Conquering Malaria Through Actions Linking Control to Research

1. Conquering Malaria Through Actions Linking Control to Research Joel G. Breman, MD, DTPH Martin Alilio, Ph.D. Fogarty International Center National Institutes of Health Global Disease Programs and Policy Course School of Public Health Johns Hopkins University 12 May 2003

4. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

5. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

7. Malaria Transmission Cycle

8. Plasmodia Causing Human Malarias Plasmodium falciparum P. Vivax (relapsing) P.malariae P.ovale (relapsing)

9. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

11. Mendis, K.N. et al. Am.J.trop.Med.Hyg.(2001) Carter, R. & Mendis, K.N. Clin.Microbiol. Revs (2002) Mendis, K.N. et al. Am.J.trop.Med.Hyg.(2001) Carter, R. & Mendis, K.N. Clin.Microbiol. Revs (2002)

16. Leading causes of death for children under 5,in the WHO African Region, 2000

17. J. Breman, AJTMH, 2001 J. Breman, AJTMH, 2001

18. J. Breman, AJTMH, 2001 J. Breman, AJTMH, 2001

20. J. Breman, AJTMH, 2001 1995 population: total 585 million, 521 million (89%) in malarious areas; children <5 years 104 million, 94 million in malarious areas; assume <5 year population grows ~ 3.2% per year and will double by 2018J. Breman, AJTMH, 2001 1995 population: total 585 million, 521 million (89%) in malarious areas; children <5 years 104 million, 94 million in malarious areas; assume <5 year population grows ~ 3.2% per year and will double by 2018

22. S. Murphy and J. Breman, AJTMH, 2001 S. Murphy and J. Breman, AJTMH, 2001

23. S. Murphy and J. Breman, AJTMH, 2001 S. Murphy and J. Breman, AJTMH, 2001

24. Disability�adjusted Life Years (DALYs, 1000s),All Cause and Malaria-related, 2002 Adapted from WHO, World Health Report, 2002 Adapted from WHO, World Health Report, 2002

25. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

27. Estimated Cost of Malaria Control in an Endemic Area: One Million People, One Round of Residual House Spraying PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002 PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

28. Estimated Cost of Malaria Control: One Million People, One Full-dose Treatment, 1999 PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002 PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

29. Type of ControlVector Control Environmental modification (urban)* Chemical and biological larvicides* Indoor residual insecticide spraying* Outdoor residual insecticide spraying *costly and effective

30. Type of ControlPersonal protection (2) Insecticide�impregnated materials: nets, curtains, clothing* House screening House location Repellents Fumigants * Shown cost effective for low-income countries

31. Type of ControlAntiplasmodial (3) Patient management: early diagnosis, treatment, referral, education Chemoprophylaxis Intermittent treatment (pregnancy)* Radical therapy for relapses (P.vivax, P.ovale) * cost effective

32. Antenatal care in AfricaProportion of Pregnant Women Seeking Antenatal Clinic Care Demographic and Health SurveysDemographic and Health Surveys

33. Type of ControlSocial Action Mobilization of individual, family, community Health education Management Effectiveness Health systems effectiveness (quality), efficiency Leadership, planning, policies, strategies, tactics Surveillance Monitoring and evaluation

34. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

35. 1899, (large scale) demonstration of successful Anopheline control in Cuba: antilarval and adult measures (large-scale) 1899�1914, multiple demonstrations of control by reduction of Anopheline larvae and adults 1899, Sierra Leone (antilarval); Cuba (large-scale); Malaysia (antilarval) 1904�1914, Panama Canal Zone; control by larviciding, large-scale environmental modification 1927, elimination of A. albimanus in Barbados (first area-wide success with invading species) Successes

36. Successes (2) 1935-1939, large-scale control by pyrethrum spraying in South Africa, Netherlands and India 1939-1957 1939-1940, Elimination of invading A.gambiae from Brazil 1942-1945, A.gambiae eliminated from northern Egypt 1946-1957, Interruption of transmission by anti-mosquito measures in Cyprus, Sandinia, Guyana, Venezuela and Greece; indoor residual spraying with DDT, a major strategy

37. Successes (3) 1987-2003 Multiple projects and programs using insecticide-impregnated bed nets demonstrate overall mortality reduction and decrease in several malaria indices

38. Insecticide-treated bednets in pregnancy, western Kenya, 1997-1999 Among Gravidae 1-4, ITNs were associated with During pregnancy 38% reduction in peripheral parasitemia 21% reduction in all cause anemia (Hb < 11 g/dl) 47% reduction in severe malarial anemia At delivery 23% reduction in placental malaria 28% reduction in LBW 25% reduction in any adverse birth outcome In summary, this study involving 3170 pregnant women of all gravidae groups living in an areas of intense malaria transmission showed that women in bednet villages had less malaria and anemia during pregnancy, and at the time of delivery, particularly in the first 4 pregnancies. In this group the mean birth weights and gestational ages were higher, and the prevalence of low birth weight was reduced by 28%, and of any adverse outcome, including fetal loss by 25%. data from ter Kuile et al. ASTMH 2003 In summary, this study involving 3170 pregnant women of all gravidae groups living in an areas of intense malaria transmission showed that women in bednet villages had less malaria and anemia during pregnancy, and at the time of delivery, particularly in the first 4 pregnancies. In this group the mean birth weights and gestational ages were higher, and the prevalence of low birth weight was reduced by 28%, and of any adverse outcome, including fetal loss by 25%. data from ter Kuile et al. ASTMH 2003

39. Eradication Programs

41. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

42. Conquering Malaria: Through Actions Linking Control to Research Background: ecology and natural history Burden: manifestations and toll Interventions: strategies and effectiveness Successes and challenges: historical and current Multilateral initiatives: Roll Back Malaria Multilateral Initiative on Malaria The way forward

43. Essential Strategies for Dealing with Malaria Use simple, cost-effective tools. Abolish �malaria taxes� and distribute insecticide-treated bednets. Promote and fund research in all its dimensions. Fund demonstration projects on and use of integrated vector management strategies. Scale-up operations.

44. Essential Strategies for Dealing with Malaria (2) Provide financial assistance to poorer countries. Engage public-private partnerships. Insure targeted diagnosis and treatment. Slow drug resistance. Integrate malaria treatment into existing programs. Invest in malaria drug and combination therapy development and distribution.

45. Prompt and effective treatment reduces mortality by at least 50% Mortality further reduced if treatment is available in home Drug resistance can be delayed through combination therapy including artesunates Insecticide-treated nets can reduce all cause mortality by 20% New rapid diagnostic techniques becoming available at lower cost Application of epidemiological and geographical information can help predict epidemics Promising developments

46. Research Agenda Pathogenesis Drug development Vaccine development Diagnostics Clinical and community-based trials Entomology

47. Research Agenda (2) Clinical issues anemia neurologic and cognition pregnancy-related Health services delivery Social, legal, ethical

48. Controversies Drugs Combination artemisinin-based compounds for treatment Chemoprophylaxis for high risk persons Burden Malaria as a cause or risk-factor (co-morbidity) Cognition and developmental issues