Professor Sir Richard Feachem

Director

The Global Health Group

University of California, San Francisco

Malaria Elimination in the Asia Pacific by 2030

Development Policy Centre

Crawford School of Public Policy

Australian National University November 25, 2014

• British officer in the Indian Medical Service

• Poet, scientist, mathematician, novelist, painter and musician

• 1897, India: Ross discovered the role of mosquitoes in transmission of malaria in humans while dissecting the stomach tissue of an anopheline mosquito that fed on a patient with malaria

• 1902: Awarded the second Nobel Prize for Medicine for his work on malaria

Sir Ronald Ross

• Malaria Control: reducing disease burden to a level where it is no longer a major public health problem

• Elimination: interrupting local mosquito-borne malaria transmission in a defined geographical area, i.e. zero incidence of locally acquired cases

• Eradication: permanent reduction to zero of the worldwide incidence of infection

Definitions

Sporozoite

Host’s liver

Anopheles gambiae

Fertilization

Sporozoite

Male gamete

Female gamete

Liver cell

Merozoites

Male

gametocyte

The Disease

The rupture of infected blood cells

causes malaria’s fever, chills and

progressive anemia. Death may

occur from severe anemia as well

as clogging of blood vessels in the

brain, lungs and other organs by

parasitized red blood cells. In

pregnancy, malaria-laden placentas

rob babies of growth before they

are even born.

Female

gametocyte

MALARIA PARASITE

needs both humans and mosquitoes

to propagate itself. This complex life

cycle has hindered efforts to engineer

a vaccine that can crush the parasite.

Current vaccine research strategies

focus on three stages of the parasite’s

life cycle (a, b and c), two in the

human and one in the mosquito.

How Malaria Spreads

Host’s red blood cells

Oocyst

a

c

b

Female Anopheles freeborni mosquito having a blood meal

1900

Malaria Transmission By Country

Wallace Line

Buxton Line

No malaria transmission

Malaria transmission

Progress Towards Elimination by Country

Seychelles

Comoros

Mauritius

Reunion

Cape Verde

Maldives Sao Tome & Principe

Solomon Islands

Vanuatu

No malaria

Malaria control

Malaria elimination

2014

2050 No malaria

The Endgame

The Eradication Strategy

1. Aggressive control in the heartland, to achieve very low transmission and zero mortality where possible;

2. Progressive elimination from the endemic margins to shrink the malaria map; and

3. Research to bring forward a vaccine and better drugs, diagnostics, and other tools

Secretariat:

Asia Pacific Malaria Elimination Network (APMEN)

• Launched 2009

• 30 partner institutions

• Country-led, country-driven

• Information-sharing, capacity

building, evidence gathering and

advocacy

• Focus on P. vivax

• Australian core funding

• Annual meetings:

Brisbane, Kandy, Kota Kinabalu,

Seoul, Bali, Manila, Hoi An

16 member countries

APMEN Malaria Elimination Goals N

ation

al

Su

b-N

atio

na

l

Sri Lanka (2014) Republic of Korea

(2017)

Taffeta Province,

Vanuatu (2014) Peninsular Malaysia

(2015) Isabel & Tempt

Provinces,

Solomon Islands

(2020)

Bhutan (2018)

China (2020)

Philippines

(2030) Vanuatu (2025)

Indonesia: 26 out of 34

Provinces (2020)

Peninsular and Borneo

Malaysia (2020)

80% of Thailand

malaria-free (2020)

Cambodia: Pf

elimination (2020)

Indonesia

(2030)

Vietnam (2030)

Cambodia (2025)

Solomon Islands

(2035)

Thailand (2030)

Nepal (2026)

Na

tio

na

l

Endemicity District/City Population

Free 128 133 M

Low < 1% 204 28 M

Moderate 1-5% 85 73 M

High > 5% 84 16 M

Malaria in Indonesia, 2012

M

M

M

M

Endemicity District/City Population

Free 128 133 M

Low < 1 ‰ 204 28 M

Moderate 1-5 ‰ 85 73 M

High > 5 ‰ 84 16 M

Five provinces selected

Papaya

Laguna

Banquet

Cavite

2005 2011

Malaria in the Philippines, 2005-2011

Malaria Elimination in China, 2011

≥1/10,000/yr 40 million

<1/10,000/yr 448 million

Malaria-free 3 yrs 623 million

Malaria-free always 189 million

Goal 2015:

Eliminate everywhere except

border counties in Yunnan and

Tibet.

Goal 2020:

Eliminate malaria in all China.

Malaria in Sri Lanka, 1911-2013

6.0

3.0

2.0

1.0

0.0

1911 First Anti Malaria Centre set up at

Kurunegala

1913 Incrimination of Anopheles culicifacies as primary vector

1921 Appointment

of first malariologist

1934/35 Devastating malaria

epidemic

1946 Introduction

of DDT

1958 Malaria eradication

programme launched

1963 Eradication nearly

achieved

1967/68 Resurgence of malaria leading

to a countrywide epidemic

1969 DDT resistance in

An. culicifacies first detected

1975 Introduction of malathion

1984 Chloroquine-

resistant Pf first

detected

1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

1989 Activities of the AMC

decentralized

1992/93 Widespread malathion resistance

in An. culicifacies first detected

1994 Introduction of

lambda-cyhalothrin

1997 WB project commenced

1999 RBM launched

2003 GFATM project launched

2007 ACT introduced

6.0

3.0

2.0

1.0

0.0

1911

2009 Elimination programme launched

2012 Last

indigenous case

Total Cases

(Millions)

264,549

210,039

66,522

41,411

10,510 3,720 1,640 591 198 672 558 736 175 93 95

0

50,000

100,000

150,000

200,000

250,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Total cases

2003 GFATM project

launched

2007 ACT

introduced

2009 Elimination

programme launched 2012 Last indigenous case reported

1999 RBM launched

1999-2013

1999 2001 2003 2005 2010 2012 2013

Shrinking the malaria map in Sri Lanka 1999-2013

The Changing Face of Malaria: Sri Lanka

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Pro

po

rtio

n o

f to

tal

an

nu

al c

on

firm

ed

in

fec

tio

ns

% P. vivax % Adults (> 15 years) % Male % Imported

76%

88%

95%

59%

54% 54%

54%

77%

60%

95%

93%

90%

71%

55%

100%

94%

84%

18

Let History NOT Repeat Itself

Graph Courtesy of Sri Lanka Anti-Malaria Campaign, 2014

Sri Lanka:

Imported Cases by Nationality, 2013

Pacific Malaria Initiative

Solomon

Islands

Vanuatu

0

500

1000

1500

2000

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

Nu

mb

er o

f ca

ses

Total microscopy confirmed Malaria cases in Isabel Province 2000-2011 (June)

21

East Asia Summit Statement 14 November 2014, Nay Pyi Taw

19. We reiterated our commitment to the Declaration of the 7th East

Asia Summit on Regional Responses to Malaria Control and Addressing

Resistance to Anti-malaria Medicines. We welcomed the Asia Pacific

Leaders Malaria Alliance (APLMA) Task Force Progress Report 2014

and agreed to the goal of an Asia Pacific free of Malaria by 2030. We

tasked the APLMA co-chairs to submit to the 10th EAS in Malaysia a

plan for achieving this goal and to implement the recommendations of

the APLMA Task Forces.

Monkey Business

Monkey Business in Sabah

Source: William et al. Malaria Journal 2014, 13:390

Percentage of total malaria notifications, 2004–2013.

1. Political Commitment

– ALMA??

– APLMA??

– Dengue! Ebola!

2. Finance

– “No malaria, cut the budget!”

– Global Fund

– Measles logic

3. Management

– Generally weak

– Sine Qua Non

4. Reengineering

– Easiest because technical

– Most likely to happen

24

The Challenges Now for Elimination

• At least 20 countries

• Dependent on the big

four

– Political Commitment

– Finance

– Management

– Reengineering

25

Elimination Between Now and 2020

Swaziland

Botswana

Sri Lanka

Rep. of Korea

Bhutan

Turkey

Saudi Arabia

Iran

Azerbaijan

Tajikistan Uzbekistan

Kyrgyzstan

Cape Verde

Argentina

Paraguay

Algeria

Costa Rica El Salvador

Belize

Mayotte

• 80 countries

• Dependent on the big four

26

Elimination After 2020

Science / Discovery +

2050 No malaria

The Need to Commit

2040 No malaria

Malaria elimination

The Need to Commit

Johann Wolfgang von Goethe (1749-1842)

Faust, 1835

“Whatever you can do, or

dream you can do, begin it.

Boldness has genius,

power and magic in it.”

“Until one is committed, there is

hesitancy, the chance to draw back,

always ineffectiveness. The moment

one definitely commits oneself,

providence moves too. A whole stream

of events issues from the decision,

raising in one’s favor all manner of

unforeseen incidents, meetings, and

material assistance, which no man

could have dreamt would have come

his way.”

W. H. Murray, OBE (1913-1996)

The Scottish Himalayan Expedition,1951 The Granite Ridge of Dungaree Peak

(16,690 feet)

Courtesy of Dr. Hugh Sturrock