Malaria

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Malaria

• Building blocks to success in malaria elimination

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Proven Successes in Global Health case studies

• Eradicating smallpox
• Preventing HIV/STDs in Thailand
• Trachoma in Morocco
• Health in Mexico
• Infant diarrhea deaths in Egypt
• Onchocerciasis in Africa
• Polio in the Americas
• TB in China
• Safe motherhood in Sri Lanka

• Guinea worm control in Africa and Asia
• Tobacco use in Poland
• Measles in Southern Africa
• Hib in Chile and Gambia
• Iodine deficiency in China
• Flouridation in Jamaica
• Chagas in Southern Cone through vector control
• Fertility in Bangladesh

Source Levine, R., Millions Saved Proven
Successes in Global Health, Center for Global
Health, What Works Working Group, 2005
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Proven Successes in Global Health common
elements

• Technical consensus about the appropriate
  biomedical or public health approach
• Technological innovation with an effective
  delivery system, at a sustainable price
• Predictable, adequate funding from both
  international and local sources
• Political leadership and champions
• Good management on the ground
• Effective use of information

Source Levine, R., Millions Saved Proven
Successes in Global Health, Center for Global
Health, What Works Working Group, 2005 .
www.cgdev.org/globalhealth
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Transformations Control vs. Elimination/Eradicat
ion

• Goal - Control

• Goal E/E

• Prevent death RTS,S
• Case management
• Risk groups such as malaria in pregnancy, severe
  malaria
• Scale up existing interventions LLINs, ACTs, IRS

• Prevent transmission TBVs, SERPAC, etc.
• Simplify toolbox single dose treatment, avoid
  and prevent resistance
• Make tough decisions
• Refocus RD targets
• MalERA

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The inquiry agenda in support of malaria
elimination
Complex systems both biology and health systems
Malaria systems
Health systems
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PLoS Medicine 25 January 2011
Summary of proposed key responses
Control Scalling for impact (SUFI) Sustaining
control (SC)
Prevention of reintroduction
Pre-elimination
Elimination
Single Encounter Radical Cure and Prophylaxis
drug suitable for MDA
SERCaP / MDA
VIMT
Vaccine (s) that Interrupt Malaria Transmission
Diagnostics
New Diagnostics (individual, community/MDA)
Surveillance as an intervention
Surveillance as an Intervention
Vector Control/TPP for outdoor populations
Sustained Vectorial Capacity Reduction Tool
Modeling Intervention Mixes inc. CEA
HSR
Predictive modeling allowing strategic and
operational, including costing, assessment of
combining different control and elimination
strategies
Essential RD backbone, enabling technologies and
platforms

• Continuous culture of P. vivax
• Biology of liver stages
• Genomic and proteomic platforms
• Approaches and tools for measuring transmission

• Framework and tool for effectiveness decay
  analysis and health system integration
• Harmonization of data bases, model outputs, user
  interface
• Training

Minimal Enabling Framework for Health Systems
Readiness
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Synergy of connected system-level interventions
Decentralization, local ownership
Household health surveillance
New communication tools
District Health Profiles
District Health Accounts
SWAp Basket 1 per capita
New planning management skills
New mix of services higher coverage, quality,
utilization
Community voice tool
Source MOHSW TEHIP Tanzania
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Decentralisation
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The systems context
From Efficacy to Effectiveness
Efficacy
80
X Access
x 80
Health System Factors / Partnership
X Targeting Accuracy
x 80
X Provider Compliance
x 75
X Consumer Adherence
X 75
Effectiveness
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10
System effectiveness of ALU in Rufiji Tanzania
1000 simple malaria fevers
Sought care
Individual behaviour
Health system behaviour
Sought care within 24 h
Individual drug behaviour
Accessed ACT provider within 24 h
Correctly diagnosed or prescribed
ACT stocked in
110 cases successfully treated
Adhered to treatment
Treatment effective
413 lost
2 lost
12 lost
50 lost
64 lost
101 lost
248 lost
890 failures to treat effectively
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Real time mHealth monitoring of ACT supply
chains..
We have good drugs for malaria! But a continuing
challenge of global, national and local responses
to antimalarial drug procurement and supply chain
system realities. Current situation in 5,126
public health facilities in Tanzania on Oct 5th,
2012 Red if a stock out this week Green if in
stock this week
Surveillance in place Modern Approaches M-Health
with incentives but Action is lacking Training Un
derstanding Management
Source SMS for Life Tanzania
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Malaria Prevalence 2012
ACT-Stockouts 2012
Source NMCP-Tanzania
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Research Priorities Surveillance - Response
Systems (SRS)

• Dynamic mapping of pockets of transmission
  and/or reintroduction
• Capturing population dynamics
• Analyses of ME data and modeling to optimize SRS
  
• Parasite Man Vectors
• Sampling in space and time
• Design and validate with use of (i) evidence from
  programs and (ii) modeling (intervention mixes)
  effective response packages tailored to different
  transmission settings and levels
• Use of new technologies (m/e-health, diagnostics)
• Validation, validation, validationalongside with
  programs

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IPTc now Seasonal Mass Chemoprophylaxis

• Field implementation Guide published (English and
  French)
• 3 workshops (2012, 2013) have been organized by
  WHO in collaboration with the UCAD / LSHTM, and
  RBM/WARN that provided countries with support and
  to guide SMC planning and implementation.
• 9 countries have adopted and added it in their
  strategy
• Large scale implementation yet to start due to
  funding constraints, small scale implementation
  ongoing in a few countries
  (Mali, Senegal, Niger, Nigeria)
• Challenges in sourcing pre-qualified medicines
• Based on implementation plans developed by the
  WARN eligible countries (9 countries), 19 million
  children can potentially benefit from SMC during
  the next three malaria seasons (up to 2016).

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Global changes in malaria incidence rate,
2000-2010
2000
2010
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Global changes in malaria death rate, 2000-2010
2000
2010
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Hypothetical phasing scenario
Select Topics
Extent of malaria transmission 1945
Malaria transmission
No Malaria transmission
Source Malaria Elimination Geography, finance,
and economics, presentation by Prof. Sir Richard
Feachem, at ASTMH 7 Dec 2008.
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Hypothetical phasing scenario
Select Topics
Extent of malaria transmission 2008
Malaria transmission
No Malaria transmission
Planning for elimination or eliminating
Source Malaria Elimination Geography, finance,
and economics, presentation by Prof. Sir Richard
Feachem, at ASTMH 7 Dec 2008.
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Global need GMAP estimates Malaria
implementation and RD combined will require
5-7B per year through 2020
Funding and investments
Millions US
6,939
6,094
5,837
5,558
3,838
Implementation
RD
2009
2010
2025
2015
2020
Source Roll Back Malaria Global Malaria Action
Plan (RBM GMAP) published September 2008
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Globally, total malaria spend estimated to be
3b in 2010
H
Funding and investments
Millions US
Does not include potential future commitments
Implementation Global Fund
Implementation World Bank
3,494
Implementation PMI
3,296
Implementation Other
3,102
2,960
RD BMGF
2,878
RD NIH
2,696
2,645
RD Other
2,215
1,604
1,496
1,117
888
370
2003
2004
2005
2006
2007
2009
2010
2011
2012
2013
2015
2008
2014
Note Implementation spend assumes all committed
spend will be disbursed. Implementation includes
World Bank, Global Fund, PMI and Other USAID,
Other International Donors, Local Country Spend,
and Private Household Spend. RD spend includes
BMGF, NIH and "Other RD Spend" 1. BMGF
implementation spend is assumed to be all
captured in donation to Global Fund and is not
listed out separately. Global Fund also
includes Round Commitments, RCC Funding, and AMFm
additional funding.2. Assumed that 2007 spend
(sourced from GFinder report) will remain
constant through 2015. Prior to 2007, estimates
from 2007 Malaria Strategy work. Total of
US468m assumed to remain constant 2007 2015.
Source WHO Malaria Report 2008, Global Fund
Pledges (website), GMAP report, USAID website
(www.usaid.gov/our_work/global_health/home/Funding
/funding_rd.html), PMI website, World Bank
website, George Institute G-Finder Report for
year 2007 and 2008
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2013 World Malaria Report

• Impact from GFATM, PMI, national investments in
  malaria
• Decrease in 45 mortality since 2000 about 627K
• Greatest impact in highest burden countries
• 50 access to LLINs
• BUT
• Still have 200M /- cases
• Gains are fragile documented resurgence
• Resistance in Thai-Cambodia-Myanmar

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WHO Malaria Situation Room focus on meeting
2015 goals

• Nigeria
• Democratic Republic of the Congo
• Tanzania
• Uganda
• Mozambique
• Côte dIvoire
• Ghana
• Burkina Faso
• Cameroon
• Niger

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Malaria the post 2015 agenda

• Global transitions
• World Bank focus on extreme poverty
• What comes after the MDGs High Level UN
  Panel
• Chronic Disease agenda
• Does health remain on the agenda?
• Eradication framework
• BMGF strategy focus on transmission, Ho is
  based on strategic use of drugs at scale
• MalERA research agenda

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IVCC Progress To Date
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New medicines for Malaria Eradication

• Replacing three days ACT and 14 days primaquine
  with a simpler therapy
• Overcoming concerns about resistance

Post treatment Protection
Fast killing
Radical cure
Transmission blocking
SERCaP single exposure radical cure and
prophylaxis
Alonso P et al.,(2011) A research agenda for
malaria eradication drugs PLoS Med. Jan 258
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Global Portfolio of Antimalarial Medicines
Non MMV
Nauclea pobeguinii DRC/Antwerp
Argemone mexicana Mali/Geneva
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MVIs current portfolio
feasibility studies
translational projects
vaccine candidates
Antigen
Delivery
Preclinical
Phase 2b
Phase 3
Phase 1/2a
Antigen discovery (Seattle BioMed)
pDNA (Inovio/UPenn)
RTS,S-AS01 (GSK)
Translational research
Multivalent ChAd63/MVA(Oxford U)
Multivalent pDNA/ adenovirus(NMRC/Oxford U)
Antigen discovery (NMRC)
Pfs25 (NIAID, Fraunhofer CMB)
PvDBPII (ICGEB/MVDP)
RTS,S-AS01/ ChAd63/MVA-TRAP(Oxford U/GSK)
CSP RI conjugates (NYU/Merck)
Translational development
RTS,S-AS01 delayed fractional dose(GSK/WRAIR)
B cell targets (Seattle BioMed, JHU, NIAID,
WRAIR, NMRC)
Pfs25-EPA-Alhydrogel(NIAID)
Antigen discovery (NIAID)
Pfs25-VLP-Alhydrogel (Fraunhofer CMB)
EBA-Rh (WEHI/Gennova)
PvDBP3-5 (WEHI)
AnAPN1 (JHU)
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Estimated declines in malaria mortality rates
from 2000-2012 45 globally49 in WHO African
RegionEstimated 3.3 million lives saved (69
in 10 countries with highest burden in 2000)
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Estimated declines in malaria mortality rates
among children lt5 years of age from 2000-2012
51 globally54 in WHO African Region90 of
lives saved (3 million) among children lt5 years
of age
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Estimated declines in malaria case incidence
rates, 2000-201229 globally31 in WHO
African Region
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A range of players in Malaria
Funding and investments
Foundations
Multilaterals
Research and Academia
Clinton Foundation
Donor Countries
Private sector
NGOs
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IT ALWAYS SEEMS IMPOSSIBLE UNTIL IT IS DONE
Nelson Mandela