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Toward a malaria-free world

Student work document (recommended for 3rd and 4th year and 5th and 6th year of secondary

school)DEVELOPED BY:

Toward a malaria-free world

You’ll be finding out all about malaria and some of the research projects currently underway with the aim of eradicating the disease (from prevention to finding a

vaccine).

Find out more, form an opinion and share it!

Malaria is one of the leading issues in world health. It mainly affects women and children under the age of five in countries with low incomes and is responsible for hundreds of thousands of deaths each year. Have a look at this link to see the magnitude of just how quickly this disease spreads.

Measures aimed at controlling the spread of the disease, education and research are essential in the fight against the spread of malaria, but will we maybe see a world without malaria one day? Are we even getting close to the possibility? Can we ensure that everyone is receiving the best treatment available?

One of the debates at an upcoming conference on malaria is the strategy that should be adopted in order to eradicate the disease in accordance with the aims established by malERA (the Malaria Eradication Research Agenda). Unfortunately, another one of the main topics of the conference will be the limited resources destined by different states to following malERA’s aims. As well as the current economic climate, the conference will have to be well aware of the fact that the disease continues to decimate populations in only the poorest of countries.

As part of the meeting, leading figures in the international community will have to decide which of the following theoretical positions would be the best and should be implemented:

Position 1: distribute the reduction in investment proportionally across all of the different fields of activity: prevention, treatment and diagnosis, programmes and research.

Position 2: reduce investment in prevention, programmes and research but keep the same budget for treatment and diagnosis.

Position 3: reduce the money spent on diagnosis and programmes and research but keep the same budget for prevention.

Position 4: spend less on prevention, treatment, diagnosis and programmes but keep the same budget for research.

Position 5: make reductions across all areas (prevention, treatment and diagnosis, programmes and research), but make the cutbacks according to the level of poverty in the region.

In this activities guide, we invite you to investigate the decisions you think need to be made in the political arena regarding this topic and, in your capacity as representatives of the

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educational community, to share your opinions on blogs and social networks so that they reach society as a whole and the politicians who actually do make these decisions.

To help you with this task, Dr. Pedro Alonso, director of the Barcelona Institute for Global Health (ISGlobal) has worked together with Xplore Health to come up with a training plan which will help you find out more about this disease and how it spreads, as well as the ethical, legal and social issues involved, so that you can contribute to the debate on the 5 different theoretical positions detailed above with a more solid knowledge base.

In order to follow this training plan, we’ll need you to do the following:1. Organise yourselves into groups of five.2. Watch a short video and work through some basic documentation for you to get an

idea of the biology of the disease.3. Interact with a virtual simulation to raise your awareness of factors involved in

controlling malaria.4. Take on one of the positions described in the introduction (each member should adopt

one of the positions) and fight for it in the debate.5. Consider and evaluate which position you as a group feel is the most ideal.6. Make a digital poster to explain the decision you have come to as a group.7. Share your position in a blog and across social networks.

But before you start, check out the message that Dr. Pedro Alonso has left for you by clicking on the following link.

Ready to begin? Find out more, investigate, debate and share!

Let’s get started...

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A. Introduction to the disease’s biology (3rd and 4th year of secondary school version)

The aim of this first activity in the training programme is to introduce you to the world of malaria.

1. Organise yourselves into groups of five (initial work groups).

2. Watch the short video entitled Working for a malaria-free world. Note down individually the ideas you think are most important and the things you don’t fully understand in a table like this one: NB: we recommend watching the video at least three times.

Most important ideas I don’t really understand...

3. In your work groups, compare which ideas you thought were most important and then try to come up with a summary of the things you didn’t fully understand. Choose a spokesperson in each group and write down all of the ideas suggested on the board. Try to clear up any remaining doubts with the help of your classmates and teacher.

4. Once you’ve finished working on the video, each member of the small group should choose one of the following topics to study in a new work group:a. What is malaria? How is it transmitted?b. What does the life cycle of malaria look like?c. Fighting malaria: vaccines.d. Preventative measures. The Roll Back Malaria programme.e. The disease’s epidemiology.

The aim of these new work groups is to pool your knowledge and investigate your topic in more detail with the help of the links below. You will then be able to come up with an answer to each of the questions and pass on this knowledge to the others in your initial groups.

What is malaria? How is it transmitted? What is malaria?

What does the life cycle of malaria look like? Video: the life cycle of malaria

Fighting the disease. Research on malaria

Preventative measures. The Roll Back Malaria programme.

Solutions

RBM Mandate

RBM Vision

Epidemiology

Key malaria facts

Endemic countries

The challenge

Participate in the work group you decided on and write down an answer to the question.

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5. Return to your initial group members and share your answer with them. Then try to answer the following questions in your groups:

a) In the past, malaria was also known under a different name: paludism. Each of the different names has a meaning - where do they both come from? What relationship do these names have with the ecosystem where the Anopheles mosquito lives?

b) Imagine that one of these mosquitoes bites you on the arm outside of the classroom. Still in your work groups, draw up a report of the likelihood of your contracting malaria.

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Introduction to the disease’s biology (5th and 6th year of secondary school version)The aim of this first activity in the training programme is to introduce you to the world of malaria.

The WHO is the world authority on directing and coordinating different activities related to health. The WHO’s World Malaria Report 2013 highlights the constant progress being made in reaching the international goals aimed at combatting malaria set for 2010-2015. The report contains a summary of all of the information from the different countries suffering from endemic malaria.

1. Organise yourselves into groups of five (initial work groups).

2. Watch the short video entitled Working for a malaria-free world. Note down individually the ideas you think are most important and the things you don’t fully understand in a table like this one: NB: we recommend watching the video at least twice.

Most important ideas I don’t really understand...

3. In your initial work groups, compare which ideas you thought were most important and then try to come up with a summary of the things you didn’t fully understand. Choose a spokesperson in each group and write down the most important ideas suggested on the board. Try to clear up any remaining doubts with the help of your classmates and teacher.

4. Once you’ve finished working on the video, each member of the small group should choose one of the following topics to study in a new work group:a. Policy development + financing malaria controlb. Progress in vector controlc. Progress on chemopreventiond. Progress in diagnostic testing and malaria treatmente. Malaria surveillance, monitoring and evaluation + impact of malaria control

The aim of these new work groups is to pool your knowledge and investigate your topic in more detail with the help of the information you will find in the document entitled Executive summary and key points World Malaria Report 2013. You will then be able to come up with an answer to each of the questions and pass on this knowledge to the others in your initial groups.

Participate in the work group you decided on and write down an answer to the question.

5. Return to your initial group members and share your answer with them.

6. Imagine that one of these mosquitoes bites you on the arm outside of the classroom. Still in your work groups, draw up a report of the likelihood of your contracting malaria.

7. Finally, complete the data sheet on malaria you’ll find on the next page to summarise all the knowledge you’ve gained. Note: all of the data can be found either in the video entitled Working for a malaria-free world or in the Executive summary and key points World Malaria Report 2013. For further information, you can read the following report which appears in the El País newspaper:

http://elpais.com/elpais/2014/01/24/eps/1390567183_402725.html

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Malaria or paludism

Cause

Vector

Number of new cases across the globe (2010)

Number of new cases in Sub-Saharan Africa (2010)

Number of newly-infected people

Number of deaths across the globe (2010)

% of deaths in Africa compared to overall figure (2010)

% of infected children under the age of 5 compared to the overall figure (2010)

Number of countries where malaria is endemic

Symptomatology

Types of treatment

% of suspected malaria cases receiving a diagnostic test in Sub-Saharan Africa

Types of prevention

% of families in Sub-Saharan Africa with access to insecticide-treated mosquito nets (ITN) (2011)

Post-treatment follow-up

Resistance to treatments

International financing for controlling the disease (2011)

International financing for controlling the disease (2010-2015)

Current areas of research

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B. Malaria and the immune system (3rd year of secondary school version)In a video entitled A shelter from malaria, researchers Pedro Alonso and Joe Campo explain to us they research project they’re working on, known as project Mal055, which aims to find a vaccine to malaria.

http://www.xplorehealth.eu/en/media/shelter-malaria

At the moment, they’ve found a vaccine which only appears to protect around half of the children to which it is given. This is why it’s so important to understand the mechanisms involved in our immune system which protect some people from infection. We invite you to play a game:

THE MALARIA BOX

Materials required: mosquito = box Plasmodium = balloons in 4 different colours vaccines = balloons in 4 different colours cut up into pieces B cells = green ball made of modelling clay T cells = blue ball made of modelling clay antibodies = needles

a)How easy do you think it is to identify how many people are infected with the malaria parasite? Are there any external signs that might give it away?Get into groups of 5. Each group is given a box (the mosquito); one of the group will then decide, without the other classmates being able to see, whether to put the balloon (Plasmodium) in the box or whether to leave it empty. They should also decide on the colour (different species of Plasmodium) and the number of balloons (more than four). Only mosquitoes carrying the Plasmodium parasite will infect your classmates. Move the boxes around the class just like mosquitoes move - randomly from one person to the next. The person in charge of the box should ensure that it is passed to at least 4 different classmates. If the box is passed onto you, you need to open it and check if it contains a balloon:

Does it contain a balloon?o Yes the mosquito bites you and the parasite enters your bloodstream. Take one

of the balloons from the box, but don’t blow it up just yet - the others don’t need to know if you’ve been infected. Pass the box onto someone else in the classroom.

o No you’ve been lucky! You’ve not been infected, so pass the box onto someone else in the classroom.

Don’t blow up the balloons until the box has been handed to at least 4 different students. No-one should know which of the boxes contains parasites and which ones

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don’t. The vector can continue to pass on the infection as the box will still contain balloons.

b)How many of your classmates have been infected with malaria?The boxes have now been passed to four different people. Now it’s time to discover as a class who has been infected, so blow up the balloons if you have one. i. Find out more information on the different species of Plasmodium that can carry

malaria:

http://www.who.int/mediacentre/factsheets/fs094/en/

ii. Assign a colour to each of the different species.iii. Note down the number of students infected with each kind.iv. Has anyone been infected by more than one species?

c) What vaccine can you give me?Seeing that part of the class has been infected, the others decide to get vaccinated. You’ll find different vaccinations in the hospital (part of the classroom should be set up). These vaccinations are represented by shreds of cut-up balloon in the different colours, each one inside an envelope. Take one of the envelopes.Return to your seat. You’ll need the shreds of coloured balloon to come into contact with the cells in your immune system, your T cells.

d)Will my antibodies be able to prevent infection?After a while, your B cells will have produced antibodies (needle with thread). The colour of the thread must coincide with the vaccine you’ve selected (the shreds of balloon). Place a few needles on the table which represent the antibodies you have available to fight the parasite and surround your B cells with antibodies; these will be your memory B cells.Students who have been vaccinated are now once again among the general population and can be handed one of the boxes (i.e. are bitten by a mosquito). As before, if you are given a box, open it and see if it contains a balloon. If it does contain a parasite:

Does the colour of the balloon coincide with the colour of your antibodies? o Yes Great! The antibody recognises the parasite. You can burst the balloon with

the needle.o No Oh dear, bad luck! Your immune system doesn’t recognise the parasite:

you’ve been given an ineffective vaccine.

e) Final activity: i. Write a report using the questions in the activity as a guide. Add a glossary containing

definitions of some of the parts of the immune system: antigen, antibody, T cell, B cell, innate immunity, acquired immunity. Your report should include all of these words.

ii. Produce a brochure explaining the game for putting on social networks to help raise social awareness of the importance of carrying out research to combat this disease.

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Malaria and the immune system (6th year of secondary school version)The document entitled The Pillars of the Earth: How Basic Science Contributes to the Fight Against Malaria published by ISGlobal explains the importance of conducting research into the structure, metabolism and genetics of the parasite in order to achieve our goal: to eradicate malaria.

You’ll be working as scientists in a basic research lab and should now split into different working groups.

GROUP 1: PLASMODIUM BIOLOGY We know different Plasmodium species that cause malaria in humans. The most common are: P. falciporum, P. vivax, P. malariae, P. ovale and P. knowlesi. Of these five species, P. falciporum and P. vivax are responsible for the vast majority of new infections and for deadly infections, some of which have developed resistance to medicines. Once Plasmodium comes into contact with the immune system, it causes a reaction whereby the antigens from the pathogen are recognised and the body starts an immune response. You can find out more about this reaction at the following link:

http://highered.mcgraw-hill.com/sites/dl/free/0072507470/291136/AntigenProcessing.swf

Compared to Plasmodium with its gene count of approximately 5,000, viruses and bacteria have very few genes. There are thousands of different proteins which could act as antigens for our immune system.

Cell st & Microbe 10.1016/j.chom.2010.12.03

a. Look carefully at the image on the left and think about which phases of the parasitic life cycle you would choose to study the proteins related to the immune response or for treating and preventing infection.

b. The right-hand image shows the merozoite recognising, attaching itself to and entering an erythrocyte (figures 1, 2 and 3), as well as some substances which can help prevent the recognition and attachment phases (figures 4 and 5). Can these inhibitors be used to prevent infection? Why?

c. The following article, which appeared in the magazine Nature, is about a protein which is essential in the development of gametocytes. Can inhibiting this protein expression help to prevent infection? Why?

http://www.nature.com/nature/journal/vaop/ncurrent/full/nature12920.html

d. Following in the footsteps of the researchers, the first thing you’ll need to do is find out

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more information on the protein PfAP2-G. You will be accessing a program called BLAST which is used to compare protein sequences with all of the proteins held in one of the available biological protein databases. In this case, they use the Swiss-Prot database which is an annotated protein sequence database for proteins with a known function, structure and post-translational modifications. The tool will help you discover the protein’s function. There are different types of BLAST, but we will be using blastp (protein sequence database search) which we can find on the National Center for Biotechnology Information’s server (NCBI). Find out more about the characteristics of the protein and read the first few papers it is quoted in.

e. In order to advance knowledge about the different aspects related to the biology of the parasite, design a global campaign to collect samples which include all of the different Plasmodium species responsible for spreading the disease. Be sure to identify samples of the parasite which may have developed resistance to treatment.

f. Design a diagnostic test which would allow you to detect the presence of the parasite in the blood. Choose one of the following options:

Examine blood smears from patients to detect the presence of the parasite.

Carry out a test similar to a Luminex test to detect parasite antibodies. To discover more about the steps involved in this kind of testing, watch the following film:

http://www.xplorehealth.eu/en/media/facing-underestimated-malaria

i. Which parasites do they work with?ii. They have observed different immune responses to infection from the same

parasite. They took blood from two groups of pregnant women who had come into contact with the parasite before pregnancy: one of the groups of women was suffering from the disease when the blood was extracted, but the other group wasn’t. When the parasite particles come into contact with the blood, we can see that half of the women have developed immunity whereas the other half haven’t. Might this observation have something to do with the fact that vaccines are not 100% effective? Why?

PREGNANT WOMAN - SUFFERING FROM MALARIA

PREGNANT WOMAN - NOT SUFFERING FROM MALARIA

CASE 1

Antibodies B lymphocyte

CASE 2

Case 1: the antibodies protect the woman from the parasite. Case 2: the antibodies show that the woman is suffering from the disease.

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g. Why should anti-malaria drugs not be given unless the presence of the parasite in the blood is confirmed? How can resistance to drugs come about?

h. In order to help answer these questions, use the information in this documentary produced by the Spanish Society of Humanitarian Medicine (SEMHU):

http://vimhu.semhu.es/?portfolio-item=4-la-malaria

GROUP 2: DEVELOPING A VACCINEIn a video entitled A shelter from malaria, researchers Pedro Alonso and Joe Campo explain to us they research project they’re working on, known as project Mal055, which aims to find a vaccine to malaria: http://www.xplorehealth.eu/en/media/shelter-malaria

At the moment, they’ve found a vaccine which only appears to protect around half of the children to which it is given; this is why it’s vital to understand the mechanisms the immune system has which are involved in protection.

a) Now go to the presentation of the virtual experiment entitled Investigate a malaria vaccine

http://www.xplorehealth.eu/en/media/investigate-malaria-vaccine

and then summarise what you’ve learnt about the immune system in the following table:

NAME DRAWING WHAT THEY DO TO INFECTIOUS AGENTS

B cells(plasma cells)

T cells

Macrophages

B cells(memory B cells)

Click on this link to find out about three more components of the immune system and then complete the table:

http://www.nobelprize.org/educational/medicine/immunity/immune-detail.html

GranulocytesDendritic cells

The complement system

b) Analyse the information in the tables and explain which elements are activated when the malaria parasite infects a person and what tools the immune system has to defend itself against infection.

c) In the case of malaria, researchers have discovered that children that have been infected several times develop a certain degree of resistance to re-infection. Choose 5 different substances for developing a vaccine and explain why you have chosen these specific substances.

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d) Before continuing with the virtual experiment, remember that each B cell can only produce one single type of antibody. The protein from the parasite which acts as an antigen specifically recognises these antibodies. When the two come into contact, clonal selection of the antibodies is triggered and only the cells which produce the specific antibody reproduce.

http://www.nature.com/nature/journal/v421/n6921/fig_tab/nature01409_F1.html

You can find out more about the process of clonal selection in the following video:

http://www.wehi.edu.au/education/wehitv/the_immune_system/

If you’re asking yourself why there are so many different antibodies, remember that the “cutting and pasting” gene fragments process is key - this is splicing, which can produce different proteins from the same gene. How many different antibodies can be made from one gene? You’ll find the answer here:

http://bcs.whfreeman.com/thelifewire/content/chp18/1802005.html

e) Now continue with the experiment:

http://www.xplorehealth.eu/en/media/investigate-malaria-vaccine

i. What do the coloured beads represent? ii. Why is it so important to collect samples from all the continents?

iii. Why don’t all of the blood samples contain specific antibodies against the candidate proteins?

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-f) Let’s now analyse the results:

- a positive result indicates that the antibody is present and that the person has come into contact with the protein.- a negative result indicates that the person has not come into contact with the protein.

g) Which of the 5 proteins is the best “candidate” to be used in the vaccine? Why?

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h) Design an experiment which will help develop the vaccine. Afterwards, record a video explaining what your goals were. Here is an example of the kind of things you might want to explain:

http://www.isglobal.org/ca/web/guest/video/-/asset_publisher/fXC2c747BWmd/content/gemma-moncunill-malaria-immunology

GROUP 3: TREATING THE DISEASE In this video by Médecins Sans Frontières (Doctors Without Borders), you’ll see two different types of medicine currently used to treat malaria:

http://www.msf.es/multimedia/videos/2013/esperando-cosecha-lucha-contra-desnutricion-malaria-en-niger

Coartem, which is given to people who are ill (for information on its composition, visit http://www.rxlist.com/coartem-drug.htm ) .

Preventive medicines which might have chloroquine and proguanil as their active ingredient.

None of the active ingredients is effective against all of the malaria infection cycle, so drugs often need to be mixed.a) Fill out the following table to summarise what you learn:

Active ingredient

Phases of the cycle which it affects: SPOROZOITE-

HYPNOZOITE* -MEROZOITE-

GAMETOCYTE

Plasmodia it has been effective

against

Plasmodia which has generated resistance

Quinine or derivatives

ChloroquineProguanil

ArtemisininPyrimethamine

HYPNOZOITE*: medical term used to designate the latent or dormant stage of the sporozoite.

(Image courtesy of the Medical Arts and Photography Branch, NIH) http://history.nih.gov/exhibits/bowman/SSmalaria.htm

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b) Draw up a report to present to a commission where you will evaluate the use of the different therapies available in:o Children and pregnant women (making sure you answer the question posed by Dr.

Azucena Bardají at the end of the video entitled Facing an underestimated malaria: http://www.xplorehealth.eu/en/media/facing-underestimated-malaria).

o Countries where the parasite has developed resistance to chloroquine or other active ingredients.

o Endemic regions where there is a seasonal increase in infections.o Temporary visitors to regions where the disease is endemic.

c) Evaluate the advantages and disadvantages of going back to using DDT to help fight malaria. To help you, have a look at this timeline:

http://www.nature.com/news/specials/malaria/timeline.html

d) A new way of delivering drugs is to encapsulate them in nanoparticles. This is a whole new strategy for selectively delivering drugs to Plasmodium-infected red blood cells. Read the following study

http://www.ncbi.nlm.nih.gov/pubmed/24412735

and discuss the advantages and disadvantages compared with traditional pharmaceutical treatments.

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C. What can we do to control malaria?The third activity in this training programme is to get you to participate in the decision-making process when it comes to helping an African village affected by malaria try to reduce the number of new infections and control the disease. We invite you to play the game entitled STOP MALARIA.You can play the game as a group, but don’t forget that you’ll need to note down the following data in a report:

1. the diagnosis and treatment measures you’ve applied;2. the education and prevention measures you’ve applied;3. the advantages and/or disadvantages of research.

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D. Debate With everything you’ve learnt from the different activities, the organisers of the training programme now believe you’re in a position to hold a debate and to try and make a well-informed decision regarding the positions we looked at right back at the beginning of the programme. Let us remind you that each of the five members of the group now needs to take on one of the different positions and defend it (whether they agree with it or not):

Position 1: distribute the reduction in investment proportionally across all of the different fields of activity: prevention, treatment and diagnosis, programmes and research.

Position 2: reduce investment in prevention, programmes and research but keep the same budget for treatment and diagnosis.

Position 3: reduce the money spent on diagnosis and programmes and research but keep the same budget for prevention.

Position 4: spend less on prevention, treatment, diagnosis and programmes, but keep the same budget for research.

Position 5: make reductions across all areas (prevention, treatment and diagnosis, programmes and research), but make the cutbacks according to the level of poverty in the region.

Once you’ve finished the activity, you’ll be expected to complete the report you started on the list of measures for diagnosis and treatment, education and prevention and research in the previous activity.

It’s now time to end the role playing. After everything you’ve looked at in this training programme, we believe you’re ready to come to a joint decision. Put forward all of the arguments for and against each position on the board and decide as a group which is the best option.

Once you’ve come to a decision, back it up with reasons why you think this is the best choice.

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E. Share your position

To finish off the programme, we invite you to come up with a digital poster which will be used to show the following points:

education and prevention measures; diagnosis and treatment measures; the importance of research; the position you have chosen from the list of 5, and what your main arguments were

for your choice.

Good luck! And keep working hard - you’ve nearly finished!

Don’t forget to share the link to your poster with your teacher. You’ll need to forward the link before your group makes a short presentation explaining your decision in front of the other members of your class.

And now we only ask you to do one more small thing for us: share your conclusions on the following blog and on different social media. Don’t forget to refer to the different bodies which have helped you find information (such as ISGlobal) when you publish on social media sites. You’ll be helping to contribute to the current discussion on how to fight against the disease while also raising social awareness of the need to dedicate resources to trying to eradicate malaria. If you want, you can also link to the digital posters you made.

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BRIEF TEACHING FOCUSThis student work document proposes a series of teaching topics aimed at discovering more about the scientific, ethical, legal and social aspects related to malaria.

It is meant to be an open proposal which can be used in full, or concentrating on just some of the sections:

A. An introduction to the disease’s biology (cycle of infection, treatment and preventive measures, development of an effective vaccine against the disease and current initiatives aimed at eradicating malaria).

B. An analysis of how the immune system behaves as a result of the disease. Research on developing a vaccine.

C. A simulation of different measures which need to be taken in an invented village in Africa in the form of a virtual game.

D. A debate on the strategies we need to adopt in the future to continue the fight against malaria.

E. Publishing a consensual strategic action plan as a digital poster and on a blog and social networks.

We hope the tasks we ask you to carry out are useful!

Good luck!

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TABLE OF CONTENTS

Level Areas Blocks Content Class hours

3rd year of secondary

schoolBiology and geology

Health and disease.

Coordination in the body.

A. Introduction to the disease’s biology.B. Malaria and the immune systemC. What can we do to control malaria?D. DebateE. Share your position

3 hours2 hours1 hour2 hours1 hour

5th and 6th

year of secondary

school

Science Health and medical investigation.

A. Introduction to the disease’s biology.C. What can we do to control malaria?D. DebateE. Share your position

2 hours1 hour2 hours1 hour

Biology 6th year of secondary school

Microorganisms and infectious diseases.

The function of the immune system.

A. Introduction to the disease’s biology.B. Malaria and the immune system

2 hours3 hours

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Authors: Àlex López-Duran López (Escola Garbí - Esplugues de Llobregat), Maria Àngels Vich Homs (SEK educational institute), Lluís Pagès Pons (3rd and 4th year, and 5th and 6th year of secondary school teacher of biology and geology), Montse Colilles (INS Can Puig de Sant Pere de Ribes), Fran Guerola (INS Verdaguer de Barcelona), Rosa M. Marín Bosquet (Institut Joan Pelegrí), Alfons López Gutiérrez (Escola St. Lluís Gonçaga, La Garriga), Sílvia Lope and Montse Cabello (CSIRE-CDEC) and Rosina Malagrida (Xplore Health coordinator).