Malaria Medicines & Diagnostics: trends and supply requirements
Dr. Andrea BosmanDiagnosis, Treatment and Vaccines WHO Global Malaria Programme4 November 2010, Geneva
Proportion of patients seeking treatment for malaria symptoms
Use of diagnostic tests in formal health sector
Source: CHAI Analysis, global estimates for patients living at risk of malaria, based on 2008 World Malaria Report & UNICEF Intervention Coverage Reports
44%Formal Health
Sector
28%No action
28%Informal Private Sector
53%Clinical
Diagnosis(355 million/yr)
8% RDT
39% Microscopy
Technical Briefing Seminar – 4 Nov 2010 3 |GLOBAL
MALARIA PROGRAMME
0.5 0.6 2.1 5
31.3
82.797
130
160
210
0
50
100
150
200
250
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
0
10
20
30
40
50
60
70
80
ACT procured No countries: ACT 1st line No countries deploying
6-24 months from adoption to implementation6-24 months from adoption to implementation
Mill
ions
of A
CT
trea
tmen
t cou
rses
Cu
mu
lati
ve n
um
ber
of
cou
ntr
ies
WHO policy on ACTsWHO policy on ACTs
GFappeal on ACTsGFappeal on ACTs
Forecast
ACT procurement for public sector distribution
Technical Briefing Seminar – 4 Nov 2010 4 |GLOBAL
MALARIA PROGRAMME
(a) Americas (high incidence)
0
2
4
6
8
10
12
14
16
18
20
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Ca
se
s p
er
10
00
po
pu
lati
on
(B
eliz
e, H
on
du
ras
, Nic
ara
gu
a, P
eru
)
0
10
20
30
40
50
Ca
se
s p
er
10
00
po
pu
lati
on
(S
uri
na
me
)Honduras
Belize
Nicaragua
Peru
Suriname
(b) Americas (low incidence)
0.0
0.1
0.2
0.3
0.4
0.5
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Ca
se
s p
er
10
00
po
pu
lati
on
(E
l Sa
lva
do
r, M
ex
ico
)
0.00
0.01
0.02
0.03
Ca
se
s p
er
10
00
po
pu
lati
on
(A
rge
nti
na
)El Salvador
Mexico
Argentina
(c) Eastern Mediterranean
0.0
0.2
0.4
0.6
0.8
1.0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006C
as
es
pe
r 1
00
0 p
op
ula
tio
n
(Ira
n, S
au
di A
rab
ia)
0.000
0.002
0.004
0.006
0.008
0.010
Ca
se
s p
er
10
00
po
pu
lati
on
(M
oro
cc
o, O
ma
n, S
yri
a)
Iran
Oman
Saudi Arabia
Morocco
Syrian AR
(d) Europe
0.0
0.5
1.0
1.5
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Ca
se
s p
er
10
00
po
pu
lati
on
(A
zerb
aija
n, G
eo
rgia
, Tu
rke
y)
0
1
2
3
4
5
6
Ca
se
s p
er
10
00
po
pu
lati
on
(T
ajik
ista
n)
Turkey
Georgia
Azerbaijan
Tajikistan
(e) South-East Asia
0
5
10
15
20
25
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cas
es p
er 1
000
po
pu
lati
on
(B
hu
tan
, Sri
Lan
ka)
0
1
2
3
4
5
6
Cas
es p
er 1
000
po
pu
lati
on
(I
nd
ia, T
hai
lan
d)
Sri Lanka
Bhutan
Thailand
India
(f) Western Pacific
0
5
10
15
20
25
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Ca
se
s p
er
10
00
po
pu
lati
on
(L
ao
PD
R)
0
1
2
3
Ca
se
s p
er
10
00
po
pu
lati
on
(M
ala
ys
ia, P
hili
pp
ine
s, V
iet
Na
m)
Lao PDR
Viet Nam
Malaysia
Philippines
(Source: World Malaria Report 2009) (Source: World Malaria Report 2009)
Reduction of >50% in cases: 29 countries outside of Africa and …
Reduction of >50% in cases: 29 countries outside of Africa and …
Technical Briefing Seminar – 4 Nov 2010 5 |GLOBAL
MALARIA PROGRAMME
0
2000
4000
6000
8000
10000
12000
2001 2002 2003 2004 2005 2006 2007 2008
Case
s
0
20
40
60
80
100
120
140
Deat
hs
Malariainpatientcases
Malariainpatientdeaths
Accelerationstarted
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
200000
2001 2002 2003 2004 2005 2006 2007 2008
Mal
aria
inpa
tient
case
s
0
1000
2000
3000
4000
5000
6000
7000
Mal
aria
inpa
tient
deat
hs
Malariainpatientcases
Malariainpatientdeaths
Accelerationstarted
Malariainpatientcases
Malariainpatientdeaths
0
2000
4000
6000
8000
10000
12000
14000
2001 2002 2003 2004 2005 2006 2007 2008
Case
s
0
50
100
150
200
250
300
Deat
hs
Accelerationstarted
Malariainpatientcases
Malariainpatientdeaths
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
2000 2001 2002 2003 2004 2005 2006 2007 2008
Malaria
inpa
tient
case
s
0
50
100
150
200
250
300
350
Malaria
inpa
tient
deat
hs
Accelerationstarted
Eritrea Rwanda
ZambiaSao Tome and Principe
Reduction of >50% in cases: …. in 9 African countries
Reduction of >50% in cases: …. in 9 African countries
Also: Botswana, Cape Verde, Namibia, South Africa, Swaziland Also: Botswana, Cape Verde, Namibia, South Africa, Swaziland
Technical Briefing Seminar – 4 Nov 2010 6 |GLOBAL
MALARIA PROGRAMME
Malaria decrease in Africa due to effective control
Median PfPR 1985-19992-10 = 37%
Median PfPR 2000-20072-10 =
17%
Median PfPR 1985-19992-10 = 37%
Median PfPR 2000-20072-10 =
17%
Systematic review: 24 studies conducted between 1989 and 2005
in 15 different African countriesincluding 15’331 patients
Proportion of malaria among fevers highly variable: 2% to 81%: Median parasite rate =
26%
Systematic review: 24 studies conducted between 1989 and 2005
in 15 different African countriesincluding 15’331 patients
Proportion of malaria among fevers highly variable: 2% to 81%: Median parasite rate =
26%
D'Acrémont et. al. (2009). PLoS Med, 6 (1): e252
Technical Briefing Seminar – 4 Nov 2010 7 |GLOBAL
MALARIA PROGRAMME
Diagnosis of malaria: % reported cases in public sector with parasitological diagnosis
Diagnosis of malaria: % reported cases in public sector with parasitological diagnosis
0%
20%
40%
60%
80%
100%
Eur
ope
Am
eric
as
Sou
th-E
ast A
sia
Afri
ca
Eas
tern
Med
iterra
nean
Wes
tern
Pac
ific
% re
port
ed c
ases
wit
h co
nfir
med
dia
gnos
is
.
Based on cases reported to WHO: African % biased upwards since countries reporting tend to undertake more case confirmation.
Technical Briefing Seminar – 4 Nov 2010 8 |GLOBAL
MALARIA PROGRAMME
Deployment of RDTs in Livingstone (Zambia): impact on malaria cases and ACT consumptionDeployment of RDTs in Livingstone (Zambia):
impact on malaria cases and ACT consumption
Source: NMCC, Zambia MoH
Reported malaria cases, Zambia Livingstone District, 2004 - 2008
0
2000
4000
6000
8000
10000
12000
14000
2004
Q 1
2004
Q 2
2004
Q 3
2004
Q 4
2005
Q 1
2005
Q 2
2005
Q 3
2005
Q 4
2006
Q 1
2006
Q 2
2006
Q 3
2006
Q 4
2007
Q 1
2007
Q 2
2007
Q 3
2007
Q 4
2008
Q 1
2008
Q 2
2008
Q 3
2008
Q 4
IRS
Introduction of RDTs
Bednet introduction
ACT
RDTsRDTs
From over 25'000 ACTs in 2007 to less than 5'000 in 2008
Technical Briefing Seminar – 4 Nov 2010 9 |GLOBAL
MALARIA PROGRAMME
Reduction of ACT consumption with RDT scale-up in Senegal public health services Reduction of ACT consumption with RDT
scale-up in Senegal public health services Courtesy of Dr S. Thiam, PNLP SenegalCourtesy of Dr S. Thiam, PNLP Senegal
~ 0.5 million less ACT consumed in 2008-2009
Technical Briefing Seminar – 4 Nov 2010 10 |GLOBAL
MALARIA PROGRAMME
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
2001 2002 2003 2004 2005 2006 2007 2008 2009
0
10
20
30
40
50
60
Malaria cases
ACT orders
Positivity rate
% malaria OPD
% malaria IPD
Rwanda: preliminary analysis (WMR 2010)Rwanda: preliminary analysis (WMR 2010)
Malaria cases Malaria cases & ACT annual orders& ACT annual ordersMalaria cases Malaria cases & ACT annual orders& ACT annual orders % malaria positive% malaria positive% malaria positive% malaria positive
LLIN distributionLLIN distribution
% malaria outpatients% malaria outpatients% malaria outpatients% malaria outpatients% malaria inpatients% malaria inpatients% malaria inpatients% malaria inpatients
%%
Technical Briefing Seminar – 4 Nov 2010 11 |GLOBAL
MALARIA PROGRAMME
Malaria Consortium
PSI/TDR
Save the Children
IRC
Catalytic Initiative
PMI/MCH
Countries with projects on (integrated) Community Case Management
Courtesy of Dr F. Pagnoni, TDR Courtesy of Dr F. Pagnoni, TDR
Technical Briefing Seminar – 4 Nov 2010 12 |GLOBAL
MALARIA PROGRAMME
Affordable Medicine Facility for malaria: Phase 1Affordable Medicine Facility for malaria: Phase 1
Ghana
Madagascar
Uganda
Tanzania
Nigeria
Niger
Kenya
Cambodia
As of Sept 2010, 92 first-line buyers are making 24 co-payment requests (equivalent to US$ 8.02 million).
AMFm co-paid ACTs are on sale in Ghana and Kenya.
Technical Briefing Seminar – 4 Nov 2010 13 |GLOBAL
MALARIA PROGRAMME
ConclusionsConclusions
Malaria reducing in near 40 countries due to high coverage of RDTs, ACTs and LLINs - often in combination
Reduction of ACT consumption in areas with high level of use of malaria diagnostics (e.g. testing >80% of suspected cases)
At global level impact on ACT needs is limited because:
– low use of malaria diagnostics in countries with high burden
– ongoing expansion of ACT access interventions, i.e. community case management and AMFm (Phase I)
– variable coverage of vector control (malaria resilience)