POVERTY: Neglected tropical diseases: Control, elimination or eradication?

Michael Regnier 7 Feb, 2012

 Last week, the world’s pharmaceutical companies announced new and renewed commitments to donating drugs needed to treat neglected tropical diseases (NTDs). Tackling these diseases requires more than providing hospitals and pharmacies with pills – usually, these drugs are actively distributed through mass administration programmes with the aim of controlling disease as well as treating the affected individuals. Michael Regnier spoke to Professor Moses Bockarie of the Liverpool School of Tropical Medicine to find out more about the strategies used.
There are basically three choices when deciding our response to endemic infectious diseases: control, elimination or eradication. On the face of it, it may seem obvious to pick eradication every time, but in all human history we have only managed to eradicate one disease – smallpox. Eradication is not easy, even when the characteristics of the disease in question are favourable. For many neglected tropical diseases (NTDs), control has been the most practical strategy.

Control
Control reduces the impact of a disease in a given area until it is no longer a major public health issue, explains Professor Moses Bockarie, Director of the Centre for Neglected Tropical Diseases at the Liverpool School of Tropical Medicine*. As a prime example, he describes the Onchocerciasis Control Programme (OCP), which was sponsored by four UN agencies including the World Health Organization (WHO) and the World Bank.

 Rivers like this one in West Africa were breeding sites for blackfly

Onchocerciasis, or river blindness, is caused by nematode worms that are passed from blackflies to humans. OCP began in 1974, using helicopter spraying to kill blackfly larvae in the rivers of 11 countries in west Africa. In 1987, the pharmaceutical company Merck Sharpe & Dohme (MSD, known as Merck & Co in North America) started to provide its drug ivermectin free to OCP so that the programme could expand to include a strategy of mass drug administration. The company’s donation continues today and MSD has committed to providing ivermectin free for as long as it is needed.
Bockarie says OCP was one of the most successful efforts of its kind: “It opened up thousands of acres of land for agriculture but the main outcome was it reduced onchocerciasis to a level where it was no longer of public health significance.” By 2002, transmission of onchocerciasis had been drastically reduced – almost stopped – in all of the participating countries except Sierra Leone, which was then in the grip of civil war.
According to the WHO, 600 000 cases of onchocerciasis were prevented by OCP and 18 million children born in areas where the risk of onchocerciasis is now controlled and minimal. OCP was followed by the African Programme for Onchocerciasis Control (APOC), which has extended the mass drug administration of ivermectin to the remaining African countries with endemic onchocerciasis.
The success of OCP was encouraging for similar schemes for other diseases such as lymphatic filariasis and schistosomiasis, although later efforts to implement disease control programmes were often initiated by scientists working in the field rather than international agencies or national governments. That there are several disease control programmes currently in place is a testament to the advocacy and dedication of those scientists, as well as the funders who support them and the national and international agencies that are helping to deliver the programmes on the ground.
A key feature of today’s disease control programmes is the level of coordination between them. “The common features of certain NTDs – their association with poverty, they are easily treated and the drugs are donated by pharmaceutical companies – allows for combination, improved ‘packaging’ to target them all together through preventive chemotherapy,” explains Bockarie. “Funders are happier to support these integrated programmes.”
By 2005/06, a package was in place to treat seven NTDs, saving 50 per cent on the cost of administrating each drug separately. Mass drug administration works for these diseases not only because the drugs are donated or provided at low cost, but also because the drugs can be given orally in a single dose every six or twelve months.

Elimination
Lymphatic filariasis (also called elephantiasis) is one of the diseases being controlled through integrated programmes – it is also treated with ivermectin – but it has already been successfully eliminated from China, Korea and ten African countries. Elimination means stopping transmission in a particular territory.
Elimination of lymphatic filariasis in certain countries has been possible because ivermectin is so effective, but there are other factors working in our favour, according to Bockarie: “The drug is very good, tools for diagnosis are very good. There is no natural reservoir for the parasite, so if you can eliminate it from humans, it is gone. If you reduce the parasite load in the community to less than 1 in 1000, transmission is impossible.”

 Man with elephantiasis of the lower regions, 1904

Like onchocerciasis, lymphatic filariasis is caused by thread-like nematode worms, although the worms that cause lymphatic filariasis are transmitted by mosquitoes rather than blackflies. Infection leads to thickening of the skin and other tissues, and massive swelling, particularly of the legs and male genitals. Of course, there are still many people with lymphatic filariasis in the countries where transmission has been successfully interrupted – it will take many more years for the signs of the disease to disappear.
Since OCP ended, strategies for onchocerciasis have also moved more towards elimination in certain countries. These were prompted, says Bockarie, by the recent upsurge in interest in NTDs generally. “We have the resources to monitor and evaluate progress and there is a bigger workforce available which means we can put in place protocols for effective monitoring.”
In its roadmap for NTDs published last week, the WHO says elimination of onchocerciasis is feasible in Latin America by 2015. In Africa, the WHO estimates the 12 APOC and 11 ex-OPC countries may all have achieved elimination by 2020, out of a total of 31 African countries affected by the disease.
Although onchocerciasis and lymphatic filariasis are treated with the same drug, it will not be simple to eliminate both diseases in all countries. “One of the biggest challenges is co-infection,” says Bockarie. “We can control onchocerciasis and lymphatic filariasis with existing tools but only in certain settings.”
One problem is another parasite called Loa loa, which is also sensitive to ivermectin. Unfortunately, in patients with large numbers of Loa loa parasites in their bodies, treatment with ivermectin can cause serious, potentially fatal, effects when dead Loa loa worms enter the bloodstream. So ivermectin cannot be used to treat onchocerciasis or lymphatic filariasis where Loa loa infections are also prevalent. This does not mean, however, that we have to give up.
“Different strategies are being developed,” says Bockarie, “such as more refined, higher resolution mapping.” Knowing precisely where the diseases are endemic is vital to using resources in the most efficient and effective way. The standard approach for onchocerciasis and lymphatic filariasis has been to go to a district and sample the people. If more than 1 per cent are infected, the whole district is classed as endemic and is eligible for treatment. This does not work in areas with Loa loa – mapping has to be done at the village level if the status of all three infections is to be accurately determined and the right strategy implemented.
In areas with co-infection of Loa loa, the drug albendazole can be used first to reduce the levels of Loa loa infection in order to dampen the adverse effects of treatment with ivermectin that follows. Of course, as with the early days of OCP, control and elimination efforts do not have to focus on drugs. Other approaches include using antibiotics to kill Wolbachia, a bacterium that lives in lymphatic filariasis and onchocerciasis parasites but not in Loa loa. The parasites are dependent on Wolbachia, so killing the bacterium kills the parasites. However, there are other issues with using antibiotics: treatment is over one or two weeks rather than in a single annual dose as with the antiparasitic drugs, which makes it harder to ensure people get the full course of treatment.
Targeting the insects that transmit the parasites – the flies that carry Loa loa, or the mosquitoes that transmit the worms that cause lymphatic filariasis – is called vector control, and it is an approach that Bockarie has been championing for years: “What pushed me into public health and advocacy,” he explains, “was that vector control was being ignored. The lymphatic filariasis control programme had two main objectives: drugs to reduce infection in humans, and reduce or manage morbidity. Vector control was missing. When the lymphatic filariasis programme was developing, there was no space to talk about mosquitoes.”

 Mosquitoes killed by insecticide on a treated net

Bockarie’s early training was in medical entomology – the use of scientific knowledge about insects to understand and address human disease. He began studying malaria but mosquitoes that transmit malaria also transmit lymphatic filariasis and other NTDs, although this sometimes seems to get overlooked: “In the last two to three years, we’ve seen the impact of [insecticide treated] bed nets on malaria,” he says. “But we know bed nets would impact on lymphatic filariasis as much as, if not more than, malaria – what’s happening in lymphatic filariasis?”
While the integrated efforts to control and eliminate various NTDs are growing, it seems there is a need to integrate them further with efforts against the big three infectious diseases – malaria, tuberculosis and HIV/AIDS – as well.

 Collecting water from an unprotected pond in Benin

Eradication

Eradication can be simply defined as global elimination. It was achieved in the 20th century with smallpox and we may be close to eradicating a second disease in the form of dracunculiasis, or Guinea worm disease. How? “Stop people drinking infected water,” says Bockarie. “It’ll completely eradicate it, get rid of the parasite completely.” It sounds simple, although as dracunculiasis is another neglected tropical disease, simple doesn’t necessarily mean easy, but the WHO has set a firm target in its NTDs roadmap to eradicate dracunculiasis by 2015.
Professor David Molyneux, acting chair of the UK Coalition against NTDs and one of the scientists who introduced the term ‘neglected tropical diseases’, has described progress on dracunculiasis so far as remarkable: “The total number of cases has declined from well over three million in the late 1980s to only 1060 reported in 2011. The end is in sight. What is remarkable is that this has been done without a drug or a vaccine. Applying basic public health principles – health education, case containment, surveillance, water filtration and enhanced access to safe water has been critical.
“Success is in sight but as always, the cost remains as we travel down the final mile and need to identify the last infected villages and isolate final cases.”
The Carter Center has been a particularly strong advocate for action against dracunculiasis over the past 25 years and will play a role along with a number of funders including the UK Department for International Development and the Gates Foundation in achieving the 2015 eradication target. Another NTD called yaws is set for eradication by 2020 but for the other NTDs, control and national or regional elimination strategies remain crucial.
 Professor Moses Bockarie

Implementing the strategy
Bockarie is Sierra Leonean. I finish our interview by asking him about science in Africa. Although he recognises the current lack of capacity as an important issue, he is optimistic about the growth of African science and its role in tackling NTDs.
“We have funding to support countries to achieve elimination,” he says. “This includes support for governments to do mass drug administration, operational research and capacity building. In Sierra Leone, just introducing operational research led to an increase in Sierra Leonean-led publications in the last couple of years compared to the 20 years prior to that.
“At the Liverpool School, we have part-time PhD students in Africa, basing their PhD research on the work they’re doing at home; we’ve built regional laboratories.
“We’re also working to take a more scientific approach to evaluating capacity-building,” he adds, “working to measure the effect of such programmes. Capacity-building will lead to sustainability and it will provide the local support and resource to do the required surveillance on which elimination of NTDs depends.”
This is one of a series of blog posts accompanying a Wellcome News feature on neglected tropical diseases. Next week: ‘One Health’ – why looking at human and animal health together can help in the fight against NTDs.

* The Liverpool School for Tropical Medicine and the University of Liverpool are collaborative partners in the Liverpool Wellcome Trust Tropical Centre and in the Wellcome Trust’s Major Overseas Programme in Malawi.
Related resources: The Wellcome Trust website has a number of scientific animations showing the life cycles of many parasites, bacteria and viruses that cause disease including many NTDs such as Lymphatic filariasis.
http://wellcometrust.wordpress.com/2012/02/07/neglected-tropical-diseases-control-elimination-or-eradication/#more-8966

MALARIA: Bhutan declares malaria elimination

 February 2, 2012 by Ted Purlain

 Malaria
According to a Bhutanese government report, the small, landlocked kingdom has virtually eliminated the incidence of malaria within its borders over the past 17 years.
The report, published by Bhutan’s Vector-borne Disease Control Program, revealed that Bhutan had one death related to the mosquito-borne illness in 2011. In 1994, there were approximately 40,000 malaria cases reported. By 2011, there were less than 200 cases confirmed, according to SciDev.net.
The VDCP lauded its successes in the face of a number of challenges that included difficult terrain, mudslides, poor road access to a large portion of the population and a constant influx of labor from India, where malaria remains endemic.
“Given these and other challenges, the recent success in reducing malaria incidence may contain lessons for other countries,” the report said, SciDev.net reports.
Bhutan is now considered to have almost achieved a zero transmission rate for indigenous cases, a remarkable feat for any country where malaria is prevalent.
“We target to eliminate malaria by 2016,” Thinley Yangzom, the chief program officer of the VDCP, said, SciDev.net reports.
Health officials in Bhutan credit malaria’s decline to improved access to diagnosis and treatment facilities, as well as the continued use of vector control programs.
Yangzom said that Bhutan and VDCP will remain vigilant. In the coming years, he expects malaria to spread into colder regions due to global warming.
“Climate change will definitely have an impact on malaria incidence in the future,” Yangzom said, according to SciDev.net.
http://vaccinenewsdaily.com/medical_countermeasures/317811-bhutan-declares-malaria-elimination/

MALARIA: Do we have tools and guidelines for malaria elimination?

Bill Brieger : 07 Dec 2011

Sessions at the current American Society of Tropical Medicine and Hygiene in Philadelphia have focused on progress in the global elimination of lymphatic filariasis (LF). Filariasis and malaria have some elements in common, such as some mosquito vectors, and possibly malaria elimination efforts could learn from LF elimination.
The duration of a typical filariasis elimination program might span around 10 years, much shorter than expected for malaria, where Roll Back Malaria has already been working hard for 13 years. Even with this difference LF elimination has important surveillance tools needed for the end game that can be adapted for malaria. As the figure here shows, the first step is mapping which can take at least a year.
Then there are at least five annual mass drug administrations (MDA) with ivermectin or DEC and albendazole. Monitoring goes along with distribution, and as pointed out at a panel presentation at ASTMH, determines whether the program can enter Step 3 (three rounds of annual surveillance) or complete a few more MDA rounds. Eventually the project site is certified as having eliminated filariasis.
An ASTMH symposium highlighted the challenges: “The decision to implement a mass drug administration (MDA) program for LF is based on convenience sampling to demonstrate that the prevalence of infection is greater than 1% in a selected district or implementation unit. Making the decision to stop MDA has been a challenge for countries,” when prevalence drops below 1%.

Fortunately those involved in LF have tools and guidelines to focus their efforts. These guide initial mapping and choice of diagnostic tools, ongoing program monitoring and endline Transmission Assessment Surveys (TAS) The purpose of the guidelines is …



“Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission. Th is manual is designed to ensure that national elimination programmes have available the best information on methodologies and procedures for (i) monitoring MDA, (ii) appropriately assessing when infection has been reduced to levels where transmission is likely no longer sustainable, (iii) implementing adequate surveillance aft er MDA has ceased to determine whether recrudescence has occurred, and (iv) preparing for verifi cation of the absence of transmission.”
The guideline manual provides general guidance to national programmes but reminds program managers that each program is unique and may require further technical guidance.
Several countries, especially in the Asia-Pacific Region and Southern Africa are working toward malaria elimination. Such tools adapted to malaria program needs are required. One of the challenges for the TAS is that while countries have received donations of medicines to eliminate LF, they have found it harder to find or allocate funds to do the necessary surveillance to know when to stop interventions and verify elimination. This also rings true for malaria - donors and governments should not stop funding malaria elimination until certification has been achieved.
http://www.malariafreefuture.org/blog/?p=1342

MALARIA: the potential for elimination

Eventually two issues called into question the validity of algorithms and clinical judgement if malaria were to be eliminated eventually. First, if we actually went to scale in providing malaria treatment for all suspected cases of malaria, we might never find adequate funding to buy all the needed ACTs, which cost upwards to 10 times that of the predecessors. Secondly, if we were ever to gain a true picture of the malaria situation as interventions were scaled up and prevalence decreased, we could no longer base our health information systems on clinical or suspected cases....
http://www.malariafreefuture.org/blog/?p=1185

MALARIA: Net coverage; how much is enough?

 Bill Brieger : 26 Mar 2011
We are unlikely to eliminate mosquitoes, according to Tanya Russell and colleagues, but she notes that this should not stop us from implementing all available interventions. Specifically their study of malaria vectors in Tanzania found that the at reduced densities of mosquito populations, they try to reproduce more, meaning we may never get below 10% mosquito elimination.
Instead, a member of the National Malaria Control Program in Tanzania says our goal “should be to reduce, and eventually halt, transmission of the parasite, rather than eliminating the vector.” If we can achieve no more than 90% elimination of mosquitoes, what is a realistic coverage figure for malaria interventions?
Applications of net and case management strategies in Rwanda and Ethiopia have definitely shown that major drops in malaria incidence are possible. But the RBM targets of 80% coverage (85% for the US President’s Malaria Initiative) are elusive. Demographic and malaria surveys from Senegal, Liberia and Nigeria show that even in homes that own nets, net use among people at most risk, does not reach this target.
Are we really sure that 80% is the right target?
Fred Binka was one of the first to demonstrate that people living in homes without nets can be protected by their neighbors’ nets, which kill mosquitoes in the community. ITNs “provided very good personal protection to children using them, and also protected nonusers in nearby compounds. Among nonusers, the mortality risk increased by 6.7% with each additional shift of 100 m away from the nearest compound” with nets. This led the researchers to speculate on the need to study whether the “mass effect from a small number of highly dispersed nets would provide equivalent protection to complete coverage.”
A few years later William Hawley and co-researchers reported that, “protective effect of ITNs on compounds lacking ITNs located within 300 meters of compounds with ITNs for child mortality, moderate anemia, high-density parasitemia, and hemoglobin levels.”
As part of the move toward universal coverage, Killeen and colleagues examined the importance of considering all household members, not just the ‘vulnerable.’ The group condluded that …
Using field-parameterized malaria transmission models, we show that high (80% use) but exclusively targeted coverage of young children and pregnant women (20% of the population) will deliver limited protection and equity for these vulnerable groups. In contrast, relatively modest coverage (35%–65% use, with this threshold depending on ecological scenario and net quality) of all adults and children, rather than just vulnerable groups, can achieve equitable community-wide benefits equivalent to or greater than personal protection.
Barat has called for ‘data driven decision making‘ in the effort to eliminate malaria. Using data in models as done by Killeen is a further important step. The onchocerciasis control community has been working with such models for over 15 years now. New data are fed into the Onchosim model based on program progress such that it is possible to forecast that onchocerciasis could be eliminated from areas with high initial prevalence if 65% coverage of ivermectin treatment were maintained for at least 25 years.
Unlike onchocerciasis control, malaria elimination rests on multiple interventions. This makes modeling much more urgent, as outlined by malERA’s research agenda for eradication. Since universal coverage unfortunately does not mean universal usage, we need to seek valid data and models to help us plan for distribution of malaria interventions more strategically in ways that are affordable and can be maintained and at the same time can achieve maximum reductions in morbidity and mortality.
http://www.malariafreefuture.org/blog/?p=1181

MALARIA: Rwanda: Nation On Track to Become Malaria-Free

Edwin Musoni : 9 March 2011
Kigali — Rwanda may be the first country to eliminate Malaria in the region if all strategies set forward are implemented according to plan.
According to the Director of Malaria unit in TRAC Plus, Dr. Corine Karema, the country intends to enter a pre-elimination phase come 2012.
"We have a strategic plan to enter a pre-elimination phase in 2012, and according to the internal review we did with the country team, we realized that we have achieved more than 80 percent of our targets," said Karema, who is also the acting Director General of Trac Plus.
She made the remarks at the beginning of a two-week meeting of experts aimed at reviewing progress regarding Malaria control.
"Today, we have external reviewers who are here to help us know where we are and re-orient our strategies towards pre-elimination of Malaria by 2012," she explained.
For the pre-elimination phase, the health sector had to first consolidate all interventions, and currently the country plans to upgrade universal coverage of mosquito nets distribution to ensure that all people in the country use them.
"The next step will be discussing with all neighbouring countries to have harmonized Malaria control strategies," she said.
"We have distributed more than six million mosquito nets since 2009 and we ensured that over 90 percent of all households in the country have at least three mosquito nets," said Karema.
During the same event, the Permanent Secretary in the Ministry of Health, Dr. Agnes Binagwaho, said that her ministry normally conducts regular Malaria reviews, but the current one was the first that brought on board external experts and health partners.
"We will review all the achievement and challenges. This is going to be done by external reviewers who will look at our policies, strategies and programme implementation," said Binagwaho.
She emphasized that; "Malaria control in the country is performing well; we have better results than other countries. Programmes are not fragmented; they are all integrated in the basic health care."
Although Rwanda has made huge strides in malaria control, Binagwaho said that the country faced a problem two years ago, when there was an eight-month delay in supplying mosquito nets.
"In the process, 600 people died of malaria but we made a quick recovery," she said.
Meanwhile, the head of the review team, Dr. Akpaka Kalu said that; "We have heard very good things about Malaria control in Rwanda. This country has a vision of moving toward Malaria elimination, and hopefully a Malaria-free country. So the assignment we have is to review the programmes and try to define strategies that would lead Rwanda towards a Malaria free future."

Kalu is an advisor to the World Health Organization on Malaria

http://allafrica.com/stories/201103090022.html

MALARIA: The cost of a malaria-free world

REUTERS : (Additional reporting by Katy Migiro in Kilifi; Editing by Simon Robinson and Sara Ledwith)

Dec. 14, 2010

THE 'E' WORD
It was Gates and his wife Melinda who on Oct. 17, 2007 first dared to revive what in health circles is known as the “e-word” in relation to malaria. Seizing the moment at a meeting of malaria specialists in Seattle, Gates declared: “We will not stop working until malaria is eradicated.” Melinda added that to aspire any lower would be “timid.” The World Health Organization went on to endorse the same ambitious goal.
Talk of eliminating malaria from endemic countries, or eradicating it from the face of the planet, had been considered dangerous and naive ever since a previous project, the Global Malaria Eradication Programme, was abandoned in 1969. That campaign had succeeded in eliminating malaria from Europe, North America, the Caribbean and parts of Asia and South-Central America, but failed to achieve anything like global reach. What was the point of calling for something that was virtually impossible and almost prohibitively expensive?
Richard Feachem, a malaria specialist and director of the Global Health Group at the University of California, San Francisco (UCSF) said the Gates’ speeches were a “shock to the system” for the malaria community. “For a couple of decades before that, the e-words were simply not used in polite company,” he told a recent meeting of malaria specialists in London. “And then suddenly, here were the richest couple in the world with a foundation largely dedicated to global health saying let’s go for eradication.”
Three years on, it’s too early to judge progress — most experts say wiping out malaria could take another 50 years. But scrutinizing the economic realities of eradicating versus controlling malaria has become a pressing question.
One person who has taken a hard look at the costs and benefits of eliminating malaria, versus controlling it at low levels, is the Clinton Health Access Initiative’s Sabot. In a paper published in The Lancet in October, Sabot looked at four malaria-endemic countries — China, Mauritius, Swaziland and Tanzania - to assess the likelihood that, over 50 years, eliminating malaria would save more money than controlling it. He concluded that elimination had a low chance of saving costs in the first three. In Tanzania, he found only a moderate chance that elimination would be cost-saving.
Sabot and others say countries could focus instead on achieving “controlled low-endemic malaria,” where the disease still infects and might still kill, but no longer ranks as a major health concern. “We know that controlling malaria and bringing it from high levels down to negligible levels is a fantastic investment — one of the best buys in global health,” he says.
Several malarial countries — including some in Africa — have already managed to fight the disease down to levels where death rates barely register. South Africa had 37 deaths from malaria in 2007; Swaziland had 14; Botswana only six. In comparison, South Africa had 350,000 AIDS-related deaths in the same year, while Swaziland had around 10,000 and Botswana had around 11,000.
Why pour so much cash into an ideal whose economic benefits can pale against other health problems? That question is especially relevant when you understand it’s the jump from keeping malaria at low levels to eradicating it altogether that makes things really costly. Every single last case has to be tracked down and treated, thousands of blood tests conducted and analyzed for infection; every border crossing and airport monitored to stop new cases coming in.
It is an issue that divides experts. MVI’s Loucq thinks it is a price worth paying and draws a comparison with smallpox. “We know that the first 50% is easy — that’s the low-hanging fruit. The next 25% are very convenient and only a little bit more difficult to get. But the final 1% requires a lot of money and doesn’t look very cost effective,” he says. “For the detection of the last cases, when people were running all over the globe chasing those last few — the costs of that were enormous — but they still did it.”
Sabot says it’s at the point where malaria is barely a problem — even if it remains — that the economic questions get tougher. “How should the global community be spending its limited pot of resources in malaria?” he asks. “It’s a very open question given this uncertainty on cost-benefit, whether those international institutions would want to invest in elimination as opposed to focusing their investments in control, where there is a very well-known and visible high rate of return.”

MALARIA-FREE TOURISM
Of course there are reasons to get rid of malaria — billions of them. In the first part of the 20th century, 178 countries had endemic malaria; now 99 do. Britain and the United States eradicated it in 1952, Australia in 1970. Morocco is the latest place to rid itself of the disease, declaring victory in 2005.
In a recent paper, the UCSF’s Feachem identified 32 countries that have now controlled the disease to a point where they could move towards wiping it out. They are all on the fringes of the malaria map. “More than 2 billion people live in the 32 malaria-eliminating countries,” he said. “The benefit to these individuals, their countries, their neighbouring countries and the world from continuing to shrink the malaria map is clearly large, even if we cannot fully quantify it or express it in terms of U.S. dollars.”
Experts trying to do just that calculate the disease costs African healthcare systems around $12 billion US a year. When you add it all up, malaria lops an estimated 1.3% off annual economic growth in the worst-hit countries, which include the likes of Democratic Republic of Congo and Nigeria. It may not sound much but that’s around half the total rate of growth in gross domestic product that a typical industrialized country might expect outside recession.
Research shows a firm link between reducing the disease and increasing economic output — because workers are healthier and take less time off work. Unsurprisingly, children without malaria do better at school.
Though hard to measure, there are other ways cutting malaria is likely to help. Tourists may be more attracted to parts of Africa that are malaria-free, for instance — a potential boon to places such as Kenya where tourism is one of the main foreign exchange earners. Foreign investors may also be more drawn to countries that have dealt with the problem.

THE SMELL OF WATER
For the people of Kilifi, the debate is little more than a distraction from life’s daily battles. Tourists bathe on the region’s white sand beaches, but most residents struggle to make ends meet by selling charcoal or picking up casual labour.
“Growing up in an average family with many siblings in the house, we knew when the malaria season came and when one of us in the family had a bout of malaria, we knew it was a question of time before it would be the next and the next and the next,” says Roma Chilengi, one of the doctors working on the vaccine trials in the district. “By the time it hits you, you have these terrible fevers, these headaches, and the mere smell of water makes you want to vomit.”
Chilengi is excited about the prospect of the first malaria vaccine, but wary of hoping for too much after years of seeing other measures like mosquito nets, insecticides and anti-malarial drugs fail to end the disease. As for the price, there’s little to dwell on. “All these things cost a lot of money,” he says. “But this money is nothing compared to the burden that malaria hits us with.”
http://chealth.canoe.ca/channel_health_news_details.asp?news_id=31495&rss=67&rid=999999&news_channel_id=1020&channel_id=1020&rot=3

MALARIA: elimination 'most feasible' in Latin America

María Elena Hurtado and Mićo Tatalović
29 October 2010


Flickr/trebol-a

Malaria elimination is most feasible in Latin America and least feasible in Central and West Africa, according to a study mapping 99 malaria-endemic countries.
Malaria elimination has been ongoing since the 1900s, Richard Feachem, director of the Global Health Group at the University of California, San Francisco, said at a press conference in London, United Kingdom, today.
Feachem said that a reasonable estimate for global eradication of malaria is 2050–2060. He was speaking at a launch of a series of papers on malaria elimination in The Lancet.
One paper examined how likely different countries are to stop transmission of Plasmodium falciparum malaria with existing control measures — and thus eliminate the disease.
The study used existing data to rank countries according to technical and operational feasibility of elimination. This included factors such as the intensity of disease transmission, the state of health systems, infrastructure, political stability, and political commitment to achieving and sustaining elimination.
A lack of data on Plasmodium vivax meant the study could only produce robust estimates for P. falciparum.
The results show that eliminating P. falciparum is most feasible in Latin America, where less than a 50 per cent reduction in 2007 transmission levels is needed to achieve elimination.This is due to economic development, improved health systems, and good accessibility to populations at risk in the region, as well as the relatively low transmission levels of the disease.
Latin American countries on the road to elimination are: Argentina, Costa Rica, Dominican Republic, El Salvador, Mexico, Panama and Paraguay. Haiti was on this list before the January earthquake.
In Africa, only a few countries — including Botswana, Djibouti and Swaziland — are well placed to eliminate P. falciparum with existing methods. In this region a new vaccine will likely be necessary for malaria elimination, said Geoff Targett, emeritus professor of immunology of parasitic diseases at London School of Hygiene and Tropical Medicine and member of the Malaria Elimination Group.
Countries in West and Central Africa face the greatest obstacles. They need a more than 90 per cent reduction in 2007 transmission levels to achieve elimination.
"Before embarking on an elimination campaign, countries must conduct a comprehensive and rigorous feasibility assessment that draws on detailed evidence that is not easily summarized at global scales," Andrew Tatem, lead author of the study and a researcher at the Emerging Pathogens Institute of the University of Florida, United States, told SciDev.Net.
Justin Cohen of the Malaria Control Team at the global health organisation Clinton Health Access Initiative said that "this work demonstrates that quantitative approaches can provide objective insights into the feasibility of malaria elimination — a sometimes contentious subject".
The Malaria Elimination Group will have its annual meeting at the Mexico–Guatemala border in ten days time "to review the Central American experience with representatives from those countries to ask about their views on what is possible for them," Feachem said.
"It will take a lot of regional collaboration, and the cross-border dimension will be critical because there are significant population movements across those borders." Such cross-border movements can import malaria cases to countries that have eliminated the disease.
http://www.scidev.net/en/news/malaria-elimination-most-feasible-in-latin-america.html

MALARIA: Control vs elimination - the great malaria debate

Photo: Wendy Stone/IRIN

Bed nets are a first step
1 November 2010 (IRIN) -
In 2007, Bill and Melinda Gates committed their foundation to eradicating malaria. It was, said Richard Feachem, director of the Global Health Group, part of the University of California, San Francisco, “a shock to the system for the malaria community, because for a couple of decades the ‘E’ words, eradication and elimination, were not used in polite company”.
That reticence was due to the very public failure of elimination campaigns, but the debate has been re-opened with the publication by the medical journal, The Lancet, of a special series on the subject.
The study sets out the real progress that has been made, assesses the chances for countries that might feel ready to try to eliminate all transmission within their borders, weighs up potential costs and benefits of elimination over control, and establishes research priorities for the tools that can make elimination possible.
The overall message is that malaria can be eliminated – indeed, has been wiped out in many places – but moving from control to elimination might not necessarily save money, or be quick or simple.
In 1945, the world malaria map was pretty much red all over, endemic almost everywhere except in the far north – Norway, Sweden, Iceland and Greenland, and in the Swiss alps. Now, 65 years later, the whole of Europe and North America is malaria free, as are Russia, Australia and some southerly parts of Latin America, as well as some islands, such as Mauritius.
The push to eliminate malaria is now going on along the borders of the world’s malaria zone, in North Africa and the Middle East, Central Asia, China and Central America. Morocco was certified malaria-free earlier this year; Turkmenistan just last week. Meanwhile, countries in Latin America and southern Africa are working to shrink the malaria zone in the south.
These are countries that have already achieved a high degree of malaria control, through vector control, the use of bed-nets, and effective diagnosis and treatment. Huge social and economic benefits have been realized. Children do not miss school; adults are no longer too debilitated to work.
Balancing act
Bruno Moonen, of the Clinton Health Access Initiative, says the decision to move from control to elimination is not as easy or as obvious as one might imagine. “When infection gets below 1 percent of the population, you have to make a choice. And you may choose to say, ‘We have almost no deaths and very few cases, and we can handle that’.”
He makes the point that elimination is much harder than control: all malaria cases have to be fully treated, including mild cases that might not normally have presented at a clinic. Then the sick person’s family and neighbours have to be screened, looking for people who have no symptoms but are carrying the parasite. Then they have to be treated with an aggressive drug regimen, even though they are not ill.
This is complicated by the fact that in most countries that could try to eliminate malaria, the predominant strain of the parasite is Plasmodium Vivax, which can lie dormant in the liver for years. Detection techniques for the dormant form are not totally effective, and the only drug available to eliminate them from the system – Primaquine – can cause a potentially fatal reaction in some people. Giving low doses over two weeks is safer, but raises compliance problems in healthy people who can see no obvious reason why they should be taking drugs at all. The Lancet identifies better tests for P Vivax and better drugs against the dormant form of the parasite as key research priorities.
And all this time control measures cannot be relaxed. As one of The Lancet contributors, Oliver Sabot, put it: “The moment you take your eye off the ball, malaria is going to come roaring back.” Even when a country is malaria-free, there still has to be surveillance to catch imported cases. Geoffrey Targett, of the London School of Tropical Medicine, said the UK still sees about 1,500 imported cases of malaria a year.
Sabot’s studies of Zanzibar, Mauritius, Swaziland and two areas of China indicate that elimination would probably be more expensive than low level control in most cases. Only Zanzibar showed a clear cost benefit, because its current control programme is already very expensive. His conclusion: “Someone considering elimination should not consider cost savings as one of the benefits.”
There may of course be other, less tangible benefits. Tourists may prefer to visit malaria-free Mauritius, for instance, rather than nearby Madagascar. There would also be a huge sense of accomplishment in being able to say a country had conquered the disease.
So is there a risk of governments embarking on elimination as a prestige project, without thinking through the implications? Feachem thinks there is, telling IRIN: “There are a number of malaria-endemic countries that have begun to speak about elimination in a way which is almost certainly premature… In our view they should do a feasibility study and be influenced by the mass of evidence, and for some of these ‘premature eliminators’, if they did such a study, they might retreat and say, ‘Not yet,’ not just because of their own situation but also because of their neighbours’.”
Even so, in the long term Feachem believes malaria can be conquered. “My guess,” he says, “would be 2050 or 2060. That would be a reasonable guess for complete eradication.”
http://www.irinnews.org/Report.aspx?Reportid=90938

MALARIA: Can malaria be eliminated?

02 September 2010
Since the perceived failure of the Global Programme for Malaria Eradication in 1969, the eradication of malaria has not been considered a feasible goal. However, in October 2007 the goal of malaria eradication was resurrected by Melinda and Bill Gates, and this aspiration has subsequently been endorsed by the WHO and by the Roll Back Malaria Partnership. This change in direction of malaria control has provoked a vigorous debate within the malaria research and control communities as to whether resurrection of the goal of eradication at this point in time is helpful or likely to be counterproductive. The consensus that has emerged is that eradication of malaria, although theoretically possible, is not likely to be feasible within the medium term using existing control tools. However, malaria elimination (cessation of local transmission) is a realistic short- to medium-term goal for an increasing number of countries that are already bringing malaria under control.
http://www.malarianexus.com/articles/read/62/can-malaria-be-eliminated/

MALARIA: Reducing Plasmodium falciparum Malaria Transmission in Africa: A Model-Based Evaluation of Intervention Strategies

Background. Half the world’s population is at risk of malaria, and every year nearly one million people—mainly children living in sub-Saharan Africa—die from this mosquito-borne parasitic disease. Most malarial deaths are caused by Plasmodium falciparum, which is transmitted to people by mainly night-biting Anopheles mosquitoes. When infected mosquitoes feed on people, they inject sporozoites, a parasitic form that replicates inside human liver cells. After
a few days, the liver cells release ‘‘merozoites,’’ which invade red blood cells where they replicate rapidly before bursting out and infecting more red blood cells. This increase in the parasitic burden causes malaria’s characteristic fever.
Infected red blood cells also release ‘‘gametocytes,’’ which infect mosquitoes when they take a blood meal. In the mosquito, the gametocytes multiply and develop into sporozoites, thus completing the parasite’s life cycle.
Malaria can be prevented by spraying the insides of houses (where most anopheles species feed and rest) with insecticides (indoor residual spraying, IRS) and by sleeping under bed nets that have been treated with long-lasting
insecticides (long-lasting insecticide nets, LLINs). Mass screening and treatment (MSAT) with effective antimalarial drugs can also reduce malaria transmission.
Why Was This Study Done? Early attempts to eradicate malaria (reduce its global incidence to zero) in the 1950s reduced the incidence of malaria to zero in some countries (malaria elimination) and greatly reduced malarial illnesses and
deaths in others (malaria control). However, this eradication program was aborted in the 1970s in part because of emerging drug and insecticide resistance. Recently, the advent of artemisinin-based combination therapies and new insecticides and the prospect of a malaria vaccine have renewed interest in
controlling, eliminating, and ultimately eradicating malaria.
Consequently, in September 2008, the Roll Back Malaria Partnership launched the Global Malaria Action Plan, which aims to reduce malaria deaths to near zero by 2015. But are the currently available tools for reducing malaria transmission
sufficient to control and eliminate malaria in Africa, the continent where most malaria deaths occur? In this study, the researchers use a new mathematical model of P. falciparum transmission to investigate this question.
What Did the Researchers Do and Find? The researchers’ P. falciparum transmission model consists of ‘‘compartments’’ through which individuals pass as they become infected with parasites, develop immunity, become
infectious to mosquitoes, and so on. The researchers used published data about parasite prevalence (the proportion of the population infected with parasites) and about relevant aspects of mosquito, parasite, and human biology, to
estimate the chances of an individual moving between compartments. Finally, they used the model to explore the impact over 25 years of increased coverage of LLINs, IRS, and MSAT, and of a future vaccine on malaria transmission in six
representative African settings. In a low-transmission setting, 80% coverage with LLINs reduced the parasite prevalence to below 1% in all age groups. In two moderate-transmission settings, LLIN scale-up alone failed to reach this target but the addition of IRS and MSAT drove the parasite prevalence below 1%. However, this combination of interventions did not control malaria in a moderate-transmission setting in which a mosquito species that bites and rests outside houses contributes to malaria transmission. Finally, in two hightransmission
settings, parasite prevalence could be driven below 1% only by setting unrealistic coverage targets for existing interventions.
What Do These Findings Mean? This new mathematical model greatly simplifies the complex dynamics of malaria transmission and includes several assumptions about which there is considerable uncertainty. The findings of this study are not, therefore, firm predictions of the future of malaria control in specific settings. Nevertheless, they suggest that it should be possible to make large reductions in malaria transmission and the associated disease burden in Africa over the next 25 years using currently available tools. Specifically, in regions where transmission is low or moderate and mosquitoes mainly feed indoors, it should be possible to reduce parasite prevalence to less than 1% provided a sustained intervention program is achieved. Importantly, however, these findings suggest that in regions where malaria transmission is high or where mosquitoes rest and bite outside houses, new approaches will be needed to control and eliminate malaria.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000324

MALARIA: Can malaria be eliminated?

Since the perceived failure of the Global Programme for Malaria Eradication in 1969, the eradication of malaria has not been considered a feasible goal. However, in October 2007 the goal of malaria eradication was resurrected by Melinda and Bill Gates, and this aspiration has subsequently been endorsed by the WHO and by the Roll Back Malaria Partnership. This change in direction of malaria control has provoked a vigorous debate within the malaria research and control communities as to whether resurrection of the goal of eradication at this point in time is helpful or likely to be counterproductive. The consensus that has emerged is that eradication of malaria, although theoretically possible, is not likely to be feasible within the medium term using existing control tools. However, malaria elimination (cessation of local transmission) is a realistic short- to medium-term goal for an increasing number of countries that are already bringing malaria under control.
http://www.malarianexus.com/articles/read/62/can-malaria-be-eliminated

MALARIA: Uganda fails to reduce malaria by 50%

27th July, 2010
UGANDA has performed poorly in the fight against malaria due to the suspension of funding by the Global Fund in 2005 over massive corruption. As a result, Uganda is not among the countries in Africa that have reduced malaria infections and deaths by 50% as it was envisaged. Countries that have reduced morbidity and mortality by 50% include Rwanda, Tanzania, Zanzibar, Eritrea, Botswana, Cape Verde, Namibia, South Africa, Zambia, Swaziland, São Tomé and Príncipe. The nations were expected to achieve universal distribution of insecticide-treated mosquito bed-nets, increase anti-malarial distribution and treatment and spraying to control mosquitoes that transmit the malaria parasite.
http://www.newvision.coug/D/8/13/727097

MALARIA: An evaluation of historical and current definitions of malaria elimination

22 July 2010
Abstract (provisional)
Decisions to eliminate malaria from all or part of a country involve a complex set of factors, and this complexity is compounded by ambiguity surrounding some of the key terminology, most notably "control" and "elimination." It is impossible to forecast resource and operational requirements accurately if endpoints have not been defined clearly, yet even during the Global Malaria Eradication Program, debate raged over the precise definition of "eradication." Analogous deliberations regarding the meaning of "elimination" and "control" are basically nonexistent today despite these terms' core importance to programme planning. To advance the contemporary debate about these issues, this paper presents a historical review of commonly used terms, including control, elimination, and eradication, to help contextualize current understanding of these concepts. The review has been supported by analysis of the underlying mathematical concepts on which these definitions are based through simple branching process models that describe the proliferation of malaria cases following importation. Through this analysis, the importance of pragmatic definitions that are useful for providing malaria control and elimination programmes with a practical set of strategic milestones is emphasized, and it is argued that current conceptions of elimination in particular fail to achieve these requirements. To provide all countries with precise targets, new conceptual definitions are suggested to more precisely describe the old goals of "control" - here more exactly named "controlled low-endemic malaria" - and "elimination." Additionally, it is argued that a third state, called "controlled non-endemic malaria," is required to describe the epidemiological condition in which endemic transmission has been interrupted, but malaria resulting from onwards transmission from imported infections continues to occur at a sufficiently high level that elimination has not been achieved. Finally, guidelines are discussed for deriving the separate operational definitions and metrics that will be required to make these concepts relevant, measurable, and achievable for a particular environment.
http://www.malariajournal.com/content/9/1/213

MALARIA: 'Needle-Free' Intervention as Natural Vaccine Against Malaria

July 23, 2010 — A study published in the journal Science Translation Medicine proposes that preventative treatment with affordable and safe antibiotics in people living in areas with intense malaria transmission has the potential to act as a 'needle-free' natural vaccine against malaria and may likely provide an additional valuable tool for controlling and/or eliminating malaria in resource-poor settings.
The research, conducted by a multinational team of researchers from the London School of Tropical Medicine and Hygiene (LSHTM), Heidelberg University School of Medicine, the Max Planck Institute for Infection Biology, Germany, and the KEMRI-Wellcome Trust Research Programme, Kenya, found that infection with malaria parasites during administration of preventative antibiotics developed a vaccine-like immunity against re-infection.
Approximately half the world's population is at risk of malaria and about one million people (mainly children living in sub-Saharan Africa) die each year from malaria, a mosquito-borne parasitic disease. Malaria parasites are transmitted to people through the bite of an infected Anopheles mosquito. Only an estimated 10 to 100 parasites per mosquito bite invade the liver where they replicate. About a week after infection, tens of thousands of parasites are released into the bloodstream where they are responsible for malaria's recurring fevers and cause life-threatening complications.
In this study, the researchers showed that the antibiotics caused a cellular defect in malaria parasites during their passage into the liver of the infected host. This action did not prevent parasite replication in the liver but blocked the malaria parasite's fatal conversion to the disease causing blood stage. The very late arrest of parasites in the liver allowed the immune system to mount a robust defence against subsequent infections, akin to experimental whole organism vaccine strategies using attenuated parasites.
As already established, antibiotics, especially in combination with other anti-malarial drugs, are safe and affordable drugs against an acute malaria infection. The novel concept is to take advantage of the immunological benefit of antibiotic prophylaxis in areas of moderate to high malaria transmission. In these settings, humans are continuously exposed to new malaria infections delivered by natural mosquito transmission that can be prevented by antibiotics. In the liver, a surplus of parasites presented to the immune system results in robust induction of memory immune responses that can recognize and destroy future malaria infections in the liver, when antibiotics are no longer taken.
Dr Steffen Borrman co-author on the paper says that 'this proof-of-principle study attempts to bridge a gap between basic malaria research and a rapid translation to a potential application in malaria-endemic countries. An important follow-up of this work is the validation of our experimental approach by clinical trials in humans. If successful, periodic administration of antibiotics, preferably in drug combinations, in high-risk population groups, particularly young, non-immune children, may provide an additional valuable tool for controlling and/or eliminating malaria in resource-poor settings.'
http://www.sciencedaily.com/releases/2010/07/100723112711.htm

MALARIA: India: controlled and not controlled

PUNE: Pune, as well as Pimpri-Chinchwad, did not report any malaria deaths last year — April 2009 to March 2010 — even as Mumbai accounted for almost 90 per cent casualties in the state, that is 206 of the total 232, due to the mosquito-borne infection during the same period. A report by the state health department has raised concerns as the state witnessed a sharp rise in the deaths due to malaria last year. According to the report, the year 2008-09 saw 166 deaths while 2007-08 reported 176 casualties. Pune escaped the scourge due to consistent efforts by the civic body. “We follow weekly anti-larval programmes to check the breeding sites of malaria causing mosquitoes across the 144 wards in the PMC limits. A total of 300 field workers, 60 supervisors and 27 inspectors are involved in monitoring potential mosquito breeding areas,” Sadashiv Patole, head of the insect control department of the PMC said on Thursday. The plasmodium vivax strain of malaria, which was considered mild and caused no deaths till 2006, itself claimed 12 lives in Mumbai in 2009-10. The strain had claimed two lives each in 2007-08 and 08-09, also in Mumbai. The main killer is the Falciparum strain of malaria. “The possibility of the plasmodium vivax strain becoming deadlier cannot be ruled out,” Kishore Hargoli, assistant health officer of the Brihan-Mumbai Municipal Corporation, told TOI. “We have asked the central and state governments to conduct research to find out if there is any change in its virulence. Besides, co-morbid conditions like diabetes and hypertension can precipitate things,” he said. Former state entomologist Ashok Bhosale said: “It is only in the last two-three years that deaths due to the Plasmodium vivax strain of malaria is being seen in the state. This is definitely a matter of concern.” Bhosale said, “A large number of construction projects in Mumbai is fuelling the rise in malaria case as these mosquitoes breed in stagnant water. High humidity levels also contribute to the increase.” Pune-based microbiologist Siddhartha Dalvi said, “Of the four strains of plasmodium, falciparum and vivax are the two strains most commonly found in India. Falciparum malaria has been typically associated with the complications of malaria like cerebral malaria.” According to Dalvi, occasional complications and deaths due to vivax malaria have also been reported in the last two years. “This could primarily be due to growing resistance of plasmodium vivax to anti-malarial drugs. Studies need to be conducted to find out if the vivax strains in India have undergone a change in virulence.” Mumbai reported 48,341 malaria cases during 2009-10 as against 27,417 a year before that. On the other hand, Pune reported 148 cases that year as against 105 registered a year before that. Pimpri-Chinchwad registered 633 cases during 2009-10 as against 366 recorded a year before that. However, no malaria deaths were reported from Pune city as well as from Pimpri-Chinchwad last year, the report states.
http://timesofindia.indiatimes.com/City/Pune/Zero-malaria-deaths-in-Pune-last-/articleshow/6088509.cms

MALARIA: "Zooprophylaxis." The diversion of disease carrying insect from humans to animals

The diversion of disease carrying insect from humans to animals may reduce transmission of diseases such as malaria. The use of animals to mitigate mosquito bites on human is called ‘zooprophylaxis’. We introduce a mathematical model for Plasmodium vivax malaria transmission with two bloodmeal hosts (humans and domestic animals) to study the effect of zooprophylaxis. After computing the basic reproduction number from the proposed model, we explore how perturbations in the parameters, sensitive to the effects of control measures, affect its value. Zooprophylaxis is shown to determine whether a basic reproduction becomes bigger than an outbreak threshold value or not. Sensitivity analysis shows that increasing the relative animal population size works better in P. vivax malaria control than decreasing the mosquito population when the relative animal population size is larger than a threshold value.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WMD-50GJ2VN-1&_user=10&_coverDate=07%2F07%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6a1ec2cd7cbe37dfd944f22e998dcbbe

The first study to quantify the effects of human migration on malaria incidence on a global scale has been published — and could lead to more effective strategies for eliminating the disease, say scientists.
Prompted by evidence that eliminating malaria in a single country is not possible if there is a steady influx of infected people from neighbouring countries, researchers mapped rates of migration and malaria transmission within and between global regions. Their work is published in Proceedings of the National Academy of Sciences (PNAS) this week (21 June).
Using migration data, transmission maps for the malaria parasite Plasmodium falciparum and global population databases the researchers identified groups of countries that were more strongly affected than others by high levels of population, and therefore infection, movement.
These groupings include countries in western and north-central Africa; central American countries where P. falciparum malaria is endemic; and countries in West and East Asia.
The researchers found that some countries, such as Ethiopia, Myanmar, China, Iran and Afghanistan, are more isolated. In these cases a nationally focused control or elimination programme stands a better chance of success.
The study also identified which nations are likely to be net exporters and importers of P. falciparum. In Africa, Mali, Burkina Faso and Niger are net migrant exporters, principally to West Africa, whereas low-transmission countries, such as Mauritania and Senegal, are receiving more malaria-infected migrants than they release.
Andrew Tatem, a researcher at the Emerging Pathogens Institute at the US-based University of Florida, and a co-author of the study, said that this is the first attempt to quantify the effects of human migration on malaria infection on a global scale.
Although there have been occasional similar studies "the datasets we used on malaria transmission and migration patterns have only recently been constructed, so it wasn't possible to examine the evidence on such a large scale before," he said.
Carlos Guerra, from the Ecuadorian Biotechnology Corporation and the Malaria Atlas Project of the UK's University of Oxford, said that the study enabled evidence-based guidelines for the design of more effective malaria-control strategies.
Countries that are connected by the flow of population and infection are already starting to work together. Examples include the Asia Pacific Malaria Elimination Network, the E8 group of eight southern African countries and PAMAFRO, a malaria reduction project between Ecuador, Colombia, Peru and Venezuela.
http://www.scidev.net/en/news/human-migration-maps-reveal-global-flow-of-malaria.html

MALARIA: Malaria Elimination in Zanzibar: A Feasibility Assessment

Due to the recent success that Zanzibar has achieved in reducing its malaria burden, the Zanzibar Malaria Control Program (ZMCP) is facing an important decision of whether to continue sustaining malaria control or to seek malaria elimination. To reach their decision, the ZMCP conducted an assessment to gauge the feasibility of reaching and sustaining malaria elimination from the operational, technical and financial perspectives. This feasibility assessment resulted in a series of evidence-based recommendations, and is the first robust analysis on the feasibility of elimination, therefore forming a strong foundation from which strategic decisions and programmatic shifts in Zanzibar can be made.

Many local and international experts provided technical advice to the feasibility assessment. This work benefited from the intellectual leadership of the Clinton Health Access Initiative and many members of the Malaria Elimination Group, with financial support provided by the UCSF Global Health Group through a grant from ExxonMobil.

The final report and recommendations on a way forward were recently presented to the senior leadership of the Zanzibar Ministry of Health and Social Welfare. Conclusions on the short- and long-term challenges of achieving and sustaining elimination are outlined as well as strategies that will be critical for elimination to succeed. The ZMCP has already begun implementing several of the recommended strategies, most notably strategies to enhance surveillance capacity, which are paramount for any elimination effort.

More information and resources on malaria elimination can be found at the Malaria Elimination Group website: www.malariaeliminationgroup.org