the Asia-Pacific region. Countries of the region vary in terms of their preparedness, their capacity to respond and in the allocation of financial resources in the prevention and control of dengue. The Strategic Plan provides generic recommendations to allow local adaptation of strategies. Dengue does not respect international boundaries. Effective dengue control is not possible if control efforts are limited to one country or a few. It requires the adoption of a regional approach through collaboration between countries and sustained partnerships to enable countries to implement evidence-based interventions and the use of best practices. The Asia-Pacific Strategic Plan would assist countries to enhance their preparedness; enable them to promptly detect, characterize and contain outbreaks; and limit epidemics of dengue for effective prevention and control. This plan should be implemented in harmony with the Strategic Framework for Asia-Pacific Partnership for Dengue Prevention and Control (APDP). The Strategic Plan should be used for elaborating national operational plans; to develop capacity and strengthen the health system; establish networking; harmonize itself with the APDP Strategic Framework for mobilization of resources and sustain ongoing information exchange; and be able to advocate for prevention and control of dengue. It would also assist in increasing access to innovations such as with tools for the diagnosis, prevention and treatment of dengue.

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Introduction 1. Dengue is the fastest emerging arborviral infection. The maximum burden is borne by countries of the Asia-Pacific region. Among an estimated 2.5 billion people at risk globally, about 1.8 billion (more than 70%) reside in countries of the Asia-Pacific region. Its epidemiology is evolving rapidly, with increased frequency of outbreaks and expansion to new geographical areas that were previously unaffected. The mortality is highest during the initial period of the outbreak/epidemic. 2. The progressive worsening of dengue in the Asia–Pacific region is attributed to unplanned urban development, poor water storage and unsatisfactory sanitary conditions. It is an integral part of urbanization because of the creation of breeding habitats. It is a domesticated species that breeds in artificial containers. The high population density of the vector increases the opportunities for transmission of dengue. 3. The occurrence of dengue in one country is a threat to other countries and the spread of dengue intensified due to proliferating trade and travel. Therefore, dengue cannot be controlled if efforts are limited to one country above. Hence, a strong case should be made for the adoption of a biregional approach for the control of dengue in the Asia-Pacific region. 4. The present dengue control programmes in the Asia-Pacific region have inadequate resources, and the capacity of the health system to respond is limited. However, several countries have had favourable experiences in Asia-Pacific and Latin American countries. Some of these include Singapore, Thailand, Malaysia and Cuba. There is clearly a need for development of new diagnostic, preventive and therapeutic tools although the interventions that are currently available are known to be effective for more than two decades. The available tools should be used wisely and widely since the cost of procrastination will be very high.

Guiding principles 5. The Strategic Plan underpins several guiding principles intended for the formulation, implementation and evaluation of activities in the prevention and control of dengue. •

The Strategic Plan supports collaboration, cooperation and biregional solidarity for effective and sustained prevention and control of dengue in countries of the AsiaPacific region. The Strategic Plan is designed that the prevention and control of dengue can be implemented using the existing policy framework of countries within the available infrastructure as an integral part of the programme for control of vector-borne

•

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diseases, and integrated disease surveillance within the umbrella of basic health services. •

It is proposed to support country activities through national, multi-country, biregional and global partnerships. This Strategic Plan will be harmonized with the Asia-Pacific Dengue Partnership. The Dengue Prevention and Control Programme will use evidence-based interventions and will be implemented by employing the best practices. Networking will be developed to optimize the use of available resources. The national programme will be designed to build on the achievements of Member countries. Intersectoral and interprogrammatic collaboration will be the thrust of the strategy to maximize the provision of integrated services. Linkages will be developed with the Asia-Pacific Surveillance for Emerging Diseases (APSED) to strengthen the health system for surveillance and to contribute to the implementation of the International Health Regulations (IHR). This would require finding a niche for interventions that would reverse or halt the rising trend of dengue. The Strategic Plan promotes the adoption of evidence-based interventions that are currently available. At the same time, the plan recognizes the need for the development of a vaccine, improved diagnostics and drugs for the prevention and treatment of dengue and other innovations.

• •

•

•

Constraints, opportunities and lessons learnt 6. Dengue is the fastest-growing arborvirus infection with a rapidly evolving epidemiology. It is listed among the 40 emerging diseases of global importance. The increasing burden of dengue in the Asia-Pacific region is a matter of serious concern since the disease is spreading to new geographical areas and the mortality rates are high in the early stages of the epidemic. 7. Dengue epidemics are an indication of the failure of the public health system to respond rapidly. Timely control of epidemics requires preparedness and capacity to undertake suitable and effective control activities during the inter-epidemic period. Resolution of an epidemic requires sustained high-level government commitment, strengthening of the public health infrastructure, intersectoral collaboration and community participation. 8. Until recently, the disease was predominantly urban. Consequently, dengue outbreaks receive considerable adverse publicity and coverage in the media (both in the case of real epidemics or rumours). This impacts negatively on tourism and industry and inflicts heavy economic losses to the country affected by the disease.

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9. Resources for dengue control programmes are inadequate. The biggest challenge in the prevention and control of dengue is to mobilize additional resources to be able to implement interventions that have been demonstrated to be effective for more than two decades. Currently the allocation of funds for larval control and source reduction through community participation is very low, though this approach has been proved to be effective. 10. There is no specific treatment for dengue/dengue haemorrhagic fever (DHF). Antiviral drugs currently available are not effective for their prevention or treatment. No vaccine exists for the prevention of dengue. Resources are required to enhance capacity, intensify research to develop vaccine and improve diagnostic tools as well as specific treatment. WHO and international partners should advocate the need for resources. 11. Dengue is an ecological disease. It requires multisectoral action for its prevention and control. Therefore, it must be everyone’s concern. Despite the worsening of the dengue situation, it has remained a neglected public health disease. 12. Although considerable progress has been made in source reduction with community and intersectoral partnerships and there are many instances of effective dengue prevention through community mobilization, these interventions have not been implemented widely for a perceptible national impact. Intercountry cooperation is required for a palpable impact in the Asia-Pacific region. 13. Evidence is available to prove that the case fatality rates can be reduced to less than 1% and even further if cases of DHF are admitted early and treated appropriately with standard treatment. This is possible when standard treatment is provided in large and small hospitals. This would require an increase in the capacity for standard case management of Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS).

Rationale for the strategy on prevention and control of dengue fever/DHF 14. The emergence of dengue, its rapidly evolving epidemiology and the economic losses resulting from the disease makes a compelling case for accelerating prevention and control efforts. The disease has attracted considerable media attention and received adverse publicity in recent years. Besides causing ill-health and excess mortality, it has also affected socioeconomic development due to loss of mandays and productivity. 15. The national programmes need to implement healthy public policy in development projects in urban and rural areas. Currently the national programmes have allocated meagre resources on dengue control; and a major part of the expense is incurred on insecticide sprays and chemical larviciding, which have had little impact on controlling the epidemic. In contrast, evidence shows that vector control through larval monitoring, source reduction

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and personal protection, combined with a good sanitary environment in households and communities has proven to be effective in preventing dengue. 16. Community participation and social mobilization for behaviour modification have begun to show good results in many different settings. Investing in this approach and in integrated vector management (IVM) will produce the desired results. 17. Dengue prevention and control should be everyone’s concern. The role of national policies is to strengthen the response to dengue within the health sector, facilitate intra programmatic collaboration and effectively mobilize intersectoral collaboration. 18. The strategy is aimed at utilizing optimally the currently available interventions based on evidence and, at the same time, advocating for intensification of research in the development of a suitable vaccine, antivirus drugs and appropriate diagnostics for dengue.

Regional goal, vision, mission and objectives 19. This Asia-Pacific Dengue Strategic Plan is part of the overall regional goal to reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems. 20. The vision of the Asia-Pacific Strategy for Dengue is to minimize the health, economic and social impact of the disease by reversing the rising trend of dengue. 21. The mission is to enhance the capacity in countries and the Region through partnerships so that evidence-based interventions can be applied in a sustainable manner through better planning, prediction and early detection, characterization and prompt control and containment of outbreaks and epidemics.

Objectives 22. The objectives, purpose and expected results are proposed in the Strategic Plan to enable countries to achieve the regional goal and realize the mission and vision of dengue prevention and control. Different countries will achieve these objectives and expected results in the context of their current capacities and policies.

General objective 23. To reduce incidence rates of dengue fever and dengue haemorrhagic fever.

Specific objectives (1) To increase the capacity of Member countries to monitor trends and reduce dengue transmission.

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(2) (3) (4)

To strengthen capacity to implement effective integrated vector management. To increase health workers’ capacity to diagnose and treat patients and improve health-seeking behaviour of communities. To promote collaboration among affected communities, national health agencies and major stakeholders to implement dengue programmes for behavioural change. To increase capacity to predict, detect early and respond to dengue outbreaks. To address programmatic issues and gaps that require new or improved tools for effective dengue prevention and control.

(5) (6)

24. For each objective, expected results, activities and key indicators have been identified using the logframe approach. This is included in the annexure.

Components of the strategy (1) (2) (3) (4) (5) (6) Dengue surveillance Integrated vector management Case management Social mobilization Outbreak response communication Research

Supportive strategies 25. Dengue outbreaks and epidemics are a reflection of the failure of the public health system in the country. Dengue is a disease that comes into focus during an epidemic and the interest on it as well as the commitment to combat it declines after the epidemic is brought under control. Many of the affected countries do not also have a national programme for its eradication. Its control requires a high level of sustained government and public commitment, strengthening of the public health infrastructure, intersectoral and intercountry collaboration and community mobilization. 26. A number of supportive strategies are needed for effective implementation of the Asia-Pacific Dengue Strategic Plan (2008-2015).

Mobilization of resources 27. Despite the growing threat of dengue, resources for the control of dengue have not increased. The magnitude of national and international support continues to fall far short of the needs. There are untapped resources at national, regional and global levels. To mobilize

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additional resources, synchronized action is needed with the support from partners and different stakeholders. The Asia-Pacific Dengue Partnership (APDP) can play an important role in advocacy and help in mobilization of required resources. To do this, it is necessary to synchronize the strategy with the APDP. Countries need to prepare operational plans that include the identification of funding gaps. An advocacy plan should be prepared and implemented for mobilizing the resources required on a sustained basis. Asia-Pacific Dengue Partnerships should be engaged in advocacy for mobilization of additional resources for the prevention and control of dengue. 28. Dengue control programmes in countries should be implemented as an integral part of the national policies. The dengue control programmes have to find a niche and visibility within the existing disease surveillance programmes, including the development of links with IHR and the vector-borne disease control programme. It has to be a part of basic health services and be able to find a place within the scope of decentralization policies in the national programme.

Partnerships 29. The Asia-Pacific Dengue Partnership (APDP) for Dengue Prevention and Control was formed in March 2006. A strategic framework has been prepared by a core group comprising national representatives and partners. It is proposed to harmonize the AsiaPacific Dengue Strategic Plan with the APDP. The Regional Strategic Plan recognizes that partnerships for the prevention and control of dengue are required to mobilize additional resources and enhance collaboration between countries. Sustained partnerships are crucial for showcasing the cause of dengue prevention and control through advocacy.

Programme planning and management 30. Effective programme management necessitates the preparation of an operational plan that identifies the resources committed and the resource gaps. The capacity of staff at different levels – national, subnational and district – in programme planning and management has to be increased. Human resource development is a key component of capacity development. The development of capacity for the prevention and control of dengue is not an isolated effort but an integral part of strengthening the entire health system for more effective control of vector-borne diseases, disease surveillance including IHR and the provisioning of basic health services. Capacity development is to be undertaken on the basis of training needs, the institutional environment and national policy. Since different countries in the Asia-Pacific region have different health systems and policies, the Dengue Prevention and Control Programme has to be consistent with the national situation. The Asia-Pacific Dengue Strategic Plan should be used by countries to evaluate the best options for use in their operational plans.

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31. Even within a decentralized or an integrated framework it is necessary to identify the specific needs of dengue prevention and control so that control measures have adequate visibility. These include increased laboratory capacity, standard case management of dengue and vector surveillance. Programme planning and management also include developing a system for procurement, logistics and effective supply management. The health management information system and revamped surveillance are crucial in the context of dengue control since the disease often strikes in the form of outbreaks and epidemics.

Monitoring and evaluation 32. A monitoring and evaluation framework is necessary to track the progress of implementation of the operational plan. Monitoring should be result-based and the framework should include outcome and output indicators that are easily quantifiable and can be verified. The indicators are included in the log frame (see annexure).

Implementation of the Strategic Plan 33. The Asia-Pacific Dengue Strategic Plan was discussed in the intercountry programme managers’ meeting held in September 2007 in Phuket, Thailand. In November 2007 the Regional Adviser from WPRO, Coordinator/CDC, SEARO, TDR fellow and a consultant refined the plan and the log frame while taking into consideration the deliberations during the meeting and the recommendations arising from the group work during the programme managers’ meeting. The revised strategy document will be shared with national programmes in countries of the SEA Region. The revised strategy will also be discussed at a programme managers’ meeting of countries of the Western Pacific Region of WHO before being approved by the Regional Committee for the Western Pacific in 2008. 34. A roadmap would be required for the implementation of the strategy. The first step after establishing a coordination mechanism will be to assist countries in preparing operational plans indicating the budgeted amounts and their source of funding, as well as the resource gaps. Political, technical and managerial expertise in countries would be mobilized for increasing the capacity to implement operational plans. To implement the Strategy it would be necessary to harness the expertise available in countries through collaboration and networking. Technical guidance should be provided by the Asia-Pacific Technical Advisory Group. Regular reviews of the programme will be conducted and efforts made to encourage research and innovation in the development of innovations in the development of diagnostics, drugs and vaccine for the prevention and control of dengue in the Asia-Pacific region.

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Annex

The Log Frame Dengue Strategic Plan Component I: Dengue surveillance Planning elements Regional goal To reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems Regional objective To reduce incidence rates of dengue fever and dengue haemorrhagic fever • The rising trend in dengue is to be stemmed between 20082010 in comparison with 20052007 • The regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • The regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Purpose To increase capacity of Member States to monitor trends and reduce dengue transmission • Number of Member States with surveillance system in place and reporting to WHO monthly • Number of Member States with national surveillance policy statements consistent with the new IHR commitments • Number of Member States with resource commitment in place for dengue programmebased on surveillance data • Number of Member States Member States’ monthly reports Political commitment Funds Interest and capacity of stakeholders to participate Impact of outbreak mitigated1 Dengue outbreak response report Regular WHO updates Political commitment Funds Human resources coordination and surveillance systems in place Indicators Verification source Assumptions and risks

National policy statements

National plans and budgets

Surveillance

1

Measured by morbidity and mortality rates, number of cases, geographical containment and duration of outbreak

SEA/RC61/11 Inf.Doc. Page 10 whose interventions are based on surveillance data. • Number of Member States able to report cases within 48 hours from health facility to programme level Planning elements Expected Results 1. Existing standard dengue case definition adopted • Number of Member States using the standard case definition based on WHO guidelines • Number of Member States where DF/DHF is made notifiable Policies on the use of standard case definition National Plans and standard operating procedures National Policy National legislation 2. Laboratory surveillance strengthened • Number of Member States with at least one laboratory able to serologically confirm dengue diagnosis, carry out serotyping and virus isolation procedures • Number of Member States with laboratories upgraded for improved surveillance (note: needs to be defined) • Number of Member States with reference laboratories providing quality control/ quality assurance services • Number of regional reference laboratories providing quality control/ quality assurance services • Number of Member States with laboratories participating in regional QC/QA networks • Number of integrated laboratory networks established in the Asia- Pacific region 3. Regional dengue information system developed • System in place and functioning with information on trends and updated situation analysis • Regional website operational Regional database Political commitment Human resources Data on website Timely availability of personnel assigned Human and financial External evaluation reports (from WHO and peer reviewers) Official acceptance of quality control mechanism Availability of sensitive tests Human and financial resources Policies are applied by Member States Indicators reports

Guidelines on outbreak response Verification source

Assumptions and risks

Cross-checking reports

Network reports

SEA/RC61/11 Inf.Doc. Page 11 resources 4. Mechanisms for sharing timely and accurate data strengthened • Number of Member States reporting validated information (i.e. data on case incidence and case fatality rate (CFR)) for working intervals (to be defined: monthly or weeks, or?) timely (to be defined) Note: different intervals may apply for case incidence and CFR • Shared information system in place • Number of Member States that sign agreement to provide data into a shared surveillance system • Number of Member States whose monthly data of the previous quarter is accessible from the regional website (dengue information system) 5. Regional/inter-country response to timely advisory and resource (personnel, financial, stockpiling) mobilization improved • Number of Member States that act upon advisory Intercountry high-level discussions for coordinated response to dengue situation within the framework of IHR • Number of Member countries reporting to WHO Regional Office and HQ as per IHR 6. Incorporate dengue surveillance (case, vector and seroprevalence) into an integrated and strengthened disease surveillance system 7. Monitoring Member States’ surveillance systems • Number of countries reporting dengue via the Integrated Diseases Surveillance Programme (IDSP) • Number of countries where dengue surveillance and vector surveillance are integrated • Number of countries subject to internal yearly monitoring and external monitoring every three years Advisories and reports on action taken Meeting reports Political commitment Funds Human resources Member States’ monthly reports and agreements Website and/or DengueNet signed agreement Political commitment (Member States’ willingness to share their data) Human resources User-friendly information system in place

Data on website

Country reports

Country reports Programme review (e.g. programme managers’ meetings, external reviews) Monitoring reports

Political commitment Funds Human resources

Political commitment Funds Human resources

Activities Expected Result 1:

Outputs

Responsible

Resources and time frame

Existing standard dengue (DF/DHF) case definition adopted and case fatality rate standardized 1.1 Circulate standard case definition to • Standard case definition Programme Funds (e.g. during regional programme

SEA/RC61/11 Inf.Doc. Page 12 Resources and time frame managers’ meetings) Quarter 4 of 2008 Starting 2009

Activities Member States 1.2 Add DF and DHF on notifiable diseases list

Outputs packaged and distributed • Legislation adopted: DF and DHF notifiable diseases in all member countries in the two regions • Standard CFR distributed and adopted

Responsible managers WHO MoH

1.3 Circulate standard case fatality rate criteria to Member States 1.4 Conduct internal discussions in countries to promote standard case definition 1.5 Organize consultation with Member States for consensus 1.6 Provide technical assistance for Member States to put in place the standard definition 1.7 Support training for personnel where necessary

Programme Manager WHO

Funds Quarter 4 of 2008

• Agreements and discussion proceedings

WHO surveillance authorities

Funds Documenter Quarter 1 of 2009

• Consensus reached during managers’ meeting Note: Meeting needs to take place during first quarter of 2009 • ToR and list of qualified consultants. • Appointment of consultant and dissemination of consultants’ report • Training results and reports

WHO Programme Managers WHO Member States

Funds Quarter 1 of 2009

Funds Expert Quarter 1 of 2009

WHO regional offices WHO country offices

Funds Experts Partners Quarters 2 to 4 of 2009

Expected Result 2: Laboratory surveillance strengthened 2.1 Develop evaluation criteria, assess/map out current status and identify gaps in existing laboratories Develop standards for all laboratories including quality assurance • Inventory of laboratories and testing available • Assessment results and reports Programme managers Laboratory managers WHO • Laboratory standards and quality assurance procedures produced and disseminated to Member States. • List of reference laboratories that meet standards 2.3 Integrate dengue • Laboratories at all levels have WPRO and SEARO Regional Reference Laboratory Political commitment Funds Experts Quarter 4 of 2008 to quarter 1 of 2009 Funds Experts Regional reference laboratory services Quarter four of 2008 to quarter 1 of 2009 MoH and related Funds for monitoring and

2.2

SEA/RC61/11 Inf.Doc. Page 13 Resources and time frame supervision Experts 2009 to 2015

Activities into existing national/regional laboratory network and ensure that the network is functional

Outputs dengue serological confirmation and or typing integrated into surveillance and routine reporting • Functional (coordination and communication) laboratory network in place • Performance reports from assessments • Plans for quality improvement

Responsible agencies WHO

2.4

Monitor laboratory performance once a year

Programme managers Laboratory managers WHO regional offices WHO country offices

Funds Human resources Experts 2009 to 2015

2.5

Set up one national reference laboratory for virus isolation and characterization or integrate into existing emerging/ remerging diseases reference laboratory Designate regional reference laboratory, at least one in each region and enhance country collaboration Enhance laboratory capacity through training and human resource development

• Reference laboratory in place with the capacity for virus isolation and characterization and seroprevalence

MoH WHO regional offices; WHO country offices Partners

Funds Human resources Experts 2010 +

2.6

• Regional reference laboratory, at least one in each region

WHO regional offices Partners

Funds Experts 2009

2.7

• Training courses for laboratory personnel conducted • Training guidelines developed

MoH National and Regional reference laboratories WHO Partners

Funds Experts 2009 to 2015

Expected Result 3: Regional dengue information system developed 3.1 Agree on a dengue information system and designate national focal points Produce and disseminate • System defined • Focal points available MoH WHO Political commitment Funds Quarter 1 of 2009 • Manual of Operation WHO Programme Funds for training Expert

3.2

SEA/RC61/11 Inf.Doc. Page 14 Resources and time frame Functional system Quarter 2 of 2009 3.3 Develop and pilottest the information system at different levels within the health sector Support training on information system • Functional system • Reports of Member States’ experiences during pilot test • Evaluation and enhancement of system • Training results and reports WHO Programme Managers WHO Programme Managers Funds for pilot test Expert Functional system Quarter 3 of 2009 to quarter 4 of 2010 Funds for training Expert Facilitator Functional system 2011 + 3.5 Implementation and use of the system. • Reports of Member States feeding/accessing data from the system • Sustained use of the information system verified through monitoring reports Programme Managers Human and financial resources 2011 + WHO Programme Managers Human resources and financial resources 2011 +

Activities guidelines.

Outputs

Responsible Managers

3.4

3.6

Monitor performance of the system and implement corrective action as needed

Expected Result 4: Mechanisms for sharing timely and accurate data strengthened 4.1 Conduct mapping exercise of existing mechanisms including information on how they function. Establish system for reporting timely (to be defined) and accurate data within countries, in the regions and between the two regions Support workshops to train on timely reporting of accurate data. • Inventory report of existing mechanisms for subnational, national and regional sharing of data. Programme managers WHO MoH Funds Human resources 2009

4.2

• Memorandum of Understanding between WHO and MoH • Reporting system in place • Focal person in each Member State and at the subnational level • Training results and report.

MoH WHO regional offices WHO country offices

Funds Expert 2009

4.3

MoH Officers in VBDCTS responsible for dengue data WHO

Funds for training Experts 2009 to 2010

SEA/RC61/11 Inf.Doc. Page 15 Resources and time frame Political commitment Funds Experts 2011 +

Activities 4.4 Conduct monitoring and assessments of the reporting system.

Outputs • Reports by programmes/reference laboratories to assess compliance with agreed-upon standards

Responsible Programme managers Reference laboratories

Expected Result 5: Regional/inter-country response to timely advisory and resource (personnel, financial, stockpiling) mobilization improved 5.1 Use the mechanisms established to exchange information within the IHR framework Conduct orientation and briefing of WHO WRs • Protocol for intercountry response • List of contact persons • Regular information-sharing between the two regions • Mission reports WHO regional offices WHO Country Offices Partners Political commitment (all levels) 2010

5.2

WHO regional offices WHO country offices

Funds 2009

5.3

Mobilize financial resources, personnel and stockpiles

• Funds, human resources available. • Stockpiles defined, purchased and maintained

WHO country offices WPRO and SEARO

Focal points at regional and country offices 2009 and on

Expected Result 6: Incorporate dengue surveillance (case, vector and seroprevalence) into an integrated and strengthened disease surveillance system 6.1 Identify strengths and weaknesses of existing national diseases surveillance systems through mapping and desk review Initiate activities to address weaknesses. • SWOT analysis MoH WHO Political commitment Funds Expert 2009

6.2

• Strengthened national diseases surveillance system.

MoH WHO

Political commitment Funds Expert 2010 +

6.3

Operationalize and integrate dengue surveillance with the national disease surveillance system in accordance with IHR

• Integrated surveillance plan/framework • Testing operationalization of integrated plan at all levels

MoH WHO

Political commitment Funds Experts 2010 +

SEA/RC61/11 Inf.Doc. Page 16 Resources and time frame Political commitment Funds Experts Ongoing

Activities 6.4 Enhance surveillance capacity through training and feedback

Outputs • Training programmes • Impact assessment of training programmes

Responsible MoH WHO Partners

Expected Result 7: Monitoring member state dengue surveillance systems 7.1 Conduct external situation analysis of existing surveillance systems Internal review of existing surveillance systems • Monitoring reports MoH WHO Political commitment Funds Expert Every three years starting in 2010 • Monitoring reports MoH Political commitment Funds Expert Yearly starting in 2010

7.2

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Component II: Integrated Vector Management Planning elements Regional goal To reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems Regional objective To reduce incidence rates of dengue fever and dengue haemorrhagic fever • The rising trend in dengue stemmed between 2008-2010 relative to 2005-2007 • Regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • Regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Impact of outbreak mitigated 2

Indicators

Verification source

Assumptions and risks

Regular WHO updates

Political commitment Funds Human Resources Coordination and surveillance systems in place

Dengue outbreak response report Purpose To strengthen the capacity to implement effective integrated vector management Expected Results 8. Vectors fully described and vector indicators regularly monitored. • Number of Member States monitoring and reporting • Reports of identified vector key containers/habits • Records of changes in vector populations • Number of Member States reporting reduced vector population 9. Regional IVM Strategy developed • Regional IVM Strategy produced and disseminated • Number of Member States Regional strategy National policy Political commitment Funds Political commitment Annual reports Vector surveillance reports Availability of qualified vector surveillance team Funds • Number of Member states with vector control policies implemented National Policy Statements Programme reports Political commitment Funds

10. Evidence-based 2

Measured by morbidity and mortality rates, number of cases, geographical containment, and duration of outbreak

SEA/RC61/11 Inf.Doc. Page 18 Assumptions and risks Funds Availability of qualified vector surveillance team

Planning elements strategies to control vector populations adopted according to IVM principles

Indicators that have adopted IVM strategy and guidelines as an integral component of their dengue national plan • Number of countries which have adopted healthy public policy • Number of Member States with regulatory mechanisms in place in relation to environment and pesticide management • Number of partners/sectors participating and contributing to vector control

Verification source statements

Regulatory mechanisms

Plans of key sectors/ agencies integrating vector control National plan with IVM component Implementation guidelines Training reports Political commitment of MoH and other sectors

11. Member State-level IVM strategy and guidelines developed consistent with regional strategy 12. Capacity to implement IVM including training and recruitment of entomologists strengthened

• Number of Member States with IVM implementation plan • Number of Member States adhering to the Regional IVM implementation guidelines • Number of Member States implementing IVM for control of dengue • Number of Member States with non-health-related staff trained on IVM • Number of Member States with trained entomologists supporting IVM activities • Number of Member States with trained personnel at national and subnational levels implementing IVM activities (i.e. changes in water management, changes in architectural design, environmental modification, solid waste management)

Political commitment Interest of agencies and public sector Staff motivation and incentives

Progress reports on national plan implementation

13. Mechanisms to facilitate community involvement for vector control established 3

• Number of Member States with organized communitybased groups planning and implementing vector control activities • Number of Member States with policies/guidelines on

Survey reports to identify groups

Staff motivation and incentives

14. Rational use of insecticides for vector 3

Reports from regulatory agencies

Political commitment

community involvement in vector control elaborated in Component IV: Social mobilization and communication for dengue.

SEA/RC61/11 Inf.Doc. Page 19 Assumptions and risks Local expertise

Planning elements control promoted

Indicators rationale use of insecticides based on WHOPES guideline for insecticides • Number of Member States that enforce guidelines

Verification source

Annual reports Monitoring results Funds Local Expertise

15. Vector resistance monitoring strengthened

• Number of Member States that have established a vector resistance monitoring system

SEA/RC61/11 Inf.Doc. Page 20 Activities Expected Result 8: Vectors fully described and vector indicators regularly monitored 8.1 Analyse and review current vector surveillance activities and availability of baseline data 8.2 Develop vector surveillance plan at national level (lower levels if needed) • Baseline data on vector distribution, ecology abundance and seasonal trends gathered for one year MoH WHO-collaborating centres (data to be gathered from other available sources if necessary) MOH with support of WHO Country focal point Funds Expert (Timeline by end 2009) Outputs Responsible Resources

• Vector surveillance plan to include:stratified areas at risk identified for intervention (district, provincial levels); frequency and coverage of surveys • Training needs assessment in terms of available resources and target groups • Training manual on vector surveillance disseminated • Training results and reports • Training of trainers and refresher courses to be considered

MoH commitment Funds Expert

8.3 Develop a training manual and guidelines on vector surveillance 8.4 Training on vector surveillance methods including data analysis and reporting Expected Result 9:

MoH WHO

Funds Expert

MoH WHO

Funds Experts

Regional IVM strategy developed 9.1 Develop guidelines for situation analysis and needs assessment on IVM 9.2 Conduct meetings with programme managers to finalize the regional IVM strategic plan 9.3 Establish IVM intersectoral task force to develop the national IVM strategy Expected Result 10: Evidence-based strategies to control vector populations adopted according to IVM principles 10.1 To organize workshops on GIS or basic mapping • Develop risk maps at appropriate levels MoH Funds Technical support (timeline 2009 -2010) • Guidelines developed and disseminated WHO regional office Funds Experts (2008-09) • Agreements recorded in minutes of meetings • Regional and national strategy • Financial proposal outlining needs for potential funding WHO regional office WHO country office MoH Partners Funds

SEA/RC61/11 Inf.Doc. Page 21 Activities methods 10.2 Develop vector control plan/ strategy based on mapping 10.3 Conduct periodic remapping (to be linked to periodic surveillance 8.1) 10.4 Carry out vector control trials/pilot test for evidencebased IVM approach at local levels • Vector control strategy developed based on risk mapping • Vector maps periodically updated MoH WHO Partners MoH WHO Partners MoH Research and collaborating centres in collaboration with other agencies (e.g. GEF/UNEP) Funds Expert Collaborating centres for vector control Funding for pilot Expert Funds Expert Outputs Responsible Resources

• Documented evidence-based strategies with appropriate indicators

Expected Result 11: Member State adopt or develop IVM strategy and guidelines consistent with regional strategy 11.1 Disseminate regional IVM strategy among programme staff 11.2 Conduct internal discussion and analysis within programmes to encourage adoption and integration into national plans 11.3 Identify and select IVM taskforce and draft strategy. 11.4 Obtain political support for strategy • National plans which incorporate IVM • Agreements recorded in minutes Programme Manager WHO regional office WHO country office Programme Manager WHO regional office WHO country office Funds Human resources (Timeline 2009) Funds Expert

• National IVM Strategy

MoH WHO Prime Minister or President’s office MoH Programme Manager Chair- National IVM Development Taskforce MoH WHO Partners

Funds Expert Effective advocacy like Melanesian Spearhead group; ASEAN heads of Government etc.

• Political commitment from national government

11.5 Mobilize intersectoral support for IVM

• Intersectoral collaboration (including public and private sector)

Effective advocacy among other sectors Funds

Expected Result 12: Capacity to implement IVM including training and recruitment of entomologists strengthened 12.1 To assess the national need for entomologists and regional training centres for • Entomologist need assessment • Regional training to address needs of countries MoH or Ministry of Environment Funds (timeline 2009-2010)

SEA/RC61/11 Inf.Doc. Page 22 Activities entomologists’ training 12.2 Mapping of entomologists or other qualified technical support at the regional level including vector control personnel) 12.3 Training of entomologists and vector control personnel on IVM • List of personnel working as entomologists and on vector control Programme managers Funds Expert Outputs Responsible Resources

• Entomologists and vector control personnel trained on IVM • Training results and reports • Integrated training to include entomology

WHO HQ WHO regional office WHO country office

Funds Expert

Expected Result 13: Mechanisms to facilitate community involvement for vector control established 13.1 Conduct assessment of Member States that have organized community-based groups Committee to be setup to provide Technical support on social mobilization 13.2 Disseminate and conduct advocacy based on results of assessment 13.3 Develop orientation modules on community involvement for VC 13.4 Conduct orientation among Member States on the developed modules Expected Result 14: Rationale use of insecticides for vector control promoted 14.1 Draft legal framework for • Develop draft legislation MoA, MoH, MoEnv Focal point on Intersectoral coordination • Assessment results and reports. • Inventory of available advocacy resources for community awareness in Member States • Taskforce set up. • Country could establish its own Task Force Programme Managers WHO Partners Urbani school kit MoH WHO Resources 4

Funds Expert (timeline 2009)

• Document/website/report on good practices • Advocacy of political leaders • Modules available for various target groups • Contents to be target group specific • Orientation workshop agendas and reports for community groups

WHO Programme managers

Political will Funds

WHO regional office WHO country office Partners Programme managers Community leaders Civil society

Funds Experts

Funds Expert

4

Community involvement in vector control elaborated in Component IV: Social mobilization and communication for dengue

SEA/RC61/11 Inf.Doc. Page 23 Activities judicious use of chemical insecticides. 14.2 Provide WHOPES guidelines on pesticide management to Member States • Recommendations during regional programme managers’ meeting • National policy on rational use of insecticides according to WHOPES guidelines • Member States’ guidelines adapted from WHOPES • Annual reporting of insecticide use Expected Result 15: Vector resistance monitoring strengthened To provide regional training on vector resistance monitoring 15.1 Identify monitoring sites for insecticide resistance and collect baseline data 15.2 Collection of data in monitoring sites at 2-3 year intervals • Regional training conducted WHO Funds Outputs Responsible Stockholm Convention etc. WHO MoH Political will Funds Resources

• Maps showing current levels of resistance to insecticides in use: species, insecticide, location

National VectorBorne Disease control Programme (VBDCP)

Political will. Funds for field collection, laboratory testing, compiling and reporting data Political will. Funds for field collection, laboratory testing, compiling and reporting data Funds Political will

• Updated maps showing recorded changes in effectiveness of insecticides

National VBDCP WHO

15.3 Use data to change national policy

• Change policy on purchase and use of insecticides based on results of resistance tests • New guidelines issued Training results and reports

MoH (Mo Environment) WHO Partners National VBDCP Regulatory procurement authorities WHO

15.4 Develop guidelines and train personnel on use of new insecticides

Funds for new guidelines and training

SEA/RC61/11 Inf.Doc. Page 24

Component III: Case management Planning elements Regional Goal To reduce the disease burden due to major parasitic and vectorborne diseases to such an extent that they are no longer major public health problems Regional objective To reduce incidence rates of dengue fever and dengue haemorrhagic fever • The rising trend in dengue stemmed between 2008-2010 relative to 2005-2007 • Regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • Regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Impact of outbreak mitigated5 Purpose To increase health workers’ capacity to diagnose and treat patients and improve health seeking behaviour of communities Expected Results 16. Public awareness increased on warning signs and actions to be taken for dengue 17. Strengthen capacity of health-care providers to diagnose, treat or refer cases 5 6

Indicators

Verification source

Assumptions and risks

Regular WHO updates

Political commitment Funds Human Resources Coordination and surveillance systems in place

Dengue outbreak response report

• Case Fatality Rate (CFR) • Number of patients who seek consultation in health facilities within 48 hours at onset of fever • As early notification as possible • Proportion of target population able to identify key warning symptoms and take appropriate action • Number of health facilities per country that have standard training guidelines • Number of Member States with health workers trained

Surveillance reports (day of illness at time of notification) Death records Community-based survey results 6

Political commitment Funds Definition of case and CFR standardized Deaths are properly recorded

Comparative analysis of KAP/COMBI survey results (pre- and post-) Follow-up/ observation/monitoring reports Health facility records

Funds Facilitators Willingness of communities Funds Facilitators Interest and willingness of health

Measured by morbidity and mortality rates, number of cases, geographical containment, and duration of outbreak.

Community-based surveys shall be conducted in conjunction with KAP surveys under Component IV: Social mobilization and communication for dengue.

SEA/RC61/11 Inf.Doc. Page 25 Planning elements Indicators on case management • Number of Member States with health workers who apply standard case management • Proportion of health facilities with at least one trained health professional • Number of Member countries that have a functional clinical management committee • Per cent of Member States’ health care facilities with reorganized services for patient care • Number of Member States with a functional blood bank 18. Laboratory support for case management improved • Number of health facilities/laboratories per Member States capable of performing laboratory clinical tests (i.e. CBC, at the very least a micro-haematocrit and microscope for platelet count) • Number of Member States with a functional patient referral system Survey of facilities Verification source Assumptions and risks facilities Cases are properly recorded

Standards for case management

Listing of available blood banks Health facility records Survey of facilities MoH records Laboratory records Funds Willingness of hospital authorities Available equipment Competent personnel MoH report External review Funds Expert

19. Referral network system in public and private sectors established

Activities Expected Result 16:

Outputs

Responsible

Resources

Public awareness increased on warning signs and actions to be taken for dengue. 16.1 Conduct KAP and investigate constraints to early health-care seeking 7

• KAP survey results

MoH

Political commitment Funds Human resources (Q1, 2009)

7

Knowledge, Attitude, Practices (KAP) Survey will be conducted in conjunction with Component IV: Social mobilization and communication for dengue

SEA/RC61/11 Inf.Doc. Page 26 Activities by the communities 16.2 Develop and implement COMBI approach 16.3 Assess the impact of COMBI strategy on behavioural change 16.4 Evaluation of sustainability of COMBI strategy Expected Result 17: Capacity of health professionals strengthened to diagnose, treat or refer cases 17.1 Set up a core group (clinical management committee) composed of public and private sector and other stakeholders 17.2 Conduct situation analysis – map capacity levels of public and private health professionals 17.3 Develop training programmes and guidelines for different target groups 17.4 Conduct training for various target groups, starting with priority areas 17.5 Monitor implementation of training and health care management capacity 17.6 Monitoring the management and 8 9

Outputs • Improvement in KAP as against baseline

Responsible COMBI resource group 8

Resources Funds Human resources (Q3, 2009-Q1, 2010) Funds Experts (six months after implementation) Funds Experts (12 months after implementation)

Partners • COMBI impact assessment COMBI Resource group • Monitoring and evaluation report 9

COMBI Resource group

• ToR and workplan: (Clinical Management Committee)

MoH WHO Partners

Funds Political commitment (ASAP, latest Q4, 2008)

• Assessment results and reports10

MoH WHO Clinical Management Committee Partners

Expert Funds (Q1, 2009)

• Training programmes, modules with guidelines and content areas

MoH WHO Clinical Management Committee MoH WHO Partners

Expert Funds (Q1, 2009)

• Training results and reports

Expert (Q2-4, 2009) Funds

• Monitoring reports showing extent to which targeted facilities adhere to guidelines • Targeted facilities with effective system in place • Case fatality rate

MoH WHO clinical management committee MoH Clinical Management

Experts Funds (Q3, 2010)

Funds (Continuous activity)

Refer to Component IV. ER1 Refer to Component IV. ER1 Assessment should include training gaps and other capacity needs such as medical supplies, and equipment, etc.

10

SEA/RC61/11 Inf.Doc. Page 27 Activities outcome of severe cases (DHF/DSS) 17.7 Conduct mortality review • Chart review • Clinical audit Outputs Responsible Committee WHO MoH Clinical Management Committee MoH Partners Experts Funds (Continuous activity) Funds Equipment Human Resources (Q1, 2009) Resources

17.7 Establish/Strengthen capacity at blood bank so these can respond to DHF/DSS Expected Result 18:

• A system in place capable of addressing adequately needs in complicated cases

Laboratory support for case management improved 18.1 Conduct situation analysis on clinical laboratory capacity including private sector 18.2 Strengthen capacities (supplies, infrastructure) 18.3 Capacity building – personnel – develop training modules • Situation analysis report with identified gaps on infrastructure, supplies and human resources • Laboratories are properly equipped • Training programmes and modules and content areas MoH Clinical Management Committee Partners MoH Public and private health laboratories. MoH Public and private health laboratories clinical management committee 18.4 Conduct training • Training results and reports MoH WHO Clinical Management Committee Public and private health laboratories 18.5 Monitor implementation of laboratory practices • Monitoring reports showing extent to which targeted facilities adhere to guidelines • Targeted facilities with effective system in place 18.6 Quality control of laboratory facilities (following national/WHO guidelines) • Checklist • Blind controls MoH WHO clinical management committee Public and private health laboratories MoH WHO Clinical Management Committee public and private health laboratories Funds Private sector Experts (Continuous, from Q1, 2010) Funds Private sector Experts (Q1, 2010) Funds Private sector Experts (Q3-4, 2009) Expert Funds Private sector (Q1, 2009) Funds Private sector Experts (Q3, 2009) Funds Private sector Experts (Q2, 2009)

Expected Result 19:

SEA/RC61/11 Inf.Doc. Page 28 Activities 19.1 Set up proper referral network mechanisms Outputs • Documented referral network system available • Impact assessments on CFR available 19.2 Make provisions for hotline consultation and communication • Functional hotline in place • Regular monitoring mechanisms of hotline • Impact assessments of hotline on CFR 19.3 Provision of adequate transport facilities of potentially complicated cases • Regular monitoring reports especially during outbreaks. • Impact assessments on CFR Responsible MoH Clinical Management Committee Partners MoH Clinical Management Committee Partners (Practitioners) WHO, MoH Clinical Management Committee Partners Resources Human resources Funds Private sector involvement (Q1, 2009) Human resources Funds Private sector involvement (Q1, 2009) Human resources Funds Private sector involvement (Q1, 2009)

Referral network system in public and private sectors established.

SEA/RC61/11 Inf.Doc. Page 29

Component IV: Social mobilization and communication Planning elements Regional goal To reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems Regional objective To reduce incidence rates of dengue fever and dengue haemorrhagic fever • The rising trend in dengue stemmed between 2008-2010, relative to 2005-2007 • Regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • Regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Impact of outbreak mitigated11 Purpose To promote collaboration among affected communities, national health agencies and major stakeholders to implement dengue programmes for behavioural change National Dengue Control Programme engaged in communitybased social mobilization and communication strategies aimed at changing behaviours towards dengue prevention and control • Resource group established and interacting with relevant agencies of dengue control programme • Assessment reports by Regional and national plans Political commitment Funds Interest and commitment of communities and other major stakeholders Regular WHO updates Political commitment Funds Human Resources Coordination and surveillance systems in place Indicators Verification source Assumptions and risks

Dengue outbreak response report

Expected Results 20. COMBI resource group for COMBI implementation established 12

Reports from resource group

Funds COMBI expert Availability of resource groups/ coordinator Funds

21. Assessment including 11 12

Assessment report

Measured by morbidity and mortality rates, number of cases, geographical containment, and duration of outbreak.

COMBI Resource Group is conceived as a professional service provider to support development and implementation of COMBI programmes, training of personnel and impact assessment.

SEA/RC61/11 Inf.Doc. Page 30 Assumptions and risks Social/behavioural expert

Planning elements situation analysis of current strategies (social mobilization/health education) and extent and success of COMBI if implemented (with respect to dengue and other vector-borne diseases) 22. COMBI training implemented

Indicators Member States

Verification source

• Number of countries benefiting from COMBI training • Number of Member States committed to COMBI • Number of Member States adopt COMBI in their national plans • Number of Member States designate National COMBI focal point

Training materials Training report Promotional materials Reports of activities Mission reports COMBI Plan

Funds Experts Political commitment Other social mobilization approaches have not been effective Political endorsement Funds Availability of resource group

23. COMBI approach disseminated and promoted. 24. Development and implementation of COMBI plan supported

National COMBI focal point Memoranda of understanding Reports of meetings and joint planning exercises Resources

25. Partnerships set up with private sector/and other multi-stakeholders

• Number of partnership agreements (i.e. MoU) with private sector and other multi-stakeholders

Interest of private sector and other major stakeholders

Activities Expected Result 20: 13

Outputs

Responsible

Timeline

COMBI resource group for COMBI implementation set up 20.1 Prepare terms of reference for COMBI Resource Group • Terms of reference WHO COMBI experts (in consultation with Member countries) • Roster of qualified experts and their availability • Multiagency/multisector COMBI WHO COMBI experts (in consultation with Member countries) Political commitment Funds Expert First quarter of year one Funds First quarter of year one

20.2 Identify experts/practitioners with experience in COMBI training, implementation and assessment, and 13

COMBI Resource Group is conceived as a professional service provider to support development and implementation of COMBI programmes, training of personnel and impact assessment.

SEA/RC61/11 Inf.Doc. Page 31 Activities social mobilization and communication 20.3 Convene meeting and brief resource group Outputs resource group established • Business plan WHO COMBI experts (in consultation with Member countries) Expected Result 21: Assessment including situation analysis of current strategies (social mobilization/health education) and extent and success of COMBI if implemented (with respect to dengue and other vector-borne diseases) 21.1 Develop a ToR on process for conducting the assessment 21.2 Conduct the assessment for each Member State Expected Result 22: COMBI training implemented 22.1 Modify COMBI training curriculum adapted to country setting and based on the outcome of the assessment 22.2 Conduct COMBI training • Modified training curriculum Resource group Member countries Funds Political commitment Expert First quarter of year two • TOR Resource Group (in consultation with Member countries) Resource group Member countries Funds Second quarter of year one Funds Expert Second quarter of year one Responsible Resources Timeline

• Assessment report

Funds Expert

Third and fourth quarter of year one

• COMBI training conducted

Resource group Member countries

Funds Political commitment Expert

Second quarter of year two

Expected Result 23: COMBI approach disseminated and promoted 23.1 Request each Member country to designate a country COMBI team 23.2 Compile COMBI orientation package • Local COMBI teams appointed Resource group Member countries Resource group Political commitment Third quarter of year two

• COMBI package developed (available at e.g. website, etc.) • Report of advocacy meetings with stakeholders

Funds Expert

Third quarter of year two

23.3 Advocate COMBI to stakeholders at the country level Expected Result 24:

Resource group Country COMBI teams

Funds

Third and Fourth quarter of year two

Development and implementation of COMBI plan supported

SEA/RC61/11 Inf.Doc. Page 32 Activities 24.1 Facilitate the development of country COMBI plans 24.2 Secure funding and resources needed before implementation 24.3 Implement COMBI Plan Outputs • Country COMBI plans developed Responsible Resource group (in collaboration with country COMBI teams) Country COMBI teams Resource Group • Plan implemented Country COMBI team (supported by Resource Group) Country COMBI team (supported by Resource Group) Resources Funds Expert Timeline Fourth quarter of year two

• Funding/resources secured

Expert Political Commitment Funds Expert Human resources Funds Human resources Expert

Fourth quarter of year two

First quarter of year three

24.4 Monitor and evaluate implementation of COMBI plan Expected Result 25:

• Progress and evaluation reports • Publication of experiences

From second quarter of year three

Partnerships set up with private sector/and other multi-stakeholders 25.1 Identify key stakeholders (e.g. donor communities, private sectors) who can make significant contributions towards dengue control programme at regional level 25.2 Formalize partnerships through MoU • Stakeholders identified Resource Group (in consultation with Member countries) Stakeholders Political Commitments First quarter of year one

• MoU defining roles and commitments of each partner

Resource Group (in consultation with Member countries) Key stakeholders/ partners

Political Commitments Funds

2nd Q of year one

25.3 Develop workplans

• Strategies and activities defined in workplan/proposal s • Report of accomplishments

Resource Group (in consultation with Member countries) Key stakeholders/ partners Resource group (in consultation with Member countries) Key stakeholders/ partners

Funds Expert

Second and third quarter of year one

25.4 Implement commitments

Funds Human resources

Third quarter of year one

25.5 Disseminate reports and achievements

• Publication

Resource Group (in consultation

Funds

From third quarter of year

SEA/RC61/11 Inf.Doc. Page 33 Activities Outputs • Media exposure Responsible with Member countries) Key stakeholders/ partners Resources Expert one Timeline

SEA/RC61/11 Inf.Doc. Page 34

Component V: Outbreak response Planning elements Regional goal To reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems Regional objective To reduce incidence rates of dengue fever and dengue hemorrhagic fever • The rising trend in dengue stemmed between 2008-2010 relative to 2005-2007 • Regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • Regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Impact of outbreak mitigated Purpose To increase capacity to predict, detect early and respond to dengue outbreaks. • Number of Member States with an effective early warning system in place and articulated into existing epidemic response (i.e. pandemic influenza; Global Outbreak Alert Response Network) • Number of Member States that have allocated financial and human resources for outbreak response for dengue • Number of Member countries with a rapid response system in place and the core capacity to respond as per IHR requirements 26. Early warning system/dengue surveillance system developed and scaled up • Number of countries having operationalized early warning system based on disease surveillance data, epidemiological information, virus serotypes (from Emergency operation centre records and IHR focal point appointed Political commitment Funds Human resources 14

Indicators

Verification source

Assumptions and risks

Regular WHO updates

Political commitment Funds Human resources Coordination and surveillance systems in place

Dengue outbreak response report

National plans and budgets

Bureau of Epidemiology/IHR focal point reports Member States’ surveillance reports. Political commitment Funds Human resources Functional surveillance system

14

Measured by morbidity and mortality rates, number of cases, geographical containment, and duration of outbreak

SEA/RC61/11 Inf.Doc. Page 35 Assumptions and risks

Planning elements

Indicators Component I), vector densities/distribution (from Component II) and environmental data (i.e. rainfall, temperature) and notify within (xx) period of time

Verification source

27. Dengue outbreak standard operating system developed

• Number of Member States with Dengue Outbreak Standard Operating Procedures (SOP) in place • Number of Member States with adequate designated staff and necessary infrastructure in place • Numbers of countries having the capacity to respond to dengue outbreaks following SOP

Standard Operating Procedure Manual

Funds Experts

Staffing records

National plans and SOP manuals.

28. Coordination mechanisms within MoH and with other programmes and sectors established 29. Intercountry coordination mechanisms in place 30. A mechanism to incorporate rumour surveillance developed and implemented

• Number of Member States with functional intersectoral dengue emergency taskforce

TOR: Dengue Emergency Taskforce Reports of task Force

Funds Experts

• Number of inter-country meetings held • Number of biregional coordinating meetings • Number of Member States with a mechanism (IHR framework) incorporating rumor surveillance into the national surveillance system • Number of Member States with a system incorporating focal persons (health workers) to verify rumours in the community • Number of countries with the capacity to verify outbreaks within (xx) hours

Intercountry meeting reports Bi-regional meeting reports National surveillance reports

Funds Political commitment

Funds Experts Political commitment

WHO/partners mission reports, outbreak investigation team reports Copy of regional guidelines Funds Experts Human Resources

31. Regional outbreak response guidelines developed

• Regional outbreak response guidelines available

SEA/RC61/11 Inf.Doc. Page 36 Assumptions and risks Funds Human resources Staff motivation Staffing records

Planning elements 32. The ability of health workers to respond to the dengue outbreak strengthened

Indicators • Number of Member States with outbreak response guidelines and training manuals for health workers available • Number of Member States with responsible health workers trained on outbreak response SOPs

Verification source National training report 15

33. Risk communication plan developed

• Risk Communication Plan with clear roles and responsibilities in communicating with the public • Number of Member States with programmes incorporating risk communication included in their National Plan • Number of Member States with standard operating procedure for media interaction

Copies of regional risk communication plan National plan.

Political commitment Funds Experts

Written SOPs.

Activities

Outputs

Responsible

Resources

Expected Result 26 National Early Warning System/Dengue Surveillance System developed and scaled up 26.1 Agree and adhere to components of early warning system • Outbreak response plans • Adherence to IHR commitments MoH* WHO Political commitment Funds Human resources Functional EOC at MoH and WHO (Fourth quarter of year two) Funds Experts (Fourth quarter of year two) Funds Availability of experts (Fourth quarter of year 2) Political commitment Funds

26.2 Develop guidelines for early warning systems

• Guidelines

MoH* WHO

26.3 Develop indicators for forecasting of outbreaks 26.4 Establish system of weekly reporting

• Expert meeting report

WHO Experts

• Weekly reports

MoH*

15

Showing results of competence tests on SOPs and Guidelines

* Or relevant agency

SEA/RC61/11 Inf.Doc. Page 37 Activities Outputs Responsible Resources (First quarter year of 3) Expected Result 27: Dengue outbreak standard operating system developed 27.1 Development of SOP including triggers for declaring outbreaks and defining stakeholders and their roles and responsibilities 27.2 Training in the use of SOP • SOP Manual MoH* WHO (tech advice) Political commitment Funds Human resources (Fourth quarter- year 1) Funds Human resources (Second quarter - year 2) Funds Human resources (Annual Exercise beginning four quarter - year 2)

• Training report

MoH* WHO

27.3 Monitoring use of SOP

• Monitoring reports

WHO MoH*

Expected Result 28: Coordination mechanisms within MoH and with other programmes and sectors established 28.1 Constitute an intersectoral dengue emergency task-force • Intersectoral taskforce coordinated by MOH* • Minutes and records resulting from intersectoral meetings within the public as well as involving the private sector • Interdepartmental joint plans, reports and records of intervention MoH* WHO Other sectors (*or relevant agency) MoH WHO Political commitment Funds Human resources Interest of other sectors (First quarter – Year 2) Funds Political commitment (Second quarter – Year 2)

28.2 Collaboration with other health programmes and disease surveillance Expected Result 29:

Intercountry coordination mechanisms in place. 29.1 Intercountry coordination meetings (4-5) • Meeting reports WHO MoH Political commitment Funds Human resources (?) 29.2 Biregional meetings (2) 29.3 Share-point site or equivalent intercountry and biregional communication mechanism • Electronic communication system in place MoH WHO • Meeting reports WHO Funds (?) Funds Human resources (Second quarter – Year 2)

SEA/RC61/11 Inf.Doc. Page 38 Activities Expected Result 30: A mechanism to incorporate event-based surveillance developed and implemented 30.1 Establish effective media/rumours scanning mechanism • Effective media scanning mechanism in place Ministry of Information MoH WHO Political commitment Private media's willingness Funds Human resources (Second quarter -Year 2) 30.2 Strengthen rumour verification mechanism • Effective rumour verification mechanism in place MoH WHO Partners (e.g. CDC) Political commitment Funds Human resources (First quarter – Year 3) Expected Result 31: Regional outbreak response guidelines developed 31.1 Develop regional outbreak response guidelines and SOP targeting different levels Expected Result 32: The ability of health workers to respond to the dengue outbreak strengthened 32.1 Mapping of personnel already engaged in outbreak response (e.g. AI) 32.2 Training need assessment. • Inventory of trained staff in outbreak response (e.g. AI) MoH Other relevant ministries (e.g. Environment) WHO • Assessment report MoH WHO Political commitment Funds Human resources (Second quarter Year 1) Funds Human resources (Second quarter Year 1) 32.3 Training in outbreak response • Training reports MoH Other ministries (e.g. Ministry of Environment) WHO Expected Result 33: Risk communication plan developed 33.1 Develop risk communication plan into dengue outbreak SOP and incorporate risk communication components specific • Risk communication plan to be incorporated into dengue outbreak SOP • Risk communication components specific to dengue incorporated into MoH Other Ministries (e.g. Environment) WHO Political commitment Funds Human resources (Fourth quarter – Year 1) Political commitment Funds Human resources (Second quarter – Year 2) • Guidelines • SOP MoH WHO Political commitment Funds Experts (Second quarter – Year 2) Outputs Responsible Resources

SEA/RC61/11 Inf.Doc. Page 39 Activities to dengue into existing epidemic alert and response risk communication plan 33.2 Training of focal points in all relevant aspects of risk communication 33.3 Collaborate with other sectors to harmonize implementation of risk communication Outputs existing epidemic alert and response risk communication plan Responsible Resources

• Training reports

MoH Other Ministries (e.g. Environment) WHO

Funds Human resources (Second quarter – Year 2) Funds Human resources (Fourth quarter – Year 2)

• Joint plans • Intersectoral meeting reports

MoH Other ministries (e.g. Ministry of Environment) WHO

SEA/RC61/11 Inf.Doc. Page 40

Component VI: Research Planning elements Regional goal To reduce the disease burden due to major parasitic and vector-borne diseases to such an extent that they are no longer major public health problems Regional objective (To reduce the morbidity and mortality rates due to DF/DHF) • The rising trend in dengue stemmed between 2008-2010 relative to 2005-2007 • Regional average reported incidence rate reduced by at least 20% (2010-2012 average versus 2005-2007) • Regional average reported incidence rate reduced by at least 20% (2013-2015 average versus 2010-2012) • Impact of outbreak mitigated16 Purpose: To address programmatic issues and gaps which require new or improved tools for effective dengue prevention and control Expected Results 34. Operational research capacity in dengue of existing academic/ scientific institutions in Member states enhanced • Number of reports/publications specifically addressing programmatic gaps • Number of collaborating centres participating in operational research • Number of institutions engaged in twinning or collaborations/ partnerships within or outside the region per year • Number of grants directly addressing programmatic gaps Publications Political commitment Commitment of academic sector/ national research councils or Ministries WHO CCs commitment Funds Experts Human resources • Programmatic issues and gaps identified • Research priorities identified • Programmatic issues and gaps successfully addressed through research Situation analysis reports Research findings (e.g. publications, reports, etc.) Political commitment Funds Experts Human resources Regular WHO updates Political commitment Funds Human resources Dengue outbreak response report Coordination and surveillance systems in place Indicators Verification source Assumptions and risks

List of WHO collaborating centres List of MoU, joint research protocols and implemented projects Grant agreements

16

Measured by morbidity and mortality rates, number of cases, geographical containment and duration of outbreak

SEA/RC61/11 Inf.Doc. Page 41 Assumptions and risks Political commitment Commitment of academic sector/ national research councils or ministries WHO CCs commitment Funds Experts Human resources 36. New knowledge gained, new tools developed, existing tools improved and new strategies created • Number of research projects per country addressing development of tools • Number of countries where new tools are being researched • Number of countries where new or improved tools are being validated Publications or reports Political commitment Commitment of academic sector/ national research councils or ministries/private sector WHO CCs commitment Funds Experts Human resources 37. Evaluation of tools and strategies for dengue control and case management • Number of cost evaluation studies involving new and improved tools • Number of cost evaluation studies involving new and improved strategies • Number of economic studies such as cost minimization, costeffectiveness, cost of utility and budget impact, etc. Publications or reports Country/programme reports Political commitment Commitment of academic sector/ national research councils or ministries/private sector WHO CCs commitment Funds Experts Human resources 38. Translation of new improved tools into programmatic activities • Number of programmes in Member States adopting research recommendations in policy formulation and programme implementation • Number of programmes publishing operational research findings • Number of countries that have established research priorities based on programme needs Country/programme reports Political commitment Commitment of academic sector/ national research councils or Ministries WHO CCs commitment Funds Experts Human resources

Planning elements

Indicators in both regions

Verification source

35. Disease burden estimated (epidemiologic impact, social costs and cost of illness)

• Number of countries engaged in disease burden estimate studies • Number of countries that have completed disease burden estimates

Country reports

Country/programme reports

SEA/RC61/11 Inf.Doc. Page 42

SEA/RC61/11 Inf.Doc. Page 43 Activities Expected Result 34: Operational research capacity in dengue of existing academic/ scientific institutions in Member States enhanced 34.1 Map of research institutions, researchers and research networks in the two regions 34.2 Conduct workshops to develop operational research protocols 34.3 Set up a system for information exchange • Listing inventory WHO MoH/MEWR/MOSTI and other relevant ministries • Workshop reports • Research protocols WHO TDR Research councils/academic institutions • Sharepoint or other system WHO Research councils/academic institutions MoH/MEWR/MOSTI and other relevant ministries 34.4 Training in applied and operational research 34.5 Brokering national and international twinning arrangements and collaboration Expected Result 35: Disease burden estimated (epidemiologic impact, social costs and cost of illness) 35.1 Conduct situation analysis on information gaps to estimate disease burden 35.2 Develop a protocol for disease burden estimation 35.3 Develop methodologies to estimate prevalence incidence and mortality from available data 35.4 Conduct research and publish studies and • Situation analysis report MoH/MEWR/MOSTI and other relevant ministries WHO • Protocol WHO Funds Experts Human resources Years 1 and 2 Funds Experts Years 1 and 2 • Develop methodologies Years 1 and 2 • People trained in operational research • Twinning arrangements in place Funds Human Resources (Year 1) Outputs Responsible Resources

Funds Experts Human resources (established in year 1 and ongoing) Political commitment and interest of research institutions Funds Expert Human resources (established in year 1 and ongoing) (established in Year 1 and ongoing) (established in Year 1 and ongoing)

• Report/publications

Researchers/academic institutions/CCs

Political commitment and interest of

SEA/RC61/11 Inf.Doc. Page 44 Activities use these for advocacy Outputs • Advocacy reports Responsible WHO MoH/MEWR/MOSTI and other relevant ministries Resources research institutions Funds Expert Human resources Year 2 and ongoing Expected Result 36: New knowledge gained, new tools developed, existing tools improved and new strategies developed 36.1 Develop and test new surveillance tools and mechanisms • GIS system in place • Effective surveillance and predictive tools developed • Identification of risk factors Researchers/academic institutions/CC WHO MoH/MEWR/MOSTI and other relevant ministries Researchers/academic institutions/CC WHO MoH/MEWR/MOSTI and other relevant ministries Researchers/academic institutions/CC WHO MoH/MEWR/MOSTI and other relevant ministries 36.4 Develop new and improved case management strategies in DHF/DSS • Report/publication Researchers/academic institutions/CCs WHO MoH/MEWR/MOSTI and other relevant ministries • Collaboration progress reports/monitoring reports of vaccine trials • Collaboration progress reports/Monitoring reports of vaccine drug trials • Collaboration progress reports/monitoring reports resulting from development of Researchers/academic institutions/CC/Private sector MoH/MEWR/MOSTI and other relevant ministries Political commitment and interest of research institutions Funds Experts Human resources Year 1 and ongoing 36.2 Evaluate improved and new vector and other preventive control strategies and tools • Evaluation reports and/or publications • Results of multicenter studies addressing key indicators Political commitment and interest of research institutions Funds Experts Human resources Year 1 and ongoing 36.3 Conduct studies on biomarkers in DHF/DSS • Publications Political commitment and interest of research institutions Funds Experts Human resources Year 1 and ongoing Political commitment and interest of research institutions Funds Experts Human resources Year 1 and ongoing 36.5 Collaborate in the development of new products and technologies Political commitment & interest of research institutions, private sector & other stakeholders Funds Experts Human resources Year 1 and ongoing

SEA/RC61/11 Inf.Doc. Page 45 Activities 36.6 Conduct research on insecticide resistance Outputs new diagnostic tools • Results of research studies Researchers/academic institutions/CCs WHO MoH/MEWR/MOSTI and other relevant ministries 36.7 Conduct studies on the effect of climate change on dengue • Reports/publications MoH/MEWR/MOSTI and other relevant ministries Year 1 and ongoing Funds Experts Responsible Resources

Sector/national research Councils on ministries Funds Experts Year 1 and on-going

Expected Result 37: Evaluation of tools and strategies for dengue control and case management 37.1 Conduct a review of costings of each of the programmes’ strategic components 37.2 Develop protocol for evaluation studies (efficacy, effectiveness, accessibility, acceptability, feasibilityand sustainability) in different settings 37.3 Perform cost studies on any existing or new dengue prevention, control and case management strategies including COMBI, intersectoral cooperation, integrated vector management, etc. 37.4 Use evidence from cost studies for advocacy and mobilization of resources Expected Result 38: Translation of new improved tools into programmatic activities • Report of cost analysis • Publications MoH/MEWR/MOSTI and other relevant ministries WHO • Protocol • Publications Experts WHO Funds Funds Experts

• Proposals/protocols • Reports and publications

Experts WHO

Funds

• Advocacy documents and materials • Resources mobilization plan

MoH/MEWR/MOSTI and other relevant ministries WHO Partners

Funds. Human resources

SEA/RC61/11 Inf.Doc. Page 46 Activities 38.1 Conduct joint meetings/workshops to establish operational research priorities and dissemination of research findings 38.2 Participation of key researchers in programme managers meetings Outputs • Meeting reports • Publication of reports TDR MoH/MEWR/MOSTI and other relevant ministries Responsible WHO Resources Funds Experts Human resources

• Programme managers meeting reports

WHO TDR Research councils/academic institutions MoH/MEWR/MOSTI and other relevant ministries

Funds Experts Human resources

38.3 Established a working groups/taskforce/ liaison among programme staff and researchers who will coordinate, monitor and evaluate the integration of research findings into operations and policies

• Formal entity established • Appropriate allocation of resources

MoH/MEWR/MOSTI and other relevant ministries

Funds Human resources