Public Health Journal No. 23

Public Health Journal No. 23

Sustainable vector control

Children’s education is key to future development all over the world. This is recognized by the second Millennium Development Goal of ensuring “that by 2015 children everywhere, boys and girls alike, will be able to complete a full course of primary schooling”. Poverty and diseases like malaria are often interlinked. They are leading causes of school absenteeism in children – and teachers. But malaria and other vector-borne diseases are preventable by stopping their transmission. In endemic countries only effective and sustainable vector control can guarantee these children’s chances for education and a better future.

April 2012

content

key facts

IMPORTANCE OF INSECTICIDE-TREATED BEDNETS (ITNs/LNs)

WHO World Malaria Report 2011

aedes mosquitoes

CASE STUDY

Leishmaniasis vector control in Bangladesh Photo: Reiner Pospischil

Photo: Michele Maroli

Malaria 350 million nets in use.

Main vector control tool.

Photo: Reiner Pospischil

sand flies

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Still huge challenges ahead

anopheles mosquitoes

Durable effect on sand fly density

by Dinesh Mondal

Towards sustainable schistosomiasis control

Eliminating a disease – it is feasible

Dengue, Chikungunya Upcoming use of bednets

Leishmaniasis ITNs control the vector, increasing use

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by Alan Fenwick and Michael French

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R E S E A R C H & D E V E L O P M ENT

culex mosquitoes

chagas disease ITNs can control the vector

Comparative life cycle assessment of LNs Photo: Reiner Pospischil

Photo: Bayer

Photo: Reiner Pospischil

triatomine bugs

west nile fever, nuisance ITNs protect against highest biting rates (better sleeping)

LifeNet®: The environmentally preferred option

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by Laurent Dini NGO

Save the Children

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Creating a better world NOTE S

fleas

plague, NUISANCE ITNs prevent bites while sleeping

Photo: Reiner Pospischil

Photo: Photodisc

bed bugs SKIN RASHES, ALLERGIC REACTIONS ITNs protect people and reduce nuisance

flies Photo: Reiner Pospischil

REM (raster electron microscopy) image of an insecticide-treated bednet (LifeNet®)

Diarrhoea, Trachoma ITNs protect people and reduce nuisance

Sri Lanka: Struggling to eliminate malaria African trypanosomiasis: Affected by warming Malaria R&D funding: Under threat?

Book review: Dealing with malaria History Schistosomiasis

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CD-ROM

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Cover photo: Michelle Cornu

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Available as poster on the enclosed Public Health CD-ROM

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content

Editorial

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Column

Challenges ahead

by Jeremy Lefroy

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cover story

Maintaining gains in malaria control

The way forward

by Clive J. Shiff and Mulakwa Kamuliwo

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S U ST A I N A B L E M A L A R I A CONTRO L

APPMG Report on malaria control

Sustaining success

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Value for money discussion

Some nets are different

by Gerhard Hesse

Bill & Melinda Gates Foundation: Malaria Forum 2011

Optimism and urgency

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Bayer workshop Seattle

Towards sustainable vector control

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content

WHO World Malaria Report 2011

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Still huge challenges ahead C A SE ST U D Y

Leishmaniasis vector control in Bangladesh

Durable effect on sand fly density

by Dinesh Mondal

31

Towards sustainable schistosomiasis control

Eliminating a disease – it is feasible

by Alan Fenwick and Michael French

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RESE A RC H & D EVE L O P M ENT

Comparative life cycle assessment of LNs

LifeNet®: The environmentally preferred option

41

by Laurent Dini NGO

Save the Children

49

Creating a better world NOTES

Sri Lanka: Struggling to eliminate malaria African trypanosomiasis: Affected by warming Malaria R&D funding: Under threat?

Book review: Dealing with malaria History Schistosomiasis

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CD-ROM

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Cover photo: Michelle Cornu

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52 53 54 56

editorial

Over the last few years, the global fight against malaria has made tremendous progress. Thanks to the mobilization of international and local resources as well as public and private partners, over a million lives could be saved. The Global Malaria Report documents how over the last decade malaria incidence and mortality have fallen. New solutions, smarter formulations for bednets, new active ingredients for indoor residual spraying, a vaccine, as well as new combination drugs and novel diagnostics are about to enter the market. All this has created much optimism in the community and should make us confident about achieving “zero deaths from malaria” by the year 2015.

However, one key question remains: How will the global community sustain the successes made so far? Over the mid-term, we will be facing a significant reduction in funding and we expect this to impact operations as of 2014. Considering this background, it is more necessary than ever to find new ways to ensure effective and sustainable vector control.

Identifying and mobilizing alternative funding sources will become more and more important. At the same time, rethinking the deployment of resources, making the right choice of commodities and focusing on those activities that provide the best value for money spent, will ensure that we can sustain today’s achievements.

With this 23rd edition of the Public Health Journal, we want to further nurture and stimulate the discussion on sustainable vector control. Clive J. Shiff and Mulakwa Kamuliwo in their cover story introduce “Active Case Detection” (ACD) as the “third leg” of a sustainable antimalarial strategy.

This edition also takes a look at a major event in 2011: the second Bill & Melinda Gates Foundation Malaria Forum in Seattle. Our article under the headline “Optimism and urgency” reviews in detail the achievements over the last few years and the outlook for the coming years.

We are also proud to have MP Jeremy Lefroy, from the UK, contributing to this edition of the Public Health Journal. Based on the 2011 APPMG report, Jeremy Lefroy provides us with an overview on the challenges ahead. Under the title “Towards sustainable vector control”, we then take a closer look at Bayer’s first vector control stakeholder workshop, which took place in Seattle in October 2011.

Two more articles on neglected tropical diseases illustrate how important sustainable local solutions are, e. g. the use of treated bednets to control the vector of visceral leishmaniasis. To sustain control of schistosomiasis Bayer has currently joined a consortium following up on the objective of eliminating schistosomiasis from the islands of Zanzibar. Finally, we come back to the topic of value for money by highlighting the results of a complete life cycle assessment recently ® conducted on LifeNet as the first LN to have undergone this assessment.

I wish you pleasant reading and hope that the contributions from the many editors of the Public Health Journal will stimulate further reflections on how we as a partner of the global malaria control community will ensure on the mid-term effective and sustainable solutions.

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Gunnar Riemann

Member of the Bayer CropScience Executive Committee and President of the Environmental Science Division Worldwide

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APPMG on Malaria and Neglected Tropical Diseases

Challenges ahead The aim of the APPMG* is to provide a forum at the heart of the UK for discussing malaria and NTDs and act as a strong advocate in and out of Parliament for those committed to tackling these diseases. The chairman of the Group, Jeremy Lefroy, discusses the main challenges emerging from the comprehensive report compiled over the last year (see page 15).

A highlight of my first year in Parliament has been chairing the APPMG. The Group continues to follow the strategy of the Department for International Development (DFID) to meet the Millennium Development Goals, and support the British Government’s leadership role in the fight against malaria.

Vector control plays an essential role in disease management, as my recent trips to Africa have so clearly demonstrated. Visiting the Hoima District in Uganda with the Malaria Consortium we found that almost every home now had a mosquito net, and the number of children admitted to the local hospital had fallen sharply since the program began. My trip

to Rwanda with the International Development Committee also showed us how effective a well-run campaign against malaria through universal distribution of bednets can be.

What I found so refreshing in such initiatives and the communities taking on malaria is the desire to work together. Partnerships are the norm and people are willing to exchange ideas and help each other. Hugely encouraging is also how increased funding and international financial commitments have translated into increased coverage of malaria control tools such as insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LNs). This is an excellent use of money, not only in lives saved, but

Photo: APPMG

* APPMG = All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases

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MEETING IN UGANDA: Jeremy Lefroy MP (left), the author of this column, and Pauline Latham OBE MP (right) meeting James Kubekeketegra (third from left) MP and member of standing committee on social services.

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also the positive impact on productivity, education, and household income in vulnerable communities.

for resistance on hold, effective monitoring and evaluation of the situation needs to be carried out to ensure the best use of the tools we have. The R&D However, success remains fragile. Gains made so pipeline for new modes of action is relatively poor, far could be lost if continuous efforts are not although some candidates are under development maintained; we cannot close our eyes and rely on for IRS (see next point). the past. Moreover, resistance to insecticides is picking up. We must continue to 3) Developing new tools: develop new tools today to maintain The antimalarial development their effectiveness tomorrow. All this pipeline is very strong and promises requires money and commitment. new drugs and first generation vaccines becoming available in the The four main challenges near future. For insecticides some promising work is going on with Over the past year the Group has been product development partnerships, informed by various key stakeholders e.g. the Innovative Vector Control about some of the urgent issues facing Consortium (IVCC), and several new The author: the malaria community. Here I list the products have successfully passed the four main challenges we see emerging WHO Pesticide Evaluation Scheme Jeremy lefroy on the horizon.

(WHOPES).

House of Commons

Chairman of the All-Party Parliamentary Group on 1) Delivering the goods to people 4) Sustaining financing: Malaria and Neglected who need them, when they need It is increasingly important to sustain Tropical Diseases them: the gains made in countries where (APPMG) Even if the money to purchase malaria control has been successful. commodities is available, there is If not, malaria will bounce back with often a problem of access. Under a given situation, a vengeance, as examples from history have shown. what is the best distribution mechanism for LNs: In particular, sustainable vector control is essential: routine delivery, or mass campaigns? How can we e.g. in parts of Zambia malaria increased in areas forecast needs? Such questions play a vital role, and where ITNs were last delivered on a large scale 2-3 are critically affected by supply chain and logistics years previously. Sao Tome and PrĂ­ncipe faced a issues, production and delivery timelines, stock similar situation after a year when IRS was not control, and lengthy tendering processes. deployed.

2) Containing resistance: Insecticide resistance is arising and spreading very quickly. Although resistance has not led to the failure of malaria control programs as yet, this may only be a matter of time, so we must invest now in research and development (R&D) of new tools.

Particularly worrying is the situation with the use of pyrethroids in indoor residual spraying (IRS) and to treat bed nets. Luckily with IRS it is possible to rotate between a carbamate (bendiocarb) and pyrethroids, and other active ingredient classes might join the resources available. To keep selection

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Financing is a challenge In general, funds for malaria control have increased considerably over the last decade, but appear to have levelled off in 2010. The worry is that with the current economical situation this might even decrease. An example is the cancellation of the Global Fund financing round 11.

However, I am delighted that the UK Government is keeping its commitment to spend up to GBP 500 million (US$ 776 million) per year on tackling malaria by 2014/15.

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How the private sector is involved in tackling malaria • Ensuring that staff members, their families and communities have access to long-lasting insecticide-treated bednets (LNs).

• Using logistic skills and assets to help transport LNs and other commodities to remote areas.

• Investing in the local manufacture of LNs and drugs to cut costs, improve reliability of supply, create jobs and bring economic development.

• Working in public/private partnerships to develop new drugs, vaccines and other tools to prevent and treat malaria.

To finance ongoing malaria control may become challenging once the country has controlled malaria.

Measuring progress will need to switch, for example from numbers of nets delivered, to number of cases and deaths, or “disability adjusted life years” (DALYs) averted. Novel mechanisms need to be developed to ensure long-term predictable funding, and new funding sources need to be found. This must include domestic sources, and with the creation of ALMA (African Leaders Malaria Alliance) a first catalyst for interactions between Ministries of Health and Ministries of Finance has started to function. Cash on Delivery funding may be attractive since it focuses attention on outcomes rather than on inputs, e.g. the country is funded if a jointly defined target (such as prevalence rates) is reached and sustained.

During the last year the Group has heard how investment in malaria control by private companies has helped economic development. Countries, funders, and industry are starting to coordinate actions around Roll Back Malaria’s Global Action Plan (GMAP). Malaria is bad for business, but investment in tackling it, for example, manufacturing nets in Africa provides direct, sustainable economic benefits for the community. In the box above we have set out some of the ways in which the private

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sector is, and can continue to be, involved in helping to tackle malaria.

Although many of the APPMG’s challenges and recommendations are directed at the UK Government, we hope to contribute internationally to the discussion on accelerating progress in malaria control. We encourage all stakeholders to strengthen international leadership on malaria, champion the issue, and press for further progress. conclusion Effective malaria control depends on the prevention of infection AND the treatment of clinical cases, and the cornerstone of prevention is – vector control. Proper use of LNs and IRS with the necessary coverage has proven to work.

Deaths from malaria in 2010 are estimated to have fallen by at least 20%, largely due to the delivery of around 145 million LNs to subSaharan Africa. Now more than ever it is essential to sustain efforts in malaria control.

APPMG Report on malaria control: see page 15 Article on the enclosed Public Health CD-ROM.

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cover story

cover story

Maintaining gains in malaria control

THE WAY FORWARD Malaria is the subject of a large global initiative focusing on both basic research and large-scale operations to control the disease. But it is not clear how the research is being integrated into control interventions, nor how these interventions can be sustained.

The public health community needs to be involved, in endemic as well as nonendemic donor countries. A new paradigm for control and a series of needs that should support these initiatives could help solve the situation.

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Photo: Š poco bw - Fotolia.com

cover story

NOW IS THE TIME to consider also the third leg of the antimalaria strategy called active case detection (ACD): attacking the malaria parasite in the human population when it is numerically vulnerable. It means finding and treating people with asymptomatic, or silent infections, which can still act as reservoir of the disease. ACD, consequent treatment of all cases and sustainable vector control are the milestones for an effective disease management.

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cover story

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he proposed new paradigm for malaria control described here is based on datadriven initiatives, but would require epidemiological expertise, particularly in endemic countries. However, there is a dearth of career opportunities for scientists in the endemic areas, particularly in Africa; and there are insufficient trained local personnel to fill critical positions in these endemic countries. A series of needs are identified here that should be a focus of international agencies, in order to provide career opportunities for personnel, and resources for universities and colleges in the endemic countries.

Such measures are required to prepare and offer appropriate training for epidemiologists and field biologists. These are the people who can integrate the results of current research appropriate to local conditions and provide the basis for sustaining the successes already achieved.

Problems facing malaria control Malaria plagues humanity in much of the tropical world. Recent publicity has brought it to the public eye and major efforts have been and are being made to improve the situation. Research is

The authors: CLIVE J. SHIFF Associate Professor, Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

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MULAKWA KAMULIWO Acting Deputy Director Public Health & Research – Malaria, Ministry of Health, Lusaka, Republic of Zambia

being done in many parts of the world and much has been said about controlling, even eradicating, malaria from Africa. But this begs a whole series of questions that go beyond most current research, e.g. where will it be removed, globally or only from some areas? What are the goals we set? How are we progressing and how can we measure this?

Have we thought through these statements?

Certainly there is a great deal of research underway, mostly to define the parasites, their population and their biology. But how are we advancing in the real world, in the field where malaria impacts society?

Here the picture is not entirely clear; think of the word “we”. Who is making these decisions? Who are “we”? This is not the global “we”, i.e. the response of humankind exposed to news but with a short retention response. In fact it is the public health “we” who realize that the effort needs to be sustained over time. But, more importantly, it is the “we” representing the actual populations afflicted by the disease, those who must continue to work on the problem, and pay for the work over protracted periods so as to improve public health locally.1 As pointed out some 30 years ago by Socrates Litsios2, to control malaria requires a whole infrastructure and teamwork; a team of local, well trained personnel operating within an effective health system. It requires personnel at all levels, from the rural health center to the epidemiologist, all trained and motivated to collect and interpret data, understand the disease and its transmission as well as its potential lethality, plan ahead and have sufficient supplies for a timely and appropriate response.2 These are the people who can address these questions, and who must implement and sustain the control. But where are they? Who are they? Where and how are they trained? What are their career opportunities?

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Photo: Š Renate W. - Fotolia.com

cover story

Gaining global attention Controlling malaria has been a major public health goal for more than 100 years. There were great successes with eliminating malaria from endemic areas in Europe, Central and East Asia, North America, and even from Mauritius, but the situation did not improve in most of Africa, SouthEast Asia, and South and Central America. In fact, after a period of apparent quiescence, the situation deteriorated, and with the arrival of chloroquineresistant Plasmodium falciparum, mortality increased in much of Africa. The public health problem became critical. At that time there were few new tools to control malaria, so there was a need to stimulate research.

Global attention was drawn to the extent of the problem first in 1992 with the Amsterdam conference of African Ministers of Health, when

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ACTIVE CASE DETECTION depends on detecting the parasite in blood samples using highly sensitive PCR methods. These techniques pick up twice as many infections as analyzing samples under the microscope.

the emphasis was on strategies and the need for technological advances to provide a mechanism to address this deficit. This was followed by the Abuja conference in 2000, when numerous heads of State from African nations agreed to prioritize the problem of malaria within endemic countries.

For the most part this did not mean a major financial commitment to control the disease, but it laid the political basis for developing malaria control programs, and provided international health agencies with a goal to expand research on malaria.

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Insecticide treated net concept This was a time when new pyrethroid insecticides were being exploited, since it was discovered that these can be polymer coated on polyester fibers, or even incorporated into polyethylene and poly­ propylene fibers. This led to the concept of washresistant long-lasting insecticide-treated bednets.

This was also the time when the value of the drug artemisinin was appreciated and efforts were made to expand production and reduce the cost. The development of artemisinin combination therapy to successfully treat malaria is the second major tool in controlling malaria and reducing the high mortality caused by this disease. The integration of these two strategies has been implemented in most endemic areas in Africa with rapid and considerable success. Sustaining this success is a matter of concern.

A new paradigm for sustaining malaria control

Photo: Š Dmitry Knorre - Fotolia.com

Epidemiological studies from numerous countries in Africa report a substantial reduction in malaria

RECENT SUCCESSES are based on a single family of insecticides, the pyrethroids. Mosquitoes developing resistance is a major concern.

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cases as well as a decline in mortality caused by 3 this disease. This has been noted in the Gambia , 4 5 as well as Kenya , Tanzania , and Zambia, providing proof that malaria control with either indoor residual spraying (IRS) or LN as vector control, and ACT (artemisinin-combination therapies) treatment as parasite control, have had a profound effect on the disease. The successes achieved in most countries are the product of a massive global effort with mobilization of international and local resources. The achievement has been due to considerable global public interest, leadership of international agencies, input from major funding organizations, and the cohesion of national programs.

In fact, the strategies and interventions behind this current success were initially laid out more than 50 years ago, now augmented with some recent technological advances. But there is still vulnerability.6 These successes are based on a single family of insecticides, the pyrethroids, and a single drug, artemisinin. Resistance to both these compounds is apparent or suspected and may spread soon. Hence it is important to move to the next phase of a control strategy based on public health principles. The issue that public health professionals must address now is how to sustain this level of success. This effort will require better local infrastructure and more trained personnel.

It will also require a new strategy.

Active case detection Now is the time to emphasize the third leg of the anti-malaria strategy called active case detection (ACD). This is to attack the malaria parasite in the human population when it is numerically vulnerable. To do this it is necessary to perfect the detection process. ACD is difficult to put into effect, since it entails finding and treating people with asymptomatic infections. These people are not likely to visit health centers or doctors, or even health workers, as they do not feel stricken with malaria. They are not easy to diagnose because they often only have light infections, and they may even be negative under the microscope, with parasites only detectable using PCR methods

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cover story

Proceeding with ACD will entail a paradigm shift in the malaria control strategy; it will have to be targeted and based on epidemiological evidence.9 First and foremost it will be evidence-based.

Evidence of transmission will direct and target the intervention rather than a nationwide scale-up of vector control. The process will involve trained epidemiologists to collect and analyze data, and skilled personnel at the grass roots level to do much of the work. It will require logistic support, synchronized supplies of equipment, and the ability to mount focused interventions, to either treat people living in defined foci, or ensure their LNs are effective and used, or both. It will be based on sound epidemiological data and implemented for the main part during the period when malaria transmission is at a minimum. In Zambia this is from June until November.10 Expanding local expertise The concept of a paradigm change is used because a change in emphasis and strategy is needed. The overall plan for malaria control must move from the donor-driven project, funded generously and operated for the main part by expatriates, to one that is owned and operated by the service sector of the endemic country. This does not exclude assistance in various forms, e.g. supplies, training, research, and publicity, but ownership, direction, and the overall strategy must be local. The new concept should focus on research, study, and intervention in the field, and emphasize the need for expanding local epidemiological strength in the ministry of health of the endemic country. It will have a better chance of being sustained because it will involve the public health “we” and

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Photo: Michelle Cornu

(polymerase chain reaction). In fact, using PCR techniques has revealed the prevalence of silent infections as well as their seasonality.7 We have shown in Zambia that during low transmission, twice as many infections were detected by PCR methods than by blood film examination.8

AN IMPORTANT PART of active case detection is to ensure that ITNs are effective and used properly.

not the more detached, global “we”. It will involve a number of special needs.

Rural health centers and active case detection Active case detection is seasonal work. Research in Zambia has shown that during the low transmission season, tracking cases to their homestead, and then examining all the people living there with PCR methods revealed foci of silent cases. These are the people sought for “active” case detection. The actual detection and targeting of active cases would be best carried out during the period of low transmission. It is at this time that case-load will be at a minimum, usually a few cases a week, and so tracking the cases to homesteads would be feasible. If this process is adopted, the RHC staff would be augmented for the duration of the low transmission season by

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appointing a trained person who, following instruction from the District Health Office and local epidemiologist, would visit the case homestead and apply an intervention. This could be treatment of all residents with ACT and/or a single primaquine tablet, checking and replacing defective LNs, or implementing whatever the official strategy is to reduce the parasite reservoir in the community. At other times of the year, as transmission expands and prevalence of malaria increases, only passive case detection and treatment would be operational.

current interventions in that it will require specialist personnel who need specific training. The health center staff who perform the diagnosis, the epidemiologists who analyze the data, and the field staff who carry out active case detection will be the key personnel. It will require employing specialists with sound epidemiological training to identify specific foci where parasites exist. It will also entail seasonal employment of implementers stationed in those rural health centers where malaria cases occur during the low transmission period.

Implementing the new strategy

Data collection centers should be set up in specific districts or regions to collect and analyze data, and direct interventions. Targeted interventions will be directed to treat a small number of people, thus reducing the costs of major vector control operations. A small team will be able to check on vector control operations at targeted foci if required. Expert malariologists / epidemiologists trained in the country will advise the national government when appropriate, based on local expertise and experience. The effort and expenditure will be less than the major national 11 program. It can be integrated into the health system progressively and in an affordable manner, and so expand the role of the public health system country-wide.

The process of implementation will require making decisions to employ professional epidemiologists and provide career opportunities for them, as well as to add training and promotion for certain rural health centre personnel. It will involve moving from a massive national resource-based intervention to a modest, less expensive, targeted intervention process that helps detect residual foci of transmission, and implements active case detection. Essentially, it implements networks of rural health centers, District Health Offices and the National Malaria Control Program to apply public health principles to malaria control.

Cost implications of the new paradigm The new paradigm proposes a sustainable approach to managing and controlling malaria. Being targeted, it will be less expensive to operate than large scale-up interventions that must be repeated every few years. To be sustainable it must be integrated into, and funded within the budget of the Ministry of Health. This data-driven program will follow on from a full-scale malaria control process that reduced malaria transmission. Being focused, it will be easier to sustain, and because it uses an additional intervention, i.e. attacking the reservoir of the parasites when their numbers are restricted, it makes programs les dependant on blanket vector control and treatment.

There will be less chance of resistance developing in mosquitoes and the parasites. It differs from 14

conclusion Current successes in malaria control are due to massive global efforts involving mobilization of international and local resources, leadership of international agencies, input from major funding organizations, and cohesive national programs. However, the question is how to sustain this level of success. This will require less expensive targeted interventions, better regional infrastructures, more locally trained personnel, and a new strategy based on active case detection.

Article with full list of references on the enclosed Public Health CD-ROM.

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s u s ta i n a b l e m a l a r i a c o n t r o l

APPMG Report on malaria control (All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases)*

Sustaining success

Photos: APPMG

TO GET FIRST HAND EXPERIENCE of recent campaigns to control malaria, APPMG group members Jeremy Lefroy and Pauline Latham visited different countries in Africa.

The latest report from a UK parliamentary group documents major advances achieved in controlling malaria over the last decade. But it also stresses that efforts must be maintained. It points to four main challenges that lie ahead, recommends ways to address them, and urges continued political and financial commitment.

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he APPMG 7th Annual Report (July 2011) reviews the positive progress achieved in reducing the burden of malaria over the last few years: decreasing infection and death rates, and increasing insecticide-treated bed net coverage in sub-Saharan Africa. Some group members gained first hand experience when visiting different countries, for example in Rwanda where an effective campaign for universal net distribution is an example of such successes. The group feels it is

important to spread the message about such success stories as the integrity of international aid is sometimes questioned.

Success stories and unique commitments The report not only confirms the “value for money” of malaria aid in terms of global health, education, and productivity, but also highlights * see column on page 5.

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how this has inspired unique commitments from governments, organizations, NGOs, and private industry to invest materials, money, and expertise in malaria control interventions. The report documents some major advances such partnerships have achieved. The data in the report speak for themselves: the WHO and National Malaria Control programs estimate an overall 7% decrease in malaria cases worldwide between 2005 and 2009, translating as 19 million fewer incidences of disease. In 11 African countries cases dropped by at least 50% from 2000 to 2009, and malaria has now been eliminated in Morocco and Turkmenistan.

Deaths from malaria have decreased by 20% over the last decade.

However, there are important variations between countries. Four countries (Nigeria, DRC, Uganda and Ethiopia) suffer around 50% of all malaria deaths in Africa. Regions with the highest disease rate tend to have the least malaria control strategies in place, pointing to obvious needs to increase efforts in these countries. The burden of malaria has possibly been underestimated in some countries emphasizing the importance of better information systems and diagnostics to monitor progress and target interventions. More worrying, malaria has resurged in some regions, such as parts of Zambia where large-scale delivery of insecticide-treated nets took place some 2-3 years ago. This raises vital questions about how to sustain control measures.

Prevention is the first line of action

APPMG The All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases (APPMG) serves as a forum in the UK for discussing and advocating strategies to combat malaria. APPMG maintains close contacts with the Department for International Development (DFID), supporting the British government’s commitment to controlling malaria and reaching the Millennium Development Goals. The British and US governments continue to be the two biggest funders in malaria and all aid, with on-going commitments to the Global Fund and World Bank pledged through UKAid in Britain. The APPMG also keeps up to date on how funders and private industry are financing intervention tools and actions, particularly in cooperation with the Global Malaria Action Plan (GMAP) of Roll Back Malaria.

Current tools to prevent, diagnose, and treat malaria have proven highly effective when optimally deployed. The challenge is to ensure they are used to their full potential, and in ways that are sustainable. Prevention is the first line of action and means vector control, with larvicides to treat mosquito breeding areas, and indoor residual spraying (IRS) to treat buildings; but both require detailed knowledge about the local mosquitoes.

By far the most effective tool is insecticide-treated bednets (ITNs). These not only provide personal protection, but also act as vector control by delivering lethal doses of insecticide to mosquitoes landing on the net.

Insecticide-treated nets Sleeping under an insecticide-treated net has long been known to reduce malaria incidence in children by up to 50%. More recently, technologies are developed which incorporate insecticide into the netting material to produce long-lasting insecticide-treated nets (LNs).

Between 2004 and 2009 annual numbers of ITNs delivered to sub-Saharan Africa increased 15-fold, from 5.6 to 88.5 million. Originally the target was to reach 80% of people at high risk (pregnant

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Commitments to malaria endemic countries 2004-2010 1800 1600

US$ (millions)

1400

Others

1200

World Bank

1000

PMI

800

Global Fund

600 400

Source: World Malaria Report 2010

200 0 Fig. 1

2004

2005

2006

2007

women and young children), but in 2008 this was raised to universal coverage, meaning everyone sleeping under a net. Around 254 million LNs were delivered between 2008 and 2010, but this still left about one third of the population at risk without protection.

Artemisinin-based combination therapy The WHO recommends artemisinin-based combination therapy (ACT) as first line treatment in Africa. Following growing resistance to older drugs such as chloroquine, the discovery of artemisinin was a break-through. Subsequently ACT was designed to prevent resistance arising from using a single agent. 77 out of 86 endemic countries had adopted ACT by 2009. However, despite being banned by the WHO in 2007, artemisinin monotherapy was still being used in 25 countries in 2010.

Moreover, ACT therapy is relatively expensive, so accurate, rapid diagnostic tests became more important to ensure that antimalarial treatment is targeted to those who actually have malaria, rather than previous presumptive practices of treating anyone with a fever.

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2008

2009

2010

Development of Rapid Diagnostic Tests A decade ago fewer than 5% of suspected malaria cases in Africa were confirmed by traditional microscopic diagnosis, which requires skilled staff. Recent development of Rapid Diagnostic Tests (RDTs) means relatively untrained staff with little equipment can accurately confirm a case of malaria. Supplies of RDTs supported by the Global Fund for AIDS, TB and Malaria (GFATM) and others have enabled some African countries to apply malaria testing at a national level. This not only saves money on ACT treatment, but also provides important information for monitoring malaria transmission and outbreaks.

Challenges and recommendations Geographical areas at risk of malaria are often difficult to access; incidence of malaria may have been under-estimated in some countries; the logistics of shipping, storing, transporting, and distributing nets on a large scale are hugely complex; payment and inspection of transactions are inefficient and time consuming; manufacturers of ITNs and ACT therapeutics need accurate and timely orders to meet demands – these are just

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some of the challenges facing the on-going task of ensuring malaria prevention and treatment tools reach, and are sustained in regions at risk. The report urges increased support for the Global Fund, which accounts for 70% of all malaria control funding worldwide, the WHO, which is critical for achieving the Millennium Development Goals (MDGs), and the World Bank. For timely and cost-efficient access to malaria control measures, countries should support the removal of taxes and tariffs on essential malaria tools.

Investing in R&D Developing resistance to any drug or insecticide is inevitable in biological systems, although as yet has not caused malaria control programs to fail.

However, it remains a major concern. The most important strategies are to delay and limit potential spread of resistance. These include targeted use of drugs and insecticides, rotation of agents with different modes of action, and combination of agents (like ACT).

The report suggests encouraging the Global Fund to renew its commitment to monitoring drug and insecticide resistance, supporting countries in enforcing a ban on artemisinin-based mono­ therapies, and investing in research and develop­ ment (R&D) of new tools.

Developing, testing and gaining approval for new drugs or insecticides with novel modes of action is extremely expensive, takes many years, and only about 1.3% of new compounds or formulations complete the whole process. Although R&D in this field has increased four-fold over the last 16 years, and a number of potential drugs, vaccines and insecticides are in various stages of development, continued support is needed to ensure they reach approval for implementation.

The report indicates that novel incentives may be needed to stimulate the development of new antimalaria tools.

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Maintaining commitment Although funding has increased over the last decade (see Fig.1 on page 17), the US$ 1.8 billion in both 2009 and 2010 has still not reached GMAP (Global Malaria Action Plan) estimated levels of around US$ 5 billion needed for effective malaria control over the next ten years. More worrying, as malaria control becomes increasingly successful, political motivation and financial commitments lose impetus. However, history shows how relaxing control measures can undermine and reverse all gains. The report urges donors to maintain their commitment to effective and sustainable malaria control, and recognize how this increases global health and reduces poverty. It also stresses how investment by businesses operating in malaria endemic regions increases productivity by improving the health of the workers and their families. conclusion The message of the APPMG report is that we cannot become complacent. Efforts to eliminate malaria must continue, indeed accelerate over the next few years. Preventive, diagnostic, and treatment tools must be optimally deployed and new ones developed.

As long as the malaria parasite and mosquito vector remain, the disease can resurge and efforts will have been in vain.

Article on the enclosed Public Health CD-ROM. Here you can also find the original APPMG Report.

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Value for money discussion

Some nets are different The malaria community has spent around US$ 400-600 million on LNs every year since 2009, making this the largest budget position in global malaria control spending. With the target of reaching universal coverage and the need to deliver the required numbers of nets, the policies of major donors like the Global Fund and others implied that all WHOPES recommended nets must be taken as (technically) identical.

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rocurement decisions were therefore taken only on a unit price basis and unit price decreases were seen. Now with expected lower rates of available funding (Global Fund Rd 11 cancelled, PMI budget to go down by 10%, etc.) and newer categories of longer lasting LNs, a number of agencies suggested looking at the system from a value-for-money perspective. To summarize these discussions the WHO / GMP has published a concept note1 describing a system that focuses on costs per year rather than unit price.

The author: GERHARD HESSE Head of Global Partnering Vector Control, Bayer Environmental Science, Lyon, France

If the now available variation in the durability of LNs is taken into account, the scope for savings is much greater for technical and economical reasons. ® For example, Bayer’s LifeNet combination of higher durability for a reasonable increase in unit price still shows a better value-for-money ratio in terms of costs per year, costs per night protected, costs for health impacts like malaria cases / deaths / DALY’s averted, etc.. More laboratory and field data on LN durability are needed using accelerated physical testing and WHO guidelines on monitoring LN durability2. With these data the buyers can make decisions on better value-for-money products, e.g. procurement on basis of cost per year protected instead of “per net”. Such a system will also give manufacturers an incentive to develop new products with better performance.

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In this context it is important to understand the role of WHOPES in testing individual products with a set of minimum performance criteria and recommending those that at least meet these criteria. Recommending several products, WHOPES does not imply they are identical – this fact is often incorrectly interpreted by donors. For example, Bayer’s LifeNet® is the only LN exceeding the minimum performance criterion of 20 washes, so is not “identical” to existing WHOPES recommended LNs.

The Results for Development Institute has recently released a Call to Action on a Net Performance Guidance, which perfectly summarizes what needs 3 to be done .

1 WHO / Global Malaria Programme – A system to improve Value for Money in LLIN procurement through market competition based on cost per year of effective coverage – Concept Note 2 Guidelines for monitoring the durability of long-lasting insecticidal mosquito nets under operational conditions (WHO/HTM/NTD/WHOPES/2011.5) 3 Results for Development Institute: Developing Net Performance Guidance, A Call to Action, 2012

Article on the enclosed Public Health CD-ROM. Here you can also find the release of the Results for Development Institute.

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Photo: Bill & Melinda Gates Foundation

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Bill & Melinda Gates Foundation: Malaria Forum 2011

Optimism and urgency Over 300 scientists, industry leaders, and policy makers, implementers, and advocates came together in October 2011, four years after the Bill & Melinda Gates Foundation hosted its first Malaria Forum (see PHJ 19, page 41). Then, the call was malaria eradication. At this second forum partners discussed progress so far and the challenges ahead to achieving a malaria-free world.

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elinda Gates reminded participants that when the Gates Foundation was created, malaria killed more than 1 million people every single year. There was no Global Fund, no President’s Malaria Initiative, no World Bank Booster Program, and the world was spending less than US$ 100 million a year on this disease. Vector control was minimal, with few mosquito nets in use; those few bednets were mostly not treated with insecticide, and even if they were, the treatment lasted no more than a few months. The only diagnostic tool was the microscope, the

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parasite had developed resistance to chloroquine, and artemisinin combination therapy was not yet being used.

Malaria continues to be one of the Gates Foundation’s top priorities, as Bill Gates reiterated and foundation CEO, Jeff Raikes, emphasized: its commitment is to “control where possible, progress to elimination when feasible, with the eventual culmination in the eradication of malaria.” This second Malaria Forum was organized as a series of sessions led by different panels of experts focusing on particular themes and questions such as: PUBLIC HEALTH JOURNAL 23/2012

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• Progress in scale-up and sustained control • Lessons learned from disease eradication efforts • Recognizing ongoing progress in malaria elimination • Research agenda for eradication • Maintaining political commitment to 2015 and beyond • Bridging the resource gap • Industry engagement in malaria • Estimating malaria burden and impact • Addressing drug resistance • Tackling vivax infection

Efforts by National Malaria Control Programs, non-governmental organizations (NGOs), and private sector partners working both in the field and the lab have led to control interventions and product developments saving the lives of over a million people, particularly small children in Africa. Much can be attributed to increased coverage by insecticide-treated nets (ITNs). Since 2007, some 300 million ITNs have been delivered to sub-Saharan Africa, providing protection for over 578 million people (World Malaria Report, page 28).

Progress

Current tools are recognized as being vitally important. But as the malaria eradication research agenda (malERA) and many participants stressed, new products need to be developed now and in the future to reduce disease and transmission (see box). The research and development (R&D) pipeline for malaria control tools has never been stronger: a test vaccine, drugs, and diagnostics, as well as new compounds under development for new active agents for bednets and indoor residual spraying (IRS), some already undergoing approval (see page 54). New tools such as spatial repellents or traps may be available in the near future. But

No participant could fail to be excited by the successes in malaria control since the first Forum in 2007. As Margaret Chan, Director-General of WHO recalled, then the call to eradicate malaria was controversial, but now tracking progress and mapping the path ahead is the main agenda.

Funding by the Global Fund, the President’s Malaria Initiative (PMI), the UK’s Department For International Development (DFID) the World Bank and others increased from US$ 200 million in 2004 to over US$ 1.5 billion in 2009 and 2010.

Strategies to stop transmission • Developing and broadly implementing surveillance is a necessary tool to understand and interrupt transmission.

• Research in drugs targeted at blocking transmission.

• The need for a transmission-interrupting vaccine.

• Novel vector control approaches to fill the gaps where IRS and ITNs do not provide protection.

• New approaches to vector control to complement and reinforce existing interventions.

• New insecticide compounds to lower the threat of developing pyrethroid resistance.

• Alternatives to fast-kill insecticides such as spatial repellents to be used in conjunction with existing nets or indoor residual spray programs.

• Innovative exposure mechanisms, including sugar-baited traps, to further decrease the risk of human-vector contact.

• A more streamlined approval process to get new products into circulation rapidly – and an approval process that can handle innovation beyond bednets and spray products.

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research and innovation efforts must expand, with streamlined approval processes to circulate new technologies rapidly.

Urgency The recent successes created optimism, but this highlighted one of the greatest challenges – how to sustain the sense of urgency, and more importantly scale-up commitment to the fight against malaria.

Lessons learned from the past highlight how the first WHO malaria eradication campaign in the 1950s failed – it rigidly assumed the efficacy of DDT was sufficient, and that no further R&D, community building, education, or follow-up was required. The smallpox campaign owed its success to comprehensive surveillance, intensive research, constant innovation, and community education throughout and right up to the very end of the program – key lessons needed now to finish the fight against malaria.

Shrinking the malaria map Over the last 50 years 100 countries have eliminated malaria; since 2007 four more have joined the list, for instance Morocco and Armenia, while 36 out of the 99 endemic countries are currently making progress towards elimination.

However, in many countries elimination efforts often fail in the last stages due to waning commitments, as in Sri Lanka (see page 52).

Malaria also knows no geographical or political borders, so one country alone cannot eliminate malaria. Countries must work together to form cross-border partnerships, such as between Saudi Arabia and Yemen. In southern Africa the “Elimination 8” countries, including Swaziland

Photo: Bill & Melinda Gates Foundation

Scale-up of interventions also carries its own challenges of how to avoid spreading of resistance, and the threat to the efficacy of drugs and

insecticides currently used. This underlines the growing need and urgency to find new solutions; otherwise the danger is losing the gains made so far. As Melinda Gates said in the keynote session, using the legend of Sisyphus doomed to push a boulder uphill for eternity, “the lesson is clear: the boulder of malaria control can come crashing down if we lose focus.”

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with 500 cases per year, and Mozambique and Zambia, now scaling up control, illustrate the importance of cooperation to prevent crosscountry transmission.

Commitment and sustainability But to shrink the malaria map further, as most participants stressed, will require sustained commitment, coordinated implementation, and scale-up of efforts in all areas of malaria control, from effective prevention to post-endemic surveillance. Relaxing interventions such as spraying or ITN coverage allows malaria to resurge. Past evidence, for example in the Eastern Mediterranean Region (EMRO), has repeatedly shown that many countries’ previous efforts to eliminate malaria often failed during the “last mile” of eradication. This is also where campaigns in Sri Lanka have stumbled, and current campaigns are again struggling to sustain commitment and public interest as malaria cases fall. Yet no country is a better example of how rapidly relapses can occur; with 18 recorded cases of malaria in 1963, numbers surged to over 500,000 each year between 1967-1968. And even if a country succeeds in eliminating malaria, it can only stop monitoring for cases among its population and visitors once global eradication is achieved.

No way back A critical focus in the coming years will be moving from malaria control to interrupting disease transmission. One important consequence of this will be that people, particularly children never exposed to malaria, will have little or no naturally acquired immunity. So once transmission interruption begins, there is no way back. Nonimmune populations would be devastated by a resurge in malaria.

Elimination is a long process, and the hardest part still lies ahead. However, Margaret Chan believes that the malaria community is no longer blinded by illusions: “eradication is a goal only achievable

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Bill & Melinda Gates Foundation Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty. With its head­ quarters in Seattle, Washington, USA, the Foundation employs about 980 people worldwide. Since 1994 it has provided grant funding totaling US$ 26.19 billion, and total grant payments in 2010 amounted to US$ 2.6 billion.

through extreme commitment and is at least four decades in the future.”

Value for money Cost-effectiveness was also a recurrent theme as the malaria community tries to bridge the resource gap, mobilize resources, maximize returns on R&D investments, and face decreased funding.

However, value for money was discussed as not necessarily meaning cost-effective, but rather delivering the most effective solutions for the least possible costs (such as focusing on costs per year rather than unit price; see page 19). It also means optimal funding allocation and responsible spending among all members of the malaria community, from donors to researchers and essentially endemic countries themselves. As Ray Chambers, UN Secretary-General’s Special Envoy for Malaria, pointed out: “emerging economies and endemic countries must increase their commitments, alongside existing donors.”

Without the continued commitment of politicians and organizations worldwide and the sustained mobilization of local communities, successes

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Challenges for private sector partners • Private sector partners are committed to the fight against malaria for the same reasons as public sector researchers and implementers: a commitment to society and a humanitarian impulse to save lives from a preventable, treatable disease.

• Pharmaceutical and chemical companies are the only ones who bridge the gap between academic research and the manufacturing of medicines that can be delivered.

• Trust is vital in these partnerships: neither party can be involved in the effort for their own personal success as the campaign against malaria cannot involve egos – and partnership is critical. Industry should not be asked to shoulder the burden of costs and development alone.

• The economics of malaria pose a huge challenge for companies – low profits and high costs make it difficult to have a sustainable, cost-effective product, and many products are provided at cost, furthering the challenge.

• In ensuring timely and consistent delivery, private and public sector organizations must work together to anticipate demand and understand the associated costs – transparency between partners is key.

gained over the last ten years will be lost. As Gina Rabinovich, Director of Infectious Diseases, Global Health Program of the Gates Foundation, pointed out: “there is no equilibrium in the fight against malaria – the community is either gaining or losing ground.” This means interventions must be scaled up today and carried through with new tools into the future to ensure finishing the fight against malaria. Rabinovich stressed that “now is the time to act – to recommit funds, to eliminate the resource gap, and to get the most value for the money that is spent.”

Industry engagement In a session including the panelist Bernard Leroux, Head of Innovation, Bayer Environmental Science, it was acknowledged that private sector partners play a critical role in the malaria community through research, manufacturing compounds, and delivering vector control tools. Industry partners face the huge challenges of low profits, high overheads, anticipating demands, and ensuring timely delivery (see box). Nevertheless they have

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achieved major results over the last ten years; and now they need to build on recent successes. While transparency and collaboration between public and private partners is essential, both parties must also continue to challenge each other to improve the tools and strategies available. Without this it will be difficult to sustain success gained so far. conclusion The aim of the Malaria Forum is bring together multiple partners, from endemic countries, donors, the private sector, and academia, for rigorous dialogue. Its success is when this dialogue continues beyond the three-day Forum, reaching all parties worldwide involved in the fight against malaria, to encourage them to reaffirm their commitment to the goal of eradicating malaria.

Article on the enclosed Public Health CD-ROM. Here you can also find the Final Report as a pdf-file.

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Bayer workshop Seattle (October 16, 2011)

Towards sustainable vector control

Photo: Justin McBeath

In 2010 Bayer started an advocacy campaign called “LifeMatters: Towards sustainable vector control”. Bayer planned to hold workshops with stakeholders to highlight this issue, with special emphasis on vector control and prevention. The first workshop was held 2011 in Seattle on October 16, the day before the Gates Foundation Malaria Forum.

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he introduction by Gunnar Riemann (President of Bayer CropScience’s Environ­ mental Science Division worldwide) highlighted that sustainable vector control is essential to maintain the success in malaria control gained so far. This should bring us closer to the goal of zero deaths due to malaria in 2015. For Bayer innovation

means improving the lives of people throughout the world, and it is the backbone of its 50 years of engagement in vector control. K-O Tab® 1-2-3, LifeNet® and its collaboration with IVCC were mentioned. Innovation needs to add value to malaria control programs, such as LifeNet® providing more nights of protection.

Facing the crossroads

Participating organizations at the first Bayer workshop included the UN Special Envoy’s Office, the United States Agency for International Development (USAID) / President’s Malaria Initiative (PMI), NetWorks, the International Federation of Red Cross and Red Crescent Societies (IFRC), Malaria Consortium, Centers for Disease Control and Prevention (CDC), Bill and Melinda Gates Foundation, Innovative Vector Control Consortium (IVCC), Liverpool School of Tropical Medicine (LSTM), GBCHealth, PSI, and Bloomberg School of Public Health.

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The workshop was opened by the keynote from Clive Shiff on sustainability in malaria control – asking what is needed. He mentioned the crossroads we face at the moment with the obvious financial stringencies for the control of malaria and lack of scientific progress in fully understanding malaria. The various mandates of different donors add confusion, for example to the distribution of bednets, and tackling the question of vulnerable groups or bednets for all. Reliance on one active

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Photo: Justin McBeath

BAYER’S FIRST WORKSHOP provided a good opportunity for exchange between different stakeholders.

ingredient for LNs, and basically one group of chemicals for malaria drugs adds threats. The essence of his arguments can be found in Clive Shiff’s article on page 8.

To summarize his request for a three-pronged approach, it means bringing malaria cases down by a massive intervention scale-up, then switching to more focused intervention types based on local data.

Higher protection standards Following the keynote, Tom McLean (COO, IVCC) was the first panelist reviewing the need for innovation. He summarized the importance of innovation in vector control with two examples: the invention of DDT (Noble Prize in 1948), which is still an important contributor to life saving indoor residual sprays, and the development of long-lasting bed nets, which was enabled by the development of the synthetic pyrethroid insecticides setting new standards in safety.

The technological innovation process is well understood by industry and their Product Development Partnerships (PDP). But it needs to be supported by innovations in funding, capacity building, and policy making processes, etc. In the discussion, points arose such as innovation in

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thinking related to value for money (see page 19), for example leading to a tender requirement to purchase by costs per night protected, or costs for protection versus unit price, etc. The WHOPES process, which defines minimum standards, should not prevent people from asking for a higher standard.

Decisions for purchase in a country should be based on local data, e.g. the durability of LNs under local conditions. Spatial repellents and new traps were also mentioned as concrete proposals for new tools.

Insecticide resistance management Janet Hemingway (LSTM) in her session confirmed that pyrethroid resistance is high on the agenda. The reliance of LNs and IRS on this chemical class has pushed main malaria vectors in Africa to develop resistance. The question remains whether such resistance has operational importance. Hemingway quoted a number totaling 168 papers on this issue. Although all of them reveal the entomological indications, not one can link the resistance to an impact on disease control.

One problem is what data and how data are collected, and then making operational decisions based on this. The request for new insecticides is justified, but it has to be discussed upfront; how will they enter the market, what is the economic impact, and which insecticide resistance manage­ ment (IRM) strategy to follow (rotation, mosaic)?

A monitoring program must be available; how should one use the gathered data, and what needs to be implemented cross-border between countries?

Use of larvicides or combination products were mentioned by the audience as IRM tools. New “old” active agents might be found in the chemical industries’ libraries, and a fresh look at agricultural pesticides might reveal new candidates.

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Focus on distribution channels

Mobilizing funds

Matt Lynch (Johns Hopkins Bloomberg School of Public Health) talked about innovations in delivery and distribution for LNs. Mass campaigns have increased ownership over the last decade.

Now with funding issues, the focus on cost efficiency has become more evident. This means that while the active ingredient is well covered by WHOPES, more importance needs to be put on the physical characteristics and related durability of the textile. Findings from field studies need to be moved into actual policies.

Alan Court (UN Special Envoy Office) defined steps for sustained financing and showed a snapshot picture of funding to date. The fact is that we have a gap for malaria control, which adds up to over US$ 3 billion for the next four years until 2015. The first step towards sustainability is to mobilize domestic funds; the African Leaders Malaria Alliance (ALMA) has made this an issue for sub-Saharan Africa, another pillar is the private sector in Africa. A second step is to maintain, better to expand traditional funding sources giving more flexibility for its use. The third step is to increase participation and engagement of emerging economies and BRIC countries (Brazil, Russia, India and China); some of them such as India and Brazil have already instigated South-South bilateral activities, and new countries such as Korea and Malaysia need to be engaged. The fourth step is front-loading activities, resulting in rapid availability of funds once an agreement is signed. Also the signing can be speeded up. A fifth step could be innovative solutions such as bonds or remittances. And a final step can be to promote greater efficiencies along the supply chain.

For physical distribution of nets Lynch discussed two systems: a PUSH system that delivers LNs by a top-down approach, e.g. via antenatal clinics to pregnant women, and a PULL system that delivers nets on request and according to individual need.

He sees the shift of responsibility to get the net from the traditional donor distribution system to the household. A precondition is that channels are available and users have an adaptive behavior to care for the nets (prevent wear & tear, repair nets, etc). He questioned the need for many different distribution channels, rather one robust channel should relate to the flow of nets, where need is defined in the household itself, and might reduce administrative costs.

The distribution mode needs to be related to usage data and transmission context, which means understanding the disease ecology before making a decision. Depending on universal coverage campaigns fully funded by international donors no longer seem economically feasible, but here and there a mass campaign might still be needed in specific situations. More attention needs to be given to designing continuous distribution programs that use a variety of innovative tools (sliding subsidies, context-specific channels, collaboration with the private sector) to maintain household access to LNs and universal coverage.

conclusion At the Bayer workshop participants discussed a number of challenges facing efforts to sustain vector control, an essential element in achieving zero deaths from malaria by 2015. In addition to the needs for innovation, mobilizing funding, and carefully managing insecticide resistance, delivery and distribution of LNs must be cost effective. An important aspect here is rethinking value for money, considering costs per night protected and higher standards of durability.

Article on the enclosed Public Health CD-ROM. Here you can also find a full list of the workshop participants.

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WHO World Malaria Report 2011

Still huge challenges ahead The World Malaria Report 2011 analyzes and updates data from the 106 malaria-endemic countries presented in the 2010 report. For the first time, the report contains individual profiles for 99 countries with ongoing malaria transmission. Also for the first time it includes data on insecticide resistance.

But not for the first time the WHO warns against complacency.

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eleased in December 2011, the latest World Malaria Report documents how over the last decade malaria incidence and mortality have fallen all over the world (see box for details). The total number of estimated malaria deaths – 655,000, the majority children under five years of age – is lower than the estimate in the 2010 report (781,000 deaths). This revised estimate is due to both lowered child mortality estimates for all causes and diseases by the UN Interagency Group for Child Mortality Estimation, and an actual decrease in malaria mortality by approximately 11% in the WHO African Region.

Most effective weapons Long-lasting insecticidal nets (LNs) have been one of the least expensive and most effective weapons in the fight against malaria. According to the report, the number of bednets delivered to malariaendemic countries in sub-Saharan Africa increased from 88.5 million in 2009 to 145 million in 2010, which adds up to 294 million LNs supplied to African regions between 2008 and 2010. Assuming all LNs last three years, and that an average of 1.8 people sleep under each net, this would be enough to cover 73% of the 800 million people currently at risk. But this is an optimistic estimate, not

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taking into account delays in delivery, loss and damage, and the need to replace older LNs. A more robust estimate is that 50% of households in sub-Saharan Africa now have at least one bed net. Some countries made great progress towards achieving universal coverage (Burundi, Madagascar, Namibia, Niger, Rwanda, Sierra Leone, United Republic of Tanzania) but others have not reached the scale required.

Of the 60 million LNs supplied to countries outside Africa between 2008 and September 2011, six countries received the majority of the nets (India 23%, Indonesia 13%, Afghanistan 10.5%, Pakistan 5.5%, Papua New Guinea 4.7%, Philippines 4.6%).

Mass campaigns have been the main route for delivering LNs, accounting for 71% of nets, with antenatal care clinics (15%), immunization clinics (7%), and other routes used, depending on the region. Although some countries report lower use than others, on average 96% of people with access to a net use it, and the main constraint to sleeping under an LN is lack of availability of nets.

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Western Pacific Region, especially China. In 2009, pyrethroids accounted for 77% of spray areas, although a much lower proportion by weight, since the equivalent amount of active ingredient for pyrethroids covers about 60 times the area of other insecticides.

Threat of resistance IRS and LNs are two primary interventions because they are powerful, effective over a long period, and robust. A threat to continued success in malaria prevention through such vector control is growing resistance to the pyrethroid insecticide class. This year’s report includes data on insecticide

resistance for the first time, with resistance detected in 27 malaria-endemic countries in subSaharan Africa from a total of 45 countries worldwide. Pyrethroids are the most commonly used class for indoor residual spraying (IRS), and are the only insecticide class used to treat mosquito nets. Although resistance has not yet been linked to widespread failure of malaria vector control efforts, the point at which this may reduce efficacy is still unknown, and may depend on local mechanisms of resistance.

Monitoring for insecticide resistance, which to a certain extent accounts for higher levels of detection, was carried out in 78 countries

“We need a fully-resourced Global Fund, new donors, and endemic countries to join forces and address the vast challenges that lie ahead.

Millions of bed nets will need replacement in the coming years, and the goal of universal access to diagnostic testing and effective treatment must be realized.”

Robert Newman, Director of WHO's Global Malaria Program

SOME KEY FACTS • In 2010, an estimated 3.3 billion people were still at risk of catching malaria; 216 million incidences of disease were estimated in 106 endemic countries worldwide, 81% of cases were in Africa.

• In 2010, malaria killed 655,000 people; 96% of deaths were in Africa, 86% were children under five years of age; this still means one child dies from malaria every minute.

• Since 2000, global malaria mortality rates have fallen more than 25%, with reductions of 42% in the Western Pacific and 33% in African regions.

• Between 2000 and 2010, 43 of the 99 countries with ongoing malaria recorded 50%, and in 8 countries 25% decreases malaria cases.

• Delivery of LNs to sub-Saharan Africa increased from 88.5 million in 2009 to 145 million in 2010.

• The percentage of households owning at least one ITN in sub-Saharan Africa has increased from 3% in 2000 to 50% in 2011.

• Resistance to at least one of the four classes of insecticides used for malaria control has been identified in 45 countries worldwide, 27 of these in sub-Saharan Africa.

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worldwide in 2010. Nevertheless, routine monitoring of insecticide resistance, and developing resistance management strategies must play an essential role in managing malaria vector control. Together with a broad group of stakeholders, WHO is currently developing a Global Plan for Insecticide Resistance Management in malaria vectors, which will be released in early 2012.

Achieving this will require leadership at global, national, and local levels. It will also require innovation. If the mosquito nets can be made more durable, giving them a life of five years instead of three, the strain on fragile health systems could be greatly reduced, the risk of resurgences in malaria could be minimized, and hundreds of millions of dollars could be saved.

“The toll taken by the current economic crisis must not result in our gains being reversed, or progress slowed.”

Raymond Chambers, the UN Secretary General’s Special Envoy for Malaria

Shortfall in funding

conclusion

Despite significant progress up until 2010, the projected shortfall in malaria funding threatens the hard-earned gains of the last decade. Due to recent developments, and despite increased support from the UK, malaria funding will decrease in the period 2012 to 2014. Triggered primarily by the reduction in available funding within the Global Fund to Fight AIDS, Tuberculosis and Malaria, this decrease will considerably alter the malaria control landscape and threaten the sustainability of the multipronged approach to fight the disease, which relies heavily on investments in bednets, indoor residual spraying, diagnostic testing, treatment, research and innovation.

Economic uncertainties, falling funding, and potential problems arising from resistance to antimalarial drugs and insecticides pose growing threats to the current remarkable progress gained in malaria control. Full advantage of all malaria prevention and vector control tools, as well as all the partnerships, collaborations, and resources built up over the last decade, must be taken, consolidated, and sustained.

The next few years will be critical in the fight against malaria. Experience shows how fragile any gains are. While the distribution of hundreds of millions of long-lasting insecticidal mosquito nets over the past several years has been a remarkable achievement that has saved hundreds of thousands of lives, those nets now (or will soon) need replacing. Data in this report show that the vast majority of distributed nets are used, and that the primary barrier to universal coverage remains access. It is essential to ensure that these and other life-saving commodities reach all who need them – before the hard-won progress slips away.

30

Source http://who.int/malaria/world_malaria_report_2011/ en/

Article on the enclosed Public Health CD-ROM. Here you can also find the full World Malaria Report, including all annexes.

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case study

Leishmaniasis vector control in Bangladesh

Durable effect on sand fly density Easy diagnosis, unique epidemiology, and available effective treatment makes eliminating visceral leishmaniasis from the Indian sub-continent possible if adequate and sustainable vector control can be implemented properly. Until recently there was little evidence for the efficacy of long-lasting insecticide treated bednets for sand fly control. Here, a study in Bangladesh shows that ® impregnating existing bednets with K-O Tab 1-2-3 provides hope for sustain­ able visceral leishmaniasis vector control.

Photo: Dinesh Mondal

V

RAJSHAHI MYMENSINGH

BANGLADESH

isceral leishmaniasis (VL) is a vector borne disease caused by the parasite Leishmania donovani transmitted by sand flies. Currently 91 countries are affected by Leishmaniasis, but visceral leishmaniasis affected countries are mostly India, Bangladesh, Nepal, Sudan, and Brazil, where VL is a major public health problem.

VL is also an emerging infectious disease in many developed countries in the west, mainly around the Mediterranean basin.

Bangladesh together with India and Nepal contribute 60% of the VL burden in the world (WHO, 2004). VL affects the poorest of the poor living in rural areas of these countries. The symptoms of VL are chronic fever, weakness, and enlargement of visceral organs particularly the spleen. In advanced stages of the disease severe anemia, and decreased platelet counts are common routine laboratory findings. The disease is deadly if not treated in time.

THE STUDY AREAS were the Godagari and Fulbaria subdistricts of Rajshahi and Mymensingh, two districts about 200 kilometers apart.

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case study

The well-studied risk factors for VL are: • Poverty.

• Living in a mud/thatched house.

• Current or recent VL patients living in the household or around.

• Poor environmental conditions and sanitation.

• Poor knowledge about VL and its vector control.

• Low use of bednets.

Favorable factors for controlling the disease in the Indian sub-continent are: • Humans are the only reservoir of the parasite.

• The sand fly P. argentipes is the only vector of the disease.

• The disease can be diagnosed at the household level among suspected VL patients.

• Oral medicine “Miltefosine” can cure the disease with a success rate of 90% and above.

• Availability of other effective drugs such as Liposomal Amphotericin B, Paromomycin, and Amphotericin Deoxycholate.

Integrated vector control management One of the main pillars of national VL elimination strategies is to control sand flies to interrupt transmission of visceral leishmaniasis. The Regional Technical Advisory Group for elimina­tion of visceral leishmaniasis in the Indian sub-continent suggested integrated vector control management (IVM) as the main tool to control the sand fly vector of VL. IVM includes indoor residual spraying with insecticides (IRS), use of insecticide-treated materials (ITM), environmental management, and social mobilization for vector control.

Unfortunately, experiences with IRS using DDT in India is frustrating due to emerging sand fly resistance to DDT, and complete lack of funding, logistics, and human resources for vector control in Bangladesh and to some extent in Nepal. All these make IRS a hard to Miltefosine resistant VL cases can reach vector control tool in these be treated with Liposomal countries. Furthermore, an operation Amphotericin B at an affordable like IRS is expensive, labor-intensive, cost thanks to WHO special and requires sustainable infrastructures, arrangements for VL cases in the supplies of insecticide, spraying Indian sub-continent. The unique equipment, trained personnel, and epidemiological features, easy funding over a long-term period. These diagnosis, and availability of create doubts about the sustainability effective treatment created hope for of IRS in poor resource settings like eliminating the disease from the The author: Bangladesh. Moreover, resurgence of Indian sub-continent if an adequate DINESH MONDAL VL in the Indian sub-continent after and sustainable vector control ICDDR,B ceasing IRS with DDT in the early method could be discovered and Bangladesh 1990s, and recently demonstrated implemented properly. lower acceptance of IRS in India In 2005 the Governments of Bangladesh, India indicate that IRS may not be a sustainable vector and Nepal signed a Memorandum of Understand­ control method. Thus as an alternative to IRS, ing, and committed to eliminating visceral other effective vector control tools with high leishmaniasis from this sub-continent. The acceptance by the community are highly desired. elimination target is to reduce the incidence of VL to less than 1 per 10,000 people by 2015 at the Seeking a sustainable vector control tool district level in India and Nepal, and sub-district A sustainable vector control tool for controlling (upazila) level in Bangladesh. vector-borne diseases like VL has to be highly effective in reducing vector density, which will lead to reduced transmission of the disease. It 32

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case study

should also be highly acceptable by the community so that high coverage can be obtained, and maintained by community participation.

Use of insecticide-treated materials (ITM), especially insecticide treated long-lasting bednets (LNs), revolutionized malaria vector control and disease in African countries. LNs were introduced to malaria vector control in Bangladesh by the Global Fund project with tremendous initial success (personal communication, Kalilur Rahman, Consultant Entomologist, WR, WHO, Bangladesh).

ITMs can control sand fly Studies in Afghanistan, Syria, Iran, Turkey, and Sudan provided the earliest evidence that insecticide treated materials could be effective for controlling sand fly. Mass distribution of insecticide treated bednets in Sudan demonstrated that nets could provide 59% protection from visceral leishmaniasis. However these studies could not demonstrate the duration of the effect, which is a very important factor for sustainable vector control. Perhaps the unavailability of longlasting insecticide treated materials during that time was the limitation of this method. Availability of long-lasting insecticide treated materials

PUBLIC HEALTH JOURNAL 23/2012

Photo: Michele Maroli

The principle of LNs combines the effect of individual protection with insect-killing activity – while a strong repellent effect could enhance its efficacy by reducing indoor and per-domestic vectors, including the sand fly. Further advantages of LNs are that the user does not depend on governmental-led interventions; there is no need for frequent re-impregnation as was the case with the first generation of insecticide-treated bednets.

Thus the use of LNs might be included as a VL vector control tool in the strategic national VL elimination programs of Bangladesh, India, and Nepal, but a national strategy for implementing LNs is yet to be developed. This is because until a few years ago there was no or little evidence for the efficacy of LNs for sand fly control.

Photo: Dinesh Mondal

Advantages of LNs

THE SAND FLY is the only vector of visceral leishmaniasis and humans are the only reservoir of the parasite.

33

case study

(commercially treated or existing nets impregnated with long-lasting insecticide formulations) indeed overcame this limitation. However, evidence for controlling sand flies with bednets impregnated with long-lasting insecticide formulations like K-O Tab® 1-2-3 (Deltamethrin containing WT) was still lacking. Thus we undertook a study in a visceral leishmaniasis endemic area of Bangladesh to investigate the effect of existing bednets impregnated with K-O Tab® 1-2-3 on sand fly control.

Impregnating existing nets The study areas were the Godagari and Fulbaria sub-districts of Rajshahi and Mymensingh, two districts about 200 kilometers apart. Godagari has 9 unions, 5 of which are endemic for visceral leishmaniasis. We selected the Deopara union for the study as it was the most endemic union for visceral leishmaniasis in Godagari. Fulbaria has 12 unions and all of these are endemic for visceral leishmaniasis, Putijana being one of the most endemic. The two sites together contained 15,254

Following the instructions supplied with K-O Tab® 1-2-3, the research team trained health assistants (health workers from the public health system) from the two unions in how to dip existing bednets with insecticide tablet, and the expected benefits, or risks, of the insecticide tablet if used properly, or misused. The research team also discussed with the community leaders, who were requested to form a village committee for visceral leishmaniasis elimination and to select community volunteers for the dipping program. Then health assistants trained the community volunteers in ® dipping bednets with K-O Tab 1-2-3, and also motivated household heads by house-to-house visits and distributing leaflets. On the dipping day, local people brought their recently washed nets to the dipping point. Community volunteers dipped the nets in a freshly prepared solution of K-O Tab® 1-2-3 containing 0.4 g Deltamethrin in a 1.6 g tablet including a chemical binder (WHO specification 333 / WT, May 2008) according to

Average chemical (Deltamethrin) concentrations on the treated bednets

100

30

95

25

90

Deopara

85 80

Putijana

75 1

12

Mean cencentration (mg/m2)

Percent corrected mortality

Efficacy of ® K-O Tab 1-2-3 treated bednets against sandflies

households with 66,722 people. The total number of existing bednets was 32,516 in the two unions.

20 15 10 5

18

0

Time in months since bed-net treatment (intervention) Fig. 1

1

12

18

Time in months since bed-net treatment (intervention) Fig. 2

Sandfly mortality over time in the two study regions.

34

The mean concentration of insecticide on nets over time.

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case study

the manufacture’s instructions. After dipping the net, owners dried their nets in a horizontal position in a shaded area. Community health workers, village committee members, and the research team observed and supported the dipping procedure. A few households without bednets bought new ones to dip, and those who were unable to buy new nets received commercially insecticide-treated nets after the dipping program at no cost from the research team.

We also investigated community acceptance of the dipping program by household head interviews and focus group discussion (FGD), the effect of impregnated nets on sand fly density by a longitudinal entomological survey and bioassay, and the decay rate of insecticide on the impregnated bednet by chemical analysis.

Excellent community participation We found that community participation in the dipping program was excellent, as 97% of the total households in the two unions participated in the program. Of 32,516 existing bednets, 30,254 were dipped (97%) and nightly observation demonstrated that the use of dipped bednets was as high as 93%98% in Putijana and Deopara. No significant adverse event was reported after dipping or over 18 months (duration of the study period). People in the community suggested expanding the program to the whole district and expressed their willingness to buy the tablet if it cost less than US$ 0.5 and was available on the market for selfdipping.

“

The community acceptance of the K-O Tab® 1-2-3 dipping program was extraordinary high, which is essential for a sustainable vector control method.

”

Cheapest vector control intervention Although community acceptance was high we had to wait 18 months to see the initial and long-term effects of the impregnated bednet on sand fly density. Repeated longitudinal entomological assessment showed that the impregnated bednet PUBLIC HEALTH JOURNAL 23/2012

successfully kept the sand fly density as low as 60% compared to a control area over a period of 18 months (Fig. 1). This observation was also confirmed by the WHO Cone bioassay test in the field. Furthermore, the concentration of Deltamethrin on the impregnated bednet over the time correlated well with the sand fly density, as well as with the bioassay test (Fig. 2).

“

Such a durable effect on sand fly density cannot be achieved by IRS after its once application.

”

Assessing the impact of the bednet impregnation program on visceral leishmaniasis disease burden is underway and preliminary findings are promising. ® Impregnation of nets with K-O Tab 1-2-3 is probably the cheapest vector control intervention compared to all other currently existing vector control methods. The commercial price of K-O Tab® 1-2-3 is about US$ 0.50. If self-dipping at a household level under the supervision of a public health assistant (who usually visits each household at least once a month) is possible, this can be implemented once every two years as a “campaign”.

conclusion High acceptability by the community, excellent sand fly density reduction, safety, long duration of effect, and affordable price for public health – these factors make a bednet impregnation program with slow release insecticide like K-O Tab® 1-2-3 the best hope for a sustainable sand fly vector control method in Bangladesh. The National visceral leishmaniasis program should consider such bednet impregnation programs as an integral component of interventions aimed at eliminating visceral leishmaniasis.

Article on the enclosed Public Health CD-ROM.

35

case study

Towards sustainable schistosomiasis control

Eliminating a disease – it is feasible Around 85% of more than 200 million people infected with schistosomiasis are found in sub-Saharan Africa. Since it mostly causes long-term disorders affecting poor rural communities, the impact and treatment of the disease are often neglected. But the parasite can be controlled with a single dose of praziquantel. With adequate funding to purchase enough medication and start again with focal targeted snail control the disease can be sustainably controlled throughout Africa.

N

eglected tropical diseases (NTDs) are a number of usually chronic, but sometimes acute diseases that were first grouped together in 2003 by the World Health Organization.1,2 They earned the title “neglected” almost by default because very little of the funding for health that goes to the poorest countries is directed at these diseases. The fact is that most African countries depend on external funding to support their Ministries of Health, and while some money goes for salaries, hospitals, and infrastructure, and some is directed at individual high priority diseases, very little goes to the NTDs.

male

female

Photo: Alan Fenwick

THE MALE AND FEMALE parasites pair off and the male carries the female to blood vessels near the intestine in the human body where they remain for 4 - 20 years.

36

The major killing diseases like malaria, TB and HIV/Aids are very obvious and “prominent”. They affect populations in urban and rural settings, hit the news and public attention because of their often acute impacts, and are therefore targets for international and national funding. The NTDs attract comparably less funding and attention because: • they affect the poorest of the poor, • infections are often chronic and give no reason for immediate complaint, • people visiting remote health facilities will not find an accurate diagnosis, nor the appropriate drugs, so they do not bother to go.3,4 In addition to being neglected for treatment and prevention, NTDs have a lower priority in terms of research and control funding allocated to them by both donors and the private sector for pharma­ ceuticals or pesticides. Less than 10% of research funds are for NTDs compared to malaria, HIV, and TB.5 Burden of schistosomiasis Schistosomiasis is one of the most prevalent NTDs with an estimated 200 million people infected globally; of these some 85% live in sub-Saharan Africa.6 In terms of burden of disease, the effect of schistosomiasis is probably greatly underestimated because little consideration is given to the large

PUBLIC HEALTH JOURNAL 23/2012

Photo: Alan Fenwick

case study

TREATING SCHOOL CHILDREN IS EASY, for example on Uganda child health days, and they benefit most because they have not yet developed serious symptoms.

numbers of people infected and the period of time they suffer disabilities and a poor quality of life.7,8 For example, intestinal worms and schistosomiasis together infect over 1 billion people, but because they are chronic infections, relatively fewer deaths are attributed to them. Sufferers may be stunted and undernourished, may have anemia, may develop liver or bladder fibrosis, and possibly die from hypertension or bladder cancer.9,13 However, due to the time lapse, these serious consequences may not be easily attributed to schistosomiasis infections acquired some 15-20 years earlier.

If we consider the Millennium Development Goals (MDGs), which the world’s politicians are trying to achieve by 2015,10 it is obvious to those who understand schistosomiasis that the first six MDGs will never be achieved unless we can get treatment for schistosomiasis and intestinal worms to the millions who are infected (see box on page 38).

Life cycles of schistosomes Schistosomes are trematodes and obligatory 11 parasites of snails. The larval stages undergo asexual reproduction in aquatic snails. When mature in the snail, the next larval stage of each species leaves the snail and swims actively in fresh water, aiming to penetrate the unbroken skin of a human host. Each infected snail will produce thousands of larvae daily. Those larvae (cercariae) that do find a human host migrate through the body and develop into adult worms. The male and female worms pair off and the male worm (about 1 cm in length) carries the female to their chosen blood vessels in the human body where they produce eggs and remain for 4-20 years.12 If infected feces or urine reach fresh water the eggs hatch and then actively seek out the correct snail where they can develop to complete the life cycle.11 Disorders caused by infection The consequences of being infected with schistosomiasis vary greatly. The first and most obvious symptom is blood in the urine caused by

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case study

Millennium Development Goals (MDGs) with reference to schistosomiasis 1. Eradicate extreme poverty and hunger To eradicate poverty we must first treat the worms that cause the poverty.

2. Achieve universal primary education Untreated children will go to school feeling tired and lethargic, and with a poor nutritional status.

3. Reduce child mortality If we treat infected women of child-bearing age they will be more likely to have a healthy birth.

4. Improve maternal health We can lower anemia in pregnancy by de-worming and so again we can expect to improve birth outcomes.

5. Combat HIV/AIDS, malaria and other diseases Treatment of schistosomiasis will contribute to combating the “other diseases” and will help reach this goal. Moreover, treating young girls for urogenital schistosomiasis will surely reduce genital lesions and therefore reduce the chances of HIV infection during sexual intercourse.

the eggs of S. haematobium bursting from capillaries into the bladder, each taking along drops of blood.13 Strategies for controlling the snails Schistosomiasis infections are usually highly prevalent in rural areas with no piped water and poor hygiene and sanitation. This is because excreta are more likely to reach snail-infested water, and human-water contact is likely to lead to further infections.

Prior to 1980 there was no safe and effective drug against schistosomiasis. Indeed from 1920 the drugs used were usually antimony-based and so toxic to the patient. For many years it was thought that the snail was the weak link in the cycle, and chemicals called “molluscicides” were used to try to eliminate the snail host: the first was copper sulfate, the second N-trityl mosrpholine, and the third niclosamide. Copper sulfate and N-trityl

38

morpholine were both highly effective under laboratory conditions. But they failed to remain active in the African canals and water bodies where the snails thrived and so proved to be 16 ineffective in stopping transmission.

Since 1975 niclosamide is the molluscicide of choice and the only WHO recommended product for this intervention (Bayluscide WP). Over the years its use has decreased due to rises in the cost of raw materials, environmental concerns and a shifting of focus to other control strategies. It was generally believed that curative treatment will and can do the job of controlling schistosomiasis. This belief was also triggered by the large-scale availability of praziquantel, the current drug of choice.

Killing the parasites Even given the extensive distribution of schisto­ somiasis, these parasites can be killed by a single dose of the drug praziquantel at a cost of less than PUBLIC HEALTH JOURNAL 23/2012

case study

US$ 0.50 per person per year, using predominantly a school-based distribution system.17 We calculate that if we could raise a total of approximately US$ 1.57 billion over a period of 7-10 years we could distribute enough praziquantel (and albendazole for concurrent intestinal helminth infections). By selectively treating the disease, schistosomiasis would be virtually gone from Africa. We are therefore conducting a campaign to raise funds to eliminate these diseases. S. japo­ nicum is already on the wane in the Far East, although surveillance is still necessary to detect any recrudescence.

The Schistosomiasis Control Initiative The Schistosomiasis Control Initiative (SCI) was established in 2002 at Imperial College London with funding from the Bill and Melinda Gates Foundation. The aim of this organization is to further the control of schistosomiasis and intestinal helminths (STH) particularly in sub-Saharan Africa. In 2002 the only schistosomaisis control

Schistosomiasis transmission cycle

Photos: Alan Fenwick

Human host

Snail host

PUBLIC HEALTH JOURNAL 23/2012

The authors: ALAN FENWICK Michael french Imperial College, London, UK

programs were in China, Egypt, the Phillipines, 18,19 and Brazil, mostly funded by the World Bank.

No control was going on in sub-Saharan Africa where most infections were to be found.20 In the first phase of its operations, Gates funding to SCI was used to start implementing praziquantel and albendazole treatments in six countries: Burkina Faso, Mali, and Niger in West Africa and Tanzania, Uganda, and Zambia in East Africa. By 2006 advocacy and the success of phase one activities led to a new donor, with Geneva Global providing funds for the control of NTDs in Rwanda and Burundi. A further donor emerged when the US government provided US$ 100 million for NTD control over a 5-year period. This has led to the delivery of over 200 million treatments against NTDs. The World Bank has supported the Yemen to initiate a 6-year program against schistosomiasis, which should be effective if good governance can prevail in that country. DFID UK (Department for International Development) has recently committed support to purchase 200 million tablets over the next 5 years from 2010, and this will assist Cote D’Ivoire, Liberia, Malawi, Mozam­ bique, Niger, Tanzania, Uganda, Zambia, and Zanzibar in their efforts to implement control programs. The US government has extended its commitment for funding to combat NTDs and so more support is on the way.

39

case study

Once a country has achieved the first goal of controlling the morbidity caused by schistosomiasis using mass drug administration, the next target should be elimination of transmission. Mass drug administration may go a long way towards reducing transmission by reducing the number of eggs reaching the environment and infecting snails. However if elimination is the target, then investment in snail control will be essential.

Snails can be controlled by biological methods (predator snails, fish or ducks), by chemical molluscicides (niclosamide) or altering water contact patterns, by changing either water contact sites or behavior. Of these, chemical molluscicides seem most likely to result in interrupting

SCI coverage by 2011* (Schistosomiasis Control Initiative)

MALI

NIGER

COTE D´IVOIRE

UGANDA TANZANIA

ZAMBIA

CHILDREN IN NIGER with red urine.

transmission, but only under certain conditions: they are most likely to succeed in smaller water bodies, and can only be used in water bodies not containing fish stocks that the population depends on. In temporary ponds chemical molluscicides applied at the start of the transmission season would provide a cost effective contribution to breaking transmission. This strategy is currently being applied in Zanzibar where elimination of schistosomiasis is the target. The contribution of chemical snail control will be evaluated over the next four years. conclusion

BURKINA FASO

LIBERIA

Photo: Alan Fenwick

A more holistic and sustainable approach

ZANZIBAR MALAWI

Schistosomiasis is now being controlled in the “easy countries”. Much work needs to be done in countries like Nigeria, Ethiopia, and Democratic Republic of Congo (DRC), where schistosomiasis infects many millions of people who are not provided access to praziquantel. In the longer term schistosomiasis transmission will continue until economic development is achieved, and water and sanitation are available in all rural areas.

However compared to 2002, many millions have been protected from the devastating effects of their infection. The challenge is to 21 expand and accelerate this progress.

MOZAMBIQUE Further projects in Rwanda, Burundi, and Yemen

Article with full list of references on the enclosed Public Health CD-ROM.

* with support from the Bill and Melinda Gates Foundation, USAID/NTD, Geneva Global, and DFID, UK

40

PUBLIC HEALTH JOURNAL 23/2012

research & development

Comparative life cycle assessment of LNs

®

LifeNet : The environmentally preferred option Early in 2011, Bayer CropScience Environmental Science Division (BCS-ES) launched a 9-month work program to perform comparative life cycle assess­ ment (LCA) of polypropylene, polyethylene, and polyester based long-lasting insecticidal bednets (LNs). BCS-ES recently developed a LN with deltamethrin® based insecticide incorporated into polypropylene fibers, called LifeNet . This report compares various environmental indicators, wash resistance, and human ® health impacts, between LifeNet and two other LN types.

M

alaria kills about one million people each year, most of them in sub-Saharan Africa, where malaria is the leading cause of death of children under five. Management of mosquitoes (vector control) or personal protection (e.g. a mosquito net) against biting remains a key intervention in the management of malaria.

Life cycle assessment

polyethylene net (Sumitomo Chemical’s Olyset® net) and a polyester net (Vestergaard Frandsen’s PermaNet® 2.0 net) as current market references.

The author: LAURENT DINI Sustainable Development Manager, Environmental Science Division, Bayer CropScience, Lyon, France

BCS-ES set up a specific sustainable development strategy in 2007, which encourages the implementation of eco-design and optimizes the environmental profile of its innovations. To reach this goal the only tool that can fully evaluate all sources and types of impacts over the entire life cycle of a product is life cycle assessment (LCA), a methodology defined by the International Organization for Standardization (ISO) 1404014044 standards (ISO 14040 2006; ISO 14044 2006).

The overall objectives of this study were to calculate and compare the environmental profile of the systems defined for the entire life cycle of the three LNs, identify the key contributor parameters, and assess their influence through a sensitivity analysis. Finally, this study also aimed at defining the overall human health benefit linked to the use of LNs.

The main conclusions of the ISO 14040-44 certified report1 are discussed here, with a focus on the methodology and scope of the study. The results are presented as end point environmental indicators, such as global warming potential, resource consumption, water withdrawal, human health, and ecosystem quality.

The scope of the study

BCS-ES, with the support of Quantis – an environmental consultancy group – launched early in 2011 a 9-month work program to perform LCA of LifeNet®, as well as two other LN types, a PUBLIC HEALTH JOURNAL 23/2012

The three LNs evaluated in this investigation were made from different materials, and treated with different active ingredients (insecticides): 41

research & development

• LifeNet® in a polypropylene (PP) net (with deltamethrin).

• High density polyethylene (PE) net (with permethrin).

• Polyethylene terephthalate (PET) net (with delta­methrin).

The insecticide treatment also differs: in the case of LifeNet® and the PE net, the active ingredient is incorporated in the fiber of the net, whereas for the PET net it is coated on the knitted material. These characteristics confer different net properties regarding their washing resistance, which is a key aspect of a net lifespan, as are material durability and user acceptability.

Protecting people in Kenya The country considered for the use of the three LN products was Kenya, since malaria represents a major burden of disease for Kenyan society. In this country of approximately 40 million people, malaria remains the leading cause of morbidity and mortality; 67% of Kenya’s population is at risk, with more than 8 million malaria cases reported (WHO 2010). Malaria is responsible for

about 40% of all outpatient visits, 19% of all hospital admissions, and causes a reported 34,000 deaths annually among children under five years of age (President’s Malaria Initiative 2010). Of the total Kenyan population, 29% live in a malaria endemic zone. These areas are around Lake Victoria in western Kenya and also in Coast Province (President’s Malaria Initiative 2011).

Effective over 30 washes LCA should express an environmental profile of a product regarding the service or function this product offers. LNs are designed to protect people against mosquito bites, in other words to protect against malaria in an endemic region such as Kenya. A sum of criteria are considered to assess LNs’ efficiency and the decision was taken to focus on the washing resistance. Indeed, these data are listed in the WHOPES dossier as 20 washes for all LNs, except for LifeNet® which mentions 30 washes. It was assumed that the three nets have the same strength and acceptability, even if polypropylene fibers have the added benefit of strength and softness.3

The LCA methodology Life cycle assessment is covered by two ISO standards, ISO 14040 describing the principles and scope, and ISO 14044 addressing the requirements and guidelines.2 LCA aims at defining environmental performance of a product or a service. It is a multi-step (from cradle to grave) and multi-criteria (covering the main environmental stakes) methodology.

LCA has to comply with the following processes: • Definition of the scope (boundaries of the studied system) and objectives.

• Life cycle inventory: listing all input / output flows at each step of the life cycle for data collection (raw materials, energy & water consumption, waste, emissions to air).

42

• Environmental impacts assessment: impact calculation based on selecting the most relevant methods up to the type of data expected, either mid-point (short-term impact) or end-point (long-term damage).

• Interpretation of the results.

According to the ISO standards, LCA critical review is an important step to ensure validity of the results prior to public communication (com­ parative assertions disclosed to the public according to the ISO 14040 standards). Ulti­ mately, an Environmental Product Declaration according to ISO 14025 standards reflects the main outcome of the performed LCA and pro­ vides stakeholders (customers, authorities, etc.) with relevant product environmental information.

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In order to ensure a consistent assessment, a Functional Unit (FU), expressing the service provided by products, was defined as following: “Efficient protection of persons against malaria, with a LN, during a period of time encompassing 30 washes.”

In other words, to provide this expected service, 1 LifeNet® (lasting 30 washes) and 1.5 PE and PET nets (lasting 20 washes) are considered in this study.

System boundaries The system boundaries (see Fig. 1) identify the phases, processes, and flows considered in the LCA and should include:

• All activities relevant to the study objectives and therefore necessary to carry out the studied function.

• All of the processes and flows that significantly contribute to potential environmental impacts.

Cut-off rules were applied to identify what has been excluded from the system boundaries. A cutoff level of 1% to mass and primary energy was implemented, meaning any process or reference flow that contributes less than 1% was neglected.

In addition, some processes were omitted, such as plant building, machinery, computers, workers commuting, service support (marketing, communication), etc. These additional data do not affect the results and can therefore be omitted from the analysis.

Data collection

System boundaries

S U P P LY

LN production Spinning, knitting & finishing, cutting & sewing LN distribution Transports (plane, boat, truck) Use stage Net washing (water, detergent) Effective use rate (physical resistance, comfort)

WASTE MANAGEMENT

Raw material production Active ingredient, plastic, anti-UV, master batch

End-of-life Net, packaging Fig. 1 Main life cycle stages included in the system boundaries. For the five identified steps, the supply sub-system (left) covers resource procurement (water, energy, chemicals, materials), including the extraction, treatment, and transformation of natural resources, and the various types of transport towards the resource use. These are also called “inputs”. The waste management sub-system (right) is equivalent to supply, except it considers all waste generated (and its potential recovery). It refers to system “outputs”.

PUBLIC HEALTH JOURNAL 23/2012

The data collection process is an important phase that was conducted iteratively between Quantis and BCS-ES. The quality of LCA results depends on the quality of data used in the evaluation.

Therefore, every effort was made for this investigation to implement the most robust and representative information available.

Primary Data This study was conducted in order to focus on primary data that was available and easily accessible. These data were provided for the most part by BCS-ES and its partners. For the PE (Olyset) and PET (PermaNet 2.0) mosquito nets, the primary data collected come from the manufacturers’ publicly available information (website, publications, etc.).

Secondary Data Missing, incomplete, or non-accessible data were completed by secondary data, mostly coming from the European Ecoinvent database 2.2 or from experts’ talks (especially for PE & PET nets).

Whenever possible, generic datasets used in this study were adapted to make them more representative of the geographical context of the systems. More specifically, for all activities taking place in Asia or Africa, the generic datasets were 43

research & development

adapted by replacing the original electricity grid mixes (European) by the corresponding one based on International Energy Agency data (IEA 2008) and using Ecoinvent sub-processes regarding the different electricity production plants.

recommendations. Finally, the assumptions regarding physical resistance and user acceptability were considered equal for the three nets, meaning the probability of the mosquito net breaking is set at zero, while its acceptance by the Kenyan population is set at 100%.

Mosquito net use Life Cycle Impact Assessment For the washing resistance of each net, evaluations from WHOPES (first evaluation for LifeNetÂŽ and final evaluation for PE and PET nets) were considered. The washing operation was described according to WHOPES washing procedure recommendations and local Kenyan studies, in particular those from KEMRI (Kenyan Medical Research Institute).

The cumulative active ingredient loss at each washing operation was measured based on the functional unit. A worst-case approach was considered, based on the retention index. The treatment of wastewater is based on WHO

The method applied to assess the environmental impacts is the peer-reviewed and internationally recognized Life Cycle Impact Assessment (LCIA) methodology IMPACT 2002+ v2.09. In addition, to provide results for sixteen impact categories, IMPACT 2002+ allows their aggregation into five classes of damage (where all classes have the same relative importance; see Fig. 2).

Critical Review The review process consisted of a critical review of the entire report by the panel of experts, taking

Life Cycle Impact Assessment

CO2

Crude oil Iron ore Irrigation water Cooling water

NOx

NOx Phosphates

Midpoint categories

Damage categories

Climate change

C L I M AT E C H A N G E

Mineral extraction / Non renewable energy

RESOURCE CONSUMPTION

Water (withdrawal)

WAT E R W I T H D R A WA L

Human toxicity (USEtox) / Respiratory effects / Ionizing radiation / Ozone layer depletion / Photochemical oxidation

H U M A N H E A LT H

Aquatic ecotoxicity (USEtox) / Terrestrial ecotoxicity / Acidification / Eutrophication / Terrestrial acidi/nitri / Land occupation / Water (turbined)

ECOSYSTEM QUALITY

And hundreds more ...

Fig. 2

44

IMPACT 2002+ midpoint and damage categories. The Usetox model, developed by UNEP and SETAC, was used to characterize human toxicity and ecotoxicity impact. BCS-ES provided the Usetox assessment for the active ingredients involved in this study.

PUBLIC HEALTH JOURNAL 23/2012

research & development

place in three distinct steps: the objective and scope, followed by the intermediary results and the final results. Therefore, a panel composed of an LCA expert and other stakeholders, was selected: • Panel chairman: expert on LCA methodology, environment, climate and energy.

• Consultant: expert for mosquito net use under practical conditions.

• Consultant: University Senior Lecturer and Director of Performance for Textiles and Clothing.

RESULTS Global warming score The PE net has the highest potential impact of all three products, with about 16.0 kg CO2-eq emitted/ functional unit (FU), followed by the PET net (14.2 kg CO2-eq/FU) and LifeNet® (7.9 kg CO2eq/FU).

The steps with the most impact are the same for all three LNs: net production (especially spinning and

Comparison among the mosquito net systems Global warming score (kg CO2 eq/FU)

Resources consumption (MI/FU)

Water withdrawal (liters of water/FU)

Human health impact (DALY/FU)

Ecosystem quality impact (PDF m2 year/FU)

Fig. 3 Comparative environmental scores for the 3 LNs on 5 damage categories. Each panel (left to right, categories from Fig. 2, except climate change B global warming) expresses the impact score for one damage category. The scores are segmented by color to provide the relative impacts linked to each specific life cycle step of LNs. From bottom to top you can distinguish relative impacts from raw materials production, net production, transport, packaging, use, and end of life of both net and packaging.

PUBLIC HEALTH JOURNAL 23/2012

45

research & development

knitting/finishing) and the plastic production (see Fig. 3). This is mostly due to the electricity consumption of these three steps that take place in countries where the electricity grid mixes mainly depend on coal and natural gas, energy sources that are high greenhouse gas (GHG) emitters. The two reasons to explain less GHG emissions from LifeNet® production are less electricity needed for the spinning heating phase and less yarn and warp.

For the plastic production, only generic data were selected. In that case, taking into account the production countries’ energy mix, PP production emits less GHG than production of the other two nets.

Human health impact LifeNet® generates less human health impact than the other two nets. Respiratory inorganic is the main environmental indicator, impacting this damage category by 53%. Emissions of particles are mostly due to coal combustion for electricity production.

For the PE net, the main contributors to human toxicity are the spinning and knitting & finishing steps. Their impacts are related to electricity consumption. For the PET net, the main contributor to human toxicity is the plastic production, which is due to the chemicals needed to produce PET.

Resource consumption Ecosystem quality impact For this damage category, the main contributors are the same as for global warming: plastic production and net production (spinning, knitting, and finishing steps). The difference concerns the most contributive step, which is the plastic production, due to the consumption of oil and gas.

A significant impact is also due to packaging, especially plastic production for such packaging.

This is also the case for the PET net’s oxobiodegradable packaging, produced with HDPE and stearic acid, which have a high energy demand.

We can conclude that LifeNet®, based on the functional unit, consumes less resources than the other two nets.

Water withdrawal The use of water is mostly concentrated at the net production level (see Fig. 3). Indeed, for the use step we considered that the same amount of water is used to wash all three nets (source: collected rain water). In addition, water withdrawal at the use step also comes from the laundry powder production. The spinning step is the most significant step for water withdrawal for LifeNet® and PE nets due to electricity consumption, whereas it is the plastic production for PET nets due to the production of purified terephtalic acid and ethylene glycol, precursors of PET.

46

On the last damage indicator (see Fig. 3), LifeNet® again has less significant impact than the PE or PET nets. The main contributor impacts are terrestrial eco-toxicity, acidification, and nitrification. The net manufacturing step has the most impact, due to coal burning for electricity production. Active ingredient losses during net washing do not generate a significant impact on the environment (less than 2% for all nets), since we have considered that users respect good practices by pouring the washing water directly into a hole in the soil.

Using LNs benefits human health We tried to estimate the benefit of using LNs on human health by expressing this in DALY (Disability Adjusted Life Years) averted along the functional unit, which means a period of 3 years in the Kenyan context. We assume the three nets have the same level of protection over this period of time, even if two out of the three have to be changed during this period. We mostly based our work on Population Service International (2009).

Some assumptions were made since the sources used were not always complete (such as death statistics without mentioning whether a net was used). The gain is about 0.5 DALYs, which represent 6 months of life. This has to be put in perspective with the human health impact

PUBLIC HEALTH JOURNAL 23/2012

research & development

Physical resistance tests

presented above, which equals 8 minutes of life lost (on average since the three nets do not have the same impact).

2) Physical resistance Since there is no methodological consensus on the way to compare different nets, we based our work on the available literature (Huchet 2004, 2011; Skovmand et al., 2011, VCWG, 2011). We took into account the seven resistance tests performed

by Huchet (20113) and for each of them, we estimated (in percentage) the strength of each net in comparison to the strongest one. Based on this relative and probabilistic approach we have expressed the result per net as the mean of all the seven values obtained (see Fig. 4).

Despite the fact that the calculation is theoretical (as only based on physical resistance laboratory tests that should be confirmed under field conditions) the result confirms the strength of polypropylene fibers. All in all, the sensitivity analysis confirms physical resistance as a key element to integrate in such analysis, since it has a clear significant impact on human health.

PUBLIC HEALTH JOURNAL 23/2012

LifeNet

50

0.513 DALYs averted

25 0 100 75

PE net

1) Washing resistance ® The washing resistance of LifeNet provides a clear advantage regarding impacts generated in its life cycle. For this reason, it was decided to assess LifeNet® in a pessimistic scenario where it can only stand 20 washes. LifeNet® at a 20 wash lifespan generates 50% more environmental damages than LifeNet® at 30 washes on all damage indicators, except on human health where the increase is only 30%. But even with the pessimistic scenario, LifeNet® still generates less impact than PE and PET nets on the 5 damage categories (from 15% less on resources consumption to 50% less on human health impact).

75

50

0.391 DALYs averted

25 0 100 75

PET net

To check the robustness of the initial assumptions, we performed seven sensitivity analyses: Three focused on the key parameters washing resistance, physical resistance, and washing operation practices.

Potential protection due to the physical resistance of the LN (%)

Sensitivity analysis

100

50

0.284 DALYs averted

25 0

1 2 Number of years

3

Fig. 4 Influence of potential LN physical resistance on the DALYs averted. Over the period of three years, the potential protection diminishes due to reduced physical resistance. It represents the chance for the net to be broken before the end of its lifespan. To illustrate that point the graph integrates the potential impact on DALYs averted.

(DALY = Disability Adjusted Life Years)

3) Washing operation practices The WHOPES recommends that the net’s washing water (charged with active ingredient, detergent, etc.) be disposed of in a latrine or directly in a hole in the soil. It specifies that the water must be disposed of away from ponds, rivers, streams, the house or animal shelters (WHO 2002). This is the recommended scenario we considered for our assessment. In case people are unaware of this

47

research & development

rule, we were interested in defining the potential environmental impacts generated with a pessimistic scenario where 100% of washing water is disposed directly into a river.

The use step is the step where the main changes occur as the direct discharge into a river influences the amount of active ingredient as well as detergent release into the environment. We have specific data regarding the active ingredient based on its initial concentration in each LN, and the specific retention index of each of net, whereas the detergent release is the same for all three nets, since we have considered a unique washing scenario.

Regarding the human health impact, the influence of washing operation practice is not important.

However, the washing operation greatly influences the ecosystem quality: if the wash water is discharged into a river, the LifeNet® related impact increases by 57%, PE net by 42% and PET by 8%.

Nevertheless, in both extreme cases, 100% discharged into the soil or 100% discharged into the river, LifeNet® remains the option with the least impact.

References 1

Environmental Assessment of Long-Lasting Insecticidal Nets, polypropylene (LifeNet) net, polyethylene net and polyester net – Prepared for Bayer CropScience Environmental Science Division, Quantis, September 2011 2 ISO 14040 : 2006 Environmental Management – Life cycle assessment – Principles and framework ISO 14044 : 2006 Environmental Management – Life cycle assessment – Requirements and guidelines 3 Physical test results on three different mosquito nets, Huchet, published in Public Health Journal 22, pages 30 and 36, 2011

More www.vectorcontrol.bayer.com

Article on the enclosed Public Health CD-ROM.

48

conclusion This study is the first Life Cycle Assessment (LCA) performed on long-lasting insecticidal mosquito nets. This work has been certified ISO 14040-44 by a critical review panel including LCA, textile, and malaria expertise.

Despite the fact that assumptions and a few limitations have been noted, the results presented are robust as proved by sensitivity analyses and the uncertainty analysis.

To efficiently protect persons against malaria during a period of time encompassing 30 washes, LifeNet® has a better environmental profile than PE or PET LNs. This is mostly due to its washing resistance, which reduces the number of nets considered and lowers electricity consumption related to the plastic type and industrial process optimizations.

Even reducing the washing resistance from 30 to 20 washes per LN (as per PE and PET nets), LifeNet® has lower impacts per functional unit than the other two nets. The PE and PET net life cycle impacts are not sufficiently different to draw clear conclusions.

This sensitivity analysis on washing practice shows that the net user’s non-respect of WHOPES recommendations can have a significant impact on ecosystem quality.

Communication through the LN packaging and during distribution campaigns has to be very clear to avoid unfavorable washing practices.

The physical resistance and user acceptability are also two key criteria to assess the efficiency of a net to protect against malaria. Even if LifeNet® seems the most favorable net regarding intrinsic features, field data as well as the WHOPES final report are necessary to confirm those results.

Finally, this study demonstrates that the benefit of using a LN is 10,000 higher than the potential damages to human health generated over the net life cycle.

PUBLIC HEALTH JOURNAL 23/2012

NGO

Save the Children

Creating a better world

Photo: GMB Akash/Panos Pictures

Save the Children is the leading independent organization for children in need, working in over 120 countries worldwide. Through mobilizing rapid assistance, relief, recovery, and ongoing development programs it provides hope for millions of children – for instance by scaling-up successful interventions to combat malaria.

W

herever needed in the world, Save the Children rapidly responds to provide food, relief, and medical care.

Save the Children USA alone manages an operating budget of around US$ 531 million, financed by individual and corporate donations, grants, cooperative agreements, and contracts from major multilateral and bilateral donors, foundations, and other private voluntary organizations.Save the Children works in health and nutrition, child protection, education,

HIV/AIDS, livelihoods, emer­ gency preparation and response, and disaster risk reduction. Save the Children’s mission is to inspire breakthroughs in the way the world treats children, and to achieve immediate and lasting change in their lives.

A woman of vision Save the Children’s vision of a world in which every child has the right to survival, protection, development, and participation, was inspired by one woman over

PUBLIC HEALTH JOURNAL 23/2012

90 years ago. After the First World War more children were starving in Central Europe than today in parts of Africa. This induced the British social reformer Eglantyne Jebb (1876– 1928) to create a charitable fund in 1919 to help these children.

To make children a major issue around the world, in 1923 she wrote the Declaration on the Rights of the Child, which subsequently formed the United Nations Convention now incorporated into law in nearly every country in the world.

49

NGO

Right to health Since then Save the Children organizations have been founded all over the world. Nowadays it is a global movement with 29 member organizations (see box).

Ensuring children’s health is one of Save the Children’s highest priorities. More than 90% of the estimated 7.6 million deaths in children under five are due to pneumonia, measles, diarrhea, HIV/AIDS, and malaria.

Save the Children USA works exten­s ively in designing, implement­ing and evaluating large-scale, sustain­able, health and nutrition pro­g rams worldwide. Its Department of Health and Nutrition works through a network of over 450 health professionals worldwide specia­l iz­i ng in maternal/ reproductive health, neonatal health, child survival, nutrition, HIV/AIDS, community mobili­ zation for health and nutrition, child health and nutrition in emergencies, and school health and nutrition. Working in

partnership with host govern­ ments, local and international organizations and donors, Save the Children works to improve the quality, availability, and use of key health practices and services, developing and imple­ ment­ing low-cost, sustainable, replicable, community-based approaches to address challenges.

insecticide treated bednets (LNs). The majority of its health programs in malaria endemic countries focus on improving access to and quality of treatment, especially for young children, as well as intermittent presumptive treatment for pregnant women, which also protects the fetus.

In October 2009 Save the Children announced a global campaign to save millions of children’s lives called “EVERY ONE”, a campaign inviting people everywhere to take action. So far almost three million people from the poorest communities to world leaders have expressed their support for child survival.

In January 2011 Save the Children became the principle recipient of the Global Fund grant in Myanmar that aims to reduce both malaria morbidity and mortality by 50% by 2015.1 It is estimated that Save the Children will provide malaria related services to around 40.9 million people located in 14 States and Divisions. Malaria intervention strategies in Myanmar include the use of not only ITN/LN, but also indoor residual spraying (IRS), inten­ sive behavior change communi­ cation (BCC), community health worker (CHW) training and strengthened Community Case Management (CCM), technical and administrative control capacity, and early diagnosis and treatment.

Malaria programs In many countries where malaria is endemic Save the Children USA is scaling up successful inter­­ventions, including inter­ mittent presumptive treatment, improved case management, and distri­bution of long-lasting

Save the Children alliance Australia Brazil Canada Denmark Dominican Republic Fiji Finland Germany Guatemala Honduras

50

Hong Kong Iceland India Italy Japan Jordan Korea Lithuania Mexico Netherlands

New Zealand Norway Romania Spain Swaziland Sweden Switzerland United Kingdom United States of America

In Pakistan, Save the Children USA is to begin implementing a Global Fund Round 10 project targeting malaria. The goal is to reduce malaria by 85% in 38 districts with an estimated population of 24.84 million people.2 The main interventions 1 The Global Fund Proposal Form Round 9-Malaria. (January, 2011). Myanmar.

2 The Global Fund Proposal Form Round 10, Single Country Applicant. (June, 2011).

Pakistan.

PUBLIC HEALTH JOURNAL 23/2012

NGO

Community Case Management (CCM) Save the Children USA focuses efforts on extending access to improved treatment of malaria through its CCM strategy. It works closely with Ministries of Health in developing countries to train, supervise, and supply community health workers to treat children with common, often life-threatening infections

MOSQUITO NETS to protect families from malaria are some of the many gifts people can choose to send from Save the Children’s website catalog (picture taken from the gift list).

such as diarrhea, pneumonia, malaria, and some­times dysen­ tery and newborn sepsis. Save the Children USA supports CCM for malaria in Ethiopia, Indonesia, Malawi, Mali, Mozam­ bique, Myanmar, Nicaragua, Nigeria, South Sudan, Uganda, and Zambia.

In March 2009 Save the Children received a grant from Canadian International Development Agency (CIDA) to dramatically scale up the CCM strategy for fever (malaria and pneumonia) over three years in Malawi, Mozambique, and Southern Sudan to directly benefit approximately 1,100,000 children under five within the total target population of 5.5 million. With support for drugs and implementation costs, Save the Children not only trains existing community health workers to assess, classify, and treat children with signs of infection, but also families to recognize and seek care for signs that indicate serious disease.

Send a gift Direct donations and sponsor­ ships provide a cost-effective way to demonstrate commitment to children. The Save the Children wish list, or gift catalog

PUBLIC HEALTH JOURNAL 23/2012

offers people the chance to send gifts that can help change the lives of children worldwide.

These range from medical kits to school books or water filters, or providing a farmer with a pair of goats. For US$ 40, a gift of mosquito nets means families can sleep protected from catching malaria. conclusion Save the Children works closely with other organi­ zations, governments, nonprofits, local partners, and communities to help children and families help themselves.

With generous support from individuals and corporate partnerships, Save the Children challenges world leaders to keep their promises to make a better world for children. A top priority is to prevent the death of millions of children worldwide.

Thanks to Eric Swedberg (Save the Children USA / Senior Director Child Health and Nutrition) for providing information for this article.

More Save the Children International: www.savethechildren.org

Article on the enclosed Public Health CD-ROM

51

Photo: Save the Children

are effective case management, multiple preven­tion measures, including aiming for 85% usage rate of LNs, and 15% of localities receiving 2 IRS rounds annually.

Other targets are to have 80% of malaria cases diagnosed and treated within 24 hours of symptoms onset, and 100% of the health facilities well stocked with antimalarial drugs and diagnostics. The main objectives to achieve these ends are: • To enhance access of populations at risk to quality assured early diagnosis and prompt treatment services; • to scale-up multiple prevention interventions, especially LNs and IRS to the level of universal coverage in target populations; • to enhance technical and management capacity of malaria control programs for improved planning, manage­ ment, and monitoring of malaria control interventions; • to improve health seeking behaviors and practices of target communities in highly malaria endemic districts through enhanced community awareness and participation.

notes

Sri Lanka: Struggling to eliminate malaria

Photo: Novak Zbyszek (fotolia)

As an island, hopes of completely eradicating malaria from Sri Lanka have waxed and waned for over half a century. The use of DDT and chloriquine in the 1950s almost achieved this by dramatically cutting cases from around one million per year to only 18 in 1963. However, discontinuation of DDT spraying due to environmental concerns led to malaria resurging to over half a million cases in 1969. Then political unrest escalating into the 26-year civil war frustrated further efforts and malaria remained, particularly in regions occupied by the Tamil Tigers in the north and east.

Concerted efforts to curb malaria, mainly financed by the Global Fund and Sri Lankan government, gained momentum between 2001 and 2004, when scaling up indoor residual spraying (IRS) achieved over 50% population coverage. Insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LNs) were also introduced for additional vector control in high-risk areas. Results were rapid. By the end of 2005, the Sri Lanka national reporting system recorded a huge drop, from an average 55,640 cases of malaria per year in 2000, to less than 2,000 confirmed cases. However, although carrying out 100% testing of suspected cases, incidences in rebel regions may well have been missed.

Annual cases of malaria in Sri 1 mio

> 500,000

55.640

18 1948

1963

1969

2000

< 2,000

558

580

2005

2009

2010

* estimated, probably undercounted in rebel regions

52

With peace eventually established in 2009, hopes were high that political stability would finally mean eradicating malaria from the island; that year there were only 558 cases. But at the end of 2010, malaria had increased again. Among the worst affected areas remained the previously rebel-occupied northern and eastern provinces.

This prompted the Ministry of Health to say they plan to open more clinics in these regions. The reasons for resurgence of malaria include a number of political and technical factors, such as stopping interventions too early, dismantling the program when initial elimination was assumed, and relaxing surveillance and monitoring. The next malaria eradi­ cation goal in Sri Lanka is fixed for Lanka* 2014, and the message is clear: to declare elimination all aspects of malaria control must be sustainably effective, while monitoring and evaluation should never stop.

UPS AND DOWNS In Sri Lanka malaria cases declined from a high level and were close to eradication in the early 1960s. Since then the figures vary dramatically, reflecting the political situation and relaxed interventions as important influencing factors.

PUBLICâ&#x20AC;&#x2C6;HEALTH JOURNAL 23/2012

notes

African trypanosomiasis: Affected by warming

Transmitted by the bite of a tsetse fly (Glossina genus), the parasite Trypanosoma brucei gambiense (found in West and Central Africa, accounting for 95% of cases) or Trypanosoma brucei rhode­ siense (East Africa) causes pro­g ressive neurological damage that is fatal if the disease is not treated.

According to WHO estimates, major efforts over the last 25 years have reduced cases from 300,000 in 1998, to 70,000 by 2005 and below 10,000 in 2009. However, since affected populations usually live in remote areas, surveillance and diagnosis is often difficult, which is compounded by poverty, war, and population displacement.

Tsetse flies transmitting the disease are only found in 36 sub-Saharan African countries.

But this still means that today

PUBLIC HEALTH JOURNAL 23/2012

more than 60 million people live in areas where sleeping sickness is endemic. Accord­ ing to a recent model of how climate change may affect the spread of trypanosomiasis, an additional 46-77 million people could be at risk of exposure by 2090.

Publishing in the Interface 1 Journal of the Royal Society , Sean Moore (US Centers for Disease Control and Pre­ vention) and colleagues, simulated the effects of climate change on various factors influencing the epidemiology of trypanoso­ miasis. The scientists’ model assumed an increase in temperature of between 1.1°C and 5.4°C over this century, depending on future levels of

greenhouse gas emissions.

The model reveals that the disease spreads when average local temperatures are between 20.7°C and 26.1°C. Although geographical areas predicted to suffer new infestation by tsetse fly are not large, the range is expected to shift by up to 60%, exposing different communities to this disease. The scientists suggest that such modeling of climate change linked to the biology of vector-borne diseases and the demography of populations and their livestock could help predict the risk of future disease incidents in subSaharan Africa.

1

http://rsif.royalsocietypublishing.org

Photo: Reiner Pospischil

Climate change will probably affect many pathogenic dis­ eases, particularly those that are vector-borne (see PHJ 20).

Temperature plays a vital role in vector biology, ecology, geographical distribution, and parasite interactions. One of the infectious diseases most likely to alter its epi­demiology due to climate warming is African trypano­somiasis (sleep­ ing sickness; see PHJ 21).

53

notes

Malaria R&D funding: Under threat?

The PATH report published mid-2011 highlighted how investment in malaria R&D is not optimally distributed, and should increase for vector control. The G-Finder report in December reviewed global investment into R&D for 31 neglected tropical diseases, including malaria. It notes large funding cuts recently in all sectors except industry. These data are reflected by the Global Fund’s decision to award no new grants until 2014.

A

98-page report1 compiled by the Program for Appro­ priate Technology in Health (PATH) together with six diffe­ rent organizations, includ­ing the Roll Back Malaria Partner­ship (RBM) and Innovative Vector Control Consortium (IVCC, established in 2005), highlighted the dramatic progress made in global action against malaria, particularly since 2004. Focusing only on research and develop­ ment (R&D), investment in­­ creased 4-fold over the past 26 years, from US$ 121 million in 1993 to US$ 612 million in 2009. The report reviews where funding is coming from, and what it has been used for so far, towards meeting the Global Malaria Action Plan (GMAP) targets set in 2008.

Vector control R&D underfunding The report warns that success depends not only on continuing funding trends but also on making important changes to funding patterns. In 2009, R&D for vector control received only 5% of the total funding. Although detailed analyses is complicated by limited data on private agro­ chemical company invest­ments, estimates suggest in­dustry invested an additional US$ 20 million on their own R&D between 2007 and 2009.

However, the analysis concludes that this still represents severe underfunding, which needs to increase from the estimated US$ 28–35 million per year to around US$ 90 million per year in 2016–2017.

Vector control, primarily IRS with insecticides and the widespread use of long-lasting insecticidal nets (LNs) has proven highly successful in reducing malaria over the last decade (see WMP, page 28).

Although four insecticide classes are so far registered for IRS, only pryethroids are approved

54

for LNs; but in both cases new modes of action are required to avoid the problem of vector resis­ tance. This requires re-directing a higher percentage of funding to these areas to discover new active ingredients and paradigms for malaria control and eventual elimination.

New formulations Development of improved public health pesticides and formulations for malaria and dengue control has been aided by the IVCC and its industry partners, including Bayer. They are working on new formulations for longer-lasting IRS and bednets (see page 41), with the first of these reaching the market in 2011, and others over the next five years. Screening for new active ingredients is more challenging, costly, and timeconsuming, but again is being actively pursued by Bayer and other chemical companies. Such developments will reduce the costs and logistics of large-scale IRS and LN coverage, as well as provide more choice of insec­ ticide classes to use.

PUBLIC HEALTH JOURNAL 23/2012

notes

Future funding

Source: 1

G-Finder survey The fourth Global Funding of Innovation for Neglected 2 Diseases: G-Finder 2010 survey is a detailed 120 page analysis of data compiled on last four years of global investments into R&D for neglected diseases. Funded by the Bill & Melinda Gates Foundation (see page 20), G-Finder is prepared by Policy Cures3, a not-for-profit group providing research, information and decision-making tools for governments, funders and organizations.

The latest survey was completed by 240 organizations, 10% more than in 2009, with a greater focus on low and middle-income countries (e.g. Argentina, Chile, Mexico, Uganda, Nigeria and Malaysia) as well as the vector control industry. It focuses on 31 neglected diseases, covering 134 product areas, including drugs, vaccines, diagnostics, micro­ bicides and vector control products. The related platform technologies and product-related R&D range from basic research, discovery and preclinical through to clinical trials and epidemio­ logical studies. As in previous years, HIV/AIDS, tuberculosis and malaria received the most funding, about 70%, of all money spent on NTDs.

Donations to health doubled between 2001 and 2008. But then the impact of global financial crises became apparent as contributions fell back to a 4% increase per year from 2009 to 2011, with the exception of the UK committed to 14% increases (see pages 5, 15). The Global Fund for AIDS, Tuber­ culosis and Malaria is the largest single source of funding for health aid, with its resources peaking between 2009-2011.

Although funding of around US$ 1.6 billion was still available early in 2011, by November this had largely vanished, mainly because some donors changed their minds, and others wanted to delay paying their pledges. As a result, the Global Fund cancelled Round 11 grant approval on November 22 at a meeting in Accra, Ghana.

The Global Fund will now only finance on-going programs planned to end before 2014. It intends to implement a number of strategies to ensure promised future funding is used as efficiently as possible (see box).

This includes limiting funding to some middle-income countries, with the ultimate aim of focusing on populations most at risk.

PUBLIC HEALTH JOURNAL 23/2012

PATH. Staying the Course? Malaria Research and Development in a Time of Economic Uncertainty. Seattle: PATH; 2011. ISBN 978-0-9829522-0-7 2

G-Finder 2011. Neglected Disease Research and Development: Is Innovation under Threat? (pdf link) 3

www.policycures.org

Please find the complete PATH report and G-Finder survey on the enclosed Public Health CD-ROM

The Global Fund’s strategic objectives • Invest more strategically in areas with high potential for impact and strong value for money, and fund based on countries’ national strategies.

• Evolve the funding model to provide funding in a more proactive, flexible, predict­ able and effective way.

• Actively support grant implementation success through more active grant management and better engagement with partners.

• Promote and protect human rights in the context of the three diseases.

• Sustains the gains, mobilize resources – by increasing the sustainability of supported programs and attracting additional funding from current and new sources.

55

Notes

Book Review

Dealing with malaria Like an odyssey, Perry takes us on an epic journey, literally as he travels around Africa, in part with one of malaria’s major campaigners of this decade, and politically as he unravels the complex story behind trying to deal with this disease. The journey is by no means over, but the plotted destination is clear: eliminating malaria.

“Lifeblood: How to Change the World One Dead Mosquito at a Time”

by Alex Perry Published by: Publicaffairs: www.publicaffairsbooks.com

P

erry expertly draws on his many years’ experience as Time’s top journalist in Africa to relate fascinating, inspiring, frustrating, and moving behindthe-scenes stories from the two sub-continents dominating the malaria map. The US as the crucible of Wall Street millio­ naires and mega-philanthropists; sub-Saharan Africa as the poverty-trapped victim (Jeffrey Sachs, PHJ 17, page 42) suffering 90% of all malaria deaths worldwide.

As he acknowledges, many thousands of people have, and are investing energy, time, money, and commitment in the battle against malaria. But Perry decides to focus on one man

56

whose story is little known. Ray Chambers, a self-made millio­ naire, had already been forging the path of entrepreneur philanthropist in the US for over 15 years when malaria caught his attention in 2006. Over the next few years Chambers pushed international aid into the highly accountable business arena, and transformed malaria elimination into a transparent time-frame target.

Then, and still today, international aid often gets criticized as being inefficient, disorganized, opportunist, even corrupt, or simply a short-term solution that creates dependency.

But this lack of accountability creates serious misgivings among donors about the integrity of international aid. Chambers’ strategy was therefore a major force in transforming the global malaria campaign into the “rare

phenomenon of a successful aid program”.

Some individual businesses had already established their own malaria control programs in Africa clearly recognizing malaria as an economic problem.

Chambers expanded this rational approach across the whole range of private-sector, public, NGO, and government initiatives involved in malaria. In 2008 he was appointed as the first UN special envoy for malaria.

Other side of the coin Accompanying Chambers on a number of visits to various Afri­ can states, Perry is also witness to the other side of the coin, the receivers. With objectivity, sometimes humor he describes how African politicians, officials, and religious leaders react to the developing world’s

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pr o f i l e

drive to help them rid their countries of malaria. It is clear they themselves need to be empowered. But first they need help to break the cycle of malaria causes poverty causes malaria, or even just the habit of accepting a disease they have lived with for millennia.

Perry’s brief history of malaria intentionally complements the more comprehensive story told last year by malaria historian Sonja Shah (PHJ 22, page 56).

Astonishingly, he reveals that the post World War II 1960s push to rid the world of malaria fatally ignored Africa. At the same time success in other parts of the world, particularly the US, Europe, and Russia, meant anti-malaria campaigns lost impetus – and malariologists.

Luckily one small group of dedicated scientists gathered around Brian Greenwood in Nigeria, moving to Gambia in 1980. As well as testing new artemisinin-based treatments, they revived the classic method to prevent malaria: bed nets.

First-line weapon Using the insecticide permethrin, Greenwood’s group reported in 1991 that insecticide-treated nets reduced childhood malaria deaths by 70% and overall child deaths by 63%. Subsequent mass trials in Gambia, Ghana, Burkina Faso, and Kenya put estimates at a more sober 40% – but still the most effective

intervention for saving children’s lives after measles vaccination.

Even more dramatic, and unexpected, as net use increased, the effect was amplified. Studies showed that more nets led to fewer mosquitoes and less disease transmission. The simple-to-use mosquito net proved to be an effective tool for vector control.

When Christian Lengeler, head of the Health Unit at the Swiss Tropical Institute, presented the bed net data in 1997 the way forward was suddenly clear. The World Bank, UN agencies, and donor governments had met in Washington to discuss possible ways to renew anti-malaria action. Forming the Roll Back Malaria Partnership to coordi­ nate these efforts, the secondgeneration global campaign to combat malaria had started – and the first-line weapon was insecticide-treated bed nets.

At the beginning, Perry describes his horrifying trip to Apac, Uganda, in August 2009.

Possibly the Mecca of malaria, it was a ghost town, nobody outside apart from three naked men completely deranged by malaria. A visit to the local clinic found it overflowing with sick children and babies, with 10-15 more arriving every day. The Apac district records showed that over the previous year approximately a quarter of the population sought treatment for malaria, including more than

PUBLIC HEALTH JOURNAL 23/2012

half of all the children under five.

On his return late 2010, Apac was transformed, the streets packed with people walking, cycling, working, and sitting outside in cafes. The first round Ugandan intervention had brought in cycles of spraying and enough insecticide-treated nets for pregnant women and young children. They were still waiting for the second round of universal coverage nets, but people’s lives had already changed dramatically.

Two-thirds of the beds in the clinic, now all with nets, were empty. Checking the records again, Perry notes that one girl died in September, but in October, no child had died from malaria. This is Perry’s most moving and probably most important tale of all – how lives of poverty and misery and suffering can be transformed once the mosquitoes have gone.

ALEX PERRY, an award-winning journalist, heads Time magazine’s African office.

Joining Time in 2001, he covered South Asia from Afghanistan to Bangladesh until 2006. Now based in Cape Town, he covers 48 countries in sub-Saharan Africa. In addition to twenty Time cover stories, he has also written: Falling Off the Edge: Globalization, World Peace and Other Lies (2009).

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pr r et or fo i lsep e c t i v e

H

ISTO

R Y

Schistosomiasis The disease was well-known in ancient times; the symptoms are depicted in hieroglyphics and described in ancient Assyrian records. Calcified parasite eggs found in Egyptian and Chinese mummies confirm the diagnosis. But the cause of schistosomiasis, also known as bilharzia, bilharziasis or bilharziosis, was mysterious until the German pathologist Theodor Bilharz first described the parasite in 1851.

T

here are two major forms of schistosomiasis caused by five main species of blood fluke.

Urinary schistosomiasis causes progressive damage to the bladder, ureters, and kidneys, with symptoms of blood in the urine. Intestinal schistosomiasis leads to progressive damage to the liver, spleen, and intestine.

These diseases, prevalent from Africa to Japan, were known by many different names until a young doctor from Germany discovered the underlying cause.

After studying medicine at the University of Tübingen, Theodor Bilharz went with his former teacher Wilhelm Griesinger to Egypt in 1850. While working at the Kasr-el-Aini hospital in Cairo, he found the trematode “flatworm” that causes urinary schistosomiasis. He realized that the platyhelminth had two sexes, the female a long thread-like worm held in the fold of the tailed, rolled up male flatworm he had first observed. The parasite was subsequently named after him: Bilharzia hae­ ma­to­bium. Later it was renamed Schistosoma haematobium.

In Japan, similar symptoms and mortalities were known among

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Theodor Bilharz (1825-1862)

rice paddy workers. In 1904 Fijiro Katsurada at Okayama Medical School discovered the blood fluke causing this disease.

He called the parasite Schisto­ soma japonicum, which causes the Asian form of schistosomiasis. This was eradicated from Japan by 1978, but is still widespread in other parts of the Far East.

How these parasitic flatworms were transmitted to man, or livestock, was still controversial.

Finally, two Japanese investi­ gators, Keinosuka Miyairi and Masatsuga Suzuki, found that the life cycle included a freshwater snail intermediate host that produced infective cercariae. These larval forms of the parasites released into water by snails penetrate the submerged skin of people or livestock.

Schistosomiasis still infects more than 200 million people per year, over half of these in Africa. Endemic in over 70 tropical and sub-tropical countries, an estimated 700 million people worldwide are at risk of infection. After malaria, it is the second most devastating socioeconomic parasitic infec­ tion. Although the mortality rate is relatively low, schistosomiasis causes chronic illness, and in children impairs growth and cognitive development. Genital lesions caused by schistosomiasis can increase vulnerability to HIV infection.

However, early treatment, especially in children can prevent lesions and reverse other adverse symptoms.

Theodor Bilharz, still remem­ bered by the disease, was later on appointed Professor of Anatomy at the Kasr-el-Aini hospital in Cairo in 1856. Aged 37, he died of typhus on an expedition to Massawa in 1862.

His memory also lives on in the Theodor Bilharz Research Institute in Giza, Egypt – and in the crater Bilharz on the Moon.

PUBLIC HEALTH JOURNAL 23/2012

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Link List With reference to the topics in this issue of Public Health Journal we include a summary of the main Internet links, where you can find further information, the latest reports and statements.

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