Fogarty International Center

“promotes and supports scientific discovery internationally and mobilizes resources to reduce disparities in global health” International Training and Research Program in Emerging Infectious Diseases, Actions for Building Capacity, partner with NIAID field research programs International Malaria Research Training Program, Global Infectious Diseases Research Training Program, 2005

International Malaria Research Training Program (1) Johns Hopkins University – Zimbabwe –Transmission blocking immunity –Vector biology –Molecular parasitology/epidemiology –Drug resistance University of Maryland - Mali –Drug resistance –Clinical trials –Epidemiology –Vector biology University of California, San Francisco - Uganda –Drug resistance –Clinical studies –Epidemiology –Molecular parasitology

FIC Malaria Programs (2) Harvard School of Public Health – Ethiopia, Senegal –Molecular epidemiology –HIV and malaria immunity –Infected RBC biology –Vector biology and control State University of New York, Buffalo - Kenya –Vector biology University of Pittsburgh - Kenya –Malarial anemia Tulane University – Kenya, Mali, others –Vector biology –Vector ecology

FIC Malaria Programs (3) Universidad del Valle, Columbia – Latin America –Malarial anemia –Clinical malaria Columbia University - Thailand –Severe malarial anemia –Hematology US Army - Kenya –Pediatric malaria –Severe malaria –Molecular pathogenesis, anemia and cerebral malaria

Global Infectious Diseases ( ) Research Training Programs University of North Carolina - Malawi –Malaria biochemistry, pathology, epidemiology Pennsylvania State University - Thailand –P. vivax Albert Einstein – global –Malaria and other diseases University of California, San Diego – Peruvian Amazon –Parasitic diseases

Centers for Disease Control and Prevention (CDC)

CDC Malaria Activities 1.Domestic Surveillance Investigations Advice to travelers Consultations Advice for blood collection Diagnostic assistance 2.International Field stations (Kenya, Guatemala) Regional programs (Mekong Delta, Amazon River) Partner organizations (WHO, RBM, UNICEF, WB, USAID) Consultations 3.Themes – Epidemiology Pregnancy Personal protection Natural history

CDC Research 4. Biology and immunology Host parasite interactions Immune response Host genetics Parasite genetic diversity 5. Clinical and control issues (Kenya, Mali, Malawi, Guatemala, elsewhere) HIV and malaria Methods of control 6.Vaccine development Animal testing, non-human primates 7.Vectors Insecticides (WHO Collaborating) –Evaluating –Resistance Sporozoite production Larval ecology Anopheles ecology and biology

The Global Fund to Fight AIDS, Tuberculosis and Malaria

The Global Fund, million die yearly from AIDS, TB and malaria Sub-Saharan Africa hit hardest HIV/AIDS –4.9 million newly infected –40 million living with HIV/AIDS TB –1/3 world infected = 2 billion –8 million developed disease –2 million died –TB and HIV

The Global Fund, Malaria –40% at risk = 2.4 billion –1 to 3 million deaths –300 – 500 million cases –5 billion febrile episodes resembling malaria

Estimated Cost of Malaria Control: One Million People, One Full-dose Treatment, 1999 Drug Tablets in millions (dose) Price/ 1000 tabs Total cost Cost per capita Chloroquine (3 days) (100 mg) $6.05 $68,063$0.08 Sulfadoxine- pyrimethamine (one dose) 2.5 (500 mgS/ 25 mgP) $47.00 $117,500$0.12 Quinine (7 d)31.5 (300 mg) $41.25$1,299,375$1.30 Artesunate (5 d)13.5 (50 mg)$365.00$4,927,500$4.93 PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

Estimated Cost of Malaria Control in an Endemic Area: One Million People, One Round of Residual House Spraying Insecticide One application (tons) Price/tonTotal cost Cost per capita DDT147 $3,950 $580,650$0.58 Malathion220 $4,300 $946,000$0.95 Deltamethrin110$20,000$2,200,000$2.20 Pyrimiphos- methyl 220$16,000$3,520,000$3.52 PF Beales and HM Gilles in Essential Malariology (DA Warrell and HM Giles, eds), 2002

The Global Fund to Fight AIDS, Tuberculosis and Malaria Principles 1.Funding needs and support ($2.3 b 2005, $3.5 b 2006, $3.6 b 2007) Financial instrument, not implementation Leverage resources 2.Program orientation (~150 people in Secretariat) Support programs with national ownership Focus on different regions, diseases, interventions Balance prevention and treatment 3.Grant process (patterned after NIH) Independent peer review process Simplified, rapid, grant-making process Transparency and accountability

The Global Fund to Fight AIDS, Tuberculosis and Malaria Pledges Paid 2005 Donor Pledges $ billions Paid $ billions Countries - 49 plus European Commission Foundations Corporations0.002 Individuals0.002 Total $6.127$3.449

Global Fund Expenditures on Malaria $2 billion needed yearly to achieve RBM goals (Commission on Macroeconomic and Health, 2002) –$600 million/year being spent (?) Focus –Finance 108 million bednets (ITN) –Deliver 145 million artemisinin-combination- treatments (ACT)

The Global Fund After Four Rounds Funding by Disease

The Global Fund After Four Rounds Funding by Income of Countries

The Global Fund After Four Rounds Funding by Expenditure Target

The Global Fund After Four Rounds Funding by Geographic Region

The Global Fund After Four Rounds Funding by Sector of Recipients

The Global Fund After Four Rounds Funding by Country Coordinating Mechanisms (CCMs) 15%

Disbursements to Malaria (US$ Millions), 2004 US $ millions Malaria Disbursements Global Fund $135 million Private/other $4 million Multilateral $57 million Bilateral $97 million Total International $295 million 45 % 1 % 20 % 34 %

Estimated Costs for 2007 for the Three Diseases (US$ Billions) MalariaTBHIVTotal Resource needs Total domestic expenditure Total international share

Malaria Resource Needs, 2007 (1) Specific Interventions No of Units in 2007 Cost per unitAnnual resource needs in US$ millions Vector control in highly endemic areas (long- lasting insecticidal nets, LLINs) for vulnerable groups 31.5 million LLINSUS$7 per LLIN procured and distributed to target population 220 Artemisinin Combination Therapies 1102 million doses Children <5 US$0.6 per dose Children 5-15 US$0.99 per dose Adults US$1.7 per dose 1,180 Rapid Diagnostic Testing 776 million tests Median cost is US$0.7/patient tested 543 Intermittent preventive treatment in pregnancy 39.7 million treatment courses US$0.164 per pregnant woman 6.5 Management of severe malaria cases 11.6 million cases Median cost is US$24/patient 280

Malaria Resource Needs, 2007 (2) US$2.9 billionTOTAL 28 Country- specific estimates 2-6 drug resistance studies per year, 2-6 insecticide resistance studies per year, routine surveillance – 5 staff and 15 visits Operational research, monitoring and evaluation 58 Country-specific incentives and support US$50,000 salary for direct hires 1 per 4,000 population 1-3 per country depending on population size Community health workers, technical specialists 91 Country-specific estimates Depending on intervention Training 362 US$2,000 per package + vehicles (based on population at risk 1 set per malarious province, 2-6 sets for central malaria program Basic infrastructure, institutions and transport 119 US$4,300 per equipment/trainin g package In all areas prone to malaria epidemics Prevention and control of epidemics Annual resource needs in US$ millions Cost per unitNo of Units in 2007Specific Interventions Source: Global Fund

United States Agency for International Development

USAID Malaria Programs Prevention and control Treatment Pregnancy Drug-resistant malaria Complex emergencies Vaccine development Strategies

USAID Malaria Country Focus Country Programs Angola Benin Congo, Democratic Republic Eritrea Ethiopia Ghana Kenya Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal Tanzania Uganda Zambia Country Programs Afghanistan Indonesia Nepal Philippines Regional Programs Mekong Regional Initiative: Cambodia Laos Thailand Vietnam Regional Programs, Central Asian Republics Kyrgyzstan Tajikistan Country Programs Bolivia Honduras Peru Regional Programs Amazon Malaria Initiative: Bolivia Brazil Colombia Ecuador Guyana Peru Suriname Venezuela

USAID Malaria Funding

United States Agency for International Development (USAID) and Global Partnerships US Government Private citizens/groups %30% %80% Malaria dollars $2 billion ~1950s-1970s $90 million in 2005 Government and Private Contributions

USAID FIGHTS MALARIA BLINDFOLDED The Examiner, April 20, 2005 “…members of Congress…expressed concern (that)…USAID could not account for the bulk of its $80 million malaria earmark.” “Only 5% is used to fund the 3 interventions….that work…and the vast majority…on nets.” Roger Bate American Enterprise Institute Director, “Africa Fighting Malaria”

Keys to Successful Malaria Control

World Bank Report: Four Success Stories Brazil Vietnam India Eritrea

World Bank Success Stories Keys to Success (1) Conducive epidemiological conditions Sound technical approach Package of effective tools Data-driven decision making

World Bank Success Stories Keys to Success (2) Strong leadership Political commitment Community involvement Decentralized control of finances and actions Overcame bureaucratic hurdles

World Bank Success Stories Keys to Success (3) Infrastructure Capacity Support from partner agencies Sufficient financing Flexible support by World Bank

Disability–adjusted Life Years (DALYs, 1000s), All Cause and Malaria-related, 2002 Population DALYs from all deaths (%) DALYs from malaria deaths (%) DALYs from malaria /total (%) World6,122,2101,467,25742, Africa 655, ,884 (24.4)36,012 (85.2) 10.1 Americas 837, ,217 (9.9) 108 (0.2) 0.07 East Med. 493, ,221 (9.3) 2,050 (4.8) 1.5 Europe 874, ,223 (10.3) 20 (0.04) 0.01 SE Asia1,559, ,844 (28.5) 3,680 (8.7) 0.9 West Pacific1,701, ,868 (17.6) 409 (1.0) 0.2 Adapted from WHO, World Health Report, 2002

Coordination, Information, and Advocacy “There is an urgent need for a non- partisan umbrella organ to coordinate and facilitate the network of alliances and programs in malaria research and control…” Alilio, Bygbjerg, Breman 2004

Vision “The goal, once again, is to promote research by African scientists and colleagues elsewhere to improve our understanding of malaria, develop new tools to combat it, and, ultimately, eliminate this scourge.”