Malaria Elimination:Future Reality?

Global Health Mini UniversityMarch 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 15th year reduced by nearly 1/5

Unprecedented Global Progress Against Malaria

Between 2000 – 2015*:

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* WHO and UNICEF report on "Achieving the malaria MDG target: reversing the incidence of malaria 2000-2015".

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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

6.2 million malaria deaths averted5.9 million in children under five

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.

20152000

What Has Driven the Progress?

“The global campaign against malaria has shownwhat is possible when the international communityjoins forces on multiple fronts to tackle a disease thattakes its heaviest toll on poor and underprivilegedpopulations…The advances of recent years show thatthe 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

Source: World Malaria Report, 2015, WHO

Trends in Total Funding for Malaria Control and Elimination

Insecticide-treated Mosquito Nets

(ITNs)

Indoor Residual Spraying(IRS)

Rapid Diagnostic Tests (RDTs) &

Artemisinin-basedCombination

Therapies (ACTs)

Intermittent Preventive Treatment for Pregnant Women(IPTp)

Key Factor of Success: Implementation of Proven-Effective Interventions

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 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

Epidemic Response in Uganda

Adapt to New Epidemiology, Uneven Progress and Tailor Approaches

Heterogeneity of malaria transmission Heterogeneity of control tools

• Targeted IRS and MIP• Complete coverage

for CM, ITNS for routine distribution, BCC, and SME

Kenya

Respond to Key Technical Challenges

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IPTp-2 Uptake

• Provider and consumer awareness and training

• Increasing availability of SP

• Spotlight on data to increase awareness

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Monitor Progress and Tailor ApproachesPercentage of reported malaria cases confirmed by diagnostic test

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ITN Ownership and Use 2010-2014Household 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 ResistancePyrethroid 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 ResistancePotential 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 IRS insecticides: Clothianidin

New active ingredients for IRS available in 1-2 years

Durable Wall Linings

Large Scale Efficacy Trial Underway

Spatial, Wearable, & Topical Repellents

Attractive Toxic Sugar Baits

Eave Tubes and Housing Modification

Mali SMC Pilot ResultsComparison of number of cases of confirmed, uncomplicated malaria cases between

intervention and control sites, 2013 and 2014

Kita (study site) Bafoulabe (control site)

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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 limit0.1-0.8 nanogram/mL0.78 -3.1 p/µL8-16 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 drug classes expected for SRA approval in 2017-2018:

− Alternatives to ACTs:

− OZ 439 and KAE 609

− Transmission reducing drugs - tafenoquin

New Antimalarial Drugs on the Horizon

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, 4th 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

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

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PMI Strategy 2015-2020

Global Strategy and Action Plan

2015 - 2030

Guiding Strategic Framework

AIM and the Global Technical Strategy for Malaria share a joint vision, goals, milestones, and targets

Shared 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 At least 40% At least 75% At least 90%

2. Reduce malaria case incidence globally

compared with 2015 At least 40% At least 75% At least 90%

3. Eliminate malaria from countries in which

malaria was transmitted in 2015 At least 10 countries At least 20 countries At least 35 countries

4. Prevent resurgence of malaria in all countries

that are malaria-free 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?