Forum: General Assembly. Issue: Roll back malaria in developing countries, particularly in Africa. Student Officer: Emma Goss.

Transcription

1 Forum: General Assembly Issue: Roll back malaria in developing countries, particularly in Africa Student Officer: Emma Goss Position: Chair Introduction Malaria killed an estimated 627,000 people in 2012 according to the World Health Organization (WHO) 1. As long as humans have existed, they have been infected by and died of malaria. Studies suggest that up to half of all the people that have ever lived and died, succumbed to malaria. Not only does the disease affect humans; 25 non- primate species of mammals and numerous species of reptiles and birds are documented to have had the disease. Even dinosaurs may have had malaria. Malaria is caused by parasites carried by mosquitoes. These parasites infect the victim s bloodstream, then manifest this disease in the liver by reproducing asexually until the host cell bursts; which spreads thousands of parasites to new cells and carrying on the cycle throughout the bloodstream. In severe cases parasites can latch onto capillaries in the brain, causing cerebral malaria. These parasites are parasitic protozoans, of the genus Plasmodium. There are five species which affect humans; the most common and deadliest being P. falciparum and P. vivax. P. ovale and P. malariae cause less dangerous forms of the disease. The final species, P. knowlesi, infects maqaues in Southeast Asia, but can cause severe infections in humans. By the 1970s malaria had been effectively wiped out in the Americas, Europe and most of Asia. This was thanks to the Global Malaria Eradication Programme, launched by the WHO in The initiative used gargantuan amounts of the insecticide DDT (dichloro- diphenyl- trichloroethane), drained many square kilometres of wetlands, particularly in the southern states of the United States of America, and widely distributed the most effective anti- malarial drug at that time, 1 Fact Sheet: Combat HIV Aids, Malaria and Other Diseases. (2013, January 1). Retrieved September 21, 2014, from Page 1 of 14

2 quinine. More than a billion dollars was spent on the programme. Financing fizzled out and the initiative was abandoned in By that time, Malaria had been eradicated in the United States of America, India, Sri Lanka, Brazil, the Caribbean and the South Pacific. However it was quickly obvious that the programme had been far too ambitious, and the disease stubbornly remained in much of the tropics. The programme never made it to Africa. Today, over 90% of malaria cases occur in Africa with over 40% in Nigeria and the Democratic Republic of Congo alone. Sierra Leone has the highest death rate at per people. Mosquitoes thrive in hot, humid areas with plentiful stagnant water in which they breed. This makes much of Africa a perfect habitat. Plasmodium parasites cannot survive in high altitudes as the temperature is too low, however climate change is warming up many areas of the globe and malaria follows wherever it leads. Which could be into cities such as Nairobi, Kenya and Harare, Zimbabwe where Malaria has up until now been present only during endemics, not year- round or on a seasonal basis. As temperatures increase, this is changing. If this disease were to manifest itself in these and other heavily populated cities, the results could be devastating. Children under 5 and pregnant women are under the greatest threat from malaria. Children are more likely to die from this disease because adults often have built up immunity from contracting malaria before and their bodies therefore react quicker, either killing the parasites themselves or giving victims more time to get treatment and requiring lighter forms for treatment. Funding for the cause has increased from less than $100 million in 2000 to over $1.9 billion in This originates primarily from the WHO, UNICEF (United Nations Children s Fund.) as well as numerous private organisations and charities such as the Bill and Melinda Gates Fund. The number of cases of malaria and people dying from malaria reached a peak in the early 2000s; fortunately the numbers have fallen considerably since then. Malaria mortality has fallen 42% between 2000 and 2012 and is projected to reach 60% by 2015, although this falls short of the 75% decrease outlined by the World Health Assembly, it is an achievement. 59 out of 103 Page 2 of 14

3 countries that had ongoing malaria transmission in 2000 are meeting their Millennium Development Goal target of reversing the occurrence of Malaria 2. The UN and the WHO continue to strive to globally eradicate malaria, despite the many obstacles that stand in their way. These include malaria becoming resistant to common types of drugs, climate change, funding becoming scarcer and the population of Africa increasing. Definition of Key Terms Parasite An organism that lives on or in an organism of another species, known as the host, from the body of which it obtains nutriment. Non- Governmental Organisation (NGO) A non- governmental organization (NGO) is an organization that is neither a part of a government nor a conventional for- profit business. Usually set up by ordinary citizens, NGOs may be funded by governments, foundations or businesses. Vaccine A substance used to stimulate the production of antibodies and provide immunity against one or several diseases, prepared from the causative agent of a disease, its products, or a synthetic substitute, treated to act as an antigen without inducing the disease. Developing country A nation with a lower living standard, underdeveloped industrial base, and low Human Development Index (HDI) relative to other countries. Vector Control Any method to limit or eradicate the mammals, birds, insects or other arthropods which transmit disease pathogens. 2 WHO. (2013). Summary and Key Points. In World Malaria Report 2013 (2nd ed., Vol. 1, p. Ix). World Health Organisation. Page 3 of 14

4 Background Information Before attempting to provide solutions to the issue of malaria it is important to understand malaria s history and current situation, particularly in Africa. The countries where malaria is still prevalent tend to be Developing countries with a low GDP. Malaria has waned in and out of the public conscious in recent history. During the second world war when American soldiers were infected in the South Pacific, posters warning of the dangers of malaria and how to prevent it were common. However, after the disease was eradicated from the western world, it became easy to forget that millions of people were still dying from the disease in Africa. History of the Disease Although the P. falciparum parasite has existed for around years, its population sky rocketed concurrently with the human agricultural revolution. Egyptian mummies show signs of this disease and Alexander the Great is suspected to have died from malaria, effectively bringing about the fall of the Greek Empire. The earliest references to a disease believed to be Malaria come from 2700 BC in China. Malaria is thought to have contributed to the decline of the Roman Empire where it was known as Roman fever. The term originates from Medieval Italian where mala meant bad and aria meant air. This is because it was believed to be an airborne disease. Malaria was the first disease to be recognised as caused by a parasite by the French army doctor Charles Louis Alphonse Laveran who won the 1907 Physiology or Medicine Nobel Prize. Carlos Finlay, a Cuban doctor, discovered that mosquitoes were responsible for transmitting these parasites. Later, the Scottish Physician Sir Ronald Ross outlined the life cycle of the mosquito. He won the 1942 Physiology or Medicine Nobel Prize for his work. Economic consequences Malaria has been known not only to be common in poorer areas, but a major hindrance to economic development. Malaria was a significant factor in the slow economic development of 19 th and 20 th century Southern USA. It has been shown that countries without malaria have, on average, a fivefold higher GDP than countries with malaria. It is estimated that malaria costs Africa USD 12 billion per annum. This is due to hospital costs, sick days lost to the work force, absence from education and reduced productivity caused by cerebral malaria related mental illness. Page 4 of 14

5 Symptoms of the Disease After being bitten by an infected mosquito, malaria incubates and multiplies asexually and asymptomatically in the victim s liver cells for 8 to 30 days. At this point the occupied cells burst open and releases up to parasites each into the surrounding area. These are carried around the bloodstream; entering a cell, reproducing until that cell bursts and continuing the cycle. Malarial parasites are fairly effective at avoiding immune detection as they exist almost solely in the liver and bloodstream. However, they are likely to be detected in the spleen, which cleans the blood. It is at this point that the body begins to react. Essentially trying to kill the parasites with heat, an infected body develops a very high fever. This fever is combined with shivering, sudden coldness, sweating, headaches, muscle pains, extreme weakness and vomiting, the symptoms of severe influenza. To avoid detection, the parasites may cause red blood cells to produce Velcro- like knobs on the surface, allowing them to stick to capillaries and thin veins and arteries. These cells may latch themselves onto walls in the brain, causing cerebral malaria. A victim may fall into a coma for up to a week. Malarial comas are characterized by the victim lying in a contorted position; arched back, rigid arms, twisted fingers and pointed toes. Prevention Prevention of malaria is primarily vector control of mosquitoes. This is either accomplished through spraying insecticides, the most powerful being DDT, or to sleep under mosquito nets at night. DDT was initially used solely for malaria control however it soon became widely used in agriculture and before long mosquitoes in some areas became resistant to the chemical. During the Stockholm convention of 2001, the use of DDT in agriculture was banned and it became harder to procure in order to use it as vector control. IRS, Indoor Residual Spraying is the process most commonly used today with insecticides including DDT, the pyrethroids; cyfluthrin and deltamethrin or one of 10 other insecticides on the WHO s recommended list. Resistance to at least one of the insecticides used has been detected in 64 malaria endemic countries worldwide. In 2012, 135 million people were protected by IRS spraying worldwide, however only 58 million of these are in Africa. Page 5 of 14

6 ITNs or Insecticide Treated Nets are widely distributed in Africa and are twice as effective as non- treated nets. Around 42% of families in Africa use ITNs. They have saved the lives of an estimated people. They are most commonly treated with pyrethroids which are low in toxicity and families are reminded to tuck them under their mattress by pamphlets, touring shows and posters. 39 countries in Africa and 88 countries worldwide provided ITNs to peoples at risk of malaria free of charge in The WHO calculates that 150 million mosquito nets are needed to be supplied every year to protect those in danger of contracting the disease; however only 92 million in 2011 and 70 million in 2012 were supplied. Although this did rise to 136 million in 2013, the amount needed for the three year period (after which the nets should be replaced) is only 298 million whereas 450 million were needed. The funding for 200 million ITNs to be supplied in 2014 has been pledged. For personal protection, DEET and picaridin are the most effective insecticides. However these are too expensive to be effective in most of Africa as they must be reapplied every day. There are also a number of preventative malarial drugs, the most common being a combination of atovaquone and proguanil hydrochloride, known as malarone. Again this is too expensive for most of Africa as it must be taken every day, but is commonly used by tourists. The WHO is trying to provide chemoprevention medications to as many pregnant women at risk of malaria as possible. The process is called Intermittent preventive treatment for pregnant women (IPTp) and is an effective means of reducing the effects of malaria in both the pregnant woman and her unborn child by administering at least two doses of the drug sulfadoxine- pyrimethamine (SP). Diagnosis Malaria is usually diagnosed using microscopic examination of blood films or by antigen based Rapid Diagnostic Tests, RPTs. Microscopic examination is more common. Approximately 165 million blood films were examined this way in 2010; however it is by no means perfect. Accuracy depends on the skill of the person using the microscope and the level of parasites in the sample. The accuracy ranges from 50% to 90%. Polymerase chain reaction tests have been developed but are not as yet in common use due to their complexity. In areas where any kind of test is unaffordable the idea that fever equals malaria unless proven otherwise is widely used but leads Page 6 of 14

7 to over- diagnosis of malaria and thereby to increased drug resistivity, wasted anti- malarial medicine and distrust in the health system. Treatment The first effective malaria treatment is derived from the bark of the Cinchona tree, indigenous to Peru, and was used by the indigenous people as an antimalarial medicine. In 1640 it was introduced to Europe by the Jesuits but it was not until 1820 that the active ingredient, quinine was extracted from the plant. Until the 1920s quinine was the dominant anti- malarial medicine when it was replaced by chloroquine. By the 1980s malaria globally had become resistant to chloroquine and it was replaced by artemisins. The most common form of antimalarial medicine today is ACTs or Artemisinin- Combination Therapy. A combination is used to decrease the likelihood of a resistance forming for any one chemical. These additional antimalarials include: amodiaquine, lumefantrine, mefloquine or sulfadoxine/pyrimethamine. Another recommended combination is dihydroartemisinin and piperaquine. Strains of malaria resistant to all antimalarial medicines but ACTs are now common, however the cost of ACTs is too high for it to be widely used in much of Africa. In severe cases, such as when cerebral malaria has taken hold, IV treatment with ACTs is recommended. Important Countries and Organisations Involved Democratic Republic of Congo In the Democratic Republic of Congo (DRC) malaria is the greatest cause of sickness and death. Around 5 million people are diagnosed with the disease each year resulting in deaths. Anti- malarial efforts in DRC focus on supplying ITNs and ACTs at much subsidised prices, around a tenth of the production costs. However these supplies are still not reaching those in need. Only 35 zones out of 115 are covered by ITNs and the ACTs are not available in many areas. This leads to increased resistance to other antimalarial medicines and thereby more deaths. Nigeria 97% of the Nigerian population is at risk of contracting malaria. The remaining 3% reside in the highlands of south- eastern Nigeria where the temperature is too low for the parasites to survive, Page 7 of 14

8 however there is fear that increased temperatures due to climate change may bring malaria to the highlands. There are around 100 million malaria cases each year resulting in deaths, more than from HIV /Aids. Malaria is responsible for 11% of maternal deaths in the country. Despite the US embassy in Nigeria s intentions and efforts, 70% of malaria cases are still treated with chloroquine or SP, antimalarial medicines with high resistance rates. Sierra Leone As is the case in many countries in Africa, malaria causes more illness and death than anything else in Sierra Leone. Out of a population of only 6 million, there are 2 million suspected cases of malaria. The economic and social consequences in a country and workforce where up to a third of its members suffer from a potentially fatal or permanently debilitating disease are unfathomable. After a 2011 campaign to provide every household in the country with at least one mosquito net, 87% of households did own at least one LLIN (Long Lasting Insecticide- treated Nets.) Antimalarial efforts in Sierra Leone are funded by the government of Sierra Leone and the Global Fund to fight Aids, Tuberculosis and Malaria. United States of America The USA is an important country in this issue not because a high percentage of the population suffers from the disease or is in danger of contracting it but because it is by far the largest contributor of aid money to the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) which supplies 65% of the public funding for antimalarial aid. The USA also manufactures many of the antimalarial medications distributed in Africa and effectively decides the price of these medications. World Health Organisation (WHO) The WHO is a specialised agency of the UN. It was established on April 7 th 1948 and has its headquarters in Geneva, Switzerland. Malaria is one of the WHO s three current priorities. The others are HIV / Aids and tuberculosis. Apart from changing sexually transmitted diseases to HIV / Aids, its main priorities have not changed since its conception. The WHO publishes the World Page 8 of 14

9 Malaria Report each year. It is led by Margaret Chan. The WHO Global Malaria Program is headed by Pedro Alonso. Millennium Development Goals The Millennium Development Goals are eight specific aims the United Nations set in Out of these eight three are relevant to rolling back malaria. Number six To combat HIV Aids, Malaria and other diseases is most specific to malaria. 3 Target 6.C states Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. By 2012 the incidence of malaria had decreased by 42%. MDG four To reduce child mortality 4 is also relevant as 70% of malaria cases are found in children under 5. Target 4.A states Reduce by two thirds, between 1990 and 2015, the under- five mortality rate. By 2013 the number of children under five dying per annum had halved. Finally MDG five To improve maternal health 5 is important to the fight against malaria. Target 5.A states Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Between 1990 and 2013 maternal mortality had decreased by 45%. These statistics show that while progress is being made, it is unlikely that the MDG will reach their targets by Roll Back Malaria Initiative The Roll Back Malaria Partnership 6 or RBM is a partnership which combines the WHO, UNDP, World Bank, UNICEF (United Nations Children s Fund) and numerous funding contributors in order to forge consensus among key actors in malaria control, harmonise action and mobilise resources to fight malaria in endemic countries. It was created in 1998 by Dr. Gro Harlem Brudtland with the aim of putting an end to malaria as a global health problem. 3 United Nations Millennium Development Goals. (n.d.). Retrieved September 21, 2014, from 4 United Nations Millennium Development Goals. (n.d.). Retrieved September 21, 2014, from 5 United Nations Millennium Development Goals. (n.d.). Retrieved September 21, 2014, from 6 The Global Partnership for a Malaria-free World. (n.d.). Retrieved September 21, 2014, from Page 9 of 14

10 Map Showing Malaria Incidence 7 Timeline of Events Date Event 1820 Quinine first purified from tree bark 1880 Charles Laveran discovers malaria parasite 1898 Sir Ronald Ross demonstrates that mosquitoes transmit malaria Hans Andersag discovers chloroquine Paul Muller tests DDT Malaria is eliminated in the United States 1957 First documented case of chloroquine resistance 1992 Malaria vaccine candidate RTS,S enters clinical trials ITNs are proven to reduce child mortality by 20% 7 WHO, Malaria Department Page 10 of 14

11 2002 Genome sequencing of Anopheles gambiae (mosquito) and Plasmodium f falciparum (parasite) completed World Malaria Forum convenes in Seattle, hosted by Bill and Melinda Gates F Foundation Relevant UN Treaties and Events Date Event / Treaty 1955 WHO launches Global Malaria Eradication Campaign 1998 RBM partnership launched 2000 UN General Assembly adopts Millennium Development goals 2001 UN prequalifies ACT and recommends them for first line treatment 2002 GFATM established 2008 United Nations adopt April 25 th as World Malaria Day Representatives of nations around the world meet in New York and endorse t April 2011 May 2011 the Global Malaria Action Plan (GMAP) RES 65/L.70 Efforts to eliminate malaria by 2015, particularly in Africa WHA64.17 Malaria report Previous Attempts to Solve the Issue Many previous attempts to solve the issue of malaria have made significant headway. Most previous attempts involve multiple prongs. The most important are prevention and medication. Subsequently they often involve education and vaccine research. Prevention can be subdivided into IRS, control of breeding habitats (this has been almost entirely halted due to the environmental impact), ITNs and IPTp. In recent years the medication side has focused on Page 11 of 14

12 replacing chemoquine and other dated antimalarial medications with ACTs. There have been a number of programs to eradicate malaria once and for all. The first began in 1955, ran out of funding and was abandoned in The decade to roll back malaria was designed to be from 2000 to 2010 and finally the WHO decreed that malaria would be no more by There are few that believe this will happen. All of these project plans sounded very good on paper, but in reality it is much more difficult to ensure that each one of Africa s one billion people have access to adequate prevention and medication. The chain of supply may be very long with the size of medical stations ranging from very large national or regional hospitals all the way to small outposts servicing a few communities. To supply all of these stations with ACTs will take a very long time and be very expensive. It is plausible that it is even more difficult to supply every household with ITNs as many areas of Africa are sparsely populated and getting to and from these communities may be near impossible. It must be kept in mind that when it comes to malaria almost wiping out the disease could be worse than doing nothing. This is because adults with built up resistance from having the disease as a child are relatively safe and if malaria were wiped out in a country but then brought back, it could spark an epidemic and kill thousands. Potential Solutions It is important for delegates to remember that they are dealing with a disease that has been a top concern of the WHO since its conception. Conferences have tried, failed and tried again to produce resolutions yielding tangible results. The issue has evolved, improved and worsened over time and now it is up to you to decide how to throw the final punch. Suggestions and guidelines for potential solutions follow. Essentially efforts must not falter since the rate of funding increase per year has fallen since 2012, if possible this should return to levels. It should also be ensured that all of the funding is used for its intended purpose and no funding is lost to corruption. One priority for the funding should be building, establishing and / or improving health centres. Apart from Namibia, South Africa, Algeria, Morocco and Western Sahara, there are less than 25 physicians per people throughout Africa. In contrast, only nine countries in the rest of the world have fewer than 25 physicians per people, and many countries have over 200. Page 12 of 14

13 Many of the victims of malaria perish on route to receiving medical attention, these deaths can and should be prevented. All medical centres must be kept fully stocked with the latest ACTs, ITNs and ITPps. As well as proficiently trained professionals to care for the ill. It must also be ensured that funding for sufficient ITNs is raised each year. ITNs are an important method of malaria prevention and should be supplied to all families in Africa. As was experienced in if less mosquito nets than required are supplied each year the next year must make up for the difference, creating a snowball effect. The insecticidal properties of the ITNs wear out after three years and therefore there must be enough infrastructure in place to effectively replace all ITNs every three years. It is also important to continue documentation. An example of much needed documentation is tracking the different strains of malaria as they become resistant to certain drugs so their future paths can be predicted. The total number of victims and deaths is also not yet accurately known and this is vital information. The search for a vaccine is an extremely difficult task not least because of the rate at which malaria evolves and the numerous strains of the disease but also the complexity of the malaria parasite DNA. This search needs to continue as this could end the crisis in the way that the polio vaccine effectively ended polio. By 2012 there were 24 vaccine candidates in clinical or pre- clinical trials. The GlaxoSmithKline vaccine, RTS, S is the first malaria vaccine to enter stage 3 clinical trials and is expected to reach the UN 2015 target of 50% protective efficacy rate. 8 In order to defeat malaria the RBM initiative s targets must be adhered to. Half of the world s population is still at risk from malaria and a concerted global effort under the framework of the RBM initiative is needed to stop deaths and transition of malaria. Ultimately the world and UN should keep the issue of rolling back malaria high on their agenda. 8 Schwartz, L., Brown, G., Genton, B., & Moorthy, V. (2012). A review of malaria vaccine clinical projects based on the WHO rainbow table. Malaria Journal, 11(11), Retrieved September 21, 2014, from Page 13 of 14

14 Bibliography WHO Malaria Report 2013 Flinkel, Michael. Bedlam in the Blood National Geographic to- z- guides/malaria- topic- overview conditions/malaria/basics/definition/con malaria- still- biggest- killer MalariaFactSheet2.pdf development- professionals- network/2014/jan/17/mosquito- nets- malaria- nigeria- who mmary_- _Malaria exclusive/2013/12/27/maleria- sierra- leone/ Page 14 of 14