1. The President’s Malaria Initiative (PMI) Mini-University 27 October 2006 Laura Harley Michael Macdonald

2. Overview of Presentation PMI Goal, Strategy and Scope PMI Goal, Strategy and Scope Technical Interventions: Technical Interventions: –Diagnosis and treatment –Malaria during Pregnancy –Vector control

3. President’s Malaria Initiative On 30 June, 2005, President Bush announced a new 5-year, $1.2 billion initiative scale-up malaria control in high burden countries in sub-Saharan Africa On 30 June, 2005, President Bush announced a new 5-year, $1.2 billion initiative scale-up malaria control in high burden countries in sub-Saharan Africa Challenged other donors to increase their funding Challenged other donors to increase their funding

4. Goal and Targets Goal: Reduce malaria-related mortality by 50% in 15 target countries. Targets: Achieve 85% coverage of vulnerable/targeted groups with: Artemisinin-based combination therapies (ACTs);Artemisinin-based combination therapies (ACTs); Intermittent preventive treatment (IPT);Intermittent preventive treatment (IPT); Indoor residual spraying (IRS) and insecticide-treated bed nets (ITNs);Indoor residual spraying (IRS) and insecticide-treated bed nets (ITNs);

5. FundingYear Funding Level Coverage 2006 (appropriated) $30 M Uganda, Tanzania and Angola 2007 (requested) $135 M Above 3 + Malawi, Mozambique, Senegal and Rwanda 2008-2010(requested) $300 M Above 7 + 8 countries TBD TOTAL $1.265 B

6. Where the money goes (in millions) : FY06FY07* Angola$ 7.5 $15 Tanzania$11.5 $27 Uganda$ 9.5 $19 Malawi ---- $15 Mozambique ---- $17 Rwanda ---- $17 Senegal ---- $16 *Working Budget, subject to change and final approval FY08: an additional 8 countries

7. PMI Strategy Support an integrated approach Support an integrated approach Build on existing donor funding e.g. GFATM grants Build on existing donor funding e.g. GFATM grants Strengthening National Malaria Control Programs; Build capacity for country ownership; Strengthening National Malaria Control Programs; Build capacity for country ownership; Close coordination with international and in- country partners. Close coordination with international and in- country partners. PMI is implemented jointly by USAID and CDC PMI is implemented jointly by USAID and CDC

8. What PMI funds support? Commodities Commodities –ACTs, SP, drugs for severe malaria –ITNs, especially long- lasting ITNs –Equipment and supplies for IRS Program Implementation Program Implementation Technical support to strengthen national malaria control capabilities Technical support to strengthen national malaria control capabilities Monitoring and evaluation Monitoring and evaluation

9. Highlights from Uganda, Tanzania, & Angola Over 1.4 M LLINs distributed Over 1.4 M LLINs distributed 600,000 ITNs retreated 600,000 ITNs retreated 500,000 LLINs sold through the private sector. 500,000 LLINs sold through the private sector. 2 million people protected through IRS campaigns in Zanzibar, Southern Angola and Southwestern Uganda. 2 million people protected through IRS campaigns in Zanzibar, Southern Angola and Southwestern Uganda. $1.8 M of Coartem procured and delivered $1.8 M of Coartem procured and delivered Over 2,000 people trained in malaria prevention and/or treatment activities. Over 2,000 people trained in malaria prevention and/or treatment activities. Over 5 million persons at risk of malaria are benefiting from PMI Over 5 million persons at risk of malaria are benefiting from PMI

10. Jumpstarts in Malawi, Rwanda, Senegal & Mozambique Rwanda- Scale up of IPTp Rwanda- Scale up of IPTp Malawi- Distribution of LLIN to poorest of the poor (Jan 2007) Malawi- Distribution of LLIN to poorest of the poor (Jan 2007) Senegal- Net Re-treatment campaign (Sept 2006) Senegal- Net Re-treatment campaign (Sept 2006) Mozambique- Net Re-treatment campaign (Nov 2007) Mozambique- Net Re-treatment campaign (Nov 2007)

11. Final 8 Countries A White House Summit in December will announce the final eight countries that will be recipients of President’s Malaria Initiative funding. A White House Summit in December will announce the final eight countries that will be recipients of President’s Malaria Initiative funding. Planning and assessments in these 8 countries will begin in early CY2007 Planning and assessments in these 8 countries will begin in early CY2007

12. Technical Interventions 1. Diagnosis and Treatment ACTs, Outpatient, community management 2. Malaria during Pregnancy SP resistance, HIV, Focused Antenatal Care 3. Vector control IRS and ITNs, ITN equity

13. Technical Interventions 1. Diagnosis and Treatment ACTs, Outpatient, community management 2. Malaria during Pregnancy SP resistance, HIV, Focused Antenatal Care 3. Vector control IRS and ITNs, ITN equity

14. Key Intervention #1 Diagnosis and Treatment Artemisinin-based Combination Therapy (ACT)

15. Treatment Failure SP cure rates (Zambia) Children under 5

16. SP +Artesunate 14-Day Cure Rate ProportionPercent Chipata53/5891.4% Isoka61/6495.3% Mansa55/55100% Shesheke50/50100%

17. Artemether-lumafantrine (Coartem ® ) 14-Day Cure Rate ProportionPercent Chongwe64/64100% Choma60/60100% Mpongwe55/5698.6%

18. Out-patient management: (Ndhlovu, et al. 2004) 2004: 4 districts, 105 HC, 1523 children, 819 older children, adults 2004: 4 districts, 105 HC, 1523 children, 819 older children, adults –Clinical diagnosis sensitive (80%) but only 35% actually had parasites –35% of consultation < 3 min –20% asked previous use of antimalarial –58.6% children with negative slide treated –14.6% mothers told diagnosis; 32% how to give medication

19. ACTs not yet widely available for CHW ACTs not yet widely available for CHW D isease recognition, esp. danger signs D isease recognition, esp. danger signs Treatment and compliance with appropriate drug Treatment and compliance with appropriate drug Don’t waste money on inappropriate or incomplete therapy Don’t waste money on inappropriate or incomplete therapy Community management :

20. Key Intervention #2 MiP “Packet of Interventions” Intermittent Preventive Treatment (IPTp) Intermittent Preventive Treatment (IPTp) Insecticide Treated Mosquito Nets (ITNs) Insecticide Treated Mosquito Nets (ITNs) Anemia Reduction Anemia Reduction UNICEF/C-55-10/Watson

21. SP still effective for IPTp Review:The relationship between drug resistance and the efficacy of antimalarial treatment and prevention in pregnant women Comparison:Prevention studies and resistance level Outcome:Placental malaria: Prevention versus case-management (CM) Study Prevention Case-management RR (random) n/N 95% CI Low resistance level: IPTp-SP, 2 doses: G1/G2 Parise 1998 50/432 128/472 Challis 2004 3/124 16/120 Subtotal (95% CI) 556 592 Total events: 53 (Prevention), 144 (Case-management) Intermediate resistance level: IPTp-SP, 2 doses: G1/G2 Shulman 1999 16/205 29/196 Njagi 2002 22/148 45/134 Subtotal (95% CI) 353 330 Total events: 38 (Prevention), 74 (Case-management) 1 0.1 0.2 0.5 2 5 10 Favors prevention Favors CM

22. Effect of Malaria and HIV on Birth Outcomes * * * * * P<0.05

23. High ANC Contact rate, but average booking at 5 ½ months Zambia Zimbabwe Botswana Kenya Uganda Malawi Tanzania Ghana Namibia Cote d’Ivoire Senegal Togo Benin Cameroon Guinea Mozambique CAR Burkina Faso Nigeria Eritrea Mali Niger Chad Survey year ranges from 1988-1999 Source: WHO 2002. Percentage

24. Key Intervention #3 Vector Control During Pregnancy: < parasitemia 27% < parasitemia 27% < anemia 16% < anemia 16% At Delivery: < placental malaria 20% < placental malaria 20% < preterm delivery 40% < preterm delivery 40% Higher mean birth Higher mean birth weight 68.8 g weight 68.8 g Pregnant Women in ITN village had:

25. ITNs: rapid but uneven growth Households with at least one net

26. Who uses the net?

27. Comparing ITNs with IRS: Is one better? PEIRSPEITN IRS: cost p.p. protected ITN: cost p.p. protected Reference Tanzania 12 villages Randomized64%55%4.6 (two rounds) 1.3 Curtis et al. 1998 India 126 villages Randomized30%54% Misra et al. 1999 South Africa 14 blocks Randomized PE ITN vs IRS: 33%2.3 (one round) 3.7 Mnzava et al. 2001 Goodman et al. 2001 Pakistan P.v. Non-random. P.f. 44%49%42%61% Rowland et al. 1999 KenyaNon-random.75%63%0.88 (one round) 2.3 Guyatt et al. 2002 PE= protective efficacy = (1-RR) x 100

28. ITNs vs IRS: is one better? No -- one is not better than the other!!! Choosing between IRS and ITNs is largely a matter of feasibility and resources.

29. PMI : ambitious goals; but vast opportunity; and great hope for the future. Diagnosis and Treatment Diagnosis and Treatment Malaria during Pregnancy Malaria during Pregnancy Vector Control Vector Control