The world's scientific and social network for malaria professionals
Subscribe to free Newsletter | 10140 malaria professionals are enjoying the free benefits of MalariaWorld today

Malaria: a full-time problem addressed on a part-time basis by amateur entomologists

July 12, 2012 - 15:51 -- Bart G.J. Knols

The editorial below was written by Manuel F. LLuberas, MS IDHA, Public Health Entomologist

More than a decade after implementation, the global malaria control strategy has proven woefully inadequate. It has reported expenditures exceeding several billion dollars and relies heavily on passive methods like mosquito nets but has been unable to meet its goals of reducing an annual morbidity rate that continues to hover around half billion and a mortality rate equivalent to six Jumbo jetliners crashing daily. The time has come to get serious about this problem. Malaria vector control programs around the world need to be placed under trained public health entomologists who can implement comprehensive mosquito population suppression methods and deploy truly integrated vector control systems. Continuing in the current path is unacceptable and wastes quickly dwindling, limited resources.

Malaria continues to inflict a heavy burden on over 3 billion people in approximately 140 countries or territories.[1], [2] Somewhere around 400 and 600 million malaria cases are reported annually, with about 60% of them and over 80% of the deaths in sub-Saharan Africa.[3] More significantly, the vast majority of the million or so who perish annually to this disease are children under five years of age.[4] 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.[5] Furthermore, malaria is estimated to be responsible for an average annual reduction of 1.3% in economic growth for those countries with the highest burden.[6]

While the malaria yoke remains heavy on the shoulders of the poor populations, the vast majority of malaria control programmes in Africa and around the world today are managed by pediatricians, ophthalmologists and other physicians who know little about the mosquitoes in their areas and even less about vector control. Moreover, the World Health Organisation (WHO) has only a handful of entomologists in all of Africa, about four in the Americas, and about as many in Asia. This may help explain why so very few, if any of these programmes have a public health entomologist at the helm.

Though physicians have a clear and universal understanding of the need for narcotics and antibiotics in human health and accept them in spite of their inherent risks and counter indications, it is rare to find malaria control programme managers who treat public health insecticides as drugs for the environment and treat them as such: “prescribed” by those with the proper training and qualifications and applied when needed and with the correct formulation and dosages. Very few of the malaria control programme managers around the world today have made this connection and may help explain the urgent need for improved management of the few public health insecticides left in the malaria control arsenal.[7] More troubling perhaps, many of them consider insecticides dangerous environmental contaminants that should be banned altogether.

Complicating the vector control picture a bit further, many of today’s international health agencies and organisations advising or directing vector control programmes speak about Integrated Vector Management (IVM)[8] and push this concept as the correct approach while continuing to focus their attention on passive methods like mosquito nets (ITNs) and place active vector control methods like space and indoor residual spraying (IRS) and larval source management (LSM) as supplementary tools deployed only if the budget allows. This scenario has played itself repeatedly over the past decades since Ronald Ross’ days, when the failure of attacks on mosquitoes to reduce malaria parts of Africa “could be fairly discounted on grounds that the attacks were never more than half-hearted and were too soon abandoned.”[9]

There is ample evidence that when properly designed and implemented, an integrated vector control plan wiped out malaria from the developed world and suppressed it in many other countries in almost every ecological zone. Today this is not a popular concept, but there are many examples where this combination has worked. The success in the US and the Panama Canal has been properly documented, but there are more recent victories from Ghana, Zambia, South Africa, Zanzibar and other parts of the world. Unfortunately, many of the details of these successes are captured in reports to board of directors and shareholders written as internal documents by companies in the mineral extraction community engaging in malaria control to protect their workers and are often not readily available or published.

Many don’t like to hear this, but today, well into the Twenty First Century, malaria is a full-time problem addressed on a part-time basis. In today’s malaria world, with at least half the world’s population at risk and a mortality rate equivalent to about six 747 Jumbo planes full mostly with children under five and pregnant women crashing daily, many programmes rely almost exclusively on passive methods like mosquito nets (ITNs), equate net distribution to usage when these terms are nowhere close to being synonymous, and only haphazardly activate active vector control programmes like indoor residual spraying (IRS) for a handful of months, after which they are disbanded.

We need to get serious about malaria vector control, take a full-time approach to it and provide job security and progression to managers and technicians so they continue in their posts and not take the first opportunity for permanent positions outside malaria control. Vector control programmes need to implement active vector suppression interventions with reliable equipment and materials, implement insecticide resistance prevention and correction methods and attack the vector on all fronts: larvae, pupae and adults. In addition, we must stop the dependence on a single class of insecticides (the pyrethroids), the group most commonly used in IRS and the only one used in ITNs. This widespread reliance on a single class of insecticides increases the risk of mosquitoes developing resistance to it, of particular concern in Africa, where mosquito nets are being deployed at unprecedented levels and IRS coverage is rapidly increasing. Once insecticide resistance is established in mosquito populations, about half of the insecticides available for vector control would be rendered useless; leaving countries with a malaria problem several orders of magnitude more severe than it is today.

It is time to get serious about vector-borne disease control and place trained public health entomologists and technicians where their training and experience can be most effective and have the highest impact. It is critical that we have programme managers who consider public health insecticides as drugs for the environment, understand their counter indications, are conscientious about their potential side effects on human health and the environment and deploy them as intended and when they can produce the greatest impact on the mosquito. We need malaria vector control programme managers who know the vectors in their areas of responsibility and are able to design and implement a programme that deploys as many vector population suppression tools as are feasible their countries and against as many of the developmental stages of the target vector as possible. Only this way can we implement truly effective and efficient integrated vector management programmes that have long lasting results and help keep the 747 Jumbo planes in the air.

Having a malaria vaccine in the malaria control toolbox would certainly help, but we succeeded in eradicating or reducing malaria in about 100 countries without the benefit of a vaccine or many of the modern technological advances. In each of these cases, active vector control was the backbone of well-organised campaigns that led to glorious victories.

Albert Einstein has been quoted as saying ”If you want different results do things differently.”[10] The World has been engaging in malaria control for at least a decade and has spent billions of dollars that have produced only meagre progress. We need to follow Einstein's advice and modify the global malaria control strategy. Proceeding on the current path will only provide job security for the current program managers while allowing malaria mortality rates to remain unacceptably high for the decades to come.


[1] Hotez P J, Fenwick A, Savioli L, Molyneux DH: Rescuing the bottom billion through control of neglected tropical diseases. Lancet 2009, 373:1570–1575.

[2] World Malaria Report 2007, WHO, Geneva

[3] WHO: World malaria report 2010. Geneva: World Health Organization. http://whqlibdoc.who.int/publications/2010/9789241564106_eng.pdf

[4] WHO Expert Committee on Malaria. Twentieth report. Geneva, World Health Organization, 2000 (WHO Technical Report Series, No. 892).

[5] WHO, 2010: Working to overcome the global impact of neglected tropical diseases. http://whqlibdoc.who.int/publications/2010/9789241564090_eng.pdf

[6] 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.

[7] Status of pesticide management in the practice of vector control: a global survey in countries at risk of malaria or other major vector-borne diseases. Henk van den Berg, Jeffrey Hii, Agnes Soares, Abraham Mnzava, Birkinesh Ameneshewa, Aditya P Dash, Mikhail Ejov, Soo Hian Tan, Graham Matthews, Rajpal S Yadav and Morteza Zaim. Malaria Journal 2011, 10:125

[9] Harrison, Gordon A. (1978) Mosquitoes Malaria & Man. Clark, Irwin & Company Ltd, Canada

[10] Einstein, Albert (1954), Ideas and Opinions, Random House, NY

 

Comments

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

The comment below was submitted by Nicolas Moiroux:

Dear Bart,

I just read the editorial written by Mr Lluberas. I dont want to comment this point of view but I think it would be useful for the readers to know that Mr Lluberas works for the Hudson compagny that have "over a century of global manufacturing and marketing experience in the sprayer business, H.D. Hudson Manufacturing Company has become known as the World Standard of Value in the sprayer category." ( http://www.hdhudson.com/about-us ;http://www.hdhudson.com/global-public-health/newsletters/about-the-author). I think you should add this affiliation at the beginning of the article.

Thank you for this very useful website !

Nicolas.

Submitted by Guest (not verified) on

Dear All:

While it is certainly true that I have been employed by H. D. Hudson Manufacturing Company during the course of almost two decades, and that Hudson has set the standard when it comes to sprayers and dusters in vector control, the opinion expressed is my own and should not be interpreted as that of the Company. You will note that I made no reference to anything related to Hudson. My comments reflect the my experiences as a public health entomologist during the past three decades in Africa and other parts of the World and the reality of the current global malaria vector control program. Any one thinking otherwise is missing the point.

Manuel Lluberas

William Jobin's picture
Submitted by William Jobin on

To our friend the Acting Medical Zoologist at IMR from 1966-68, who lived in Petaling Jaya -
You say you didn't notice any anti-malarial activity while you were in Malaysia. Well they weren't using drugs or biocides, so you would not have seen that during your stay there from 1966 to 1968. However if you check the last pages of their website http://www.actmalaria.net/IRW/IRW_Malaysia.pdf, you will see that the incidence of malaria cases reported to public health centers dropped from 250,000 cases per year in 1950 to only 5,000 cases per year at present, and it is remaining low and steady. That is what happens when you rely on integrated management of mosquito vector habitats, instead of drugs and biocides.

William Jobin Director of Blue Nile Associates

Submitted by Guest (not verified) on

I found the article most interesting and important,and the points stand on their own, however, when there is an affiliation that could be a "perceived" conflict of interest, it is important to disclose this up front rather than have someone else point it out after the fact.
I agree with the content and spirit of the article, but I think it would have been wise for Manuel to have noted the affiliation as a disclosure at the end of the article. There is a very passionate argument against pesticide regulation made using malaria deaths as the justification for use of DDT (though it is long gone and likely of not much value). Of course, it is easy for those living in non malaria zones to argue for restrictions of pesticides, and for those arguing against restrictions to use a fallacious argument comparing onions and apples as if they were both fruit. The reality in the risk/benefit evaluation is quite different.
Still, Manuel's article is very insightful..
thanks,
Sam

Submitted by Guest (not verified) on

Sam, thanks for your comment and support, but I find your position a bit puzzling. While pressing the issue of affiliation, I find a bit interesting that your comment arrived as a "Guest" and you only used your first name.

It may not have been obvious in my editorial, but I am not advocating the use of IRS over any other method or taking advantage of the opportunity to promote a product. I intentionally left my affiliations out of the original editorial to reduce or eliminate any bias a reader would have had after reading my affiliation. This may be the same reason why you left yours out.

Having said that, we are on the same side.

All the best,

Manuel

Submitted by Guest (not verified) on

Although Manuel is affiliated with HD Hudson, his editorial piece makes numerous valid points.  Malaria control efforts, and other vector-borne disease programs, are almost always short staffed and short lived.  When comprhensive and substantial intervention takes place, malaria has been reduced substantially, but often only temporarily.

We can do better, and perhaps some of the massive funding that now goes for vaccine development, a worthy cause, could instead be used for integrated vector management programs.  This would likely result in a very rapid decrease in malaria cases while we await improved technologies to combat this disease.

William Jobin's picture
Submitted by William Jobin on

Thank you Manuell Lluberas for your global analysis of better ways to suppress malaria.  I merely want to add one more country to your list of successes where entomologists have studied the vectors, learned their habitat requirements, and then attacked the important vectors with modifications of the habitats.  In Malaysia they started this in 1939, and continue to have the most successful of malaria control programs in Asia.  The key, as you point out, is that they had highly trained entomologists to learn about the vector.

Contrast this with the WHO led effort in Burma, where they are using drugs and bednets, without entomological information.  Now Burma is the source of the new resistant strains of the malaria parasite.  The lack of appreciation of the WHO staff for entomology might thus wipe out the most hopeful drugs we have left in the fight.  It would have been so helpful if WHO had some entomologists.

I appreciate your viewpoint because I know of your global experience and committment to suppressing malaria. We need more people like you who have seen the real world, and who have common sense as well as superb training and experience.  Thanks for your editorial.

 

William Jobin Director of Blue Nile Associates

Submitted by Guest (not verified) on

I must have missed a lot when I was in Malaysia at the Institute  for Medical Research  between 1965-1968 working as a Parasitologist in  the U.C. G. W. Hooper Foundation  Internationl Center for Medical Research and Training (ICMRT) , and as Acting Medical Zoologist for the IMR in 1966-1968.

Many of the department heads met for coffee in the morning to socialize and discuss problems.  The IMR Entomolgist  was a regular attendee.  I was asked on a few occassinals to meet wiht high Goverment officials, including the Deputy Prime Minister and Minister of the Interior to discuss topics of potential medical problems of significant projects.  I am unaware of any concerted IPM or IVM program in Malaysia at that time and know, from my local colleagues at the Coffee club, that there none during the Japanese occupation.

I lived in Petaling Jaya and never saw any mosquito surveillance or control, until we had a Group B Encephalitis epidemic.  As one of those seriously affected by the, then unknown, virus I pushed for more control, that unfortunately was shortlived.

I hope that Malaysia does have a strong anti-malaria program and maintains it.

 

 

 

Submitted by Guest (not verified) on

T agree entirely with this authors comments. In 2002, seeing the high numbers of malaria cases in the south of Zanzibar.,I offered to set up and find funding for the provision of ITNs for the under fives and pregnant women.
Firstly, i consulted the groups of villagers to explain their usage and having done so asked if they had any questions or concerns regarding their usage.Later when I provided LLINS I sought to reassure them regarding their safety in usage.
Vector breeding sights were sought out and destroyed.A small financial incentive was given to school children to assist in this.Thermometers were given to the schools to take the temperatures of pupils who seemed to be feverish so that rapid diagnosis and treatment could be undertaken.
Later, under a national scheme more nets became available and IRS undertaken .
To-day as we know Zanzibar is malaria free, but the population are well aware that it could return.Those with whom I worked are ever watchfull.

Submitted by Guest (not verified) on

Nicolas, I see no conflict of interests in this most valuable editorial provided by Manuel. Hudson, no doubt, underwrite the transparency that effects all suppliers of prducts as per the IATI - Accra Statement dated 4th Sept.2008 as we do for our product. They are in a tough market competing with products from South Korea and China. Good luck to them.

We are faily 'new boys' on the block but let me assure you that I have met plenty visiting doctors in West Africa that left after days to go home to write the 'rule-book' on good pay. Most of them, I must say are medical doctors with links as consultants to a lucrative pharma - industry. Great for treatment of Malaria, not so good for prevention.

To find an experienced Entomologist, with local language skills, who is prepared to come up with a vector control program - after site studies in the impoverished areas is like looking for hen's teeth.
At best they can provide details of species and reports that thousands of unused bed-net wrappings that go to the land-fill sites provide wonderful breeding sites. They have no voice in Geneva or the UN.

We all need to thank Bart, William and Manuel for their expertise.

To anyone out there intending to self-fund R&D for new products for the Prevention of Malaria tool-box as we did : Don't - go for grants.

Bart, you will have read that a young chap in East Africa experienced an increase of mosquito bites on his ankles, feet, as he did not wash his socks for 3 days. He now enjoys a grant of $750.000 to develop this into a sensory trap. There is something wrong with this picture.
Odor is copied by Universities to make our oranges smell like oranges, no problem to copy smelly feet either but it takes time, investment, case studies and a business plan to assess market potential.

Submitted by Guest (not verified) on

I couldn't help making one more comment in support of your position Manuel, Before the current leadership took over WHO and the malaria effort, WHO was a leader in developing environmental management for mosquito control in general, and malaria control in particular. See the 1982 WHO offset publication No. 66 entitled "Manual on environmental management for mosquito control". Ask Rob Newman or Michael Macdonald at the Global Malaria Program in Geneva for copies of it, they should be able to find them. If not, you might ask the Director General, Dr. Margaret Chan. She might be able to have it reprinted.

Submitted by Guest (not verified) on

Many thanks for your note. I have a copy of the document you mentioned. It should be updated, but it remains very useful. May I also mention WHO Offset Publication No. 1 titled "Manual on Larval Control Operations in Malaria Programmes". This one may be burried in the WHO archives, but I also have a copy. Very useful. Maybe we need to bring this up to Dr. Chan as a group during the next Vector Control Working Group meeting in Geneva or through the regional offices; or both simultaneously. As you alluded to, What happened?

To paraphrase Dr. Savioli statement during the last WHOPES meeting in Geneva, "The message from Dr. Chan is that the WHO's mission is to inspire, not to do or direct." Somewhere those who had the experience and expertise to do, which at this point are very few, are now inspiring, but it is what are they inspiring to that remains an illusive subject somewhat up to interpretation.

Submitted by Guest (not verified) on

I liked this article and its overdue,the problem in Africa every one is an expert in malaria control as he mention,the doctors especially dominate all programs concerning malaria why?,simply its where the biggest budget lie in the sub Saharan countries such as Uganda and thus it becomes a political decision when selecting a program manager.
The poor but skilled entomologists or vector control officers at the center and districts are not even called in meetings concerning malaria control,all decisions go without their input!. Its true the world need to weak up and be serious on malaria,those in "business" should accept that its time to seriously fight the disease,and i suggest that WHO should change the strategy now.How can an opthalmic clinical officer heads a malaria control unit at the district when a vector control officer is available this is madness!I thank the author again.

Submitted by Guest (not verified) on

That is one of the unfortunate realities of malaria control. What we need to do is increase and improve our visibility and involvement in these programs. Please voice your concerns to the WHO and others while remaining diplomatic. Forgive me for sounding like this, but we need to take action in a way that does not place the entomology community, both at the PhD and field levels as whinning about this.

Submitted by Guest (not verified) on

Sir i have read your article.It has highlighted the importance for prevention and control of vector borne disease,specially Malaria.
I am from Pakistan , i am a Medical Entomologist and Vector control expert,WHO has organized a specialized Post graduate course for Eastern Medditerian region.
Problem is that most of the health officials across the GLOB do not pay attention on implement ion of integrated vector control programs. So problems exist there as usual.. And it is increasing day by day...
Can we get the initiative for Prevention and control of vector borne disease by designing and implementing projects with your support. thanks

Submitted by Guest (not verified) on

I would be honored and delighted to help in any way I can. Please contact me via this means or at lluberas@hdhudson.com. If you contact me directly, please put something in the subject line in reference to this note so I can recognize your note. Otherwise, it runs a good chance I will not open it.