Memorandum by the Malaria Consortium
Whilst the Malaria Consortium works on a range
of communicable diseases, including malaria, tuberculosis, childhood
infections and neglected tropical diseases, we have focussed on
malaria in this submission.
1. We believe that the assessment that post-war
optimism regarding the control of infectious diseases was unfounded
is correct. However, the situation cannot be called a crisis but
rather reflects the "natural" development and the ability
of the biological agents to adapt to medicines and control measures
by developing resistance and finding new epidemiological niches.
The rapid progress of reduction of infectious diseases after World
War Two, as a result of new antibiotics and the socio-economic
changes through industrialisation, misled the public health community
to believe that this progress could go on and drive many infections
to extinction. Although one such success was achieved with small
pox, this remains the only one. Other diseases have made progress
towards elimination such as polio and guinea worm but efforts
drag on, demonstrating the enormous inputs needed at the final
stages of such endeavours to "mop-up" the last foci
of the disease. At the same time diseases such as HIV/AIDS, ebola
and SARS have demonstrated the potential of viruses in the biotope
to jump the animal/human barrier, creating new infectious threats
and/or epidemics. Two issues, which threaten progress in elimination
of communicable diseases are resistance and increasing mobility
of human populations. Resistance to drugs and insecticides has
set back progress. For instance, resistance of the malaria parasite
Plasmodium falciparum to chloroquine was associated with
increased child mortality in Africa in the 1990s. Large and small
scale population migrations make containment of communicable diseases
more challenging. While the situation today is not a crisis, it
should remind us that infectious diseases will always be part
of human life and that we cannot relax the attempts to develop
new and better weapons to counter this threat, especially given
the genetic potential of the infectious agents to mutate and adjust
to new environments and counter-attacks. The rate of progress
in reducing spread of communicable diseases is slower than acceptable.
We do now have excellent and proven tools to combat diseases,
but lack of investment has meant that, until very recently, there
was little impetus to apply them on a meaningful scale.
2. Among the four infections the committee
is primarily concerned with, malaria is probably the one with
the least reliable figures on disease burden and incidence of
infection and disease. This is not a flaw of the monitoring and
surveillance system but rather a function of the complexity of
the interaction between the human host and the infectious agent,
the malaria parasites. Depending on the level and history of exposure
(transmission) humans develop a partial immunity to the parasite
that will generally prevent death from the disease and greatly
reduce and mitigate clinical episodes of malaria without suppressing
infection and (asymptomatic) parasite presence in the blood. In
areas with high levels of transmission almost continuous presence
of some parasites and often multiple simultaneous infections are
the norm rather than the exception among children and adolescents.
This makes it almost impossible to monitor incidence of infection
or get reliable counts of clinical episodes attributable to malaria.
Similarly, many deaths through malaria—which occur in highly
endemic areas mainly among very young children—are not attended
to at a hospital and hence not registered making accurate counts
of the death toll from malaria very difficult. That being said,
there have been increased efforts in recent years to apply complex
epidemiological and mathematical techniques to get a reasonable
estimate of the number of deaths which all seem to agree in the
order of magnitude of deaths and clinical episodes. Based on these
figures (including the most recent UNICEF Malaria in Children
Report 2007) the number of deaths has not been dramatically increasing
in recent years and is now showing a trend to decline owing to
the efforts of intensified malaria control particularly in Sub-Saharan
Africa in recent years. Data from particular countries such as
Eritrea and Zanzibar clearly demonstrate these declines in malaria
prevalence, morbidity and mortality. It can be expected that such
success stories will be coming from an increasing number of countries
in the coming years. In Southeast Asia malaria has shown a sharp
decrease in recent decades, which relates to a combination of
better control programmes, changes in the environment. The effect
of economic development is likely to be important, but more difficult
to assess.
4. Given the significantly increased funds
available for malaria control in general and particularly in Sub-Saharan
Africa, one can expect a dramatic decline of malaria incidence,
prevalence, morbidity and mortality. However, while it should
be possible to eliminate the infection in areas of the world where
transmission is moderate or low, most experts agree that with
our current tools and interventions a sustainable interruption
of transmission in the high transmission areas of Africa is not
possible. This means that control efforts have to be maintained
at high level and the continuous efforts to find new drugs for
treatment and new insecticides for prevention must continue, as
the parasites will eventually develop resistance to the currently
effective weapons. Elimination of tropical malaria (Plasmodium
falciparum) from Africa will, however, require additional
interventions currently not available, namely safe medicines that
are able to kill gametocytes (the forms taken up by the mosquito
vectors) and additional leverage to reduce transmission such as
a transmission blocking vaccine. Malaria eradication, is an important
vision for the future but one we should only practically engage
in once we are certain to have the necessary means to achieve
it.
5. With funds available at the time the major
blockage for rapid implementation—particularly in Sub-Saharan
Africa—is the limited capacity of countries to absorb these
funds and implement prevention measures at high quality at scale
and to make treatment available to all who need it while at the
same time increasing the capacity for adequate diagnosis of malaria.
This is largely a result of insufficient prioritisation of funding
into national health systems as a whole with much health funding
disease specific and poorly co-ordinated. In addition the unpredictability
of funding from inter-governmental sources seriously hampers long-term
planning.
6. Malaria Consortium engages in the control
of malaria as well as other communicable diseases such as tuberculosis,
pneumonia, diarrhoea and some so called neglected tropical diseases
such as lymphatic filariasis, and visceral leishmaniasis (Kala
Azar). We support national malaria control programmes in the design
and implementation of intervention strategies such as distribution
of long-lasting insecticidal nets through various mechanisms,
applying indoor residual spraying, rolling out new treatment and
diagnostics policies in the government, non-for-profit and private
health services including approaches to community based treatment
and diagnosis. We also directly implement some of these interventions
and test new tools in vector control for their field effectiveness.
Other areas of our work are operational research and monitoring
and evaluation of inputs, outputs, processes, outcomes and impact.
These include the development of new tools and research on implementation,
and also design and establishment of routine monitoring and surveillance
systems and national and sub-national household surveys to assess
coverage and impact. Finally, we have played a significant role
in development of international policy for several years, and
are increasingly engaging in advocacy. Our configuration consists
of a small UK-based head office with a large regional office in
Uganda and several country and subnational offices in Africa and
one in Asia. Our team is multi-disciplinary and based on high
level technical specialist expertise combined with operational
delivery capacity. Our decision to place most of our resources,
where the communicable diseases programmes are operating has been
extremely effective in linking up-to-date awareness of the practical
country level issues with clear awareness of global policy and
strategy context. As our organisation has no core funding, it
depends on executing projects for various donors including GFATM,
DFID, Irishaid, USAID/PMI and the Bill & Melinda Gates Foundation.
We are not adequately resourced for playing a more advisory role
at regional and international level, but have tried to contribute
as much as we can. Our close involvement in the coordination efforts
of the Roll-Back Malaria Partnership through its sub-regional
networks and various working groups ensures maximum synergy with
others in the field. We collaborate with ministries of health
and a wide range of international organisations.
7. Poverty probably is the most important
non-health related driving factor in malaria or rather the factor
preventing rapid progress. Global warming only plays a marginal
role in some highlands and at the fringes of malaria transmission
at present. However, environmental factors, particularly man-made
sources of malaria transmission are also significant (agriculture,
construction sites) and much could be achieved by involving these
areas more in control efforts. At times environmental changes
have also worked in support of malaria control, eg deforestation
in Southeast Asia which has reduced the habitats of the malaria
vectors. Lack of general country development particularly transport
infrastructure is an additional important non-health barrier to
rapid progress making implementation and monitoring of high quality
programmes—key for achieving ambitious control or elimination
targets—highly problematic. Greater investments in the education
sector at all levels, primary to tertiary, will be crucial to
overcome the barrier of inadequate capacity to control communicable
diseases.
10. The 2004 Stockholm convention against
persistent organic pollutants including DDT has—in our assessment—not
in the least contributed to spread of malaria (which has not occurred
at a significant level) nor the increasing number of cases (which
had been mainly due to drug resistance). This is because most
countries in Sub-Saharan Africa have never applied indoor residual
spraying at national scale and, therefore, lacking the systems
and capacity, spraying DDT was until recently not an option. In
addition, in most of these countries other insecticides such as
pyrethroids are sufficiently effective meaning that DDT is not
the only solution.
14. While patents do play a role with respect
to medicines against malaria and insecticides against the vectors
they are not limiting control efforts in the same way as is the
case with HIV/AIDS. The problem lies more in the rate at which
companies producing medicines are prequalified to supply to the
major funding sources.
15. Outbreaks of malaria are currently a
problem only within some counties (highlands, refugee situations,
other population migrations) but not between countries or continents.
This is due to the more complex transmission modalities of malaria
compared to bacteria or viruses. Outbreaks will only become a
more than local concern when malaria elimination has succeeded
in large areas currently endemic.
20. We should be willing to provide more
detailed information if called upon by the committee.
The responses presented have been contributed
by several staff within our organisation, and are an organisational
submission.
21 January 2008
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