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Africa: Eliminating Malaria
AfricaFocus Bulletin
Oct 20, 2011 (111020)
(Reposted from sources cited below)
Editor's Note
"Over the past decade, scaling up the delivery of existing
interventions [against malaria] is estimated to have saved
more than one million lives in Africa alone, with the
majority of these deaths averted since 2007. That was the
year when the big push to improve coverage really hit the
ground." - Dr. Margaret Chan, Director-General, World
Health Organization
It is far too soon to declare victory. Over 700,000 people
a year are estimated to be dying from malaria. But, noted
Dr. Chan, the rapid progress in recent years makes it
possible to think that the world can achieve the goal of
"near-zero" deaths from malaria by the end of the target
year of 2015. Full elimination of the disease may take four
decades. "The goals of near-zero deaths and eventual
eradication are idealistic and aspirational," she noted,
"but not foolhardy as some critics suggested in 2007."
This AfricaFocus Bulletin contains the keynote address by
Dr. Margaret Chan at the Malaria Forum hosted by the
Bill & Melinda Gates Foundation in Seattle, Washington this
week. Also included is an article from the Citizen (Dar es
Salaam) on the successful trials of a new anti-malaria
vaccine, which could be ready for production by 2015.
For the most recent updates on the global fight against
malaria, see http://www.rollbackmalaria.org
Recent issues of AfricaFocus on malaria include:
Senegal: Music to Fight Malaria
http://www.africafocus.org/docs11/mal1104.php
Africa: Ending Malaria in Sight?
http://www.africafocus.org/docs09/mal0911.php
Africa: Progress on Malaria
http://www.africafocus.org/docs09/mal0904.php
Africa: Malaria Control Up, Majority Not Covered
http://www.africafocus.org/docs08/mal0809.php
For ongoing coverage on malaria, see
http://allafrica.com/malaria
For previous AfricaFocus Bulletins on health issues, see
http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++
Keynote Address at the Bill and Melinda Gates Foundation
2011 Malaria Forum - Optimism and Urgency
Dr Margaret Chan
17 October 2011
World Health Organization (Geneva)
http://www.who.int /
http://allafrica.com/stories/201110180901.html
Distinguished scientists, colleagues in public health,
ladies and gentlemen,
As we all know, the previous malaria forum organized by the
Bill and Melinda Gates Foundation in 2007 created a
sensation. The Goal Whose Name Must Not be Spoken
(eradication) was mentioned, and this unspeakable ambition
stimulated considerable scepticism.
Moreover, there was dismay, as I, the head of a respected
and technically exacting health agency, took up the
challenge. I endorsed eradication as the ultimate goal for
the future.
Sceptical reactions were entirely understandable. After
all, malaria had been soundly outwitting and defeating
control efforts for centuries, and most spectacularly so in
the global eradication initiative launched by the World
Health Assembly in 1955.
As with Sisyphus, the boulder was painstakingly rolled
upwards only to tumble back down again in an absurd
exercise of futility. Malaria always resurged and often
roared back with a vengeance, causing deadly epidemics in
areas where control had almost been achieved. Periodic
epidemics took an even heavier toll on communities, causing
more cases and deaths.
At the close of the previous century, ambitions for malaria
control had been reduced to holding the disease at bay,
aiming to keep a very bad situation from getting any worse.
Back then, the one good thing that could be said about
malaria was that the situation was stable. It could hardly
get any worse.
As the African Leaders Malaria Alliance, or ALMA, stated
last month: "In Africa, we used to track malaria by metrics
of despair: cases and deaths, wasted life and squandered
opportunity. We tracked numbing statistics like the million
Africans who died annually from this preventable disease a
decade ago."
Now, what we are tracking is progress, some very recent
progress, and some stunning gains on age-old fronts. Since
2007, endemic countries have seen record-breaking progress
in terms of funding, intervention coverage, and public
health impact.
This is not linear step-by-step progress, the boulder
gradually nudged up the slope, but progress characterized
by huge leaps and bounds forward.
As set out in the World Malaria Report 2010, the annual
number of malaria cases and deaths continues to decline,
especially in Africa. The number of countries that have
successfully cut their malaria burden in half over the past
decade continues to rise.
Let me repeat some figures that support the revival of
optimism.
Between 2008 and early 2011, nearly 300 million treated
mosquito nets were delivered to sub-Saharan Africa, enough
to protect 578 million people.
Over the past decade, scaling up the delivery of existing
interventions is estimated to have saved more than one
million lives in Africa alone, with the majority of these
deaths averted since 2007. That was the year when the big
push to improve coverage really hit the ground.
The malaria map is shrinking. In 2009, for the first time,
not a single case of falciparum malaria was reported in the
European Region, and this trend continues. WHO procedures
for certifying a country as malaria-free, abandoned in the
1980s, were reinstated in 2004.
Since 2007, Morocco, Turkmenistan, and United Arab Emirates
have been certified as malaria-free.
Today, I have great pleasure in announcing that Armenia has
been certified by WHO as malaria-free. This happens only
when a country has excellent surveillance and response
capacity, able to detect every imported case and ensure
that it does not ignite a re-establishment of transmission.
We have much to learn from success stories, as well as from
places where things have not gone so well. Today, WHO, the
Roll Back Malaria Partnership, and PATH are issuing a
report on Eliminating malaria: learning from the past,
looking ahead.
Malaria now benefits from considerable investment in the
research required to develop tomorrow's transformative
tools. Several new R&D initiatives show how the development
of new medical products is accelerated when public and
private efforts join forces.
Examples include the Medicines for Malaria Venture, the
Foundation for Innovative New Diagnostics, or FIND, the
Innovative Vector Control Consortium, and the Malaria
Vaccine Initiative.
One of these products, the RTS,S candidate malaria vaccine,
is now undergoing a very large phase III trial in Africa.
Malaria has never had a vaccine get this far. If licensed,
it would be the very first human vaccine against a
parasitic disease.
WHO has established a Joint Technical Expert Group to
ensure accelerated review of data emerging from this and
other trials of malaria vaccines. The RTS,S trial is
scheduled for completion in 2014. A WHO recommendation
based on the full results will follow shortly in 2015.
Ladies and gentlemen,
What is behind these gains? More money, for sure, but also
much better interventions, better evidence, and strongly
unifying policies and strategies that keep partners working
on the same track.
The landscape for making inroads in the malaria situation
is dramatically different today than it was in the 1980s.
In fact, the landscape is dramatically different from that
of just a decade ago.
Let me pinpoint some of the changes that have created hope
and stimulated ever-higher aspirations in the midst of
great urgency.
First, the importance of strengthening health systems is
now recognized. Malaria cannot be controlled, much less
eradicated, when health infrastructures are weak. This is a
problem that must be faced head-on. It cannot be
circumvented. This was attempted during the failed
eradication programme.
That programme used oversimplification and highly
standardized, rigid operational procedures in an effort to
compensate for weak health infrastructures in the vast
majority of endemic countries.
That approach ignored the extraordinary complexity of
malaria and the striking variety of its epidemiological
patterns. It suppressed the need to stimulate indigenous
and ingenious solutions to local problems.
It assumed that success in one part of the world could be
replicated elsewhere using the same tools and strategies.
Moreover, it assumed that existing tools were good enough
to get the job done and did nothing to confront rapidly
shrinking investments in malaria research and new product
development.
In many countries, tremendous inroads were made in the
control of all vector-borne diseases, and countless lives
were saved. But the programme eventually failed.
In contrast, China's impressive success in controlling
malaria has at least one historical reason. China first
developed an effective peripheral health infrastructure
before tackling its huge malaria problem.
The failure of the eradication programme created a belief,
held by many, that malaria was impregnable to any kind of
frontal attack. The disease would always find a way to
sneak out of any trap, whether through vectors adapting to
a new ecology, or the development of resistance to frontline
medicines and insecticides.
This conventional wisdom no longer applies. I can think of
at least three reasons why.
First, we are not blindsided by illusions.
Ambitions such as near-zero malaria deaths by 2015 and
eventual eradication are extraordinary ambitions that must
be matched by an extraordinary intensification of current
efforts.
Our eyes are wide open to the realities, the formidable
challenges, the inevitable threats, and the fragility of
progress. We know that eradication will take at least four
decades. This is a long-term investment, not a quick win.
We know that, using currently available tools, malaria can
be eliminated from the fringes where prevalence is already
low. But we also know that these tools are insufficient to
defeat malaria in its heartland and eventually interrupt
transmission.
We know this is impossible right now, but we also know the
kind of game-changing tools needed and the research agenda
that will get us there. We know that we must first reduce
the human disease burden before attempting worldwide
eradication. And we know that, in the process, the public
health successes that will stack up will be amazing.
Second, we are strong in our shared conviction that this is
a job worth doing. The goals of near-zero deaths and
eventual eradication are idealistic and aspirational, but
not foolhardy as some critics suggested in 2007.
The vast harm done by malaria, those "metrics of despair",
now has much greater political and public awareness, almost
outrage. In this day and age, no one should be dying from a
disease that is entirely preventable and treatable, and
certainly not more than three-quarters of a million people
each year, mostly very young or pregnant.
Third, this time we are staying one step ahead of malaria.
We have strategies in place for protecting the
effectiveness and lifespan of existing interventions. We
have better surveillance that picked up the earliest signs
of parasite resistance to artesunate in the Mekong Region.
WHO has developed a detailed plan for stopping the survival
and spread of resistant parasites.
Today's toolkit for combating malaria is better, also
because it is more varied. As we have learned, malaria is
an extremely complex disease that can be defeated only
through a comprehensive mix of multiple interventions.
Today, the governments of endemic countries are respected
as the most important parties in collaborative efforts.
National malaria control programmes are at the centre of
everything, and I am pleased to see so many participants
representing these programmes, especially in Africa.
Today, action is immediate and proactive, not passive and
reactive. Most important, the groundwork is being laid in
systematic fashion. When new tools arrive, countries and
their partners will have already lowered the malaria burden
dramatically. They will be ready to finish the job.
We have new policy recommendations that take advantage of
better tools that already exist.
In March 2010, WHO introduced a major policy change that
recommends diagnostic testing for malaria in all suspected
cases before initiating treatment. This policy marks a
striking change from previous practice, when malaria was so
common that every child with fever was presumed to have the
disease and was given antimalarial drugs.
Such a practice is straightforward, but no longer
defensible as cases continue to drop dramatically,
especially in Africa.
Antimalarial treatment without diagnostic confirmation
means poor care for patients. It masks other deadly
childhood illnesses, wastes precious medicines, hastens the
inevitable emergence of drug-resistant parasites, and makes
it impossible to know the true burden of malaria.
The 2010 policy change was made possible by the
availability of rapid diagnostic tests that can be used
right down to the community level.
With transmission now dropping in so many areas, it no
longer makes sense to treat malaria in shotgun fashion. In
Africa, just a decade ago, fewer than 5% of suspected cases
in the public sector were tested. By 2009, that figure had
risen to 35%.
We have a long way to go to reach the goal of universal
access to diagnostic testing. But rapid scale-up of
diagnostic testing is entirely feasible. Senegal rolled out
diagnostic testing in all health facilities within 18
months and is now saving a quarter of a million ACT courses
each and every year.
As yet another value-added benefit, widespread testing is
giving us, for the first time in history, precise data on
the malaria burden. In some areas, for example, we are
learning that the malaria burden is actually much lower
than has long been presumed.
The tests and the related policy recommendation support
another new target. That is: achieving accurate
surveillance in all endemic districts. One statistic
indicates the magnitude of the challenge.
At present, some 85 countries, representing 65% of the
world's population, do not have reliable cause-of-death
statistics. This means that causes of death are neither
known nor recorded, and health programmes are left to base
their strategies on crude and imprecise estimates.
With more countries using diagnostic tests to confirm
malaria, we are no longer working in the dark in terms of
actually seeing the real disease burden and where it is
concentrated. We are not yet in broad daylight, but at
least we see the dawn.
Good surveillance means knowing where the enemy lies. The
better we know the enemy, the better we target human and
financial resources, and shape the research agenda for the
future.
In terms of staying one step ahead of malaria, I have a
warning. Modern vector control for malaria is exceptionally
dependent on a single class of molecule, the pyrethroids.
These are probably the best insecticides ever developed for
public health purposes, but this exceptional dependence is
dangerous.
To ensure a coordinated response to this threat, WHO is
working with multiple partners, including industry, to
develop a Global plan for insecticide resistance
management, which will be released in early 2012.
WHO operates a scheme, WHOPES, for testing and evaluating
the safety, efficacy, and operational performance of public
health insecticides and developing specifications for use
in quality control and international trade.
Products that make it through this rigorous scheme of
testing and evaluation earn a seal of approval that makes
them eligible for public sector procurement.
With thirteen new products now under review for malaria
control, this scheme needs greater support. We cannot
afford the risk of losing a class of first-rate
insecticides with no suitable replacements ready to step in
and do the same job.
We must never forget. Vector control is by far our most
important tool for preventing malaria.
Ladies and gentlemen,
WHO has kept pace every step of the way with practical howto
technical advice and operational manuals, whether for
monitoring the durability of insecticidal nets or selecting
and procuring the best rapid diagnostic tests.
Technical guidance on these and many other issues has been
produced from a distinct, and I believe, absolutely
essential vantage point.
It combines the insights of the academic world, the
capacities of the research-based pharmaceutical industry,
and the experience of implementing agencies with their feet
on the ground in some very rough places.
It includes the passion and courage of civil society
organizations, and the self-interests of businesses and
multinational corporations, their methods of problemsolving,
and their enviable track-records for getting
things done. It includes the generosity of philanthropies
and of governments in countries where malaria vanished ages
ago.
Above all, it includes the perspectives and will of African
leaders. As ALMA recently stated: "We know that continued
partnership and funding will allow us to sustain the gains
we've made. Global dollars are essential to this success,
but the buck stops with us."
The statement continues: "As heads of state and government,
we are ultimately responsible for demonstrating that aid is
being used wisely, effectively and efficiently. We are
responsible for the wellbeing of our citizens, who have put
their trust in us."
This is what is meant by stewardship and accountability.
Ladies and gentlemen,
In 2000, the Millennium Development Goals brought malaria
into sharp focus. The work of this Foundation has broadened
that focus with added dimensions of hope, inspiration, and
ever-higher ambitions.
The course we are jointly pursuing is not a blunt assault,
but a diversified multi-pronged approach.
It draws on lessons learned in the past, as you will be
doing during this forum, and it looks ahead to the
innovations that can launch a final confrontation with this
ancient foe, this ancient cause of so much human misery, in
its heartland.
Thank you.
Dr Margaret Chan is the Director-General of the World
Health Organization
Malaria vaccine coming soon
19 October 2011
By Songa wa Songa, The Citizen Correspondent
The Citizen, Dar es Salaam, Tanzania
http://thecitizen.co.tz /
direct URL: http://tinyurl.com/3lwuwh8
[For additional background on the vaccine trials, see
http://www.malariavaccine.org/pr2011Oct18-RTSS.php]
Dar es Salaam. Tanzanian children will be among the first
in Africa to benefit from a malaria vaccine developed
following a successful medical research. The vaccine has
been proved to give significant protection against clinical
and severe malaria while showing an acceptable safety
profile. Researchers say the efficacy and safety results in
six to 12-week-old infants would come out by the end of
2012 and added that the findings on the longer-term
protective effects of the vaccine, 30 months after the
third dose should be available by the end of 2014.
The report showing first results from a large-scale phase
three trial of RTS,S vaccine were unveiled yesterday by the
National Institute for Medical Research (NIMR) in Dar es
Salaam. They indicated that three doses of the vaccine
reduced the risk of children experiencing clinical malaria
and severe malaria by 56 per cent and 47 per cent,
respectively.
The trial of the vaccine was conducted in 11 sites in seven
countries across sub-Sahara Africa, including Tanzania
where the study took place at Korogwe and Bagamoyo. Other
countries were Burkina Faso, Ghana, Gabon, Kenya, Malawi
and Mozambique. According to the report, the analysis was
performed on data from the first 6,000 children aged five
to 17 months, over a 12-month period following vaccination,
out of the total of 15,460 infants and children enrolled in
the pilot study.
Regarding safety, the presentations made by Dr Salim
Abdulla, the principal investigator of the trial for
Bagamoyo site and Dr Samwel Gesase of Korogwe pointed out
that the overall incidence of Serious Adverse Events (SAEs)
comparable between the RTS,S/AS01 vaccine which was 18 per
cent and those receiving a control vaccine was 20 per cent.
An analysis of severe malaria episodes so far reported in
all the children enrolled in the study showed 35 per cent
efficacy over a follow-up period ranging between 0 and 22
months (average 11.5 months).
The Director of Preventive services in the ministry of
Health and Social Welfare, Dr Donan Mmbando, said the
results were a milestone in the fight against malaria in
the country as it celebrates 50th anniversay of
independence.
He said malaria, which is preventable, was claiming more
than 20,000 lives in the country annually, most of whom
being expectant mothers and children under the age of five.
He said 60 to 80 per cent of deaths occurred at home before
patients reached a health facility. He, however, expressed
optimism that the vaccine, coupled with other malaria
control interventions such as treated mosquito nets would
reduce the number of deaths in the country significantly.
"My ministry will include the vaccine in the national
health system if all safety and efficacy indications prove
positive as demonstrated in this first result of phase
three" he said. According to NIMR, malaria incidents occur
in approximately 225 million people worldwide each year
killing about 781,000 of them, mostly those in Africa.
Malaria remains the major health threat in Africa.
The results show that the RTS,S vaccine has consistently
shown protection against Plasmodium falciparum malaria in
children and infants since phase two trials.
The bigger advantage of the vaccine according to the report
is that it can be administered safely with other childhood
vaccines without restrictions or complications.
From March 2009 through January 2011, the researchers
randomly assigned 15,460 children to one of the three
original groups in a one-one-one ratio and comparator
vaccines; rabies vaccine for children of 5 to 17 months of
age was administered at enrollment and minningococcal
serogroup for children of six to 12 months. Passive
surveillance for malaria was thereafter undertaken from the
time of administration of the first dose of vaccine until
the end of the study whereas the participants were
encouraged to seek care at health facilities within the
study area for any illness, for which transportation was
facilitated.
According to the research team, the study was conducted
rigorously by the centres and provided a high standard of
clinical care.
The 25-year research was financed by the Bill and Melinda
Gates Foundation with more than US$200 million (about sh300
billion) in grant monies. Another $50-100 million (about
sh80 – sh170 billion) would be invested before the
completion of the project.
AfricaFocus Bulletin is an independent electronic
publication providing reposted commentary and analysis on
African issues, with a particular focus on U.S. and
international policies. AfricaFocus Bulletin is edited by
William Minter.
AfricaFocus Bulletin can be reached at africafocus@igc.org.
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