sustaining the momentum: the challenges ahead · barcelona 15 march 2010 robert d. newman, md, mph...

Sustaining the momentum: Sustaining the momentum: gThe challenges ahead

gThe challenges ahead

Medicines for Malaria Venture (MMV)Medicines for Malaria Venture (MMV)

ggMedicines for Malaria Venture (MMV)

Barcelona

15 March 2010

Medicines for Malaria Venture (MMV)

Barcelona

15 March 2010Robert D. Newman, MD, MPHDirector WHO Global Malaria Programme

Robert D. Newman, MD, MPHDirector WHO Global Malaria Programme

15 March 201015 March 2010

WHO Global Malaria ProgrammeWHO Global Malaria Programme

2009

Estimated number of malaria cases and deaths 2008Estimated number of malaria cases and deaths 2008

%Region Estimate Range falciparum Estimate Range % <5Africa 208 (155 276) 98% 767 (621 902) 88%

Cases Deaths

Africa 208 (155-276) 98% 767 (621-902) 88%Americas 1 (1-1) 32% 1 (1-2) 30%Eastern Mediterranean 9 (7-11) 75% 52 (32-73) 77%European 0 (0-0) 4% 0 (0-0) 3%p ( ) ( )South East Asia 24 (20-29) 56% 40 (27-55) 34%Western Pacific 2 (1-2) 73% 3 (2-5) 41%Total 243 (190-311) 93% 863 (108-1003) 85%

85% of 243 million cases are in Africa; 9% are in South East Asia

91% of 863 thousand deaths are in Africa, 85% in children <5 years of age

Barcelona, 15 March 20102GLOBAL

MALARIA PROGRAMME

International funding commitments for malariaInternational funding commitments for malaria

1600

1800 UNITAID

1000

1200

1400

1600(U

S$m

illio

ns)

WorldBank

PMI

GF

200

400

600

800

Com

mitm

ent(

0

200

2003 2004 2005 2006 2007 2008 2009

Source: GF, PMI, UNITAID World Bank


MALARIA PROGRAMME

Procurement of artemether-lumefantrineProcurement of artemether-lumefantrine

Others7080

s WHO

UNICEF506070

ment

cour

ses

203040

mber

oftre

atm

01020

Num

2005 2006 2007 2008

Source: Ajanta, Cipla, Guilin, Ipca, Sanofi Aventis, Strides Arcolab


MALARIA PROGRAMME

Use of anti-malarial drugs in children <5Use of anti-malarial drugs in children <5

100aria

l .

60708090

with

ant

inal

a

treated with other anti-malarial

treated with ACT

20304050

n <5

trea

ted

w

010

ambia

ganda

Ghana

Liberia

eroon

nzania

Benin

ambiaMali

Fa

soTog

oBiss

auam

biaam

bianzi

barTogo

Ivoire

Nigeria

Niger

Leone

DRCAng

olaMala

wiKeny

aKeny

aGhan

abiq

uerita

nianeg

alGuin

eahio

piawan

da% c

hild

ren

GamUga Gh LibCam

erTanz B Zam M

Burkina

F TGuin

ea-BisZamZamZanz T

Cote d'I

voNig NSier

ra Le D AngMal Ke Ke Gh

Mozam

biqMau

rit Sen

Equato

rial G

uEthi

oRwa

Source: DHS, MICS and MIS surveys conducted 2006-2008


MALARIA PROGRAMME

Diagnosis of malaria: % reported cases in public sector with parasitological diagnosis

Diagnosis of malaria: % reported cases in public sector with parasitological diagnosisin public sector with parasitological diagnosisin public sector with parasitological diagnosis

100%

nosi

s .

40%

60%

80%co

nfirm

ed d

iagn

0%

20%

40%

rted

case

s with

c

Euro

pe

Amer

icas

Sout

h-Ea

st As

ia

Afric

a

n Me

diter

rane

an

Wes

tern

Pac

ific

% re

por

S

Easte

rn W

Based on cases reported to WHO: African % biased upwards sinceBased on cases reported to WHO: African % biased upwards since countries reporting tend to undertake more case confirmation.


MALARIA PROGRAMME

Reduction of >50% in cases: 9 African countries and 29 outside of Africa

Reduction of >50% in cases: 9 African countries and 29 outside of Africa9 African countries and 29 outside of Africa9 African countries and 29 outside of Africa

12000 140Malariainpatient casesMalariainpatient deaths

Malariainpatient casesMalariainpatient deaths

12000

14000

250

300Eritrea Rwanda

6000

8000

10000

Case

s

80

100

120

Deat

hs

6000

8000

10000

12000

Case

s

150

200

250

Deat

hs

0

2000

4000

0

20

40

60

Accelerationstarted 0

2000

4000

2001 2002 2003 2004 2005 2006 2007 20080

50

100

Accelerationstarted

02001 2002 2003 2004 2005 2006 2007 2008

0

160000

180000

200000

6000

7000Malariainpatient cases

Malariainpatient deathsMalariainpatient cases

Malariainpatient deaths

14000

16000

18000

300

350

ZambiaSao Tome and Principe

80000

100000

120000

140000

Malar

iainp

atien

tcas

es

3000

4000

5000

Malar

iainp

atien

tdea

ths

6000

8000

10000

12000

Mala

riainp

atien

tcas

es

150

200

250Ma

laria

inpat

ientd

eath

s

0

20000

40000

60000

2001 2002 2003 2004 2005 2006 2007 20080

1000

2000

Accelerationstarted

0

2000

4000

6000

2000 2001 2002 2003 2004 2005 2006 2007 20080

50

100

Accelerationstarted


MALARIA PROGRAMME

World Malaria Report 2009World Malaria Report 2009


MALARIA PROGRAMME

Malaria control directly impacts on 3 of the United Nations' Millennium Development Goals

Malaria control directly impacts on 3 of the United Nations' Millennium Development GoalsUnited Nations Millennium Development GoalsUnited Nations Millennium Development Goals

1. Eradicate extreme poverty and hunger1. Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empower women

4 Reduce child mortality4. Reduce child mortality

5. Improve maternal health

6. Combat HIV/AIDS, Malaria and other diseases

7 Ensure environmental sustainability7. Ensure environmental sustainability

8. Develop a global partnership for development

9GLOBAL

MALARIA PROGRAMMEBarcelona, 15 March 2010

Reductions in all-cause mortality mirror reductions in l i ifi t lit

Reductions in all-cause mortality mirror reductions in l i ifi t litmalaria-specific mortalitymalaria-specific mortality

Zambia – malaria inpatient deaths <5Zambia – all cause inpatient deaths <514000 5000

120

140

12000

14000

1–59monthschildmortalityrate

All-causedeaths1–59monthschildmortalityrate

All-causedeaths

120

140

4000

4500

5000Malaria deaths

100

eper

1000

child

ren

8000

10000

aths

80

100

eper

1000

child

ren

3000

3500

hs

60

80

mon

thsc

hildm

orta

lityr

ate

6000

All-c

ause

dea

60

80

9m

onth

schil

dmor

talit

yrat

e

2000

2500

Malar

iade

at

20

40

1–59

2000

4000

20

401–59

500

1000

1500

01999 2000 2001 2002 2003 2004 2005 2006 2007

0 1999 2000 2001 2002 2003 2004 2005 2006 20070 0Source: IHME


MALARIA PROGRAMME

Increasing our efforts in countries with the greatest malaria burden

Increasing our efforts in countries with the greatest malaria burdenmalaria burdenmalaria burden

100%Cumulative % of deaths

80%

90%

100%

50%

60%

70% 5 countries account for 53% of deaths15 countries account for 80% of deaths22 countries account for 90% of deaths28 countries account for 95% of deaths

30%

40%

50%

0%

10%

20%

0%

Nigeria

DRCUgand

aSudan

Tanzani

aEthi

opia

Kenya

Burkina

FasoNigerMaliChad

Camero

onIndia

Côte d'I

voire

Mozambiq

ueAngo

laGhanaGuine

aZam

biaMala

wiSen

egalBenin

Myanmar

Burundi

Somalia

Sierra

Leone

Togo

Banglades

hIndo

nesia

Congo


MALARIA PROGRAMME

Funding required to meet targetsFunding required to meet targets

6,000

7,000

4,000

5,000

(mill

ions

Program supportCase management

1 000

2,000

3,000

US$

( gPrevention

-

1,000

2009 2010 2015 2020 2025

Source: Global Malaria Action Plan (RBM, 2008)


MALARIA PROGRAMME

Malaria control and elimination beyond 2010:Areas requiring major focus

Malaria control and elimination beyond 2010:Areas requiring major focusAreas requiring major focusAreas requiring major focus

The unfinished agenda - filling the gapsThe unfinished agenda - filling the gaps– Achieving universal diagnostic testing for malaria– Increasing access to effective treatment for those with confirmed malaria

E i ti l d l t l i ill – Ensuring timely and complete malaria surveillance – Ensuring universal coverage with vector control interventions

Mitigating threats to successg g– Drug resistance– Insecticide resistance

P lit di i di ti i ti id h lth i– Poor quality medicines, diagnostics, insecticides, health services– Unstable financing

Developing capacityDeveloping capacity– Capacity at district level is critical for malaria programme management– Community ownership over malaria control


MALARIA PROGRAMME

Universal diagnostic testingUniversal diagnostic testingg gg gWHO recommends confirmation of malaria through parasite-based diagnosis in all patients prior to instituting treatment (Malaria Treatment diagnosis in all patients prior to instituting treatment (Malaria Treatment Guidelines 2010)

R ti lRationale:– Malaria prevalence amongst fever cases decreasing in many areas

– Parasitologic confirmation in persons with suspected malaria will:• Improve differential diagnosis and fever management p g g• Diminish unnecessary use of ACTs

• Provide accurate surveillance data to manage programmes & monitor impactg p g p

Major resources still needed to ensure access to adequate malaria diagnosis and treatment


MALARIA PROGRAMME

g

Strengthening malaria surveillanceStrengthening malaria surveillanceSt e gt e g a a a su e a ceSt e gt e g a a a su e a ce

• Surveillance data should be principal source of information in p pendemic countries at all levels to:

– monitor burden and trends of malaria– evaluate impact of intervention – respond to increases in transmissionp

We cannot control and ultimately eliminate malaria without timely and complete malaria surveillance at all levels of thetimely and complete malaria surveillance at all levels of the health care system

We cannot have a robust surveillance system without universal diagnostic testing


MALARIA PROGRAMME

Potential new foci of artemisinin resistance

??

?

?


MALARIA PROGRAMME

Spread of chloroquine resistant P. falciparumSpread of chloroquine resistant P. falciparum


MALARIA PROGRAMME

Strategies to address the threat of drug resistanceStrategies to address the threat of drug resistanceStrategies to address the threat of drug resistanceStrategies to address the threat of drug resistance

1. Avoid emergence of drug resistanceH lt th k ti d f l t i i i th iHalt the marketing and use of oral artemisinin monotherapiesImprove access to quality assured diagnosis and treatmentReduce transmission rates

2. Monitor drug efficacyRoutine surveillance of therapeutic efficacy Routine surveillance of therapeutic efficacy Develop new tools for early detection of drug resistance

3 Contain the spread of drug resistance3. Contain the spread of drug resistanceRemove drug pressureEliminate malaria from areas with resistant parasites

4. Develop new medicinesA robust pipeline of new alternative medicines to artemisinins


MALARIA PROGRAMME

p p

Withdrawal of marketing authorizations of oral artemisinin based monotherapiesWithdrawal of marketing authorizations

of oral artemisinin based monotherapiesof oral artemisinin-based monotherapiesof oral artemisinin-based monotherapiesor

al

National Drug Regulatory Authorities:

zatio

n of o

apies

46 countries are implementing WHO policy to phase-out oral artemisinin monotherapies

National Drug Regulatory Authorities:49/78 (63%) in line with WHO recommendations

(last updated 23.02.2010) s

Countries implementing WHO policy tophase-out oral artmisinin monotherapies

ng au

thori

mono

thera

p p

50

60

70

er o

f cou

ntrie

s

ng m

arke

tinin-

base

d m Risk of artemisinin resistance20

30

40

Num

be

Risk of development of resistance

es pr

ovidi

nar

temisi

ni

0

10

Jan.0

6Apr.

06Ju

l.06

Oct.06

Jan.0

7Apr.

07Ju

l.07

Oct.07

Jan.0

8Apr.

08Ju

l.08

Oct.08

Jan.0

9Apr.

09Ju

l.09

Oct.09

Jan.1

0

of resistance

Coun

trie

A A A A

Number of countries still allowing monotherapies


MALARIA PROGRAMME

Building capacity in endemic countriesat regional national district and community levels

Building capacity in endemic countriesat regional national district and community levels

Regional

at regional, national, district, and community levelsat regional, national, district, and community levels

Regional– Need regional canters of excellence capable of training tomorrow's scientists and

programmatic leaders

National– Need adequate number of well trained staff capable of managing integrated

malaria control programme

District– As malaria transmission falls, malaria programme management will need to take

place at the district le elplace at the district level– Staff need to be able to use data for decision making

CommunityCommunity– Need to take ownership over defeating malaria– Should not be seen as passive recipients of goods and services


MALARIA PROGRAMME

Malaria EradicationMalaria Eradication

Eradication is the only acceptable goal; challenge is to make people Eradication is the only acceptable goal; challenge is to make people understand the timeline and commitment required, and that along the way we WILL achieve incredible global public health goals

Eradication will require new tools, including new antimalarial drugs– Malaria vaccine remains an important goal

malERA has been an important exercise in bringing science community together to discuss research priorities to develop tools

Zenith week in Washington DC 22 25 March 2010– Zenith week in Washington, DC 22-25 March, 2010

Need to determine way to map execution of malaria eradication research going forwardresearch going forward

– Critical to keep endemic country scientists engaged


MALARIA PROGRAMME

Potential new approachesPotential new approachespppp

Opportunity to involve communities not only in Opportunity to involve communities not only in reducing morbidity and mortality from malaria, but also in reducing malaria transmission to zeroin reducing malaria transmission to zero

Interventions such as mass screening and treatment of Interventions such as mass screening and treatment of asymptomatic individuals as well as active case detection may create a greater role and therefore detection may create a greater role and therefore increased demand for antimalarial drugs


MALARIA PROGRAMME

Investment in R&D for antimalarials is criticalInvestment in R&D for antimalarials is critical

We will always need antimalarials to treat confirmed malaria We will always need antimalarials to treat confirmed malaria cases – until we reach the very last case

We need antimalarials for prevention IPTp IPTi and new We need antimalarials for prevention – IPTp, IPTi, and new strategies (e.g. IPTc) being evaluated

The development of resistance is inevitable – we must stay at least one step ahead of the parasite

Pressing need for new antimalarials for a variety of purposes:– Blocking transmission

R di l f P i d P l– Radical cure of P. vivax and P. ovale– Potential mass administration


MALARIA PROGRAMME

Fighting malaria - a continuous cycle i i b l d i t t

Fighting malaria - a continuous cycle i i b l d i t trequiring balanced investmentrequiring balanced investment

Basic and applied Surveillance,monitoring & pp

researchmonitoring & evaluation

Policy changeProgram implementation y gimplementation


MALARIA PROGRAMME

Some closing thoughtsSome closing thoughtsg gg g

The business case for investing in malaria control is crystal clearg y– Rapid increase in funding has resulted in rapid scale-up of today's tools– Where scale-up has occurred, malaria cases and deaths drop, as does all-

cause child mortalityy– Quickest path to achieving MDG 4 in many countries, especially in Africa

The greatest risk to continued success is unstable financingThe greatest risk to continued success is unstable financing– We need to fully fund the RBM Global Malaria Action Plan– R&D for development of new tools, including new antimalarials, is a critical

piece of the puzzlepiece of the puzzle

No one sector alone can win the fight against malaria– Product Development Partnerships will be critical in sustaining the momentumProduct Development Partnerships will be critical in sustaining the momentum– MMV is an outstanding example of just such a partnership


MALARIA PROGRAMME

Thank youThank youThank youThank you


MALARIA PROGRAMME

sustaining the momentum: the challenges ahead · barcelona 15 march 2010 robert d. newman, md, mph...

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