Global Framework for Multi-disease Elimination

Supporting countries to implement an integrated approach to eliminating multiple diseases

Briefing Global Leprosy Programme 26-27 October 2020 Background • 2019 PAHO developed regional framework for integrated elimination of communicable diseases.

• countries in the region have multiple disease elimination commitments, e.g., SDG 3.3.

• Identified 30 relevant regional diseases that impose a significant health burden and where elimination is feasible using existing tools and technology.

• Framework develops a coherent and coordinated Regional approach to disease elimination, facilitates more integration and synergies between priority public health programmes and primary health care. Background • PAHO experience prompted assessment of need to develop a Global Framework for Multi-disease Elimination.

• Review of global disease elimination programmes: • Multiple diseases (30+) targeted for elimination (SDG 3.3) HIV, TB, malaria, NTDs, hepatitis, measles, rubella, neonatal tetanus, cervical cancer, others; 4 diseases targeted for eradication • Major burden on countries to manage multiple vertical disease elimination programmes at once • Inconsistencies with elimination terminology, criteria and processes • Significant opportunities exist to increase the effectiveness and efficiency of programmes by identifying and maximizing synergies between programmes, across populations and service delivery platforms and within health systems to establish integrated people-centred healthcare approaches. • Individual strategies exist and remain critical, but no existing overarching framework to guide development of comprehensive, coordinated multi-disease elimination programmes. Diseases with global elimination targets Goal Diseases targeted

Eradication Dracunculiasis; malaria; polio; yaws

Elimination of Human African trypanosomiasis (HAT) (gambiense); leprosy; transmission onchocerciasis

Elimination as Cervical cancer; Chagas disease; cholera; gonorrhoea; hep B & C; a public health HIV; HAT (rhodesiense); leishmaniasis (visceral); lymphatic filariasis; problem maternal and neonatal tetanus; measles; meningitis; rabies; rubella (including CRS); schistosomiasis; STH/strongyloidiasis; syphilis; trachoma; TB; vector-borne diseases (including Japanese encephalitis); yellow fever Country Priorities for Disease Elimination WHO focus countries Impact of achieving elimination targets

Projected healthy life-year gains, ambitious intervention scale-up Stenberg K et al. Lancet SDG pricetag 67 countries

NTD – neglected tropical diseases MNS – mental health and substance use NCD – noncommunicable diseases RMNCH – reproductive, maternal, newborn, and child health Disease elimination impact across 3 billions

➢ Each year, diseases targeted for elimination cause >4 million deaths and suffering in many millions more ➢ UHC Single Measure includes child immunization, TB and HIV treatment, malaria prevention and basic sanitation

➢ Building resilient health ➢ Multi-disease systems with people- elimination requires centred approaches to multi-sectoral address multi-disease approaches (e.g. elimination prepares WASH) to address countries to address social, economic and emergencies. behavioural determinants of health. ➢ COVID-19 disruption of disease elimination ➢ 2 billion people do not services estimated to result have access to basic in increases of deaths due sanitation, sanitation is to HIV, TB, and malaria by key to eliminating th up to 10%, 20%, and 36% 4 billion – multi-disease many diseases e.g. over 5 years. elimination promotes integrated Cholera, polio, NTDs systems, surveillance, financing, strategic information Global strategies and targets already exist

Global strategies – multiple diseases/conditions

• NTD Roadmap (Chagas disease, dracunculiasis, HAT, leishmaniasis, leprosy, lymphatic filariasis, onchocerciasis, rabies, schistosomiasis, STH, trachoma, yaws) • Global vaccine action plan (measles, meningitis, neonatal tetanus, polio, rubella) • Global vector control response (Chagas disease, Japanese encephalitis, leishmaniasis, Lyme disease, lymphatic filariasis, malaria, onchocerciasis, plague, schistosomiasis, typhus, trypanosomiasis, yellow fever, others) • Global health sector strategy on STIs (chlamydia, gonorrhoea, HIV, syphilis)

Global Disease Strategies (individual diseases) • Cervical cancer, cholera, HIV, malaria, measles & rubella, meningitis, polio, TB, viral hepatitis, yellow fever Different Types of Disease Elimination Targets/Criteria Incidence/prevalence • Cervical cancer, gonorrhoea, HAT, HBV & HCV, HIV, leprosy, malaria, maternal and neonatal tetanus, meningitis (vaccine preventable), polio, rubella, schistosomiasis, STH (except strongyloidiasis), syphilis, trachoma, TB, LF Mortality • Cholera, hepatitis B&C, HIV, leishmaniasis (visceral), meningitis (vaccine preventable), rabies, TB Morbidity • Meningitis Intervention coverage • Cervical cancer, HBV & HCV, Chagas disease, HIV, measles, rubella, strongyloidiasis Absence of outbreaks • Yellow fever Elimination of risk factors • Industrially produced trans-fatty acids Definitions of Control, Elimination, Eradication

Stage Definition Examples Type of Governance Confirmation Level Control Reduction of disease incidence, prevalence, morbidity or high disease N.A. N.A. mortality to a locally acceptable level as a result of burden to low deliberate efforts. Continued action required. burden Elimination as a public health problem Elimination Reduction of disease incidence, prevalence, morbidity or 90% reduction in Validation Regional as a public mortality to a level at which the public health burden is TB deaths and health considered negligible as a result of deliberate efforts. The 80% reduction of problem target level is generally defined globally by WHO. When TB incidence reached, Continued action required. (SDG 3.3) Elimination Reduction to zero incidence of a specified disease through EMTCT of HIV, Validation Regional of specific a specific transmission pathway, defined geographic area syphilis, HBV, transmission as a result of deliberate efforts. Continued action required. Chagas pathways Elimination Reduction to zero incidence, specified disease, defined Neonatal Validation Regional of disease geographical area as a result of deliberate efforts. tetanus, fetal Continued action required. alcohol syndrome Definitions of Control, Elimination, Eradication

Stage Definition Examples Confirmation Governance process Level

Interruption of transmission in a specified geographic area Elimination Reduction to zero of the incidence of infection caused by Human African Verification Global (interruption a specific pathogen in a defined geographical area, with trypanosomiasis, of minimal risk of reintroduction, as a result of deliberate leprosy, transmission) efforts. Actions to prevent re-establishment of onchocerciasis transmission required. Global interruption of transmission Eradication Permanent reduction to zero of the worldwide incidence Smallpox, Certification Global of infection caused by a specific pathogen, as a result of dracunculiasis, deliberate efforts, with no risk of reintroduction. No malaria, polio, further actions required* yaws

* Interventions may be required for a buffer period; eradication is permanent barring release from containment laboratories maintaining stocks, genetic engineering to recreate pathogen or other unforeseen events Accountability - Validation Guidance, Structures & Governance

Validation guidance, processes and independent review mechanisms • 14/30+ have validation guidance, processes and designated independent review structures • One disease with validation guidance but no designated independent review structure • Several diseases in the process of developing validation/verification guidance and processes • Regional disease elimination confirmation (measles, rubella) • Regional and global confirmation processes - polio Governance • 5 Global level committees, 10 Regional Committees Diseases with multiple elimination targets • HAT, Rabies (EPHP, Elimination – Interruption of transmission); hep B, HIV, syphilis (EMTCT – EPHP); malaria (global eradication; country level interruption of transmission) Malaria Elimination Certification Processication Process

Documentation

National Independent elimination evaluation report mission Reorientation to prevent re- establishment Plan of action Certification Panel 3 years (36 months) of and timeline recommendation no indigenous cases

Endorsement of Readiness recommendation Official request by Policy assessment Advisory Committee

Publication in Certification by Weekly Director-General Epidemiologic Record Objectives of Multi-disease Elimination Framework

• Guide countries/regional organizations to develop integrated disease elimination strategies covering multiple priority diseases; people-centred approach, framework of UHC, based on global agreements and their local setting;

• Identify programme synergies, optimize effectiveness/efficiency through integrated approaches to multi-disease elimination that also address other health priorities;

• Guide countries on how best to integrate elimination of multiple diseases or conditions into national health and development strategies and plans according to local context, disease burden and other considerations – and to develop a locally appropriate ‘pathway to elimination’;

• Harmonize elimination terminology, definitions and processes globally;

• Provide an overview of all diseases currently targeted for elimination/eradication through WHO or other United Nations commitments or processes; and

• Outline potential roles and responsibilities of countries, WHO and partners to support multi- disease elimination efforts in countries and regions. Possible Structure and Elements of a Global Framework for Multi-disease Elimination

Section A: Disease Elimination On The Path To Health For All

1. Introduction

2. Context and alignment with other frameworks and principles

3. Existing measures for disease control, elimination and eradication Section B: Framework for Country Action on Multi-disease Elimination

1. Strategic information and research for better decision making and accountability

2. Planning and advocacy for integrated multi-disease elimination

3. Defining multi-disease disease elimination services, intervention and benefits packages

4. Strengthening health and community systems to deliver integrated and equitable services

5. Financing of integrated multi-disease elimination Possible Structure and Elements of a Global Framework for Multi-disease Elimination

Section C: Global Action for Sustained Disease Elimination

1. Leadership, actioning global commitments and mobilizing partner action for multi-disease elimination

2. Global public goods and standards for multi-disease elimination

3. Validation processes and governance for multi-disease elimination

4. Adapting the multi-disease elimination framework to different regions and contexts Annexes 1 – 4 Annex 1 Current global targets Annex 2 Disease information Annex 3 Diseases by life-course Annex 4 Disease intervention mapping Framework for Multi-disease Elimination Possible options

• Internal WHO framework to facilitate greater coherence/coordination across different disease elimination programmes. • Compilation of existing information including targets, high-impact interventions, validation & governance processes. • Standardization of terminology, definitions and selection of elimination criteria and governance structures. • Policy and normative guidance for countries on integration/linkages across different disease elimination programmes (advocacy, data, planning, intervention packages, service delivery, financing).

• Global framework to guide integrated multi-disease elimination efforts of countries, WHO and partners Added value

• Standardized terminology and processes will facilitate programme and service integration and coordination across multiple diseases.

• Increased efficiency in delivering multiple disease elimination programmes at the same time.

• Promotion (operationalization) of people-centred services and UHC principles.

• Disease-specific elimination strategies will still be necessary to set specific elimination targets and disease specific intervention packages. Challenges

• Possible difficulty in reaching consensus (internally and externally, across regions and disease programmes).

• Additional work required to produce new guidance on integrated approaches and standardized governance structures

• Risk of taking focus away from existing disease-specific programmes and investments.