On 9-11 August, the Asia Pacific Malaria Elimination Network’s (APMEN) Vivax Working Group, chaired by Dr Karma Lhazeen from the Ministry of Health, Bhutan and Dr Caroline Lynch of Medicines for Malaria Venture (MMV) organized its virtual annual meeting to address the ongoing threat of P. vivax infections and accelerate malaria elimination programs in the region.

More than 80% of the global P.vivax burden is in Asia Pacific.  P.vivax malaria is much more difficult to manage than malaria caused by other parasite species, as it requires specific control strategies to prevent relapse. The APMEN Vivax Working Group (VxWG) supports accelerating implementation of these strategies and uptake of new tools to address P.vivax.

This year's annual meeting brought together experts from across the globe, from national malaria programs, partner institutions, civil society organizations, funding partners, the private sector, and researchers to cover the theme ‘from pipeline to policy and towards optimized implementation’ and focused on the following topics:

• Optimizing radical cure –including an introduction to the development of an Options Assessment Toolkit with National Malaria Programs
• Learning from history and early implementation
• ‘Show me the vivax’– exploring strategies to ensure access to optimized radical cure

“The work of APMEN Vivax Working Group is so important and the meeting theme couldn't be more timely. If we have to meet the 2030 targets, we're going to need not just the novel tools, strategies, interventions and incredibly important operational research but it will have to be coupled by commitments to capacity building and tailored approaches to the context, to the social sociocultural and medical environments, because there isn’t a one-size-fits-all.”

Dr Sarthak Das, DrPH, CEO, Asia Pacific Leaders Malaria Alliance

Highlight of Day 1: Pipeline to Policy

Day 1 concentrated on exploring pipeline to policy for implementation and improving current practices. Dr Sarthak Das, CEO of APLMA and Dr Karma Lhazeen, Chair of the APMEN VxWG opened the Annual Meeting. Dr Das reiterated that “the shift in focus from research to implementation requires the national malaria programs to be in the driver’s seat.  There has to be ownership and commitment from within the program to implement radical cure for P.vivax.” 

The first session highlighted new tools, or changes to new tools emerging from the R&D pipeline; Dr Gonzalo Domingo presented on higher sensitivity diagnostic tests and point of care G6PD testing, Dr Neena Valecha provided an update on WHO guidelines for malaria including current and future recommendations. Dr Penny Grewal provided an account of the latest tools for P.vivax radical cure, emphasizing that “these new tools once seen as a dream are now becoming a reality for the P.vivax community.”

The topic on the operational research database was presented by Dr Bipin Adhikari, MORU. This was followed by group work of the National Malaria Programs to reflect on the APMEN Vivax Working Group 2019 roadmap on timelines, progress achieved, and bottlenecks encountered in the regional malaria elimination effort.  A poster session, including posters from Afghanistan, through Cambodia to Malaysia were presented on strategies to increase access to radical cure.

A quick poll was administered to check what tools or information the participants are most interested in learning after Day 1. More than half of respondents (56%) stated 'higher sensitivity Rapid Diagnostic Tests for vivax', followed by the 'Primaquine 7-Day (47%)' and 'Tafenoquine (41%)'.

Highlight of Day 2: To Policy and Towards Optimized Implementation

Day 2 began with an outline of two deliverables from the APMEN Vivax Working Group: a) A framework to identify NMP questions and priorities; and b) an options assessment toolkit. Dr Caroline Lynch introduced the prioritization framework to systematically capture input from national malaria programs and understand what is required for vivax elimination across the region. Dr Manash Shrestha shared the development of an assessment toolkit that will be available in 2022 to assist in determining the best potential combination of radical cure tools for NMP contexts. 

A new study on ‘Policy Processes & Implications for Future Changes’ was presented emphasizing that malaria policy change along can take up to three years in sub-set of countries studied in the region. Varunika Ruwanpura indicated that “further work is required to ensure that the timeline for policy change process is reduced where possible so that new tools can be introduced and implemented for countries to achieve their elimination targets.”

Dr Kamini Mendis shared an account of patient adherence and experiences of malaria elimination in Sri Lanka. She reiterated the need for an integrated approach to control, early case detection and treatment. A pathway suggested was to supervise treatment or directly observe treatment approach which can be implemented when the caseload is low for vivax elimination. Dr Chansuda Wongsrichanalai presented the early experiences of implementing G6PD point of care testing in the region with a reminder that quality training and follow up is needed for effective implementation.

To end day 2, the participants were surveyed on which areas are most important for stakeholders to understand to achieve vivax elimination. Most of the respondents rated 'very important' on the subject of ‘adherence to treatment’, ‘reliability of quantitative G6PD point-of-care tests’, ‘efficacy and safety of Tafenoquine’, ‘value and acceptability of new tools’, and ‘perceptions of affordability of these new tools’.

Highlight of Day 3: Towards Optimized Implementation

Day 3 covered access issues including targeting new tools to achieve impact,  strategies being used to access remote populations and how engaging with other sectors may enable access to more remote vivax patients.

There were presentations from Dr Rosalind Howes on Diagnostic Network Optimization - Informing the Role Out of G6PD Testing in which she outlined ways to target implementation of G6PD analyzers to achieve cost-effectiveness.

A lightning talk session included presentations on access and multisectoral approaches by three presenters: Dr Issac Quaye, from the Roll Back Malaria Mulitsectoral Working Group on Integrated Activities to Detect and Prevent Malaria Disease including an overview of the malaria councils being established in many African countries; Mr Lieven Vernaeve, Malaria Consortium, on Expanding Mobile Malaria Services to Hard-to-Reach Communities in Northern Cambodia; and Mr Leo Makita, Director National Vector Borne Disease Program – PNG, on Australia, China, PNG Trilateral Collaboration on Malaria and Health Security.

This was followed by group work to identify and learn about current strategies for increasing access to vivax diagnostics and treatment. Discussions centred around five main topics: 1) dedicated strategies to increase access to vivax case management among remote, mobile or hard-to-reach populations; 2) feasible approaches to increase coverage of vivax case management; 3) innovative strategies or research on access utilized by countries or partners; 4) ways to improve access to vivax diagnostic, treatment, and care among most at-risk communities; and 5) ways to leverage multisectoral collaborations to increase access.

The meeting concluded with the following key call to action:

• Accelerate policy processes. The average time frames for policy change are between 7 to 20 years. Now is the time to accelerate these processes to achieve the 2030 elimination goal. We also need to move the conversation beyond malaria programs and the Ministry of Health to bring in other government ministries and make it multisectoral by engaging more senior officials and political leaders.
• Leverage successes and learnings. Learning from each other's experiences has long been the foundation of our fight against malaria. National malaria programs must be equipped to leverage these experiences by building on learnings from pilot programs, researches and clinical studies that have been taken by other countries without having to reinvent the wheel every time.
• Prepare for sustainability. Donor transition is especially relevant for the greater Mekong sub-region by 2023. Countries need to start thinking about what this transition means for procurement policies as well as implications on the overall health systems. The new innovative radical cure tools and quality standards and specifications for them which go beyond the norms that have been established by the Global Fund need to be in place so as to enable procurement by country programs. 

“As more countries approach malaria elimination, taking on P.vivax malaria is an incredibly timely and important challenge. The increase in clinical and epidemiological research on P. vivax and notably, Sri Lanka and China managing to eliminate all forms of malaria, provide hope for countries to tackle the once-neglected malaria strain. At this juncture, the learnings from the annual meeting and the shift of APMEN Vivax Working Group’s focus from research and development to implementation is critical to support countries in Asia Pacific to reach the 2030 malaria elimination target.”

Ms Amita Chebbi, Senior Director, Asia Pacific Malaria Elimination Network

A participant pack from the meeting is being developed which will include slides, notes from breakout rooms, polls and key Q&A and responses. YouTube links to different sessions are available below.

• VxWG Meeting Invitation: https://www.youtube.com/watch?v=IxV6wQyoVlg
• Day 1: https://youtu.be/NHqH_eTCoAA
• Day 2: https://youtu.be/N9voJaks8RQ
• Day 3: https://youtu.be/WX-p1iDR3g4