Fogarty International Center

Fogarty International Center

“promotes and supports scientific discovery internationally and mobilizes resources to reduce disparities in global health”

• International Training and Research Program in Emerging Infectious Diseases, 1995-2004

• Actions for Building Capacity, partner with NIAID field research programs

• International Malaria Research Training Program, 2001-2005

• Global Infectious Diseases Research Training Program, 2005

International Malaria Research Training Program (1)• Johns Hopkins University – Zimbabwe

– Transmission blocking immunity– Vector biology– Molecular parasitology/epidemiology– Drug resistance

• University of Maryland - Mali– Drug resistance– Clinical trials– Epidemiology– Vector biology

• University of California, San Francisco - Uganda– Drug resistance– Clinical studies– Epidemiology– Molecular parasitology

FIC Malaria Programs (2)• Harvard School of Public Health – Ethiopia, Senegal

– Molecular epidemiology– HIV and malaria immunity– Infected RBC biology– Vector biology and control

• State University of New York, Buffalo - Kenya– Vector biology

• University of Pittsburgh - Kenya– Malarial anemia

• Tulane University – Kenya, Mali, others– Vector biology– Vector ecology

FIC Malaria Programs (3)

• Universidad del Valle, Columbia – Latin America– Malarial anemia– Clinical malaria

• Columbia University - Thailand– Severe malarial anemia– Hematology

• US Army - Kenya– Pediatric malaria– Severe malaria– Molecular pathogenesis, anemia and cerebral

malaria

Global Infectious Diseases (2004-2009)

Research Training Programs

• University of North Carolina - Malawi– Malaria biochemistry, pathology, epidemiology

• Pennsylvania State University - Thailand– P. vivax

• Albert Einstein – global– Malaria and other diseases

• University of California, San Diego – Peruvian Amazon– Parasitic diseases

Centers for Disease Control and Prevention (CDC)

CDC Malaria Activities1. Domestic

• Surveillance• Investigations• Advice to travelers• Consultations• Advice for blood collection• Diagnostic assistance

2. International• Field stations (Kenya, Guatemala)• Regional programs (Mekong Delta, Amazon River)• Partner organizations (WHO, RBM, UNICEF, WB, USAID)• Consultations

3. Themes – Epidemiology• Pregnancy• Personal protection• Natural history

CDC Research4. Biology and immunology

• Host parasite interactions• Immune response• Host genetics• Parasite genetic diversity

5. Clinical and control issues (Kenya, Mali, Malawi, Guatemala, elsewhere)• HIV and malaria• Methods of control

6. Vaccine development• Animal testing, non-human primates

7. Vectors• Insecticides (WHO Collaborating)

– Evaluating– Resistance

• Sporozoite production• Larval ecology• Anopheles ecology and biology

The Global Fund to FightAIDS, Tuberculosis and Malaria

The Global Fund, 2004-2005

• 6 million die yearly from AIDS, TB and malaria• Sub-Saharan Africa hit hardest• HIV/AIDS

– 4.9 million newly infected– 40 million living with HIV/AIDS

• TB– 1/3 world infected = 2 billion– 8 million developed disease– 2 million died– TB and HIV

The Global Fund, 2004-2005

• Malaria– 40% at risk = 2.4 billion– 1 to 3 million deaths– 300 – 500 million cases– 5 billion febrile episodes resembling

malaria

Estimated Cost of Malaria Control: One Million People, One Full-dose Treatment, 1999

Drug

Tablets in millions (dose)

Price/ 1000 tabs Total cost

Cost per

capita

Chloroquine (3 days)

11.25 (100 mg)

$6.05 $68,063 $0.08

Sulfadoxine-pyrimethamine (one dose)

2.5 (500 mgS/

25 mgP)

$47.00 $117,500 $0.12

Quinine (7 d) 31.5 (300 mg) $41.25 $1,299,375 $1.30

Artesunate (5 d) 13.5 (50 mg) $365.00 $4,927,500 $4.93

PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

Estimated Cost of Malaria Control in an Endemic Area: One Million People, One Round

of Residual House Spraying

Insecticide

One application (tons) Price/ton Total cost

Cost per capita

DDT 147 $3,950 $580,650 $0.58

Malathion 220 $4,300 $946,000 $0.95

Deltamethrin 110 $20,000 $2,200,000 $2.20

Pyrimiphos-methyl

220 $16,000 $3,520,000 $3.52

PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Principles1. Funding needs and support ($2.3 b 2005, $3.5 b 2006,

$3.6 b 2007)• Financial instrument, not implementation• Leverage resources

2. Program orientation (~150 people in Secretariat)• Support programs with national ownership• Focus on different regions, diseases, interventions• Balance prevention and treatment

3. Grant process (patterned after NIH)• Independent peer review process• Simplified, rapid, grant-making process• Transparency and accountability

The Global Fund to Fight AIDS,Tuberculosis and Malaria

Pledges 2001-2008Paid 2005

DonorPledges

$ billions

Paid

$ billions

Countries - 49 plus

European Commission

5.973 3.295

Foundations - 2 0.150 0.150

Corporations 0.002 0.002

Individuals 0.002 0.002

Total $6.127 $3.449

Global Fund Expenditures on Malaria

• $2 billion needed yearly to achieve RBM goals (Commission on Macroeconomic and Health, 2002)

– $600 million/year being spent (?)

• Focus

– Finance 108 million bednets (ITN)

– Deliver 145 million artemisinin-combination-treatments (ACT)

The Global Fund After Four Rounds

Funding by Disease

The Global Fund After Four Rounds

Funding by Income of Countries

The Global Fund After Four Rounds

Funding by Expenditure Target

The Global Fund After Four Rounds

Funding by Geographic Region

The Global Fund After Four RoundsFunding by Sector of Recipients

The Global Fund After Four RoundsFunding by Country Coordinating Mechanisms (CCMs)

15%

Disbursements to Malaria (US$ Millions), 2004

US

$ m

illi

ons

0

50

100

150

200

250

300

350

Malaria Disbursements

Global Fund $135 millionPrivate/other $4 millionMultilateral $57 millionBilateral $97 million

Total International $295 million

45 %

1 %

20 %

34 %

Estimated Costs for 2007 for the Three Diseases (US$ Billions)

Malaria TB HIV Total

Resource needs 2.9 2.0 14.5 19.4

Total domestic expenditure

0.3 1.2 3.0 4.5

Total international share

2.6 0.8 11.5 14.9

Malaria Resource Needs, 2007 (1)Specific Interventions

No of Units in 2007

Cost per unit Annual resource needs in US$ millions

Vector control in highly endemic areas (long-lasting insecticidal nets, LLINs) for vulnerable groups

31.5 million LLINS US$7 per LLIN procured and distributed to target population

220

Artemisinin Combination Therapies

1102 million doses Children <5 US$0.6 per dose

Children 5-15 US$0.99 per dose

Adults US$1.7 per dose

1,180

Rapid Diagnostic Testing

776 million tests Median cost is US$0.7/patient tested

543

Intermittent preventive treatment in pregnancy

39.7 million treatment courses

US$0.164 per pregnant woman

6.5

Management of severe malaria cases

11.6 million cases Median cost is US$24/patient

280

Malaria Resource Needs, 2007 (2)

US$2.9 billionTOTAL

28Country-specific estimates

2-6 drug resistance studies

per year, 2-6 insecticide resistance studies per year, routine surveillance –

5 staff and 15 visits

Operational research, monitoring and evaluation

58Country-specific incentives and support

US$50,000 salary for direct hires

1 per 4,000 population

1-3 per country depending on population size

Community health workers, technical specialists

91Country-specific estimatesDepending on intervention

Training

362US$2,000 per package + vehicles (based on population at risk

1 set per malarious province, 2-6 sets for central malaria program

Basic infrastructure, institutions and transport

119US$4,300 per equipment/training package

In all areas prone to malaria epidemics

Prevention and control of epidemics

Annual resource needs in US$

millions

Cost per unitNo of Units in 2007Specific Interventions

Source: Global Fund

United States Agency for International Development

USAID Malaria Programs

• Prevention and control

• Treatment

• Pregnancy

• Drug-resistant malaria

• Complex emergencies

• Vaccine development

• Strategies

USAID Malaria Country Focus

Country Programs Angola Benin Congo, Democratic Republic Eritrea Ethiopia Ghana Kenya Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal Tanzania Uganda Zambia

Country Programs Afghanistan Indonesia Nepal Philippines Regional ProgramsMekong Regional Initiative: Cambodia Laos Thailand Vietnam

Regional Programs,

Central Asian Republics Kyrgyzstan Tajikistan

Country Programs Bolivia Honduras Peru Regional Programs Amazon Malaria Initiative: Bolivia Brazil Colombia Ecuador Guyana Peru Suriname Venezuela

USAID Malaria Funding

United States Agency for International Development (USAID) and Global Partnerships

US Government

Private

citizens/groups

1970 70% 30%

2005 20% 80%

Malaria dollars $2 billion ~1950s-1970s$90 million in 2005

Government and Private Contributions

USAID FIGHTS MALARIA BLINDFOLDED

The Examiner, April 20, 2005

“…members of Congress…expressed concern (that)…USAID could not account for the bulk of its $80 million malaria earmark.”

“Only 5% is used to fund the 3 interventions….that work…and the vast majority…on nets.”

Roger Bate

American Enterprise Institute

Director, “Africa Fighting Malaria”

Keys to Successful Malaria Control

World Bank Report:

Four Success Stories

• Brazil

• Vietnam

• India

• Eritrea

World Bank Success Stories

Keys to Success (1)

• Conducive epidemiological conditions

• Sound technical approach

• Package of effective tools

• Data-driven decision making

World Bank Success Stories

Keys to Success (2)

• Strong leadership

• Political commitment

• Community involvement

• Decentralized control of finances and actions

• Overcame bureaucratic hurdles

World Bank Success Stories

Keys to Success (3)

• Infrastructure

• Capacity

• Support from partner agencies

• Sufficient financing

• Flexible support by World Bank

Disability–adjusted Life Years (DALYs, 1000s),All Cause and Malaria-related, 2002

Population

DALYs from

all deaths (%)

DALYs from

malaria

deaths (%)

DALYs from malaria

/total (%)

World 6,122,210 1,467,257 42,280 2.9

Africa 655,476 357,884 (24.4) 36,012 (85.2) 10.1

Americas 837,967 145,217 (9.9) 108 (0.2) 0.07

East Med. 493,091 136,221 (9.3) 2,050 (4.8) 1.5

Europe 874,178 151,223 (10.3) 20 (0.04) 0.01

SE Asia 1,559,810 418,844 (28.5) 3,680 (8.7) 0.9

West Pacific

1,701,689 257,868 (17.6) 409 (1.0) 0.2

Adapted from WHO, World Health Report, 2002

Coordination, Information, and Advocacy

“There is an urgent need for a non-partisan umbrella organ to coordinate and facilitate the network of alliances and programs in malaria research and control…”

Alilio, Bygbjerg, Breman 2004

Vision

“The goal, once again, is to promote research by African scientists and colleagues elsewhere to improve our understanding of malaria, develop new tools to combat it, and, ultimately, eliminate this scourge.”