Malaria Eradication: Back to the Future


Uploaded by CDCStreamingHealth on 22.11.2010

Transcript:
GOOD AFTERNOON EVERYBODY, IT'S ONE O'CLOCK
AND THIS IS OUR NEW TIME. SO PLEASE, I HOPE
YOU CAN GET USE TO IT.
THIS IS AT THE REQUEST OF A LOT OF COLLEAGUES ON THE WEST
COAST WHO WERE NOT ABLE TO JOIN US AT 9:00 IN THE MORNING.
I'M TANJA POPOVIC, DIRECTOR OF THE GRAND ROUNDS.
I'M REALLY DELIGHTED TO SEE SO MANY OF YOU STILL IN PERSON.
I WOULD ALSO LIKE TO WELCOME THOSE WHO ARE WATCHING US ON
ICTV OR VIA INTERNET.
YOU CAN SEE THAT THE GROUND ROUNDS ARE PROMINENTLY DISPLAYED
ON OUR DIRECTOR'S WEBPAGE.
THIS ONE SHOT HAS BEEN CLIPPED FROM THIS MORNING.
SO WE'RE ALWAYS ON HIS WEBPAGE.
WE WOULD LIKE TO WELCOME MANY, MANY MORE PEOPLE WHO ARE
WATCHING US LIVE THROUGH OUR INTERNET.
AS YOU DO KNOW, THIS IS A CONTINUING EDUCATION ELIGIBLE
EVENT AND SO IF YOU GO TO THE WEBPAGE BELOW, YOU CAN REGISTER
AND THEN, AGAIN, CHECK THE MONTH, THE DATE AND FOLLOWING
THE COMPLETION OF THE EVENT YOU CAN SIGN UP AND SUBMIT FOR YOUR
CREDIT.
WE ACTUALLY HAVE BEEN TOLD BY THE OFFICE WHO DOES TRAINING AND
CONTINUING EDUCATION THAT THEY ARE GETTING A LOT MORE REQUESTS
FOR CONTINUING EDUCATION THAT IS ASSOCIATED WITH OUR EVENTS AS
WELL.
THE OTHER THING THAT I DO WANT TO POINT OUT IS THAT WE ARE
COORDINATING THESE EVENTS WITH OUR WEEKLY ISSUES OF SCIENCE
CLIPS SO YOU WILL SEE THAT THIS MONTH WE HAVE A NUMBER OF
MALARIA FOCUSED MANUSCRIPTS FEATURED IN OUR SCIENCE CLIPS.
ONE OF THE THINGS THAT I DO WANT TO POINT OUT IS THAT WE HAVE
CONTINUED TO HAVE LARGE NUMBER OF EXTERNAL VIEWERS AND IN SOME
CASES, ACTUALLY, WE HAVE THE NUMBERS GO THROUGH THE ROOF AS
WAS THE -- OUR CHLAMYDIA SESSION THIS PAST JUNE.
THIS STILL HOLDS THE BIGGEST NUMBER OF VIEWERS, ALMOST 25,000
EXTERNAL VIEWERS THAT DAY.
AS YOU MAY KNOW, WE ARE NOW ON YOUTUBE AND THERE'S A LOT OF
INTERESTING THINGS GOING ON THESE DAYS ON YOUTUBE, BUT I
DON'T WANT TO TALK ABOUT BEING RADIOGRAPHED AND CHECKED WHEN I
GO THROUGH THE ATLANTA AIRPORT.
THAT WOULD PROBABLY GET A LOT MORE VIEWERS THAN THIS, BUT
STILL YOU WILL SEE THAT EACH ONE OF OUR SESSIONS HAS GOTTEN MORE
THAN 1,000 PEOPLE WATCHING US ON YOUTUBE AS WELL.
FINALLY, WHEN YOU COMBINE EVERYTHING, VIDEOS, LIVE,
DOWNLOADS, OVER 168,000 VIEWS, ATTENDANCES OR HOVER YOU SS OR
HOW FAR SS OR HOWEVER YOU WANT TO CALL THEM.
I FEEL GOOD ABOUT IT AND OUR SPEAKERS APPRECIATE THIS LEVEL
OF EXPOSURE.
TODAY WE ARE GOING TO BE TALKING ABOUT MALARIA ERADICATION.
WE HAVE AN OUTSTANDING GROUP OF EXPERTS AND SPEAKERS HERE.
LARRY SLUTSKER WHO IS GOING TO BE TALKING ABOUT CHALLENGES IN
THE PAST, CHALLENGES TODAY AND THOSE THAT ARE AWAITING US IN
THE FUTURE IF WE WANT TO ELIMINATE AND ULTIMATELY
ERADICATE MALARIA.
JOHN MacARTHUR WILL TALK ABOUT WHAT IS IT THAT IS NECESSARY FOR
THE FIRST STEPS TOWARDS ELIMINATION.
PATRICK KACHUR WHO WILL TALK ABOUT SCIENTIFIC EVIDENCE THE
CDC HAS PROVIDED TO SUPPORT AND POSITION THE WORLD FOR
ELIMINATION OF MALARIA, AND THEN RICHARD STEKETEE.
I DO WANT TO BRING TO YOUR ATTENTION AND I KNOW JUDY
SITTING HERE IN THE AUDIENCE IS DELIGHTED THAT THERE WILL BE AN
EXHIBITION COMING TO CDC AND WILL BE WITH US FOR SEVERAL
MONTHS FOCUSED ON MALARIA, CALLED MALARIA: BLOOD, SWEAT AND
TEARS.
I WOULD LIKE TO SHARE WITH YOU A FEW PHOTOGRAPHS THAT ARE GOING
TO BE PART OF THAT EVENT THAT I THINK ARE EXTREMELY TELLING OF
THE MALARIA STORY.
THINGS ARE NOT ENTIRELY GLOOMY.
AS YOU WILL HEAR FROM OUR SPEAKERS THERE IS SOME OPTIMISM
AS WELL AND THERE ARE TOOLS THAT PEOPLE ARE USING AGAINST THIS
DISEASE.
AND THIS IS ONE OF THE EXAMPLES.
YOU WILL CERTAINLY HEAR ABOUT THAT OVER AND OVER AND OVER.
AND YOU WILL SEE FROM THIS LITTLE CLIP HOW IMPORTANT AND
PRECIOUS THOSE THINGS ARE IN THE LIVES OF PEOPLE WHOSE HEALTH
THEY PROTECT.
THESE ARE THE FOUR MUSKETEERS THAT ARE GOING TO TALK ABOUT
THEIR OWN EXPERIENCES IN FIGHT AGAINST MALARIA.
AND WHO I THINK WILL LEAVE YOU FEELING BETTER ABOUT WHAT IT IS
THAT CDC AND THE GLOBAL COMMUNITY CAN DO TO ELIMINATE
AND ERADICATE THIS DISEASE.
AND WITH THAT, I AM GOING TO ASK THAT WE PUT A VERY BRIEF TAPE OF
DR. FRIEDEN WHO HAS TAPED HIS COMMENTS, AND THEN WE'LL MOVE ON
TO OUR FEATURED SPEAKERS.
>> MALARIA WILL KILL NEARLY A MILLION PEOPLE THIS YEAR AND
ALMOST ALL OF THESE DEATHS COULD BE PREVENTED WITH CURRENTLY
AVAILABLE, RELATIVELY INEXPENSIVE TOOLS.
TO MAKE PROGRESS IN MALARIA PREVENTION AND CONTROL, WE NEED
TO BETTER APPLY AND PROTECT THE TOOLS WE HAVE TODAY.
AND WE NEED TO DEVELOP NEW TOOLS FOR TOMORROW.
WE NEED TO OPTIMIZE INDOOR PROTECTION WITH BED NETS, DRIVE
DOWN MOSQUITO POPULATIONS WITH INDOOR RESIDUAL SPRAYING AND
SAVE LIVES THROUGH ACCURATE DIAGNOSIS AND EFFECTIVE
TREATMENT.
WE ALSO NEED TO PROTECT AGAINST AND DEVELOP NEW TOOLS TO COMBAT
RESISTANT BY BOTH MOSQUITOES AND MALARIA PARASITES.
DEVELOPMENT OF NEW TOOLS COULD ENABLE FURT ARE AND MORE
SUSTAINED PROGRESS.
BUT THE CURRENT CHALLENGE IS TO SCALE UP AND PRESERVE THESE
TOOLS AND TO PERSEVERE WITH GOOD MANAGEMENT FOR AS LONG AS IS
NEEDED TO SAVE LIVES EITHER UNTIL MALARIA IS UNDER LONG-TERM
CONTROL OR NEW TOOLS BECOME AVAILABLE TO ENABLE ELIMINATION
AND ULTIMATELY ERADICATION.
I'M SURE THAT YOU'LL FIND TODAY'S PUBLIC HEALTH GRAND
ROUNDS ON MALARIA THOUGHT PROVOKING, INTERESTING AND
IMPORTANT.
THANK YOU.
>> MY INTRODUCTION.
THANK YOU.
I'VE GOT THE HONOR OF INTRODUCING THE TOPIC TODAY.
AND SORT OF SETTING THE SCENE.
I'M GOING TO START OFF BY BRIEFLY REVIEWING MALARIA
BASICS.
AND THEN WE'LL REVIEW THE FIRST PUSH FOR MALARIA ERADICATION.
I'LL THEN TOUCH ON HOW MALARIA CONTROL WORSENED IN THE 1990s
AND CONCLUDE WITH AN INTRODUCTION TO PROMISING
DEVELOPMENTS OVER THE PAST DECADE THAT HAVE REAWAKENED
INTEREST IN MALARIA ERADICATION.
SO ALTHOUGH MALARIA HAS BEEN RECOGNIZED FOR CENTURIES AS A
DISTINCT DISEASE ENTITY THE CAUSE WAS OFTEN ATTRIBUTED TO
ENVIRONMENTAL SOURCES SUCH AS EXPOSURES TO MIASMAS FOR BAD
HAIR AIRS.
IT WAS ONLY A YEAR AGO WHERE THIS TRIO ELUS KATED THE BIOLOGY
INCLUDING THE PRESENCE OF PARASITES IN THE BLOOD,
TRANSMISSION BY MOSQUITOES AND THE COMPLETE
MOSQUITO-MAN-MOSQUITO LIFE CYCLE.
MALARIA IS CALLED BY A PARASITE OF THE GENUS PLASMODIUM.
HUMAN MALARIA IS CAUSED BY FOUR MAJOR SPECIES.
VALSIRARUM EXACTS THE BIGGEST TOLL ALTHOUGH PEOPLE ARE AT RISK
OF BOTH.
FALCIPARUM MAY BE FATAL IN 10 TO 20% OF CASES IN NONIMMUNE
PERSONS.
EITHER FATAL SEVERE ANEMIA OR BECAUSE OF SEIZURES AND COMA.
FALCIPARUM IS ALSO THE SPECIES IN WHICH THE ANTI-MALARIALS HAS
APPEARED IN THE PAST 50 YEARS.
WORLDWIDE, ABOUT 50 ANOPHELESAN SPECIES HAS DISTINCT NICHES.
BREEDING SITES CAN INCLUDE SALT OR FRESH WATER AND MAY BE SMALL,
TEMPORARY OR LARGER BODIES OF WATER.
THE MAJOR AFRICAN VECTORS BITE INDOORS AND AT NIGHT BUT OTHER
SPECIES MAY BITE OR REST OUTDOORS.
THESE CHARACTERISTICS AFFECT VECTOR TRANSMISSION EFFICIENCY
AS WELL AS SUSCEPTIBILITY TO VARIOUS CONTROL MEASURES SUCH AS
SPRAYING HOUSES OR USING INSECTICIDE TREATED BED NETS.
FALCIPARUM MALARIA IS ONE OF THE LEADING GLOBAL CHILD KILLERS.
IN 2008 IT CAUSED AN ESTIMATED 250 MILLION CLINICAL CASES WITH
OVER 80% OCCURRING IN AFRICA, MOSTLY IN CHILDREN UNDER FIVE.
IN PREGNANCY PLA SENTAL INFECTION INCREASES THE RISK OF
LOW BIRTH WEIGHT AND SUBSEQUENT INFANT MORTALITY OF THE DEATHS
EACH YEAR MORE THAN 90% OCCUR IN AFRICA AND THE BURDEN INCLUDES
DISABILITY FOLLOWING SEVERE DISEASE AND ECONOMIC LOSSES THAT
ARE ESTIMATED AT OVER 1% OF GDP ANNUALLY IN SUB-SAHARAN AFRICA.
HERE WE SEE THE SPATIAL DISTRIBUTION AND INTENSITY OF
FALCIPARUM MALARIA.
THE DARKER AREAS IN CENTRAL AFRICA CORRESPOND TO THE MOST
INTENSE TRANSMISSION WHERE THE AVERAGE PREVALENCE OF INFECTION
IS MORE THAN 40% IN CHILDREN UNDER TEN.
IN SOME OF THESE AREAS RESIDENTS MAY RECEIVE MORE THAN ONE
INFECTIOUS BITE EVERY DAY OF THE YEAR.
THERE WERE A NUMBER OF EVENTS THAT INFLUENCED THE DECISION TO
LAUNCH THE MA LARA ERADICATION CAMPAIGN.
THERE WERE EARLY SUCCESSES IN MOSQUITO CONTROL INCLUDING
IMPRESSIVE REDUCTIONS IN MALARIA IN THE PANAMA CANAL.
CHLOROQUINE AND DTT BECAME AVAILABLE AT THE END OF WORLD
WAR II AND ACCURATE DIAGNOSIS WAS AVAILABLE WITH RELATIVELY
SIMPLE AND CHEAP MICROSCOPY.
WITH THESE TOOLS CONFIDENCE SWELLED AND ENTHUSIASM FOR
ERADICATION GREWP IN 1955 W.H.O.
LAUNCHED THE GLOBAL ERADICATION CAMPAIGN.
THE KEY STRATEGY RELIED ON USING THE MAGIC BULLET DDT TO REDUCE
AND HOPEFULLY INTERRUPT TRANSMISSION.
THE UNDERLYING ASSUMPTIONS WERE THAT PEOPLE STAY INDOORS AT
NIGHT AND ANOPHELES WOULD FEED ON RESTING PERSONS THEN REST ON
THE WALLS WHERE THEY RECEIVE A TOXIC DOSE OF DDT.
OTHER MAJOR ACTIVITIES INCLUDED ANTI-MALARIAL DRUG TREATMENT FOR
PATIENTS OR OCCASIONALLY AS MASS DRUG ADMINISTRATION TO RAPIDLY
REDUCE INFECTIOUS BURDEN.
SURVEILLANCE WAS CONDUCTED FOR CLINICAL CASES AND THROUGH MASS
BLOOD SURVEYS TO DETERMINE ASYMPTOMATICCALLY INFECTED
PERSONS.
THOUGH WE KNOW THE ERADICATION FAILED OVERALL.
THERE WERE SOME SUCCESSES.
37 OF THE COUNTRIES THAT WERE ENDEMIC IN 1950 WERE FREE FROM
MALARIA BY 1978.
IN MANY COUNTRIES MAJOR GAINS WERE MADE IN DECREASING THE
BURDENS OF DISEASE AND DEBT.
IN THE U.S., MALARIA CONTROL WAS ESTABLISHED IN THE EARLY 1940s
THROUGH THE MALARIA CONTROL IN WAR AREAS PROGRAM WHICH
SUBSEQUENTLY BECAME CDC.
IN 1951 MALARIA WAS CONSIDERED AS ELIMINATED IN THE U.S.
OVERALL, THOUGH, OF COURSE, THE CAMPAIGN HAD SERIOUS PROBLEMS.
THESE RANGE FROM TECHNICAL SETBACKS SUCH AS DEVELOPMENT OF
RESISTANCE IN MOSQUITOES TO DDT AND PARASITES TO CHLOROQUINE.
SO STRATEGIC ISSUES WITH A RIGID INFLEXIBLE PROGRAM THAT RESULTED
IN SLOW RESPONSES TO PROBLEMS AND A LACK OF RESEARCH TO FIND
SOLUTIONS.
AFRICA WAS LEFT OW, MEANUT, MEANING
THERE WAS NEVER REAL HOPE OF GLOBAL ERADICATION.
THE MILITARY STYLE CAMPAIGN DID NOT BUILD COMMUNITY BYEUY-IN,
LEADING TO DECREASING COOPERATION WITH THE PROGRAM
INCLUDING ALLOWING ACCESS TO HOMES FOR SPRAYING.
IN 1969, THE WORLD HEALTH ASSEMBLY ACKNOWLEDGED THE
FAILURE OF THE CAMPAIGN AND SUSPENDED IT INDEFINITELY.
THE GOAL SHIFTED TO CONTROL TO MINIMIZE THE HEALTH DAMAGE BY
MALARIA.
THE LESS AMBITIOUS, THE NEW STRATEGY WAS MORE FLEXIBLE AS IT
EMPHASIZED CONTROL ADAPTED TO LOCAL CONDITIONS.
THERE WAS A PROGRAMMATIC SHIFT AWAY FROM DDT AND A RELIANCE ON
TREATMENT AS THE MAJOR INTERVENTION INTEGRATED INTO THE
PRIMARY HEALTH CARE PACKAGE.
IN THE LATE '80s AND EARLY '90s, THE MALARIA SITUATION IN
SUB-SAHARAN AFRICAN WORSENED.
DECREASED FUNDING LED TO POOR ACCESS TO TREATMENT.
PARASITE RESISTANCE TO CHLOROQUINE EMERGED IN SOUTHEAST
ASIA IN THE LATE 1950s AND SPREAD ACROSS SOUTH ASIA AND
INTO AFRICA BY THE LATE 1970s.
DESPITE WORSENING RESISTANCE WITH TREATMENT FAILURE RATES
EXCEEDING 50% IN EAST AFRICA IN THE 1990s, CHLOROQUINE REMAINED
THE MAINSTAY OF THERAPY RESULTING IN HUNDREDS OF
THOUSANDS OF EXCESS CHILD DEATHS.
DURING THIS PERIOD, APPROXIMATELY 30% OF CHILDHOOD
DEATHS IN SUB-SAHARAN AFRICA WERE ATTRIBUTED TO MALARIA.
AGAINST THE SOMEWHAT GRIM BACKGROUND, NEW DEVELOPMENTS AT
THE TURN OF THE MILLENNIUM GIVE RISE TO OPTIMISM.
NEW GLOBAL PARTNERSHIPS TO CREATE WORK WERE ESTABLISHED AND
FUNDING FOR PROGRAM SCALE UP BECAME AVAILABLE.
ENDEMIC COUNTRY LEADERS PRIORITIZED AND COMMITTED TO
CONTROL.
BETTER TOOLS BECAME AVAILABLE INCLUDING NEW DRUGS FOR
TREATMENT AND INSECTICIDE TREATED NETS FOR PREVENTION.
I'D LIKE TO NOW TURN TO JOHN MacARTHUR, WHO WILL TELL THE
NEXT PART OF THE STORY.
>> THANK YOU, LARRY.
MY NAME IS JOHN MacARTHUR.
I'M THE CHIEF OF THE PROGRAM IMPLEMENTATION UNIT, CDC'S
MALARIA BRANCH.
TODAY I'LL PROVIDE AN OVERVIEW TO KEY GLOBAL FRAMEWORKS USED IN
MALARIA CONTROL.
AND HOW THE PRESIDENT'S MALARIA INITIATIVE HAS SUPPORTED THESE
FRAMEWORKS UNDER TWO PRESIDENTS.
FINALLY I WILL PRESENT SOME RESULTS THAT MALARIA CONTROL
PROGRAMS HAVE ACHIEVED IN AFRICAN COUNTRIES.
THE ROLLBACK MALARIA PARTNERSHIP WAS LAUNCHED IN 1998 BY WHO,
UNICEF AND THE WORLD BANK IN AB EFFORT TO PROVIDE COORDINATED
RESPONSE TO MALARIA.
THE PARTNERSHIP IS A GLOBAL FRAMEWORK THAT AIMS TO
COORDINATE ACTIVITIES MOBILIZE RESOURCES AND FORGE CONSENSUS
AMONG PARTNERS THROUGH THE ESTABLISHMENT OF WORKING GROUPS
AND SUB REGIONAL NETWORKS.
TO ASSIST IN BUILDING CONSENSUS, DEVELOPED THE GLOBAL MALARIA
ACTION PLAN IN 2008 TO REDUCE MORBIDITY AND MORTALITY BY
SCALING UP INTERVENTIONS FOR IMPACT AND SUSTAINING THEM OVER
TIME.
THE U.N. MILLENNIUM DEVELOPMENT GOALS AIM TO REDUCE POVERTY BY
THE ESTABLISHMENT OF DEADLINE OF 2015.
ADEQUATE CONTROL OF MALARIA IS IMPERATIVE IF COUNTRIES ARE TO
REACH THESE GOALS.
RELATED TO THREE OF EIGHT.
GIVE THAN THE GROUPSED A HIGHEST RISK OF DYING ARE CHILDREN AND
PREGNANT WOMEN.
SIGNIFICANT REDUCTIONS IN MALARIA WILL REDUCE CHILD
MORTALITY AND IMPROVE MATERNAL HEALTH.
LASTLY, IT IS DIRECTLY RELATED TO MALARIA CONTROL AND SERVES TO
DRIVE THE PROGRAMS TOWARDS ENSURING THAT EVERY CHILD SLEEPS
UNDER A BED NET AND HAS ACCESS TO APPROPRIATE ANTI-MALARIAL
MEDICINE.
WITH THE ONSET OF RBM AND THE MPGs, INTERNATIONAL
DISBURSEMENTS TO COUNTRIES HAVE DECREASED FROM APPROXIMATELY
$100 MILLION IN 2003 TO NEARLY $1.5 BILLION IN 2009.
THIS INCLUDES LARGE INCREASES BY THE GLOBAL FUND, THE PRESIDENT'S
MALARIA INITIATIVE AND THE WORLD BANK.
IN 2005, PRESIDENT BUSH ANNOUNCED THE LAUNCHING OF THE
PRESIDENT'S MALARIA INITIATIVE.
IT WAS AN AMBITIOUS PLAN TO SCALE UP MALARIA CONTROL AND
PREVENTIONS IN HIGH BURDEN COUNTRY.
THE PRESIDENT PLEDGED $1.2 BILLION OVER FIVE YEARS AND
CHALLENGED OTHER DONOR NATIONS TO INCREASE THEIR FUNDING.
IT IS LED BY USAID AND CO-IMPLEMENTED WITH CDC.
THE GOAL OF THE PLAN WAS BY THE END OF 2011 TO REDUCE MORTALITY
BY 50%.
THIS WOULD BE ACCOMPLISHED BY SCALING UP COVERAGE OF TEE
TARGETS OF PEOPLE LIVING IN ENDEMIC REGIONS OF AFRICAP THE
FOUR KEY INTERVENTIONS ARE RAPID DIAGNOSIS AND PROMPT TREATMENT
WITH ARTEMSININ, PREVENTION USING INSECTICIDE TREATED BED
NETS, THE USE OF SPRAYING IN PLACES WHERE APPROPRIATE AND
PROTECTING PREGNANT WOMEN AND THEIR UNBORN CHILDREN USING
TREATMENT.
THE PLAN BEGAN IN 2006 WITH $30 MILLION INVESTED IN THREE
COUNTRIES.
THE U.S. GOVERNMENT RAPIDLY SCALED UP RESOURCES WHICH
ALLOWED EXPANSION INTO AN ADDITIONAL FOUR COUNTRIES IN
2007 AND REACHING THE TARGETED 15 COUNTRIES IN 2008 WITH THE
FUNDING AVAILABLE DURING THE CURRENT YEAR THE PLEDGED AMOUNT
OF $1.2 BILLION WAS REACHED.
DURING THE PRESIDENT'S CAMPAIGN OF 2008, BARACK OBAMA SIGNALED
HIS SUPPORT FOR ONGOING U.S.
GOVERNMENT EFFORTS IN GLOBAL HEALTH INCLUDING MALARIA.
AFTER HIS ELECTION, THE PRESIDENT LAUNCHED A BOLD NEW
APPROACH.
THE GLOBAL HEALTH INITIATIVE IS A FRAMEWORK THAT THE US USES TO
IMPROVE HELD OUTCOME.
THIS PLAN IS A MAJOR COMPONENT OF THE GLOBAL HEALTH INITIATIVE.
THE 2008 ACT AUTHORIZED UP TO $5 BILLION FOR MALARIA
PREPREVENTION AND CONTROL THROUGH FISCAL YEAR 2013.
CONGRESS INSTRUCTED CDC TO ADVISE THE U.S. MALARIA
COORDINATOR AND BE MONITORING SURVEILLANCE AND OPERATIONS
RESEARCH.
CDC IS FULFILLING HA MANDATE THROUGH COORDINATION WITH
MALARIA INDICATOR AND PROGRAMS THROUGH FIELD AND ATLANTA BASED
STAFF.
THIS MAP HIGHLIGHTS THE ORIGINAL 15 COUNTRIES THAT WERE SLATED
FOR INVESTMENTS.
IF YOU REMEMBER FROM LARRY'S PRESENTATION, THESE REPRESENT
COUNTRIES IN AFRICA WITH SOME OF THE HIGHEST BURDEN OF DISEASE.
WITH THE ADDITIONAL FUNDING MADE AVAILABLE THROUGH THE ACT, THE
PLAN HAS EXPANDED TO NIGHERIA AND
THE DEMOCRATIC REPUBLIC OF CONGO.
HERE ARE SOME SPECIFIC OUTCOMES.
THEY CANNOT BE COMPLETELY ATTRIBUTED TO SUPPORT AS A
RESULT THEY ARE A RESULT OF CUMULATIVE EFFORTS.
SINCE ROUTINE SURVEILLANCE SYSTEMS ARE OFTEN WEEK, THESE
DATA ARE GATHERED THROUGH SURVEYS DONE EVERY YEAR.
THE LIGHT BLUE BARS REPRESENT ITN COVERAGE PREPMI AND THE
LIGHT BLUE BARS ARE DATA COLLECTED AFTER PMI BEGAN
INVESTING IN COUNTRIES.
WE SEE A SIGNIFICANT INCREASE IN THE PROPORTION OF HOUSEHOLDS
WITH AT LEAST ONE BED NET.
WHILE BED NET COVERAGE IS IMPORTANT, IT IS EVEN MORE
IMPORTANT THAT RISK GROUPS UTILIZE THE INTERVENTION.
THESE DATA SHOW THE PROPORTION OF CHILDREN UNDER 5 THAT SLEPT
UNDER A BED NET THE NIGHT BEFORE A SURVEY.
THE TARGET FOR THIS IS 85%.
WHILE ALL COUNTRIES HAVE MADE PROGRESS, NONE HAVE YET REACHED
THE TARGET.
IN ZANZIBAR, PMI SUPPORTS THE PROGRAM'S EFFORTS TO SCALE UP
INTERVENTIONS.
IT IS THE PERCENTAGE COVERAGE OF KEY INTERVENTIONS AND THE
RIGHT-SIDED IS THE PROPORTION AF PATIENTS AND FACILITIES WITH
LABORATORY CONFIRMED MALARIA.
AS THE COVERAGE OF BED NETS AND/OR RESIDUAL PRAYING
INCREASED THE MALARIA POSITIVITY RATE DECREASED FROM OVER 40% TO
0.5%.
THESE DATA SHOW THE REDUCTION IN ALL CAUSE UNDER 5 CHILD
MORTALITY IN PMI COUNTRIES.
THESE DATA ECHO WHAT WE SAW IN ZANS ZA BAR BUT ACROSS A LARGER
SUB SET OF PMI COUNTRIES.
WE ARE SEEING REDUCTIONS IN ALL CAUSED CHILDHOOD MORTALITY.
WHILE IMPRESSIVE STRIDES ARE BEING REALIZED WITH THE MASSIVE
SCALEUP OF MALARIA CONTROL INTERVENTIONS RESISTANCE IS A
LURKING THREAT.
PMI TEAMS ARE BEGINNING TO REPORT THE EMERGENCE OF
RESISTANCE OF INSECTICIDES.
ADDITIONALLY THERE ARE EARLY SIGNS THAT RESISTANCE IS
DEVELOPING TO THE ARTEMSININS, A KEY DRUG CLASS.
THIS IS OCCURRING IN THE HISTORICAL BIRTHPLACE OF THE
ANTI-DRUG RESISTANCE, THE THAI CAMBODIAN BORDER.
IT WOULD LIKELY SLOW OR REVERSE THE REDUCTIONS SEEN IN
MORTALITY.
IN SUMMARY, IN ALL SEVEN PMI CONDITIONS WITH HOUSEHOLD
SURVEYS WE SEE SUBSTANTIAL REDUCTIONS IN CAUSED MORTALITY
IN CHILDREN FROM 19 TO 36%.
WHILE OTHER FACTORS MAY CONTRIBUTE TO THE DECLINE IN THE
MORTALITY RATES THERE IS STRONG EVIDENCE THAT ANTI-MA LAIRIAN
EFFORTS ARE PLAYING A MAJOR ROLE.
THESE REDUCTIONS FOLLOWED A MASSIVE SCALEUP OF PROVEN
INTERVENTIONS.
A THOROUGH ASSESSMENT IS UNDER WAY FOR THE 15 PM COUNTRIES.
I'LL NOW HAND OVER THE LECTERN TO DR. PATRICK KACHUR WHO WILL
SPEAK ON THE POSSIBILITY OF ELIMINATION.
>> THANK YOU, JOHN.
GOOD AFTERNOON.
I'LL REVIEW THE SCIENCE BASE FOR CURRENT MALARIA INTERVENTIONS
THIS AFTERNOON, TALK BRIEFLY ABOUT THE GLOBAL MALARIA
ERADICATION RESEARCH AGENDA AND FINALLY DESCRIBE HOW CDC'S
CURRENT OPERATIONS RESEARCH PRIORITIES ADDRESS THE
UNFINISHED WORK OF SCALING UP INTERVENTIONS AS WELL AS THE
PROMINENCE OF MALARIA ELIMINATION.
CDC SCIENCE CONTRIBUTED TO DEFINING THE EFFECTIVENESS OF
EACH ONE OF THE FOUR KEY INTERVENTIONS THAT JOHN
DESCRIBED.
I'M GOING TO TAKE A MOMENT TO DEMONSTRATE THIS IN MORE DETAIL
WITH REFERENCE TO INSECTICIDE TREATED NETS.
HERE ARE DATA FROM THE IMPACT OF ITNs ON CHILD DEATHS FROM A
COCHRAN REVIEW THAT CONDUCTED A MET TAANALYSIS OF ALL FOUR
PUBLISHED TRIALS.
CDC AND THE KENYA MEDICAL RESEARCH INSTITUTE COMPLETED THE
FINAL AND MOST COMPREHENSIVE TRIAL AND THE ONLY ONE CONDUCTED
IN AN AREA OF INTENSE YEAR-ROUND TRANSMISSION.
THE COLLECTIVE RESULTS DEMONSTRATED A PROTECTIVE
EFFICACY OF 17% ON CHILD MORTALITY AND THAT THE
INTERVENTION COULD SAVE 5 1/2 LIVES PER EVERY 1,000 CHILDREN
PROTECTED OR A TOTAL OF A QUARTER MILLION CHILDREN EACH
YEAR.
THE ON CONTRIBUTING EFFICACY DATA, THOUGH, STUDIES CONDUCTED
BY CDC HAS IMPORTANT POLICY IMPLICATIONS IN OTHER WAYS.
THEY SHOWED THAT PEOPLE WITHOUT NETS EXPERIENCED THE SAME
BENEFITS IN TERMS OF REDUCED MALARIA INFECTION, ILLNESS,
ANEMIA AND IMPROVED CHILD SURVIVAL AS LONG AS THEY LIVED
WITHIN 300 METERS OF THE HOUSEHOLD THAT USED NETS.
THEY SHOWED THAT CHILDREN PROTECTED BY BED NETS FOR UP TO
SIX YEARS EXPERIENCED A SURVIVAL BENEFIT THAT LASTED BEYOND EARLY
CHILDHOOD.
THE INFANT AND CHILD MORTALITY RATES WERE AS LOW AFTER THE
FOLLOW-ON PERIOD AS THEY HAVE BEEN DURING THE INITIAL TWO-YEAR
STUDY.
AND FINALLY, THEY SHOWED THE DATA THAT HIGH COVERAGE WITH
NETS INCLUDING COVERING SCHOOL-AGED CHILDREN AND ADULTS
COULD ENSURE PROTECTION EVEN FOR THOSE WHO DID NOT HAVE NETS.
TOGETHER, THESE FINDINGS LED TO POLICIES THAT SUPPORTED
WIDESPREAD SCALEUP OF INSECTICIDE-TREATED NETS IN ALL
TRANSMISSION SETTINGS AND FOR PROMOTING UNIVERSAL COVERAGE.
BEFORE I TALK ABOUT GLOBAL RESEARCH PRIORITIES FOR
ELIMINATION, I'D LIKE TO ACKNOWLEDGE THE OBSERVATION THAT
CONTINUED PROGRESS TOWARDS SCALEUP AND ULTIMATELY
ELIMINATION WILL REQUIRE IMPROVED TOOLS FOR MALARIA
CONTROL AND SURVEILLANCE.
IT ALSO REQUIRES A SLIGHTLY DIFFERENT EMPHASIS.
WHILE SCALEUP AIMS TO MINIMIZE MORBIDITY AND MORTALITY FROM THE
DISEASE, ELIMINATION FOCUSES ON REDUCING TRANSMISSION AS
MEASURED BY THE BASIC REPRODUCTION NUMBER.
AS LONG AS EACH HUMAN INFECTION RESULTS IN TRANSMISSION TO NO
MORE THAN ONE ADDITIONAL PERSON, LIL
ELIMINATION IS POSSIBLE ALTHOUGH THE PROSPECT MAY BE LONG RANGE.
FOR THE PAST 18 MONTHS, MORE THAN 200 SCIENTISTS FROM AROUND
THE WORLD HAVE BEEN WORKING TO DEFINE RESEARCH GAPS NEEDED TO
MALARIA ELIMINATION.
THEIR RECOMMENDATIONS UNDER THE MALARIA ERADICATION RESEARCH
AGENDA CONSIDER ALL ASPECTS OF MALARIA INCLUDING BASIC SCIENCE
AND PROGRAM.
IN ADDITION TO NEW DRUGS, VACCINES, DIAGNOSTICS AND
INSECTICIDES, THE EFFORT WILL REQUIRE HEALTH SYSTEMS THAT CAN
ADAPT TO ACCOMMODATE THEM.
IT WILL REQUIRE STRATEGIES TO MANAGE THE TWIN THREATS OF
ANTI-MALARIAL DRUG RESISTANT AND INSECTICIDE RESISTANT.
IN THIS EFFORT, COMBINATION TREATMENTS HAVE BECOME THE
MAINSTAY, BUT COMBINED DELIVERY SYSTEMS AND ROTATIONAL OR MOSAIC
DEPLOYMENT OF INSECTICIDES OR MALARIA DRUGS HAVEN'T YET BEEN
EXPLORED.
AS LARRY NOTED, OUR BEST VECTOR INTERVENTIONS HOUSE SPRAYING AND
NETS ARE PRIMARILY EFFECTIVE INDOORS.
BUT IN MANY PLACES MALARIA VECTORS FEED OUTSIDE AND
INTERVENTIONS LIKE LARVA CIDING AND TRAPS GIVE HOPE FOR
COMBATING THAT.
NEW APPROACHES USING TREATMENT DRUGS IS ALSO IMPORTANT SUCH AS
ACTIVE SCREENING AND DRUGS AND VACCINES.
FINALLY BETTER SURVEILLANCE METHODS ARE NEEDED FOR MEASURING
MALARIA TRANSMISSION BOTH FOR DETECTING AND RESPONDING TO THE
OUTBREAKS THAT WILL INEVITABLY OCCUR ALONG THE WAY TOWARD
ELIMINATION.
I'LL SPEND THE REST OF MY TIME TALKING ABOUT CDC'S CURRENT
OPERATIONAL RESEARCH PRIORITIES WHICH ENCOMPASS BOTH THE
UNFINISHED WORK OF SCALEUP OCCURRING TO INTERVENTIONS AND
THE PROMISE OF ELIMINATION.
THESE ADDRESS THREE BROAD ISSUES.
FIRST, TO OPTIMIZE THE DELIVERY OF THE CURRENTLY RECOMMENDED
INTERVENTIONS, SECOND, TO ESTABLISH ROLES FOR NEW AND
REVISITED INTERVENTIONS THROUGH RESEARCH AND DEVELOPMENT AS WELL
AS CLINICAL AND FIELD TRIALS.
AND THIRD, TO INTEGRATE MALARIA CONTROL WITH OTHER HEALTH AND
DEVELOPMENT INITIATIVE.
ONE PROMISING R&D EFFORT CENTERS AROUND MALARIA DIAGNOSTICS.
WHILE LIGHT MICROSCOPY CAN IDENTIFY PARASITES MOST PEOPLE
TREATED FOR MALARIA AROUND THE WORLD DON'T BENEFIT FROM THEM.
ONLY RECENTLY HAS THE WORLD HEALTH ORGANIZATION CALLED FOR
UNIVERSAL ACCESS TO MALARIA DIAGNOSIS AND TREATMENT FOR
EVERY CASE.
DIAGNOSTIC CONFIRMATION COULD HELP MINIMIZE THE OVERUSE OF
MALARIA DRUGS, IMPROVE DETECTION AND TREATMENT OF OTHER ILLNESSES
AND FORM THE BASIS OF A RELIABLE SYSTEM FOR MONITORING MALARIA
AND ITS CONTROL.
AS ENDEMIC COUNTRIES APPROACH THE ELIMINATION THRESHOLD
ACCURATE AND SENSITIVE TESTS WILL BECOME MORE CRITICAL.
WHILE THE CURRENT DIAGNOSTIC FORMATS WILL IMPROVE MANAGEMENT
OF ILLNESS, ELIMINATION MAY FINALLY REST ON MOLECULAR THAT
HAVE ONLY BEEN PRACTICAL IN LABORATORIES FAR FROM THE REMOTE
AREAS WHERE TRANSMISSION IS LIKELY TO PERSIST THE LONGEST.
RESEARCHERS AT CDA AND THE UNIVERSITY OF GEORGIA ARE
DEVELOPING A NOVEL SYSTEM FOR MOLECULAR DIAGNOSIS THAT COULD
OVERCOME THIS LIMITATION.
THE TECHNIQUE, CALLED REALLAMP FOR SHORT MAKES IT POSSIBLE TO
DETECT PARASITES AT LOW NUMBERS AND WITHOUT ACCESS TO REFERENCE
LABORATORY STAFF AND EQUIPMENT.
THEY'VE ALREADY VALIDATED THEIR FIRST GENERATION PROTOTYPE ON
SPECIMENS FROM TANZANIA.
WE'RE WOULD INVOLVED IN SEVERAL CLINICAL AND FIELD TRIALS.
IN KENYA, THE FIRST PHASE THREE TRIAL OF A MALARIA VACCINE IN
AFRICAN CHILDREN.
THE DEVELOPMENT OF THIS VACCINE IS SUPPORTED BY THE MALARIA
VACCINE INITIATIVE AT 11 SITES IN NINE AFRICAN COUNTRIES.
IN EARLIER STUDIES IT PREVENTED 39% OF SEVERE MALARIA OR UP TO
SIX MONTHS.
THE VACCINE CANDIDATE CURRENTLY UNDER TRIAL COULD BE DEPLOYED AS
SOON AS TWO OR THREE YEARS FROM NOW.
WHILE IT WILL BE IMPORTANT IN REDUCING MORBIDITY AND MORT ATY,
THIS VACCINE WON'T HAVE A DIRECT EFFECT ON MALARIA TRANSMISSION.
THERE ARE DOZENS OF OTHER VACCINES AND HUNDRED OF
CANDIDATE ANTIGENS IN VARIOUS STAGE OF DEVELOPMENT AND SOME OF
THOSE MIGHT ULTIMATELY HAVE AN IMPACT ON TRANSMISSION.
THE DEVELOPMENT OF A MALARIA VACCINE HAS BEEN PARTICULARLY
ELUSIVE PARTLY BECAUSE OF THE COMPLEX WAY THE PARASITE AND
HUMAN SYSTEMS HAVE CO-EVOLVED.
SOME OF OUR OTHER FIELD ACTIVITIES INCLUDE FIELD TRIALS
OF INSECTICIDE-TREATED NETS IN COMBINATION WITH OTHER VECTOR
CONTROL INTERVENTIONS INCLUDING INDOOR RESIDUAL HOUSE SPRAYING
AND IN COMBINATION WITH DURABLE INSECTICIDE-TREATED WALL LINERS.
OUR THIRD OPERATION'S RESEARCH FOCUS IS TO EXPLORE INTEGRATION
OPPORTUNITIES.
THIS IS IN KEEPING WITH THE GLOBAL HEALTH INITIATIVE AGENDA,
AN EXAMPLE OF OUR CURRENT WORK INCLUDE COMMUNITY BASED DELIVERY
OF MALARIA PREVENTION SUCH AS NETS ALONGSIDE COMMUNITY BASED
CHILD HEALTH CAMPAIGNS AND CAMPAIGNS FOR ELIMINATING
NEGLECTED TROPICAL DISEASES.
IT INCLUDES MANAGEMENT OF FEBRILE ILLNESS, EXPLORING
INTEGRATED VECTOR CONTROL PROGRAMS AS WELL AS INTEGRATED
OPPORTUNITIES TO MONITOR AND EVALUATE OUR PROGRAMS.
THANK YOU POREFOR THE OPPORTUNITY TO
DISCUSS CDC'S PAST, PRESENT AND FUTURE ROLE IN MALARIA CONTROL
AND HOPEFULLY ELIMINATION.
NEXT STEPS WILL REQUIRE INTENSIVE PARTNERSHIPS AND SHOWN
HERE ON THIS SLIDE ARE THE LOGOS OF SOME OF THE GLOBAL AND DOOM
STICK PARTNERS WITH WHICH WE CURRENTLY WORK.
I'D LIKE TO INTRODUCE OUR FINAL SPEAKER, RICK STECKKETEE WHO
REPRESENTS THE MALARIA CONTROL AND EVALUATION PARTNERSHIP IN
AFRICA.
>> THANKS VERY MUCH, PATRICK.
IT'S A PLEASURE TO BE HERE AND SEE A LOT OF FAMILIAR FACES.
I HAVE THE OPPORTUNITY TO TALK TO YOU A LITTLE BIT ABOUT
MALARIA ELIMINATION AND CDC'S ROLE AND PROVIDE AN EXTERNAL
PERSPECTIVE THAT, AS MANY OF YOU REALIZE, I LEARNED MY MALARIA
HERE IN THIS AGENCY.
SO IT RUNS THE RISK OF BEING A RECYCLED INTERNAL PERSPECTIVE.
BUT LUCKILY, I STILL HAVE MY BEARD AND WHILE IT'S A LITTLE
GRAY IT DOES QUALIFY AS FACIAL HAIR.
LET ME POINT OUT FIRST, THAT THERE'S A 500-PAGE BOOK THAT
TELLS US WHAT TO DO AND HOW TO DO IT.
THIS DATES BACK FROM THE GLOBAL MALARIA ERADICATION PROGRAM, WAS
WRITTEN BY DR. POMPOMA WHO AT THAT POINT LED THE W.H.O. EFFORT
FOR MALARIA ERADICATION.
WE HAVE THIS SESSION TWO WEEKS AFTER THE "LANCET" PUBLISHED A
SERIES OF FOUR ARTICLES ON MALARIA ELIMINATION AND SEVERAL
COMMENTARIES ABOUT THIS AS WELL.
SO MAYBE MALARIA ELIMINATION IS ACTUALLY BEING RECYCLED AS WE
SPEAK.
THE PROGRESS THAT JOHN AND PATRICK JUST SPOKE TO YOU ABOUT
LED PEOPLE TO SAY THAT NOW IS THE TIME TO ACT.
WE SHOULD NOT IGNORE THE SHRINKING OF THE MALARIA MAP
WHICH HAS BEEN SUCCESSFULLY UNFOLDING OVER THE PAST CENTURY.
SO TODAY I'LL TALK A LITTLE BIT ABOUT THE OPPORTUNITY FOR
ELIMINATION SUCCESS AND WHY TODAY.
I'LL GIVE YOU A BRIEF AFRICAN COUNTRY EXAMPLE WHERE THEY'RE
TRYING TO MOVE FORWARD AND ELIMINATION IS POTENTIALLY IN
THEIR SITES.
A PARTNERSHIP PERSPECTIVE IN TRANSITIONING FROM SCALE UP TO
ELIMINATION AND SOME OPPORTUNITIES WHERE CDC CAN MAKE
A DIFFERENCE.
FIRST, LET ME BEGIN WITH THIS GRAPHIC.
SOME OF THIS HAS BEEN SHOWN WITH THE ROLL BACK MA RARE YA
PARTNERSHIP AND SUGGEST THAT THERE ARE STEPS ALONG THE PATH
FROM WHAT I'LL CALL PRESCALEUP TO ELIMINATION.
WHEN THIS IS DESCRIBED IT IS OFTEN SUGGESTED THAT EACH STEP
ALONG THE WAY REQUIRES SOME RECONFIGURING AND DOING WORK IN
SLIGHTLY DIFFERENT WAYS.
I OFFER THIS INSTEAD, AND THAT IS THAT IF WE THINK THAT WE HAVE
TO TAKE SIDE STEPS AND CHANGE THE WAY WE DO THINGS, THEN WE
MAYBE HAVEN'T THOUGHT OUT THE PATH TO ELIMINATION.
AND THE REAL OPPORTUNITY HERE AND THE BEAUTY OF CONSIDERING
ELIMINATION AND THE REASON WHY WE CAN DO THIS TODAY IS THAT THE
RECENT PROGRESS HAS ALLOWED US THE OPPORTUNITY TO SEE THAT PATH
AND PERHAPS FIGURE IT OUT AND THEN TAKE IT.
SO A LITTLE BIT BACKWARDS.
WHY TODAY?
WELL, FIRST OF ALL, WITH THE GLOBAL MALARIA ERADICATION
PROGRAM AND BETWEEN THAT AND THE START OF THE ROLLBACK MALARIA
PARTNERSHIP, IT WAS REALLY A TIME OF SCIENCE.
THIS HAS JUST BEEN DESCRIBED, BUT TO SUMMARIZE THAT, THE
SCIENTISTS BASICALLY IDENTIFIED PREVENTION DIRECTED TO THE
BIOLOGY OF THE VECTOR AND ABLE TO BE DELIVERED PROACTIVELY INTO
THE MOST VULNERABLE PEOPLE.
AND UNTIL WE GOT TO THAT POINT, WE DIDN'T REALLY HAVE PREVENTION
INTERVENTION.
THE SCIENTISTS ALSO IDENTIFIED NEW TREATMENT WITH COMBINED
DRUGS TO OPTIMIZE EFFICACY AND DELAY RESISTANT, GAVE US HUGE
HOPE AND DIAGNOSTICS THAT CAN BE DEPLOYED CLOSE TO HOME AND IN
FACILITIES AND CAN CLARIFY WHERE MALARIA TRANSMISSION, ILLNESS
AND DEATH IS OCCURRING.
THAT SAID OF TR ARKSIAD TAKES US A
LONG WAY.
WHILE SCIENTISTS ARE STILL SEEKING NEW DIAGNOSIS AND
TREATMENT AND NEW INTERVENTIONS WE ALREADY HAVE THE FINAL
INTERVENTION.
AND I'LL CALL THAT OUT AS SURVEILLANCE FOR INFECTION
DETECTION AND TRANSMISSION CONTAINMENT.
AND I'LL COME BACK TO THIS.
SO LET ME MOVE BRIEFLY TO AN AFRICAN COUNTRY EXAMPLE FOR
ZAMBIA, A PLACE I'VE HAD THE PLEASURE OF WORKING OVER THE
LAST FIVE YEARS WITH THE NATIONAL MALARIA CONTROL
PROGRAM.
ZAMBIA'S LOCATED IN THE CENTER OF SOUTHERN AFRICA.
THERE'S PLENTY OF WATER THERE AS SEEN BY THE PHOTO IN THE UPPER
RIGHT.
AND THAT TRANSMISSION MAP FOR 2006 IN THE LOWER RIGHT SHOWS
DARK AREAS WHERE THERE'S MORE INTENSE TRANSMISSION AND THE
SOMEWHAT LIGHTER AREA WITH A LITTLE BIT LESS.
BUT LET ME SUGGEST THAT IN 2006 MALARIA WAS ENDEMIC ACROSS THE
NATION.
WELL, THIS IS SHOWING THE MALARIA INTERVENTION SCALEUP
OVER THE LAST DECADE.
AND THE OWNERSHIP AND USE OF INSECTICIDE-TREATED NETS BY
VARIOUS GROUPS, PREVENTION AND PREGNANCY ARE ALL SHOWN TO BE
DRAMATICALLY INCREASING PARTICULARLY FROM 2005 TO 2010.
AND THAT RED LINE IS THE LINE INDICATING THOSE HOUSEHOLDS WITH
EITHER OWNERSHIP OF AN ITN OR USE OF INDOOR RESIDUAL SPRAYING.
AND THAT'S GETTING QUITE CLOSE TO THEIR 80% TARGET.
WHAT DOES THAT TRANSLATE TO?
SO LET ME MOVE TO SOUTHERN PROVINCE AND KULANGOOLA DISTRICT
IN ZAMBIA.
THEY REPORTED 981 CASES IN THEIR SURVEILLANCE SYSTEM AT
FACILITIES PER THOUSAND POPULATION.
ESSENTIALLY, EVERYONE WAS GETTING MALARIA THAT YEAR.
THEY SCALED UP INSECTICIDE HAD BEEN TREATED NETS AND INDOOR
RESIDUAL SPRAYING AND IN SUBSEQUENT YEAR THEY
DRAMATICALLY REDUCED THE NUMBER OF CASES OF MALARIA.
2008 AND 2009 STABLE AT 20 CASES PER THOUSAND POPULATION.
THEY ALSO INCREASED RAPID DIAGNOSTIC TESTS AND INTRODUCED
THEM BACK IN 2005, 2006.
SO ON THE ONE HAND, THIS SET OF 981 CASES OF MALARIA IN 2005 WAS
REALLY REPORTED FEVER AND NOW THEY'RE REPORTING MALARIA.
ON THE OTHER HAND, 6,850 RAPID DIAGNOSTIC TESTS USED IN 2008,
ONLY 21 SHOWED UP WITH MALARIA.
SO THEY'VE HAD HUGE PROGRESS, AND THE DIAGNOSTIC TESTS HAVE
ALLOWED THEM TO ACTUALLY KNOW WHAT THEY HAVE.
WELL, THAT WAS ONE DISTRICT.
AND THESE ARE THE REMAINING NINE DISTRICTS IN SOUTHERN PROVINCE
WITH KUZANGOOLA.
I SHOWED YOU THE BEST EXAMPLE.
BUT THERE ARE MANY DISTRICTS IN THE PROVINCE THAT HAVE ACHIEVED
RAPID REDUCTION IN MALARIA AND ARE LOOKING AT WHAT TO DO NEXT.
LET ME MOVE BACK TO THE PARTNERSHIP PERSPECTIVE.
ELIMINATION IS ON SOME BUT NOT ALL OF THEIR AGENDAS.
THE BILL AND MELINDA GATES FOUNDATION IN 2007 TOOK A QUITE
BOLD STEP AND PUT MALARIA ELIMINATION IN THE CENTER OF
THEIR AGENDA.
THE ROLLBACK MALARIA PARTNERSHIP AND THE ROLLBACK MALARIA
STRATEGIC PLAN ACTUALLY HAS EMBRACED ELIMINATION IN THE
MIDST OF THIS.
WHAT ABOUT CDC?
SHOULD CDC TAKE A POSITION ON MALARIA ELIMINATION?
MAYBE, MAYBE NOT.
BUT LET ME SUGGEST THAT YOU CONSIDER EMBRACING ELIMINATION.
AND NOT BECAUSE YOU CAN ELIMINATE MALARIA SOON AND
EVERYWHERE, BUT BECAUSE CHARTING THE PATH TO ELIMINATION IS
ACTUALLY CHARTING THE IMPORTANT WAY FORWARD AND CDC CAN BRING A
HUGE NUMBER OF STRENGTHS TO THAT.
SO SOME COMMENTARY FROM -- AGAIN FROM THE OUTSIDE ON CDC
ENGAGEMENT.
FIRST, TO FOCUS ON AFRICA BUT WORK ELSEWHERE BECAUSE THERE'S
STILL PLENTY OF MALARIA ELSEWHERE, AND YOU ALREADY DO
THIS.
THE SECOND IS WORK WITH MANY PARTNERS.
PATRICK JUST SHOWED YOU A SLIDE WITH THE MANY PARTNERSHIPS.
SO YOU ALREADY DO THIS.
PARTICULARLY WITH THE U.S.
PRESIDENT'S MALARIA INITIATIVE AND W.H.O. AND OTHER.
WHAT DO YOU DO WITH YOUR OWN RESOURCES, YOUR PEOPLE AND YOUR
MONEY?
AND YOUR FOCUS?
FIRST, I'LL SUGGEST THAT YOU CONTINUE TO DO CONTROL AS YOU DO
WITH THE PRESIDENT'S MALARIA INITIATIVE.
BUT IMPORTANTLY, I'M SUGGESTING THAT YOU CONSIDER THE SCIENCE OF
ELIMINATION ON CDC'S DIME.
DO THIS MORE EXPLICITLY AND BRING YOUR STRENGTHS.
UNFORTUNATELY, IT WILL BE MORE THAN A DIME.
THE OTHER ISSUE IS ON CAPACITY BUILDING.
AND I THINK FOR A MOMENT ABOUT THE WORK THAT CDC HAS DONE WITH
STATE HEALTH DEPARTMENTS ACROSS THIS NATION AND HAS REALLY
TRAINED A CADRE OF PUBLIC HEALTH OFFICIALS DOING WORK IN ALMOST
EVERY STATE HEALTH DEPARTMENT.
SO THERE'S A HUGE AMOUNT OF STRENGTH TO BRING TO THIS.
LET ME RETURN TO SURVEILLANCE IN THE MIDST OF THE DISCUSSION OF
THE SCIENCE OF ELIMINATION.
SURVEILLANCE DESCRIBED IN VARIOUS PAPERS WITHIN CDC IS THE
ABOUT THE CONSISTENT COLLECTION, ANALYSIS AND INTERPRETATION OF
DATA USED FOR PLANNING, IMPLEMENTING AND EVALUATING
PUBLIC HEALTH PROGRAMS.
THAT'S A FAIRLY BROAD DEFINITION.
IN POM POMA'S BOOK, HE DESCRIBED SURVEILLANCE AS EPIDEMIOLOGIC
AND REMEDIAL ACTION TO DETECT CASE, REGISTER THEM, TREAT THEM,
FOLLOW UP WITH AN INVESTIGATION FOR THE SOURCE AND POSSIBLE
ONGOING TRANSMISSION, DISCOVER THAT TRANSMISSION, ESTABLISH ITS
CAUSE, ELIMINATE RESIDUAL FOCI AND END TRANSMISSION AND AVOID
ITS RESUMPTION.
AND TO SUBSTANTIATE THAT ELIMINATION HAS BEEN ACHIEVED.
THAT'S DIFFERENT.
I'LL SUGGEST TO YOU THAT THAT'S AN INTERVENTION IN AND OF
ITSELF.
AND SO CDC HAS THE OPPORTUNITY TO TAKE THAT SURVEILLANCE AND
INTERVENTION SPECIFICALLY TO REDUCE TRANSMISSION.
TO USE THE DIAGNOSTICS AND THE ANTI-MALARIAL DRUGS AND PAIR
THEM WITH INVESTIGATIONAL PROCEDURES AND TO TEST THAT
INTERVENTION AGAINST ITS RESPONSIBILITY FOR CONTAINING
TRANSMISSION.
THE SECOND ISSUE WAS ABOUT CAPACITY BUILDING.
CAPACITY DEVELOPMENT FOR INFORMATION MANAGEMENT IS
PERHAPS A HUGE STRENGTH OF THIS AGENCY.
AND YOU CAN BUILD ON SURVEILLANCE AND TRANSMISSION
REDUCTION IN THE MIDST OF THAT.
AN EXAMPLE IS TO LOOK AT THE STOP POLIO MODEL THAT WAS USED.
THIS IS A PARTNERSHIP WITH CDC AND ROTARY INTERNATIONAL AND
WITH THE WORLD HEALTH ORGANIZATION WHERE PEOPLE WERE
ABLE TO VOLUNTEER AND SPEND TIME OVERSEAS WORKING ON SURVEILLANCE
EFFORTS, SPECIFICALLY TO IDENTIFY PARALYSIS AND IMMUNIZE
AROUND IT AND CONTAIN TRANSMISSION.
SO A STOP MALARIA MODEL IS SOMETHING THAT AT LEAST OUGHT TO
BE THOUGHT ABOUT.
THE SECONDARY IS AROUND THE FIELD EPIDEMIOLOGY AND
LABORATORY TRAINING PROGRAMS.
YOU DO A NUMBER OF THESE IN MALARIA ENDEMIC COUNTRIES AND I
WOULD SUGGEST THAT FIRST YOU TAKE A SPECIFIC LOOK AND MAKE
SURE THEY'RE WORKING ON MALARIA IF IT'S THERE THIS THAT COUNTRY
AND, SECONDLY, WHAT MORE COULD THEY BE DOING?
IT GOES WITHOUT SAYING THAT PARTNERING FOR THIS WORK WILL BE
CRITICAL.
THE OTHER THING THAT CDC BRINGS IS A POTENTIALLY LONG VIEW, AN
ELIMINATION AND ERADICATION WILL REQUIRE NOTHING IF NOT A LONG
VIEW.
AND SO THIS CDC'S ABILITY TO LOOK AT SUSTAINED PUBLIC HEALTH
FOCUS AMIDST MANY COMPETING PRIORITIES WILL ACTUALLY BE
QUITE CRITICAL HERE.
BELIEVE ME, THERE ARE PLENTY OF COMPETING PRIORITIES.
SO I'LL BEGIN TO CLOSE BY SUGGESTING THAT YOU BRING
DURABLE COMMITMENT, YOU PROVIDE LEADERSHIP IN THE SCIENCE OF
ELIMINATION, THAT WILL INCLUDE THE DEVELOPMENT OF NEW TOOLS AND
TESTING OF NEW STRATEGYIESSTRATEGIES, BUT
IN PARTICULAR, YOU SHOULD CONSIDER BUILDING ON YOUR
STRENGTHS IN WHAT YOU ALREADY KNOW HOW TO DO.
AND THAT YOU TRAIN THE NEXT GENERATION.
YOU ACTIVELY SEEK THE STRATEGIC PARTNERSHIPS EN ROUTE TO THIS.
BUT ELIMINATION AND ERADICATION IS ACTUALLY NOT FOR THE FAINT OF
HEART.
THIS WON'T BE EASY, AND IT WON'T DO WELL IF YOU HAVE ONE FOOT IN
AND ONE FOOT OUT.
THE ONE FOOT OUT LEAVING YOU ABLE TO PERHAPS DENY
RESPONSIBILITY WHEN THINGS DON'T GO SO WELL.
BUT STAYING OUT IS A DECISION, TOO.
AND THAT WON'T BE VERY HELPFUL FOR AFRICAN CHILDREN AND THEIR
FAMILIES.
SO CONSIDER COMMITTING.
THANKS VERY MUCH.
[ APPLAUSE ] >> THANK YOU VERY MUCH, RICK,
AND I'D LIKE TO NOW OPEN UP THE FLOOR FOR ANY QUESTIONS OR
COMMENTS.
I'M INSTRUCTED TO ASK YOU TO BE BRIEF, THAT YOU GET ONE QUESTION
PER CUSTOMER, AND THAT YOU IDENTIFY YOURSELF AND IF YOU
HAVE FACIAL HAIR, YOU GET TO GO FIRST.
ANN?
[ LAUGHTER ] >> THANK YOU.
ANN SHOOK.
THAT WAS TERRIFIC.
ALL OF YOU.
YOU KNOW, I LOVE THE LINE ABOUT NOT FOR THE FAINT OF HEART.
AND BEING IN THE MIDST OF THE POLIO ERADICATION EFFORT AND
CONSIDERED MEASLES ELIMINATION OR ERADICATION RESOLUTIONS IN
THE FUTURE, WE'RE FINDING THAT YOU CAN LEARN A LOT ABOUT
ELIMINATION CHALLENGES IN THE PLACES WHERE IT'S THE MOST
DIFFICULT.
AND I WONDER, RICK, IN YOUR ZAMBIA SLIDE YOU HAD A LOT OF
PROVINCES GOING DOWN AND YOU HAD ONE PROVINCE IN YELLOW THAT
LOOKED PRETTY FLAT.
IS THERE A STORY BEHIND WHAT WAS HAPPENING THERE THAT WOULD BE
SOMETHING TO LEARN FROM FOR THE PROCESS?
>> MOST DEFINITELY.
FIRST OF ALL, WE'RE ACTUALLY GOING THERE LOOKING TO SEE ONE
ISSUE IS ABOUT THEIR USE OF DIAGNOSTICS BECAUSE YOU CAN
IMAGINE THAT SOME OF THE BENEFIT THAT YOU SAW IN THE SLIDE WAS
BECAUSE OF DIAGNOSTICS USE.
SO THAT IF YOU DIDN'T SEE ANY CHANGE ACROSS THAT TIME, IT'S
PROBABLY INDICATIVE THAT DIAGNOSTICS DIDN'T ACTUALLY
REACH THAT PARTICULAR DISTRICT.
SO THAT'S BEING INVESTIGATED.
I'LL POINT OUT, THOUGH, THAT YOU'RE ABSOLUTELY RIGHT.
AND IN A COUPLE OF OTHER PROVINCES IN THE COUNTRY, THEY
ACTUALLY HAVE HAD SOME CHALLENGES WITH RESOURCES.
AND THEY'VE HAD SOME DELAYS IN DELIVERING THEIR
INSECTICIDE-TREATED NETS TO MAINTAIN THEIR COVERAGE AND
THEY'VE ACTUALLY SEEN RESURGENCE.
SO THIS IS NOT -- LIKE I SAY, THIS IS NOT FOR FAINT OF HEART
AND EVERY TIME WE SEE A PROBLEM, WE REALIZE HOW MUCH MORE
AGGRESSIVE AND MORE PROACTIVE WE NEED TO BE.
AND THAT'S THE NAME OF THIS GAME WILL BE BEING PROACTIVE ABOUT
IT.
THIS WON'T HAPPEN WITHOUT THAT KIND OF WORK.
>> DAN, PREPAREDNESS AND EMERGENCY RESPONSE.
STRUCK BY THE STATEMENT PATRICK MADE ABOUT BENEFIT IN AREAS THAT
WERE NOT HAVING THE INTERVENTION DIRECTLY BUT WERE ADJACENT TO
THEM.
AND OBVIOUSLY, ONE OF THE EXPLANATIONS IS YOU'RE ALSO
DOING MORE DIAGNOSTICS AND THEREFORE CATEGORIZING MORE
ACCURATELY.
YOU DON'T WANT THAT TO BE THE ANSWER.
HAVE STUDIES BEEN DONE OF INFECTED VECTOR BURDEN TO
ESTABLISH THAT THE BED NETS THEMSELVES ARE REDUCING THAT
BURDEN.
AND THEN ARE BAITS AND INSECTICIDES A SOLUTION FOR SOME
OF THE EXTERNAL MOSQUITO ISSUES?
>> THANKS, DAN.
YES.
A NUMBER OF THE STUDIES, BOTH OF THE EXTENSIVE TRIALS LIKE THE
ONE IN WESTERN KENYA DID INCLUDE DOCUMENTING THE IMPACT ON THE
VECTOR POPULATION AND, IN FACT, BED NETS IN A RURAL AFRICAN
CONTEXT WILL REDUCE THE TOTAL POPULATION OF MOSQUITOES THAT
ARE BITING.
I EITHER, BY HAVING A DIRECT EFFECT ON KILLING MOSQUITOES
THAT HAPPEN TO LIGHT ON THEM, OR SIMPLY BY CAUSING THEM TO FORAGE
FURTHER FOR EACH MEAL AND YOU JUST HAVE SOME MORTALITY AND
DEFICIENT -- EXTRA TIME THEY'RE SPENDING IN THAT EXTRA EFFORT.
WE DO THINK OUR FOLKS WHO ARE REALLY KEENLY INTERESTED IN R&D
IN THE TRANSMISSION REDUCTION ASPECT, THE GATES FOUNDATION IN
PARTICULAR ARE VERY KEENLY INTERESTED IN EXPLORING WHETHER
SPATIAL REPELLENTS AND BAITED TRAPS WILL HAVE AN IMPACT ON
OUTDOOR BITING MOSQUITOES THAT TRANSMIT.
>> KEVIN, THANK YOU VERY MUCH INDEED FOR THE PRESENTATION.
TO RICK.
HOW FRAGILE IS ALL OF THIS?
WHEN WE TALK ABOUT ELIMINATION, THE DONORS OFTEN TALK ABOUT THAT
WITH A VIEW THAT AT SOME STAGE IN THE FUTURE THEY'RE GOING TO
HAVE TO DO LESS OR PUT IN LESS.
AND I GET THE IMPRESSION FROM MALARIA THAT THAT'S NOT
NECESSARILY THE CASE.
AND ALLIED TO THAT ARE ANY OF THE CHAMS S CHANGES IN AFRICA,
COULD THAT BE CHANGES IN CLIMATE, THE
EXTENSIVE DROUGHT THAT'S HAPPENING IN A LOT OF COUNTRIES?
>> THERE'S NO -- I THINK THE IDEA THAT IN THE NEAR TERM THAT
THIS WOULD ACTUALLY BE -- YOU COULD START TO SAVE THINGS BY
DOING AGGRESSIVE CONTROL MOVING TOWARDS ELIMINATION AND STOP
DOING SOMETHING AS YOU GET THERE, I THINK THAT'S ACTUALLY
FOOLING YOURSELF.
THIS WOULD -- THIS WILL REQUIRE AND MORE WORK.
ON THE CLIMATE CHANGE ISSUE, THERE'S NO QUESTION THAT THE UPS
AND -- WHEN YOU DON'T DO ANY PREVENTION ACTUALLY AND YOU
DON'T CONTAIN TRANSMISSION, MALARIA GOES UP AND DOWN WITH
THE CLIMATE.
WITH GOOD PREVENTION IN PLACE, WE SEE HUGE BENEFIT EVEN AGAINST
CLIMATE CHANGES.
HAVE WE GOTTEN BENEFIT FROM A FEW DRY YEARS?
SOME PEOPLE CLAIMED SOME BENEFIT IN ETHIOPIA OFF OF WATCHING WHAT
HAPPENS AFTER AN OUTBREAK WHERE THEY NORMALLY IN ETHIOPIA COME
AND GO.
AND SO WITH THE CLIMATE CHANGE, ETHIOPIA GETS A HUGE OUTBREAK,
THEN IN SUBSEQUENT YEARS THEY HAVE MUCH LESS MALARIA, THEN
THEY CLAIM A LOT OF PROGRESS IN THOSE YEARS.
WE RUN THAT RISK BUT ACTUALLY THAT DATA WOULD SAY AT THIS
POINT THAT IT'S REALLY HUGELY BUILT AROUND HIGH PREVENTION
COVERAGE.
BED NETS AND INDOOR RESIDUAL SPRAYING REALLY WORK.
IN SUB-SAHARAN AFRICA.
WHILE THE WORST MALARIA IN THE WORLD, IT IS THOSE TWO
INTERVENTIONS ARE SO MUCH BETTER ATTUNED TO THAT MOSQUITO VECTOR
IN THAT ENVIRONMENT THAN THEY ARE ELSEWHERE.
SO IT'S ACTUALLY HUGELY FOCUSED AND POSITIVE, BUT IT IS FRAGILE.
AND PART OF THE REASON I'LL JUST PUSH ON THIS FOR A SECOND.
PART OF THE REASON FOR PUSHING TOWARDS ELIMINATION IS THAT THE
BUFFER BETWEEN JUST GOOD ENOUGH CONTROL AND REALLY SUBSTANTIAL
TRANSMISSION REDUCTION SO THAT TRANSMISSION EDGES BACK AND
YOU'VE GOT THE SYSTEM IN PLACE TO TURN IT AROUND AND STOP IT,
YOU WON'T GET THE MORBIDITY AND MORTALITY AT THAT POINT WHERE
YOU WILL IF YOU JUST GOT ALMOST ENOUGH CONTROL BUT YOU LOSE IT.
IN WHICH CASE IT WILL COME BACK OVERNIGHT.
>> DAN ROSS, CENTER FOR GLOBAL HEALTH.
MY QUESTION HAS TO DO WITH THE PROBLEM OF FATALISM AND
COMPLACENCY WHICH I ASSUME ARE BOTH ISSUES IN THE AREAS THAT
YOU'RE WORKING AT.
THE SUCCESS, RICK, THAT YOU POINTED TO, WHICH IS REALLY
DRAMATIC OVER A SHORT PERIOD OF TIME, IS THERE ANY EVIDENCE THAT
THAT KIND OF SUCCESS IS SHOWING OTHERS THE POSSIBILITIES AND CAN
BE USED AS A VEHICLE FOR GAINING TRACTION IN AREA WHERE PEOPLE
MAY NOT THINK THAT THIS IS EVEN POSSIBLE FOR THEM OR IN THE
CARDS FOR ANY OF THEIR CHILDREN?
IN TERMS OF IMPROVING THE RECORD ON THE MALARIA?
>> YOU KNOW, I THINK YOU'RE ABSOLUTELY RIGHT.
THIS IS -- THIS IS KALGTCATALYTIC
WHEN YOU CAN GET IT TO HAPPEN.
THE WORLD IS FULL OF PEOPLE WHO ARE QUITE REASONABLE AND AWARE
OF WHAT'S GOING ON AROUND THEM.
WHEN THEY STOP SEEING THEIR KIDS DYING DURING THE RAINY SEASON,
THEY START TELLING THEIR FRIENDS THAT THEY MADE A DIFFERENCE.
WE'VE WATCHED -- EVERYBODY'S WORRIED ABOUT WE GIVE YOU AN
INSECTICIDE-TREATED NET TO USE, WILL YOU USE IT?
THE ANSWER IS IT TAKES A LITTLE WHILE, BUT WE'RE SEEING
INCREDIBLY HIGH RATES OF USE THAT WE DIDN'T SEE TWO YEARS
AGO.
I THINK THAT'S BECAUSE THE WORD GETS OUT AND THE WORD COMMUNITY
TO COMMUNITY IS JUST HUGE.
>> IF I COULD JUST ADD, I THINK THAT IT'S A DELICATE BALANCE
BETWEEN IDENTIFYING SUCCESSES AND USING THAT AS A CATALYST AND
AVOIDING IRRATIONAL EXUBERANCE WHERE ELIMINATION GOALS ARE
DECLARED IN PLACES THAT REALLY HAVEN'T MADE MUCH OF A SUCCESS
IN SCALING UP AND REDUCING TRANSMISSION WHICH HAS ALSO
HAPPENED.
THERE NEEDS TO BE SOBER CONSIDERATION OF THE SITUATION
AND CAREFUL USES OF THE WORDS ELIMINATION AND ERADICATION.
AS THE DISCUSSION GOES FORWARD.
>> THANK YOU.
MARK EBBER HART, PARASITIC DISEASES.
LOOKING FORWARD TO THIS CONCEPT OF ERADICATION AND A LITTLE BIT
ABOUT THE DETAILS.
SO YOU TALKED ABOUT GETTING YOUR TRANSMISSION LEVEL BELOW OR NOT
WHERE YOU'RE LESS PARASITES COMING INTO THE SYSTEM.
YOU'VE GOT GOOD INTERVENTIONS, POSSIBLY NEW INTERVENTIONS, THE
COVERAGE RATES ARE GOING UP, THE RATES S
INCIDENT RATES ARE COMING DOWN, BUT YOU STILL HAVE TO SOME
INDICATORS TO MEASURE THAT YOU'VE INTERRUPTED TRANSMISSION.
SO SURVEYS IN YOUNG KIDS SHOWING THAT YOU'RE NOT HAVING EXPOSURE
AND YOU'RE LOOKING AT THE VECTOR TO MAKE SURE IT'S BELOW A
CERTAIN LEVEL AND YOU HAVE A MODELING SYSTEM THAT CAN ACCOUNT
FOR VARIOUS THINGS.
IN THAT REGARD, WHERE ARE WE WITH MALARIA LOOKING FORWARD TO
ERADICATION IN TERMS OF WHAT ARE THE INDICATORS GOING TO BE AND
WHAT ARE THE LEVELS THAT YOU THINK YOU'RE GOING TO HAVE TO BE
MEASURING OR GETTING TO TO ACTUALLY START WITHDRAWING YOUR
INTERVENTIONS AND MARSHALING YOUR RESOURCES INTO OTHER AREAS?
>> THANKS.
THAT'S A VERY GOOD QUESTION AND A VERY PACKED TOPIC TO DISCUSS.
BUT I THINK IMMEDIATELY THE APPLICATION OF CONFIRMED
DIAGNOSIS AND GETTING SYSTEMS TO WORK THAT REPORT ILLNESS AND
CONFIRMED ILLNESS DUE TO MALARIA WILL BE IMPORTANT.
THAT WILL TAKE US VERY FAR WITH THE SCALE UPOF THE CURRENT SET
OF INTERVENTIONS AND WITH AND WITH THE FIRST GENERATION
VACCINE THAT WE'RE LIKELY TO HAVE AVAILABLE.
BUT PART OF THE NEXT STEP WILL HAVE TO BE BETTER METHODS FOR
MEASURING MALARIA TRANSMISSION AND WE CAN LOOK AT THING LIKE
AGE DISTRIBUTION OF SEROLOGIC OUTCOMES.
THAT'S A BULKY MEASURE.
WE CAN LOOK AT THINGS SUCH AS EXVIVO STUDIES TO EXAMINE
WHETHER OR NOT SOMEONE HAS BEEN -- HAS TRANSMISSION
BLOCKING IMMUNITY.
THAT'S INCREDIBLY CUMBERSOME AND DIFFICULT TO AK TUALLIZE IN ANY
WAY.
SO THE TOOL THAT WE NEED ARE NOT JUST PARASITE DIAGNOSIS OR
VACCINES OR DRUGS, BUT THEY'RE ALSO UNDERSTANDING TRANSMISSION
BETTER AND HAVING A BETTER WAY OF MEASURING I SO THAT WE CAN
MARK PROGRESS.
>> I THINK WE HAVE TIME FOR ONE MORE QUESTION.
I DON'T KNOW IF THERE ARE ANY FROM THE VIRTUAL WORLD.
IF NOT, ONE LAST QUESTION?
SURE.
GO AHEAD.
>> I WAS JUST WONDERING, YOU MENTIONED ABOUT THE VACCINE AND
THE FACT THAT IT REDUCES SEVERITY AND MORTALITY.
BUT MY QUESTION IS THE CONSEQUENCES BY BRSING SUCH A
VACCINE ON THE CURRENT EFFORTS THAT ARE GOING ON IN PREVENTING
MALARIA.
MALARIA IMMUNOLOGY IN NATURE IS VERY COMPLEX.
AND IT COMES AT THE EXPENSE OF QUITE A FEW LIVES LOST IN THE
PROCESS.
SO THERE IS A LOT OF CONCERN THAT MALARIA VACCINES MIGHT
ALSO -- MIGHT ALSO ELICIT A LOT OF THE IMMUNE PROCESSES THAT ARE
ASSOCIATED WITH SEVERE ILLNESS FROM THE DISEASE.
I THINK THAT HAS TO BE WATCHED VERY CAREFULLY AND THAT'S BEEN A
STUMBLE STUMBLING BLOCK FOR A NUMBER OF
MALARIA VACCINES IN EARLY STAGE OF DEVELOPMENT.
WE HAVEN'T GOT THIS FAR AS WE ARE WITH THE CURRENT VACCINE,
THE RTSS VACCINE BEFORE.
SO RIGHT NOW I THINK ONE OF THE MAJOR OUTCOMES FOR THESE LARGE
FIELD TRIALS IN 11 SITES IN AFRICA IS NOT ONLY TO LOOK AT
THE IMMUNOGENICTY BUT THE OTHER VACCINES THAT ARE DELIVERED TO
CHILDREN ALONGSIDE IT.
>> THANK YOU ALL VERY MUCH FOR ATTENDING IN PERSON OR
VIRTUALLY.
PLEASE CONTINUE SENDING YOUR FEEDBACK.
WE ARE RECEIVING A LOT OF FEEDBACK.
AND REWE REALLY NEED TO CONTINUE IMPROVING OUR EVENTS.
WE'LL SEE YOU IN SEVERAL WEEK, SAME TIME, SAME PLACE.
ONE MORE ROUND OF APPLAUSE FOR