1. Conquering Malaria Joel G. Breman, MD, DTPH Fogarty International Center National Institutes of Health Improving Population Health Workshop Instituto Nacional de Salud Publica (INSP) Cuernavaca, Mexico 21 – 22 June 2003

2. Conquering Malaria Burden Ecology and manifestations Successes Control Research and training

3. Burden

4. The Global Burden of Malaria  1.5 – 2.7 million deaths annually  Over 1 billion clinical episodes  300 – 500 million people infected  Every 10 - 30 seconds a child dies of malaria

6. Ecology and Manifestations

7. Malaria Ecology Intrinsic and Extrinsic Factors Control and prevention measures Human ParasiteMosquito Social, behavioral, economic and political factors Environmental conditions EXTRINSIC INTRINSIC

8. Malaria’s Toll: Major Intrinsic Components Plasmodium falciparum Anopheles gambiae

9. Malaria Ecology and Burden Clinical Manifestations Infected Mosquito Infected Human Chronic effects Anemia Neurologic/ cognitive Developmental Impaired growth and development Malnutrition Acute febrile illness Severe illness Hypoglycemia Anemia Cerebral malaria Death Respiratory distress Pregnancy Fetus Maternal Acute illness Anemia Impaired productivity Low birth weight Infant mortality

11. MARA/ARMA Model of Malaria Transmission, 2003

12. Successes

13. 1899-1914, multiple demonstrations of control by reduction of Anopheline larvae and adults –1899, Sierra Leone (antilarval); Cuba (large- scale); Malaysia (antilarval) –1904-1914, Panama Canal Zone; control by larviciding, large-scale environmental modification 1927, elimination of A. albimanus in Barbados (first area-wide success with invading species) Successes: Vector Control

14. Successes: Vector Control (2) 1935-1939, use of pyrethrum spraying in South Africa, Netherlands and India 1939-1957 –1939-1940, Elimination of A. gambiae from Brazil and upper Nile, Egypt, 1942-1945 –1946-1957, Interruption of transmission by anti-mosquito measures in Cyprus, Sandinia, Guyana, Venezuela and Greece; indoor residual spraying with DDT, a new major strategy

15. Successes: Personal Protection (3) 1987-2003 –Multiple projects and programs using insecticide-impregnated bed nets demonstrating overall mortality reduction and decrease in several malaria indices

16. Control

17. Vector Control Drainage and filling: urban* Chemical and biological larvicides* Indoor residual insecticide spraying* Outdoor residual insecticide spraying *costly and effective

18. Personal protection (2) Insecticide–impregnated materials: nets, curtains, clothing* House screening House location Repellents Fumigants * Cost-effective for low-income countries

19. Antiplasmodial (3) Patient management: early diagnosis, treatment, referral, education Chemoprophylaxis Intermittent treatment (pregnancy)* Radical therapy for relapses (P. vivax, P. ovale) * cost effective

20. Social Action (4) Mobilization of individual, family, community Health education Management Effectiveness Health systems: access, use, quality Leadership: policies, strategies, tactics Surveillance of infection and disease Monitoring and evaluation of programs

21. Research and Training

22. Research, Training, and Support Needs According to Understanding of Diseases and Efficacy of Control Methods Research Needs Efficacy of Control Methods High Training SomeHighModerate Research Support Needs Low

23. Research, Training, and Support Needs According to Understanding of Diseases and Efficacy of Control Methods Research Needs Efficacy of Control Methods High Training SomeHighModerate Research Support Needs Low Smallpox Guinea worm Poliomyelitis H. influenzae type B Measles Tetanus Malaria Dengue HIV/AIDS Tuberculosis Ebola/Marburg Influenza Cancers Alzheimer’s

24. Research Agenda Pathogenesis Drug development Immunology and vaccine development Diagnostics Entomology Recent genetic breakthroughs

25. Conquering Malaria For More Information MIMhttp://mim.nih.gov RBMhttp://www.who.int DCPPhttp://www.fic.nih.gov/dcpp/ Joel Bremanjbreman@nih.gov