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Column: Will the current global malaria programme pass a Cochrane Review?

July 24, 2014 - 21:12 -- Manuel Lluberas
The column below was contributed by Dr. Manuel Lluberas.
 
Public health entomology was an exciting career during the latter part of the 19th Century and the first half of the 20th Century. During those years, the “let’s go” attitude of a number of public health entomologists made significant strides against vector-borne diseases like malaria and yellow fever. Their discoveries were so significant and earth-shattering that they were recognized by their peers, their governments and the world and continue to amaze many in the public health arena. Some were even recognized and rewarded with Nobel Prizes...

A short list of the luminaries of this period includes Dr. Giovanni Battista Grassi, Dr. Ronald Ross, Dr. Walter Reed, Dr. Carlos Finlay, Colonel William Gorgas, Dr. Fred Soper, Dr. Israel Kligler and Dr. Le Prince, just to name a few. Many are well known while others have been relegated to the back pages of history books, but their work set the stage for other monumental accomplishments that continue to shine today.
 
Confirming the link between the malaria and its mosquito vector was an earth-shattering and controversial discovery. It led to the creation of the organized and systematic mosquito control programmes we know today as Integrated Vector Management (IVM). Though not known by that name then, these programmes identified the tools and procedures required to suppress mosquito populations over a wide area and provided adequate control soon after their implementation. Some of the significant milestones under these programmes include the completion of the Panama Canal, the eradication of Anopheles gambiae s.s. from northern Brazil and the eradication of malaria from “Mandate Palestine” (now Israel), the United States, the Soviet Union and Europe.
 
Today, in spite of the successes of the previous century, malaria is the most widespread vector-borne disease. About half of the World’s population remains at risk for malaria. It is estimated to be responsible for an average annual reduction of 1.3% in economic growth in Africa [1]. Over 3 billion people in approximately 140 countries or territories carry the highest malaria burden [2,3]. In addition to tangible effects, malaria has a heavy emotional burden on the populations it affects. Well into the 21st Century, about half a billion annual cases are reported and a person dies of malaria every thirty to forty seconds, mostly in sub-Saharan Africa, with the vast majority of those perishing annually being children under five years of age [4,5]. In addition to acute disease episodes and deaths, malaria also contributes significantly to anemia in children and adverse birth outcomes in pregnant women in Africa [6]. Moreover, at least 125 million non-immune travelers from malaria-free countries visit malaria-endemic regions annually.
 
In response to continuous malaria threat, the World Health Organization (WHO) launched the Global Malaria Program (GMP) in January 2006. This program focuses on scaling up delivery of three major interventions: widespread distribution long-lasting insecticidal nets (LLIN) as a primary means of malaria vector control, Indoor Residual Spraying (IRS), and the use of and Artemisin-based Combination Therapy (ACT) as first-line malaria treatment. Of these, IRS has been demonstrated very successful in reducing malaria vector populations in many countries and under a wide range of conditions and is considered by many as the backbone of malaria control programmes [7].
 
Unfortunately, the documented successes of the 19th Century, when malaria control campaigns were driven by a “we-need-to-do-something-about-malaria-now” approach seem to have been replaced by a “does-this-meet-a-Cochrane-Review” mentality of the 21st Century.
 
Cochrane Reviews are systematic reviews of primary research in human health care and health policy, are internationally recognized as the highest standard in evidence-based health care and investigate the effects of interventions for prevention, treatment and rehabilitation [8]. As such, these are very valuable tools. Unfortunately, many of the details of successful vector control programmes are captured in reports to boards of directors and shareholders written as internal documents of companies engaging in malaria control to protect their workers and neighbouring communities and are often not readily available to be included in a Cochrane Review [9]. Making matters a bit more complicated, though there are many examples of programmes that have significantly reduced or eliminated malaria from the areas they were implemented, many of them are not structured in a way that would permit them to be included in a Cochrane Review.
 
The poorest of the poor, who carry the burden of malaria, are counting on those of us in a position to affect some change to take action against it. We need to place malaria vector control programmes back in the hands of public health entomologists who are familiar with the vector and the methods and procedures to suppress their populations [10]. While a handful of us believe the malaria world needs to replicate the successful programmes as quickly and in as many places as possible, many in the malaria world seem hung up on subjecting these programmes to the scrutiny of a Cochrane Review until they pass it. The result has been described as “paralysis by analysis.”
 
References
[1] Sachs JD. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, December 2001.
[2] Hotez P J, Fenwick A, Savioli L, Molyneux DH: Rescuing the bottom billion through control of neglected tropical diseases. Lancet 2009, 373:1570–1575.
[3] World Malaria Report 2013, WHO, Geneva 
[4] WHO: World malaria report 2010. Geneva: World Health Organization. http://whqlibdoc.who.int/publications/2010/9789241564106_eng.pdf
[5] WHO Expert Committee on Malaria. Twentieth report. Geneva, World Health Organization, 2000 (WHO Technical Report Series, No. 892).
[6] WHO, 2010: Working to overcome the global impact of neglected tropical diseases. http://whqlibdoc.who.int/publications/2010/9789241564090_eng.pdf 
[7] Bulletin of the World Health Organization, 2000, 78 (12) 139
[9] Lluberas, M. F. (2012). Malaria: A full-time problem addressed on a part-time basis by amateur entomologists, MalariaWorld, July 12, 2012 - 15:51 (http://www.malariaworld.org/blog/malaria-full-time-problem-addressed-par...)
[10] Lluberas, M. F. (2011): Vector Control in the Thinkers vs. Doers Environment, Wing Beats, Vol. 22, No. 3; pp 17 - 22 (Fall 2011)