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Innovative approaches have demonstrated that a greater impact on malaria can be achieved through better integration with other health interventions and programmes, such as those tackling neglected tropical diseases, nutrition, maternal and child health. Links with other sectors (for example, water and sanitation) and broader poverty reduction programmes can also strengthen impact.
What innovative approaches should DFID focus on to increase impact and yield additional health outcomes? What are the priorities for operational research to support effective delivery?
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Our thanks for all the comments submitted. All of the ideas and suggestions put forward will feed into our new policy, helping to shape the direction of our work.
Once the final policy document is released you will be able to find it at www.dfid.gov.uk
As the scientific community works hard to bring a vaccine to the market, develop new drugs, and possibly a vaccine, there is much need to develop better implementation strategies for existing methods – again with the aim to eliminate, not control malaria. In many parts of Africa, where transmission is not intense and seasonal, the right implementation strategy should yield elimination. Area-wide integrated mosquito management strategies should form the basis for such campaigns and be integrated with adequate and proper case management.
For all the high-sounding rhetoric on “The war against malaria” at present the analogy with waging war isn’t a very good one. No modern democratic society would list complete elimination of the enemy among its objectives. Mosquitoes and Plasmodium have been around a very long time and will resist any attempts to destroy them by developing resistance. We should recognize the importance fo looking at ways to “co-exist” with these organisms by reducing contact between man, vector and parasite through a better undertanding of all aspects of disease ecology. Insecticides are a necessary evil at best and nobody wants to take antimalarial drugs or insect repellents for life. An effective vaccine like that of yellow fever would solve the problem but by looking at environmentally sound and sustainable ways to reduce the risk of being bitten and taking the views and customs of local people more into account we could go a long way to solving this and other public health concerns.
@Bruce – although I appreciate your concerns that anophelines and Plasmodium will resist all attempts to permanently remove them, I would argue that such sentiments were not tabled when Europe, the USA, Russia, Taiwan, Australia, and the Caribbean were eliminating malaria. It was a ‘war’, and it was won. Although I appreciate that the ‘battle’ will be tougher in the heartland of malaria (Africa), I am highly optimistic that the disease can be permanently removed from large chunks of the continent, given the right resources, and backed by political will. At present there is no single area-wide large-scale attempt going on in any African country to try to accomplish this…
We believe that a major area to focus on should be transfusion transmitted malaria. This is an area that has been completely neglected in the fight against malaria but remains crucial. Dealing with the problem of transfusion transmitted malaria will involve key areas such as diagnosis, treatment and policy implementation.
Transfusion transmitted malaria is preventable if the diagnosis can be made and the appropriate treatment given. In Africa, pregnant women and children make up the majority of recipients of blood transfusions. They also are also highly susceptible to malaria infections because of their low immunity. Published evidence indicates that the prevalence of malaria parasitaemia in donated blood could be between 5-50% in malaria endemic countries, so there is potential for a huge proportion of malaria to be transmitted by blood transfusions. Detection of malaria parasites in donors who are mostly healthy adults poses a challenge because parasitaemia is low and available tests are either not very sensitive or too expensive.
DFID should encourage collaboration with government/governmental agencies, pharmaceutical and diagnostic companies and researchers in private-public partnerships to tackle the problem of transfusion transmitted malaria. Operational research at the hospital/blood banks is needed to establish the true prevalence of malaria parasitaemia in each country or region, determine the incidence of malaria in transfusion recipients, and establish the most appropriate diagnostic methods. Pharmaceutical and diagnostic companies in collaboration with blood transfusion researchers should work to develop and test new malaria screening tools and treatments, to tackle the problem of transfusion transmitted malaria. The role of governments/ministry of health will be to support operational research and rapidly use the acquired evidence to establish and promote policies on screening for malaria parasites and treatment options in donors and recipients of blood products.
Imelda Bates and Alex Owusu-Ofori
Mr. Bruce Alexander could be right when he commented that “Mosquitoes and Plasmodium have been around a very long time and … looking at ways to “co-exist” with these organisms by… a better understanding of all aspects of disease ecology,” will be an effective and sustainable plans for Africa’s endemic infectious diseases. Philosophically, I would not agree with his argument, but semantically, he cut my attention. As a researcher in integrated health care model and a field researcher in biobehavioral medicine, currently working on Africa’s infectious disease, I thought most of the treatment plans and intervention used in Africa are not ground in evidence-based practices or substantive research findings.
However, a lot of high-profile research have linked traumatic stress, caused by war, violence, insecurity, abuse, geopolitical instability, desperation, and starvation (poor nutrition) to immunosuppressive syndrome (drastically weakened state of innate immune system). According to these scientific findings, situation such as this makes the necessary functional corporation between the innate and acquired immune defense system impossible therefore, leaving the individual highly susceptible to any slightest attack of disease-causing pathogens. With such as condition, blanketing the nation with insecticide-treated mosquito nets (to paraphrase Nigerian Health Minister), but without addressing the biobehavioral risk factors responsible for the immunosuppressive syndrome is not only a window dressing, but a disservice for the people.
I am happy and grateful for DFID’s relentless efforts to eradicate infectious diseases in Africa, but the whole effort and funding should not be directed only to treating symptoms. The cause of Africa’s endemic health care crisis should be addressed through integrated health care model.
The integrated approach does not claim to be a panacea; for me it means a recognition of the intricate balance of nature, and seeks to maximize the positive impacts and synergies therein. We cannot divorce malaria eradication from poverty, poor housing and drainages, poor healthcare etc. To sustain a malariua eradication campaign is easier done within an integrated system. Thise countries that have succeeded in this effort had various levels of integration into which the massive one-time all – out effort was devoted. Lets create such scenario agaon for Africa; its been done before in other climes, it can be done here too
Area wise stratification must be carried out before implimentation of malaria control stretegies in a particular area. Intgrated vector management (IVM) seems to be most appropriate and can be linked with environmental improvement, edible fish culture, plantation, waste / sewage water manegment and agriculture practices specially the rice cultivation.
Integrated systems will work when the integral parts work well. Education, economic empowerment, and political will will help us make progress in this matter. Governments must first agree to love their people and be ready to serve them by ensuring good governance.
There are best practice models in different parts of India and other countries which need to be documented and disseminated as well as exposed to different people involved in malaria programme planning and implementation.
In case of India, an innovative approach in vesting power and authority to local governance syster (3 tier Panchayatiraj) in planning, monitoring and implementing malaria programme can be one. Because the local government has the mandate and constitutional authority and they are actually responsible for planning, implementing & monitoring all the development programme- health, nutrition, education, employment, water and sanitation etc.
Federating Village health and sanitation committees at Panchayt level can be starting point. This federating will work under village Panchayat.
Integration of all development committees (Health, education, sanitation, forest etc.) at village can be another starting point.
These initiatives will have a synergetic effort for all the programmes.
Operational research on community participation, behavior change communication, functions of different committees in villages, role of Panchayati Raj institutions and explore possibilities in integration. The need based bottom up multi stake holders planning issues are some of the suggested prirotity issues on which liitle information on concrete form (Qualitative and quantitative) is available. The above operational researches would provide necessary insights and directon for action.
Capacity needs assessment of managers at different level, issues on corruption are some priority issues on which operational research needed basing on which actions can be undertaken.
Assessment of need of private organizations and mapping such organizations is another issue of research.
Malaria control requires reducing the biomass of parasites in both the human and vector population. In an integrated program both these groups need to be addressed. ITNS and IRS help to reduce the vector held biomass of parasites while the insecticides remain effective. However the human held biomass is not addressed. For this we need some form of mass drug administration (MDA). The problems with MDA is it is expensive to deliver and we risk generating resistance. However a more focussed application of drugs maybe more effective.
For sustainable effects, the DFID programme should not ignore the risk that ‘proven effective tools’ may not continue to be effective. Continued investment in novel antimalarial drugs and insecticides has to remain on the agenda.
Although tremendous gains can be achieved with currently available tools, and we should make the most of this opportunity, I disagree with the first comment of Bart Knols. The right implementation strategy will not result in malaria elimination in most areas in Africa. The reproduction number of malaria is likely to be too high in most settings to achieve elimination with currently available tools, as indicated by a recent simulation models for several African settings (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000324).
Adequate and proper case management is probably the most difficult but most sustainable element of malaria control. It requires an improved health infrastructure and improved supply chains. This will result in a general improvement in public health that will not only reduce severe malaria morbidity and death but severe morbidity and death rates in general.
Education, Education, Education
How many existing problems associated with malaria persist due to a a lack of integrated education? It is not simply enough, in my view, to distribute bednets or drugs to a community with the promise that they will prevent or cure episodes of malaria. For a start, we need to ensure that malaria is never misdiagnosed through educating and deploying trained personnel who can use the most up-to-date and resource-light methods for detection of infection. We need trained personnel to spot signs and symptoms of malaria to prevent inappropriate treatment. We need citizens educated in the basic biology of infection through to the specific factors of malaria transmission. Malaria is so important to the lives of hundreds of millions of people that it cannot be such a bad thing to devote a significant chunk of their education to learning about the infection from every angle.
Scientists can bring the latest biomedical research much more fully into educational systems through a robust system of knowledge transfer. How many African children know that a malaria vaccine is being developed? How many are inspired to take part in research because they have become fascinated by the issues? Peer-to-peer systems can rapidly transfer information across large groups. Novel methods of engagement through activities that act as magnets for hard to reach people.
For my contribution, I’d like to make a blatant call for my company’s product to be included in at least one malaria program. We have a unique product for mosquito control called Aquatain AMF. It’s a silicone based liquid which self-spreads across the water surface, forming a very thin film and disrupting the mosquito lifecycle. It is non-toxic, having a physical action rather than a chemical action, and is certified for application to drinking water storages in the US. It can be applied without spray equipment, and it lasts for around 4 weeks on the surface.
Trials by several independent authorities around the world have confirmed the effectiveness of the product. These include trials by the Uganda Ministry of Health.
As bed nets and fog spraying are aimed only at adult mosquitoes, Aquatain AMF could play a complementary role because it targets the pupae and larvae.
We are looking for an opportunity to be included in a malaria program so that we can demonstrate the benefits of the product.
Aquatain AMF and other larval control strategies do indeed deserve much more attention. We have published on Aquatain against Asian and African malaria vectors: http://www.ajtmh.org/cgi/content/full/80/5/758?maxtoshow=&hits=10&RESULTFORMAT=&author1=knols&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT