Malaria Medicines & Diagnostics: trends and supply requirements

Dr. Andrea BosmanDiagnosis, Treatment and Vaccines WHO Global Malaria Programme4 November 2010, Geneva

Proportion of patients seeking treatment for malaria symptoms

Use of diagnostic tests in formal health sector

Source: CHAI Analysis, global estimates for patients living at risk of malaria, based on 2008 World Malaria Report & UNICEF Intervention Coverage Reports

44%Formal Health

Sector

28%No action

28%Informal Private Sector

53%Clinical

Diagnosis(355 million/yr)

8% RDT

39% Microscopy

Technical Briefing Seminar – 4 Nov 2010 3 |GLOBAL

MALARIA PROGRAMME

0.5 0.6 2.1 5

31.3

82.797

130

160

210

0

50

100

150

200

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0

10

20

30

40

50

60

70

80

ACT procured No countries: ACT 1st line No countries deploying

6-24 months from adoption to implementation6-24 months from adoption to implementation

Mill

ions

of A

CT

trea

tmen

t cou

rses

Cu

mu

lati

ve n

um

ber

of

cou

ntr

ies

WHO policy on ACTsWHO policy on ACTs

GFappeal on ACTsGFappeal on ACTs

Forecast

ACT procurement for public sector distribution

Technical Briefing Seminar – 4 Nov 2010 4 |GLOBAL

MALARIA PROGRAMME

(a) Americas (high incidence)

0

2

4

6

8

10

12

14

16

18

20

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Ca

se

s p

er

10

00

po

pu

lati

on

(B

eliz

e, H

on

du

ras

, Nic

ara

gu

a, P

eru

)

0

10

20

30

40

50

Ca

se

s p

er

10

00

po

pu

lati

on

(S

uri

na

me

)Honduras

Belize

Nicaragua

Peru

Suriname

(b) Americas (low incidence)

0.0

0.1

0.2

0.3

0.4

0.5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Ca

se

s p

er

10

00

po

pu

lati

on

(E

l Sa

lva

do

r, M

ex

ico

)

0.00

0.01

0.02

0.03

Ca

se

s p

er

10

00

po

pu

lati

on

(A

rge

nti

na

)El Salvador

Mexico

Argentina

(c) Eastern Mediterranean

0.0

0.2

0.4

0.6

0.8

1.0

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006C

as

es

pe

r 1

00

0 p

op

ula

tio

n

(Ira

n, S

au

di A

rab

ia)

0.000

0.002

0.004

0.006

0.008

0.010

Ca

se

s p

er

10

00

po

pu

lati

on

(M

oro

cc

o, O

ma

n, S

yri

a)

Iran

Oman

Saudi Arabia

Morocco

Syrian AR

(d) Europe

0.0

0.5

1.0

1.5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Ca

se

s p

er

10

00

po

pu

lati

on

(A

zerb

aija

n, G

eo

rgia

, Tu

rke

y)

0

1

2

3

4

5

6

Ca

se

s p

er

10

00

po

pu

lati

on

(T

ajik

ista

n)

Turkey

Georgia

Azerbaijan

Tajikistan

(e) South-East Asia

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Cas

es p

er 1

000

po

pu

lati

on

(B

hu

tan

, Sri

Lan

ka)

0

1

2

3

4

5

6

Cas

es p

er 1

000

po

pu

lati

on

(I

nd

ia, T

hai

lan

d)

Sri Lanka

Bhutan

Thailand

India

(f) Western Pacific

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Ca

se

s p

er

10

00

po

pu

lati

on

(L

ao

PD

R)

0

1

2

3

Ca

se

s p

er

10

00

po

pu

lati

on

(M

ala

ys

ia, P

hili

pp

ine

s, V

iet

Na

m)

Lao PDR

Viet Nam

Malaysia

Philippines

(Source: World Malaria Report 2009) (Source: World Malaria Report 2009)

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

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

Technical Briefing Seminar – 4 Nov 2010 5 |GLOBAL

MALARIA PROGRAMME

0

2000

4000

6000

8000

10000

12000

2001 2002 2003 2004 2005 2006 2007 2008

Case

s

0

20

40

60

80

100

120

140

Deat

hs

Malariainpatientcases

Malariainpatientdeaths

Accelerationstarted

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

2001 2002 2003 2004 2005 2006 2007 2008

Mal

aria

inpa

tient

case

s

0

1000

2000

3000

4000

5000

6000

7000

Mal

aria

inpa

tient

deat

hs

Malariainpatientcases

Malariainpatientdeaths

Accelerationstarted

Malariainpatientcases

Malariainpatientdeaths

0

2000

4000

6000

8000

10000

12000

14000

2001 2002 2003 2004 2005 2006 2007 2008

Case

s

0

50

100

150

200

250

300

Deat

hs

Accelerationstarted

Malariainpatientcases

Malariainpatientdeaths

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008

Malaria

inpa

tient

case

s

0

50

100

150

200

250

300

350

Malaria

inpa

tient

deat

hs

Accelerationstarted

Eritrea Rwanda

ZambiaSao Tome and Principe

Reduction of >50% in cases: …. in 9 African countries

Reduction of >50% in cases: …. in 9 African countries

Also: Botswana, Cape Verde, Namibia, South Africa, Swaziland Also: Botswana, Cape Verde, Namibia, South Africa, Swaziland

Technical Briefing Seminar – 4 Nov 2010 6 |GLOBAL

MALARIA PROGRAMME

Malaria decrease in Africa due to effective control

Median PfPR 1985-19992-10 = 37%

Median PfPR 2000-20072-10 =

17%

Median PfPR 1985-19992-10 = 37%

Median PfPR 2000-20072-10 =

17%

Systematic review: 24 studies conducted between 1989 and 2005

in 15 different African countriesincluding 15’331 patients

Proportion of malaria among fevers highly variable: 2% to 81%: Median parasite rate =

26%

Systematic review: 24 studies conducted between 1989 and 2005

in 15 different African countriesincluding 15’331 patients

Proportion of malaria among fevers highly variable: 2% to 81%: Median parasite rate =

26%

D'Acrémont et. al. (2009). PLoS Med, 6 (1): e252

Technical Briefing Seminar – 4 Nov 2010 7 |GLOBAL

MALARIA PROGRAMME

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

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

0%

20%

40%

60%

80%

100%

Eur

ope

Am

eric

as

Sou

th-E

ast A

sia

Afri

ca

Eas

tern

Med

iterra

nean

Wes

tern

Pac

ific

% re

port

ed c

ases

wit

h co

nfir

med

dia

gnos

is

.

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

Technical Briefing Seminar – 4 Nov 2010 8 |GLOBAL

MALARIA PROGRAMME

Deployment of RDTs in Livingstone (Zambia): impact on malaria cases and ACT consumptionDeployment of RDTs in Livingstone (Zambia):

impact on malaria cases and ACT consumption

Source: NMCC, Zambia MoH

Reported malaria cases, Zambia Livingstone District, 2004 - 2008

0

2000

4000

6000

8000

10000

12000

14000

2004

Q 1

2004

Q 2

2004

Q 3

2004

Q 4

2005

Q 1

2005

Q 2

2005

Q 3

2005

Q 4

2006

Q 1

2006

Q 2

2006

Q 3

2006

Q 4

2007

Q 1

2007

Q 2

2007

Q 3

2007

Q 4

2008

Q 1

2008

Q 2

2008

Q 3

2008

Q 4

IRS

Introduction of RDTs

Bednet introduction

ACT

RDTsRDTs

From over 25'000 ACTs in 2007 to less than 5'000 in 2008

Technical Briefing Seminar – 4 Nov 2010 9 |GLOBAL

MALARIA PROGRAMME

Reduction of ACT consumption with RDT scale-up in Senegal public health services Reduction of ACT consumption with RDT

scale-up in Senegal public health services Courtesy of Dr S. Thiam, PNLP SenegalCourtesy of Dr S. Thiam, PNLP Senegal

~ 0.5 million less ACT consumed in 2008-2009

Technical Briefing Seminar – 4 Nov 2010 10 |GLOBAL

MALARIA PROGRAMME

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

2001 2002 2003 2004 2005 2006 2007 2008 2009

0

10

20

30

40

50

60

Malaria cases

ACT orders

Positivity rate

% malaria OPD

% malaria IPD

Rwanda: preliminary analysis (WMR 2010)Rwanda: preliminary analysis (WMR 2010)

Malaria cases Malaria cases & ACT annual orders& ACT annual ordersMalaria cases Malaria cases & ACT annual orders& ACT annual orders % malaria positive% malaria positive% malaria positive% malaria positive

LLIN distributionLLIN distribution

% malaria outpatients% malaria outpatients% malaria outpatients% malaria outpatients% malaria inpatients% malaria inpatients% malaria inpatients% malaria inpatients

%%

Technical Briefing Seminar – 4 Nov 2010 11 |GLOBAL

MALARIA PROGRAMME

Malaria Consortium

PSI/TDR

Save the Children

IRC

Catalytic Initiative

PMI/MCH

Countries with projects on (integrated) Community Case Management

Courtesy of Dr F. Pagnoni, TDR Courtesy of Dr F. Pagnoni, TDR

Technical Briefing Seminar – 4 Nov 2010 12 |GLOBAL

MALARIA PROGRAMME

Affordable Medicine Facility for malaria: Phase 1Affordable Medicine Facility for malaria: Phase 1

Ghana

Madagascar

Uganda

Tanzania

Nigeria

Niger

Kenya

Cambodia

As of Sept 2010, 92 first-line buyers are making 24 co-payment requests (equivalent to US$ 8.02 million).

AMFm co-paid ACTs are on sale in Ghana and Kenya.

Technical Briefing Seminar – 4 Nov 2010 13 |GLOBAL

MALARIA PROGRAMME

ConclusionsConclusions

Malaria reducing in near 40 countries due to high coverage of RDTs, ACTs and LLINs - often in combination

Reduction of ACT consumption in areas with high level of use of malaria diagnostics (e.g. testing >80% of suspected cases)

At global level impact on ACT needs is limited because:

– low use of malaria diagnostics in countries with high burden

– ongoing expansion of ACT access interventions, i.e. community case management and AMFm (Phase I)

– variable coverage of vector control (malaria resilience)