Malaria Elimination: Future Reality? Global Health Mini University March 4, 2016
Outline Highlight tremendous progress recorded in malaria control Discuss key challenges to further progress Highlight new tools in the pipeline Focus on the future
Global Burden of Malaria in 2000 Health Burden 3.5 billion people at risk Cases: 500 million per year Deaths: >1 million per year; mostly African children Economic Burden Estimated annual loss of economic growth due to malaria -> up to 1.3% per year Compounded for 15 years, the GDP level in the 15 th year reduced by nearly 1/5
Unprecedented Global Progress Between 2000 2015*: Against Malaria 1 6.2 million malaria deaths averted 5.9 million in children under five 2 3 Dramatic reductions in estimated malaria mortality rates: by 60% of all ages by 65% of children under five years of age Gains against malaria account for an estimated 20% of total progress in reducing preventable child and maternal deaths Majority of progress has been observed in the latter part of this fifteen year time period * WHO and UNICEF report on "Achieving the malaria MDG target: reversing the incidence of malaria 2000-2015".
Evidence of Dramatic Progress Globally: The MDG of reversing malaria incidence by 2015 was achieved! The estimated malaria mortality rate fell by 60% worldwide (66% in SSA) in all ages and by 65% worldwide (71% in SSA) in children under 5 years of age Progress in malaria considered one of development s greatest success stories
Impact - Shrinking the Map Community Plasmodium falciparum parasite rate in children 2 10 years. 2000 2015
What Has Driven the Progress? The global campaign against malaria has shown what is possible when the international community joins forces on multiple fronts to tackle a disease that takes its heaviest toll on poor and underprivileged populations The advances of recent years show that the battle against malaria can be won. UN Secretary General Ban Ki-Moon, 2014 I really do believe that malaria can be eradicated in my lifetime. Bill Gates, 2014
PMI from 2005-2015: A Decade of USG Leadership
Trends in Total Funding for Malaria Control and Elimination Source: World Malaria Report, 2015, WHO
Key Factor of Success: Implementation of Proven-Effective Interventions Insecticide-treated Mosquito Nets (ITNs) Indoor Residual Spraying (IRS) Rapid Diagnostic Tests (RDTs) & Artemisinin-based Combination Therapies (ACTs) Intermittent Preventive Treatment for Pregnant Women (IPTp) Seasonal Malaria Chemoprevention (SMC)
Investments Strengthen Health Systems: Benefits Beyond Malaria Control Fewer cases and deaths reduces burden on the health system, resulting in: Improved delivery of: Antenatal care services for pregnant women Care for the sick child Laboratory services Stronger capacity for: Pharmaceutical and supply chain management Surveillance, monitoring, evaluation, and operational research to answer key questions impeding progress Extension of health services into communities through iccm - increases access to care for the most vulnerable
Malaria Control a Best Buy in Global Health Consistently high ROI, beyond the direct benefits of better health 50% reduction in global malaria incidence could produce $36 in economic benefits for every $1 invested ROI in SS Africa is estimated at 60:1 potential for transformative impact Investing in malaria equates to unparalleled investment in economic productivity and people-centered development
Sustaining and Accelerating the Gains?
Continue to Build National Surveillance and Response Capacity Epidemic Response in Uganda Epidemic detected in northern Uganda (exacerbated by heavy rains) in area where IRS previously conducted Quick response: data confirmed, team deployed, and mass fever treatment initiated Implementation of response possible because of built capacity No increase in mortality
Adapt to New Epidemiology, Uneven Progress and Tailor Approaches Targeted IRS and MIP Complete coverage for CM, ITNS for routine distribution, BCC, and SME Kenya Heterogeneity of malaria transmission Heterogeneity of control tools
Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Respond to Key Technical Challenges Increasing IPTp-2 Uptake Provider and consumer awareness and training Increasing availability of SP Spotlight on data to increase awareness 70 65 60 55 50 45 40 35 30 80% 60% Kenya 2011 2012 2013 2014 2015 100% 2013 2014 2015 Tanzania 40% 20% 0%
% of cases confirmed by diagnostic test Monitor Progress and Tailor Approaches Percentage of reported malaria cases confirmed by diagnostic test 100 90 80 70 60 50 40 30 20 10 0 2008 2009 2010 2011 2012 2013 2014 Angola Ethiopia Kenya Liberia Mali Nigeria Rwanda Senegal Tanzania Uganda Zambia Zanzibar Zimbabwe
ITN Ownership and Use 2010-2014 Household Ownership of at Least One ITN ITN Use among Children Under Five Note: Data shown are from the most recent household survey conducted in the country.
Key Challenges and Threats to Continued Progress
2015 Insecticide Resistance Pyrethroid Resistance Status Carbamate Resistance Status Susceptible Possible Resistance Resistant No data
Artemisinin Resistance Resistance continues to emerge/spread in SE Asia Prolonged drug courses still effective
Artemisinin Resistance Potential threat to progress in Africa Concern that history could repeat itself (e.g., chloroquine) Artemisinin-based treatments: vital component of continued progress Treatment failures first described in Cambodia in 2008; Active tracking of resistance in SE Asia Implications of spread to Africa
Counterfeit and Poor Quality Antimalarials Market Surveillance: Geographic footprint
Mitigating These Threats Will Require Monitoring of mosquito susceptibility to insecticides and malaria treatment efficacy Rotating or selectively deploying insecticides Limiting treatment to only diagnostically-confirmed cases Intensifying efforts to prevent import and remove substandard/counterfeit drugs Supporting approaches to sustain appropriate behaviors as burden drops
Newer Tools and Approaches New Vector Control Tools Seasonal Malaria Chemoprevention Mass Drug Administration More Sensitive Diagnostics New Antimalarial Drugs RTS,S Vaccine
PBO Nets Next-generation nets under review for efficacy
New active ingredients for IRS available in 1-2 years New IRS insecticides: Clothianidin
Large Scale Efficacy Trial Underway Durable Wall Linings
Spatial, Wearable, & Topical Repellents
Attractive Toxic Sugar Baits
Eave Tubes and Housing Modification
Number of Cases Number of cases Mali SMC Pilot Results Comparison of number of cases of confirmed, uncomplicated malaria cases between intervention and control sites, 2013 and 2014 800 Kita (study site) 700 Bafoulabe (control site) 700 600 600 500 500 400 300 2013 2014 400 300 2013 2014 200 200 100 100 0 Jan Fev Mar Avr Mai Jun Jul Aou Sept Oct Nov Dec 0 Jan Fev Mar Avr Mai Jun Jul Aou Sept Oct Nov Dec Reduction in parasite prevalence: 66% Reduction in severe anemia: 53%
SMC Pilot Conclusions Feasible to implement on existing iccm platforms Substantially contributed to reductions in malaria-associated morbidity and mortality at scale Can be an addition to an effective control program in areas that meet WHO-defined eligibility criteria and with an established iccm program
Mass Drug Administration (MDA) Malaria treatment of a population irrespective of the presence of symptoms and without diagnostic testing Aims for broad reduction of parasite burden in a malaria elimination context Also used in the context of Ebola control to reduce burden of clinical malaria on the health sector WHO is reviewing the evidence for MDA, with attention to the duration of impact Historic use of MDA in Italy circa 1930
High Sensitivity RDT (SD Bioline) Detection limit 0.1-0.8 nanogram/ml 0.78-3.1 p/µl 8-16 fold more sensitive than current tests HRP2 Concentration range at 200 parasites/µl for product testing Will enable identification and treatment of infected individuals who would otherwise be missed by current RDTs given the ability to detect at very low parasite densities
New Antimalarial Drugs on the Horizon New drug classes expected for SRA approval in 2017-2018: Alternatives to ACTs: OZ 439 and KAE 609 Transmission reducing drugs - tafenoquin
Vaccine: RTS,S (Mosquirix) World s first malaria vaccine received positive opinion from EMA July 2015 Efficacy lower than expected; assessed in combination with other interventions WHO Recommendation of large-scale implementation pilots in moderate to high burden areas WHO Call for collaboration with MOHs 3-5 countries selected; 3 year sub-national pilots planned to start in for 2017 Target group: children (5-17 months) 4 dose schedule (3 doses from 5 to 9 months, 4 th dose 15-18 months later) Evaluate operational feasibility; impact on child mortality; surveillance for adverse events; consider impact on EPI, malaria control measures, health system & community engagement
Source for maps: The Economist Looking Forward 3 billion people remain at risk from malaria Malaria remains a major cause of disease, death and economic loss Expanded resources and efforts will be required to achieve a world without malaria Current 2020 2030
Guiding Strategic Framework PMI Strategy 2015-2020 Global Strategy and Action Plan 2015-2030
Shared Vision, Goals, Milestones and Targets AIM and the Global Technical Strategy for Malaria share a joint vision, goals, milestones, and targets Vision: A world free of malaria Goals Milestones Targets 2020 2025 2030 1. Reduce malaria mortality rates globally compared with 2015 2. Reduce malaria case incidence globally compared with 2015 3. Eliminate malaria from countries in which malaria was transmitted in 2015 4. Prevent resurgence of malaria in all countries that are malaria-free At least 40% At least 75% At least 90% At least 40% At least 75% At least 90% At least 10 countries At least 20 countries At least 35 countries Resurgence prevented Resurgence prevented Resurgence prevented
2015 - A Memorable Year For Malaria February 2015 White House event launched PMI 2015 2020 Strategy Dr. Tu wins Nobel Prize Economist calls for malaria elimination Aspiration to Action maps the path to eradication in a generation Nobel Prize Awarded to Dr. Tu
UK s Recent Pledge
Momentum for Malaria Control and Elimination Continues to Grow We are on track to end the scourge of HIV/AIDS that s within our grasp. And we have the chance to accomplish the same thing with malaria. That s something I ll be pushing this Congress to fund this year. President Barack Obama, State of the Union Address, 2016
President s FY17 Budget Following President Obama signaling his intent to call on Congress to more heavily invest in malaria control in the SOTU: The President s Budget Request for FY 2017 included an increase for PMI of $200m On Feb 23, Ambassador Rice detailed Administration plans for expanding malaria efforts Addition of Sierra Leone, Cote D Ivoire, and Cameroon and the expansion nationwide of Burkina Faso Acceleration of elimination package in Zambia and Cambodia Focus on research and innovation West to Central Africa Corridor
Thank You! Questions?