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Dr. Ambrose Talisuna

From malaria eradication to control, control to elimination in Africa: Moving the full circle!. First Malaria Forum, Kigali Rwanda, 26-28 th September 2012. Dr. Ambrose Talisuna. 2009.

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Dr. Ambrose Talisuna

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  1. From malaria eradication to control, control to elimination in Africa: Moving the full circle! First Malaria Forum, Kigali Rwanda, 26-28th September 2012 Dr. Ambrose Talisuna 2009

  2. Today, we are here in this great city of Kigali, because we have chosen hope over fear of failure AND unity of purpose to face the challenges/threats for malaria elimination in AfricaWe have to draw lessons from our past to chart the path for the futureWe are all aware that failure could lead to frustration and apathyBUT! these numbers here are not just statistics, they are real people!!!! 679 million people at risk of Pf – ¾ Africans 171 million (25%) in stable PfPR 5-39% 377 million (56%) in Stable PfPR 40%+ Hay et al., PLoS Medicine 2009

  3. Largely based on IRS with DDT With urbanisation and favourable climate, it was successful in the temperate zones-Europe and North America In Italy malaria decreased substantially because of the availability of quinine and the presence of medical doctors in remote places. In Africa eradication failed because: Implementation was only in a few countries Transmission was too intense to interrupt with then tools Poor administrative organisation Inadequate epidemiological skills/knowledge Inadequate surveillance and HIS Absence of a solid health infrastructure Vertical organisation of programmes Required efficient and stable organisational infrastructure Emergence and spread of DDT and drug resistance Where did we come from? The malaria eradication era:1950-Kampala, 1955-WHA, 1969-WHA

  4. Country programmes collapsed due to lack of resources (human and financial) Little effort (international and national) resulted in a resurgence of malaria in Africa WHO and partners shifted focus to searching for new tools/ improving existing ones 1975:Special Programme for Research and Training in Tropical Diseases (TDR) established to promote research and generate critical new information to strengthen capacity of low-income endemic countries to undertake research for developing and implementing new and improved disease control approaches Era of apathy and lack of resources:1970-1990

  5. 1992: A global malaria control strategy with the aims of preventing mortality and reducing morbidity-adopted-WHO, 1993 Increased malaria burden catalyzed many multilateral initiatives-programmatic and research 1997: The Multilateral Initiative on Malaria (MIM) launched Aims: training scientists, coordinating research funding, promoting greater research and control leadership in Africa -Siegel, et al, 2001, Sina, 2000, Nchinda, 1998 1997: Harare Declaration for Malaria Prevention by member states of the then Organization of African Unity (OAU) Era of renewed optimism: 1990-2007 (I)

  6. 1998: Global Roll Back Malaria effort announced by heads of WHO, UNICEF, UNDP, and the World Bank 1999: The Medicines for Malaria Venture (MMV), a novel PDP was initiated-Ridley, 2002, Moerman, 2003 1999: PATH-Malaria Vaccine Initiative (MVI) another PDP initiated 2000: The African Summit on Roll Back Malaria held in Abuja, Nigeria and the Millennium summit held in New York African leaders committed: to halve the malaria mortality for Africa’s people by 2010 Leaders from every country agreed on a common vision for the future-the MDGs Era of renewed optimism:1990-2007 (II)

  7. Resource allocation for malaria was still inadequate-The GF was initiated to alleviate the funding gap By 2004: GF had allocated 2 billion US dollars for malaria control and prevention over a 5 year period Yet this was still short of the global needs To date: GF has approved approx. 25 billion USD for the three diseases and disbursed 17 billion Worryingly contributions have dropped for the period 2010-2013 2002: Birth of the Global Fund (GF)

  8. 2002: African Development Bank (AfDB) Group-malaria control strategy 2002: Clinton Health Access Initiative (CHAI) 2003: Islamic Development Bank (IDB)-Roll Back Malaria quick win 2005: US-President Malaria Initiative (PMI) 2008: TheLantos-Hyde Act authorized an expanded PMI program for 2009-2013 2005: World Bank’s Booster programme 2005: The Bill and Melinda Gates foundation (established in 1994-96) deepened its support announcing grants totaling $258 million to develop a malaria vaccine, new drugs, and innovative mosquito control methods. On going regular bilateral support-DFID...and Several others The birth of other initiatives

  9. 2007 (Seattle): Bill and Melinda Gates challenged global community to re-new commitment to end death from malaria Clarion call taken up by the RBM Partnership and WHO 2008: Global malaria action plan (GMAP) formulated with a vision to end malaria suffering and death 2007: New call for elimination

  10. Post 1969, global malaria strategies (WHO, 1993) focused on high malaria burden countries Little focus on the low burden countries where elimination is feasible 2008 WHO GMAP recognizes different categories of countries WHO GMAP differs from previous malaria strategies…

  11. Eradication- Permanent reduction to zero of the world wide incidence of malaria as a result of time bound deliberate efforts Intervention measures are no longer needed once eradication has been achieved Elimination- Reduction to zero of the incidence of malaria in a defined geographical area as a result of deliberate efforts Continued measures to prevent re-establishment of transmission are required Is malaria elimination feasible in Africa now? May be yes- In some settings because it depends on the local epidemiological context-“one size does not fit all” Eradication Vs. Elimination: The differences

  12. Malaria elimination in Africa: The debate -1 • Does the focus on elimination in certain settings right now cause harm? • In the high burden countries there could be potential risks: • Inequitable distribution of scarce resources • Lack of targeting of interventions • Overzealous universal combination of IRS with LLINS without targeting based on the local epidemiology and malaria risk • Resistance to drugs and insecticides as a result of mismanaged scale up • Bad timing of mass screening and treatment (MSAT) strategy • Program management challenges • Inadequate human resources -managerial and technical, overwhelmed by premature deployment of vertical elimination interventions!!!

  13. Malaria elimination in Africa: The debate -2 • A misunderstanding of the important BUT practical differences between elimination and control • The relative priority given to high vs. low burden target areas • The choice and timing of interventions • How robust surveillance should be? • The need for cross border collaborations

  14. Where elimination is currently not feasible Impact will be maximized by universal coverage in context of a strengthened health system Un-justified elimination programs could fragment an already fragmented health system A premature paradigm shift could raise expectations that need to be managed Expectations of elimination targets among donors, politicians, policy makers, health workers, and communities Likely to be higher than what is realistic Explanation of a long term vision-not likely to temper those beliefs Eradication/elimination vision is a good BUT needs proper communication to maintain trust AND proper execution to really benefit lives Malaria elimination in Africa: The debate -3

  15. Is there light in the middle of the tunnel in Africa today? Yes & No Intervention coverage is not uniform across Africa Estimated households with at least one ITN in SSA, June 2011 Proportion of population at risk of malaria protected by IRS in SSA, 2010 Source: WMR, 2011

  16. Some evidence of intervention impact Source, WMR, 2010

  17. No evidence yet of intervention impact Burundi Kenya DRC Sudan Tanzania Mainland Uganda Malaria admissions in some Ugandan hospitals increased by 47-350 % between 1999 and 2009-Okiro et al, BMC Medicine, 2011 Source: WMR, 2011

  18. Challenges for Africa-1 • Weak health systems, including community systems and referral systems • Inadequate human resources for health • Price/affordability of life saving medicines: especially in the private sector • Procurement supply chain management challenges especially in the public sector • Inadequate coverage of curative and laboratory services • Inadequate integration of different sectors and programmes

  19. Challenges for Africa-2 • Weak organisational, supervisory and management capacity • Inadequate monitoring and evaluation systems • Inadequate capacity for communication of knowledge to the public • Sub-optimal quality in the management of severe malaria- a neglected population • Continued use of artemisinin monotherapy • Un-regulated informal private sector use

  20. ? ? ? Threats: Artemisinin resistance Dondorp et al, 2009, Phyo et al, 2012

  21. Threats: Insecticide resistance Malaria endemic countries reporting resistance to pyrethroids in at least one vector in at least one monitoring site, 2011 Source: WMR, 2011

  22. Threats: Fakes, poor quality & counterfeit medicines

  23. Threats- Fakes & counterfeits

  24. Implications of artemisinin and insecticide resistance to Africa? Past and projected funding for malaria control Malaria and child mortality rose in the 1990s due to CQ resistance The decline in African child mortality is speeding up again Snow et al. (2003), Trends in Parasitology Source: World Bank Source: WMR, 2011 Can you imagine artemisinin resistance COMBINED with insecticide resistanceCOMBINED with declining funding for malaria? A public health disaster!!

  25. Conclusion-1 • The African malaria elimination journey will NOT be one of shortcuts • NOR will it be a path of quick fixes or patchy interventions: rather it will be a journey of sustained universal coverage of evidence based interventions • The challenges and threats we face today are real, numerous, and some are serious

  26. Conclusion-2 • Rwanda, Zambia, Eritrea, Sao Tome and Principe, the Island of Zanzibar make us optimistic that with good political commitment and sustained domestic and international resources, these challenges and threats can be surmounted • We can choose to do “business as usual” and have ONLY modest success OR we can decide to put all resources and every effort together and be counted as the generation that eliminated this old scourge from Africa!

  27. Thank you

  28. Priorities for Africa-1 • Strengthen community based initiatives • Improve health systems and Human resource capacity • Performance based financing models • Increase access to integrated preventive, diagnostic and curative services • Improve the management of severe malaria • Using new channels to increase the coverage /access to cost effective interventions • Strengthening advocacy, communication and social mobilization (ACSM) for behaviour change across all malaria strategic thematic areas

  29. Priorities for Africa-2 • Narrow the commodity gaps for critical malaria interventions-ACTs, LLINs, IRS, IPTp etc. • Address malaria control in politically complex/unstable settings • Robust monitoring and evaluation • Strengthen pharmacovigilance and post marketing surveillance • Regular insecticide and drug resistance monitoring • Better documentation of the changing epidemiology and burden of malaria • Better documentation of intervention coverage at national and sub-national level by thematic area

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