Proposal for an
Evidence Review Group
on MDA, MSAT and FSAT
Dr A. Bosman and Dr P. Ringwald
Malaria Policy Advisory Committee Meeting
WHO HQ Geneva, 11 September 2014
Impact of MDA, MSAT and FSAT
on malaria transmission
VECTOR
larvae
WHO 98123
HUMAN
uninfected
incubating
infective
infective
incubating
uninfected
LARVAL CONTROL
ADULT VECTOR CONTROL
DIAGNOSIS & TREATMENT MSAT & FSAT
MASS-DRUG ADMINISTRATION
CONTROL OF MAN-VECTOR CONTACT
Resilience of malaria transmission
The curves show probable growth of falciparum infection rates in epidemics
assuming primary cases at time 0 (arrow) as 0.1 per cent of the population with
falciparum infection, an incubation interval of 35 days, under the influence of
different reproduction rates for malaria. (Adapted from the Bulletin of the World
Health Organization, 1956, vol. 15:380)
Current WHO recommendations
MDA – mass treatment of all, or a large section, of the
population whether symptoms are present or not
Based on the review of results of 19 MDA projects during the
period 1932–1999 by von Seidlein and Greenwood 1 and a
Technical Consultation held in 2003 2 , WHO concluded that there
is little evidence that MDA is effective in reducing transmission
although reduction in parasite prevalence and transient reduction
in mortality and morbidity have been documented in some
cases.
1 von Seidlein L, Greenwood BM (2003). Mass administration of antimalarial drugs.
Trends in Parasitology, 19: 452–460.
2 Malaria epidemics: forecasting, prevention, early detection and control From policy to practice.
Report of a WHO Informal Consultation, 8–10 December 2003.
Current WHO recommendations
In 2010 a WHO consultation 3 reviewed the potential role
of MDA in the context of artemisinin resistance in the Greater
Mekong subregion based on evidence of impact of existing
interventions, operational and modelling considerations. The
consultation recommended immediate planning of a pilot MDA
operation in western Cambodia or eastern Thailand and the
collection of essential information on the safety and efficacy of the
candidate drugs for MDA.
3 Consideration of mass drug administration for the containment of artemisinin resistant malaria
in the Greater Mekong Subregion. Report of a WHO consensus meeting, 2010.
Current WHO recommendations
● The same consultation also reviewed the role of mass
screening and treatment (MSAT/FSAT – people in a
broad/defined geographic area are screened, regardless of
whether they have symptoms of malaria, providing treatment
for those who test positive).
● MSAT generates important information on the epidemiology of
malaria that can be useful for further containment efforts, but it
is resource-intensive and logistically challenging - lack of field-
ready, high-throughput, highly sensitive diagnostic tests.
● FSAT operationally more feasible than MSAT, this is not
delivered in all villages simultaneously, and, therefore, it is
unlikely to contribute significantly in elimination efforts.
● The contribution of MSAT and FSAT effective in reducing
transmission needs to be confirmed.
Background
● A recent systematic review 4 of 32 studies assessed MDA in
areas with different endemicity, with different medicines and
dosages, different timings and number of rounds and
concomitant implementation of vector control measures. The
review concluded that MDA appears to quickly reduce malaria
parasitaemia and several clinical outcomes, but more studies
are required to assess its impact after 6 months, the barriers
for community uptake and the potential contribution to the
development of drug resistance.
4. Poirot et al., Mass drug administration for malaria.
Cochrane Database of Systematic Reviews 2013, Issue 11.
Art. No.: CD008846. DOI: 10.1002/14651858.CD008846.pub2.
Background (continued)
● A subsequent review of the literature 5, including
unpublished studies, identified 12 MDA studies
demonstrating zero indigenous malaria cases in the
target population maintained over six months after
the end of drug administration.
● Over the last few years implementation research on MDA
and FSAT have been conducted in Cambodia , and in other
countries for which results are not yet in the public domain
(e.g. FEMSE in Comoros, MDA in Zanzibar, MSAT in Zambia
and MDA at Thai-Myanmar border). 5. UCSF Global Health Sciences. Review of mass drug
administration and primaquine use: background paper prepared for
the Bill & Melinda Gates Foundation, 2014 (unpublished document).
Impact of T3, MDA and LLINs in Anjouan Island (Comoros) Malaria reported cases: April 2010 – Dec 2013
0
50
100
150
200
250
300
Disponibilite des
données (Avril 2010 )
Formation personnelprise en charge (Juil10)
Distribution
MILD (Déc10)
Application Protocole Confirmer avant de traiter
(Juin2011)
Gratuite des
ACT
Avril2010
Gratuité TDR et formation pour utilisation( mars.11)
Affectation
Microscopistees(juil.11)
Prise en charge gratuitedes cas graves (Janv.12)
Application strict du protocole de Prise
En Charge du Paludisme (Juil.12)
Traitement de mMsse
pour l'élimination rapide
du paludisme( Oct-Nov-Déc.12)
Suivi thérapeutique. Recherche active des cas. Contrôle ded qualité des lames; Déclaration obligatoire des cas ( Janv.13)
Distribution MILD
permanet( Déc.13)
1
2
3
9
T3 MDA LLIN
1. Is there evidence of impact on malaria transmission at six month
and one year following implementation of MDA, MSAT and FSAT?
2. What are the key determinants of "durable impact" on malaria of
MDA, MSAT and FSAT?
3. What are the optimal conditions for application of MDA, MSAT and
FSAT to reduce malaria transmission in terms of endemicity levels,
combination of medicines and dosages, use of diagnostics, timings
and number of MDA rounds, concomitant deployment of vector
control interventions, IEC and pharmacovigilance?
4. What are the major limitations and challenges faced by multiple
groups in the successful application of MDA, MSAT and FSAT to
reduce malaria transmission?
ERG preliminary list of questions (1- 4)
5. What is the specific role of MDA, MSAT and FSAT in the
advanced phase of malaria elimination?
6. What is the specific role of MDA, MSAT and FSAT for the
elimination of artemisinin resistant falciparum malaria?
7. What are the main knowledge gaps and what data need to be
collected to recommend wider deployment of MDA, MSAT and
FSAT as part of initiatives to reduce malaria transmission?
8. Which of methodological aspects and ethical requirements need
to be considered by research groups and national ethical review
boards for planning and assessment of studies on the durable
impact of MDA, MSAT and FSAT on malaria transmission?
ERG preliminary list of questions (5 – 8)
Discussion points for MPAC
● Refine ERG questions to be addressed
● Systematic reviews, and recent unpublished studies
to be reviewed
● Methodological aspects and timing of ERG
(tentative: 8-10 December 2014)
● Investigators/programme managers to include as
presenters and reviewers
● Co-Chairpersons (from MPAC members) and
Rapporteurs
● AOB