PRB Discuss Online: Combating Malaria, What More Can We Do Now?

(April 2008) Encouraging progress against malaria was made in the Americas and some parts of Asia in the last century, but the first global campaign to stop malaria didn’t succeed. Experts, advocates, and communities have renewed efforts to stop malaria, but what will it take to ensure that the global health community is able to sustain the effort to stop malaria this time around?

During a PRB Discuss Online, Nicole K. Bates, director of government relations at the Global Health Council, answered participants’ questions about what the global health community is doing to fight malaria.

April 22, 2008 1 PM EST

Transcript of Questions and Answers

Dr. F.A Badru: What about several efforts at rolling back malaria? Is the effort sincere and empirical based? Does it employ the right caliber of professionals?
Nicole K. Bates:Malaria is most effectively addressed through a comprehensive strategy based upon guidance provided by the World Health Organization (WHO). Key components of the strategy include: for prevention, the use of insecticide-treated nets, indoor residual spraying with insecticides, the intermittent treatment of pregnant women and, for treatment, the administration of artemisinin-combination therapies. These strategies should be implemented based on the needs and appropriate application in local communities. The U.S. President’s Malaria Initiative (PMI), the Global Fund to Fight AIDS, TB and Malaria and the World Bank Malaria Booster Program are three initiatives making great progress in reducing malaria’s global burden. Working through strong national malaria control programs in malaria-endemic countries, these initiatives are proving effective. However, long-term gains will depend upon sustained resources, strong health systems, monitoring and evaluation to ensure intervention effectiveness and the coordination of malaria control efforts with efforts to address other health and social challenges facing communities.

Dr. James Akpablie: i believe the next level of combating malaria is sanitation management and sustained education to change human behavior. what do you have to say to this and how do we mobilise more resources to meet these two challenges?
Nicole K. Bates: You have raised two important issues critical to global efforts to reduce malaria’s global burden. First, regarding sanitation management: Poor sanitation is one of many reasons why malaria continues to thrive in many areas and has begun to emerge in locations, like cities, where it was once eliminated. In addition, intensified irrigation, dams and other water related projects in once remote areas contribute to malaria’s burden. Like you, the WHO believes that better water management can reduce malaria transmission. Agriculture and water projects may make policy or program considerations when designing new programs to have minimal impact or otherwise integrate malaria prevention and treatment aspects into work to protect the health of local communities. Second, regarding behavior change: for too long, malaria has been considered a fact of life. Now that interventions are reaching more communities, people see that it isn’t so. Malaria prevention and treatment is heavily reliant upon the proper choices before and immediately following infection. Examples include the proper (consistent and appropriately hung) use of a bed nets, early recognition of malaria symptoms (fever, lethargy) and the appropriate dosage and full administration of treatment regimens. Health professionals, community workers and mothers are equally important parties whose behaviors are critical to malaria prevention and treatment. As with advocacy for basic malaria resources, securing resources for sanitation efforts and behavior change rely upon communicating past successes and articulating, based on evidence, what may happen without these elements of malaria control.

Maxwell V Madzikanga: Is there any hope for fighting Malaria in Sub-Saharan Africa? What are the challenges?
Nicole K. Bates: Thanks to significant investments in recent years by the U.S. President’s Malaria Initiative (PMI), the Global Fund to Fight AIDS, TB and Malaria and the World Bank Malaria Booster Program, we are seeing unprecedented progress in the fight against malaria in sub-Saharan Africa. For example, in 2007, Ghana announced that it halved the number of malaria deaths and cases dropped from 3.5 (2003) to 3.1 million (2006). The program was based upon community workers who raised awareness, helped to sustain demand for malaria interventions and strengthened home-based care of malaria. In addition to Ghana, Zambia has experienced a drop in malaria incidence and deaths. Similarly, Tanzania has had a measurable reduction in mortality over past five years. The countries are demonstrating what is possible with sufficient and sustained resources, donor coordination and strong national malaria control programs. Donor and government efforts in many countries are being complemented by increased activity by civil society and local communities that are demanding resources for malaria control efforts and taking control of education, prevention and treatment at the community-level. Challenges: As you know, malaria is an environmentally driven disease. Therefore, efforts must be substantial and sustained. As we’re seeing, progress is quite possible and promising for a future in which malaria’s impact on children, communities and nations is significantly diminished.

Richard Cincotta: Malaria-preventing drugs have come and gone since I first used chloriquin while working in Africa 30 years ago. Is this continual shift a response to drug restistance by the parasite or are there other reasons? And is the problem of widespread multi-drug resistance on the horizon for this disease, as well?
Nicole K. Bates: As with most biologically driven infections, malaria is a smart disease. It adapts to changes in the environment – oftentimes more quickly than human interventions can be developed or reach those in need. The continual shift is due to changes in the parasites that grow resistant to current drugs and the mosquitoes that grow resistant to insecticides. As we have seen with the widespread use of monotherapies, drug resistance has grown. In 2006, WHO issued guidance to replace the use of monotherapies with combination therapies. This move lengthens the efficacy lifespan of drugs. How can drug resistance be addressed? Among other strategies: 1) stop use of monotherapies which promote drug resistance, 2) support appropriate diagnosis to reduce unnecessary use of malaria medicines, 3) invest in research and development for new classes of drugs, 4) rotate insecticides used for spraying and bed nets and 5) invest in development of new classes of insecticides. Drug resistance is best viewed as inevitable which should motivate a continuous search for new intervention tools and techniques.

Sarah R. Kaslow: What efforts should be made in the short-, mid-, and long-term to control malaria? How might these efforts be best prioritized and carried out?
Nicole K. Bates: In the short-term, existing interventions that are known to be effective should be made available to all in need. Current efforts must be supported financially, by national governments, strong health systems and accepted by local communities. Interventions must be monitored for effectiveness and opportunities to improve efforts. Complementing direct program efforts must be an ongoing investment in research and development for new diagnostic tools, prevention strategies and treatment regiments. As I am sure you are aware, there have been recent calls for malaria eradication. This call to action has been made and attempted before. There are many steps between the current situation with malaria and eradication. Therefore, the short-term focus must be on control. As progress is achieved, countries that are able in terms of financial and health systems resources and an amenable physical environment can work toward elimination. Eradication is a long-term goal that reminds us of the need for long-term investments by the international and local communities.

Bishnu Kumari Sharma Gyawali: According your data I got information Today there are nearly 1 million malaria deaths per year, mostly of children. Nepali people also lose their lives because of malaria, could you give me any clue what should be the role of media,and government and how could poor people can live safly ?
Nicole K. Bates: In 2005, over 17 million of the country’s 28 million people were at risk of malaria. While the majority of the burden is in sub-Saharan Africa, malaria is certainly a risk in non-African nations and deserves attention. USAID’s first presence in the country was 1954. First efforts at eradication were in 1958. The Nepalese government has recognized this and has a strategy based on early detection and treatment, laboratory capacity, the use of bed nets, indoor spraying where appropriate, skilled health staff and field research. We are seeing very impressive successes where there are committed efforts by governments and communities to address malaria. Investing in public campaigns and basic community education is absolutely necessary to get the best return on investment in malaria control efforts.

Dr.Bhudeb Sen Gupta: 1)The biggest problem in malaria in our zone is high death rate from P.F. The time lag from onset to diagnosis and initiation of effective treatment becomes vital and crucial. How P.F cases can be very quickly diagnosed to start immediate treatment ? The method of diagnosis should be cheap,acceptable,affordable and easily available. People should die from mosquito bite is not all acceptable. However,considering the global climate changes and unrestricted human growth and activities,mosquitoes will never perish till the end of civilization. We can allow them as peaceful co existence but please,no more death from malaria.
Nicole K. Bates: Particularly for remote communities, the lag time between accurate diagnosis and treatment is too often the difference between life and death. As a result, many treatments are presumptive, based on physical presentation of fever and other symptoms rather than on diagnostic testing that may require equipment and trained technicians. While this approach saves many lives, it also results in the sometimes unnecessary use of medicines which can lead to drug resistance. Rapid diagnostic tests (RDT) are intended to address this challenge by allowing on-site diagnostic testing to verify clinical diagnosis. The widespread use of RDTs is limited largely by cost (an estimated $25/test) versus the gold standard of blood smear (an estimated $7/test). Even this less expensive strategy is not available in all communities in need. Continuous investments in research and development in tools like microscopy and RDTs can lead to reduces cost and wider dissemination/use over time.

Ahmed Nuri Musa: What are the long term and short term plans for containing Malaria in Somaliland/Somalia? What do you think could be done to sensitize the people to fight against Malaria?
Nicole K. Bates: An estimated 88% of Somalia’s population is at risk for malaria. Currently artemisinin-combination therapies (ACTs) and rapid diagnostic tests (RDTs) are available in hospitals. Local clinics are improving their capacity to treat simple cases of malaria. Somalia is a Global Fund recipient (Round 2, Round 6). Since baseline, nearly every malaria performance indicator has improved significantly. This includes: the number of households with a bed net, the percentage of children under age five and pregnant women sleeping under nets, malaria knowledge and the percentage of epidemics detected and controlled. Continued public education, visible commitments by the government via campaigns (including those integrated with Immunization campaigns and maternal-child health programs) and demonstration of the successes possible (particularly saving young lives) can reinforce the importance and return on investment in malaria control efforts. The Somalian government has developed a 10-year communications strategy (2006-2015). Health workforce, community mobilization and advocacy are critical to sustain Somalia’s progress.

Daniel Azongo: Which package of interventions has proven to be critical for reducing malaria morbidity and mortality in sub-saharan Africa?
Nicole K. Bates: Please see previous response to Dr. F.A Badru.

alHajHamad(ph.d): Don’t you think that the funds made available by international donor community are more of a subsidy for Their ailing chemical industry than to eradicate malaria, especially in Africa?
Nicole K. Bates: International donors have enabled malaria endemic countries to make significant progress in the fight against malaria. Resources have come from developed country governments, most notably through the PMI, World Bank Booster Program and the Global Fund. Corporations and other private industry companies are increasingly engaging in the fight against malaria. Exxon Mobil, Standard Charter Bank and member organizations of the Global Business Coalition are demonstrating their commitment through a number of public private partnerships. Malaria eradication is a long-term goal that will depend upon significant and sustained investments from a diverse set of supporters including innovations generated by the chemical industry.

Adamu M. Garun Gabas: For a poverty striken community with low literacy levels, what could be the best option of dealing with the malaria scourge?
Nicole K. Bates: Health education is a critical component of disease control efforts, particularly ones that rely on behavior choices. At the community-level, word of mouth and peer encouragement is often the most effective tool toward communities engaging in appropriate malaria prevention, diagnosis and treatment behaviors. Examples of reaching low-literacy communities include: folk theatre in India – this is an effective mass media strategy that delivers key malaria messages and raises awareness; Population Services International (PSI) has developed pre-packaged treatments that enable mothers to deliver home-based care to children affected by malaria; other examples include billboard displays, television commercials, illustrations and other visual depictions to replace written instructions and radio skits.

NIWAHEREZA SIMON: Why is that malaria which has various mean to be treated and has many preventive measures is becoming [a threat] in most countries more than hiv?
Nicole K. Bates: Malaria is a disease of the environment. It is more easily transmitted than HIV, i.e., mosquito bite vs. exchange of a significant amount of bodily fluids. Malaria is so common in many areas that it has long been considered a fact of life. Now that impact has been demonstrated, countries and international donors are recommitting to anti-malaria effort. Malaria’s threat is perpetuated by many factors. For example, even when bed nets are available, they may be used by the breadwinner (father) rather than children or pregnant women who are at greater risk if infected. Some regions continue to use monotherapies (if there is not a high prevalence or high resistance). ACTs are used more in regions with high prevalence and high resistance rates and should be more widely available in the future, but are more expensive. Finally, climate change, urbanization and migration, trade, and the increased mobility of people are aggravating the situation. As a result, malaria is spreading to previously non-endemic areas. Malaria has many links to other tropical diseases. There is also increasing evidence to co-infection with HIV. This fact highlights the importance of strong health systems able to address the menu of health concerns and where education, prevention, diagnosis and treatment of malaria are integrated with other health conditions that can exacerbate or be worsened by malaria.

Ochieng’ Ogodo: Why has malaria ravaged Sub-Saharan Africa? What could be done to arrest the situation?
Nicole K. Bates: Malaria is a tropical disease that thrives in the sub-Saharan African environment. Please see previous comment about a comprehensive approach to prevention, care and treatment. Rapid scale up of existing interventions is critical, as is sustained control. Over time, countries can move toward elimination. This will require getting available interventions to communities in need and simultaneously investing in research and development of new tools and interventions, including a malaria vaccine.

Rahat Bari Tooheen: What global policy changes are required to address the current malaria situation? Has malaria ceased to be a priority for global funding?
Nicole K. Bates: To the contrary. Malaria is currently one of the top global funding priorities. This is demonstrated by bilateral efforts by donor nations including the U.S., multilateral initiatives like the Global Fund and World Bank Booster Program, innovative financing mechanisms for malaria medicines and commitments by governments in endemic countries. Despite a significant increase in global spending, we still fall far short of the true need which is at least US$3.2 billion for implementation and US$0.9 billion for research and development per annum. This need will increase significantly as we begin to consider sustained control and elimination. Global policy changes include: investments in stronger health systems, breaking delivery bottlenecks at country level for critical interventions, shoring up the ACT pipeline, drug resistance, support for community-based care, technology development (diagnostic, treatment, prevention) and sustained financing (note: this list is illustrative, not exhaustive).

J Kishore: Malaria is linked with safety of water and sanitation. It is also environmental degradation. Both these issues are hardly handled in malaria control programs. Personal protection (environment friendly) is another area where people are not taking concrete step such as using bed net. Using bednet is becoming out of fasion in lower and middle class people where it is definitely required.
Nicole K. Bates: Your comment highlights the importance of public education and behavior change strategies. Having a bed net does not guarantee use and inconsistent use put individuals at risk. Investments in operational research to understand facilitators and barriers to bed net use, public awareness and other educational campaigns to sensitize local communities to the need and benefits of personal protection. These strategies should be planned into programs as they are developed.

Sophie Githinji: Malaria diagnosis remains a problem in rural areas with limited health facilities leading to overtreatment of malaria especially among children under five. How can diagnosis be improved?
Nicole K. Bates: Remote communities are addressing missed malaria diagnoses by using community workers to identify symptoms and begin treatment. The benefit is that, many times, symptoms are in fact malaria and illness is avoided. The challenge is that malaria symptoms are similar to other infectious diseases so presumptive treatment may result in using medicines that could be used otherwise. It can lead to drug resistance over time. It can also leave children to suffer from the other, undiagnosed condition. Community workers will benefit from additional training. It will also be helpful to make clinical tests (microscopy and RDTs) available in rural settings. This will require funding to increase the availability and reduce the cost of these diagnostics and health systems able to deliver and administer tests and treatment. It is most realistic and beneficial to build capacity at the community level than to attempt to get all (or most) cases from remote areas to formal health settings for diagnosis and treatment. Please see response to Dr.Bhudeb Sen Gupta for further comment.

Lanre Olusegun Ikuteyijo: Do you think that the MDG of eradicating malaria is feasible given the incidence and seeming intractable nature of malaria in sub-saharan Africa?
Nicole K. Bates: In Fall 2007, “eradication” reemerged as a priority topic in global conversation. Global efforts began in the 1950s; they were abandoned in less than two decades with mixed results. This lesson from history highlights the fact that sustained malaria control, elimination and possibly eradication will require long-term commitments that the world has yet to demonstrate. Malaria is a product of tropical environments. In those environments, eradication will be most challenging. The road toward eradication involves the rapid scale-up of existing interventions. These efforts must be sustained over time and complemented with research to improve current tools and develop new ones. Health systems will need to be strengthened, programs monitored and revised and stakeholders mobilized for long-term advocacy and support.

Nina: Eradication Vs. Elimination. What does this mean to you and do you think eradication is possible?
Nicole K. Bates: Please see response to Lanre Olusegun Ikuteyijo.

Alice Emasu: Do we hope to address the poverty problem that previously made the fight against malaria in Sub-Saharan Africa fail?
Will the current efforts first deal with the issues of corruption tendencies that have undermined service delivery in Sub-Saharan Africa? I would be glad to learn about some of the new strategies and the available resources to kick malaria out of the rural Uganda where majority of the poor live.
Nicole K. Bates: Malaria costs the African continent US$12 billion each year in lost productivity. Is is more than a health challenge; it is in the economic interests of nations to address the disease.At the national level, progress is being made in some countries to remove the barriers imposed by taxes and tariffs on bed nets and other commodities. Civil society has a critical role to play in callling for the transparency and accountability of donors and national governments to ensure that pledged resources are allocated responsibly.

Hezron K. Sanga: Will Developed Countries be ready to use their resources as [they] did for themselves to fight and eradicate malaria in Less Developed Countries (LDCs)? Countries like Singapore though it is within the tropics, but do not have mosquitoes to transmit malaria at all (I visited the country in 1988). It is known that DDT was used to eradicate mosquitoes spreading malaria in developed countries, but same DDT was banned in poor countries like Tanzania … on anticipation that it was very toxic. Pease elaborate.
Nicole K. Bates: Please see earlier response regarding global spending and programming for malaria. Global financial commitments to malaria have never been higher. Now, the commitments must be sustained and well-programmed. Regarding DDT, the WHO has issued guidance about its appropriate use and a number of countries are applying the guidance and using DDT in rotation with other insecticides. Insecticide rotation is critical to guard against resistance