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Table of Contents
RESEARCH ARTICLE
Year : 2019  |  Volume : 56  |  Issue : 1  |  Page : 66-69

Role of a dedicated support group in retaining malaria-free status of Sri Lanka


1 Asia Pacific Leaders Malaria Alliance, Helios, Singapore
2 Independent Consultant, Sri Lanka
3 University of Kelaniya, Kelaniya, Sri Lanka
4 World Health Organization, Regional Office for South-East Asia, New Delhi, India
5 University of Colombo, Colombo, Sri Lanka
6 Public Health Writer and Researcher, Canada

Date of Submission28-Feb-2019
Date of Web Publication7-May-2019

Correspondence Address:
Ms Rittika Datta
Asia Pacific Leaders Malaria Alliance, 11 Biopolis Way, #04–01/02. Helios
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9062.257778

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  Abstract 


Keywords: APLMA; elimination; malaria; Sri Lanka; taskforce


How to cite this article:
Datta R, Mendis K, Wikremasinghe R, Premaratne R, Fernando D, Parry J, Rolfe B. Role of a dedicated support group in retaining malaria-free status of Sri Lanka. J Vector Borne Dis 2019;56:66-9

How to cite this URL:
Datta R, Mendis K, Wikremasinghe R, Premaratne R, Fernando D, Parry J, Rolfe B. Role of a dedicated support group in retaining malaria-free status of Sri Lanka. J Vector Borne Dis [serial online] 2019 [cited 2019 Nov 19];56:66-9. Available from: http://www.jvbd.org/text.asp?2019/56/1/66/257778



The Asia Pacific Leaders Malaria Alliance (APLMA) is an affiliation of Asia and Pacific heads of government, formed to accelerate progress against malaria and to eliminate it in the region by 2030. The APLMA Malaria Elimination Roadmap[1], endorsed by 22 Asia Pacific countries, calls for each country to consider establishing a National Malaria Elimination Task Force (or similar body), chaired by a senior central agency official for national stewardship towards the 2030 malaria elimination goal. The APLMA Leaders’ Dashboard[2] was developed to track progress and achievement in malaria control and elimination in 22 countries in the Asia Pacific. One of the indicators on the APLMA Leaders Dashboard is to note the progress towards formation of a National Task Force (or equivalent). It is proposed that the task force or equivalent body meets at least once a year to take necessary actions to ensure that national targets are met. This case study elaborates on Sri Lanka’s success story in eliminating malaria and maintaining the malaria-free status. The case highlights the role of a committed advisory group in achieving this and the lessons learnt from Sri Lanka’s experience. The case study also briefly mentions the formation of the National and State Task Forces in India (refer [Box 1]), to support the phased elimination strategy, and the need of having a ‘whole of society’ approach in the light of the complexity of the malaria landscape.



Malaria in Sri Lanka

Sri Lanka’s last indigenous case of malaria[3] was reported in October 2012. In the run-up to this milestone, i.e. the pre-elimination phase from 2008 to 2011, there were pockets of persistent transmission, predominantly among military personnel and confined to military camps near forested areas[4]. Since November 2012, the country transitioned to the prevention of reintroduction of malaria phase, and all the subsequent detected cases have been classified as imported[5] or introduced[6]. With 57 imported malaria cases in 2017, Sri Lanka is considered to be moderately vulnerable to the reintroduction of malaria, and maintaining the level of threat at or below this level requires constant vigilance.

Avoiding re-introduction

Having sustained zero indigenous cases for more than three consecutive years, Sri Lanka applied for official WHO certification of malaria-free status. In September 2016, WHO officially certified Sri Lanka to be malariafree, thus making it the second country in the WHO South-East Asia Region, and the first signatory to the APLMA Leaders’ Roadmap, to be awarded this distinction. Sri Lanka’s challenge now is to ensure that any imported or introduced cases are tracked, tested and treated, and do not lead to onward domestic transmission and re-introduction of the disease.

A National Malaria Strategic Plan for Elimination and Prevention of Re-introduction—Sri Lanka, 2014–2018 was developed and implemented. There had been no indigenous cases reported in Sri Lanka since 2012. Very recently, in December 2018, a single introduced case of malaria was reported[7]. Immediate and effective response to the introduced case has ensured that there is no further transmission. The containment of the cases serves as an excellent example of the efficient surveillance and response capacity that Sri Lanka has developed.

Malaria Technical Support Group: Background and context

The Anti-Malaria Campaign (AMC), Sri Lanka’s National Malaria Control Programme, was established as a field office in 1911. In 1989, the programme was transformed into a decentralized campaign implemented by 9 provincial health authorities. The main objectives of the AMC are to prevent re-introduction of malaria and maintaining zero deaths due to malaria. In Sri Lanka, the Technical Support Group (TSG) to the AMC, appointed by the Director General of Health Services fulfils the role of a National Malaria Elimination Task Force. Prior to 2012, the TSG supported the AMC with evidence-based strategic and technical advice on elimination. Since then, it has continued to provide advice on prevention of re-introduction.

Composition of Technical Support Group

The 17-member TSG includes independent external experts, selected for their expertise and guidance to the AMC in parasitology, entomology, malaria, epidemiology, clinical medicine, pharmacology and sociology. These independent experts do not represent institutions or organizations, but function in their individual capacity to provide expertise and guidance to the AMC. In addition to the permanent members, additional members with specific expertise in particular fields are co-opted to the TSG meetings to provide comprehensive recommendations, as required. The full TSG member-ship attends regular meetings every two months, or as required, and they are paid an honorarium for attendance.

The TSG Secretariat comprises of the: Director General of Health Services; Deputy Director General, Public Health Services; Director, AMC; Deputy Director, AMC; Consultant Community Physicians, AMC; Two Regional Malaria Officers from the Provinces; and Secretary.

Additional members with expertise in particular fields may be invited to attend TSG meeting as temporary advisors or as co-opted members to respond to specific challenges as they arise. Membership is reviewed annually and revised according to the needs. The TSG is chaired by the Director General of Health Services. Members are appointed to serve a term of two years and may serve multiple terms.

In Sri Lanka, the creation of the TSG aligns with both the APLMA call to action for the creation of a task force and with the World Health Organization (WHO) guidance to countries to set up an advisory body. However, because it is a technical body, charged with providing technical guidance to the AMC, it does not have strong representation from non-health sectors. Although the TSG does not include representatives from other sectors and does not deal directly with other government departments, it acts as an advisor to the AMC when such inter-sectoral collaboration is required. It does not play any direct role in initiating collaboration between different ministries.

Roles, responsibilities and reporting structure

The TSG functions in a purely advisory capacity to make recommendations to the Director-General, Health. Prior to malaria elimination, the TSG regularly reviewed the malaria situation in collaboration with the AMC, to identify bottlenecks, human resources gaps and challenges for the successful implementation of the country’s malaria elimination programme, and then to provide strategic advice and technical inputs to help improve the national malaria elimination programme.

The TSG supported the National Malaria Control Programme to develop the 2014–2018 National Strategic Plan, compiled annual reports on the malaria situation, and promoted advocacy and capacity building through contracting of local and international experts. It reviewed procurement of buffer stocks of antimalarial drugs, long-lasting insecticidal nets, indoor residual spraying of insecticides and rapid diagnostic test kits, developed research proposals, assisted AMC to prepare the National Strategic Plan for Malaria, and the malaria elimination certification report for the WHO certification team, prepared and submited manuscripts for publication and helped to identify local and international research fundings.

Matters for discussion are identified and circulated to the members prior to the meeting and they are briefed by the Director, AMC at each meeting on the current malaria situation and issues and challenges. Decisions are made by consensus, and care is taken to identify and take into consideration potential conflicts of interests among members.

In exceptional situations where a consensus is not reached, the Chairperson reports on the majority and minority views, and the TSG may request a study and analysis to seek evidence required to resolve a particular issue or to formulate recommendations. The Chair heeds and takes due consideration of potential conflicts of interest of the members when arriving at a decision.

TSG case review Subcommittee

The subcommittee meets every month and the meetings also comprises the following staff members of the AMC: Surveillance Officer, Case Management Officer, Parasitologist, Entomologist, Regional Malaria Officers (either in person or by phone) and the Director of the AMC or its representative. The subcommittee reviews all information on every confirmed malaria case that has been reported during the past month, including confirmation of diagnosis (including the diagnostic methods used), origin of infection, treatment schedule, patient therapeutic response, follow-up procedure and notification of the AMC and the health management information system. It also reviews case investigation details including, if relevant, a foci investigation. The subcommittee reviews the National Malaria Case Register, Malaria Patient Register, Laboratory Register and Parasite Strain Bank. Its other roles include formulation of criteria for confirming and verifying malaria diagnosis, and classification of cases. It supports development of standard operating procedures for malaria cases and verifies whether these have been followed in each case. It identifies gaps in case confirmation and reporting and advises the AMC on bridging these gaps.

Achievements of the Task Force

While the TSG has a fairly large membership, AMC works very closely with a sub-group of three members who, on a voluntary basis, work directly with the Director, AMC and staff. Having a smaller group of dedicated members is one of the TSG’s critical success factors. They were closely involved in the planning and preparation for WHO certification and were also an integral part of the case review committee. In the post-elimination phase, the group is still very active in case review and preparing an investment case for malaria elimination, as well as in academic research on the resources required preventing re-introduction of the disease. The area of focus for the group has shifted, away from routine coverage of malaria prevention supplies towards surveillance and advocacy. One of the challenges faced by the TSG though, is that not all members devote time to the follow-up activities of the TSG, particularly post-elimination.

What others can learn from Sri Lanka’s experience

There is no ‘one size that fits all’ approach for building a task force for malaria elimination, and malaria programmes must be given a free hand in the formation of their task force. Other countries’ experience can only help determine principles and general guidelines, but practical implementation depends on each country’s focus, available resources and malaria state of play.

That said, a key lesson from the Sri Lanka experience is the identification of three key members who were available at any time on call to work through any issues that came up between meetings and follow-up on decisions. Without a few key committed individuals, the TSG might not have been as effective. This underpins the need for ensuring a cadre of leaders, who are committed to the cause, and to drive the process.

Receptivity and the responsiveness of the national programme is another critical success factor. Similarly, the attitude of the members of the TSG, willingness and commitment to actively participate in the national programme’s activities, are extremely important.

For countries in the elimination and post-elimination phase, continuing to have an active task force is important to ensure that the country remains vigilant and retains its malaria-free status.


  Acknowledgements Top


We would like to thank the colleagues of AMC, Sri Lanka for their technical support and expertise that greatly assisted the research.



 
  References Top

1.
Asia pacific leaders lalaria alliance malaria elimination roadmap, July 2017. Available from: http://aplma.org/upload/resource/ Roadmap/APLMA_Roadmap_final_EAS_2015.pdf.  Back to cited text no. 1
    
2.
APLMA leaders’ dashboard, 2017. Available from: http://aplma.org/upload/resource/files/APLMA_Dashboard_2017.pdf.  Back to cited text no. 2
    
3.
A case contracted locally with no evidence of importation and no direct link to transmission from an imported case, WHO Malaria Terminology  Back to cited text no. 3
    
4.
Sri Lanka free of malaria: Case study. World Health Organization, Regional Office for South-East Asia, 2017.  Back to cited text no. 4
    
5.
Malaria case or infection in which the infection was acquired outside the area in which it is diagnosed, WHO Terminology  Back to cited text no. 5
    
6.
A case contracted locally, with strong epidemiological evidence linking it directly to a known imported case, WHO Malaria Terminology  Back to cited text no. 6
    
7.
Personal communication, Director AMC.  Back to cited text no. 7
    



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