Malaria Challenges

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Malaria Challenges

• Mary Ettling
• Malaria Team Leader BGH
• 12 May 2003

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Malaria Basics

• Geographic variability parasite, vector,
  transmission, behaviors, impact
• Four species of Plasmodium in humans
• Many anopheline species transmit
• As yet no vaccine
• Parasite resistance to drugs
• Some vector resistance to insecticides
• Roll Back Malaria partnership

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Brief history

• Early environmental methods
• Eradication era DDT and chloroquine
• Holding the line with drugs
• Amsterdam Ministerial Conference
• Global Strategy/Africa Strategy
• New tools and building commitment
• Roll Back Malaria

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Resurgence of Malaria

• Ecological change
• Breakdown of health systems/control
• Political upheaval
• Population movement
• Relaxing of control capacity and political will
  after eradication effort successes
• Marginal populations

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Distribution of 4 Million Deaths Among Children
less than 5 Years Old Africa
Malnutrition 34
Note HIV/AIDS is contributing substantially to
rising child mortality rates in Africa,
increasing rates by as much as 20.
Source Adapted from Fact Sheet 109, Childhood
Diseases in Africa, World Health
Organization, 1996
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Abuja Declaration

• By 2005
• 60 of children receiving prompt effective
  treatment
• 60 of pregnant women receiving IPT
• 60 of children and pregnant women sleeping
  under ITNs

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Key intervention Prompt, effective treatment

• Recognition and prompt response
• Drugs that work
• Access and affordability
• Commodities
• Good use

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Emergence and Spread of Drug-Resistant Malaria

• Underlying Conditions
• Constant mutation
• Lots of drug around
• Migration/displacement/
• war/failure of control
• Poor drug use and quality
• Poorly regulated private sector

Emergence/spread of CQ-resistant malaria
(1957-1980s)
Burma

• Now significant resistance to CQ, SP,
• MQ, Q in Asia
• To CQ throughout Africa
• To SP in East Africa

Thailand
Cambodia
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Regional Progress on Treatment

• Mekong Initiative quality evidence, shared
  technical and strategic experience, capacity
  building, engagement with local pharma, access by
  marginal populations
• Amazon Initiative quality evidence, shared
  lessons, capacity building

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Intercountry Response in The Mekong Region

• 36 sentinel sites
• In vivo testing (clinical
• treatment failures)
• Testing at each site
  once every 2 years
• Standardized testing and reporting
• Optional additions
• In vitro testing
• Drug quality
• Drug use behaviors

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Progress Effective Treatment
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Major Issues

• Combination therapy artemisinins
• Access and coverage private sector
• Appropriate use-- adherence
• Drug quality regulation and demand
• Cost and financing

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Key intervention IPT and ITNs in Pregnancy

• Early attendance at ANC
• Commodities
• Provider performance
• Partnership with RH

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Burden in Pregnancy

• 45 million pregnancies annually in endemic areas
  of Africa 23 in high transmission
• Mothers 3-15 of severe anemia and 10,000
  malaria anemia deaths per year
• Infants 30 of preventable low birthweight and
  75-200,000 infant deaths per year

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Malaria in Pregnancy
Malaria
Pregnant Women
parasitemiaspleen ratesmorbidity anemia
fever illness cerebral malaria
hypoglycemia puerperal sepsismortality
severe disease hemorrhage
Fetus
abortionsstillbirthscongenital infection
Newborn
low birth weight prematurity
IUGRmalaria illnessmortality
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Antenatal care in AfricaProportion of Pregnant
Women Seeking Antenatal Clinic Care
Demographic and Health Surveys
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• Intermittent Preventive Therapy

Rx
Rx
Rx
R
20
30
10
Quickening
Conception
Birth
Weeks of gestation
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Progress Malaria in Pregnancy
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Bednets Birth Outcome
Gravidae 1-4
ter Kuile 2001 Kenya
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Key interventions ITNs

• Building retail distribution
• Targeting subsidies
• Improved quality
• Good use
• Sustainable markets

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New products

• Low rates of re-treatment
• Long-lasting nets
• Permanently treated nets
• What is the life of a net?
• Cost

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Annual needs in LLITNs to protect the most
vulnerable groups at risk of malaria in Africa
(285 million people)

• Year 1 to year 5
• 115 million nets
• After year 7 (maintenance)
• 29 million nets/year

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Going to National Scale with ITNs

• Taxes and tariffs
• Market priming
• Targeted subsidies
• Sustained supply

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Progress ITNs with NetMark
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Scope of the Challenge

• lt5 of African children sleep under an ITN
• lt15 under any net at all
• lt10 of women sleep under a net
• lt5 with IPT in ANC
• Effective treatment still not widely available

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USAID Malaria Program
Bilateral Projects
Regional Programs
Complex Emergencies