Conquering Malaria Joel G Breman MD DTPH Fogarty

Conquering Malaria Joel G. Breman, MD, DTPH Fogarty International Center National Institutes of Health Improving Population Health Workshop Instituto Nacional de Salud Publica (INSP) Cuernavaca, Mexico 21 – 22 June 2003

Conquering Malaria • • • Burden Ecology and manifestations Successes Control Research and training

Burden

The Global Burden of Malaria § § 1. 5 – 2. 7 million deaths annually Over 1 billion clinical episodes 300 – 500 million people infected Every 10 - 30 seconds a child dies of malaria

Ecology and Manifestations

Malaria Ecology Intrinsic and Extrinsic Factors EXTRINSIC Control and prevention measures Human Social, behavioral, economic and political factors INTRINSIC Parasite Mosquito Environmental conditions

Malaria’s Toll: Major Intrinsic Components Plasmodium falciparum Anopheles gambiae

Malaria Ecology and Burden Clinical Manifestations Hypoglycemia Anemia Acute febrile illness Severe illness Infected Mosquito Respiratory distress Cerebral malaria Death Anemia Chronic effects Infected Human Neurologic/ cognitive Developmental Fetus Impaired growth and development Low birth weight Pregnancy Maternal Acute illness Anemia Malnutrition Infant mortality Impaired productivity

MARA/ARMA Model of Malaria Transmission, 2003

Successes

Successes: Vector Control • 1899 -1914, multiple demonstrations of control by reduction of Anopheline larvae and adults – 1899, Sierra Leone (antilarval); Cuba (largescale); Malaysia (antilarval) – 1904 -1914, Panama Canal Zone; control by larviciding, large-scale environmental modification • 1927, elimination of A. albimanus in Barbados (first area-wide success with invading species)

Successes: Vector Control (2) • 1935 -1939, use of pyrethrum spraying in South Africa, Netherlands and India • 1939 -1957 – 1939 -1940, Elimination of A. gambiae from Brazil and upper Nile, Egypt, 1942 -1945 – 1946 -1957, Interruption of transmission by anti-mosquito measures in Cyprus, Sandinia, Guyana, Venezuela and Greece; indoor residual spraying with DDT, a new major strategy

Successes: Personal Protection (3) • 1987 -2003 – Multiple projects and programs using insecticide-impregnated bed nets demonstrating overall mortality reduction and decrease in several malaria indices

Control

Vector Control • • Drainage and filling: urban* Chemical and biological larvicides* Indoor residual insecticide spraying* Outdoor residual insecticide spraying *costly and effective

Personal protection (2) • Insecticide–impregnated materials: nets, curtains, clothing* • House screening • House location • Repellents • Fumigants * Cost-effective for low-income countries

Antiplasmodial (3) • Patient management: early diagnosis, treatment, referral, education • Chemoprophylaxis • Intermittent treatment (pregnancy)* • Radical therapy for relapses (P. vivax, P. ovale) * cost effective

Social Action (4) • Mobilization of individual, family, community • Health education Management Effectiveness • • Health systems: access, use, quality Leadership: policies, strategies, tactics Surveillance of infection and disease Monitoring and evaluation of programs

Research and Training

Research, Training, and Support Needs According to Understanding of Diseases and Efficacy of Control Methods High Training Efficacy of Control Methods Low Research Needs Some Moderate Research Support Needs High Low

Research, Training, and Support Needs According to Understanding of Diseases and Efficacy of Control Methods High Efficacy of Control Methods Low High Training Malaria Dengue Research HIV/AIDS Needs Tuberculosis Ebola/Marburg Influenza Cancers Alzheimer’s Smallpox Guinea worm Poliomyelitis H. influenzae type B Measles Tetanus Some Moderate Research Support Needs High Low

Research Agenda • Pathogenesis • Drug development • Immunology and vaccine development • Diagnostics • Entomology • Recent genetic breakthroughs

Conquering Malaria For More Information MIM RBM DCPP Joel Breman http: //mim. nih. gov http: //www. who. int http: //www. fic. nih. gov/dcpp/ jbreman@nih. gov