00. 11 22 bill & melinda gates foundation malaria forum a meeting of grantees, partners,...
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Bill & Melinda Gates Foundation Malaria Forum
A meeting of grantees, partners, leaders, scientists and advocates
Space constraints limited number of participants – 250 total
Timing dictated by opportunity of leadership schedules and review after $1 B grant investments in malaria
Goals: »Review progress»Share challenges and successes»Think creatively how to solve problems
Themes»Collaboration»Innovation»Impact
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MALARIA FORUM AGENDA
Plenary discussions with malaria leadership; breakout sessions on cross-cutting topics
Side meetings with country delegations; AMFm
Keynote speeches by Bill and Melinda Gates
Leadership Summit
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State of the malaria world…
Compared to a decade ago, malaria is more visible as a global health problem » GFATM, World Bank Booster Program, US President’s Malaria Initiative – total of $3.6B has been committed for
malaria control and in the process of being rolled out to over 70 countries
New tools have been globally recommended – uptake is beginning, but challenges remain» ACTs (Artemisinin combination therapies) being deployed in >40 countries; prices for adults in the public sector have
dropped from $2.40 to $1 » Over 70M nets were procured in 2006, three quarters of which were long lasting nets (LLIN)» Barriers to distribution, uptake and compliance are still significant, but are beginning to be addressed, including:
distribution / logistic difficulties, demand forecasting, and access in the private sector
Resistance is threatening the new tools» SP resistance emerged rapidly over the past 5 years in East Africa » Artemisinin (ACT) resistance has been tentatively described in Asia» Resistance to pyrethroids on bednets has been documented in East and West Africa
Research and development of new anti-malarials drugs, vector tools and vaccines shows promise, but much work remains
» Advancing pipelines of drugs, vaccines and vector control tools that are intended to address significant gaps in current toolkit, overcome resistance, and improve efficacy and efficiency, uptake, cost and compliance of existing interventions
Few examples of demonstrable national impact on disease morbidity and mortality» Need stable level of utilization for 2 years to assess impact on disease rates» Focus has been on the effective scale up of current tools; assessment of impact available in near future» Early example of single intervention: WHO claims widespread distribution of free nets in Kenya led to 44% reduction in
child mortality from 2003-2007 (to be validated)
Malaria is regaining lost foothold in disease control, but that only points to the need for a more comprehensive, longer term strategy
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Prevent infection
severe disease and death
Prevent illness / treat
infected persons
Prevent transmission/
reduce parasitepopulation
Reduce vector population /
prevent parasite asexual maturation
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Prevent human contact
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Breaking the malaria transmission cycle through multi-pronged attack is key to sustainable control
DrugsVaccine
VaccineIPT
Vector controlDrugs
Stable transmission requires parasite to complete life cycle
» Multiple points (1-5) where transmission can be interrupted
Parasite resilience, imperfect tools and implementation / compliance issues mean multiple intervention points required to break transmission cycle
» When delivered in combination, imperfect tools can have significant health impact
If the transmission cycle isn’t broken, will need to pay for control in perpetuity
» If parasite reservoirs are not eliminated, incidence will rebound rapidly if control measures are scaled down
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100% efficacy of an intervention and perfect 100% implementation at any phase would break the transmission cycle. This is not possible with any of the current tools, nor is it possible with any of the tools in the foreseeable future. Therefore effective control requires a multi-pronged approach
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Cost ($M)
Funding less than 80% coverage for implementation lessens impact and delays timeline to sustainable control
Note: Hypothetical need model assuming 80%/60% coverage possible in all malaria endemic countries. Deaths figures assume a case fatality rate of 0.26%. See funding model appendix for further details of scenario assumptionsSource: Global Fund; Akhavan (2005); Malaria R&D Alliance (2005); Expert interviews; BCG analysis
0
3000
6000
9000
2008 2012 2016 2020 2024 2028 2032 2036 2040
0
100
200
300
400
500
“80%” scenario: 80% coverage with current and future tools
“80%” scenario: 80% coverage with current and future tools
R&D
Implementation
Ongoing support
Cases
Higher implementation spend today leads to faster decline in implementation cost,
cases, and deaths
Totals ('08-'40) Cost = $164 BCases = 6.2 BCost per case averted = $17 Deaths = 16M
“Abuja” scenario: 60% coverage with current and future tools
“Abuja” scenario: 60% coverage with current and future tools
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3000
6000
9000
2008 2012 2016 2020 2024 2028 2032 2036 2040
0
100
200
300
400
500Cost ($M) Cases (M)
R&D
Implementation
Ongoing support
Cases
Cost, cases, and deaths decline more slowly due to lower coverage and therefore slower
shrinking of malaria-endemic areas
Totals ('08-'40) Cost = $126 BCases = 11.3 BCost per case averted = $28Deaths = 30M
Cases (M)
88
6920
1266
2751
580
836
1486
80% coverage at today's cost
LLIN
IRS
IPTACT
Ongoing support
Meeting global needs requires annual spend of $500-800M for R&D and ~$7B for implementation
To meet global needs for tool development...
Information needs
Control and scale up: resistance monitoring, market data collection, mapping, disease burden quantification, performance evaluation studies
Effectiveness: of individual and combined interventions, cost effectiveness
Vector control
3 novel active ingredient (AI) classes in next 10 years; 1 in subsequent decades
2-3 new formulations every 2 years
Drugs Therapeutic: 2 combinations, 4 line extensions in 10 years; declining need over time
Preventive: 1 combination, 1 monotherapy, 4 line extensions in 10 years; declining need over time
Vaccines Completion of RTS,S development Discovery and development of series of improved
second generation and combination vaccines
R&
D f
or
too
lsIm
ple
men
tati
on
To meet “80%” global coverage targets today Ongoing support
Includes environmental management, training, human resources, disease and resistance surveillance
ACT 80% coverage of entire population who become ill (with both public and private channels)
IPT IPTp in perennial and seasonal endemic areas, 1 treatment in second and third trimester of pregnancy
IPTi/c: IPTi in perennial areas, 3 courses/yr or IPTc in seasonal areas, 3 courses/yr
Vector control
80% coverage with either LLINs or IRS in perennial endemic and seasonal endemic areas where vector is indoor biting and/or resting; ratio between LLIN and IRS varies according to vector behavior, setting
LLIN: 2 net per household, (last 3-5 years) IRS: 2 sprays/yr (perennial), 1 spray/yr (seasonal)
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200
400
600
800
2008 2012 2016 2020 2024
...need ~$500-800M annually for R&D...need ~$500-800M annually for R&D
$M
Vector control
Preventive drugs
Vaccine
Therapeutic drugs
Information needs
... need ~$7B annually for implementation
... need ~$7B annually for implementation
Cost will decrease over time as the number of cases decreases and cheaper tools
become available
80% coverage at today's cost
LLIN
IRS
IPTACT
Ongoing support
LLIN
IRS
IPT
$6,920 M
$1266M
$2751M
$580M
$836M
$1,486M
LLIN
IRS
IPTACT
Ongoing support
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What is needed by the global community to control malaria?
R&D for tools
Advocacy
Implementation
Three types of innovation required across all the categories of tools (vector control, vaccine, drugs and diagnostics)
» Innovation to fill gaps in current arsenal (e.g. vaccine)» Innovation to manage resistance (e.g. new classes of insecticides and drugs)» Innovation to improve uptake and compliance (e.g. one dose cure, affordable accurate
point-of-care diagnostic ) Improved biological understanding of the parasite, vector and host response to enable
development of better tools
Enhanced management and on-the-ground support for critical components such as demand estimates, logistics, and effective supply chains
Systems in place to measure impact, resistance and adjust programs Clear data and guidelines to inform choice of most effective and cost efficient intervention
packages in a particular epidemiological setting Adequate financial and human resources
Sustained and increased national and global funding, as well as political will to meet goals » Continuation of current PMI, World Bank funding» Estimated $3-7B per year required to achieve impact at 80% uptake with current tools and
meet R&D needs; Current global spend ~$2B per year is well short of this» Political will at the national level to sustain commitment to controlling disease
Global plan for malaria that is owned by the community Streamlined regulatory and policy processes to ensure rapid translation of innovation into impact An even broader and more vocal constituency for malaria
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Key points arising from Malaria Forum…
Collaboration – key to success in control but also discovery and development – and we need to use new approaches to improving this.
Innovation - needed to overcome resistance merely to maintain the status quo. BUT targeting a long term goal of eradication challenges and changes the R&D agenda. NOT just a vaccine.
Impact - the true outcome of all these efforts must be measured in impact against the disease. The degree of desired impact became a major focus of discussion.
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Key points arising from Malaria Forum…
Focus on malaria does not displace other global priorities (polio, MDGs)
Innovation is key across Discovery, Development and Delivery – to manage resistance, but to reach more ambitious goals
Costs of sustained control somewhere between $3-6 B per year – and costs of continued impact of malaria at least $12B/year – need better data
Importance of other tools and communities, such as modeling and mapping, which can strengthen how programs are implemented – climate rather than weather maps
Need to communicate commitment to a vision, rationale and strategy as part of single, global business plan
Long term strategy further emphasizes the need for credible success in scaling up malaria control in the near term
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Next steps
Communicate discussions and outputs of forum
• Forum Report – to be distributed tomorrow
• Broad access to videos (Kaiser Foundation website) and access to videos for those to whom webstreaming is a challenge
Need to collaborate, combine intellect and resources to develop, implement and monitor a comprehensive and adaptive plan
We must be willing to innovate, knowing that some things will fail, but we will overcome barriers
Bill & Melinda Gates Foundation commits to the creation of a long term common vision, and to collaborate as a member of the RBM community