Progress report:the National LF and STH programme

in MYANMAR

Dr. Ni Ni Aye, Program Manager (ELF)

LF and STH program Mangers Meeting,Jakarta(23-24 sept,2014)

Background Information

• Geography and Population– Total population – 51419420 (2014

Census)– Ecological zones - Myanmar ,the largest

country in mainland in South East Asia with a total land area of 676,578 square kilometer

• Political & Health Administrative Divisions:- First level (7 States and 7 Regions)- Second level (69 Districts, 330

townships, 82 sub townships and 396 towns)

- Third level (3045 wards, 13267 village tracts and 67285 Villages)

Historical Perspective • 1877 - First case of elephantiasis -Indian man, Thayet tsp

• 1956 - Dr Nandy, a surgeon of RGH – found out the relation

between hydrocoele and presence of Mf

• 1959, Municipal Council of Rangoon - Anti- filarial campaign -

vector control.

• 1960 -Division of Health Dep; - NMBS & treatment of (+)ve cases.

• 1962-1965, Filariasis Research project (WHO)in Rangoon

• 1966-69 Pilot vector control programme - using 50% EC

fenthion larvicide in 16 tsp; of Rangoon by health

department.

• 1970 -(D.O.H )Directorate of Health - Filariasis control project -

Historical Perspective (Cont;)

• 1978 - integrated with Malaria, DHF and J-B Encephalitis control

Programme into VBDC Program

• 1983, Culex larval control was stopped because of vector

resistant to insecticide, although case finding with NMBS and

treatment of positive cases -

• 2001, the Global Strategy for Elimination of Lymphatic

Filariasis (ELF) has been adopted.

National programme overviewIndicator LF STH

Year of inception of the national programme

2000 2003

Target date for elimination 2020

Name of administrative unit for implementation of PC

District District

Total # administrative units requiring PC at the start of the programme

45 67

Total population requiring PC in the country

Total pop in endemic IUs(40,014,402)

Sum of preSAC & SAC requiring PC (14,634,198)

PC Programme Financing

• Contributors to the 2013 programme costs (and rough estimate of contributions by each if available):

Contributor Funding (US$)National government Travel allowanceSub-national government Transport cost for drugInternal donors External donors (GNNTD) 27000Others (WHO) 7500Others (JICA) IEC

PC programme achievements 2013

Indicator Targeted Achieved

M&E

Total # sentinel and spot check sites surveyed (LF) 13 13

Total # sentinel sites surveyed (STH) 8 0

Total # IUs where stopping-MDA TAS implemented (LF) 0 0

Total # IUs which passed TAS and stopped MDA (LF) 0 0

Total # IUs where surveillance TAS implemented (LF) 3 0

MMDP# IUs where hydrocele surgeries performed 65 65

# IUs where lymphedema and ADLA management provided 45 45

Activities

Targeted Achieved

# administrative

units for PC# people

# administrative

units for PC# people

PC

MDA2 (DEC + ALB) 36 35488298 36 30313249

T3 (ALB/MBD) for STH 1st round 67 3151312 67 2790809

T3 (ALB/MBD) for STH 2nd round 67 12745578 67 12018002

Progress Towards LF Elimination

Definitions

Started MDA ≥5 MDA rounds Surveillance MMDP access

42%

7%

42%

96%

0% 20% 40% 60% 80% 100%

MMDP access

Surveillance post-MDA

≥5 MDA rounds

Started MDA

Progress Towards LF Elimination

14.7%

5.6%

0.6%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Baseline (2001) Mid-term (2007) Pre-TAS(2014)

Progress Towards STH scale up

 *Coverage =

Progress Towards STH scale up

 *Coverage =

PC coverage, 2013

*65% for LF and 75% for STH**reported coverage was verified by coverage survey or similar independent activity

PC type#

administrative units receiving

PC

# administrative units with

reported coverage above target*

# administrative units where

coverage was verified**

MDA2 (DEC + ALB) 36 36 36

T3 (ALB/MBD) for STH 1st round 67 67 67

T3 (ALB/MBD) for STH 2nd round 67 67 67

Impacts of MDA in Sentinel Sites (LF)# SS/SC sites

Sentinel Sites<1% mf

Sentinel Sites≥1% mf

Spot Check sites

<1% mf

Spot Check sites

≥1% mf

Baseline surveys 41 28 42 31

Latest surveys (post-MDA)

59 10 55 9

PC Monitoring and Evaluation

Describe how coverage is monitored• Post MDA survey, • Area coverage survey, • Pop coverage

SAE protocol (Severely affected Event)Detection, Management , Reporting

For <5 children and the ones who has problem to swallow the drug - Tablets should be crushed and given with sufficient water to prevent choking

To exclude those people - who were taking other drugs for treatment of other diseases from MDA

- who were suffering from other chronic diseases like, TB, Hypertension, Heart / renal / liver diseases (with evidence of taking treatment from any health facility)

- who were ill or bed ridden during the time of MDA - < 2 year age group and pregnant women from MDA

Progress to date in assessing transmission #

# administrative units currently eligible for surveys to stop mass treatment 5

# administrative units where surveys to stop mass treatment were conducted 0

# administrative units where criteria was passed and mass treatment stopped

• Justification for stopping MDA without TAS in the above IU s

• Integrated assessment of STH considered?

LF Transmission Assessment Survey to stop MDA

LF Transmission Assessment: Forecasting

YearNumber of IUs to

be coveredTAS1 TAS2 TAS3

Total number of EUs

ICT/LF ST Required*

2014 2 3 5 1600*5

2015 12 12 1800*12

2016 4 2 6 1800*6

2017 12 12 1800*12

2018 22 4 26 1800*26

2019 2 2 1800*2

2020 24 24 1800*24

*sum of the total sample size required for each EU assessed;

Integrated Vector Management (LF)

• Describe any activities targeted to control LF vectors (including those conducted by other programmes)

• Training, Entomology survey (Malaria ,JE and DHF)

• Describe monitoring and evaluation of such activities

LF MMDP – StrategyLF

National policy exist? Morbidity Mx as in strategy

Organizational placement within the government (who is responsible?)

National ELF program PM is responsible

How integrated with the health service? National LF programme and Public health division at various level

Training of service providers conducted (by who? How frequent?)

RO and TL from Reginal VBDC team are already trained and they give training to VBDC staff and BHS annually before MDA conduct.

Patient mobilization and registration (by who? How?)

VBDC staff register patient who come to VBDC clinic

LF MMDP – monitoring and evaluation

LF

Describe how MMDP services are currently monitored and reported to the national programme

Monitored at regional level and reported to National program ,but it need to be strengthen

How is “access” determined? Determined by Regional RO and TL as clinically and also mf positive cases.

Is there any quality assessment of provided services?

Not yet, need to be done quality assessment

Best Practices

• Describe interventions and/or M&E activities that worked welli. Integrated activities with STH program ,Nutrition program ,Basic

Health under umbrella of DOHii. Disease-specific activities – as VBDC include

malaria ,DHF ,Chikungunya and JE diseases, So that manpower work together for all diseases.

iii. Voluntarily participated – VHW as drug distributors are voluntarily participate and BHS monitor them at grass root level

iv. In spite of no incentives- incentive like materials can not be given since MDA was conducted , most of VHW are still participating during MDA. It is most important weakness to raise drug coverage. It must be fulfil by all partners as well as by goverment.

Issue and Challenges during the preparation of MDA in 2013

• Micro-planning- Region and State ,Township• population register were distributed all Tsps ,but it

were not enough and copied during population data collection

• Due to planned for MDA in 2012 training for TMO and SMO and VBDC staff were trained since early month of 2012, but late arrival of DEC ,we could not conduct MDA in 2012

• BHS guide line for MDA were distributed to all BHS before MDA start

• Some of the trained TMO and BHS transfer to non LF endemic township

Issue and Challenges during the preparation of MDA in 2013

• distribution of drug and IEC and arrived to RHC before MDA started

• Transportation cost of Drug and IEC were borne by ELF porgram with the support of GNNTD, WHO and government

• Drug distribution Team were not well formed in some of the township both existing and New IU

• Distribution of pamphlet were not received by each household before MDA

• Advoccay on MDA at central ,State/region and township level

Issue and Challenges during MDA in 2013

• No death due to drug, only one child death due to chocking of drug in 2013

• Deaths case were reported during MDA are co incidental death during MDA conducted

• Most s/e are Dizziness, Head ache ,vomiting• MDA was implemented during I week without

discontinuation even rumors on MDA • Although some of township has low population

coverage of ingestion of drug ,more than 65 % of coverage was achieve in district

During the implementation of MDA• Drug distributers team could not explain about drug

and about LF to household member. • They left drug for some person who were not at home

and they marked as ingested drug • People were not ready to ingest drug because they did

not know that drug distributor will come and • people refused to ingest when they heard rumors on SE

of drug starting 2days of implementation• weak supervision and monitoring during MDA by central

, Regional and state ,even in Township level

after the implementation of MDA• Post MDA survey were mainly done by central and

some TMOs• But weak supervision and monitoring post/after MDA

by central , Regional and state ,even in Township level • Post MDA survey did not conduct in every township • Still rumors came out even after the MDA was finished

in some state and Region especially Thai border

• Out of 45 Endemic Districts (IU), Myanmar has covered 43 IU from 2001-2013

• Within 13 years, 3 IUs have reached the elimination target, • Now 36 out of 43 IU was conducted in 2013 • only new 21 district could be started MDA in 2013 (2 IU from

Kachin state left)• Total pop 35.3 M were covered,85% of total pop ,90.9 % of

eligible pop in 2013• Previously the main threat of the program is availability of

DEC and late arrival of DEC. • Integrated NTD of Joint request for Preventive chemotherapy,

it will be regular availability of drug of LF and STH

Issues and challenges

Availability of resources• Now DEC tablets are donated through WHO & Albendazole is

donated by the GSK company, • IUs of high baseline Mf rate may need more rounds of MDA which

in turn need more resource• WHO (2014-2015 )RB –10800 USD only• No external or internal financial support previously• Funding from GNNTD support 35000 US$ for operational cost in

2011 ,27000 US$ will support for operational cost for implementation of MDA (2013)

• Government support – in terms of staff, salary, traveling allowances, warehouses, transportation cost at township level and provision of IEC ,training cost for BHS and VHW will be supported in 2014 ( request budget for MDA to government- 400,000 USD

• CNTD will support for TAS in 2014 and find to continue support for more activities.

Activities Year 1 Year 2 Year 3 Year 4 Year 5 5-Year Total

Coordination and training $702,240 $350,000 $350,000 $350,000 $350,000 $2,102,240 Mapping $0 $0 $0 $0 $0 $0 Drug distribution $263,000 $263,000 $263,000 $263,000 $263,000 $1,315,000 Social mobilization $199,030 $199,030 $199,030 $199,030 $199,030 $995,150 Monitoring and evaluation $328,636 $60,836 $417,636 $19,136 $680,636 $1,506,880 Morbidity control $10,500 $3,500 $3,500 $3,500 $3,500 $24,500 Total (USD) $1,503,406 $876,366 $1,233,166 $834,666 $1,496,166 $5,943,770

Budget for NTD control and elimination in Myanmar (2010-2014)

30

Myanmar’s national NTD program aims to treat 41 million people for at least one NTD at an estimated cost of less than US$0.04 per person

per year, underscoring the cost-effectiveness of NTD control and elimination programs.

Programme Plan Activities

2014 target 2015 target

# administrative

units for PC# people

# administrative

units for PC# people

PC

MDA2 (DEC + ALB) 36 37.7 M 40 40563359

T3 (ALB/MBD) for STH 1st round 69 12037657 69 11223182

T3 (ALB/MBD) for STH 2nd round 42 3282274 42 1277045

Activities 2014 Target 2015 Target

M&E

# districts/IUs where coverage surveys are planned for any PC diseases 36 IU/205 tsp 40

# IUs where pre-TAS sentinel site and spot checks planned (LF) 6 IU 12

# IUs where TAS for stopping MDA is planned (LF) 5 IU 10

# IUs where STH survey integrated with LF TAS planned

# IUs where MMDP is to be evaluated (LF) 2IU 10 IU

# IUs where surveillance activities are to be carried out (LF) 3 IU 5 IU

MMDP # IUs where MMDP services newly initiated (LF) 10 IU 10 IU

IVM # IUs where IVM coordinated to target LF vectors 10IU 10IU

PC medicine request for 2015　 ALB (LF) ALB (STH) MBD DEC

required 40563359 2554090 101408398

in stock

in pipeline

requested to WHO 40563359 2554090 101408398

requested toMDP (IVM) or ITI (AZI)

Procured from other sources(source, # tablets and target age group)

Thank You for Attention