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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, 1995-2004
• Actions for Building Capacity, partner with NIAID field research programs
• International Malaria Research Training Program, 2001-2005
• 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 (2004-2009)
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
CDC Malaria Activities1. 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 Research4. 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, 2004-2005
• 6 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, 2004-2005
• 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)
11.25 (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/ton Total cost
Cost per capita
DDT 147 $3,950 $580,650 $0.58
Malathion 220 $4,300 $946,000 $0.95
Deltamethrin 110 $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
Principles1. 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 2001-2008Paid 2005
DonorPledges
$ billions
Paid
$ billions
Countries - 49 plus
European Commission
5.973 3.295
Foundations - 2 0.150 0.150
Corporations 0.002 0.002
Individuals 0.002 0.002
Total $6.127 $3.449
Global Fund Expenditures on Malaria
• $2 billion needed yearly to achieve RBM goals (Commission on Macroeconomic and Health, 2002)
– $600 million/year being spent (?)
• Focus
– Finance 108 million bednets (ITN)
– Deliver 145 million artemisinin-combination-treatments (ACT)
Disbursements to Malaria (US$ Millions), 2004
US
$ m
illi
ons
0
50
100
150
200
250
300
350
Malaria Disbursements
Global Fund $135 millionPrivate/other $4 millionMultilateral $57 millionBilateral $97 million
Total International $295 million
45 %
1 %
20 %
34 %
Estimated Costs for 2007 for the Three Diseases (US$ Billions)
Malaria TB HIV Total
Resource needs 2.9 2.0 14.5 19.4
Total domestic expenditure
0.3 1.2 3.0 4.5
Total international share
2.6 0.8 11.5 14.9
Malaria Resource Needs, 2007 (1)Specific Interventions
No of Units in 2007
Cost per unit Annual resource needs in US$ millions
Vector control in highly endemic areas (long-lasting insecticidal nets, LLINs) for vulnerable groups
31.5 million LLINS US$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
28Country-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
58Country-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
91Country-specific estimatesDepending on intervention
Training
362US$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
119US$4,300 per equipment/training package
In all areas prone to malaria epidemics
Prevention and control of epidemics
Annual resource needs in US$
millions
Cost per unitNo of Units in 2007Specific Interventions
Source: Global Fund
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 ProgramsMekong 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
United States Agency for International Development (USAID) and Global Partnerships
US Government
Private
citizens/groups
1970 70% 30%
2005 20% 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”
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 (%)
World 6,122,210 1,467,257 42,280 2.9
Africa 655,476 357,884 (24.4) 36,012 (85.2) 10.1
Americas 837,967 145,217 (9.9) 108 (0.2) 0.07
East Med. 493,091 136,221 (9.3) 2,050 (4.8) 1.5
Europe 874,178 151,223 (10.3) 20 (0.04) 0.01
SE Asia 1,559,810 418,844 (28.5) 3,680 (8.7) 0.9
West Pacific
1,701,689 257,868 (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