Policymakers, national control program professionals, and practitioners problem solve and exchange best practices in this community with the goal of improving the prevention, management and treatment of malaria.

Discussion Briefs

Classical Methods Against Malaria In Africa: A Conversation With Dr. Bill Jobin

Over the last century, classical environmental interventions like improved housing, land reclamation, larviciding, and irrigation and hydroelectric systems have led to the eradication of malaria in the United States, Europe, the Mediterranean region, and parts of Southeast Asia. These classical methods are simple, economical, and durable. To many, they represent durable methods to fight malaria in Africa that should complement the use of insecticides, especially with the recurring development of insecticide resistance.

Dr. Bill Jobin joined us for an expert panel discussion on this topic the first week of April 2013. Jobin is a public health engineer with degrees from MIT in hydraulics and sanitary engineering and a doctorate in tropical public health from Harvard. He has worked for over 50 years, starting in Puerto Rico with the U.S. Centers for Disease Control and Prevention, with the World Health Organization on the Blue Nile Health Project, and continuing on various health impact assessments of large water and energy projects in the tropics for the World Bank and the U.S. government. He helped start the U.S. President’s Malaria Initiative, and in 2009 published a report in the WHO Bulletin. He’s authored two technical books, more than 50 articles, and more recently a series of technical monographs.

This discussion outlines some important steps in further promotion of classical malaria control methods involving physical, biological and community approaches. Although not everyone agreed on the value of the classical methods, participants were emphatic about the value of community participation as a basic requirement for success, no matter what control methods were involved.
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Lessons from the Malaria Institute at Macha, Zambia

Malaria persists as a major public health problem, claiming a global toll of 215 million clinical cases and 655,000 deaths, mostly in Africa. (WHO. 2012) Phil Thuma, M.D., pediatrician, Senior Scientific Advisor and founder of Macha Research Trust, which does business as the Malaria Institute at Macha (MIAM), shares experiences on remarkable success at decreasing malaria burden in southern Zambia. Illustrating the power of uniting community, research, and care to fight malarial burden, the “Macha model” hails from a humble mission hospital that “took the bull by the horns” after many years of high malaria cases and fatalities.

MIAM partners are the Macha Malaria Research Institute (a USA-based NGO); the Johns Hopkins Malaria Research Institute at the Johns Hopkins Bloomberg School of Public Health; the Macha Mission Hospital (located right next to MIAM) in southern Zambia; and the Zambian government through its Ministry of Health. The result of this collaboration is a preeminent malaria research and education centre in the midst of a hyperendemic area, which is proving instrumental in developing “home-grown” approaches to conquer of malaria. In order to sustain impact, these approaches are constantly being adapted to the changing epidemiology of the disease. (Kamanga et al. 2010. Sutcliffe et al. 2011)
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The Future of Malaria Vector Control and Insecticides

Anti-vector interventions are proven strategies in preventing transmission of malaria. As such, these efforts remain integral in the global fight against malaria which has, by most counts, made slow but steady progress. But the distribution of insecticide-resistant mosquitoes — recently reported in Nature (Malaria surge feared, 15 May 2012, and Mosquitoes score in chemical war, 5 July 2011) — puts said gains in jeopardy. In various countries, resistance to DDT, pyrethroid, as well as carbamates and organophosphates, has been discovered and is now threatening the sustainability of vector control programmes. For many working to reduce the burden malaria through vector control, this is not news. Many vector control specialists would like to see more comprehensive, and carefully planned, anti-vector strategies.
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Rapid Diagnostic Tests for Malaria - From policy to end-user

Malaria diagnosis in most endemic countries was largely based on clinical symptoms that are non-specific. This resulted in the over-diagnosis and therefore, over-treatment of malaria, negation of other non-malarial febrile illness, exertion of drug pressures on the malaria parasites with fear of early on-set of drug resistance etc. The gold standard for malaria diagnosis, microscopy, requires high skills, long training, electricity, laboratory equipment, reagents and the turn-around-time for the malaria test could be extremely long in a number of settings and thus not available to guide the prescription of antimalaria medicines. The need for a rapid malaria test was therefore imperative for an effective malaria case management. The availability of good performing malaria rapid diagnostic tests (RDTs) has made the paradigm shift from clinical diagnosis to parasite-based confirmation of malaria a possibility.

In the last decade, millions of RDTs for malaria have been implemented worldwide. These simple and easy-to-use tests can diagnose malaria from blood in about 15 minutes, making a diagnostic possible at all levels of the health system. While the tests have enabled better access to malaria diagnosis, many challenges remain.

Members and panelists from The London School of Hygiene and Tropical Medicine, The Foundation for Innovative New Diagnostics (FIND), The University of Lagos, The University of Yaounde I, PATH, USAID/Deliver Project, and the U.S. Food and Drug Administration (FDA) addressed many challenges in this three-part discussion: interpreting test results in context; the impact of RDTs on the behavior of health care providers; the implications of the WHO “test and treat” guidelines; as well as regulations and procurement issues.
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Presumptive treatment, Rapid Diagnostic Test, and the need for differential diagnosis

Effective case management of malaria is essential in the context of increasing drug resistance. The recent WHO guidelines recommend prompt parasitological confirmation by microscopy or alternatively by Rapid Diagnostic Tests (RDTs) in all patients suspected of malaria before treatment is started, and that treatment solely based on clinical suspicion should only be considered when a parasitological diagnosis is not accessible.

In malaria-endemic countries, people commonly assume they have malaria when sick and treat themselves accordingly. Of equal concern is that negative test results—meaning no malaria—are often ignored and patients treated anyway. (Whitty, 2008; Juma, 2011). Although RDTs have been shown to be robust diagnostic tools, and a couple are commonly used in countries (Batwala, 2010; Singh, 2005), “one size does not fit all;” If parasite prevalence in the population is low, a diagnostic test is relevant; if the prevalence is high, the test does not provide information of any clinical usefulness, as happens with any test in medicine when the prevalence of the tested characteristic is high in the healthy population. (Grass, 2011)

Members representing a broad range of health professions and organizations spanning four continents (Asia, Africa, North America and Europe) discuss challenges in misdiagnosis and presumptive treatment, as well as policy, training, and behavior change.
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