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Progressi sui Millennium Developmental
Goal:
MALARIA
SERGIO SPINACI
Global Malaria Programme
Organizzazione Mondiale della Sanità, Ginevra
La malaria è uno dei quattro grandi flagelli dell’Africa
(gli altri sono la fame, la tubercolosi e l’HIV)
Global strategic objectives
Ecco la serie dei progetti internazionali per controllarla, dal 1998 a oggi.
I progetti sono progressivamente meno ottimistici (meno miracolistici)
 RBM Partnership (1998): halve the burden of malaria by 2010
 Abuja coverage targets (2000): by 2005, achieve a 60%
coverage of all at-risk populations with suitable curative and preventive
measures
 Millennium Development Goals (2000): by 2015,
– MDG 4: Reduce child mortality
– MDG 5: Improve maternal health
– MDG 6: Combat HIV/AIDS, malaria and other diseases; particularly,
halt and begin to reverse the incidence of malaria and other major diseases
 World Health Assembly Resolution (2005): by 2010, at least
80% of at-risk populations benefit from major preventive and curative
interventions
Associations between malaria & the MDGs
La malaria in realtà non è implicata in uno solo degli MDG, quello che la
menziona formalmente, cioè lo MDG6; ma è implicata nella maggioranza dei
traguardi da raggiungere: 6 MDG su 8

MDG 1: Eradicate extreme poverty and hunger
–

MDG 2: Achieve universal primary education
–

Malaria is a leading cause of illness and absenteeism in children and teachers in malarious areas, impairs attendance and
learning and can cause lasting neurological damage in children.
MDG 4: Reduce child mortality
–
–

Malaria keeps poor people poor, costing Africa an estimated US$ 12 billion/yr in lost GDP & consuming up to 25% of
household income and up to 40% of government health spending.
Malaria is a leading cause of child mortality in Africa, accounting for nearly one death in five among African children under
five. Every day, an estimated 3000 children and infants die of malaria– representing approximately 82% of all malaria
deaths.
It is estimated that the indirect effects of malaria - which are mostly overlooked in estimates of malaria-related morbidity
and mortality - result in up to 200,000 infant deaths per year in Africa alone.
MDG 5: Improve maternal health
–
–
Approximately 50 million women become pregnant in malaria-endemic countries each year.
Malaria during pregnancy is a major cause of severe maternal anemia and puts women at increased risk of dying from the
complications of severe malaria, and of experiencing spontaneous abortion, premature delivery or stillbirth.

MDG 6: Combat HIV/AIDS, malaria and other diseases

MDG 8: Global partnership for development
–
GMP is part of the RBM partnership and especially involved in the partnership working groups GMP is working in
strengthening Health Services delivery by supporting countries to strengthen their monitoring, supervision and supply chain
management practices.
Malaria imposes a staggering worldwide burden
High
None
Level of malaria
burden
Death toll
 At least 1 million deaths annually; one child every 30 seconds
Incidence
 350 to 500 million cases worldwide
Health impacts
 Debilitating fevers, low birth weights, anemia, epilepsy—and death
Economic impacts
 Reduced current productivity resulting from days and often weeks of
missed work, reduced foreign direct investment and tourism
 Constraints on future growth resulting from reduced investments in
human capital (missed schooling, higher fertility rates)
Source: World Malaria Report
2005, expert interviews
Ecco i numeri e le sedi di maggiore impatto.
L’Africa è il regno di Plasmodium falciparum
Current global estimates of population at risk by WHO Region
L’Africa è anche il continente dove l’endemia di malaria è infinitamente
più alta che altrove: qui la malaria è oloendemica o iperepidemica
Approximately 0.95 billion at risk (Source: WHO regional offices, Kicewski, 2007)
Reproduction rate of malaria varies by endemicity
Dove la malaria è oloendemica o
iperepidemica ogni persona infetta dà luogo
ad altre 2000-3000 infezioni
4.000
2000 - >3000
new cases
For every 1 infected case,
there will be...
(R0) # new
infections
per infected
person
100 - 2000
new cases
3.000
2.000
1.000
2.5 – 100
new cases
>2.5
new cases
0
# of infectious
bites per yr (EÌR)
Hypoendemic
Mesoendemic
Hyperendemic
Holoendemic
<0.25
0.25 - 10
11 - 140
>140
Source: Smith DL, et al (2007); Prospects for
Eradication and Elimination of Malaria, DFID, 2007
L’azzeramento della malaria richiederebbe un R0 (cioè un numero di
nuove infezioni per ogni persona infetta) <1;
e in Africa ne siamo lontanissimi
Sub-Saharan Africa bears a disproportionate share of the
malaria burden
Majority of
cases/deaths
 Africans suffer from the majority of worldwide malaria deaths
(90% or at least 900,000) and malaria cases (60% or at least
300 million)
High proportion of
health expenditures
 Countries in Africa with the heaviest burdens are forced to
expend significant resources on malaria:
Unfavorable
entomology & climate
 Africa is home to the most deadly form of the parasite
(Plasmodium falciparum) and has the climate and vector
(mosquito species) most conducive to its proliferation
Lack of domestic
capacity
 Many sub-Saharan African governments lack the funds
and/or infrastructure to single-handedly mount large-scale
anti-malaria campaigns
– 40% of health expenditure
– 20-45% of hospital admissions
– 50% of outpatient visits
Source: World Malaria Report 2005, expert interviews
L’Africa è dunque, come abbiamo visto, non solo il Continente che più soffre per questa
malattia, ma anche, con ogni evidenza, quello che più difficilmente se ne potrà liberare
Ecco il ciclo vitale del parassita malarico, tra il vettore infetto, che immette nell’uomo lo
sporozoite, l’uomo nel cui fegato lo sporozoite svolge il suo ciclo trasformandosi in
merozoite e alla fine in gametocita, che viene succhiato dal vettore infettante, all’interno dei
cui organismo i gametociti si uniscono per dar luogo a uno zigote, da cui derivano gli
sporozoiti, che il vettore infettante trasmetterà ad altri umani.
Host
Parasite
Infecting vector
Infected vector
Source: http://encarta.msn.com/media_461541582/Life_Cycle_of_the_Malaria_Parasite.html Accessed on 31 March 2008
Elements of malaria control strategies
Human
Drugs and diagnosis
at health centre and
community level
STOP
STOP
Universal
LLIN coverage
Parasite
Infected
vector
STOP
Infecting
vector
Universal LLIN coverage/ IRS
Ecco come l’associazione della protezione mediante zanzariera impregnata LLINs e della
pronta ed efficace terapia terapia con antimalarici IRS può bloccare il ciclo del parassita tra
vettore infetto, uomo, e vettore infettante. Zanzariera impregnata e antimalarici
rappresentano gli strumenti essenziali e possibili per contenere e ridurre la mortalità e la
trasmissione della malaria
Case management: recommendations
 Malaria diagnosis: Parasitological confirmation (microscopy or RDT) before treatment
except in U-5s, in areas of high transmission
 Malaria treatment: ACTs are recommended for all cases of uncomplicated falciparum
malaria,
– artemether-lumefantrine; artesunate + amodiaquine; artesunate + mefloquine; and artesunate +
sulfadoxine-pyrimethamine
Second-line treatment:
– an effective alternative ACT to the 1st line or
– quinine + tetracycline or doxycycline or clindamycin
 Community / home management of malaria: Effective treatment with ACT should be
made available at all levels of service delivery up to the community including through
the private sector
 Intermittent preventive treatment in pregnant wWomen: IPTp w/ith SP is a strategy
for malaria control in pregnant women in sub-Saharan African in countries with stable
malaria transmission
Malaria vector control: IRS & ITNs/LLINS
 ITNs: Free or highly subsidized LLINs should be provided to the entire
population, initially targeting high risk groups
 IRS: Can be used in all epidemiological settings, and is mostly indicated:
– to control 1). malaria outbreaks, 2). emerging drug resistance, 3). malaria in
complex emergencies, and 4). to decrease malaria transmission in stable areas
– to interrupt transmission with the objective of eliminating malaria (where feasible)
 LLINs & IRS can be deployed in combination as complementary
measures to enhance extended insecticide coverage
 Insecticide resistance monitoring in sentinel sites must be an integral
part of effective vector control.
Ma la sfida principale è quella dell’emergenza di
nuove resistenze
 Monitoring therapeutic efficacy must be an integral component of effective case
management.
 Consequences of anti-malarial drug resistance:
– Increased morbidity and mortality (including anaemia, low birth weight)
– Increased gametocyte carriage
• switch to effective drug combinations in situations of low to moderate endemicity has always
resulted in a dramatic decrease in transmission
– Economic impact
• increases cost to health services (to both provider and patient) because of returning treatment
failures
– Greater frequency and severity of epidemics
– Modification of malaria distribution
– A chaotic informal private sector (including with sub-standard and counterfeit medicines)
Ecco la geografia della resistenza alla clorochina,
farmaco a bassisimo costo, difficilmente sostituibile
Countries with at least one study indicating chloroquine total failure rate > 20%
Countries with at least one study indicating chloroquine total failure rate > 10%
No recent data available
Ecco la strategia per rallentare o inibire la
progressione delle resistenze
 Change antimalarial treatment policies when treatment failure is >10%
(as assessed through monitoring of therapeutic efficacy at 28 days)
 Change to a treatment which has an average cure rate ≥ 95% as
assessed in clinical trials
"…Prompt and accurate diagnosis of malaria is the key to
effective disease management and to the reduction of
unnecessary use of antimalarial medicines."
Storia dell’insorgenza di resistenze agli antimalarici
La comparsa delle resistenze è sempre più rapida: dal momento in cui è stato usato
la prima volta il chinino alla prima resistenza segnalata sono passati 300 anni; la
clorochina ci ha messo 20 anni, la meflochina ce ne ha messi 5, il proguanil, la
sulfadoxina-pirimatamina, l’atovaquone non ci ha messo nemmeno un anno.
Quinine
1632
X 1910
Chloroquine
Introduced
1934
Proguanil
First case of
resistance
X 1957
1948
SulfadoxinePyrimethamine
X 1949
1967
Mefloquine
1977
X 1982
1996
(herbal)
Reports of in vitro
resistance. Example:
Resistance of P. falciparum
field isolates (French
Guiana /Senegal) to
in-vitro Artemether
Lancet (Dec 2005)
X 1967
Atovaquone
Artemisinin
X
1972
X 1996
?
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Source: Talisuna et al, Clinical Microbiology Reviews (2004)
Progress on malaria control goals
(in particular towards MDGs)
Ma quanto occorrerà perché almeno gli strumenti oggi
disponibili possano essere distribuiti o comunque utilizzati da
tutte le persone in bisogno?
In particolare, quanto siamo distanti da un’utilizzazione
sufficientemente diffusa delle zanzariere impregnate e degli
antimalarici per tutti i bambini sotto i 5 anni, la classe di età
più esposta alla morte per malaria?
Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 8: Have halted by 2015 and begun to reverse the incidence
of malaria and other major diseases
Indicator 22: Children under 5 sleeping under insecticidetreated bednets & with fever who are treated w/ appropriate
anti-malarial drugs
Malaria-control efforts are
paying off, but additional effort
is needed
% of children sleeping under ITNs in selected African countries:
Base year (around 2000) and Latest year (2005) São Tomé and Pr incipe
São Tomé and Pr incipe
Gambia, The
Guinea- Bissau
Gambia, The
Guinea- Bissau
Togo
Togo
Zambia
Zambia
Malawi
Malawi
Ghana
Ghana
Benin
Benin
Tanzania
Tanzania
Cent r al Af r ican Republic
Rwanda
Camer oon
Camer oon
Uganda
Uganda
Bur kina Faso
Bur kina Faso
Bur undi
Senegal
Niger
Cent r al Af r ican Republic
Rwanda
Bur undi
Senegal
Niger
Côt e d’Ivoir e Côt e d’Ivoir e
Congo, DR
Congo, DR
Come si vede, la copertura è molto
cresciuta, in tutti o quasi tutti gli stati
africani, nel 2005 rispetto al 2000; ma
siamo egualmente molto lontani da una
copertura soddisfacente
Sier r a Leone
Sier r a Leone
Kenya
Kenya
0
10
20
30
Source: Demographic and health surveys and Multi-indicator household surveys.
40
50
60
Recent impact: Rwanda & Ethiopia
Ethiopia 2003-2007, 7 in-patient facilities
Rwanda, 2001-2007, 19 health facilities
In-patient malaria and non-malaria cases in children <5 years old
In-patient malaria and non-malaria cases in children <5 years old.
12000
10000
LLINs, ACTs
Sep-Oct 2006
LLINs, ACTs
2,500
ACTs
3,000
9000
10000
8000
2,500
2,000
7000
8000
4000
1,500
1,000
4000
1,000
3000
2000
Malaria cases
2000
Malaria
500
500
Non-malaria
Non-malaria cases
1000
0
0
2001
2002
2003
2004
Year
2005
2006
2007
0
0
2003
2004
2005
2006
2007
Year
Eppure le facilitazioni economiche (in particolare la distribuzione gratuita o a
prezzo molto conveniente di zanzariere impregnate e la distribuzione di antimalarici
scontati) riducono oggettivamente e significativamente, dove vengono introdotte,
l’impatto della malaria
Non-malaria cases
5000
1,500
Malaria cases
Malaria cases
6000
Non-malaria cases
2,000
6000
Conclusioni
Challenges
 Implementation
– Countries need continued clear guidance & support on how to implement global
policies and use funds effectively
 Integration of malaria control into health systems, particularly at district level
– Focus on the integration of malaria with EPI for commodity distribution and
malaria programme supervision
 Resource mobilization
– Strategies for human resource training and retention to be put in place
– Effective mobilization for technical assistance to countries
 Malaria impacts 6 of the MDGs
– More resources need to be put towards M&E to ensure that resources are being
effectively targeted.
Malaria control getting to the MDGs
 Comprehensive packages need to be put in place: malaria control objectives cannot
be achieved without focusing on both prevention, treatment, diagnosis and monitoring &
evaluation.
 Increased scale-up will also demand greater vigilance and monitoring to prevent
resistance and loss of tools
 Frontloading and increased scale-up in 2008-2010 will demand greatly increased
resources – both human & financial
– However rapid scale up in 2008-2010 could save at least 3.5 million lives and
avert about 672 million cases
 Research and development are needed both in the near term (particularly operational
and new and improved tools to replace those lost to resistance) and with a view to longterm development of new tools (e.g. vaccines)