Fogarty International Center Fogarty International Center promotes and

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 Activities Domestic 1. • • • 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 Research 4. 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 Fight AIDS, 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 Tablets in millions (dose) Drug Chloroquine (3 11. 25 (100 days) mg) Sulfadoxine 2. 5 (500 mg. S/ pyrimethamine 25 mg. P) (one dose) Quinine (7 d) 31. 5 (300 mg) Artesunate (5 d) 13. 5 (50 mg) Price/ 1000 tabs Cost per capita $6. 05 Total cost $68, 063 $47. 00 $117, 500 $0. 12 $41. 25 $1, 299, 375 $1. 30 $365. 00 $4, 927, 500 $4. 93 $0. 08 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 DDT Malathion Deltamethrin Pyrimiphosmethyl One application Cost per (tons) capita Price/ton Total cost 147 $3, 950 $580, 650 $0. 58 220 $4, 300 $946, 000 $0. 95 110 $20, 000 $2, 200, 000 $2. 20 220 $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 Principles 1. 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 -2008 Paid 2005 Donor Countries - 49 plus European Commission Foundations - 2 Corporations Individuals Total Pledges Paid $ billions 5. 973 3. 295 0. 150 0. 002 $6. 127 0. 150 0. 002 $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-combinationtreatments (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 Rounds Funding by Sector of Recipients

The Global Fund After Four Rounds Funding by Country Coordinating Mechanisms (CCMs) 15%

Disbursements to Malaria 350 (US$ Millions), 2004 300 US $ millions 250 45 % 200 1% 150 20 % 100 34 % 50 0 Global Fund Private/other Multilateral Bilateral $135 million $4 million $57 million $97 million Total International $295 million Malaria Disbursements

Estimated Costs for 2007 for the Three Diseases (US$ Billions) Resource needs Total domestic expenditure Total international share Malaria TB HIV Total 2. 9 0. 3 2. 0 1. 2 14. 5 3. 0 19. 4 4. 5 2. 6 0. 8 11. 5 14. 9

Malaria Resource Needs, 2007 (1) Specific Interventions No of Units in 2007 Cost per unit Vector control in highly 31. 5 million LLINS endemic areas (longlasting insecticidal nets, LLINs) for vulnerable groups 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 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 US$0. 7/patient tested Annual resource needs in US$ millions 543

Malaria Resource Needs, 2007 (2) Specific Interventions No of Units in 2007 Cost per unit Prevention and In all areas prone to control of epidemics malaria epidemics Basic infrastructure, institutions and transport Training Community health workers, technical specialists US$4, 300 per equipment/trainin g package Annual resource needs in US$ millions 1 set per malarious US$2, 000 per package + province, 2 -6 sets for vehicles (based on central malaria population at risk program Country-specific Depending on estimates intervention Country-specific 1 per 4, 000 population incentives and support 1 -3 per country depending US$50, 000 salary for on population size direct hires Operational research, 2 -6 drug resistance studies monitoring and per year, 2 -6 insecticide evaluation resistance studies per year, routine surveillance – Source: Global Fund 5 staff and 15 visits Countryspecific estimates TOTAL 119 362 91 58 28 US$2. 9 billion

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 Programs Mekong 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 Government and Private Contributions Private US Government citizens/groups 1970 70% 30% 2005 20% 80% Malaria dollars $2 billion ~1950 s-1970 s $90 million in 2005

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, 1000 s), All Cause and Malaria-related, 2002 Population DALYs from all deaths (%) DALYs from malaria deaths (%) World 6, 122, 210 1, 467, 257 42, 280 Africa 655, 476 357, 884 (24. 4) Americas 837, 967 145, 217 (9. 9) 108 (0. 2) East Med. 493, 091 136, 221 (9. 3) 2, 050 (4. 8) Europe 874, 178 151, 223 (10. 3) 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 36, 012 (85. 2) 20 (0. 04) DALYs from malaria /total (%) 2. 9 10. 1 0. 07 1. 5 0. 01 Adapted from WHO, World Health Report, 2002

Coordination, Information, and Advocacy “There is an urgent need for a nonpartisan 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. ”