The Role of International Agencies in Conquering Malaria

Joel G. Breman, MD, DTPHFogarty International Center

National Institutes of Health

Malaria and Human AffairsSchool of Public Health

Harvard University

5 May 2005

The Role of International Agencies in Conquering Malaria

1. Principles

2. Vision, Goals, Targets, Strategies

3. Major Initiatives

4. Selected Agencies and Initiatives

5. Keys to Successful Malaria Programs

Principles

• The Five Commandments

• Multilateral, Bilateral, and Unilateral Approaches

Research, Training, and Support Needs Research, Training, and Support Needs According to Understanding of Diseases According to Understanding of Diseases andand

Efficacy of Control MethodsEfficacy of Control Methods

Research Needs

Efficacy of

Control Methods

High HighTraining

Some HighModerateFunding, Research Support Needs

Low Low

The Five Commandments for Successful Programs: Thou Shalt Have…

• Control

• Research

• Training

• Funding

• Advocacy

Comparison of Multilateral, Bilateral and Unilateral Programs (1)

Low/variesMediumHighFunding/resources

Low/noneLimitedSuccessfulSynergies/networks

Generally lowLimitedSuccessfulGlobal coordination/

communication

ShortOften long

LongTime to form coalition

None (nation)TwoMultiplePartners

UnilateralBilateralMultilateralFactor for success

Comparison of Multilateral, Bilateral and Unilateral Programs (2)

MinimalVariesHighMutual benefits

VariesVariesHighly successful

Shared experiences

FragileVariesGoodSustainability

VariesVariesHighStandardized methods

Decisive (possibly)

Often donor-imposed

Can be ambiguous

Leadership (vision, decisions)

UnilateralBilateralMultilateralFactor for success

Vision, Goals, Targets, Strategies

• Abuja Declaration and Roll Back Malaria

• Millennium Development Goal

• Vision (proposals)

• Strategies

Abuja Declaration and Roll Back Malaria

“To halve the burden of malaria by 2010”

Millennium Development Goal“To halt and begin to reverse the incidence of malaria globally by 2015”

WHO Executive Board, 2005“…at least 80% coverage of major preventive and curative interventions by 2010”

Abuja, Nigeria, 2000Malaria Summit Targets By December 2005

• Treatment > 60% of patients will have access to and use drugs

within 24 hours• Prevention

> 60% at risk have insecticide treated nets; priority to children and pregnant women

• Pregnancy> 60% of women have access to and use Intermittent

Preventive Treatment; priority to 1st and 2nd pregnancy

• Epidemics > 60% will be detected within 2 weeks> 60% will be responded to within 2 weeks of detection

Vision (proposals)For All Malaria Activities

“With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality”

For RBM“…to promote, support, and implement operational activities to reduce the burden of malaria and, ultimately, eliminate it”

Essential Strategies for Dealing with Malaria

• Use simple, cost-effective tools (C)

• Abolish “malaria taxes” and distribute insecticide-treated bednets (C)

• Promote and fund research in all its dimensions (R)

• Fund demonstration projects on and use of integrated vector management strategies (C)

• Scale-up operations (C)C=control, R=research

Essential Strategies for Dealing with Malaria (2) • Provide financial assistance to poorer countries

(F)• Engage public-private partnerships (C,R,T,F)• Insure targeted diagnosis and treatment (C)• Slow drug resistance (C, R)• Integrate malaria treatment into existing

programs (C)• Invest in malaria drug and combination

therapy development and distribution (C, R)

C=control, R=research, F = funding, T=training

• Prompt and effective treatment reduces mortality by at least 50%

• Mortality further reduced if treatment is available in home

• Drug resistance can be delayed through combination therapy including artesunates

• Insecticide-treated nets can reduce all cause mortality by 20%

• New rapid diagnostic techniques becoming available at lower cost

• Application of epidemiological and geographical information can help predict epidemics

Promising developments

Major Initiativesand Agencies

• Initiatives

• Agencies

Major Malaria Initiatives (1)

General/ malarious regions

$35 million/year

National governance, coordination, support, health systems development

Roll Back Malaria Partnership (RBM, 1998) (C, A)

General/ global$40 million

Discovery, development, commercialization; one new product/5 years

Medicines for Malaria Venture (MMV, 1999)

(R)

General/ global

$1.2 billion/year

($72 million)

Attract, disburse, manage funds to reduce disease burden and contribute to poverty reduction

Global Fund to Fight AIDS, TB, and Malaria (Global Fund, 2002)

(F)

Location/Coverage

Budget (malaria)MissionName (year began)

F = funding, R=research, C=control, T=training, A=advocacy

Major Malaria Initiatives (2)

New York/global?Advocacy, information to public, exchange of views among malariologists, cost-effective use of resources

Malaria Foundation International (MFI, 1992) (A)

Dar es Salaam/Africa$500,000/yearRegional training for clinical trials, capacity strengthening

Africa Malaria Network (AMANET, 1996) (R,T)

Stockholm (rotating)/Africa

$2 million/yearGlobal research alliances, maximize impact of research and training on control

Multilateral Initiative on Malaria (MIM, 1997) (R,T)

Location/CoverageBudget (malaria)MissionName (year began)

F = funding, R=research, C=control, T=training, A=advocacy

Agencies and Roles in Conquering Malaria ResearchCountry institutions

Special Programme on Research and Training in Tropical Diseases (TDR/WHO)Multilateral Initiative on Malaria (MIM)Foundations Bill & Melinda Gates Wellcome TrustNational Institutes of Health (NIH) National Institute of Allergy and Infectious Diseases (NIAID) Fogarty International Center (FIC)Centers for Disease Control and Prevention (CDC)Public Private Partnerships Medicines for Malaria Venture (MMV) Malaria Vaccine Initiative (MVI)Drug Companies, Glaxo-Smith-Kline (PPP)Others

Agencies and Roles in Conquering Malaria

Control

CountriesBilateral and multilateral (including USAID, DFID, etc.)WHO WHO/AFRO and other regional offices Roll Back Malaria (RBM/WHO)United Nations Childrens Fund (UNICEF)Others

Agencies and Roles in Conquering Malaria

TrainingCountriesWHO RBM TDR Regional OfficesMIMNIH , FIC and NIAIDLondon School of Hygiene and Tropical Medicine (LSHTM)African Malaria Network (AMANET)Others

Agencies and Roles in Conquering MalariaFunding

Countries

Global Fund for AIDS, Tuberculosis and Malaria

Bilateral and multilateral

World Bank

Foundations Bill & Melinda Gates Foundation Wellcome Trust

Others

Selected Agencies and Initiatives• Multilateral Initiative on Malaria (MIM) (R)• National Institute of Allergy and Infectious Diseases (NIAID)

(R)• Fogarty International Center (FIC) (R, T)• Centers for Disease Control and Prevention (CDC) (R, C, T)• Roll Back Malaria Partnership (A)• The Global Fund to Fight AIDS, TB and Malaria (F)• United States Agency for International Development

(USAID) (C, F, R)

F = funding, R=research, C=control, T=training, A=advocacy

Multilateral Initiative on Malaria

Multilateral Initiative on Malaria (MIM)

“…to strengthen and sustain, through collaborative research and training, the capability of malaria-endemic countries in Africa to carry out research required to develop and improve tools for malaria control – and to strengthen the research-control interface”

Multilateral Initiative on Malaria MIM Components

MIM/TDR: Malaria Research and Capacity Strengthening in Africa

Between 1998-2003, MIM/TDR supported 30 research projects involving 24 African countries, 7 European countries and the United States: total US$6.5 million

MIMCom.Net: Malaria Research Network for Africa

Connected 15 major malaria sites benefiting more than 1,000 scientists

Secretariat: Coordinating the Collaboration in Malaria Research and Capacity Strengthening

Career development training

Organization of malaria conferences

Newsletter

Electronic information exchange system

MR4: A Resource for Malaria Research and Training

Over 300 reagents, including: antibodies, antigens, plasmids, EST clones, PCR primers and genomic/cDNA libraries, and numerous species and strains of Plasmodium and Anopheles; all contributed for gratis distribution world-wide.

Malaria Research and Reference Reagent Resource Center

Multilateral Initiative on Malaria (MIM)The Multilateral Initiative on Malaria (MIM) is a global alliance of organizations and individuals concerned with malaria. Its aim is to maximize the impact of scientific research against malaria in Africa, through promotion of capacity buildingactivities and facilitating global collaboration and coordination. What is TDR's role? TDR's role in MIM is to help assess the scientific needs and take responsibility for strengthening the research capacities of malaria-endemic countries in Africa. TDR is responsible for coordinating the MIM/TDR Task Force on Malaria Research Capability Strengthening in Africa, which was established in 1997 to strengthen capacity through supporting research institutions in malaria-endemic countries.

MIM/TDR Task Force: Projects and Partnerships

Multilateral Initiative on Malaria Communications Network (MIMCom) sites

National Institute of Allergy and Infectious Diseases

NIAID Implementation Plan for Global Research on Malaria (1)

Drug resistance network

Drug development

Genome sequencing

Screening for active compounds

Additional clinical research centers

Clinical testing

Development of lead compounds

Drug Development

Expand clinical research on malaria pathogenesis

Expand partnerships with industry

Augment capability for pilot lot production

Supplement capability for clinical testing

Additional clinical research

Vaccine Development

InitiativeResearch Focus

NIAID Implementation Plan for Global Research on Malaria (2)

Expand research on vector biology and genome sequencing

Identify targets of insecticide action and mechanisms of resistance

Expand research on vector ecology and develop new control methods

Develop detection methods for resistance

Establish field sites

Field-test new control methods

Vector Control

Expand partnership with industry

Identify markers of drug resistance

Determine generic polymorphisms

Diagnostics

InitiativeResearch Focus

NIAID Implementation Plan for Global Research on Malaria (3)

Technology transfer/education

Internet connectivity

Endemic Area Data Management Center

Centers for International Clinical Research

Infrastructure/Research Capability Strengthening

InitiativeResearch Focus

NIAID Malaria Budget, 2001-2005

$0

$10,000$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

2001 2002 2003 2004 2005

Dollars inmillions

The role of MR4 in the malaria research community

Contract awarded Sept 30 1998- Sept 29 2005Improve global access of research tools and modelsStandardize and validate reagents and protocolsServe as a knowledge resourceProvide workshops and training in critical areas Initiate R&D to add value to collectionMR4 at ATCC, Vector Resource at CDCScientific Advisory CommitteeWebsite for information, registration (www.mr4.org)

NIH/NIAID/DMID

NIAID Malaria ResearchRecent Achievements

Genomics -- Plasmodium/Anopheles sequencing projects Vaccines -- Trial in Mali -- >20 candidates under study -- Implementation of all elements outlined in 1997 NIAID Malaria Vaccine Plan Treatments -- Intervention trial with GSK in Thailand Research Resources -- Training -- MR4 -- Vaccine production

Source: Lee Hall, NIAID

NIAID’s Research Plan for Malaria Vaccine Development:

Implementation

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Expand Preclinical Development of Vaccine Candidates

Initial Clinical Testing

Establish a Repository

Malaria Clinical Research and Trial Preparation Sites

Sequencing Efforts to Identify New Targets

Intervention Trials in Endemic Areas

Fiscal Year

Maj

or

Init

iati

ves

Expand the Vaccine Research Grant Program

Clinical studies of resistance to malaria in endemic areas

planned currently underway Source: Lee Hall, NIAID

Highlights of NIAID's Research Plan for Malaria Vaccine Development

(http://www.niaid.nih.gov/dmid/malaria/malvacdv/toc.htm)

• Improved access to well characterized research materials

• Discovery and preclinical testing of new vaccine candidates

• Production and evaluation of candidate malaria vaccines

• Clinical research and trial preparation sites in endemic areas

Source: Lee Hall, NIAID