Hot Topics in Malaria

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HOT TOPICS in MALARIA

Hot Topics in Malaria
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USAID The Blind Hydra
USAID Fails to Buy DDT
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Senate Bill Proposes to Move Malaria Program to
State
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RBM Attacked as Failed Program
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Welcome to the
Malaria Wars
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Prevention

• The most effective way to prevent malaria is
  through the selective and safe use of
  insecticides that kill the malaria transmitting
  mosquito.
• There are two options for getting these
  insecticides into the homes of those most at
  risk indoor residual spraying (IRS) and
  insecticide-treated nets (ITNs).
• USAID supports the use of both IRS and ITNs.

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When is IRS the Best Option?

• IRS is best suited for areas of unstable malaria,
  epidemic prone malaria, in urban settings when
  local transmission of malaria is well documented,
  and in refugee camps.
• In each of these settings IRS has important
  advantages it has rapid and reliable short-term
  impact and can be targeted to communities at
  highest risk.
• IRS is, however, relatively demanding in terms of
  the logistics, infrastructure, skills, planning
  systems and coverage levels.

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When are ITNs the Best Option?

• The consensus is that in endemic Africa (south of
  the Sahel and north of the Zambezi River) ITNs
  are the most practical and effective means for
  protecting the population
• ITNs have been shown to be highly deployable in
  rural Africa using the existing NGOs, commercial
  sector, community groups and public sector
  infrastructure.

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When are ITNs the Best Option?

• ITNs provide significant protection to those
  sleeping under them, and can reduce all cause
  mortality in children by one-fifth and episodes
  of malaria by half.
• Maintaining supply chains and behavioral
  promotion activities to keep ITNs widely
  available, insecticidally-active and effectively
  used is a challenge, but well-designed programs
  are having good success in many countries.

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Are there Prohibitions Against Procuring
Insecticides?

• USAID resources can be used to procure
  insecticides for its health programs, including
  DDT.
• Purchase or use of insecticides require an
  environmental risk assessment.
• The required environmental assessment procedures
  are described in Title 22 of the Code of Federal
  Regulations, Part 216 (22 CFR 216).

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Should people living with HIV/AIDS be targeted
for ITNs?

• Among adult men and non-pregnant women, HIV/AIDS
  may augment the risk of malaria illness,
  especially in those with advanced
  immuno-suppression.
• In areas of unstable malaria transmission,
  HIV-infected adults with low CD4 cell counts may
  also be more susceptible to treatment failures of
  antimalarial drugs. In addition, acute malaria
  episodes temporarily increase viral replication
  and HIV viral load.
• As an important cause of anemia, malaria
  frequently leads to blood transfusion, which is a
  potential risk factor for HIV infection

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Should people living with HIV/AIDS be targeted
for ITNs?

• The following are the recommended strategies for
  addressing the risk of malaria and HIV
  co-infection
• In areas of malaria transmission protection by
  ITNs is a high priority for people living with
  HIV/AIDS.
• HIV-positive pregnant women as risk of malaria
  should always be protected by ITNs, and in
  addition receive either intermittent preventive
  treatment with SP (at least 3 doses) or daily
  cotrimoxazole prophylaxis.

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Are there any other new technologies on the
horizon?

• An exciting new product that is expected to be on
  the market in early 2005 is a long-lasting
  retreatment KO Tab 1,2,3.
• Employing a new technology that mixes traditional
  insecticide with chemical binders the
  traditional dipping of nets will be sufficient
  to transform them into long-lasting nets.
• The advent of permanent retreatments creates an
  opportunity for transforming all of the
  traditional ITNs already in the field into
  long-lasting nets dramatically increasing the
  number of households benefiting from ITNs.

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Are there any other new technologies on the
horizon?

• In addition, USAID has been working with textile
  groups to develop a new LLIN using the KO Tab
  1,2,3 chemistry.
• This LLIN will be marketed as Dawa plus and be on
  the market this summer - at significantly lower
  cost than current LLINs.

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Treatment

• Prompt treatment with a safe and effective
  antimalarial drug is a fundamental component of
  the World Health Organizations, Roll Back
  Malarias and USAIDs strategy to control
  malaria.
• Correct use of antimalarial treatment will not
  only shorten the duration of malarial illness,
  but also reduce the frequency of complications
  and the risk of death.

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What is the current status of antimalarial drug
resistance in the world?

• The spread and intensification of antimalarial
  drug resistance represents one of the most
  serious challenges to malaria control worldwide.
  
• In Southeast Asia, strains of P. falciparum have
  developed resistance to multiple antimalarial
  agents and very few drugs remain effective.
• In South America, high levels of resistance to
  both chloroquine and SP are already present
  throughout the Amazon Basin.
• In Africa south of the Sahara, chloroquine
  resistance is now widespread and increasing
  resistance to SP has been documented in East and
  southern Africa.

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What drugs are currently recommended for
treatment of malaria?

• WHO now recommends that all countries
  experiencing resistance to their current
  first-line single-drug antimalarial therapy
  change to combination therapy, preferably with an
  artemisinin drug.
• Four ACT regimens are recommended
• artemether-lumefantrine (Coartem),
• amodiaquine-artesunate,
• SP-artesunate, and
• mefloquine-artesunate.
• A fifth, non-ACT, combination, SP plus
  amodiaquine, is another alternative in settings
  where both drugs remain efficacious.

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What is the status of ACTsupplies worldwide?

• By 2006 worldwide demand for artemisinin is
  expected to increase to 150 million treatments
  (up from 50 million treatments in 2004).
• This forecasted increase has to-date outstripped
  the worldwide production capacity for ACTs
  leading to shortfalls in supplies.
• In response, USAID is supporting efforts to
  increase the cultivation in east Africa of
  Artemisia annua, the plant from which artemisinin
  is extracted, to increase availability of the raw
  product. This is expected to lead to an
  additional 50 million pediatric treatments by the
  end of 2005.

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What is the status of ACTsupplies worldwide?

• USAID, in addition, is actively working with
  pharmaceutical companies to upgrade their ACT
  production capacity.
• By 2007 it is expected that worldwide supplies of
  ACTs will be more in line with demand. In the
  interim, strategic targeting of ACTs will be
  required to ensure that those countries with high
  levels of drug resistance have adequate drug
  supplies.

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GFATM budget for all ACTs by PSM Plan stages and
by countries
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Are there prohibitions against USAID purchasing
antimalarial drugs?

• There are no prohibitions to the purchase of
  antimalarial drugs with USAID funds.
• In the case of antimalarials, such as ACTs, which
  have not been approved by the Food and Drug
  Administration, they can still be purchased by
  USAID if their safety and efficacy have been
  demonstrated by a recognized authority, such as
  WHO.

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Are there prohibitions against USAID purchasing
antimalarial drugs?

• Generally, USAID has limited its purchase of
  antimalarials to emergency or transitional
  situations, finding it more effective to work
  with other financing institutions, such as the
  World Bank and the Global Fund to Fight AIDS,
  Tuberculosis and Malaria, to ensure adequate
  supplies of effective antimalarials.
• USAID has focused its efforts on the provision of
  technical assistance to countries to update their
  malaria treatment policies, implement those new
  policies smoothly and effectively and monitor the
  results of the changes in policy.

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Are people living with HIV/AIDS at greater risk
of malaria?

• HIV infection diminishes the ability of pregnant
  women and immunocompromised adults to control P.
  falciparum infections.
• The prevalence and intensity of malaria infection
  during in HIV patients is higher.
• Similarly, patients with HIV infections are more
  likely to have symptomatic malaria infections and
  pregnant women have an increased risk for
  malaria-associated adverse birth outcomes.

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Are people living with HIV/AIDS at greater risk
of malaria?

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• Co-infections with HIV/AIDS and malaria increase
  both the severity of illness and the risk of
  anemia.
• For these reasons, accurate diagnosis and prompt
  therapy with a highly effective antimalarial drug
  regimen, preferably an ACT, is recommended.
• The impact of HIV/AIDS on malaria infections in
  children is less clear.

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Are there any new technologies or treatments on
the horizon?

• Final approval of a new rectal artesunate
  treatment for severe malaria in children is
  expected in 2006.
• A pediatric formulation of artemether-lumefantrin
  e (Coartem) should marketed by early 2008.
• Several other new artemisinin combination
  therapies that are likely to be significantly
  less expensive than those currently available and
  co-formulated for easier compliance.should become
  available over the next 3-4 years. These include
  artesunate-chlorproguanil-dapsone (Lapdap) a
  combination of dihydroartemisinin and piperaquine
  (Artekin) and a combination of artesunate and
  pyronaridine.

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Malaria in Pregnancy

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• The major impact of P. falciparum infection
  during pregnancy is related to anemia in the
  mother and the presence of parasites in the
  placenta.
• The resulting impairment of fetal nutrition
  contributes to low birth weight and is a leading
  cause of poor infant survival and development in
  Africa.
• There are between 100,000 and 200,000 deaths
  annually in Africa of infants from complications
  associated with malaria-related low birth weight.

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Malaria in Pregnancy

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• For areas with moderate to high levels of malaria
  transmission, such as most of sub-Saharan
  Africa,WHO recommends a three-pronged use of
  intermittent preventive treatment (IPT)
  insecticide-treated nets (ITN) and case
  management of malarial illnesses.

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What is intermittent preventive treatment (IPT)?

• IPT involves the administration of two or three
  full, curative antimalarial treatments with an
  effective drug, beginning in the second trimester
  after quickening.
• At present SP is the only drug recommended by
  the WHO for IPT.
• The spread of resistance of P. falciparum to SP
  in eastern and southern Africa has raised
  concerns about the efficacy of SP for IPT. The
  current guidance is that SP remains an effective
  strategy for IPT providing adequate protection
  from malaria infection in pregnant women.

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What is intermittent preventive treatment (IPT)?

• There are efforts, however, to identify
  alternative IPT options which would be
  introduced as evidence mounts that SP is no
  longer an effective option for IPT.
• Since more than 70 of pregnant women in Africa
  attend antenatal clinics at least once during
  their pregnancy, the provision of IPT during ANC
  visits is both feasible and attractive.

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Is IPT recommended for women living in areas of
low malaria transmission?

• There is no evidence that pregnant women living
  in areas with low levels of malaria transmission,
  as found in Asia or Latin America, benefit from
  IPT and as such, is not recommended

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What is the impact of HIV/AIDS on malaria during
pregnancy?

• Co-infected pregnant women are at very high risk
  of anemia and malarial infection of the placenta.
  As a result, a considerable proportion of
  children born to women with HIV and malaria
  infection have low birth weight and are more
  likely to die during infancy.
• It is unclear whether malaria during pregnancy
  increases the risk of mother-to-child
  transmission of HIV, as studies examining this
  relationship have shown conflicting results

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What is the impact of HIV/AIDS on malaria during
pregnancy?

• While the risk of malaria in HIV women is
  greatest during the first and second pregnancies,
  in the presence of HIV infection, the risk
  associated with placental malaria seems to be
  independent of the number of pregnancies, and
  multigravidae with HIV infection are similar to
  primagravidae without HIV infection in terms of
  their susceptibility to and the negative
  consequences of malaria infection.

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What is the Recommended Treatment for HIV
Infected Pregnant Women?

• A minimum of three doses of SP is required to
  obtain maximum protection. for HIV pregnant
  women living in areas with high levels of
  transmission

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