Title: Hot Topics in Malaria
1HOT TOPICS in MALARIA
Hot Topics in Malaria
2 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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3Welcome to the
Malaria Wars
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6Prevention
- 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.
7When 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.
8When 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.
9When 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.
10Are 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).
11Should 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
12Should 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.
13Are 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.
14Are 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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18Treatment
- 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.
19What 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.
20What 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.
21What 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.
22What 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.
23GFATM budget for all ACTs by PSM Plan stages and
by countries
24Are 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.
25Are 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.
26Are 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.
27Are people living with HIV/AIDS at greater risk
of malaria?
- .
- 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.
28Are 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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32Malaria in Pregnancy
- .
- 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.
33Malaria in Pregnancy
- . .
- 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.
34What 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.
35What 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.
36Is 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
37What 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
38What 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.
39What 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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